9th Renewal Convention on
Adult Children, Recovery, & Trauma
Las Vegas , NV � February 23-26, 2005
The Truth About Depression: An Evidence-Based Approach
Charles Whitfield, MD (ACOA25-021-Whitfield)
WHITFIELD: <Begins midstream.> � of what have written in much more detail in my new book The Truth About Depression , and its companion volume is called The Truth About Mental Illness . What I'm going to tell you is in many ways the opposite of what you may have heard about depression and mental illness and about some other things too about the drugs that are used to treat these conditions; and so if it appears to be a little bit off the mark from what you are used to, just remember that a lot of things have been off the mark from what we've been told in our growing up.
The first thing is that seratonin is really not the problem. Where do you think that came from? Well, what we are going to find out, what I found out is that it came from drug companies that want to sell their drugs, and they market their drugs in order to make people think that they have a problem, that they have a seratonin deficiency. Depression is not, first of all, it doesn't have a simple, single cause. It's not a seratonin deficiency. As a matter of fact, there is little or no evidence about a seratonin problem. I'm going to be coming back to that more and more throughout this today. It is not acceptably responsive to antidepressant drugs. Let me just check it out with you: How many of you have ever thought that you might be depressed? Let's just see a show of hands. Leave your hands up and look around the room. So most of the people here, okay? How many of you have tried at least one antidepressant drug? Keep your hands up, look around the room. Okay, most, again, most. How many of you have tried more than one antidepressant drug? Now if they worked, you wouldn't be raising your hands, because these drugs, there are some 30 of them now, and if they worked you wouldn't have to go to another, to another, to another. How many of you have tried three different antidepressant drugs? Okay, maybe, still about two-thirds.
So this is the same picture that I get when patients come in to me in my practice. For assistance in recovery, they give me this same history. First of all, the drugs didn't work very well; and second of all, they've been on a string of drugs. I've had one person who has been on nine different antidepressants and not one has helped. Or here is what else can happen, is that the drug may work in a certain percentage of people for a time, but then it doesn't last; it runs out steam somehow. Has that happened to anybody, that it worked for awhile for you and then it stopped working? I'll come back more to the drugs in a bit.
There is unconvincing evidence for any genetic transmission of depression. Now, there's kind of the opposite of what we've been told; and because it's easier to sell treatment when it's got this genetic thing, especially when it's claimed that there's a biochemical abnormality in our brains and it's a seratonin problem, but you can fill in the blank with any other brain biochemical and say, �Yes, it's abnormal in addition, or too, and that's genetic. It's a genetic problem; and here, you need our drug.� Many people with depression have Post-Traumatic Stress Disorder. In the work that I do, which is specializing in working with adults who were abused as kids, and that's what I've been doing for a couple of decades now, is that I screen everybody for PTSD because not only is it so common among people with depression and addictions and other kinds of common so-called �mental disorders,� it's one of the most treatable of all of the so-called �mental disorders.�
Many people with depression also have multiple co-morbidities, and one of the markers of a trauma survivor is multiple co-morbidity: People who have an addiction, who have depression, who have an anxiety disorder, who have whatever, fill in the blank with whatever you've been diagnosed with or thought you might have or believe that you did have. A history of multiple drug treatment failures. Now there is overwhelming database linked � and that's why I subtitled this talk today �An Evidence-Based Approach� � because there is overwhelming evidence now�overwhelming database link with trauma. There are now 327 studies on over 200,000 people. There are scientific, rigorously controlled studies done by multiple international authors, who are independent, over a time span of approximately the last two decades. There are a few studies that go back a little before, and I'll be reviewing with you this data.
Depression has a delayed or sleeper effect just like almost all of the trauma effects do, that these effects are not there immediately, that there can be a time of months, commonly to years, before a common effect of trauma occurs. Witness addictions: You can be repeatedly traumatized as a child, which most people with addictions have experienced, and then the addiction doesn't come on until years later. And difficulty remembering the trauma; this whole idea that I'm sure you've heard over the last 12 or 15 years, this notion of a False Memory Syndrome, have you heard about that? There is little or no data to support the existence of any such thing as a False Memory Syndrome. Do you know where that came from? It came from an organized group of child molesters, of accused child molesters. They banded together and named themselves �The False Memory Syndrome Foundation,� and they pledged, initially, to support and disseminate research on False Memory Syndrome, which they made up. That has not come about, but the media bought it and we all now have this notion. Anybody who watches Court TV? In the last couple of weeks, Paul Shanley, the priest in the Boston area, did anybody see that? He was found guilty of sexually abusing this 27-year-old man who came and testified, and one of the defenses for the priest was that this man, this 27-year-old man, made it up and that he had False Memory Syndrome. So just know that whenever you hear this notion that trauma survivors make up having been abused, those beginning facts, and I have a book with Health Communications that I did back in 1995 that still stands accurate and comprehensive called Memory and Abuse.
A high use of inpatient and outpatient medical and psychiatric care and psychologic care�it is just quite common to see people with depression with that. And finally, depression is more treatable when we link it to trauma or some other cause, because there may be another cause of depression. So one of the first orders of business in helping someone with depression is to find out the cause. I mean, we do that in most other areas of medicine and psychology, but we don't do enough with depression. And we need trauma treatment therapists and time to make that work. How many of you work with trauma survivors? Let's just get a sense. Keep your hands up and look around the room there. I would say at least half, maybe a little more than half. I hope I'm not preaching to the choir too much here, that you already know all this, but some of this may then be in review for you and some of it may be new or interesting or whatever. Yes?
PARTICIPANT : I was struck by no evidence for genetic transmission because it's a truism that I parrot to my patients that alcoholism and the addictions seem to cycle in families.
WHITFIELD : I didn't say alcoholism and addictions, I'm talking about depression. However, there is evidence also that alcoholism and the other addictions are more trauma effects than they are genetically transmitted. You know, because there is the old dilemma, what else besides addictions or depressions or whatever you want to name, runs in families? Trauma. And how did these researchers try to evaluate genetic transmission? They used pretty sloppy methodology, one of which is interviewing only one generation. They don't go back multiple generations because they can't very easily. It's very difficult to do that, if not impossible. I've got a whole section in The Truth About Depression , some in The Truth About Mental Illness, where I discuss that.
Now, I'm not saying that there is no genetic transmission, no evidence of genetic transmission for addictions, but I'm saying that there is more evidence for a trauma-based than there is for genetics, and I'm not ruling out genetics completely. Was that your question?
PARTICIPANT : [Inaudible] and he relapsed and he went to the ER for detox and his doctor asked him, �Are you depressed?� and he said, �No.� �Well, I'm going to put you on Zoloft anyway.� And he's been relapsing ever since, and I can't take him off the Zoloft. It's a real problem. I also wrote a letter on SSRI's for the California Association of Alcohol and Drug Abuse Counselors against SSRI's, and that got a lot of people mad at me.
WHITFIELD : Yes, you know, we are finding out more and more about these drugs. First of all, that they don't work very well; and second, they are addicting. Antidepressants, SSRI's, are addicting, not in the conventional sense of addiction that you and I know so well, that people use it to get high or to alter their state of consciousness in a regular way that we are familiar with, but they are taking the antidepressant to try to feel better from their �depression.� The problem is that when you try to stop it, more than half the people have a serious withdrawal syndrome that is bothersome. Now, the worst withdrawal syndrome is, of course, from the benzodiazepine sedative drugs, like Valium, Atavan, Xanax, and family; but these drugs also have withdrawal. So the order of business is to taper those drugs slowly and to tolerate the emotional pain and the physical pain while you are tapering them. Take as long as you need to taper, and do it under the supervision of a physician who knows how to do that tapering.
PARTICIPANT : I was just going to say I had a drug and alcohol client who was getting off Paxil; they suicided, but with an overdose because they were so out of control with the withdrawal.
WHITFIELD : Yes, yes, so you can get suicidal, sometimes homicidal, coming off the drugs, but you can also get that way going on the drugs. People can get very agitated; and what is called acathesia, which I discuss in The Truth About Depression . They get suicidal and sometimes homicidal. Surely it's probably less than five percent of people who take antidepressants, but that's still a pretty big number. The drug companies, just like the tobacco companies, have tended to minimize that, if not strongly minimized it.
Let's look quickly, this is not in your handout here, but I just want to give a couple of highlights for you. This is taken from a very important book, if you have an interest, that I reference in The Truth About Depression and The Truth About Mental Illness , but it's by Elliot Valenstein from the University of Michigan . It's called Blaming the Brain, The Truth About Drugs and Mental Health , 1998, Basic Books. What he is saying here is that of depressed patients studied, now he's reviewed the world literature up to 1998, and he says of the depressed patients studied, half of them have a normal cerebral-spinal fluid seratonin, and only one fourth of those people have low levels of seratonin, and another fourth have high levels of seratonin. So even if you could measure seratonin in the cerebral-spinal fluid or in the urine or in the blood, it offers no help, which backs up the fact that there is no such common test that psychiatrists or psychologists or anybody runs on their patients when they are concerned about depression.
As a matter of fact, there is no laboratory test for any common mental disorder, period. So if these so-called �disorders� are biologically based, then why isn't there a laboratory test? I mean, there's a laboratory test for just about every other kind of physical illness. We can only guess at brain neurotransmitters by measuring the metabolite which is 5HIAA in the urine and the cerebral spinal fluid, but less than half of seratonin or norepinephrine metabolites, which are the breakdown products found in these, come from the brain. The seratonin norepi come from all over the body, all other organs. David Healey, Metzler, Carlson and [Shell] agree that the biogenetic amine theory � that's the seratonin, norepinephrine, etcetera, theory of depression and schizophrenia�Valenstein notes, are seriously in error. He didn't say they were in error or possibly in error, seriously in error, and we don't know how treatments work. We also don't know the cause of bipolar disorder or how Lithium works.
Bipolar disorder is another whole can of worms. How many of you have been diagnosed with bipolar? Let's see a show of hands. Only one? Now that's unusual, that's unusual, because when I talk to groups this large there are usually several people who have. How many of you have thought you might have it or seriously wondered whether you might have bipolar? Okay, another one, two, three people. Okay. Okay. Bipolar is another disease of the month, disease of the year, disease of the decade. There is little clear information about it. However, I think it's real. I think it has�in many people, it is real where there is the classic cycling pattern, and it can be very disruptive to a person. But conventional antidepressants don't usually work very well, nor do any other drugs, including Lithium, although for some people Lithium can work for a time.
PARTICIPANT : I had just had a statement. I've worked at a college for 30 years and work with students, and the last three years that I was working, probably three or four, maybe five students a week would come in telling me they were diagnosed with bipolar disorder, all of a sudden. I am of the understanding that bipolar disorder is genetically based.
WHITFIELD : Again, well, as I've done my research and as Valenstein and other people have, there's again little evidence that it's really genetically based. I don't know, because again, what else runs in families besides these so-called �disorders,� including addiction? Trauma, okay? Hold yours for one second and let me finish with this one here. Stress, therefore trauma, can cause, and commonly does cause, a low seratonin. The biological problems in the brain that we are measuring and have been measuring for the last couple of decades may, instead of being the cause of the various kinds of mental illnesses may, in fact, be one of the possible mechanisms. So they are just intermediaries; they might just be the intermediary and not the direct cause, and the trauma may be the most common cause. Valenstein says over and over that pursuing the biochemical approach to mental disorders has taught us a lot about neurochemistry and proposed drug action, but little about the nature of mental illness itself.
If you want to read a book that has it documented chapter and verse from a neuropsychologist from the University of Michigan who has devoted his life to neuropsychology, he's a neuroscientist, and he started out researching for this book, not to prove what I'm telling you. He was going to document the opposite of all these things. Why it's a seratonin problem, why the drugs help people, etcetera; and it turned out he found the opposite. So to me, that's much more believable than if he had set out to do it and then proved what he didn't find, proved, basically, the party line. Yes, why did they change the name? No, do you know?
PARTICIPANT : I suspect [inaudible].
WHITFIELD : Yes, probably. You know, they change names for a lot of things; we change names. Political correctness, hopefully it would be scientific correctness. I don't know. I think it's important though for all of recovery to name things accurately. When we name things accurately, it opens doors to all kinds of healthy things, right? How many of you have ever named that you had an addiction to alcohol or drugs or food or anything, okay? Was it useful to have named that accurately? Did that give you personal power? So, to name things accurately is personal power, including to name, that if it happened, that we were abused as kids�we were traumatized, we were neglected, etcetera.
Here is a key study among those several hundred that I just mentioned. It is called �The Adverse Childhood Experiences Study,� abbreviated �ACE Study,� A-C-E. This was published in The American Journal of Preventive Medicine in May 1998; it just has all kinds of good stuff. It was conducted on a large number of people, 9,500 respondents out of 13,500 people who were members of Kaiser Permanente in Southern California in the San Diego , greater San Diego area. Now, these people were studied pretty extensively over a number of years. These were adults who were medically evaluated and completed a 68-question survey about seven categories of childhood trauma or ACE's. The authors found that a large percentage of this general medical population reported the following traumatic experiences from their childhood. These were not necessarily symptomatic people; these were people who were coming in for their yearly check-ups, which Kaiser wisely does. But the most common, one in four, where they lived with an alcoholic or a drug-dependent person � they found, in this general population, a mixed group of people, that one in four had it. It is at least that common, probably, possibly, in the rest of the country. Sexually abused, this is overt sexual abuse now, not covert, not the non-touching, but touching kind, 22 percent. At least one in four lived with a mentally ill person, 19 percent. Witnessed their mother being treated violently, 12.5 percent. They did not look at whether the father was treated violently, there is good evidence that when violence happens, it commonly happens, usually happens, both ways. And so that the man is also being physically abused by the female spouse, but we didn't look at that here and most people don't look at it.
The big problem here� this is the United States studies by Archer and others�but here is the difference, that men being most of the time larger than their spouse and stronger. They can inflict more damage physically upon her, and so that's why it's refocused on that. This is work of Archer and other people. I'm not making any value judgments on this. Emotionally abused, 11 percent; physically abused, 11 percent. And had a household member went to prison, about 3.5 percent. Now, here were the disorders that were found in the ACE study. Cigarette smokers, over two times the people who were not abused. I'll get into that in a minute to differentiate depression here and show you some details about depressions. Cigarette smoking is at least twice, probably a little more, common. And so now, what we know is that the people in this country, in the 40s and 50s, about 44 percent of the population smoked. That's a lot. What is it now? 23 percent. That's almost halved. Vince [Fillitti], who is the senior author here and Rob Ander, who is the co-senior author of the ACE study, have suggested that the people who are continuing to smoke cigarettes are the more severely traumatized and that the ones who were perhaps less traumatized were able to stop smoking. I don't know, it's an interesting idea. I cite in The Truth About Mental Illness some eleven studies�there have only been eleven studies that have tried to look at cigarette smokers and tobacco users who were differentiated either trauma survivors or not trauma survivors. Severe obesity, close to 1.6 times. Usually you can't tell a trauma survivor by looking at them, right? Here is one way you can. Anybody who is 100 pounds or more overweight, it is 99.99 percent likely they were trauma survivors. Now we can say cigarette smokers, anytime you see somebody smoking cigarettes. And there are other things now we can look at too that have not been looked at as much, but multiple tattoos, multiple piercings, and another interesting one, this is not looking at the person themselves, but looking at their medical chart�the thicker the chart, the more likely trauma history. Why? Because they've got all this co-morbidity, and they overuse and use a lot of the health-care system.
No leisure-time physical activity increased 1.3 times. Depressed for two weeks or more in the last year, 4.5 times. Suicide attempt 12 times �t hese are all odds ratios �i n other words, 4.6 times and 12.2 times for depression and suicide. And remember, an odds ratio, every time you go up a number you go up 100 percent. So 4.6 odds ratio would be 460 percent. Alcoholics, 7.4, that's a big number. See, because if you look at heart disease and cigarette smoking, that's got to be seriously related. Smokers get heart disease at least twice as often, and that's considered enough for the Surgeon General to write on the cigarette pack the warning label, and that's just two times odds ratio. Here we've got 7.4 for alcoholism and 4.6 for depression? Those are very high odds ratios. Illegal drug use, 4.7, and ever injected drugs, 10.3. More than 50 intercourse partners, 3.2. Ever had a sexually transmitted disease, 2.5. And now we get into some physical disorders. Ischemic heart disease or coronary artery disease, 2.2. Cancer, 1.9. Stroke, 2.4. Chronic obstructive pulmonary disease, which mostly comes from cigarette smoking, is 3.9. Diabetes, 1.6. Broken bones, 1.6. Hepatitis or jaundice, 2.4. And fair to poor health estimated by the person, 2.2. These are odds ratios, not percents. So these serious medical conditions and disorders were clearly more common by the above number than they are known to exist in the general population.
And if we look just now at depression and say, �Well, what details do we know?� we can see a lifetime history of depression by ACE Score �Adverse Childhood Experience Score� various women with the dark bars and men with the grey bars, this is no adverse childhood experiences, this is one�history of one, history of two, three, four, or more; the more trauma history, history of traumas, various kinds, ACE's, the more association with depression. This is called an increased graded relationship between a trauma history and a history of depression.
This is considered in epidemiology to be a strong, evidentiary connection here, and you can't say, �Well, just the one ACE study alone, you cannot read, as scientists and clinicians, we cannot conclude that there is causality.� But we've now got over 300 similar studies to the ACE show a statistically significant correlation. So I'll say more about that as I go along.
So here is a conclusion from the ACE study. It's called �Mechanisms by Which Adverse Childhood Experiences Influence Health and Well-Being Throughout the Lifespan.� So here is conception and birth and the whole lifespan and death. Adverse childhood experiences bring about disruptive neuro developments. So all of this stuff that we are learning from neuroscience and psychiatry and some psychology and others, other research, about disruptive neuro development and brain structure and function and chemistry problems, come commonly from childhood�repeated childhood trauma, which then brings about social, emotional and cognitive impairment and then adoption of high-risk behaviors or health risk behavior, which then brings about disease, disability, and social problems and early death.
So this diagram is also from The Truth About Depression , sorry to move a little bit fast here. For those of you who want to take the notes. I want to mention here an interesting connection because for children of alcoholics we've always thought that maybe what the problem is, that not only is alcoholism possibly associated with having an alcoholic parent, but depression is too, and here is what we found when we took that same database from the ACE study, we found that when there were alcoholic parents that there were more ACE's present and that there was more association of the depression in their usually adult children with the childhood trauma, with the ACE's, than there was in just having an alcoholic parent. So, having an alcoholic parent is really a marker more for repeated childhood trauma than for a genetic relationship. Yes, stand up and talk loudly so everyone can hear.
PARTICIPANT : [Inaudible].
WHITFIELD : Yes, I'm going to mention that in just a minute, I'm going to go into some detail, right. So here is kind of a summary or one summary that comes from The Truth About Depression , so basically the childhood trauma brings about brain damage and illness, which can be mental and physical. And the assumption is that these effects here, the illnesses, mental and physical, come from the central nervous system damage. That is the assumption. The correction is that childhood trauma is the cause of both the brain damage and the illnesses. So that's why I said earlier that these brain abnormalities that we found are probably the mechanism and not the cause.
An interesting one here that Vince [Filliti] in San Diego, who is senior co-author of the ACE Study, looked at the ten leading causes of death: With cause or association of disease or disorder and risk of having a history of childhood trauma or ACE's and related or cited the ACE risk that was found in the ACE study and all their smaller papers that have focused on these details of various disorders, heart disease being the most common. Basically, what it shows is the ten leading causes of death in this country are highly associated with a history of repeated childhood trauma.
ARTICIPANT : [Inaudible].
WHITFIELD : Good. 1.6 to 2.2 times and here 3.2 to 7.4, and this one here for pneumonia, is 2-plus to 7.4 times. Yes, if they had received treatment, these trauma effects would not have happened; and, of course, the first treatment would have been to be born to healthy parents in a healthy family in a healthy world, but the chances of that are not so good, although today, I think it's getting better, but certainly 100 years ago, 500 years ago, and 1,000 years ago there was a lot more childhood trauma than there is today. Yes, and then the second order of business�that would be primary prevention that I just said. The second one then would be secondary prevention, which would be early intervention to stop the abuse and neglect.
Okay, here is a quick 101 about childhood trauma. Different kinds of abuse; four main kinds of abuse childhood trauma. The first one, the most common, is psychological and emotional abuse. This is in your handout: Things such as teasing, shaming, judging, threatening, terrorizing, comparing the child, invalidating the child, etcetera. The opposite, the flip side of that, is the healthy parenting. Unconditional love, support, validation, giving appropriate attention, recognizing, etcetera. Okay, thank you. Sexual abuse, 10 to 30 percent. Now my sense is that the psychological abuse is probably there in 80 or 90 percent of families even today. I once knew someone who grew up in a healthy family. Sexual abuse, 10 to 30 percent � 30 percent probably for girls, ten percent for boys, although that can vary depending. Some people think it's higher for both of those. There are two kinds of sexual abuse; covert, that's the non-touching kind and then overt. The non-touching or covert, like telling dirty jokes, inappropriate nudity, preoccupation with sexual matter, etcetera, would be some examples of covert sexual abuse. Overt sexual abuse is things like touching, stimulating them sexually, penetrating, threatening, those kinds of things.
Physical abuse, 12 percent have serious physical abuse. Hitting, slapping, pushing, punching, kicking, bruising, burning, choking. That's really serious. I'm not talking about occasional, moderate, or light spanking, which I do not recommend because I think any spanking is abuse. Alice Miller has written about this masterfully and there's a guy, James Dobson, who is a Christian writer, a psychology kind of a guy, who does some good stuff, but he says it's appropriate to spank the child to discipline them. So, that's kind of a debatable thing, but at least we are raising the issue, and Sweden has outlawed it. It is one of the few countries where it is a crime to spank a child.
PARTICIPANT : Does this include bullying as well from peers?
WHITFIELD : Yes, it would be bullying also. That's not on there. The flipside, of course, is appropriate touch or caress or hugging. And now finally, child neglect. At least 25, at least one in four kids are neglected, and that could include food, clothing and education, medical care and shelter. Now most of us maybe got most of that, but some of us maybe didn't. Just one second here. Neglect regarding safety, protection from other traumas, there is a big one. Somebody witnesses the child being abused, and they do not stop it or seriously try to stop it. And, of course, the flipside of the neglect would be to provide all of those above. Yes?
PARTICIPANT : How long has it been in Sweden a crime?
WHITFIELD : I don't know how long, but I think it's just a few years. I haven't seen any studies, but I haven't looked for them either. Yes, good question. Yes, shaken baby, that's severe abuse, and then if you look at the association then of these kinds of trauma, you can see�and this is in your handout too, that then the most common kind of abuse is psychological or emotional abuse and then how big it is, sexual abuse, physical abuse and neglect. This is a Venn diagram showing this. This is in your handout.
Now, I want to show you just kind of the summaries of the relationship to depression and what kind of studies have been done. These were the first 209 clinical, community and prospective and index case reports that I found that are described in some detail or at least summarized in The Truth About Depression . So, this is just one main summary table showing these. 96 clinical studies, 70 community studies, 22 prospective studies, 21 index case studies; that is, index cases are people who are depressed and then you check them out to see what kind of histories they have, and then all four we see here, 209 studies, on 121,500 trauma survivors and their control. And depression was increased from 1.6 times to 12.2 times and increased up to 12 times for suicidality in these various samples here. And there was a common, graded relationship to trauma severity, and that there was a high and multiple co-morbidity found. Two studies showed substantial improvement with treatment�with trauma-focused treatment.
Now, that's interesting. Most of these studies have not looked at treatment, but some have.
PARTICIPANT : Yes, which kinds are the worst?
WHITFIELD : No, I haven't seen enough data there to show, but that's something good to look at.
PARTICIPANT : In situations where they present as exposed to multiple kinds of abuse simultaneously.
WHITFIELD : That is common. Once there is one kind of abuse there is usually another kind of abuse. And the most common, of course, there is that there is almost always psychological, emotional abuse whenever there is physical abuse or sexual abuse.
PARTICIPANT : So, looking at the relationship of trauma and depression makes me think that the action of the SSRI's is to dampen the anxiety, the anxiety related to trauma, rather than the depression.
WHITFIELD : Yes, that is a common one because anxiety is so common with depression, commonly found, and many of these SSRI's are first anxiety disorders, but do you know why that was not promoted or talked about or marketed by the drug companies? Because they already had benzodiazepines and other kinds of sedatives and they already thought, you know, well we are going to have another one or two or 20 or 30 more anti-anxiety drugs? No, we can sell more if we create this disorder called depression. Remember, depression was�30 years ago was uncommon to rare. It was uncommon to rare 20 to 30 years ago, and this is a common thing that drug companies do. In television ads now over that last few years what the drug companies do is they try to create the disease or the disorder and then introduce their drug or start marketing their drug. Witness ADHD, Adult ADD, depression, anxiety disorders, social anxiety disorder, on and on �y ou know, all kinds of them. Obsessive compulsive, all kinds of things. I'm not saying these things are not real or important or useful to look at, but what I'm saying is here is a commonly observed dynamic of the behavior of drug companies.
PARTICIPANT : I noticed that ECT is coming back into vogue, and it seems to me that it's the result of people trying all different kinds of medications, getting no results, and it's a last resort and it's considered a miraculous cure. I just wondered if you could comment on that.
WHITFIELD : Yes, I got a section of�a couple of pages there, Peter [Bregan] is one of the most outspoken critics of electroshock therapy, but he's not the only one. There are many others; and it is, he thinks, barbaric, and I tend to agree with him. I have had probably 10 or 12 of my patients over the decades who have been treated with electroshock treatment, electroconvulsive treatment � remember, it's another word for it � you're put into convulsions. And the only reason they don't have it now is because they are paralyzed during the procedure. And so they can't convulse. Their body can't convulse. They have to be breathed with an air bag to keep them alive during the thing. It is pretty barbaric and it's neurotoxic. It is clearly neurotoxic. It messes up the memory, short tem and to some extent long term. I have never seen, in my experience, these 10 to 12 patients that I've seen shocked, which I did not recommend or order, I've never seen anybody benefit from it long term. I've seen a couple of times some short-term benefit of their depression.
Okay, good question. So here's�if we add those 209 studies and then 29 studies I found on suicide � suicidality � that gives us 238 studies. So that's getting big numbers now. These are not just small numbers. And then if we look at bipolar, there are 13 published studies that I summarize in The Truth About Depression ; and these 13 studies were done on 2,655 people and their controls, and there was found an increased childhood trauma among these bipolars and increase of other co-morbidity.
So while a little smaller number, still 13 studies on this many people is sizeable. So then if we add those bipolars to all of these above studies that I've been summarizing, now we get kind of a grand total of 251 such studies. After I finished and submitted for publication The Truth About Depression , I was working on the next book, The Truth About Mental Illness and during that time I found another 76 studies that showed a statistically significant link between depression or suicidality or both and a history of childhood trauma. So this is from The Truth About Mental Illness where I am summarizing depression, and now we've got, that brings it up to 327 such studies. This is not just big, it's not just impressive, it is overwhelming�an overwhelming connection.
And then if you look at alcohol and drug problems, which we know as alcoholism and chemical dependence, there are 153 such studies. This is maybe not as overwhelming certainly as the depression link, but it is powerful. This is what could be called a powerful link. As a matter of fact, I've said over the years when I was writing Healing the Child Within and writing my other books that I had never met an alcoholic or a drug dependent person who grew up in a healthy family. I was saying that in the �80s and I still haven't. So this is over a decade later and I still have not met anybody with those disorders who grew up in a healthy family. And these are mostly my patients that I've evaluated and then some other people who have told me their stories, you know, and gave that kind of a history.
Eating disorders, very strong � 108 studies. PTSD, strong, 85. Of course, most of them have PTSD. PTSD is I think the therapeutic and clinical glue that holds all these together that allows us to offer some help, some hope. Anxiety disorder, very strong, 100. Personality disorders, 76 such studies, very strong. Psychosis, 110 studies. ADHD, strong, 77 studies are linking ADHD, and here we are putting these kids on drugs. Who is doing it? Teachers, some administrators, pediatricians, other physicians�but nobody who knows trauma is doing this as a rule. So we could be growing up a whole generation now of chemically disturbed and possibly addicted children who then become adults. Aggression and violence; strong relationship. I mean, you can look at what Alice Miller has written about Adolph Hitler, who was beaten most every day. Sadaam Hussein, the same thing. You look at others�these other people who are terrorists, who are physically violent, etcetera, they have a strong childhood trauma history. Low self-esteem we know about, disassociative disorders, nicotine and then somatization and re-victimization, strong or firm to strong. I go into every one of these disorders or most of these in The Truth About Mental Illness as well.
Now, what can we do about depression? The first thing is to address the cause. I mean, in most of medicine and psychology and psychiatry, well not so much psychiatry, we try to find the cause of whatever it is and try to address it, right? Not depression, rarely depression. And so, I'm just suggesting that maybe there is an important link to look at when you have a person who is �depressed� sitting in front of you. And estimated effectiveness here is two-plus to four-plus. Two-plus is the potential for being effective here is 50 percent for two-plus and 100 percent for four-plus.
Being in the presence of positive company, one to four-plus. That could be people in recovery; that could be a family of choice instead of a family of origin that may have been toxic, etcetera. Be around people, other people who are in recovery. And again, the cost is generally low for that one, depending. If you have to go into a 30-day or longer treatment program just to get around safe people, that can cost $30,000-plus�you know, $1,000 a day. That's getting really expensive. Individual psychotherapy, one to four-plus. The acceptability to the person varies, the toxicity is usually none to low, and the cost is moderate to high. Group therapy, important, one to four-plus effective. Every Wednesday night in Atlanta , Georgia , my wife Barbara and I co-lead a therapy group for adults who were abused as kids. It is remarkable; I've been doing this since the early �80s, and I've seen many people get better. It is unusual to see anybody to get problem free�that is really unusual�but they get better. They get better self-esteem; they get more peace, ability to feel peace, many other benefits. Bibliotherapy, reading appropriate literature. Stop smoking. Here is an interesting one, that smoking aggravates depression if not causes it. Now why would a stimulant like nicotine not help? Because if somebody is down and they are using a stimulant, why wouldn't they go up? Well, I don't know. There is something about nicotine that is associated with that.
PARTICIPANT : A nutritionist told me recently that salt is a depressant.
WHITFIELD : Okay, that's interesting. Did they give you any evidence why?
PARTICIPANT : No. Maybe that's what lithium does.
WHITFIELD : Yes, I don't know. You know, salt is also a toxin. I don't know, interesting thing to consider. Regular exercise, clearly an antidepressant. Stimulates endorphins, does a lot of beneficial things. Regular, strenuous exercise. Nutrition and diet as well. Recovery from co-morbidity. Sleep restriction, this is a brief kind of therapy, and people in southern California and elsewhere and a lot of people in Europe have been looking at this. Keeping a depressed person up, at least until 2:00 a.m. and preferably until 3:00 a.m. or 4:00 a.m.; and then if they go to sleep after that, they have to get up by 8:00 and stay up the whole rest of the day with no nap. And if people can just stay up, the longer they can stay up, the less depressed they are. But the problem with that is, it only lasts for two or three days to a week, but an interesting idea.
Massage therapy is not on here, but certainly that is body-centered therapy. I haven't seen studies that have shown that to be beneficial, but it just makes clinical and common sense to me that it would. Yes, but what you can do, if you get the doctor to write a prescription and you keep it in a record, you can take it off your income tax as a medical deduction possibly. Sure.
Let's move on here. Another interesting one, morning light exposure. Getting up in the morning and having light, there have been these light boxes for the seasonal affective disorders, called SAD. Well, that's come out over the last decade or so. It's been effective, too; but what about just getting up and going out and working in the fields? You get morning light exposure, you get regular exercise, you get a lot of other things too. And then spirituality I listed there. I didn't find a lot about that, but I think it's certainly worth considering.
So these are some treatments for depression that can be useful. What I've found is that many of these people, instead of being depressed actually have PTSD. And in Table 2.3 of�it's not in your handouts�but of The Truth About Depression , the second chapter, I show the similarities between depression and Post Traumatic Stress Disorder. Douglas Bremnar, who is a widely published neuroscientist about depression and other problems and childhood trauma and brain structure and function, says that the only difference between PTSD and depression is association of suicidality, as far as making a diagnosis, that they are more alike than they are not alike and that the main difference is suicidality. So you've got all these things like diagnostic criteria for depression, a sad or down mood or anxiety or depressed facial expression, or body aches and pains. Well, who doesn't have that sometimes, you know? But that's the first diagnostic criteria for making a diagnosis of depression. Loss of interest or pleasure in various and important areas of life. Decreased appetite or increased appetite, decreased or increased sleep. Decreased psychomotor activity, low energy or fatigue, low self-esteem, difficulty concentrating or remembering. Both depression and PTSD have those, and PTSD has more and then the major thing that differentiates them is suicidal ideation or attempt. I think many people with PTSD have that too; we just don't know how to sort it all out always.
So this is a quick look at PTSD. Of course, �post� means it comes after; painful effects happen subsequent to the trauma. It's traumatic, it's stressful, it's a disorder, etcetera, but I think it's a powerful diagnosis because what it does is it helps the person understand that they are not bad, sick, crazy, or stupid, that they are a trauma survivor because you've got to have a trauma to make this diagnosis, and that they didn't cause it, and that there's a way out. What does that sound like? What other disorder does that sound like? Addiction and co-addictions like we look at in Al-Anon. So I always screen for PTSD in my patients, and it is remarkable how common it is among trauma survivors. You see, I can help people recover a lot more efficiently from PTSD than I can from depression and etcetera.
This is the flowchart for decision making for depression. Chronic depressive symptoms, you do an initial psychological and/or medical evaluation. If depression is present, you determine the severity and then use these various ones. If it's a mild to moderate depression, these approaches, which we've already been over a minute ago; and if there's a history of childhood trauma, yes, then you may want to consider a trauma-focused recovery program long term, which is what I call Stage Two Recovery. No follow-up for trauma history, why? Because many trauma survivors authentically forget the trauma. They have dissociative amnesia so they are not able to accurately name what happened to them as having been traumatic. Another possibility and keep an open mind that a substantial number may eventually remember a serious trauma history. So what we know is from all the research about trauma memory is that at least one-third of trauma survivors had something like traumatic amnesia and they forgot what happened.
Yes, something triggers, something triggers. Hearing somebody else's story, seeing a movie, seeing whatever, it can just happen. A smell can bring it about; various movements, all kinds of possibilities that can trigger the memory of the trauma, and they didn't cause it likely. One of the least common causes of a trauma memory is seeing a therapist who asks the patient about that, which, of course, the falsies�the false memory camp�really wants to promote because in our eyes, we are the bad guys, not them. So basically what they are doing is they are projecting, they are using this ego defense mechanism, defense against their own emotional pain of owning up to what they did to their kids, who are now adults who are saying, �Hey, wait a minute! You molested me.� And so, we are the bad guys now, and that's why a bunch of us were sued over the years. I might mention that I was one of those people who was sued; and I was sued not by an ordinary member of the False Memory Syndrome Foundation but by the king and queen who founded the organization. They had never seen me; I didn't know them personally or as patients or anything. They sued me because I was blowing the whistle on what their daughters had already proclaimed publicly. In my workshops I was saying, I was repeating what their daughters had said and what other information I had found out. So they sued me for alleged defamation. Luckily, I had some good lawyers who got a summary judgment against that bogus lawsuit.
PARTICIPANT : I was just going to say I had back shots, and that's when I cried and shook on the table for about 11 minutes and that brought back the PTSD from when I was a year old.
WHITFIELD : And when did you have that memory come back?
PARTICIPANT : It was a month or so later because I�
WHITFIELD : How old were you?
PARTICIPANT : Oh, three years.
WHITFIELD : Three years ago, yes. So, one in three people, one in three sexual abuse trauma survivors have disassociative amnesia. Now, here is a big one that John mentioned this morning, the importance of healthy grieving. You see, what I think is what depression may well be instead of �depression� is what I call �stuck grief��that this is grief that has been like an abscess underneath the skin that has just been smoldering for all this time and can't come out. Why can't the grief come out? It wasn't taught, it wasn't permission, it wasn't safe, exactly. Because every time we've tried to express our grief as kids or adolescents or adults, what happened? We got slapped back down�verbally, emotionally, physically, or whatever way invalidated, including, possibly, by some religious systems. Here we see the big explosion of this stuff in the Catholic church, and we can understand why, perhaps, that up to five percent�somewhere between two, maybe as high as five percent, I don't know�Catholic priests have molested children. And, of course, that is giving the rest of priests a bad name.
Now, I want to just suggest that it may not be the priests; it may be the system they are in and that the priests, certainly I think the fundamental religious system is usually shame based and has many other problems, fear based and that alone is serious psychological abuse. And my guess is, as was said this morning, that this was not Jesus' or any of the other spiritual leaders' original intent. So, the difference between healthy grieving and depression are here on this page and on your handout. Let me see, is that one your handout? Okay. So I'm going to just leave that for you to look over. The main difference between healthy grieving and depression is that healthy grieving tends to have a bittersweet tonal quality to it, feeling quality to it, and it tends to have movement over time. That is healthy grieving. Those are the two major ways to differentiate those two. Why? Because depression is stuck, and so that's why I call it stuck grief. Does that make sense? And drugs may not be the most helpful.
So when we look then at the whole treatment process, we can look at the stages of recovery. This is from most of my books. It is a table showing the stages of recovery�recovery and duration according to stages. And stage zero there is an active illness, the focus of recovery is usually none because they are not in it, and the approximate duration is indefinite. Stage one is a basic illness full-recovery program that takes months to three years to stabilize the disorder, whether it's an addiction, whether it's diabetes, whether it's you name it. Then if the person is interested or somehow he's pushed into it, they can enter Stage Two recovery, which addresses the trauma. This is the trauma-focused area that this conference has been, I think, looking at pretty seriously, and all of these nine�these eight previous conferences too. I may say as well that all of this research that I've just published in The Truth About Depression and Mental Illness verifies just about everything we have talked about and learned and used over the last two decades in the adult child recovery movement. It just validates it, supports it, strengthens it. So everything that I wrote about in 1987 when I published Healing the Child Within is still true, and what most of the other authors here and not here have written about that you know are recovery focused in an appropriate way.
PARTICIPANT : One of the things that I read or heard was that if there are repeated relapses and the person has trouble getting into any stable recovery, then it may be necessary to start addressing the trauma earlier.
WHITFIELD : Exactly. That is true. The relapse is a marker for trauma, exactly. Relapse from whatever condition it is, yes. So the treatment here is a trauma-specific recovery program and its approximate duration is three to five years or more. So the people in our recovery groups that we do every Wednesday evening are long-term workers on their recovery. Stage Three recovery is spirituality, not because spirituality is not important in zero, one and two, but because now it's easier to get and realize. Why? Because now I know the real me, which I have called the child within for a long time, which is nothing more than the real self as opposed to the false self or what we can call today the ego. And now it's easier to get spirituality and, of course, this is ongoing. The whole thing is spiritual. It's not like, you know, at stage zero there is no spirituality; it's just easier to get it and realize it.
Okay, yes, that was privately published, yes. And, of course, that was borrowed from Ken Keyes' Handbook to Higher Consciousness and many other people. Those are kind of a universal seven levels of consciousness or spiritual awareness and being, which related it to addiction, yes. So here are just a couple of little bits to consider. First of all, forgiveness, we hear a lot about this all the time. In trauma-recovery principles, my sense is that forgiveness is optional. It is not a requirement, and that's based on a lot of experience, but also from Susan Forward and Buck's book called Toxic Parents . There is a very good chapter in there on forgiveness because see, forgiveness can be, we may think forgiveness is letting somebody else off the hook, but in fact it's really letting go. In that respect, it's instead taking the hooks out of us� the way that we have been hooked into all of this pain.
Suffering is mostly optional. I know John this morning talked about suffering, �No, it's a requirement� and all that stuff. Well, it depends on how you define suffering because, see, I think healthy grieving is not suffering. That's you move on through it. Robert Scaer of Denver writes in his books, The Body Bears the Burden and in his subsequent book, how animals when they are traumatized, their reaction is to shake and go into this kind of a crazy response. For us humans looking at this animal, we may say, �What in the world is going on with this dog or cat or opossum or whatever has been traumatized, a deer?� but what they are doing is they are expressing and releasing the toxicity of the trauma. What we do because it's unsafe for us to do it or we were not validated or taught it was okay, etcetera, many reasons, our toxicities have not been allowed to be expressed so that's what I would call suffering. The best definition I have found of suffering in that regard is �resistance to what is��now that's as adults, not as children because children being in an unsafe environment commonly have not been able to get it out. Now as adults we could get it out if we found a safe and supportive place to do that.
Grieving is healthy. We've talked about the bittersweet emotional pain, the movement, and the grieving comes and goes in waves. Naming things accurately is personal power. Absolutely needed to grieve. If we don't name the trauma, how can we grieve it? So giving things an accurate name is important to all these kinds of traumas. Basic in this whole process, too, is age regression and how to handle it. I have written about this in several of my books, including A Gift to Myself, Boundaries in Relationships , and Memory and Abuse . This is like Recovery 101. I try to teach all of my patients what age regression is and how to handle it. The simplest outline of it is in A Gift to Myself , but it's the same material that is covered in Boundaries in Relationships and Memory and Abuse .
Removing distractions or addictions helps healthy grieving and the whole healing process, including having healthy boundaries and working on core recovery issues.
That everybody has PTSD?
PARTICIPANT: How do you get through life without a trauma?
WHITFIELD: How do you get through life without a trauma? Well, I think it's, yes, first of all, it would be nice if we were in a healthy family of origin and a healthy community, society, and world. That way we could get through this stuff and grieve it every time it happened, every time the traumas happened. I'm talking about serious traumas, not like you won't let a child have a TV in their own room. That's not a trauma; that's not an example of a trauma. I'm talking about serious ones; and if kids are allowed to grieve it and are supported and nurtured, I think that's the best remedy to prevent all of this. Yes, I think being a human, being on this planet, whether we are a human or some other kind of animal, there are traumatic features to it.
Okay, let's look quickly in conclusion here at some very important things. We are kind of coming back to where we started. This is not in your handout, but this is in The Truth About Mental Illness , and the title of this table is that �There is No Evidence of a Specific Biological Cause for any Mental Illness.� Do you remember I said at the beginning that a lot of this stuff might be the opposite of what you had been taught or assumed or understood or believed? My sources are the Surgeon General's report from 1999, the American Psychiatric Association statement that was written in response to challenges by a group of clinicians and researchers just before that time, and from two textbooks, two well-accepted textbooks of psychiatry by [Andresson] and Black and by [Hales] and [Udovsky], and here is what it is:
The cause is unknown. The cause of mental illness is unknown. Every one of them say this. The Surgeon General says the precise cause or etiology of mental disorders are not known�Surgeon General, a lot of back up there. He had a lot of staff helping him write this and research. American Psychiatric Association says it on the next page; we will get to that. The textbooks: �In the areas of patho-physiology and etiology, psychiatry has more uncharted territory than the rest of medicine.� Abnormal biology is not necessarily the cause of the disorder. The Surgeon General: �All too frequently a biological change in the brain is purported to be the �cause' of a mental disorder, but the fact is that any simple association or correlation cannot and does not by itself mean causation.� Also the Surgeon General says: �Few lesions or physiological abnormalities define the mental disorders, and for the most part their causes remain unknown.�
The American Psychiatric Association in this letter, where they were challenged, show us one paper that proves the specific biological cause for any mental illness, they said, �There are no biological markers for mental disorders.� Remember, I said there is no laboratory test, no blood test, any of those kinds of tests. �There is no diagnostic laboratory test capable of confirming the presence of a mental disorder� they write in their letter, which has been published. The two textbooks: �In identifying the pathophysiology and etiology of major mental illnesses, this goal has been achieved for only a few disorders, such as Alzheimer's Disease, multi-infarct dementia��that means in the brain where you have little strokes where there's not enough blood to various areas��and substance-induced syndromes, such as amphetamine-related psychosis or Wernke-Korsikov Syndrome,� which is from alcohol excess as we know.
These are just introductions here to this, and I want to finish this particular page and then conclude with one other one. These same three now, genetic evidence, the Surgeon General says, �This report offers or cites no proof of any genetic evidence of any common mental disorder.� We're not talking about rare mental disorders, the common ones that we've been talking about here. The American Psychiatric Association says, �Brain science has not advanced to the point where we can point to readily discernible pathologic lesions or genetic abnormalities that are reliable or predictive bio-markers of a given mental disorder or mental disorders as a group.� Very strong. They are finally admitting it. It took them two or three letters to finally write this final letter because they were tap dancing all around in their first ones. The two textbooks say: �Most of these genetic studies examine candidate genes in the sertonergic pathways and have not found convincing evidence of an association between genes and mental illness.� Two big textbooks are saying this. Diagnosis is often difficult. The Surgeon General: �The diagnosis of mental disorders is often more difficult than diagnosis of somatic mental disorders since there is no definite lesion, laboratory test, or abnormality in brain tissue that can identify the illness.� The APA says: �There may be triggering by certain adverse environmental influences.� Hmm, trauma, possibly? �Here environment may refer to traumatic events.� They say it in their letter, in their kind of confessional letter. The two textbooks say: �Although reliable criteria have been constructed for many psychiatric disorders, validation of the diagnostic categories as specific entities has not been established.�
So let's just summarize all of that then. None of these three mainstream psychiatry and one highest U.S. government medical sources is able to provide any proof for the existence of a biologic or genetic cause for any common psychiatric illness�interesting�nor for the existence of any biologically-based laboratory test for any of them. In fact, they argue from the absence of evidence for every one of these. Any abnormal biology fan is likely, of course, as we mentioned earlier, the intermediary mechanism caused by the primary trauma and not caused by the mental illness itself.
Who had one here? Stand up and speak please. Well, I'm saying the track record� our experience�if you really look at it carefully that the drugs have not helped, have not regularly helped any major psychiatric disorder. Schizophrenia? No, there's evidence. I've got two chapters in The Truth About Mental Illness that goes over that. As a matter of fact, the people who are schizophrenic who do not take drugs, who do not take anti-psychotic drugs, over the long term of their recovery and their life do better than people who get the drugs. These drugs are highly toxic. The anti-psychotics are the most toxic of all the psychoactive drugs. I mean, they cause major problems, and still today we are pushing these drugs that cause diabetes, all kinds of other physical problems, as well as mental and emotional problems; and they are numbing, seriously numbing of our psyches. I mean, these are bad actors. Now, do I have some patients on them? Yes. I've got two patients now who take low dose Haldol. Why? Because I'm pushing them? No. Because it's their choice, because they feel better taking two milligrams a day of Haldol, which is a relatively low dose, and they are just doing better. One of them had a diagnosis of psychotic, but he is clearly a trauma survivor; and the other one is also a trauma survivor but has what appears to be bipolar, and he's just doing better on it so he hasn't stopped it and I haven't pushed him to, although I have recommended it.
And some of my patients are on antidepressants, and I just do what I can to assist them in their use or their choice not to use those. Okay, here is the last one then: �Exploring the door in the room of depression,� which is in The Truth About Depression , this diagram. This is a door that says, �Depression, Do Not Enter,� and inside the room are trauma memories, trauma effects, ungrieved pain, and recovery potential; and blocking the person's use, recognition, personal power from these are the drug industry, managed care, special interest groups, and a lack of knowledge. So that's one of the reasons I wanted to write�some of the reasons I wanted to write these two books because we've got a complex political, socio-political web here that the drug companies and these organized groups like the APA. Find a psychiatrist today who understands trauma�find one who understands addiction. Now, are there more of those? Yeah, but not enough.
I want to just say if you want to look at our Web site, we've got a Web site with a lot of this stuff and more and some streaming audio talks like this. It is cbwhit.com; and if anybody is in the Dallas , Texas area or you know anybody that might want to do a one-day workshop on The Truth About Mental Illness , I will be in Dallas , Texas the 16 th of April, this coming. So in about a month and a half that'll be happening. I hope this was useful, and I thank you all for coming. <Applause.>
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