I regret that I am not in a position to offer professional advice to readers of The Inflamed Mind concerning their personal experiences of mental or physical health disorders. Therefore, I will not be able to provide individual responses to questions about the healthcare issues experienced by readers or their relatives or friends. I apologise in advance if this may seem unhelpful to people who may be seriously in need of help; but my remit as a clinical psychiatrist is strictly limited to the work I do for Cambridgeshire & Peterborough NHS Foundation Trust.

 

However, I hope that it may be useful to offer my opinion in response to some frequently asked questions about the personal implications of the book’s focus on depression and inflammation. 

 

Ed Bullmore

22 April 2018

What can I do if I am experiencing symptoms of depression which I think might be linked to an inflammatory disorder of my body?

Many people experience psychological symptoms like fatigue, and loss of pleasure in life, as part and parcel of their experience of living with one of many long term medical conditions, like rheumatoid arthritis or Crohn’s disease, which are associated with high-grade bodily inflammation.  So, if that’s your experience, perhaps the first thing to do is to recognise that you are not alone: depressive symptoms are common among people living with chronic inflammatory disorders.

 

The next thing to do is to speak up about your mental and physical health symptoms as if they were equally important. There is no reason not to bring mental symptoms to the attention of your physician or GP. And don't feel ashamed to ask for a referral to a psychiatrist or clinical psychologist for a more specialist assessment of mental health issues related to your physical health. For many major disorders there are well-organised advocacy and information organizations, which can be an excellent source of more detailed guidance about so-called comorbidity or multi-morbidity – the association of physical and mental health disorders. 

 

If you are depressed, and you think it might be related to obesity or stress or any of the other factors that can cause low-grade bodily inflammation, and you consult your GP or psychiatrist on this basis, please don’t be surprised if it doesn't make much difference to the treatments on offer to you (at least in the British NHS in 2018). As recounted in the book, there are very few blood tests or biomarkers that a GP or psychiatrist could use to assess your level of bodily inflammation. None of the available biomarkers, like CRP, is very informative about the precise cause of low-grade inflammation. And even if your GP or psychiatrist is prepared to do a blood test for inflammation, and the result indicates that your immune system is indeed a bit inflamed, there is no new anti-depressant treatment available that is proven to make a significant difference to “inflamed depression”, or depressive symptoms in the context of low-grade inflammation. The best medical advice your GP or psychiatrist could give you now is probably mens sano in corpore sano: a healthy mind in a healthy body. Meaning can you think of any possible sources of bodily inflammation, like obesity and social stress, that could be tackled, perhaps by a behavioural or psychological intervention that is already available through the NHS or privately?

Should I try vagal nerve stimulation for symptoms of depression that could be related to inflammation?

If you have severe depression associated with high- or low-grade bodily inflammation, and you have already tried many anti-depressant drugs without lasting benefit, it might be advisable to discuss with your psychiatrist the options for treatment by vagal nerve stimulation. As discussed in the book, devices for vagal nerve stimulation are licensed for treatment of depression, but the clinical trial evidence for efficacy is limited, and treatment requires a surgical operation to place electrodes close to the vagal nerve. There is an increasing range of products claiming to stimulate the vagal nerve mechanically but without the need for an operation. For example, a vibrating device placed over the ear can deliver a 21st century version of the alderman’s itch by stimulating the one patch of skin on the surface of the body where the sense of touch is directly detected by the vagal nerve. Many psychological or meditative interventions, like controlled deep breathing, are also claimed to boost vagal tone. And any intervention that can boost the vagal signals from the brain to the spleen, and other parts of the immune system, is theoretically expected to reduce bodily inflammation and therefore depressive symptoms. External vagal nerve stimulation and meditation are both very safe interventions but I am not aware of compelling clinical trial data in support of their efficacy as anti-inflammatory or anti-depressant interventions. For these reasons, I would not immediately recommend vagal nerve stimulation by any technique, but it might be an interesting option to discuss with your psychiatrist or clinical psychologist. 

 

Once you know you have low-grade inflammation, in my opinion, it is probably advisable to keep it under regular review, by repeated blood tests from time to time in future.  It may be encouraging to see that the level of CRP or another biomarker is coming down at the same time as lifestyle or psychological treatments are dealing with plausible causes of low-grade inflammation like obesity and stress. If inflammatory biomarker levels remain outside the normal, healthy range over a period of a few years, or become increasingly elevated over time, or are associated with a deterioration in physical health symptoms, then it may be advisable to seek a specialist medical opinion.

If I am taking SSRIs or other anti-depressant drugs, and I think my depression might be related to inflammation, should I stop taking the anti-depressant drugs?

No.  Do not change your medication without discussing it with your GP, psychiatrist or physician.

 

There is a considerable amount of evidence that existing anti-depressant drugs, like SSRIs, work moderately well on average for patients with major depressive disorder (MDD). If you are currently taking anti-depressants, which don't seem to be working, it is important to talk to your doctors about what else could be done before making any change to your existing medication.

If I think my depression might be related to inflammation, should I start taking anti-inflammatory drugs, like aspirin or ibuprofen, that I can buy over the counter?

No.  Do not change your medication without discussing it with your GP, psychiatrist or physician.

 

All anti-inflammatory drugs have side-effects. For example, aspirin causes irritation and bleeding of the stomach wall. And none of them have been proven to work as an anti-depressant in clinical trials. So taking an anti-inflammatory drug for depression now would be unsafe and of unproven benefit. It is therefore not medically recommended.

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