A laptop on a woman's lap while she sits cross legged and uses the trackpad

Ketamine for Depression: Misconceptions, Stigma, and Prejudice Online

I just watched a video that Kyle Kittleson of the MedCircle YouTube channel posted about IV ketamine. It’s called, “What It’s Like to Do Ketamine Treatment for Depression.” The video itself was great; I love that Kyle and his producer, Brigid, were so open about sharing their first ketamine treatment experiences with over 950,000 subscribers. I think their courage will have a big impact on the public’s understanding of why and how professionals administer ketamine for depression.

Online Discussions about Ketamine for Depression

Building awareness about ketamine in mental health treatment is good because we have a LONG way to go. Scrolling through the comments on Kyle’s ketamine infusion video was a rollercoaster of feelings. I have a ketamine infusion about every 4 weeks. I write about ketamine on my blog, and if someone were to ask me about it in public, I would happily talk about it. But I don’t tell just anyone that I use this treatment. I thought that I was being overly cautious, but frankly, after reading the comments I’m about to present to you, I’m not so sure. The judgment, condescension, flippant jokes, and dangerous misinformation were hard for me to read. I could imagine people reading those comments and losing hope in a potentially lifesaving treatment.

Abstract landscape with orange trees and blue sky with lines of movement
Photo by Jr Korpa on Unsplash

Ketamine has many uses as an anesthetic in human and veterinary medicine, and yes, as a recreational drug. It works as a powerful treatment for suicidal thoughts, depression, PTSD, and more. When I get a ketamine infusion, I’m using a legal treatment that helps my brain repair itself. Then, I go home and resume the rest of my regular mental health practices – therapy, medication, being outside, confronting painful issues – the whole nine yards.

I was so excited to see that many comments on the MedCircle video were positive, ranging from support to curiosity to stories of success with ketamine treatments for depression.

Other comments featured honest questions about addiction, cost, what it feels like, and how to get a referral.

And then there were THOSE comments. The ones that spread misinformation, jumped to conclusions, and judged others for their choices. The ones that doubted Kyle’s depression, saying, “He looks fine to me.” And the ones that declared ketamine a dangerous street drug and the people who use it for depression irresponsible high-chasers who can’t face their problems.

Let’s visit some of these comments. I’ve covered the names, but these are real comments from the comments section of Kyle’s ketamine infusion video I linked above. My intent is not to harass anyone with this post. I only want to point out misinformation and address some damaging attitudes about ketamine infusions.

The “this is just a high” comments:

youtube comments about the effectiveness of ketamine treatment for depression against suicide

I haven’t found a source for the 99% statistic, but there are many studies demonstrating the rapid improvement of suicidal thoughts in a majority of patients following a single ketamine infusion. Assuming you share the moral conviction that people deserve to live, that is a wonderful thing. So to respond with a flippant question is insensitive, and that particular question is such an oversimplification that it misses the point entirely.

To be clear: the way in which ketamine leads to improvements in mood is not simply through the perceptual experience of being high, although it’s possible that contributes to the benefits. The biochemical effects of ketamine in the brain, which happen as a consequence of the part where you’re high, can improve depression for weeks or months at a time.

The “not even once” comments:

Here, we get into just a few of the many, many comments about Kyle’s interest in experiencing a ketamine infusion again. In the brief interview immediately following his treatment, he emphatically expressed a sense of amazement and wonder. He said that he wanted to go back to “where [he] got it.” He wanted to be back “in that space.” Lots of comments labeled Kyle’s enthusiasm a “red flag” for addiction.

Youtube comment with two upvotes stating looks like dude just made himself a k addict
He literally just turned into a fiend....
text comment saying thats how you make drug addicts I suppose
text comment saying kyle is a drug user
Text comment discussing ketamine for depression

I have to wonder if those commenters are reading into Kyle’s words a little too much. I don’t know Kyle, so I can’t say whether he really is in danger of abusing ketamine, but he and Brigid were screened and each consulted their psychiatrists. It’s not something that anyone can go into lightly. I didn’t become a candidate for ketamine infusions until I had spoken to my psychiatric nurse practitioner, my therapist, and the doctor at my ketamine clinic. I explained my lengthy history with antidepressants, consistent psychotherapy, and my hospitalization for suicidal ideation. The doctor then spoke to my psych NP, I filled out a whole lot of forms and then had an initial appointment, in which I asked questions and he explained the process, its risks, and what to expect. I take a pregnancy test before every infusion, I’m still in therapy once a week, and I still take my oral medications. I couldn’t have just rocked up to the ketamine clinic and demanded they accept me as a patient. If I had indicated that I’d had a history of addiction, I’m sure the screening process would have been altered to address that.

Starting treatment with ketamine for depression was a fascinating experience for me, and it still is. I think it’s reasonable to expect a bit of wonder and excitement about the experience. Without knowing Kyle Kittleson personally, I don’t think anyone can determine whether those feelings indicate anything more than innocent fascination for him.

lilypads-on-blue-water-with-reflected-clouds

Exploring the way my mind works on ketamine is sometimes bizarre, sometimes soothing, and sometimes it gives me new ways to think about my depression. And yes, when I’m severely depressed, it’s nice to escape for 45 minutes in a dim room with a blanket and people I trust. That doesn’t mean I’m going to “chase down” ketamine and become addicted. I have absolutely no desire to seek out illegal sources of ketamine, nor would I know how.

While I’m glad that last commenter is content to live their life sober, I’m also glad that I have access to medically supervised ketamine infusions. I didn’t start ketamine infusions so that every day can be “sunshine and lollipops, cherries and all that stuff.” I did it so I could stay alive. So that I wouldn’t spend every waking moment in crushing depression anymore. Let’s not minimize the suffering that people with treatment-resistant depression endure.

A Drug By Any Other Name…Would Act the Same

There is a subset of comments that argue that using ketamine for depression is dangerous. Many of those comments revolve around the fact that it has other uses. The comments were full of references to each of ketamine’s names as a party drug. Those who disagree with ketamine treatments for depression seemed split between people who worry that patients will become addicted and people who look down on its history as a recreational drug.

(Why leave a comment if you haven’t watched the video yet??)
text comment saying how can k treat anything its crazy stuff

Ketamine was developed in the 1970s and was quickly adopted as a battlefield anesthetic. It now has uses in elective and emergency surgery and chronic care settings. And yet, the applications for ketamine that everyone seems to focus on as reason not to use it are its uses in veterinary medicine:

Text comment discussing ketamine infusion and animal tranquilizer
text comment reading ketamine is also used to euthanize animals too isn't it
A youtube comment discussing depression, ketamine, and ssri antidepressants

SSRIs are commonly prescribed for depression, and they work great for some people. This person’s claim that THE chemical cause for depression is about serotonin is not accurate. Many other neurotransmitters are involved in depression – possibly even more than we know about yet. Not to mention, the antidepressant effect of ketamine involves, among other neurotransmitters, serotonin.

Chemicals are everywhere. They are everything. The combinations and amounts of them are what make them behave differently in different environments. Ketamine is used to anesthetize animals, whether they have four legs or two. Things that can be deadly in large amounts can also be safe and therapeutic in small amounts.

The “say it with conviction and people will believe you” comments:

A youtube comment describing misinformation about the risks of ketamine for depression as including tooth loss and itchy skin

Good God, my teeth will fall out?! How horrifying and comically inaccurate. Barring accidental facial trauma due to intoxication, the only way you’ll lose teeth on ketamine is if a dentist is removing them while you’re anesthetized. Memory loss and anxiety can be associated with a ketamine high, but the half-life of ketamine is short and, as these researchers found, “ketamine-induced long-term cognitive deficits were confined almost exclusively to frequent users.” There is a big difference between using ketamine for legitimate medical purposes and abusing it.

I noticed that many of the comments expressing shock, derision, or confident predictions about Kyle’s ketamine infusion came from people who identified themselves as having experience with addiction in one way or another. I can see how learning that people are using ketamine to treat depression could be initially disturbing, especially if you have a background with addiction. What I don’t understand is that people left comments like this when the video very clearly states that there is research to back it up, people are carefully screened beforehand, and it’s administered by a licensed anesthesiologist. This isn’t the guy down the street telling vulnerable people he can cure their depression with some special k. This is science.

woman face in profile with eyes closed against dark background
@gabrielizalo on Unsplash

Understanding the Risks of Ketamine for Depression

The bottom line with many of these comments is that they argue against the use of ketamine treatment for depression because it has risks. Everything has risks. NOT using ketamine to treat depression has risks. When the alternative is death and you’ve tried the other options already, it’s ok to take a calculated risk. Ketamine may not be safe for people who are prone to addiction – it’s a very individualized decision that should be made with communication between every mental health professional who treats you.

Although a StatPearls overview of ketamine toxicity argues that, “…patients…should [be] risk-stratified similar to those under consideration for chronic opioid therapy,” we see a significant difference of opinion from practitioners and strong evidence that ketamine can be used to treat addictions of many kinds, including alcohol, cocaine, and opioid use disorders.

What About Overdose?

It’s difficult to find statistics on ketamine-related deaths, possibly because there are so few that major trend-monitoring bodies don’t seem to report them in their own category. Instead, I can only guess that, if there are any deaths at all, they might be included under broad diagnosis codes that encompass several other substances. When researchers use death certificate data, they sometimes attribute the deaths to ketamine use when, confusingly, multiple drugs were involved or physical accidents were the direct cause of death. This strikes me as extremely misleading; actual ketamine overdoses are rare.

One review, stated to be the most comprehensive review of ketamine-related deaths published to date, found that there were 283 ketamine-related deaths in England and Wales between 1997 and 2020. The majority of these deaths involved the use of other drugs. Only 32 involved just ketamine, and only 23 were attributed strictly to the drug as opposed to accidents resulting from its use.

Mysteriously, the authors go on to say, “[This review] should dispel the myth that ketamine-related deaths are rare events.” On the contrary: while tragic, 23 deaths over the course of 23 years indicates that ketamine-only-related deaths are quite rare, as are ketamine-related deaths in general.

As for the StatPearls quote about risk stratification, there were 2,263 opiate-related deaths in England and Wales in 2020 alone. In 2019, there were 49,862 fatal opiate overdoses in the US. I can’t find a single mention of ketamine-related deaths in 2019 from US statistics providers, either because the few cases are hidden among various ICD codes or because there are zero. (I have also heard the latter from experienced professionals who may have access to data that I don’t.) Regardless, the fact is that ketamine is implicated in far, far fewer deaths than opiates are. Its use in surgery can reduce postoperative opioid consumption and, as previously mentioned, it can be a valuable tool for treating addiction.

Ketamine in medical contexts is highly controlled, constantly monitored, and the patient should always be active in therapy while undergoing ketamine treatments for depression. No, this isn’t foolproof, and not every clinic provides adequate support for their patients. On the whole, though, ketamine is very safe. I hope that as ketamine becomes more widely accepted for this use, our understanding of the entire picture will improve. Discouraging all people from getting a lifesaving treatment because “drugs are bad” and, as some of these commenters want you to think, risks inevitably become reality, is a dangerous attitude to take when it comes to treating mental illness.

The “stop avoiding your problems by getting high” comments

This comment is like saying, “They have the ability to help people without TMS. It’s just zapping magnets on your head.” It dismisses a complex treatment without considering the actual mechanism by which it works.

A youtube comment saying That's what I'm thinking as well - people need to deal with their problems head on not just get high for awhile as pleasant as that sounds
text comment reading This guy just wanted to get high - what bs
A youtube comment arguing that ketamine infusions are a temporary escape no different than a street drug user
text comment reading Just drink a bottle of nyquil and lie on the couch - same thing
text comment reading This is just taking drugs man - but somehow legal

I’ll speak for myself when I say that all of these commenters seem to think that by being in therapy once a week for several years straight, revealing extremely painful, personal details about myself, digging into my thought patterns and history and beliefs, spending time in a psychiatric hospital, patiently titrating up and down on numerous medications, and working every day to improve my treatment-resistant depression through behavioral change, I’m simply avoiding my problems now by getting high on ketamine.

It’s also important to note that some of these types of comments are problematic in more than one way. People getting ketamine treatment for depression shouldn’t be shamed, and neither should people suffering from addiction. The stigma of having ketamine treatments relies in part on the stigma of drug abuse and addiction, and ultimately, I think it creates more division and fewer solutions.

A reputable clinic will not allow you to start ketamine infusions for depression unless you’ve demonstrated a clear need for it. It’s a tool like any other. It does help people “get to the root of it” and ketamine patients often use their experience to change their mindsets and heal from trauma.

I agree with the overarching message of this comment. It is hard work to treat depression, and it does take more than one strategy. However, I dislike the implication that people who turn to ketamine for depression are trying to avoid doing that work. Ketamine infusions should not be used in isolation. In my experience, it’s less like a band aid on a cyst and more like a life raft on the ocean. I still have to deal with the waves, but at least I’m floating.

(Band-Aid on a Cyst is going to be my new punk rock band name. I called it first.)

Ketamine for Depression Saves Lives

Ultimately, I’m disappointed but not surprised that so many people left ignorance, insensitivity, and moral judgments in the comments of the MedCircle ketamine video. Kyle took a chance and shared something he likely knew would be controversial. I don’t want to gloss over the fact that there were lots of comments supporting him and Brigid, as well as ones expressing excitement and interest in this emerging treatment. I loved seeing other people refuting misinformation and sharing their own stories of healing with ketamine for depression. There was a significant portion of the comments section that was bursting with positivity.

text comment reading Yes-thanks for doing this-ketamine completely changed my life-thanks kyle
Youtube comment reading-gave me my life back-didn't realize I had lost the joy of life-saved a friend from committing suicide-love yourself enough and just do it
(I’m not encouraging anyone to do it without careful consideration. Just a positive comment I liked.)
text comment reading-k infusions saved my life-simple as that
text comment written by a ketamine infusion patient describing the positive outcome they had from ketamine

And those were just a few. ❤

More Research is Always Needed

It’s absolutely true that more research is needed on the long-term effects of ketamine treatments for depression, chronic pain, and PTSD. Ketamine has been in use for over 50 years, but we still need to understand more about its effects in order to more accurately predict its efficacy in each patient and its risk of addiction when used for depression in this way. I just wish that we could all respect each others’ mental healthcare decisions and keep an open mind about a promising treatment.

Shaming People Who are Desperate for Help is Counterproductive

The comments I’ve highlighted here may come from people who have experience with addiction and a strong bias against the use of ketamine. They have a right to their opinions, and I hear their concern. Ketamine is a schedule-III drug that should continue to be handled carefully in medical settings. When people come to a judgment about something without being informed and then leave comments intended to divide through fearmongering, insulting assumptions, and straight-up incorrect information, it moves all of us back in the fight against mental illness stigma.

scrabble tiles reading Mental Health with sprig of greenery on side

I struggled immensely with the idea of treating my depression with ketamine. The unknowns of what it would feel like scared the pants off me and I was completely intimidated by the social implications of using a mind-altering substance for any reason. If I had read these comments when I was in the process of deciding to try ketamine infusions, I might have been ashamed enough to reconsider. That might have been catastrophic for me. I was recently past my hospitalization and subsequent partial hospitalization and I had been thinking about suicide every single day for years. Ketamine became my life raft, and I’m so thankful that I have the privilege to access it.

If you’d like to read more about my experience with ketamine for depression, start from the beginning of The Ketamine Chronicles or visit the archives. Click here for mobile-optimized archives of The Ketamine Chronicles.

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A man wearing a red jacket walking away doing a rural road on a foggy day

Depression in Men: Why is it Different?

Social, Psychological, and Diagnostic Aspects of Depression in Men

Four times more men die by suicide than women, and yet half as many men are diagnosed with depression as are women (1). In researching this topic, I was encouraged by the shift our society is making towards understanding depression in men and the factors that push them to such lengths. However, there is clearly still a long way to go. A book I skimmed early on in my search, aptly titled Men and Depression, by Sam Cochrin and Frederic Rabinowitz, mentions in the introduction that “A book that examines distress and depression in men may be seen by some as politically provocative.” In 2000, when that book was published, many researchers and clinicians were working to move public perception of mental disorders in men inch by inch. They recognized that the disparity between the number of men diagnosed with depression and the number of men who kill themselves indicates a hidden population of men who battle their depression in secret. 21 years later, the number of articles under a “depression in men” search in Google Scholar numbers over 3.5 million.

As a woman who suffers from depression, I feel relatively safe in disclosing my diagnosis. People are generally sympathetic and understanding when I discuss my symptoms. But how do men feel about the way their depression is received? A man I know has been dealing with depression for a long time, so I asked him exactly that question. Thankfully, he told me that his social circles have been largely supportive, which I think is an encouraging sign for our culture’s direction. But what factors make the rates of suicide between men and women so different? If we’ve come from “politically provocative” to millions of research articles in two decades, why are many men still suffering in silence? I want to dig into this issue to understand the historical trends, what sometimes makes depression in men different, and what we can do to keep the conversation going.

Historical Epidemiology of Suicide

In a really deep dive, we could go way back to Hippocrates and Galen to explore the perceived gender divide on mental disorders, which would be interesting. But in this context, we’ll stick to the 20th and 21st centuries. Let’s take a look at this set of data from the CDC’s Data Finder (12). It’s compiled mostly by decade between 1950 and 2015. This graph of the data, which I made with my rusty skills in Excel, illustrates the suicide trends by rate among men in various age groups.

A graph showing the suicide rates of men of different age groups by decade

Although the rate of suicide among all ages has remained relatively stable, trends within age groups are concerning. Suicides among 15-24 year-olds have increased dramatically, as have those among 25-44 year-olds. Despite a somewhat steady decline in the suicide rate of men aged 65 and older, they remain the group with the highest rate. By 2019, the rate of suicide in men had increased from 21.1 deaths per 100,000 to 23 deaths per 100,000 (13). For every 100,000 men, 23 deaths doesn’t immediately sound shocking. But to illustrate the numbers in a different way, consider that in 2019, a horrifying total of 37,256 men killed themselves in the U.S.

It introduces another layer of complexity to compare the data on men to the data on women. The suicide rate among women of all ages has increased since the 50’s more than it has among men, but it still sits markedly lower. In 2019, the overall suicide rate among women was 6.2 deaths per 100,000 people (13). Compared to 37,256 male suicides, the country saw 10,255 female suicides. Both of those numbers are unimaginable to me, but it’s worth investigating; why is the rate for men so much higher than it is for women?

older-man-with-white-hair-sitting-on-park-bench-with-back-toward-camera-and-yellow-garment-folded-on-bench-beside-him-and-blue-car-parked-ahead
Photo by Mykyta Martynenko on Unsplash

Diagnostic Factors

The wildly higher rate of suicides among men than in women, combined with the average 2:1 ratio of depression diagnoses in women versus men, convincingly suggests that depression in men is going undiagnosed. An increasingly accepted hypothesis regarding this conclusion is that depression in men and women can be experienced in different ways (10). The current diagnostic tools don’t capture all of the symptoms of depression that men commonly face. The gender differences in symptomatology have led some to argue for the recognition of separate depression diagnoses for men and women. Magovcevic and Addis conceptualized the differences as constituting typical depression plus a subtype, masculine depression (6). Subsequent research shows that some men who don’t fully fit the diagnostic criteria on traditional depression questionnaires may be diagnosed when masculine depression symptoms are considered.

Masculine Depression Symptoms

“Masculine depression” (also called male depression and a variety of other terms), is characterized by more symptoms of anger, aggression, risk taking, and substance abuse than tend to occur in women. These symptoms are examples of “externalizing features.” They serve to express a person’s emotions in an outward, active way. “Internalizing features” of depression are identified by retreating into one’s self, such as by ruminating, engaging in negative self-talk, and isolating from others.

New Self-Report Scales

To investigate the efficacy of adjusted self-report scales at identifying depression in men, researchers created the Gender Inclusive Depression Scale (GIDS) using two other male depression scales validated with small cohorts. When symptoms of masculine depression – the externalizing features – are included in a traditional diagnostic survey, the rates of depression diagnoses among men and women are not significantly different (7). In other words, the gender differences disappear. Another scale, the Male Depression Risk Scale (8), measures emotion suppression, drug use, alcohol use, anger and aggression, somatic symptoms, and risk-taking. The sensitivity of the MDRS is similar to that of the PHQ-9 in recent suicide attempt identification (9).

Why is Depression in Men Sometimes Different?

To be clear, it’s a continuum; many men are diagnosed with depression using traditional questionnaires. But for the ones who aren’t, the answer is probably based in gender norms. Men who have depression and who identify with traditional ideals of masculinity are more likely to experience masculine depression symptoms (4). In a society that has traditionally viewed men who express sadness as “weak” or “feminine,” it makes sense that sometimes, depression in men is displayed as anger or in attempts to cope with it through substances. Sadly, it’s more socially acceptable for men to express anger than sadness, self-doubt, or anxiety.

A young man wearing a black shirt standing in profile outside against an unfocused, bright background
Photo by Andre Hunter on Unsplash

Why is the Suicide Rate Among Men so Much Higher?

If newer diagnostic scales indicate that the rates of depression in men and women are actually more alike than previously thought, what is going on with the suicide rates? Why would men die by suicide four times more often than women? It’s hard to know how many suicides could have been prevented by mental health intervention, but it’s logical to think that men who aren’t seeking counseling or who are dismissed without a diagnosis would be more likely to turn to suicide as the answer. Additionally, we know that although men complete suicide more often than women, women attempt it more often (11). Men tend to use more lethal methods, and for some men, the act of suicide represents an affirmation of strength and independence (2). It is crucial that we improve identification and treatment of depression in men (5).

A Note on “Masculine” and “Feminine”

With all of this discussion about a “masculine” depression facet, I have a small fear that readers of this post will leave feeling as though their diagnosis of depression must have been of the feminine kind. It’s not. It’s just depression – men, women, nonbinary people – it doesn’t impose judgment on your identity, it simply is. Just as men may experience more anger and impulsivity as part of their depression, women may be more likely to suffer body image issues and self-harm behaviors. But it’s a bell curve; just because men are more likely than women to exhibit anger as a sign of depression doesn’t mean that women can’t as well. Statistically, neither gender is more closely associated than the other is with the typical symptoms (8). The only gendered difference exists in the subset of “masculine” symptoms. The core set of symptoms that are covered in typical scales like the PHQ-9 remain the main diagnostic components of what we know depression to be. Expanding the criteria by creating a subset of symptoms more associated with men is just a way of widening the net in order to keep people from falling through the cracks.

For more reading on how men can view depression, suicide, and masculinity, check out this article. The author provides evidence for a variety of views that men hold about how mental health and suicide relate to masculinity.

Identifying Depression in Men Going Forward

For a long time, our definition of depression was too narrow. The research on gender differences in depression, which I have only barely scratched the surface of, is vast and still growing. Although the standard depression questionnaires remain focused on internalizing features to the exclusion of the externalizing ones, authorities on the matter have acknowledged the issue in other ways. The American Psychiatric Association has a webpage from 2005 that describes the early research and what to watch out for in men who may have depression. They now have a number of web pages, magazine articles, fact sheets, and books about men and depression. Someday, I hope that standard depression questionnaires will include measures for symptoms that men exhibit, but until then, we can continue to reduce stigma and spread the word about how depression in men can manifest.

two-drawing-mannequins-embracing-in-black-and-white-as-depression-in-men-concept
Photo by Marco Bianchetti on Unsplash

You can pass online resources on to the men you know. You can talk about it with your doctor. You can listen to your friends, fathers, brothers, and sons. Assure them that having feelings doesn’t make them less of a man, it just makes them human.

Resources

  • National Suicide Prevention Lifeline: 1-800-273-TALK (1-800-273-8255)
  • Advice on looking out for friends: beyondblue.org
  • Potential symptoms and tips for self-care: texashealth.org
  • Information, resources, and community: headsupguys.org

Citations

  1. “By the Numbers: Men and Depression,” December 2015. https://www.apa.org/monitor/2015/12/numbers.
  2. Canetto, Sylvia Sara, and Anne Cleary. “Men, Masculinities and Suicidal Behaviour.” Social Science & Medicine 74, no. 4 (February 2012): 461–65.
  3. Cochran, Sam, V, and Frederic Rabinowitz E. Men and Depression: Clinical and Empirical Perspectives. Academic Press, 2000.
  4. Genuchi, Matthew. “Anger and Hostility as Primary Externalizing Features of Depression in College Men.” Psychological Sciences Faculty Publications and Presentations, August 1, 2015. https://scholarworks.boisestate.edu/cgi/viewcontent.cgi?article=1223&context=psych_facpubs.
  5. Keohane, Aisling, and Noel Richardson. “Negotiating Gender Norms to Support Men in Psychological Distress.” American Journal of Men’s Health, October 11, 2017. https://pubmed.ncbi.nlm.nih.gov/29019282/.
  6. Magovcevic, Mariola, and Michael Addis. “The Masculine Depression Scale: Development and Psychometric Evaluation.” APA PsycNet, 2008. https://psycnet.apa.org/record/2008-09203-001.
  7. Martin, Lisa, A, Harold Neighbors W, and Derek Griffith M. “The Experience of Symptoms of Depression in Men vs Women: Analysis of the National Comorbidity Survey Replication.” JAMA Psychiatry, October 2013. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1733742.
  8. Rice, Simon, M, and Anne-Maria Moller-Leimkuhler. “Development and Preliminary Validation of the Male Depression Risk Scale: Furthering the Assessment of Depression in Men” 151, no. 3 (December 2013): 950–58.
  9. Rice, Simon, M, John Ogrodniczuk S, David Kealy, and Zac Seidler E. “Validity of the Male Depression Risk Scale in a Representative Canadian Sample: Sensitivity and Specificity in Identifying Men with Recent Suicide Attempt.” Journal of Mental Health, November 2017, 132–40.
  10. Rutz, Wolfgang, Jan Walinder, and Lars Von Knorring. “Prevention of Depression and Suicide by Education and Medication: Impact on Male Suicidality.” International Journal of Psychiatry in Clinical Practice, January 8, 1997. https://www.tandfonline.com/doi/abs/10.3109/13651509709069204.
  11. Schumacher, Helene. “Why More Men than Women Die by Suicide.” BBC Future (blog), March 17, 2019. https://www.bbc.com/future/article/20190313-why-more-men-kill-themselves-than-women.
  12. “Table 30. Death Rates for Suicide, by Sex, Race, Hispanic Origin, and Age: United States, Selected Years 1950-2015.” CDC, 2017. https://www.cdc.gov/nchs/data/hus/2017/030.pdf.
  13. “Underlying Cause of Death, 1999-2019 Request.” Data Table. CDC WONDER. Accessed January 17, 2021. https://wonder.cdc.gov/controller/datarequest/D76.
nighttime time lapse of mountain road curving and car lights driving around pine tree

Sensory Processing Disorder and Driving

Ah, driving. The ultimate achievement of teenage freedom (in the US, at least). For anyone learning to drive, teenage or adult, the convenience and independence of a license is powerful motivation. I’ve been driving for years, now, but it wasn’t an easy process to get my license. At the time, I wasn’t as cognizant of my symptoms, but looking back, I can see why I struggled so much with having Sensory Processing Disorder and driving.

Proprioception in Cars

Sensory Processing Disorder (SPD) makes it hard for me to interpret sensory stimuli, including proprioceptive information. Proprioception is the sense that tells you where your body is located in space. I struggle with motion sickness on buses, boats, even escalators, because the movement doesn’t match my brain’s sense of where my body should be. Initially, this made driving a car incredibly stressful; relative to your body, the car is not moving, but relative to the ground, it’s moving a LOT. Coordinating the movements of driving with the interpretation of how the car responds took a while to become natural. Once it did, though, it made my motion sickness in cars much better, as long as I’m the one driving.

Peripersonal Space

When you’re driving a car, your “body” sense expands to include the dimensions of the vehicle. This is called “peripersonal space”- the sense that expands and contracts to include the objects in our immediate surroundings. In The Body Has a Mind of its Own, authors Sandra and Matthew Blakesley explain,

“When you drive a car, your peripersonal space expands to include it, from fender to fender, from fender to door, and from tire to roof. As you enter a parking garage with a low ceiling, you can “feel” the nearness of your car’s roof to the height barrier as if it were your own scalp. This is why you instinctively duck when you pass under the barrier.”

Learning how to manage Sensory Processing Disorder and driving took me a while, in part because it was a challenge for me to get a sense of the dimensions of a car. Now that my brain has established it as effectively a part of my body, driving with SPD is much simpler. However, there are additional layers of difficulty that, no matter how much I learn, might always be challenging.

car side mirror with city and other cars in reflection
Photo by Onaivi Dania on Unsplash

Visual Challenges

The visual tasks involved in driving can quickly become overwhelming. Monitoring the movement of cars around you, watching for signals, brake lights, and obstacles in the road is already a lot to handle. Add to that the stress of driving in an unfamiliar area and attempting to read street signs and highway exit signs while managing the rest of your visual tasks, and you have a veritable mountain of sensory stimuli to deal with.

Driving with Dyspraxia

I think that the processing power I dedicate to handling visual stimuli while driving leaves little for planning complex movements, known as praxis. I have symptoms of dyspraxia, meaning I have trouble following sequences of actions and, even more so, planning the steps involved in getting from A to B by myself. If I can prepare ahead of time, I’m fine, but I really struggle to make decisions in the moment because I feel like I can’t process all of the information fast enough to take the right action.

Driving with dyspraxia makes me an anxious planner. If I’m going somewhere new, I study Google Maps obsessively, considering the factors I do or don’t like in each route. Is there a highway involved? Can I take a route with fewer lanes? If I miss a turn, how easy would it be to fix? How early should I leave to account for any mistakes? As I’ve become more comfortable with the other aspects of driving- the sensitivity of the pedals and the steering wheel, the dimensions of the car, predicting what other drivers are going to do- I can dedicate more mental energy to handling praxis. I still plan my routes in new places, but I’m more confident in my ability to get back on track if I get lost.

Sensory Processing Disorder and Driving Takes Practice, Practice, Practice

If you’re struggling with Sensory Processing Disorder and driving, an occupational therapist can help you identify your particular difficulties and come up with ways to make them easier. Whether you work with an occupational therapist or not, the best way to get comfortable with driving is to practice. When you have sensory overstimulation in the car, the last thing you feel like doing is getting back in the driver’s seat, I know. Trust me, I rolled my eyes so hard at everyone who told me that practicing would make it feel more natural; I felt like I just wasn’t made for driving and no amount of practice would change that. I admit- I was wrong. Practice does help, and I find that now that I’m adept at each aspect of driving and can better regulate my nervous system, my sensitivities probably make me a more mindful, safer driver than I would be otherwise.

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A young woman wearing a white sweater sitting on a medical exam table.

How Depression Affects Immune System Function

Did you know that immune changes are associated with Major Depressive Disorder? Let’s dive into what scientific research says about how depression affects immune system function.

Lately, I’ve been fascinated by the research on depression and immune system function. Perhaps you’re more in-the-know about this topic than I am and this doesn’t surprise you, but I was shocked to learn that not only do there appear to be measurable changes to the immune system with Major Depressive Disorder, but there are also numerous studies on it dating back decades. This isn’t a fringe area of research! Let’s take a look at how depression affects immune system function and what it means for people with depression.

The Evidence: T Cells and Depression

flow-chart-of-types-of-leukocytes
Photo from bodytomy.com

T cells are a kind of lymphocyte, which are themselves a type of leukocyte, or white blood cell. Lymphocytes are involved in what’s called adaptive immunity; they use molecules on other cells – the body’s and invading pathogens – to recognize foreign material and defend against it. Kinds of lymphocytes include T cells, B cells, and Natural Killer cells. Different types of T cells perform different roles, such as “helper” cells (Th- cells), “regulatory” cells (Treg cells), and cytotoxic cells. CD4 and CD8 (which refer to markers on the cell surface) are the two main categories of T cells. CD4 T cells are mainly helper cells, and CD8 T cells are mainly cytotoxic, meaning they mount direct attacks against invaders.

Both main types of T cells, CD4 and CD8, have other molecules attached to their surfaces. Some are receptors that grant the cell access to infections; two such receptors are known as CXCR3 and CCR6. Antidepressant-free patients with MDD have been shown to have significantly lower expression of both receptors on both types of T cells. The same study also found a significant trend in MDD towards fewer Natural Killer cells, a finding that was corroborated in another study.

Research has shown that T cells have a neuroprotective quality. T cells migrating to the brain can reduce stress, promote neurogenesis (growth and development of nervous tissue), and reduce inflammation. Study after study have found inflammation, changes in immune cell composition, receptor alterations, and gene expression changes associated with Major Depressive Disorder.

Causes and Effects of MDD Immune Changes

All of these changes are fascinating in themselves, but are they the results of depression, causes of it, or some intermediary factor?

The Sickness Behavior Hypothesis

Some researchers view depression as a maladaptive result of what’s called “sickness behavior”. Sickness behavior is a vertebrate trait that, through behaviors like somnolence, anhedonia (loss of interest or pleasure), and reduced or no eating, conserve energy that can be directed towards fighting infection. Researchers have presented evidence that both sickness behavior and depression are mediated by pro-inflammatory cytokines– proteins that act in cell signaling roles. These two observations- depression and sickness behavior share symptoms as well as mediators- led to the following hypothesis. Depression is the alternate, maladaptive pathway of molecular processes that, on the other pathway, lead to sickness behavior. Under this hypothesis, the depression pathway leads to neurodegenerative changes that make repeated episodes more likely. Adding that to other research that shows a link between sickness behavior and major depression, and a fascinating picture emerges.

Sickness behavior and major depression do look remarkably alike in their symptoms, and we do know that major depression is often a lifelong illness.

Approximately 60% of people with MDD who experience a single depressive episode go on to have a second episode, and about 70% are likely to experience a third episode. Similarly, having had three episodes increases the chances to about 90% that a fourth episode will occur.

Functional Consequences

Biochemically, these changes are significant. Functionally, do they affect the people who have them? The answer may be yes. One study found a 59% increase in the risk of infection following one depressive episode. The increases weren’t linear, but the risk did go up again after the fourth episode. In addition, among college students, poor mental health is correlated with acute infectious illness.

Fortunately, treatment with antidepressants, if effective for depression, also returns T cell subsets to normal ratios. Differences in the subset ratios between those who responded to treatment and those who didn’t may help determine the chances of efficacy for a particular patient with antidepressant treatment.

An open book with unlined paper and the words "thought catalogue" written in block letters at the top. Two black markers are resting on the page.

What are Automatic Thoughts?

We all have those sneaky thoughts that come unbidden when we make a mistake or are faced with a change. I don’t know a single person who hasn’t mentally beat themselves up over a perceived shortcoming. Often, it isn’t deserved. But when your automatic thoughts are that you deserve those thoughts, what do you do?

Types of Automatic Thoughts

First, some background. The Handbook of Social Psychology describes four types of automatic cognitive processes:

“Automaticity is granted if the perceiver lacks awareness of the process, does it with efficiency (i.e., with minimal use of cognitive resources), has no intention to do it, or cannot control it.”

Based on this definition, automatic thoughts include those about others, such as deeply held prejudices. It also includes the intrusive thoughts that characterize Obsessive Compulsive Disorder, but I’ll be focusing more on those automatic thoughts that don’t necessarily play a direct role in psychopathology. For example, self-referential thoughts like, “I’m going to fail this exam. I always fail.” Those are the types of thoughts I’m talking about here.

Negative Automatic Thoughts

The most well-known measure in this area is the Automatic Thoughts Questionnaire (ATQ), a 30-item instrument developed in 1980. The ATQ contains statements like “I am a failure,” and asks participants to rate each statement on a scale representing the frequency with which they experience that thought. It’s a cross-validated questionnaire that’s been shown in several studies to correlate with depression and separate depressed from non-depressed individuals.

When presented with a distressing stimulus, previously depressed participants and people who have never been depressed experienced stronger belief in negative automatic thoughts. The researchers propose that cognitive reactivity is related to relapse and recurrence of depression.

Cognitive reactivity refers to the triggering of negative thought patterns by small declines in mood. The ability to resist slipping into negative cognitions seems to have a protective effect; inpatient surveys taken at two time points show that decreases in negative automatic thoughts are strongly correlated with reduced suicidal ideation.

Positive Automatic Thoughts

The relationship between negative automatic thoughts and depression and anxiety is well documented. We can infer that the lack of negative automatic thoughts has beneficial effects on mental health, but this still isn’t quite the same as the presence of positive automatic thoughts. However, research does support the assumption that positive thinking is related to positive mood. A variation of the ATQ was developed to measure positive automatic thoughts. It’s called the ATQ-P, and higher scores on it are strongly associated with lower levels of depression. A healthy balance of positive and negative thoughts appears to be weighted toward more positive than negative- a ratio of 0.62 to 0.38, to be exact (according to one study).

Where Exactly Do Automatic Thoughts Come From?

Parahippocampal gyrus

One area of the brain that is linked to automatic thoughts is the parahippocampal gyrus, a part of the limbic system.

limbic system

Let’s look at a study that investigated the relationship between depression and brain tissue volume in the limbic system. The results can be summarized as follows:

“The voxel-based morphometry results showed that the GMV of the right parahippocampal gyrus and fusiform gyrus and the WMV of the right superior temporal pole increased with the severity of depression.”

Let’s break that down. A voxel is a value assigned to a three-dimensional grid. Think “pixel” but with volume. Voxel-based morphometry is a technique for assessing differences in brain volume. Brain scans are registered to a standard, voxel-based template, then each voxel is “smoothed” by averaging it with the values of the surrounding voxels. Finally, the image volume of each scan is compared to the other scans’ volumes and the differences between voxels are evaluated statistically. Basically, it’s a way to quickly compare lots of structural brain scans using computers.

The study found that increases in the volume of grey and white matter in certain regions of the limbic system are associated with increasing severity of depression, as measured with the ATQ. So, negative automatic thoughts are associated with depression, and depression is associated with higher volume in the emotional center of the brain. That doesn’t necessarily mean that negative automatic thoughts are directly related to grey and white matter volume. Or does it?

Statistical tests showed that the combination of automatic thoughts and grey matter volume in the parahippocampal gyrus predicted depression measured by the ATQ and the Self-Rating Depression Scale. The automatic thoughts mediate the relationship between volume and depression. They also seem to mediate the relationship between neuroticism and depression.

Medial Prefrontal Cortex

The medial prefrontal cortex is not part of the limbic system. It’s located at the very front of your brain and is associated with the processing of social information. Hyperactivity in this region has been linked to neuroticism and self-generated thought. The tendency to worry and impose self-generated beliefs onto a reality that doesn’t match those beliefs sounds a lot like the automatic thoughts in the studies above. But it’s not all bad; the same hyperactivity and self-generated thoughts are also associated with creativity.

Combatting Negative Automatic Thoughts

Hopefully, you haven’t read all of that and decided that the next time someone tells you to be more positive you’ll just say “the grey matter in my parahippocampal gyrus says, ‘No can do.'”

Two men facing each other while seated at a table in a sunny lobby having a discussion.
Photo by @linkedinsalesnavigator on Unsplash

Cognitive behavioral therapy has been shown to result in reductions of automatic thoughts and dysfunctional attitudes associated with non-clinical depression. CBT makes use of behavioral experiments and automatic thought records. People perceive behavioral experiments to be more powerful than combatting automatic thoughts with logic alone, which could be because behavioral experiments function through emotion-based cognitive systems. Mindfulness has also been shown to reduce automatic thoughts, and it’s associated with increased life satisfaction.

There are plenty of reasons to believe that we have the power to effect change in our own brains.

What helps you recognize negative automatic thoughts, and how do you practice self-compassion?

How Does Nature Affect Mental Health?

I’m hoping to make this the first post in a series called “Science Saturdays” (now taking suggestions for a more creative name) where I dive into the research at the intersection of mental health and (fill in the blank). I dipped my toes into these waters with previous posts like “Pets and Mental Health“, “Can You ‘Grow Out Of’ Childhood OCD?“, and “What’s the Deal with MTHFR and Psychiatric Conditions?” My intention is to take an objective look at recent research, let it percolate through my noggin while I sift through the dozens of tabs I’ve amassed in Google Scholar, then report back with what I think are some important takeaways.


embroidery-of-wooden-fence-and-red-poppies

Here in the northern hemisphere, we’re perched on the cusp of spring, and boy, am I ready to get outside. I live in Colorado, and hiking is one of, if not the most, enjoyable ways I spend my time in the warmer months. I’ve been gazing longingly at the mountains, perusing dog backpacks (that’s backpacks for dogs to wear) on Amazon, and figuratively dusting off my trail map app in anticipation. It could just be that I’m particularly drawn to being outside because of my personality and upbringing, but I’ve recently come across some buzz surrounding the positive effects that nature has on our emotional and physical health. So, I figured, what better way to become even more entrenched in spring fever than to spend a few hours reading about the outdoors?

Nature and Physical Health Studies

Nearly every article I’ve read so far has referenced a study published in 1984 by RS Ulrich. The study looked at a group of 46 hospital patients, all of whom had their gallbladders removed and were monitored postoperatively. 23 patients stayed in rooms with views of trees, while the other 23 had views of a brick wall. The now classic study found that the patients who had views of trees recovered faster and required less pain medication than the other group of patients.

From what I can tell, the Ulrich study seems to have sparked an interest in, and an understanding of, how nature might benefit us. Countless subsequent studies have been conducted that suggest that exposure to nature reduces blood pressure and increases positive affect, promotes healthy composition of microbiota involved in immune functioning, and lowers mortality from circulatory disease. In terms of emotional health, nature is associated with reduced stress and decreased activation in an area of the prefrontal cortex associated with rumination and mental illness. Higher vegetation cover is associated with a lower prevalence of depression and anxiety. Even potted plants have been found to increase the quality of life for employees in office settings.

What’s in a Dose of Nature?

Nature has the power to make us feel better, but what is it about being outside that has this effect?

Species Richness and Biodiversity

“Nature is not biodiversity, nor a proxy for biodiversity, but certainly encompasses biodiversity.”

Sandifer et al., 2015

Increasingly, researchers are investigating the relationship between biodiversity in green spaces and psychological benefits. Several nature and mental health studies have found significant associations between higher plant and bird diversity and positive mental effects. A 2007 study by Fuller et al. found a positive correlation between plant species richness and participants’ sense of identity and ability to reflect. The 312 participants were fairly accurate at assessing plant species richness, which muddies causality. The question then becomes: are the benefits derived from species richness or perceived species richness?

colored-pencil-drawing-of-western-meadowlark-perched-on-branch

Here’s another study to elaborate on that distinction. Researchers here found that psychological benefits of nature exposure were correlated not with biodiversity, but with participants’ perception of biodiversity only. In this study, participants were apparently not at all good at estimating species richness, and it affected their experience of being outside, regardless of how many species were actually present.

Frequency and Duration of Nature Exposure

So it seems that the more varied and species-rich the environment, the better. But is glancing out a window now and then the same as going for a walk outside, psychologically? I’d say no, but that doesn’t mean that short exposures to nature don’t benefit us. After all, just a 40-second break to look at a green, plant-filled roof has been shown to improve attention and performance on cognitive tasks, as compared to a break of the same length with views of concrete roofs.

In a sample of over 1500 Australian respondents, longer duration of nature excursions is associated with decreased prevalence of depression and high blood pressure. More frequent visits to public green spaces are associated with a greater sense of social cohesion, which I imagine contributes positively to mental health in general.

Criticisms of Nature and Mental Health Research

Few studies on the topic of nature and mental health take an epidemiological approach, leading some to point out that we have very little data on long-term, population-level health effects of nature exposure. Criticisms of some studies also include sample size, lack of adequate controls, and statistical rigor. However, the number of studies that demonstrate a correlation between nature and mental health benefit vastly outweigh the number of studies that show no relationship. While this does not negate the weaknesses mentioned previously, it does seem to suggest that there is validity to the idea that nature is emotionally beneficial.

The Daffodils are Blooming

All the signs that winter is ending are here; the daffodils are blooming, more birds are singing, the neighbors are cleaning out their garage, and before spring really gets underway, Colorado is scheduled to get one or two more last-minute dumps of snow.

Speaking of, now that I’ve gotten myself extra excited to get outside and let my brain soak in the wonderful sights, sounds, and smells of spring, it’s time to prepare myself for tonight’s snowstorm.

Dear Spring, please hurry.

scale-from-more-bad-to-less-bad-ranking-depression-as-potatoes

The Potato Scale of Depression

I’m prone to an almost crippling inability to verbalize my feelings. Some of that is because of Sensory Processing Disorder, and some is probably due to depression and other factors, like my need to feel capable and independent, which results in me pretending I have no feelings whatsoever and consequently getting no practice in identifying them, but the point is: metaphors. I love ’em.

For inexplicable reasons, I find it so much easier to say “everything is mashed potatoes” than to say “I’m lost in a miserable fog of  depression.” (Actually, come to think of it, that second one is also a metaphor, but you get the idea.) Hence: The Potato Scale of Depression.

It’s Not a Good Scale (but it kind of is)

Roughly ten months ago, I really did tell my friends “everything is mashed potatoes,” and thus, The Scale was born. Unlike other scales, there are no numbers, no frowny faces, and no defined increments between items. In other words, it’s a terrible scale. There’s no way to objectively determine how someone is feeling based on the potato scale of depression, but it worked for me during a time when talking about my feelings was both very difficult and very important. It became a kind of inside joke, and my friends would ask me “how are the taters?” and I’d respond with some arbitrary, starchy answer:

“Tots,” or “potato pancakes,” or “undercooked hash browns,” or “just the eyes.”

They’re all utterly meaningless answers, but they started a conversation. We’d debate the relative positive and negative qualities of each dish, and it served (pun intended) to connect us when all I wanted to do was withdraw.

Laughter = The Okayest Medicine

Eventually, I became more comfortable with talking about my emotions. A silly scale opened the door (metaphors are everywhere) to talking about how I really feel. Sometimes using humor to defuse stressful situations and topics gets a bad rap, but it’s incredibly common. Plus, research shows that the right kind of humor can have a protective effect against recurring depression. The adaptive forms of humor (self-enhancing and affiliative) are associated with emotion regulation and positive mental health. The maladaptive forms of humor are the aggressive and self-defeating types. I could probably dedicate an entire post to why I think suicide jokes aren’t funny or healthy, but this is a post about a nonsensical tuber scale. So- perhaps another time. Back to the adaptive humor:

In consequence, an individual can successfully distance himself/herself from a negative situation and appraise its meaning from a less distressing point of view.

When you mentally distance yourself from a negative situation, you’re creating what researchers call “metacognitive awareness,” where thoughts and behaviors are interpreted as “mental events, rather than as the self.” Mental illnesses can often be associated with feelings of guilt and inadequacy, which is why it’s important to take a step back and remember that your symptoms are not character flaws. This has become a regular mantra for me, and anytime I start thinking badly of myself for my symptoms, I turn it around with I’m not lazy, I’m just soggy hashbrowns right now. Y’know, the kind that maybe didn’t get cooked enough, so now they’re getting cold and seeping oil onto your toast. Depending on your humor preferences, this might border on maladaptive, but it reminds me to not get bogged down in a temporary feeling or judgment. And really, what potato dish isn’t still delicious, no matter how poorly cooked?

Depression Scales: PHQ9, Who?

The Potato Scale of Depression is obviously not a tool that will ever be used in any kind of professional setting, but that doesn’t mean that it can’t be beneficial. Maybe potatoes aren’t your thing, and some other metaphor would be more helpful. Whatever it is, I know that for me, finding a less clinical way to communicate how I feel has made it way easier to do so.

May you all have curly fries and solid taters for the foreseeable future.

2021 Update: My therapist and I now have a wide repertoire of replacement metaphors, including “clams” in place of “goals” and “feathers” in place of “small barriers between inaction and action.” The Potato Scale of Depression has fallen to the wayside, likely because I have gotten better at saying words about how I feel. Therapy works!