The Inflamed Mind: A Radical New Approach to Depression is written by psychiatrist Edward Bullmore, and presents inflammation as a new frontier in tackling depression. The author’s bio at the beginning of the book reveals that he works at pharmaceutical giant GlaxoSmithKline. He doesn’t try to be subtle about disclosing this, and I didn’t pick up any sense of bias. He explains that in 2010 GSK shut down its mental health research and development (R&D) programs, and this was what prompted him to start thinking seriously about neuro-immunology and the role of inflammation.
The author refers multiple times to an anecdote of his experience of social withdrawal and morbid rumination immediately following root canal surgery. It was gone by the next day, but he wrote “you could say I had been a bit depressed”, and attributed this to inflammation related to the surgery. While I understand the point he was trying to make, as a person living with depression myself I couldn’t help but roll my eyes.
Cartoon drawings are used effectively to capture neuro-immunology concepts. Explanations are given in simple terms, without making the mistake of sacrificing accuracy for metaphor. Scientific terms are used, such as the immune cells known as macrophages, and the signalling molecules they release, called cytokines. While it’s somewhat difficult for me to judge, as I was familiar with many of these concepts before reading the book, I think it was pitched to a level that a reasonably intelligent person could understand without having a science background.
A patient referred to as Mrs. P. makes frequent appearances throughout the book. The author encountered Mrs. P. during his medical training. She had rheumatoid arthritis as well as depressive symptoms, but her treating physician insisted that the depression was a normal psychological reaction to her physical disease. It was a relevant example, but it struck me as a bit over-used.
There was what initially felt like a bit of a detour to philosopher René Descartes to explain the persistent idea of separation between mind and body. However, Descartes ended up appearing even more often than Mrs. P. did, to the point that it got to be a bit much. The author writes “I can fondly imagine that Descartes himself might have agreed with me, but I can’t be sure.” Oh my. He did make the interesting point, though, that the mind/body divide is a sort of “medical apartheid”, and I very much agree that a more holistic approach will better serve patients.
Bullmore argues that placing depression solely within the mental domain actually serves to increase shame and the likelihood that people will think the illness is their fault, which is in many ways what the idea of a “chemical imbalance” tries to counteract. He goes on to explain the shortcomings of the serotonin hypothesis, which was used as the basis for the development of selective serotonin reuptake inhibitor (SSRI) antidepressants. He also explained that approaching depression with a focus on serotonin and related neurotransmitters has stalled out, and there have been no major advances in the treatment of depression since around 1990. He writes: “To this day, in 2018, I could still safely and acceptably treat most patients with mental health disorders based solely on what was written in those those textbooks” that he used when he started his specialty training in 1989. While I understand the underlying point that there haven’t been any revolutionary advances in psychiatry, the notion of seeing a psychiatrist whose knowledge base is rooted in 1989 is unpalatable, to say the least.
The book explains that according to the DSM: “According to the official diagnostic criteria of the American Psychiatric Association, depressed patients can only have a diagnosis of [major depressive disorder] if they do not also have a bodily disease.” Based on this, he concluded that Mrs. P. who had rheumatoid arthritis couldn’t have a depression diagnosis. To me this interpretation seemed a bit odd. The exact wording in the DSM-5 is: “The episode is not attributable to the physiological effects of a substance or another medical condition.”
The possible relationship between depression and evolution is discussed. The author explained that back in the caveman days social withdrawal could have been a form of quarantine to prevent infectious disease, adding that: “One might even wonder if the stigmatization of depression in 2018 is somehow related to the isolation of ancestral tribe members who were behaving as if they were inflamed.” That seems like a bit of a leap, and is followed by yet another leap: “Could the common feeling that ‘we don’t know what to say’ to our depressed friend conceal an ancient inherited instinct to recoil from close contact with people who are behaving as if they are inflamed and infectious?” By that argument, though, why is there not such a social recoil from people with type I diabetes or Crohn’s disease? Or the oft-referred-to Mrs. P. with rheumatoid arthritis?
While there is a strong argument that inflammation is a factor in depression and an important target for research, there isn’t much yet in practical terms. The book describes the “Remicade high” that some clinicians have seen in patients who rapidly cheered up while getting an infusion of that anti-inflammatory medication. There have been some small studies with anti-inflammatories that have had positive results, but there isn’t a clear indicator of something particularly effective that’s available right now.
Vagal nerve stimulation is also mentioned as a possible intervention to target inflammation. Cytokine receptors on the vagus nerve respond to high levels of inflammation by signalling to the spleen to deactivate macrophages in order to maintain homeostasis.
I started this book quite prepared to buy what the author was selling, given my prior knowledge of some of the research in this area. I was a bit surprised by the book’s presentation of the idea as though it’s something that everyone is denying, because it’s sufficiently accepted to have made its way into the mainstream continuing medical education activities that I’ve viewed. Bullmore writes that “we could be on the cusp of a revolution”, and I know personally I’m hoping that advances in anti-inflammatory treatment approaches will end up being able to help with my own depression.
The book makes a strong argument that further research into inflammation is going to open new doors in depression treatment. However, the fact that we don’t have keys to those doors yet limits its practical usefulness. Still, this book is worth reading if you’re interested in finding out more about a new way of looking at the biology of depression.
I received a reviewer copy of this book from the publisher via www.netgalley.com.
Originally published at mentalhealthathome.org on January 2, 2019.