Feel Better, Live More with Dr Rangan Chatterjee - #35 Why Depression Isn’t All In The Mind with Professor Edward Bullmore

Episode Date: November 7, 2018

“There is no family in the country that’s going to be untouched by depression”   Worldwide, depression will be the single biggest cause of disability in the next 20 years. But treatment for it has not changed much in the last three decades.  In the world of psychiatry time has apparently stood still.  Up until now, depression has not been considered to be a physical illness but rather something that is all in the mind. In this week’s episode, I talk to world-leading researcher, Professor of Psychiatry and author, Edward Bullmore, about the new science on the link between depression and inflammation of the body and brain. We delve into how and why we now know that mental disorders can have their root cause in the immune system and how identifying the root cause in each individual patient would lead to more effective targeted treatment.  Professor Bullmore explains that stress is probably the biggest risk factor for depression and we talk about how lifestyle can be used to combat it. I hope you enjoy the conversation!  My upcoming book 'The Stress Solution' is full of actionable tips to help you live a calmer, happier life. You can pre-order it on Amazon. Show notes available at drchatterjee.com/inflamedmind Follow me on instagram.com/drchatterjee/ Follow me on facebook.com/DrChatterjee/ Follow me on twitter.com/drchatterjeeuk Hosted on Acast. See acast.com/privacy for more information.

One of the big things that we know cause depression, stress is right at the top. Absolutely. Yeah, it's huge. There's no getting around that. Stress is probably the single biggest risk factor for depression that we know about. Hi, my name is Dr. Rangan Chatterjee, medical doctor, author of The Four Pillar Plan and television presenter. I believe that all of us have the ability to feel better than we currently do, but getting healthy has become far too complicated. With this podcast, I aim to simplify it. I'm going to be having conversations with some of the most interesting and exciting

people both within as well as outside the health space to hopefully inspire you as well as empower you with simple tips that you can put into practice immediately to transform the way that you feel. I believe that when we are healthier, we are happier, because when we feel better, we live more. Hello and welcome to another episode of my Feel Better, Live More podcast. My name is Rangan Chastji and I am your host. In today's conversation, I dive deep into the subject area of depression with none other than Professor Edward Bulmore, who has written an absolutely fantastic, I'd go as far as saying a game-changing book,

The Inflamed Minds, A Radical New Approach to Depression. I'm utterly obsessed with this book at the moment. I think it's absolutely fantastic. Professor Bulmore is a professor of psychiatry at the University of Cambridge and is someone who is really shaking things up in the medical profession in terms of how we evaluate and treat depression. Today's episode is possibly a little bit different from most of my previous episodes in that there is possibly less in the way of actionable tips that you can apply in your everyday life, but there is plenty of take-home information here about depression. Remember, one in four people in the UK will have a mental health problem in any given year. So this is something that will affect or touch most of our lives either directly or indirectly. I'm delighted to have Professor

Bulmore here as my guest today and I really think you're going to enjoy this conversation. Before we get started, just a quick announcement about Athletic Greens who are the sponsors of today's show. For me, the right nutrition is an essential ingredient to having a healthy and happy life. And whilst I absolutely prefer people to get their nutrition from eating foods, I recognize that for some of us that can be a little bit challenging. Many of us are rushing around, trying to meet competing demands. Often we get home late and even with the best intentions on some days it can be a little bit tricky to cook a wholesome nutritious meal. If

you want to take something each morning as an insurance policy to make sure that you are meeting your nutritional needs I can highly recommend Athletic Greens. It is a really tasty whole food greens powder that you can take each morning and unlike most green supplements that I've tried in the past, it tastes absolutely fantastic. It is so much more than a green supplement. It includes vitamins, minerals, prebiotics and digestive enzymes. Many of you have been in touch on social media to let me know that your energy has improved significantly since starting to take it each morning. For listeners of this podcast, if you go to www.athleticgreens.com forward slash

live more, you can access a special offer where you get a free travel pack box containing 20 servings of Athletic Greens, which is worth around £70 with your first order. So do go and check it out at athleticgreens.com forward slash live more. Now, on to today's conversation. We've been trying to set this up for a few months now. I'm delighted we've actually, you know, managed to steal some of your time to talk about your work and particularly your book, which has been out for a few months now, when you're really making the case that perhaps what we thought caused depression wasn't the case, or perhaps we need to modify our understanding of depression. Is that fair to say? Yeah, I think it's fair to say that we

should think a little bit more broadly about depression in terms of possible causes. And I think one thing that's really, I've really tried to sort of ram home in the book is that depression isn't going to be all one thing. You know, it's not like everybody with depression is depressed for the same reason and therefore equally likely to respond to the same few treatments. And if you think about what happens to somebody with depression in the NHS today, somebody comes to see you in your surgery and you refer them on to a psychiatrist, say, what's going to happen? They're probably going to get offered treatment with one of a few drugs like serotonin tweaking drugs like Prozac, or maybe they'll be offered a course of psychotherapy. But there are rather limited options and we don't have any very good way at the moment of predicting which patient's going to respond to which of those treatments. I think we ought to imagine that actually there are many different causes for depression. If we

could get a bit better at identifying the root cause of depression in each individual patient, we might be more effective in terms of treatment because we might be able to target treatment in a more personalised way for an individual patient. So it's focused on the cause of depression in their case. Yeah. So your book really goes into what some of these causes might be, some of the latest research. But one thing that struck me early on in the book, I think, was when you were talking about your experience as a psychiatrist seeing patients. And please correct me if I've got this slightly wrong, but I seem to recall quite early on, you were talking about, you know, you were seeing a patient and you were being

told all the guidelines were to prescribe an SSRI, a medication designed to raise levels of serotonin in the brain. But you were thinking, well, I don't know if my patient's got low serotonin or not. So I don't really know if he or she needs that treatment. Yeah. Actually, it was the patient that put me straight on this. The patient came and said to me, you know, I'm depressed. And I said, well, let me give you this antidepressant drug. And he said, well, what is it? And I said, it's an me give you this antidepressant drug. And he said, well, what is it? And I said, it's an SSRI.

It's going to boost your serotonin levels. And I started kind of repeating all the stuff I was just learning then in the textbooks of psychiatry. And he stopped me and he said, well, look, how do you know that's true of me? How do you know that the serotonin levels in my brain are low and are going to need boosting by this drug? And that was a real sort of epiphany in a way

because I realised I didn't know the answer to that question. And what's more, there was no way of finding out what the levels of serotonin were in his brain. And we looked at each other. And I think we both realized that you know he he um he's got a point he's got a very good point um but we carried on in the usual sort of polite way he left with a prescription and you know i arranged to see him in a couple of weeks but it left me thinking you know what is the rationale for treatment in an individual with

depression and couldn't we do a better job of developing tests, blood tests, or some other investigation that you could use to show whether the drug that you were offering or intervention more generally that you're offering was really right for that individual patient? Yeah, I mean, depression, and I guess all mental health problems are on the rise at the moment. I don't know what the current rates are. I think the Mind Charities say that one in four people in the UK in any given year will be diagnosed with either depression or a mental health problem, which I find a staggeringly high statistic.

Do you know what the current stats are? Well, I think people say you've got a one in four lifetime risk of depression. That's quite a lot, isn't it? The way I think about it is there's no family in the country that's going to be untouched by depression. I mean, it might not be you, but you'd be a very lucky family if there wasn't somebody, a niece, a grandmother, somebody in the family tree who had been impacted by depression. It's tremendously common. who had been impacted by depression. It's tremendously common.

And I think, you know, another thing that I hope the book kind of does a little bit is to break down this idea of us and them. You know, the idea that I think we sometimes have that people with mental illness, they're very weird, they're very different from us, they should be kind of segregated and kept apart. Really, that flies in the face of the epidemiological evidence. This is, you know, extremely common. Very common indeed, yeah. I think it would probably be useful to try and define a few things right at the start of this conversation.

I mean, you know, everyone feels a bit low sometimes, but that's not quite what depression is, is it? I mean, how would you define depression? Well, depression has a formal definition you know it's a uh and that's written up in a diagnostic manual called dsm-5 uh for example and there's a checklist of symptoms there so you know low mood is obviously part of it sleep disturbance guilt um loss of pleasure uh thinking about harming yourself or putting an end to your life. Those are some of the symptoms of depression. And to have a diagnosis of major depressive disorder,

you have to tick off some of those symptom boxes and there has to be a certain kind of consistency to the symptoms and severity of the symptoms. consistency to the symptoms and severity of the symptoms. So you're right that there is a difference between the day-to-day experience of feeling a bit blue sometimes and what you might call the more severe end of it, the clinical depression that psychiatrists would diagnose as a major depressive disorder. And your book is primarily based around depression or other mental health problems as well? Because I think at the end,

you talk about schizophrenia as well. So the book is mainly focused on depression, but I think one thing that, again, I try and touch on here is that there are people whose main diagnosis, the main reason for seeing a doctor is that they have low mood and they have other symptoms of depression. They have major depressive disorder. There are also a lot of people out there

whose main problem they wouldn't think of is psychiatric. Their main problem might be they've got arthritis, they've got inflammatory bowel disease, they've got psoriasis, they've got one of many, many inflammatory disorders of the body. And a lot of those people have psychological symptoms. So if you ask patients with rheumatoid arthritis, for example, what's the main problem that you face in day-to-day living? Most surveys will put depression, fatigue, something called brain fog, which is like a difficulty in sort of thinking clearly and planning ahead. Most patients with arthritis would put those psychological symptoms right at the top of their list of things that they'd like to fix to help them live a more complete life

so i think when we're thinking about depression from a sort of medical psychiatric point of view it's quite important to realize i think that there this affects not just the patients that might be seeing a psychiatrist, but also a lot of patients that are seeing a physician or a GP for a bodily disorder that has these psychological symptoms. That's a great point. And I guess really fits in nicely with the topic of a lot of what's in your book, this whole idea that inflammation may be the root cause of some cases of depression's in your book, this whole idea that inflammation may be the root cause of some cases of depression, or certainly more than we thought. And I automatically think of that rheumatoid arthritis patient you're talking about, who is inflamed, and will probably

have a high level of a marker in the blood that, you know, we measure as doctors CRP, which is a marker of inflammation. And, you know, the research that you sort of go through and walk us through in the book about inflammation and its impacts on depression, its possible impacts on depression, it would kind of make sense, wouldn't it, that in an autoimmune disease such as rheumatoid arthritis, where you are inflamed, if inflammation causes depression, well, of course, you may well be inflamed then with rheumatoid arthritis.

You may well be depressed if you've got rheumatoid arthritis yes and in the book i tell a story about another patient uh i call her mrs p who uh also opened my eyes a little bit and she was a woman with arthritis and i saw her in a medical outpatient clinic before i started specializing in psychiatry but But because I was interested in psychiatry, I did ask her questions that perhaps most physicians wouldn't have asked her. I didn't just talk about her joint pain. I also asked her about her state of mind. And she very quietly, fluently came out with all the symptoms of depression. I realized she was pretty severely depressed. And I went to see

my consultant, feeling quite pleased with myself because I'd made this additional diagnosis. And he said, depressed? Well, you would be, wouldn't you? And that was kind of the end of the conversation. And his thinking, you know, coded in that rather kind of succinct cryptic way was, you know, Mrs. P, she's got chronic joint disease and, you know, her mobility is poor. You know, her prognosis is not great. Maybe in five years she's going to need mobility aids, a wheelchair or something to get around. If that was your future, you'd be depressed, wouldn't you? Just by thinking about it. future, you'd be depressed, wouldn't you? Just by thinking about it. And that is the way I think that a lot of this so-called comorbid depression has been kind of, I would say, discounted medically over the years. We've told ourselves that this isn't really part of the physical illness. It's

not. It's something to do with the way. But it's all in the mind. It's all in the mind it's all in the mind it's the way the patient is thinking about their condition and i i think that's difficult for a lot of patients to deal with because it's like saying you've got your you've got a bodily disease you've got a joint problem and the fact that you're also really struggling to get out of bed in the morning because you have so little energy or you're feeling very gloomy about the future that's kind of you know your fault it's a sort of you're not strong enough to deal with to deal with the challenges that your disease presents and that's you know who wants to hear that when they're going to see the doctor so you know i don't think that's a very helpful way of thinking about it and the there is an alternative way which i've outlined in the book which is and

you've already said this and that maybe we could think, well, actually, if you've got an autoimmune disease like rheumatoid arthritis, the whole immune system is going to be deranged. There are going to be inflammatory proteins, inflammatory cells in circulation. Those signals could get across the blood-brain barrier. those signals could get across the blood-brain barrier they could change the way the brain works and that could directly cause symptoms of energy loss low mood and so on so maybe we should be thinking about the kind of symptoms that mrs p was telling me about maybe they're not kind of all in the mind maybe they are another aspect of her autoimmune problem we should be thinking about them in the same kind of way as we think about you know her joint pain or some of the other more familiar physical symptoms yeah

arthritis yeah absolutely and i think certainly if i think back to when i was at medical school and even in my early years practicing um you know i think we very much did think depression was all in the mind and you you present a very beautiful case of how it may well not be the case. Well, I'm sort of softening it, that it's not the case, that actually it may also be a disease or a problem of the body as well that's maybe having symptoms in the mind. And I wonder if you could just talk me through that. What have you found through your research that's different from the way you were trained?

Yeah. Well, so I guess I should say, first of all, that the research I'm talking about in the book is by no means not all my research. I've really drawn on, you know, there's a body of work there that's been growing over the last, you know, 25 years, I would say, but particularly in the last five, 10 years, there's really been an inflection point and we're seeing a lot of new evidence. I think the, you know, the way I think about it is, first of all, is there an association between depression and inflammation? Do those two things go together? And, you know, yes, they do. There's lots of evidence for that.

You know, I've already mentioned that people with inflammatory disorders have increased risks of depression. So that's one aspect of that association. You can also look at blood inflammatory markers. You mentioned CRP. We can also look at inflammatory proteins called cytokines in patients who have major depressive disorder. So that's the kind of psychiatric flavor of depression. They turn out to have slightly but significantly increased levels of inflammatory proteins in circulation on average. So again, that's evidence for an association. But if you take that

back to sort of more skeptically minded scientists or clinicians, they will say, well, you know, association or correlation, it's not causation. And for us to get serious about this, we have to have evidence that inflammation isn't just a kind of a passenger. It's not just a coincidental finding in somebody who's depressed. It's really the cause of their depression. So that gets you into the kind of next level of scientific investigation, which is trying to build the evidence for a causal effect. Now, you can look in animals and you can look in humans. If you look in animals, obviously, you've got much more opportunity experimentally to make animals inflamed, make perfectly healthy animals inflamed and see what difference it makes to their

behavior. And it turns out that very, very robustly, if you make an animal inflamed, it becomes less mobile. It kind of withdraws from contact with other animals. it kind of withdraws from contact with other animals it may be less interested in things like sugary liquids that it would normally enjoy drinking presumably because they're more pleasurable so you can see these kind of behavioral changes in animals that look a lot like some of the symptoms of human depression and they're directly caused by inflammation. Then some people would say, well, you know, how can you possibly have, you know, a credible animal model for the distinctly human experience of being depressed,

feeling gloomy, guilty, and so on. So we do need human evidence as well. And there are various places you can look for that. And the first place that I think the case has been made is, you know, if inflammation caused depression, then inflammation should sometimes come before depression. You know, it causes, precede, affects. So is there any evidence that we can find in humans that inflammation has come before people were depressed? And there are a couple of big

studies that have shown that that is the case was there not one you talked about in the book about nine-year-olds yes that i found that staggering i wonder if you could just elaborate on that well yeah i think that is a very provocative finding so that was a big uh epidemiological study that was done in new zealand It's called the Dunedin study. And basically, they followed up a birth cohort. So they basically identified everybody that had been born in the city of Dunedin in a couple of years. And they followed those, originally babies, they followed them up repeatedly over time. And what they discovered when they looked back at the data was that the children that had had slightly increased levels of inflammation in childhood, sorry, the children, I'm sorry, I've misspoken there, what they found was the children who had experienced abuse or adversity in childhood

had slightly increased levels of inflammation and depression in adulthood. So that's a study that actually makes a slightly different point, which is about where inflammation might come from in people who are depressed and the possible importance of stress, particularly childhood stress. But I think I might have misunderstood the study you were alluding to, actually. There's another study, also a very large long-term follow-up study, where they measured the inflammation in the blood at the age of nine, I think it was, in children who were later assessed for depression

at the age of 18. And they found that the kids who had been sort of in the top third of the range for inflammation at the age of nine, had a significantly increased risk of depression. Yeah, that was a study I remember reading and thinking, wow. So, you know, many years before they actually get depression symptoms, potentially there were signs of increased inflammation. That's right.

Which helps to make the case, doesn't it, that inflammation potentially can precede depression and therefore might be cause of depression? Yes. And there have been other studies that have made the same point. And that's a bit of work that we published recently in, I think it was 60-year-olds. high levels of this inflammatory marker CRP, four and two years before they were assessed for depression, had an increased risk of depression up to four years later. Wow. So that's encouraging. You know, it tells us that inflammation can precede depression, which is what it would

have to do if it was going to be causal. But still, you know, people are sceptical and people will want to say, well, OK, it could cause these longitudinal data. They tell us inflammation could cause depression. But how exactly, step by step, does that work? How do you have and how does an inflammatory protein in the blood lead to somebody feeling gloomy? And that's where you've got to, you know, I think the new science of neuroimmunology generally has been quite helpful. Because when I was at medical school, I don't know if this is true when you were at medical school, when I was at medical school, I was told as a matter of fact that, you know, the brain was protected from the immune system. Yeah, me too.

It had nothing to do with the immune system. I was taught it was immune-privileged. Absolutely, I remember that term very well. And there was supposedly the blood-brain barrier. Keep the brain apart, separate. The body can do what it wants, but the brain's protected. That's right. I was taught the blood-brain barrier was like a Berlin Wall in my imagination.

It was an absolutely impermeable barrier that protected the brain from the peripheral immune system in the body. Sorry, Professor. I think there's kind of a wider point there, isn't there? Which I would say, in general, even some of those anecdotes you talk about earlier on in your career, how before you specialise in in psychiatry you're talking to someone with arthritis and you know because you're that way inclined you spoke to them about their mental health and realize actually there are some you know some symptoms of depression here um you know but that's they're probably in their arthritis clinic and they're seeing an arthritis doctor i think on some level, that's really how

reductionist we have become in medicine over the last, what, 20, 30 years to a certain degree. We have become quite reductionist. And I understand for the scientific method to kind of tease out causation and tease out what is causing what, that reductionism can be beneficial. But then when you translate that to clinical practice, I sometimes feel that we have overly specialised and overly, you know, we're trying to treat a lot of these things as separate conditions. But I guess there is potentially the case here that if, you know, it's very hard, you know, what comes first, but could it be that, you know, someone has had an insult, which has caused them to be inflamed and that inflammation potentially in someone who's genetically susceptible might cause depression in them might also cause arthritis in them but

someone else may have that inflammation and not be genetically susceptible or they may exhibit a different symptom when the same that the same underlying process potentially might be the same. Did that make sense? Yeah. And I'm sure that's conceivable. It sounds quite plausible to me that there are going to be individual differences in how people respond to pretty much everything. But certainly inflammation is going to have different effects in different people.

I mean, I said 25% of people with arthritis have depression, but 75% don't. So, you know, right there, you've got some evidence that there are differences in how people respond to these inflammatory shocks, you might say, to the system. And not everybody's going to be equally susceptible, and there could well be genetic reasons for that. But going back to the sort of more philosophical point you're making, I mean, the word I've used a lot in the book is not actually reductionist, but dualist. I mean, I think that's where Western medicine really, you know, could usefully take a fresh look at some of its kind of underlying assumptions. You know, we are, I was certainly trained in, you know, in the view that the body and the mind were completely different. You know, they're quite, you know, poles apart, really,

completely different kinds of thing. And, of course, you know, that dualist way of thinking, the idea that the body and the mind are split apart, you see that in so many aspects of current Western medicine. Mental health services and acute medical services are provided by completely different organizations. Psychiatrists and physicians, GPsps have completely different training tracks um the the patients that see mainly mental health services will typically have not very much attention paid to the medical symptoms they have the patients that attend mainly medical services will not have very much attention paid to the psychological symptoms they have i I call it medical apartheid, where we've sort of forced a separation in the way that we think about the body and the mind, which I think is to the disadvantage of many patients who have both physical and mental

symptoms. And I think one implication of the book and the science that it describes is that maybe the time is right to rethink a little bit, you know, that separation. And maybe we could do a better job for many patients if we reconfigured existing services so that, you know, somebody like Mrs. P, who I mentioned, the patient with arthritis, in that arthritis clinic, there's a clinical psychologist, for example. Or there's somebody, you know, it's understood when she goes to see her arthritis team that psychological symptoms could be part of what she's attending to. Likewise, you know,

if you think about serious mental illness, so-called, one of the most shocking statistics I think at the moment is that, you know, somebody with a diagnosis of major depressive disorder or bipolar disorder or schizophrenia, so-called serious mental illness, their life expectancy is about 10 or 15 years less than it should be. You know, so roughly speaking, serious mental illness is about as lethal as cancer on average.

Wow. Yeah. But if you've got a serious mental illness and you go to see a psychiatrist, you'll be lucky if they take a blood test or an ECG or they think about your medical condition at all. So I think this, again, apartheid is a strong word, but I think it's kind of justified. I think that's a good term because i agree one of the things i've been talking about in the media for the last years is is that you know we really have made these things very separate you know you have to choose almost which camp you belong to uh are you

in the you know if you've got a mental health problem or a physical health problem you sort of got to choose and then you go down that path and really you know the body is connected so it does it kind of i don't know really what happened to us at medical school because it's kind of quite intuitive when you think about it it sort of makes sense doesn't it of course one part of the body would affect another but yeah i think somewhere we've slightly got off track and i think hopefully this book will help bring people back to more integrated care yes um one thing you do say towards the end of the book when you you touch on this right at the start which is you know there can be no talk of panaceas depression is not just one thing and i really i

really like that because yes the book's about depression i would almost sort of expand it out to other chronic diseases where we're very used to having one modality of treatment. We make the diagnosis, which is what we get trained to do a lot. First of all, let's make that diagnosis. And then there's a treatment protocol. And the more science I read, the longer I have been in clinical practice, nearly 20 years now, that label, that disease symptom that they've come in with can actually have many different causes. And actually the same disease might require a different treatment depending on who that patient is, which again, sounds relatively obvious, but I do think that it's not really the way that we practice medicine for a few years.

It's become very, I don't think we've quite recognized how much individuality there is. And I guess you're making that case in depression, but that depression could be multifactorial. And there's going to be multiple factors. And in different patients, different factors are going to be more relevant and in different patients different factors are going to be more relevant is that fair to say yes it is and i mean you know i think i think if you look at um some areas of medicine uh this process that you're talking about of trying to sort of fine tune the diagnosis a little bit more precisely and get away from the big sort of umbrella terms as further advanced.

So, for example, you know, again, going back to when I was at medical school, somebody came in with a lump in their breast. It was enough to say they got breast cancer. And there wasn't really much, you know, refinement of that diagnosis. And now, of course, in the treatment of breast cancer, actually, there's tremendous refinement. People take a biopsy of the tumour, they'll look in detail at the complexion of the tumour, the expression of different genes, and some of the most effective new treatments for breast cancer are not going to be panaceas. They're going to work extremely well for people that have a tumour and a genetic profile that predicts response to a particular treatment. Same story with some of the varieties of leukemia out there. The new treatments that

are really making a difference in cancer, I don't think are going to be generally, you know, for everybody with breast cancer, everybody with leukemia, they are going to be a bit more stratified, a bit more personalized. Now, psychiatry is behind the curve. If you think about where medicine as a whole is going, you know, I would say oncology, immunology are kind of close to the front, close to the cutting edge. Psychiatry is a bit at the back of the queue at the moment. And in one respect in which I think psychiatry needs to catch up is, you know, we need to be doing more to understand the causes of depression, psychosis, addiction. You know, some of the, you know, you think about all the diagnoses that are common in psychiatric practice. They're all those kind of big umbrella terms.

And we don't have very much refinement in how we think about the causes. umbrella terms. And we don't have very much refinement in how we think about the causes. One of the practical attractions of thinking about how the immune system might contribute to depression is that the immune system is relatively very accessible to investigation. You can take a blood test, you can take 20 mils of blood, and you can learn an enormous amount about the immune system from that relatively simple blood test. And as I mentioned already, in research studies, people have shown that inflammatory proteins in the blood are on average associated with depression. I would like to think that over the next five, 10 years or so, we'll be able to build on that. We'll be able, perhaps,

to develop our understanding to the point where somebody comes to see you in your clinic, there's a particular test that you could run as their doctor to see whether their depression is likely to be linked to a particular inflammatory signal. And that, in turn, might predict a good response to a particular anti-inflammatory treatment. Yeah, well, there was that study, wasn't there, from King's College London in 2006, I think 2016? Yeah. Where they demonstrated that, I can't remember what they measured actually now, I think it was a complement, but they basically measured levels of inflammation yeah and this cohort of depressive patients and i think with almost 100 certainty they could predict

who would respond to an ssri and who wouldn't and i think it was something like if you if you reach a certain cut off a certain level of inflammation those patients were not going to respond to SSRIs, for people listening, so those common antidepressants that doctors prescribe, such as Prozac or Fluoxetine, these kind of things. And it was really quite striking because I think even in primary care as a GP, we see lots of mental health problems. And I remember early on in my career, you would see some patients who responded pretty well, but some patients really just didn't seem to respond.

And it's incredibly, certainly, of course, it's frustrating primarily for the patients. As a doctor, it's incredibly soul-destroying because you want to be able to help your patient who's coming to seek help, yet sometimes you find your treatment options were quite limited. Is that something you've also seen in your career as a consultant psychiatrist? a psychiatrist, they'll see a general practitioner. And general practitioners will offer treatment with SSRIs or perhaps a referral for a course of cognitive behavioral therapy. And it's only when those first-line options fail, typically, that patients are going to get referred on to secondary. So you're left with an even tougher job. Yeah.

So the people we see in psychiatric practice, by definition definition tend to be um people who have not responded quickly to the easy treatment options so yeah this is an absolute has that been a frustrating thing as a clinician as well as a doctor has that frustrated you in your career frustrated you in the sense that obviously as doctors we like to help our patients and we like them to get better you know yes for them but it also feels good for us if we can help our patients get better have you you know i'm saying this because i've spoken to a few psychiatrists not with your level of experience having said that and some of them do express to me a degree of frustration with when the therapies are limited in terms of what else they can do for their patients i'm just

interested is that is that something that you've come across in your career? Yes. I mean, I wouldn't say it's, I don't know, to me it's not really so much a frustration, but I think it does contribute to a motivation to try and make things a bit different in the future. try and make things a bit different in the future and i think that's probably why i've you know gone long in my career on the research side of things um you know i think if you're i think if you're a young doctor coming into psychiatry um it helps if you are prepared to think about the sort of prospects for changing the field in the long term because i think it's pretty clear that psychiatrists and other mental health practitioners of course they do make a positive difference you know it's not all doom and gloom no sure but you can't help

feeling we could do a better job i mean you know i a thought experiment i often run in my mind is you know 100 years time are people going to be looking back at mental health services in the UK in 2018 and thinking, well, you know, they might not have got a lot of things straight, but boy, oh, boy, they really knew what they were doing with the treatment of depression. Of course, I don't think that's going to happen. I think in 100 years' time, people will probably be looking back

and they'll be thinking, oh, that was pretty rudimentary what they were doing back then. So for me, the challenge of, you know, people with depression who don't respond to the first line treatment options, that has been a powerful sort of, to me, motivation to do research and try and find different ways forward, rather than it hasn't really, for me, surfaced in a sort of kind of clinical frustration, but it's been more of a sort of research drive. Yeah, I know I understand that. You obviously mentioned in the book about inflammation and how inflammation may be driving certain cases of depression. And you also mentioned social stress.

And I wonder if you could just elaborate on the relationship there between social stress, inflammation and depression. So I think this is fascinating, fascinating area. And one of the things I like about it, before I sort of explain, well, before I answer your question directly, I mean, I think one of the things I like about the stress being part of the story is that I think it helps us again think about mental health and depression, particularly in a slightly more integrated way. You know, the field of mental health can get a little bit split. It can get a little bit internally divided. And there'll be people that think, you know, it's all in the mind.

People think it's all in the mind. People think it's all in the brain, you know, and those sometimes can be, you know, competing camps, almost sort of ideologically divided. But what we are beginning to see is that stress and stress could mean anything, really, from the stress of public speaking, which is, you know, an acute stress that can affect anybody, to, you know, the more chronic stresses, for example, of looking after an elderly relative, you know, being a carer for somebody with a chronic disease is an extremely stressful role to play. Some of the more extreme stresses, divorce, losing employment, all of these factors come under the general heading of stress. And what we are beginning to understand

is that one of the ways that stress works on the body is it stimulates an immune reaction, an inflammatory reaction. And, you know, we didn't really know that, or I certainly didn't know that, you know, five or 10 years ago. And there's pretty good evidence emerging in the scientific literature to support it. But actually, if you think about it intuitively, it's not that surprising once your mind has been open to it. Because the immune system, what is it there for? It's there to keep us alive in a hostile world. And we know the immune system reacts to physical stresses like an infection or a trauma. But why is it so surprising that it might also react to social stresses? And some of those social stresses, particularly in childhood,

you know, if you think about the stress of losing your mother or your father in infancy, that is a very severe threat to your survival as a young child. And, you know, once you allow the thought to enter your mind, it seems quite intuitive that part of the way that a child's going to survive that kind of extreme social stress is through an immune or inflammatory reaction. So that is emerging as a, I think, a very, very interesting area of research. It's particularly interesting in depression because if you think about what are the big things that we know cause depression, stress is right at the top. Absolutely. Yeah, it's huge. There's no getting around that. Stress is probably the single biggest risk factor for depression that

we know about. What we haven't, I don't think, known about so clearly is how or why stress causes depression. So to me, the idea that stress induces an inflammatory response, which might under some circumstances be protective and advantageous, but in some individuals can nevertheless particularly interested in the idea that very early childhood stresses could kind of induce an immune memory, if I can put it that way. Absolutely. You know, because again, going back to, you know, what we know about psychiatry have done for a long time, if you've been exposed to abuse adversity as a child, that is a major risk factor for depression emerging in adult life. But we, again, we don't have a clear understanding of the mechanism. But you know, we know the immune system's got a terrific memory. If you're exposed to a physical stress like infection as a child, your immune system will have a memory of that into adult life.

Is it conceivable that if you're exposed to childhood abuse, your immune system carries a memory of that, which may predispose you to react to other stresses in adult life in a way that makes you more likely to become depressed? It's quite plausible to me. I think it is plausible the research on on aces yeah and adverse childhood experiences and their impact on your likelihood of autoimmune disease later on in life or depression yeah it all starts to fit together potentially this could be the the unifying idea potentially that it's inflammation yeah um which i guess you know people have been saying you know there's there's talk of this for a few years and of course we'd like to see more and more robust

research so we can understand some of those mechanisms um i've just spent a few months holed away in a room trying to write i've just completed a book on stress called the stress solution that comes out um just after christmas this year and in the introduction i think i i try and look through this through an evolutionary lens and so go you know back in our caveman days you can see the you know this whole idea of sickness behavior where a caveman might have got unwell with an infection and they would feel they'd retreat to the back of the cave they'd be low they're feeling low they don't want to go and mingle with people they don't want bright lights they just want to they're feeling tired lack of motivation and these are sort of

the symptoms that we tick off yeah for depression yeah in clinical practice and you can see how those symptoms of inflammation you know if you you have an infection, your immune system will get ramped up and your body will become inflamed as a way of trying to fight that infection. And as a result of that, you will have certain behaviours which will probably help you rest, you know, stay away from the outside world and recover from your infection. world and recover from your infection. I was thinking about this and thinking, well, that's sort of what's happening in the modern world with maybe with chronic stress, maybe a mechanism which is helpful in the short term becomes unhelpful in the long term. And I found that really interesting. Yes. Well, it is very interesting. I hope hope you're i'm sure your book said something about immune mechanisms i do that's good yeah absolutely immune system so i when i was at medical school i did a i did a bsc honors degree in immunology right okay um back in edinburgh and um well i

started medical school in 1995 and you know i did the honors degree i really enjoyed immunology and then i you know got back to medicine and started practicing without a thought of the immune system for years yes and it was about six years ago i think when i really started to restudy the immune system and the microbiome i really became obsessed reading a lot of science and papers on it i thought wow immunology that i learned in 1998 is highly relevant now and i think about immunology all the time with my patients now which i find incredibly exciting because i think the immune system you're right what is it that is fundamentally there to protect us yeah and a lot of these illnesses that we're now seeing there is in some way a dysfunction of the immune system and so maybe even skin conditions like eczema and

psoriasis are immune system there is immune system dysfunction which is why for those severe treatment resistant cases they go to these immunosuppressant drugs and so you think hold on the immune system is playing a role in multiple

chronic diseases yet we don't really think about it as doctors. And I think that's going to change, actually. I think your book's going to really help drive some of that change, particularly in psychiatry. Well, I had a very similar experience in medical school. We learned a bit about the immune system. At the time, I'm a bit older than you,

so this is kind of like early 1980s, right? Immune disorders were kind of, there weren't very many of them. And there were things, arthritis was one of them, systemic lupus, erythematosis is another one. There were a cluster of them. They all had rather ungainly names and they were difficult to get a grip on. And it didn't, it seemed to me like a backwater, actually, immunology in medicine. Didn't seem that important. Then I went into psychiatry. I then went't went neuroscience i did a lot of neuroimaging research i didn't really pick up a immunology textbook again until about 2012 2013 and i was absolutely dazzled by what had happened in the intervening period and how fast and far immunology had advanced and how much more detailed, you know, our understanding

of the basic science of the immune system had become. And the other thing that I think you're touching on is awareness that actually, you know, this isn't just important for a few obscure diseases like SLE or rheumatoid arthritis. This is, you know, the immune system has got a part to play in, I would venture to say almost every disease is going to have an immune or inflammatory component to it. So immunology is moving from, you know, where I first sort of became acquainted with it. It was sort of slightly sort of nerdish sort of enclave of specialist medicine. I think it's going to move centre stage. I think a lot of medicine is going to turn out to be, you know, immune based.

And a lot of therapeutics, if you look at where the new drugs are coming across a range of different areas and the drugs that are under development, a lot of them are focused on immune mechanisms or immune targets, even if the disease in question is not one that you know we conventionally thought was inflammatory i mean you know heart disease to take one example yeah well we we now know that you know chronic inflammation may be one of the root causes of cardiovascular disease and potentially stroke well not potentially in the stroke as well and it's and this is immune system. Where does inflammation come from? It comes from the immune system. There was actually, I think it was in,

I think the journal was called BMC in 2013, I think it was. It was from Australia, this editorial. I think it was called, so depression is an inflammatory disease, so where does the inflammation come from? Which I found that a really good read, actually. And I think in the conclusion, or the I think in the conclusion or the sort of discussion at the end of that paper I think the authors started to speculate

on potential therapies that could come up to help with depression and reducing inflammation but they also mentioned a few lifestyle factors to say that some of these lifestyle factors can modify inflammation levels and potentially might be helpful in treating inflammatory conditions including depression and so i'd love to you know a lot of listeners of my podcast um are really looking for inspiration on you know nutrition and lifestyle and how the what can they do in their own lives that's going to

help improve their health and potentially help their mood and i know we don't have all the science in yet to to say that but i know we've spoken a little bit about stress and how stress can cause inflammation and i think you know generally trying to reduce stress levels a lot easier said than done can certainly be helpful there's a lot of good evidence now on physical activity and how beneficial it can be for our mental health. And I wonder what you think to the whole idea that exercise and increasing physical activity can be anti-inflammatory. So I wonder, could some of the mechanisms for how exercise helps depression and mental health problems, do you think some of that could be mediated by its impact on depression? Yeah, I think that's quite plausible.

I mean, you know, so I think it's perhaps the easiest place to start is obesity. You know, we know obesity is a pro-inflammatory disorder. Actually, fat tissue in the body is packed full of inflammatory cells. Another thing I didn't, I wasn't taught at medical school, but it's true. Yeah, it is true. You put on a pound of fat, you're actually increasing the kind of volume of inflammatory cells you have in the body. And people with, you know, higher body mass index, they very predictably have higher levels of inflammation in the blood. And we know obesity is associated with depression. So in answer to the question,

where does the inflammation come from that might cause depression? Obesity could be part of the answer for some people. Now, you know, exercise might help with that, diet might help with that, but we know it's not always easy to lose weight. You know, most people who are overweight or obese, you know, might want to lose weight and it's not always that easy to do. No, sure. But I think there are lifestyle adjustments that, you know, one could try that would, you know, perhaps improve obesity and reduce the inflammatory risks that come with that. I've been interested also in, you know, there's a bit of research out

there looking at sort of psychological interventions. I mean, you mentioned stress isn't easy to fix, and that's certainly true. But of course, there are, you know, there's mindfulness, there are meditational practices that are, you know, a lot of people use yoga as a stress management tool. And it's interesting to me to begin, you can begin to see that some people are looking at how that works and what's the science behind it. And there are a couple of small-scale studies out there showing that if you practice, for example, Tai Chi or meditation,

that can have an effect on the immune system too. I think when researching for my book on stress, I think I found a randomized controlled trial. Just trying to remember now, I think it was six weeks of yoga and its impacts on depression. And I think it was quite a small study, but it was a randomized controlled trial nonetheless. And I thought, well, this is pretty interesting that yoga might be a...

I think the science is emerging yes on what else people can do yes uh which which is incredible yes well you know we do i know it's you know it's great if yoga works for you from a scientific point of view i want to understand how it works you know and i think i think for you for medicine to embrace some of these kind of quote-unquote alternative approaches, the mechanism is quite important. If we were a little bit more confident how yoga worked or how meditation worked or how exactly a dietary change might impact on the microbiome, make the gut less inflamed, gut less inflamed you know if we could understand some of the kind of mechanistic details of these interventions a bit more i think that would accelerate their adoption by mainstream medicine and get us into a slightly more kind of holistic way of i think that's a great point i mean because a lot of listeners to this podcast will wonder why some of these things aren't being adopted

more by mainstream medical practitioners and i think you've really hit the nail on the head there which is i think maybe the conventional medical profession want to see a bit more in terms of mechanisms so before they start openly recommending these i guess the flip side to that is that you know doing yoga or trying to work on stress management or meditation comes with very little downsides and you know whereas even an SSRI, for example, will have, you know, SSRIs just make sure I'm not using too much medical jargon. You know, these antidepressants that we often use

as first line drug therapy in depression, you know, even in our BNF, our British National Formulary, you know, in the list of side effects, it will say an increased risk of suicide, you know. And so I think starting to look at that risk benefit ratio and yes we want more evidence but also i think sometimes maybe in medicine we need to be a bit quicker to adopt a bit of common sense sometimes say well i don't think there's any any downside here and this there's some some science that suggests that this may be helpful and it may also be that we have to do multiple therapies in one go it may not be that maybe that yoga and isolation is not enough but

maybe yoga stress management exercise and maybe some form of therapy to help the immune system maybe together might you know bring that patient away from symptoms and make them better, if that makes sense. Because if we're saying that there's no panaceas and that it's multifactorial, but maybe we need to address multiple factors in each patient. And I know just before we came on air, I was chatting to you about that study from just maybe a year and a half ago now. I think it's called the SMILES trial, S-M-I-L-E-S.

And guys, I will link to everything that Professor Bullion and I have spoken about, we'll link to in the show notes for this episode, which will be drchatty.com forward slash inflamed mind. So any of the papers that Edward's discussed, I think we'll try and get links to all of those things and put them there so you can actually, you know, continue your learning once this podcast is over. But the SMILES trial was brilliant because they had 67 people. It was done australia by i think professor felice jacker and she had patients were already diagnosed with either moderate or severe depression they were already on therapies but then they were split into two groups one group was put on a modified

mediterranean diet with dietician support for 12 weeks. And the other group, the control group, had some form of social support. And there was a statistically significant remission rate at the end of 12 weeks. And 67 is a small amount of patients. I understand that. And I think she recognised that and she said that in her discussion. But I found that that was the first randomised control trial I had seen that showed you know a significant improvement in patients with depression and I wonder

what your thoughts are on diet and depression so it's interesting because when the book came out I got a lot of

you know a lot of people wrote to me contacted me and you know that was a very common question people had

it was about diet. And I didn't really touch on it much in the book. I suppose the way I think about it is, could diet have an effect on the immune system, which makes people less depressed? And in principle, I'd say the answer to that is yes, because diet is going to change the microbiome. That is the, you know, the gazillions of bacteria that we've got living in our gut. Their constitution, the type of bacteria that we have,

is to some extent sensitive to diet. And if you change the kind of bacteria that are swilling about in very close proximity to your gut, that could have an effect on the immune system. The immune system lines the walls of the gut very densely. The gut is a major kind of point of vulnerability in the body's defenses. So the immune system is packed in there quite tight. Change the diet, change the microbiome, you could change the inflammatory response. That could have an effect on mood. I can see all of that quite plausibly. um you just want to see a bit more research yeah and it does

get more complicated you know because the microbiome is another very very complicated thing sure so you suddenly got three or four very complicated things interacting with each other you've got the microbiome you've got the immune system which we've just talked about incredible complexity dazzlingly complex you've got the the brain you know and then you've got the immune system which we've just talked about incredible complexity dazzlingly complex you've got the the brain you know and then you've got the mind uh four rather big and complex things which are kind of interacting in some way uh we think so it's going to be you know it's going to be tricky to unpick that but is it worth trying yes i think it's you know i think plausibly you can imagine

how that could be a connection and it would be very interesting to understand these things a bit more holistically. Yeah, I think understanding the mechanisms would be fantastic. I can certainly tell in my clinic experience, having tried to utilise some of these lifestyle therapies

for a number of years now, it's incredible to see the benefits. You know, I tend to do more than one thing at once. I tend to change multiple things together. I often – I wrote a book on what I consider to be four pillars, four very important factors, lifestyle factors of health that we have a pretty high degree of control over, food, movement, sleep, and also relaxation relaxation which is the whole piece on stress and i found that when

you can these things can be very hard to change for people but when you can actually um you know really understand the science behind these things but also encourage your patients to help change these things you can have quite a profound impact on multiple different conditions and what's quite interesting is that uh with a colleague of mine who created a course called prescribing lifestyle medicine that was the first royal college of gpa accredited course on this we ran it in january for the first time run it again in april we've trained almost 500 healthcare professionals this year we had a few psychiatrists on our course which was um i've had some really good feedback from them saying we're applying so we taught them a lot about the immune system, the microbiome,

and therefore some simple practical things that they can do that aren't going to do any harm but may have some benefits. And, you know, initially the course was, we wrote the course to appeal to GPs. But I think, you know, I was surprised at how many psychiatrists came. We had a few gastroenterologists, endocrinologists. I think because there's a, I think we're understanding what we're talking about inflammation it's it's probably

not going to be exclusive to psychiatry it's going to it's going to it's going to go across the board and there are everything we do in some way impacts our immune system and i think i think we're still at a very early stage off that but i think your book's been incredible to help people. You know, who is your book written for, would you say? Well, I've tried to write it so that it could be read by anybody. So it's hard to do that. Which is tricky, because at the same time, I don't want to dumb down the science. You know, I think it's important that people are clear about what we know with some certainty. We know, I would say, beyond doubt, that inflammation and depression are associated with each other.

And then the next question is, well, is there a causal relationship? And the next question after that is, does it how exactly does inflammation drive depression? And then there are questions about, OK, if you've understood the whole mechanism, how can you intervene? How can you predict who's going to respond to which intervention and so on? So there in a way that was understandable to as many people as possible. I mean, I had a lot of feedback, obviously, on earlier versions of the book. And I have to say, you know, the first draft I wrote, I thought I'd already dumbed it down to, you know, an extraordinary degree. And I showed it to my editor at Short Books and she said you're going to have to sort this out nobody's going to be able to understand this

it's way too dense you're using far too much technology Writing a book is such a humbling experience isn't it? You think you've got it sorted and then your editor looks at it and goes yeah but what about that and what about that and you're like really? They won't get that? So she said you know just these, almost without realising it, I'd used technical jargon that, you know, is in common parlance scientifically, medically, but just gets in the way of the story.

So I've tried to, you know, in terms of the immunology, for example, there's a chapter in the book which tries to introduce the immune system to people because you know we're talking about it we both understand that the mixed blessings of you know uh medical training so we know something about the immune system but i you know i find that if you talk to uh people that you know aren't specialized or trained you know most people pretty vague about the immune system where it is what it does you know, aren't specialised or trained, you know, most people are pretty vague about the immune system, where it is, what it does, you know. Sort of protects me against getting the flu, doesn't it, Doc? You know, that's what the immune system does. Where is it? Exactly.

Yeah. You know, I mean, if you say, where's the nervous system, right? It's in your head. Where's the immune system? It's everywhere. And it's not very obvious in any of the places. You know, it's in your tonsils.

It's in your gut. Yeah. It's in the spleen. It's in the bone marrow. You's in your gut. It's in the spleen. It's in the bone marrow. You know, actually, it's everywhere. So I tried to sort of explain the immune system. And I've tried to do it using as few technical terms as possible. I figured there were maybe six words, seven words, something like that in the book that

you might not have come across if you know you hadn't um been trained in this you know macrophage for example yeah uh it's a it's a particularly important type of inflammatory cell and i thought well i've got to call it a macrophage because if you don't if you don't use the right word you're not helping people make the the real connection to the science but i've tried to keep the technicalities absolutely to a minimum. And I've tried to kind of focus more on the sort of the logic, if you will, of the science.

And I've tried to use wherever I can stories about my own training, some of which we've talked about today, and make it as far as i can accessible to people yeah i think you've done you know i really enjoy the book and i i think i like the way that you've really tried to build the case up make the case for what you're what you're saying which is almost like a detective almost just trying to i guess in many ways that's what you have been as a detective um since i came across the book, and I actually first came across it

when I saw this great piece you wrote in The Guardian, I think, back in April when the book came out. So it was a really great piece. In fact, I'll link to that, guys, in the show notes as well, drchastity.com forward slash inflamedminds, so you can see all these pieces. And it was just going to help you guys really understand depression a bit more and what might be causing it, whether it's for yourself, just general interest, or for a family member or friends. I think it can

be incredibly helpful to read. But certainly some medical professionals who I've told about the book really, really enjoyed it. And I know a lot of healthcare professionals listen to this podcast, and I very much encourage guys, you check out The Inflamed Minds. I think it may well, you know, turn a few things on your head about what you thought about depression. It may help you understand why some of your patients may not be responding to the therapies that you might be giving them. Edwards, any final thoughts at all for anyone listening to this? Anything that you've seen work in practice particularly well that you'd recommend or, you know, anything that you can give to the listener at all about this area? Well, you know, I think Watch This Space is, you know, going to be part of it.

Things are, I think, moving quite fast in the way that we think about the immune system in general. And I think that it could have significant impact in psychiatry. I'm desperate to see evidence of treatments that work. Anti-inflammatory drug treatments, for example, that have a real antidepressant benefit in patients that are not responding to other options. And my day job basically is trying to push forward that research. So we are just beginning this later this year, we're beginning a drug trial which will take a new anti-inflammatory drug into treatment for depression. And to get into that

trial, you've got to be depressed and you've got to have a blood test that indicates that you're likely to be inflamed. Right. Now that might sound kind of like motherhood and apple pie, but believe it or not, I think it's one of the very, very first drug trials of depression ever to use a blood test in that way to kind of predict who's going to respond. So one take home I'd say to people is if you're interested in participating in research, if you've got depression or you know somebody's got depression and you think that you'd like to participate and see if you can contribute to helping move things forward,

we have a trial about to start later this year and there's more detail on that on our website, which perhaps you could also link to. I will link to, definitely. What is that website? Do you know off our website which perhaps you could also i will link to definitely what is that website do you know at the top of your head or if not you it's called www.neuroimmunology.org.uk wow so it's a bit of a mouthful it is but guys you know don't worry about remembering that i'll find i'll get that link i'll make sure it's working and also if there is a link to that study potentially i'll also put that in the show notes at drchastity.com forward slash inflamed minds. Because, you know, Professor Bullymore is, you know, he's a world leading researcher. He's really at the forefront of this field. And the reality is, is that we need a whole multitude of treatments to help people with mental health problems. Depression is on the rise. As Professor Bullymore said right at the start, this, at the start there'll be no family who goes

untouched by this arguably across the world but certainly in the UK and so the more understanding we've got, the more therapies that we've got at our disposal to help people the more good we can do, the more people we can help so I wish you all the well with your

research, I think you're doing fantastic work in helping change, you know, the medical profession's understanding of depression. I think you're coming at it from a very different angle from me, which I think is fantastic and very much needed because, you know, you're there as a psychiatrist in a very, you know, in a very traditional field of medicine and you're really trying to you know bring about some change there and you're really looking for some really robust good quality evidence before you

go and make recommendations and i really respect that i think i think the listeners will as well and um you know i look forward to hearing more about it and maybe as your research develops maybe i can get you back on in the future we can talk about and update it'd be a pleasure really enjoyed talking to you. Yeah, me too. I really appreciate the book that you've written, The Inflamed Minds. And I really appreciate your time today.

Thank you so much. That concludes today's episode of the Feel Better, Live More podcast. I hope you found today's episode insightful and that it has changed, or at the very least caused you to re-evaluate the way you think about depression. Of course, depression rates are on the rise all over the world. So do please share this episode with anyone who you feel may benefit.

If any of you are interested in helping Edward with his clinical trial, the link to that, as well as everything we talked about on the show today is on the show notes page at drchastity.com forward slash inflamed mind. There is no question for me that depression is caused by different things in different people. And therefore the nature of the treatment often needs to be personalized to the individual. I have been seeing patients now for over 17 years and I've seen that making small changes to one's lifestyle can have a huge impact on our mental health. My first book, The Four Pillar Plan, is all about helping people to make simple and accessible lifestyle change. It has literally inspired thousands of people to make lifestyle change

that many had previously thought unachievable. If you don't have a copy yet, please do consider picking one up. For those of you listening in the US and Canada, it has been released over there with a different title, How to Make Disease Disappear. Stress is another big driver for mental health problems and I have taken a deep dive into stress in my brand new book The Stress Solution. I discuss all the places that stress lurks in the modern world and most importantly I give you plenty of take-home strategies to help lower your stress levels so that you can live a happier and calmer life. The Stress Solution is available to order now in both paperback as well as audiobook, which I am narrating.

As always, please do let me and Edward know your thoughts on today's podcast on social media and anything you can do to help me spread awareness of the podcast is very much appreciated. Tell your friends, your family, or simply take a screenshot right now of the podcast and share it on your social media channels. That's it for today. I hope you have a fabulous week. Make sure you have pressed subscribe and I'll be back next week with my latest conversation.

Remember, you are the architect of your own health. Making lifestyle changes always worth it because when you feel better you live more i'll see you next time