Mental Illness Is All In Your Body
The paradigm-bending results of a new study
Note: This column explores the emerging paradigm shift in how the field known as “mental health” is conceptualized, researched, and translated into treatment interventions. This column includes quotes by the World Health Organization and the United Nations that challenge the widespread use of antidepressants to build individual emotional well-being without addressing the larger social context of mental health. I want to highlight what sometimes can feel like a binary. Either antidepressants are necessary and good, and therefore no social or other factors need be discussed or, when social and other factors are discussed, the people doing so are implying that antidepressants are unnecessary or inferior forms of treatment. This is a false binary. Antidepressants are helpful, even life-saving, and are not sufficient alone. Alongside current treatments, which are themselves undergoing profound shifts, we must also consider physical health, including the immune system, the enteric nervous system, fascial system, genetic and epigenetic history, and our larger social body. The integrative nature of this both/and approach is the factor that will move the needle on our suffering.
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And now, on to the study that I promised, in my last Substack Note, to share.
Most people list emotional balance and physical health as the two most important factors in well-being. Yet in growing numbers worldwide, we struggle with both. Mental illness affects more than 450 million people worldwide, with depression slated to be the top contributor to global disease by the year 2030. The WHO gave this prediction in 2013, long before the pandemic. Experts and now estimate that 2023 is the new 2030, and that depression is now the number one global burden of disease.
Research has long examined the impact of mental health on the body. This makes sense, because emotional distress doesn’t affect the mind alone. A worldwide survey shows that negative emotions have an even greater impact on physical health than even basic needs like adequate nutrition. As you might expect, our declining physical health reflects this; nearly 38 million people die each year from non-communicable physical diseases, and that number continues to rise.
But what about the impact of the state of the body on mental health? The existing body of research on this question is sparser, but beginning to take off. (As you know, this is an area of great interest to me and one of the focus areas of this column.)
The study we look at together today addresses how body health affects the mind, brain, and mental health. A note from me: Understandably, the researchers’ conclusions are cautious, and their estimates of the study’s implications conservative. Because I’ve been writing about this, including in last week’s column, and because I have greater academic freedom to play with the implications, mine will be less so.
The Modern Mental Illness Paradigm
The historian Thomas Kuhn studied the process of scientific revolutions, in which paradigms shift from one long-held theory to a new one. The first phase, before a shift occurs, is characterized by disorganized and even chaotic activity. In the second phase, which is more stable, a new paradigm exists and the presence of anomalies are tolerated. The third phase is characterized by crisis, and also by novel science and many competing theories. If anomalies are not resolved in this phase, a scientific revolution occurs that changes the long-held paradigm. In the fourth and final phase, the new paradigm better explains the observations, and offers a model closer to objective research. (This is a little linear and doesn’t take into account the relationship between western science and epistemic traditions, where the forces of colonization extract what they wish to from indigenous traditions, skewing the process—but the notion of paradigm shift itself is helpful for the purpose of this discussion.)
I think we’re somewhere around the end of Phase 2 in medicine, where the presence of mind-body anomalies are “tolerated,” but not yet in the crisis that augers Phase 3.
Many thanks to the uber-brilliant Cassandra Horii, the uber-brilliant author and director of the Stanford Center for Teaching and Learning, for introducing me to Kuhn’s work years ago. It helped me with teaching and teacher training pedagogy. It also offered perspective on the early resistance I encountered to my work and, paradoxically, gave me the confidence to pursue the integration of seemingly disparate fields of knowledge before this was commonly done.
My take: For me, and I think many of you, the notion of paradigm shifts illuminates the social context of yoga and mind-body teaching. Many yoga teachers and therapists attuned to mind-body methods, for example, teach a more interoceptive, awareness-based, slower-moving form of yoga. There’s a cost in doing so when more popular, even culturally accepted methods are faster and more challenging. You may not get many students. Studios and conferences may pressure you to teach differently. And you may feel a little “out there” on your own. Understanding a bit about paradigm theory can give you the courage to stay the course, and to honor your own unique approach to therapeutics and to mind-brain-body medicine.
What’s the relevance of paradigm theory to the way we approach mental health today, you might wonder?
Our modern western medical paradigm has long viewed mental illnesses as brain disorders, biochemical issues, or genetic diseases. However strong it is, this paradigm is not empowering. Its implications: There’s something “wrong” with your brain. You’ve got a “biochemical imbalance” and therefore, antidepressants alone (and perhaps psychotherapy) will “fix” it. Or it’s in your genes and there’s nothing you can do about it. Underneath all this is a presumption I’ve long lamented: Mental health is an individual prospect. Health is then up to you individually (i.e. you’re on your own); if you’re suffering, it’s your fault and your responsibility. In this paradigm, mental health exists apart from social context.
The system of beliefs that underlies this paradigm has seemed almost frozen in time. But those of us paying attention can hear the low groan of ice beginning to crack.
The Paradigm Shift in Progress
One of the signs of a paradigm shift for me has been the acknowledgement of organizations such as the United Nations and the World Health Organization that our current mental health paradigm is inaccurate and, in fact, harmful.
Way back in 2009, the World Health Organization issued a strong statement that critiqued individualized approaches to mental health and emphasized the social determinants of mental health.
“A focus on social justice may provide an important corrective to what has been seen as a growing over-emphasis on individual pathology,” the WHO stated. “Mental health is produced socially: the presence or absence of mental health is above all a social indicator and therefore requires social, as well as individual, solutions. A focus on collective efficacy, as well as personal efficacy is required. [Focusing on a] person with individual symptoms may lead to a ‘disembodied psychology’ which separates what goes on inside people’s heads from social structure and context.”
And in 2017, the United Nations came forward to publicly decry the medicalization of mental health issues, and to link these issues to social justice and equity:
“Regrettably, recent decades have been marked with excessive medicalization of mental health and overuse of biomedical interventions, including in the treatment of depression and suicide prevention. The biased and selective use of research outcomes has negatively influenced mental health policies and services. Important stakeholders, including the general public, rights holders using mental health services, policymakers, medical students, and medical doctors have been misinformed. The use of psychotropic medications as the first line treatment for depression and other conditions is unsupported by the evidence. [Italics mine] The excessive use of medications and other biomedical interventions, based on a reductive neurobiological paradigm causes more harm than good, undermines the right to health, and must be abandoned.”
It's notable that even slow-to-change institutions such as the WHO and the U.N. have been saying for 10-15 years that the accepted paradigm in mental health is outdated.
And they’re not alone: Emerging research has for a decade or more supported a paradigm shift.
The Emergence of a New Paradigm
Here’s just one example of such research. Studies show that people with depression have high levels of circulating inflammatory cytokines such as lipopolysaccharides (LPS), which we talked about in last week’s column in relation to brain health.
Other studies support the causal role of inflammatory molecules in depression and have found, for example, that people with major depressive disorder have chetokines (inflammatory molecules) in their blood and cerebrospinal fluid. They also have high interleukin-6, interleukin-8, tumor necrosis factor, c-reactive protein, and other signs of inflammation. [I’m going to talk about the inflammation-depression connection in this Substack soon.]
And now, a new study has emerged which highlights the mind, brain, and body connection in mental health. Organ systems like lung health, liver dysfunction, bone health and loss haven’t been assessed, and the authors of this study wanted to look at these organ systems alongside inflammation.
The Study
Ye Ella Tian, Andrew Zalesky, and their colleagues selected 85,748 adult participants aged with neuropsychiatric illnesses and 87,420 control participants. Subjects came from neuroimaging “banks” in the U.S., the U.K., and Australia, and were between 19 and 95 years old.
The researchers focused on four neuropsychiatric illnesses: generalized anxiety, depression, bipolar disorder, and schizophrenia.
They used two types of MRI-related brain-imaging: structural and diffusion-weighted MRI scans.
For my neuro-nerd cohort: The brain-imaging element of the study used two types of scans, structural and diffusion-weighted MRI scans. (Diffusion MRI, or dMRI, assesses molecular diffusion in biological tissues. It provides insight into minute details of tissue architecture.) The scans assessed gray matter, which makes up the cortex, or outer layer of the brain. The brain imaging in this study also looked at white matter architecture. White matter is composed of millions of nerve bundles that link neurons in different regions of the brain. White matter pathways are the primary route of communication in the brain. Their structure takes a long time to develop: Full maturation occurs in our mid-30’s. Importantly, stress has a degrading impact on white matter pathways.
The study integrated blood- and urine-based markers and other physiological measures. It examined organ health across various metrics, including cardiovascular, pulmonary (lung), hepatic (liver), renal (kidney), musculoskeletal (bone and joint), and immune systems.
Their primary finding: In all four illnesses studied, poor body health, particularly in the metabolic, hepatic, and immune systems, was a more marked manifestation of mental illness than brain changes. Sadly, despite profound deviations from the norm for multiple organ systems, chronic physical comorbidities (conditions occurring with the primary illness) often went undiagnosed. This likely indicates the marginalization of people with “mental” illnesses, seen in lack of screening, preventive care, intervention, and access to healthcare in this population. Our current paradigm of mental illness cements these inequities in place.
One Key Note on Social Context
In this column, I talked about the bias in representation with respect to who does the studying, what they choose to study, and who they study. The database for this study came primarily from people with European ethnicities, which is its main weakness. As the authors themselves acknowledged, it’s unclear to what extent the results would apply to other demographics.
My take: In previous columns, I’ve outlined numerous links between racial and sexual/gender discrimination and physical, mental, and brain health. My sense is that including in studies people outside the WEIRD demographic—that is to say, western, educated, industrialized, rich, and democratic and also young, white, and able-bodied—would yield an even stronger correlation mediated by oppression. The chronic stress and trauma of race-based discrimination, for example, causes weathering, inflammation, compromised organ health, and mental health challenges.
The authors concluded that the management of serious neuropsychiatric illnesses should incorporate the importance of poor physical health and target restoration of brain and body function. They stated—and here’s the part I think was understandably cautious—that they’d like to do further work to determine whether organ health scores can predict physical comorbidities in psychiatric illness.
Aging, Mental Health, and the Brain
As it happens, the authors of the study had access to a large database of individuals with dementia, which they used for a supplementary analysis. Unsurprisingly, they found that of all the disorders studied, dementia manifested the poorest brain and body health. At the time that body function was assessed, most of the participants had not yet experienced or been diagnosed with dementia.
My take: Last week, we saw that markers of gut health today can predict the emergence of Parkinson’s Disease not just years, but decades, down the road. Given the strong link between inflammatory markers and depression [stay tuned for more], I’d like us to consider that early manifestations of disease in the seven body systems studied might someday soon be able to predict not just neurodegenerative diseases, but mental health illnesses years, if not decades, in the future.
This, I believe, is a new paradigm well worth exploring.
Sources:
Mental illness affects more than 450 million people, with depression: http://www.who.int/mental_health/action_plan_2013/mhap_brochure.pdf?ua=1. Accessed June 11, 2016.
A worldwide survey shows that negative emotions have: University of Kansas. (2009, March 5). Human Emotions Hold Sway Over Physical Health Worldwide. ScienceDaily. Retrieved June 11, 2016 from www.sciencedaily.com/releases/2009/03/090304091229.htm.
Way back in 2009, the World Health Organization issued a strong statement that critiqued: Friedli, Lynne & World Health Organization. Regional Office for Europe. (2009). Mental health, resilience and inequalities / by Lynne Friedli. Copenhagen : WHO Regional Office for Europe:. https://apps.who.int/iris/handle/10665/107925
And in 2017, the United Nations came forward to publicly decry: OHCHR | Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Mr. Dainius Pūras. (n.d.). Retrieved August 30, 2021, from https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=21480&LangID=E
For example, studies show that people with depression have high levels of circulating inflammatory: van Eeden, W. A., van Hemert, A. M., Carlier, I. V. E., Penninx, B. W. J. H., Lamers, F., Fried, E. I., Schoevers, R., & Giltay, E. J. (2020). Basal and LPS-stimulated inflammatory markers and the course of individual symptoms of depression. Translational psychiatry, 10(1), 235. https://doi.org/10.1038/s41398-020-00920-4
Other studies support the causal role of inflammatory molecules in depression: Miller, A. H., & Raison, C. L. (2016). The role of inflammation in depression: from evolutionary imperative to modern treatment target. Nature reviews. Immunology, 16(1), 22–34. https://doi.org/10.1038/nri.2015.5/ See also: Felger J. C. (2018). Imaging the Role of Inflammation in Mood and Anxiety-related Disorders. Current neuropharmacology, 16(5), 533–558. https://doi.org/10.2174/1570159X15666171123201142
And now, a new study has emerged: Tian, Y. E., Di Biase, M. A., Mosley, P. E., Lupton, M. K., Xia, Y., Fripp, J., Breakspear, M., Cropley, V., & Zalesky, A. (2023). Evaluation of Brain-Body Health in Individuals With Common Neuropsychiatric Disorders. JAMA psychiatry, e230791. Advance online publication. https://doi.org/10.1001/jamapsychiatry.2023.0791
White matter pathways are the primary route of communication in the brain: Fani, N., Harnett, N. G., Bradley, B., Mekawi, Y., Powers, A., Stevens, J. S., Ressler, K. J., & Carter, S. E. (2022). Racial Discrimination and White Matter Microstructure in Trauma-Exposed Black Women. Biological Psychiatry, 91(3), 254–261. https://doi.org/10.1016/j.biopsych.2021.08.011
In an interview about their work with JAMA Psychiatry, Tien and Zalensky noted that: Listen Here