Book review: The Inflamed Mind

book cover: The Inflamed Mind

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.

You can find my other book reviews here.

My first book, Psych Meds Made Simple: How & Why They Do What They Do, is available on Amazon as an ebook or paperback.

12 thoughts on “Book review: The Inflamed Mind

  1. Meg says:

    That’s the most thorough book review I’ve ever read!! Great job!

    Yeah, I don’t know science at all. I could read this, and I’d be like, “The blah-blah-blah chemical then goes and blah-blah-blahs in the blah-blah section of the brain.” And I don’t understand what type of inflammation he’s discussing. Is he referring to the sort Mrs. P has with arthritis, or is he referring to inflammation of the brain, or to all inflammations? I’m just glad it was you who read this book and not me! It would frustrate me beyond belief, I’m sure!

    I kind of see what he’s saying about how antidepressant research hit a wall after the SSRIs came out. Aside from SNRIs and using other drugs (e.g., antipsychotics or mood stabilisers) or other treatment approaches (light box therapy), there haven’t been any huge drug advances beyond the basic SSRI. It could be helpful for research to go in a different direction, I suppose.

    Liked by 2 people

  2. DV says:

    I know that adding minocycline (an antibiotic) to the psych drug cocktail specifically for its anti-inflammtory effects is a thing, my friend A who has bipolar was put on it for a while.

    But whoah, no advances in psychiatry since 1990’s?? No advances resulting in lucrative new drugs ≠ no advances at all. Showing his pharma bias there. A huge amount of research has been done since then on the contributions of trauma, immunology and genetic and epigenetic influences on mental illness, with actual, useful changes to therapeutic approaches as a result. Was there much discussion of diet in the book? Because my understanding is that a lot of the benefit of mediterranean and similar healthy diets vs bad effects of high fat/high sugar junk food on mental health is mediated via immune/inflammatory effects. As in diabetes, drugs are likely to be of limited use if everything else in your lifestyle is working against them, especially if you’re talking about long term outcomes and overall quality of life as opposed to the limited things which can be easily measured.

    Liked by 1 person

    • ashleyleia says:

      I’ve considered trying minocycline myself, but am not keen on the effects on gut bacteria of a long-term antibiotic.

      One thing that really stood out for me as an example of drug advances is the use of ketamine for depression, since targeting NMDA receptors is a novel approach. But of course that’s not a new drug and therefore not doing much for Pharma.

      My memory is a bit fuzzy but I don’t think much attention was given to diet. In 2017 I tried sticking quite rigidly to an anti-inflammatory diet, and it brought down my C-reactive protein numbers, although I’m not sure if it had any impact on my mood.

      Liked by 1 person

      • DV says:

        re the effect on gut bacteria – I think that’s representative of one of the big problems, that any intervention is going to have flow-on effects that we don’t really know the long term consequences of. But the gut microbiome itself is one area of new-ish research that is opening up some interesting new prospects.

        Liked by 1 person

  3. Looking for the Light says:

    I was very fortunate to get the Vagaus Nerve Stimulator right after receiving FDA approval. The device worked for so many but not me. My doctor and I worked for two years changing the settings to see if something would kick my depression that meds had not provided. The device is long turned off and now just scars and a device sticking up in my chest. The clinical trails showed great results but years later doctor’s in this area had written it off.
    The device was originally used for epileptic patients, the noticed depressed people with epilepsy were less depressed after a seizure. I can’t speak for other’s who may have great experience with the device, I’m very happy for them.
    Trans cranial stimulation was is trials at the same time the VNS was wrapping up. Again very high hopes, I don’t think it’s high on doctors list as a treatment.
    The only treatment that has changed lives is Brain Stimulation. I haven’t kept up and not sure if passed by FDA yet. After 35 years I’ve seen 50/50 on most drugs or the last east technology. The day will come, just not,in my life. The brain is more complex than doctors understand. Some day they will know more.
    Thanks for the great post.

    Liked by 1 person

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