Sober Synthesis

I. Managing Depression: Self Help Strategies

Prevalence

• Nearly ⅓ of people with major depressive disorder also have a substance use disorder
• Major depressive disorder is the most common co-occurring psychiatric disorder among people with Alcohol Use Disorder (AUD).
• Depression, even for those that did not have a history of depressive episodes, is a common symptom of Post Acute Withdrawal Syndrome (PAWS)
• Fifty-60% of people recover from depression after 6 months of abstinence, especially when a participant in a treatment program and/or a self help group

Types of Depression

• Substance induced and/or medically induced
• Situational 
• Seasonal Affective (winter months when sunlight is more limited))
• Dysthymia 
• Major Depression
• Bipolar Depression

Basic Pain/Pleasure Neurobiology

• Our pain and pleasure system is a scale: if you overwhelm the pleasure system, you will set yourself up for anhedonia (lack of enjoyment) and depression.
  • As we experience pleasure there’s a tilt on the scale of pain-pleasure and we crave more of the thing that brought us pleasure.
  • If we remain in constant pursuit of pleasure, we’ll achieve less dopamine release every time while the amount of pain increases.
  • To reset the balance, we will experience states of dopamine downregulation (e.g. PAWS).
• There are at least three major chemical pathways in the brain related to depression: norepinephrine, serotonin, dopamine.
  • Norepinephrine relates to the lethargy and exhaustion
  • Dopamine relates to the anhedonia (loss of pleasure)
  • Serotonin relates to the grief, guilt, and the cognitive effects of depression

Self Help Activities

Important Note: Any activities, especially those with more effort, are best started as soon as possible after awaking to maximize optimal body/brain chemistry. 

• Exposure to sunlight or a blue (UVB) light substitute, especially within 2 hours after awakening and as much as possible throughout the day. Note: clouds do not block UVB light.
  • Important to set circadian rhythm for restorative sleep and boosts serotonin levels.
• Exercise
  • Increases the norepinephrine in the body
  • Has a positive effect on the tryptophan-serotonin pathway 
  • Optimal exercise dose: 150-180 minutes exercise per week
  • When depression significantly impacts ability to exercise, any physical activity (making a bed, washing dishes) can activate these responses. In addition, there is evidence that focused visualization of exercise can stimulate the same brain activity until one can physically exercise. 
• Nutrition
  • Evidence points to excessive inflammation as a precursor or exacerbator of depression.
  • People who are depressed have more of an appetite for carbohydrates because they are trying to get more tryptophan which is eventually converted into serotonin.
  • Carbohydrates increase inflammation.
  • Supplement to limit inflammation and relieve some symptoms of major depression: increase intake of essential fatty acids – critical threshold level: 1,000 mg EPA (not DHA).
  • The phosphocreatine system in the brain has been shown to be involved in the regulation of mood pathways
  • Creatinine(monohydrate): improve mood and symptoms of major depression (dose 1g – 5g)
  • A keto diet has been explored for potential relief of depressive symptoms by modulating gabba 
• Laughing: exposure to people, places, and things that can induce laughter
• Journaling and/or mindfulness exercises to observe unhelpful thinking
• Social and/or animal connection
• Minimizing social media and/or electronic scrolling, especially early in the morning 
• Understanding & Conquering Depression – Huberman Lab

 Proposed questions for thinking/sharing

1. If you have experienced or are experiencing depression, what activities have helped decrease your depression to support your recovery/wellness?
2. If you are experiencing depression, what activities are you planning to start to help decrease your depression?

II. Depression: Professional Interventions

• Research Validated Psychotherapies: These are different doors to enter with a professional to motivate/initiate and reinforce change (neuroplasticity). 
  • Cognitive Behavioral Therapy (CBT) focuses on addressing both the unhelpful thought patterns and the behaviors that contribute to depression. Acceptance Commitment Therapy (ACT) is a variation of CBT.
  • Behavioral Activation Therapy teaches clients to identify and engage in rewarding activities.
  • Interpersonal Psychotherapy is a structured and relatively brief form of therapy that stresses attachment patterns and relationship issues.
  • Dialectic Behavioral Therapy (DBT) is mostly based on CBT. The key difference is that it asks individuals with depression to acknowledge and accept their negative thoughts and behaviors. Through the practice of validation, individuals can come to terms with their negative emotions, learn to cope with stress and regulate their reactions to it, and even improve their relationships with others. Incorporates mindfulness practices.
  • Psychodynamic Therapy focuses on helping clients become aware of their unconscious conflicts, many of which have their source in the past. Therefore, considerable time is often spent exploring childhood experiences and past relationships with significant others, particularly parents.
  • Problem-solving Therapy involves defining personal problems, generating solutions, and determining whether a solution works.
  • Group therapy can be as effective as individual psychotherapy.

• Medications
  • Selective serotonin reuptake inhibitors (SSRIs) help regulate the amount of serotonin that is active in the synapses between neurons. Serotonin-norepinephrine reuptake inhibitors (SNRIs) address levels of both serotonin and norepinephrine. Norepinephrine/dopamine reuptake inhibitors (NDRIs) help regulate both norepinephrine and dopamine levels.

Brain Plasticity & SSRIs: Breakthrough on How Antidepressants Work – Why They Take Weeks To Kick-In (scitechdaily.com)

• Extensive research validates that a combination of psychotherapy and medication is more effective with moderate to severe depression. 

Depression Treatments for Adults (apa.org)

Professional Somatic Interventions: Professional/medical interventions that may be alternative treatment options when medication is either contraindicated or has had minimal effect. 

• Transcranial Magnetic Stimulation (TMS)
  • TMS pushes electrical charge into nerve cells to alter their activity and communication. TMS increases or decreases neural activity in certain regions, with the goal of shifting brain activity from patterns associated with depression to patterns associated with healthier brain function.
  • 30-64% of patients report an improvement in symptoms of depression.
• Electroconvulsive therapy (ECT)
  • A medical procedure that involves passing a mild electric current through your brain, causing a short seizure. This procedure is proven to have strong positive effects on severe, treatment-resistant mental health conditions, including depression. 
  • Between 70 and 90% of individuals who receive ECT treatment report an improvement in their depression. However, without continued treatment such as medication or maintenance ECT, many patients may relapse.
• Vagus Nerve Stimulation (VNS)
  • VNS alters nerve activity in the body by sending mild electrical pulses through the vagus nerve to the brainstem. This pulse is then sent throughout the brain to change the way brain cells function, much like a pacemaker.
  • VNS study results appear promising, with estimates ranging from a 50-70% response rate.

ECT, TMS and Other Brain Stimulation Therapies | NAMI: National Alliance on Mental Illness

Medical Use of Psychedelics

• Psilocybin 
  • Psilocybin closely resembles serotonin and powerfully activates 5HT2A receptors, leads to increased neuronal growth in the prefrontal cortex). 
  • Has hallucinative properties that often produce mystical experiences
  • Can lead to profound changes in perception, cognition, and mood.
  • Psilocybin is being extensively studied for the treatment of major depression and addiction
• Ketamine
  • Ketamine is a dissociative anesthetic and NMDA receptor (memory formation) blocker used for depression treatment
  • Ketamine creates a sense of dissociation from emotions and is currently legal for medical use depression and PTSD
  • May lead to shifts in circuity and plasticity so depression doesn’t feel as heavy

Understanding & Conquering Depression – Huberman Lab

 Proposed questions for thinking/sharing:

1. If you have participated or are participating in psychotherapy, have taken or are taking antidepressants, and/or have participated or are participating in any alternative/additional professional intervention, what has been helpful to support your recovery/wellness? Why?

Disclaimer

This summary is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed.