The Opposite of Depression, with Dr. David Carreon

Good morning, my friend. I'm so excited to be with you today. I'm Dr.

Lee Warren, and I'm your host for some self-brain surgery. We're going to get

after it in just a minute.

Today, I have a conversation with Stanford-trained psychiatrist, Dr.

David Carreon. David's first book, The Opposite of Depression,

is coming out today, and it is a doozy. This is one of the most powerful books I've ever read.

And if your first thought was, well, I'm not depressed. I don't need to read

this book. Let me just tell you, the book is not really about depression.

He studies depression as a psychiatrist, but the book is actually called The

Opposite of Depression, What My Work with Suicidal Patients Has Taught Me About

Life, Hope, and How to Flourish.

The book's really not about depression as much as it's about how to flourish

in life. Because he says the opposite of depression is not just feeling better.

It's actually learning how to live a life of meaning and purpose and hope.

And that's what the opposite of depression is. This conversation covers a lot of ground technology.

He's an expert in a technology called transcranial magnetic stimulation,

which has some tremendous power to help people with depression and other forms

of mental strife. strife.

I've been exposed to transcranial magnetic stimulation for close to 20 years,

and it's really powerful and helpful in people with PTSD.

And it's got a real use in the veteran community that I've been fascinated by since Dr.

Daniel Amen first introduced me and Lisa to it in probably 2014 or so.

And this technology has a lot to offer people. But David's work is not not just

about technology, it's about helping people overcome these illnesses and conditions

and even lifestyles that are keeping them from flourishing.

He's got passion for his patients, passion for his faith, passion for Jesus,

and he's just integrating all the neuroscience and faith elements,

just like we do on this show every day.

And I think you're going to find a new friend and maybe even some new ways to

look for hope in the story of what Dr.

David Carreon has to tell us about the opposite of depression.

My friend, this is an incredible talk. I highly encourage you to read his book.

And we've got free copies of the book to give away. way. We'll choose some random

winners if you send me your name, mailing address, and zip code.

Listen, please send your name, mailing address, and zip code.

If you don't include all that information, you will not be included in the drawing for the free books.

We've got about three copies to give away, The Opposite of Depression by Dr. David Carreon.

Send me an email, lee at drleewarren.com, with your name, your mailing address,

and your zip code. Don't leave it on Facebook. Don't leave it on YouTube.

Don't send me your name without your mailing address or you won't get a book,

but we're going to give away three copies of this unbelievable book.

Get ready for an incredible conversation with a powerful new friend.

I think you're going to love Dr. David Carreon and Lord willing,

he's going to be back on the show another time to talk about these issues at a deeper level.

But today we're talking about his book, The Opposite of Depression and what

you can learn from it. But before we get started, I have a question for you.

Hey, are you ready to change your life? If the answer is yes, there's only one rule.

You have to change your mind first and my friend there's a

place where the neuroscience of how your mind works smashes together

with faith and everything starts to make

sense are you ready to change your life well this is the place self-brain surgery

school i'm dr lee warren and this is where we go deep into how we're wired take

control of our thinking and find real hope this is where we learn to become

healthier feel better and be happier this is where we leave the past behind

and transform our minds.

This is where we start today. Are you ready? This is your podcast.

This is your place. This is your time, my friend. Let's get after it.

Music.

Friend, we're back, and I'm so excited to introduce you to a new friend today. I've got Dr.

David Carreon, a psychiatrist and innovator who's working with all kinds of

exciting new things relating to depression and other mental issues and maybe

even some some other diseases, as we'll talk about in a few minutes.

But David, welcome to the show.

Thank you so much. It's such a pleasure to be here, and thank you for the opportunity to be on.

Absolutely. I'm excited about your new book, The Opposite of Depression.

We're going to talk about that extensively here in a minute.

But give the listeners just a 30,000-foot view of you and your life and your story.

I am a Christian who, when I was around 18, started to really ask the questions

to him. I started taking my faith more seriously, asked the question,

how could I honor God best with my life?

And how could I love my neighbor as myself in the best way?

And I, at that point, partly out of lack of creativity, I think,

thought it's got to be a doctor.

That's surely, that's got to be the way for a smart kid to do something in the world.

I think I've got a much broader perspective of there's other ways to do good

in the world than being a doctor. But, hey, it was a good start.

And that was the thing that I'd like my life to be about.

What I've aspired to is trying to love my neighbor as myself and trying to think

in each decision point in my life. Not always doing it perfectly,

but trying to say, how can I help people?

How can I do good with the talent, skills, abilities, relationships that God has given me?

And so I went to UCLA, studied engineering, wanted to be a medical missionary

at the time and focused on water resources.

Maybe a two for one. Maybe I could do missionary medicine and help with the

water resources. That's not an issue.

Ended up spending a year, got into Stanford Med, spent a year in Kenya,

realized there's a lot of good that could be done and should be done in the developing world.

But that ideas really mattered and that coming back to the United States and

focusing in areas that mattered for ideas because of, for better and worse,

maybe more worse than better, but,

the West and especially certain parts of the West had enormous and inordinate

influence on the rest of the world, whether it be institutions or whatever else.

So I shifted to neuroscience and psychiatry and over the course of the last

decade or so really, really started to fall in love with how to use the best

technology available, but also bring in philosophy.

Bring in what are the truths about who we are as human beings,

how we've been created, and trying to blend these in clinical practice in the

rough and tumble world of American healthcare,

which is its own book, which I've considered writing about how nightmarish this

environment is for people trying to navigate.

But nonetheless, that's how things got started.

Wow, that's amazing. My friend Daniel Amen has written a lot and talked a lot

about how psychiatry is one of the only specialties, maybe the only specialty

that commonly treats an organ without imaging it.

And so I think you and he seem to be pretty aligned because you're dealing with

brain imaging and functional neuroanatomy and all that.

So how did you first get interested in transcranial magnetic stimulation?

I guess I should say, what is it first before we drop that on the listener? Sorry. Sorry.

Yeah, we'll be using all kinds of opaque acronyms throughout this interview.

Yeah, we'll do our best to explain.

Okay, so transcranial means it's through the skull.

Magnetic is the physics of how it gets through the skull and stimulation is

it activates the neurons or it deactivates them depending on how you tune the machine.

But the idea is you can, it's about the size of your palm, put it on the part

of your head that you want to change and flip the machine and it zaps.

It's like a wireless phone charger, but for your brain.

But you focus this beam on about a centimeter patch of cortex,

though that's controversial how big exactly is being activated or depolarized.

And you can turn it on, turn it off.

You tap the part that controls the thumb, you get thumb movement.

You tap the part that controls the index finger, you get index finger movement.

It's like you neurosurgeons can do that all the time with the skull on.

But it's cool for us outside of the OR being able to move stuff around.

You hit the Broca's area, the part that controls speech, and you can get a little

bit of slowing in your speech. It's all the stuff that is like textbook.

So textbook neuroscience, you

can demonstrate just in an outpatient clinic with this super safe device.

All to say it was a so 2008 was around the time that it came into it was FDA

approved for treatment of depression.

So people who've tried a bunch of stuff, usually two, three, four medications.

And so these are people who've really gone through the ringer. They've done therapy.

They've been sick for a long time. You come into an office, you get tapped on

the head with this magnet, and all of a sudden, the decade of depression evaporates.

It's incredible. It's incredible to see.

And people don't believe it at first, but it sticks.

It stays around. And even with this older version of the technology,

people getting better. So that's TMS.

And when I got interested in it, it was still in the early days of the early

clinical trials and things like that.

And I guess it had been a little bit later than that. But I was interested in

it for mapping the brain.

There's being able to turn on or turn off different parts of the brain is a

really great way to figure out what they do.

And so it's a so you can increase activity of I was working on the part that

was involved with willpower or self-control, trying to see if we can increase

that with the magnetic stimulation.

It turns out it was easier to decrease than increase. But you live and learn.

And I guess that's what science is about. But I was in the lap of a guy named

Damit Etkin, who was a great research mentor.

And it's partly where I fell in love with neuroscience, was playing around with

this on my own and volunteers brains and trying to learn what the different parts of the brain did.

Wow. So I first got interested in TMS basically, I think 2006 or so.

There was a conference out at Oakley, the company that makes sunglasses.

They do a lot of work with veterans.

And Daniel Lehman invited me to speak out there. And there was a presentation

from a group that was working on using TMS in PTSD patients.

And I saw a couple of veterans who had been in Iraq and had come home and they

were just wiped out and alcoholic and couldn't sleep. Almost all of them had severe insomnia.

And these guys had just amazing life changes from TMS.

And I saw that happen. I saw their testimonies and their stories,

and I've been following it along ever since then.

It's just when I heard about your book, I was like, I've got to talk to this guy.

But the idea of treating depression with surgery even goes back further.

In my career back 20 years ago in Pittsburgh, we were using vagal nerve stimulators

for epilepsy, and we started using it for depression.

We were one of the first centers that looked at that. And it turns out it works

for a lot of people, but nobody wants to pay for it. So it hasn't ever really taken off.

Yeah. Now, this is one of the, I'm sure a lot, I don't think anybody in America

is untouched by the giant mess of a system that we have, but that's exactly right.

It's one of the things I've realized over the last few years is that it's all

well and good. And TMS is a perfect example.

We've got clinical trials showing benefit in a dozen conditions and one is regularly

paid for and that with great significant restriction.

And then if we had a treatment for whatever else, like surely it would be paid.

People would be demanding it would be paid for. But like through a variety of

causes that I can elaborate on, it just so happens that the systems restrict

its access when the clinical evidence is quite good for a whole variety of conditions.

Everything from stroke recovery to treating all manner of conditions,

auditory hallucinations and schizophrenia, depression, some studies on PTSD,

some studies on anxiety, some studies on the list is huge.

Alzheimer's or some studies out on that and Parkinson's. It's remarkable.

And it's who's ever heard of this? Nobody.

Because it's not paid for. It's not available. It's part of it.

It's like on us, psychiatrists, like we don't, it's like procedures. We don't touch.

We don't, we just like to talk. We like to talk. We don't like to ever actually do a physical exam.

That was medical school. This is now part of it as a culture thing,

but part of it is really payment access systems.

And unfortunately, I think that a lot of people who could benefit from this

and other treatments just don't have access.

And that is one of the things that we're trying to work on with the clinic that I run.

I feel like I could have this conversation with you for a long time where we

go into science and technologies and all that.

But I want to get around to your book because you've written this incredible

book called The Opposite of Depression.

And I'm telling you, this is close to a thousand episodes of my podcast now.

So I've interviewed hundreds of people and there's very few books that I've

read and very few people I've had on my show where I felt just this immense,

immense, almost passion for your work and the words that you're writing.

And I think you're going to really help a lot of people with this book, David.

But as we get into talking about it, first of all, I want to tell you,

it doesn't feel like your first book. You did an excellent job with the writing.

It's an outstanding job.

So, listener, this is a book that feels like somebody who's been writing for

a very long time. It doesn't feel like a first book.

But you start the book off talking about the difference between what you call

depression versus weariness. this. And I thought it was just an incredibly insightful conversation.

So talk to us about that. Unpack what it means to be depressed and what it means

to be just weary and who might be in those categories.

Yeah, it's first of all, we very much appreciate those words.

This is definitely a team effort. And any single author on the front of a book,

there's a whole bunch of people from editors and supports and my wife and all

manner of people who like helped support me in allowing this to happen. But thank you for that.

In terms of depression, so depression is a condition that is a medical condition. It's a disorder.

I think of it as primarily a brain disorder or a circuit disorder in the brain.

That is, by definition, disabling.

You are unable to or significantly limited in your abilities to function in

some important domains. remains.

And there are nine symptoms of depression, but usually some kind of feeling

of depressed mood, feeling sad, down, depressed, hopeless perhaps.

And then the other is anhedonia, a lack of pleasure or ability to experience those things.

And along with that comes a whole bunch of other symptoms, everything from physical

symptoms like appetite problems to problems with what I I would consider a thought disorder,

so thoughts that life is not worth living, or that things are never going to

get better, or I'm worthless.

The main difference between depression and what I call weariness is mainly a

matter of degree and the degree to which it is disabling, where you really can't move.

That's where I would call it a disorder, something that you need help with.

And the numbers are something, it's astonishingly high.

So 5%, 7%, 8%, depending on the survey you look at at any given time,

something like 1 in 20 people has this disabling condition across demographics, across geography.

It's just incredibly prevalent that people are just really hurting and really

suffering with what we might call depression.

But on top of that, there's a whole bunch more people that aren't that bad,

but are still pretty bad. they're really having a hard time with many of those

same symptoms, not experiencing the full degree of pleasure,

not being able to have positive experiences.

And, but the difference is, and I sometimes in the book, I break out advice

for each of the groups in various places.

It's really targeted at those who are weary, but could also be helpful and is

aware of the existence of depression.

And a lot of people will say, Hey, just do some exercise. And that's great advice.

There's nothing wrong with that advice. That's true enough. But when you are

having difficulty difficulty literally moving your body from bed to upright,

you're not going to go to the gym.

That's unreasonably, it's unreasonable advice.

And so, but it's not wrong. What might be a good goal today is to literally

just walk to the mailbox and back.

It's going to take everything in you. If you're depressed to walk to the mailbox

and back, you should try it. And that's, that would be a Herculean and admirable effort.

But look, if you're not depressed and you're just weary, yeah,

you really should just go to the gym. Come on.

Bootstrapping it with weariness is bootstraps still work with weariness is maybe another frame.

And so I think that the difficulty with, and I think one of the other things

I've realized in retrospect,

after writing the book is that it's good if you have somebody who you love and

care about, who's in one of these two states, because you might be giving like

weariness advice when they need depression advice or support.

And that's there and recognizing that there really is a state called depression.

That's, that is legitimate. That's real. And like, how do you help somebody

in that state? Some of the advice in the book may help with empathy or appreciation

for people in that state, if your loved one is in that state, if you're in that state.

I love it. So talk about for a second, if somebody's struggling with depression,

what are the various kinds of things that people do to treat them?

And we talk about psychotherapy, cognitive behavioral therapy,

medications, and the role of SSRIs and all that.

And then we get into things like electroconvulsive therapy. And what do you think about that?

And then the new thing that you're doing, transcranial magnetic stimulation,

like to talk about the options that people have and when somebody might think

about one versus the other. Sure.

This is a great question. And I'll share my treatment course.

And again, there's all kinds of individual circumstances.

My preference, there's all sorts of practice variation within this.

So if your doctor has recommended something else, this is not medical advice.

Talk to your doctor because your doctor cares about you and is able to adjust

for your personal situation. situation, often psychotherapy,

like formal psychotherapy is a great place to start.

So if you have like honest to goodness depression, schedule time with a therapist,

particularly somebody who's going to do a, we'll sometimes call evidence-based therapy.

So something like CBT. Now a lot of people say they do CBT and don't do CBT.

But one, one key question is, is this going to end in something like a few months

or is this going to be ongoing?

Evidence-based CBT is like, you you should be able to make progress in a few months.

You should be able to actually address depression in a matter of a few months.

Now, there's other therapies which also have evidence, longer form therapy,

which is more common today, that's eclectic. That's fine. It can be helpful for many people.

But if you're just starting off, try to find somebody who will do a course of

CBT. That's a great place to start.

If that doesn't work, often what's usually a good next step is a medication.

The medications are safe. They're cheap. They've been used for three decades

now, around 1990s when they really started to pick up being used.

Very limited chance of long-term side effects, usually pretty tolerable.

And there's a two-thirds chance you're going to be better. And that's great. That's a great number.

Trouble is that for the third that doesn't, what do they do?

Okay, they can try a second medication. Go back to your psychiatrist or your

primary care, say, hey, it's not working. After a few months,

they'll try a second medication.

If that doesn't work, that's where there's a decision point and there's more controversy.

There's a decent chance, maybe two thirds, you'll get better with number one,

maybe two thirds chance you'll get better with number two.

If neither of those work, then the odds drop pretty substantially.

And then it's almost never a bad idea to try another medication,

but the chance it's going to work drops as you keep trying new stuff.

After that, you start to get into what I call the interventional options.

Interventional psychiatry, there's interventional cardiology,

there's interventional other stuff.

So at that point, branch point in my mind is between ketamine or esketamine,

Spravato is another name for it.

And TMS tends to stick quite a bit better if you have access to it.

Some insurance companies require you try four medications and not two,

but TMS is a great option.

You go to a clinic, usually within 10 or 15 miles of most people,

there's some kind of a clinic.

You go, you show up for 36 weekdays for something like half an hour.

And most people are better even after they've tried all the other stuff.

Ketamine numbers are similar, but the durability is less good.

TMS tends to last for a year.

Ketamine doesn't tend to last, but what I mean, it's okay. Cause you're,

Hey, you're better. That's the main thing.

After that, you might think about more invasive options like electric convulsive

therapy, more and more, more heavy side effect burdens.

And one of the new things we're doing is after TMS or sometimes even before

For TMS, we've got an approach that is using, based on a study out of Stanford

called the SAINT study, where you concentrate, navigate.

So you take a brain scan and you find the location and you stimulate a lot over five days.

And so we have people fly into our clinic in California from all over the country

and world, get those five days of treatment and fly back home.

And most of them get better. And so, that works even if you've tried ketamine,

even if you've tried TMS, even if you've tried ECT.

Focused transcranial magnetic stimulation really works, though it's not yet

covered by insurance, which is something we're working on.

And then there's a fine option, a pretty significant side effect burden.

There's a chance that it really will affect your memory. Usually it's short-term,

sometimes it's not, but again, compared to being depressed, it,

I think just you, many people listening are depressed.

Many people listening are not depressed for those who are not depressed.

Depression is one of the worst states a human being can be in.

It's like, there's some objective ways that you measure human misery.

It's near the top. It's in quantitative terms.

It's approximately as bad as those last days when a person is dying of cancer.

That versus day of depression is about as bad. According to people who quantify

these levels of suffering, it's terrible. The day you have a heart attack,

like your first day, crushing chest pain, go to the hospital,

that's less bad than a day of severe depression.

It's extremely bad. And so to say, oh, ECT has side effects.

Yeah, it has side effects, but compared to what?

You're going to do some pretty intensive things and you have a heart attack.

You should probably think about doing intensive things and you have treatment-resistant depression.

So our office doesn't do ECT, but it's a great treatment.

And for anybody considering who's stuck in the midst of it, yeah,

you probably should think about it.

Do something. thing yeah i remember a woman in our vagal

nerve stimulator trial who hadn't gotten

out of bed and had a shower in three months and two

days after she had her vagal nerve stimulator she took a shower like it was

just this dramatic change in her life because she felt better right and that's

not placebo i mean that's a real thing so i guess a question we're both christians

we're both scientists we're both practitioners of medicine some people listening

to this and in fact frankly Frankly, I've heard it in my own family.

Some people are going to think depression is a faith problem.

If you have enough faith, you ought not to be depressed.

To address that from a spiritual and from a scientific point for a minute,

just to talk to us about faith and depression and how they play with each other or not.

This is something that I think there is a kernel of truth from both sides that

I think that both the secular scientist and the conservative religious thinker

can learn from each other in this question.

From one perspective, it's true.

If it's something that responds to a magnet, it's probably not a faith problem. Yeah.

So, like, I think the magnet's powerful, but it's not that powerful.

But that does raise a, I said probably not, because we are starting to discover

circuits in the brain that affect spirituality.

And so there's a great study, one of our colleagues, one of the guys that works

with us at our clinic, Sean Siddiqui, does this incredible study where,

where you look at, you map out changes in spirituality in people who had penetrating head trauma.

And you cross correlate where all of these traumas were.

There's like databases, very

morbid database where they kept really good records of Vietnam veterans.

And they found out, how did you change after you got some piece of shrapnel through your brain?

And it didn't make any, the data didn't make any sense until you were able to

map, until you had computing power to map it all.

So he mapped it all into this thing and found a circuit that affects.

And yeah, we might be changing things in ways that are really uncomfortable

from a faith perspective when we take a medication or stimulate the brain or

have surgery or remove a tumor. Like people's personalities change.

And that's so that the degree to which we are embodied creatures is can't be

taken lightly and that God gave us a brain, not just a spirit,

and that those things are inextricably linked while on earth.

And there's all kinds of fun speculation about what is it going to be like?

What is a person like who happens not to have a body for the moment?

But I think even in Christian theology, that's not a natural state.

I know some thinkers like Aquinas have it like it's basically it's like a it's like a spirit ICU.

You've got to be like hooked up to spirit life support because you don't have

a body. It's like, yeah, we can keep you alive.

God will keep you alive between now and the resurrection. But it's not normal.

You shouldn't be aspiring to that state. And so, yeah, if our body's affected,

we're going to be different. Another study I did when I was,

it was a bit of separate from my current work, but we did, that was a study called soul pulse.

We measured multiple surveys per day and we asked people, how are you feeling? What are you doing?

One of the major impacts on willpower was, did you sleep and did you fight with somebody?

And to explain like most of the variation and were like a huge percentage of

the variation in willpower and you're being in this depleted state, those two things.

And it's okay. One of those is, yeah, you probably shouldn't fight with people.

And but like physical sleep, is that really all it takes to make us irritable at our part? Yeah, it is.

And not speaking from experience, sometimes when I don't sleep,

I'm not as friendly to people I would otherwise care about.

But all that to say, so to your question, OK, somebody who's who's concerned

that you just don't have enough faith, there's a degree to which,

yeah, there are radical conversions and there are radical experiences.

If I just turned this over to God and realized that, in fact,

God loves me and that I shouldn't feel worthless.

And that's great. And I would say that's either a miracle, which happens in

physical health too, or it's a person who is weary, who is using their-

Resources they have left and using voluntarily changing thoughts.

But I think the problem, the extreme version of that is just don't get mental

health care because it's a faith problem.

So I think that's, of course, too simplistic. But on the other side,

it's like, it's not, it's just not a faith problem.

The most significant modifiable risk factor for suicide completion is church attendance.

Yeah. All kinds of stuff you could do all sorts of different.

Yeah, yeah, you should exercise. Yeah, you should eat well. Yeah,

you should. If you are in church every Sunday, the chance you're going,

the person is going to commit suicide is drastically lower, not zero,

but it's drastically lower.

And so it seems to affect, the faith portion seems to affect that aspect a lot

more than it does depression, which makes me think that they're different.

And this gets into what exactly is depression, this conglomeration of nine symptoms.

Is that that really reality, but definitely on the suicide, suicidality and

the suicide action part, when you believe there's a God that loves you fundamentally,

and you're reminded about that and the, and your part and you're participating

in the body of, of Christ every week, like there's a huge difference in how

you see the world, how you change, how you relate with these thoughts.

And with this, what I would consider disease in the midst of that,

you could wrestle with it better as a Christian.

But the interesting thing is depression is less common, but not all that much

less common in people of faith.

So, what's that about? Maybe our theology needs to be better,

maybe our practice needs to be... Sure, but there are big differences in a lot

of other conditions, but not as much as we should expect if it really is a faith problem.

Wow. That's powerful. Some people also, even people that understand that faithful

people can be depressed, some people think, and we've been told a lot in the

media, that it's just a chemical imbalance in your brain.

You need more serotonin. So you talked a lot about SSRI, serotonin,

selective serotonin reuptake inhibitors and what they do.

And you have some surprising, I think, things that might surprise the listener

about what serotonin uptake inhibitors really do.

Talk about that for a second. It was really fascinating how you wrote that.

Yeah, no, it's interesting.

The serotonin theory of depression is more a marketing campaign than a legitimate scientific thesis.

And this is really a really interesting fact about or part of the history is

it wasn't really ever like all scientists everywhere believed in the thing.

And then we had to displace it with better understandings. It was it was in

very large part of very good Zoloft commercial back in the late 80s or early 90s.

The Zoloft commercial came out and it's the cloud and the little serotonin neuron

and the little bubbles hitting it.

And it's popping. Oh, yeah, that's OK. OK, we knew from the beginning that like

if it was that, then when you take it as a strike, you should feel better immediately

because the serotonin levels, we know the serotonin levels immediately increase.

And so if that was what was going on, like, why don't you immediately feel better?

That's right. It takes a month or two. Yeah. Yeah. So you don't even see anything for the first month.

So like, how could it possibly be the serotonin? And then like further,

it's oh, yes, it does correlate with depression, higher serotonin.

Yet now, actually, technically, it correlates with suicidality.

If you separate the suicidality out from the regular it's

no no effect it doesn't it doesn't even like correlate with depression

if you take out the suicidality and it's

so all of these make the main things you'd want in a theory of does it predict

this does it do that it's no it's just like lazy back-end assumption that was

a really but i think this gets to like how do you persuade somebody but also

what are people wanting to be persuaded into my guess is that something in the the 1990s,

people wanted this to be true.

And it was like the Zoloft ad was a match on a Tinder box and it just lit up

and everybody's, yeah, it's a chemical imbalance.

It's not because of how we're living. It's not because of sadness.

It's not because it's something that has been with us from time immemorial.

It's because of a chemical imbalance.

And it just drastic rise in people trying to fix the chemical imbalance,

which hasn't really worked.

And we got 15% of the population on SSRIs, but like depression rates are the

same now as they were 30 years ago. So, what's that about?

But that said, and the challenge here is that it works.

You see people go from despairing, wanting to kill themselves,

to all the way better in a matter of six weeks with a $3 a month prescription. That's pretty cool.

But the basis of the theory is not that. What is the basis?

My favorite, and again, this is an ongoing work, my favorite idea is that the

SSRI affects a circuit just like we're affecting the circuit.

That there are more serotonin receptors on parts of the brain that we think

involved in depression.

And by blitzing those receptors with the serotonin, it changes the regulation.

And the timing lines up for that. If you've got a bunch of serotonin,

the neuron says, hey, I'm getting too much serotonin signal. Let me tone it down.

Let me not make as many serotonin receptors because there's too much serotonin noise coming through.

And so the parts of the brain that are involved in anxiety, anxiety,

depression, et cetera, turn down their ability to function.

And so it's like turning down especially negative emotion globally in response to this SSRI.

So that checks out with the timing. That checks out with the fact that they do work.

And the sort of adaptation period is more consistent.

But again, that too is a theory that's really hard to falsify.

So the brain's complicated, it turns out. I'm finding this out.

You probably knew this for a long time.

Well, it's fascinating because the depression has to do with hyperactivity in

the subgenual anterior cingulate cortex.

And our listeners are familiar with that. We talk about brain circuits all the

time. And Jeffrey Schwartz's work, I was amazed to see that he was your mentor.

I was like, yeah, that's cool.

I've been reading Jeffrey Schwartz for years. So we talk about the ACC.

And it's interesting to me because I was reading Mary Frances O'Connor's book

about grief, The Grieving Brain. And she showed, or there's been a lot of work

that showed that people that get stuck in complex grief, the big problem is

anterior cingulate cortex, this hyperactivity there.

So what's the difference then from your perspective between somebody that's

really not moving on from grief and somebody who's depressed?

And are they really just the same thing and we're talking about different words

or is there a difference?

And this is where we might need to get into psychiatry and nosology.

Like, what do we call stuff?

And so the hard part is that the hope in the early when biological psychiatry

was really coming of age, you got the Freudian age and that's not falsifiable.

You got these really cool sounding theories and you got these amazing recoveries and analysis.

But the problem was every people were calling stuff different things.

Like when you called the neurosis, somebody else called something else. said it was just a mess.

People were getting better, or so the story went. People were getting better,

but it was just disorganized.

And so the idea was, hey, it's the late 20th century, the last half of the 20th

century, we got to come together. We got to agree on at least what we're calling stuff.

And so they came up with this sort of multiple checkbox idea of we don't,

it's the olden days, we don't understand the brain enough yet.

So we can't really do a organ system basis of go from what we do in the rest

of medicine where it's okay, okay, here's the kidney, and here's a part of the

kidney, and this part of the kidney is diseased, and so we're organizing it

according to the organ that we understand.

They decided, let's just cluster

symptoms together, because that seems to be at least all we've got.

And at least we can agree on the symptom clusters. At least that's something we can start with.

And they weren't trying for what's called scientifically validity.

They were going for reliability, that whatever's going on with depression,

we don't have to agree on what actually is wrong in the brain.

We can agree that if you have five of nine symptoms, you're you're depressed.

And so great. Okay. Great project. Let's start this half century long project of the DSM.

And DSM three was the big shift in this trying to do this. And then four came

along with some revisions and trying to fine tune things.

And five came along and that really consolidated things. And they,

but that, by that time they really wanted to test it and they tested it and

they had expert raters who really went through the ringer and studying DSM.

They had had them try to rate like the cornerstone diagnosis that.

One of the major contributors to human suffering in the world,

major depressive disorder.

Again, it's not that hard, right? Five of nine symptoms. Everybody can agree.

Five of nine. Is that six?

Okay. That counts. Four? Nope. Not quite. Okay, great. Let's go to work.

What percentage of people agree? What's the inter-rater reliability after 50

years of work trying to cluster symptoms on this major diagnosis of major depressive disorder?

Under 40%. It was like in the 30s. And it's, dudes, we've been doing this for

50 years. We've You've been trying to get together.

This is the best of the, that's the, that's like the best. And you,

you give this out to random psychiatrists in the community. They're not going

to beat that. That's as good as it's ever going to get.

Oh gosh, that project was a failure, but okay. So how about we do what now?

Like it's functional brain imaging. How about that?

Okay. And there we go. Like functional brain imaging. And this is the problem.

And this is an ongoing challenge of that.

Also, the predictive power of one person's brain scan also doesn't predict stuff

very well. That's right.

So, okay, what are we stuck with? We're stuck with this system that we know

is garbage, but it's at least the best garbage anybody's ever come up.

40% is better than 30%. That's true. That's right.

So, okay, so what is complex grief versus depression?

We don't even know what depression is, let alone like a less well-studied,

less well-characterized condition is complex grief.

Now, OK, what does that mean for the average regular human after this diatribe

on history of psychiatry?

It means that the names that we give are not gospel.

It means that this is a system that's in place that's the best system that we

all know is broken, that it's as good as we're going to get or it's as good as we've gotten.

And maybe in the next five years, 10 years, 20 years, we'll have a neuroscience

based diagnostic system. They tried with something called R-Docs some years

back, and it was like, yeah, let's use brain systems and go.

It's not really working in a clean, helping more than the DSM kind of a way.

So, okay, back to the drawing board. But there isn't really a drawing board.

There's not a good alternative because we just don't know enough about the brain.

But all to say that these labels can be helpful in guiding treatment.

And that's, I think, their main utility. If a person's got a diagnosis of OCD

as disorganized as that diagnosis is, you need higher doses of SSRIs to get them to move.

That's something we found out empirically. And so that's great.

It's going to help with treatment.

But at the same time, if that label is, I don't like what that label is called,

I think it might be complex grief and the psychotherapy that's based on or the

spiritual work I'm doing in complex grief that grief is helpful.

Helpful, hey, by all means, don't let these categories of us trying to do the

best we can to guide treatment get in the way of things that are working.

I think that's the, yeah, I think the complex grief is a construct,

is a concept that has been helpful for many people.

But I also think the other side of arms at your side and I don't have depression.

I have complex grief. Right.

No, if it's a useful construct, use a construct. But it may well be that if

you have five of nine symptoms of depression and you also happen to have the

symptoms of complex grief and the necessary might help.

But then again, it might be a distraction from the work that you're doing.

And so this is why the nuances of the individual patient situation really matter.

A person hates drugs, never wants to be on drugs, and is finding help with complex

grief, spiritual counseling, by all means, if you're not getting help with the

spiritual counseling, maybe consider a medication more than you have.

So I really, and maybe this is just the doctor showing and not the neuroscientist,

is just a lot of this, for better or worse, is empirical,

is trying to find what works and trying to have wisdom about what's effective

for an individual and what's a compatible treatment for an individual.

There are certain medications I would never recommend if a person's trying to get pregnant.

There are certain medications I would absolutely recommend if they weren't.

And so you got to be aware of the individual patient when even recommending

a psychotherapy or embracing a diagnostic construct.

Wow. I think I could talk to you forever.

I got so So many questions about mental health and psychiatry,

but I want to get just back to your book for a minute because we're running

out of time. I promised you about 45 minutes.

And the thing I want is I'm praying and listener, I'm begging you to read this book.

If you struggle with depression or even just weariness or if you love somebody

who does, this is a book that's going to help you.

And we've had a high level conversation here about a lot of different things

related to the brain and mental health.

But coming back to your book, David, it's obvious that you love your patients

and it's It's obvious that you hate depression.

Give us a, I guess, a quick overview of the work that you've done in this book

and how you hope that it helps people. What's your goal for this and who should read it?

So I think one of the one of the main insights of the book is that a lot of

these systems that we have, for example, pleasure, pleasure or hope or truth.

These are almost like capacities of sight, or it's almost like a physical sense.

And I think that God has given us the ability to detect, to see,

in a sense, truth and identify, oh, that's true, that's false.

And that's almost a spiritual sense, partly, but it's also based in the brain,

or at least there's a part of the brain that's contributing.

And that this can be disordered or affected in depression, just like your eyes

can have a cataract and things start getting fuzzy.

And there's things that you could do to restore the vision.

Yeah, there's like biological stuff, but also when people are weary or even

to some extent when you're depressed, you can try to make changes to realize

the truths about yourself, to experience pleasure that you might not have otherwise experienced.

And I think that the part from the Gospels where from Matthew,

where Jesus is talking about the eye, the eye is the lamp of the body.

So if your eyes healthy, your whole body will be full of light.

But if your eyes bad, your whole body will be full of darkness.

If the light, if then the light in you is darkness, how great is that darkness?

This is he's talking about a lot of things. But I think that at least one application

of that is your vision, what you're looking at, what your attention is focused on matters immensely.

And this is an insight I got from or I was taught by Jeff Schwartz,

is that your focused attention is probably the thing may well be actually restructuring,

reprogramming, changing even the physical structure of your brain.

And so it will focus your attention.

Yeah, and the quantum zine effect is one of the proposed mechanisms by which

the thing we know to be true, when you focus on your, one of my favorite studies

is your abductor digidaminomide, this tiny muscle right here on the side of your pinky.

When you move that, so they had a study where they had people think about moving

this out, actually exercising this, and they got 50% stronger by doing this

exercise 15 minutes a day.

But then they had another group think about doing the exercise, size, 15 minutes a day.

And they got 35% stronger. Right.

So you're getting like physically stronger by thinking. And it's like,

how's that happening? Probably you're like expanding the part of the brain that controls that finger.

And that's able to send more electrical impulses to that existing,

the same sized muscle. And that's cool.

That's like incredible. But like these examples of your brain is physically

changing when you change your attention.

And so depression makes it very hard because it sucks your attention to your faults.

It sucks your attention to your failures and And things that have gone wrong,

things that might not even be your faults or failures, that are like false ideas

about who you are. And that's just where your attention is stuck.

And so it takes all of your effort to redirect and say, hey, maybe I'm okay.

But if you're in the middle stage of weariness, then you can with effort keep

doing that. And if you keep doing that, it too is like a muscle.

And then you can reinforce the ideas or the beliefs or the ways that you live.

That are good behaviors or patterns of thought or spiritual disciplines.

And that is the I think that the book is that's one of the main ideas of the

book. But then, OK, how does that apply to pleasure?

How does that apply to hope? How does that apply to exercise across the spectrum of human capacities?

This main idea of if you redirect your attention, if you exert effort, you can do something.

Now, it's not always going to work by itself.

And so sometimes the effort you have to exert is to pick up a phone or Google a psychiatrist.

That's sometimes what you need to focus on is the little f attention energy

you have on getting help.

Just like an AA, often the best use of your attention is find a group to go

to that's meeting tonight.

But, and then it gets in then getting into more detail about,

okay, how does it affect a history of trauma?

How does it affect a person with difficult past or difficult intrusive thoughts or memories?

And across the spectrum, there's the, that there's different ways that idea

plays out in these different domains.

Wow. You did a beautiful job with the book. I want to give you one last thing

to leave with us is somebody that's listening to this, David has like literally

just buried their child or literally just found out their wife has glioblastoma.

They're in the midst of the hardest thing they're going to go through.

And maybe you can direct them towards some reason that they have a valid reason

to think that there's still hope. So that's one thing.

And then the last thing is depression.

I thought it was beautiful how you tell us that the opposite of depression is

not actually just feeling better, but it's something that you call flourishing.

So take us home, land the plane with what flourishing means and why somebody

out there who's really struggling should think that there still is a chance

that they might have hope again.

Yeah. Yeah, it's there's so much suffering and so much pain in the world and

so many tragedies happen every day.

And so if that's you, if there is something that just happened that just rocked your world, yeah.

There, there is hope. And I think that from a secular perspective,

there is hope because for the first time in my lifetime, not that I'm that old,

there's actually like advancements happening in neuroscience.

There's actually like new treatments that are going to be available next year

that were not available that this wasn't true in the past.

So if you're really in the depressed frame or you just can't function or needing

help frame, there is hope because you probably haven't tried all the stuff that's already out there.

And further, there's going to be new stuff next year and the year after that.

So we really are in a golden age, I think, of neuroscience and applied neuroscience.

From a Christian perspective, I end the book with a chapter on blessedness.

And it's a great idea to exercise, it's a great idea to redirect your attention in these willful ways.

But all of that is not the same thing as what I think Jesus was talking about with blessedness.

How is it the case that a person can be blessed when they're mourning?

How is that possible? And the answer is they're going to be comforted and that

there's going to be this state of being that transcends the body.

And maybe not transcends the body, it transcends this body because we're slated

for a resurrection as Christians.

And so whatever parts of your brain are disordered or broken or hurting.

Those are going to die and be resurrected without those things.

And so I think the Christian hope, and there are some people and there are examples

of people who are able to have that new life now and that that's something that's

available in principle to anybody.

And that this is the sense in which, yeah, no, if you just had enough faith, OK, fine.

If I was truly a saint, of course, I wouldn't be having these problems. But that's hard.

So, yeah, in a sense, sure, that there is a way to transcend all of this.

But it's not like that's it. So we should always keep that in mind.

Mind that, yeah, don't eat junk food and then ask God, why does my stomach hurt?

But at the same time, no amount of healthy or clean eating is going to solve

the problem of death and sin.

I think that just keeping that intention while on this planet,

this age that we're in, is important.

But also, as a Christian, keeping our eyes on Christ, on the resurrection,

on the hope that is beyond the material.

But not just without the material, but beyond this set of material circumstances.

And there is hope in Christ. There is hope in Christ. Isn't that incredible?

What a great talk. Listen, The Opposite of Depression is a tremendous book.

If you're suffering from depression or anxiety or other issues,

there is hope, and there's hope in Christ.

I love how he landed there with there is hope in Christ.

Friend, we're praying for you. We are with you. Dr. Carreon's book will help you.

We'd love to give you a free copy. Send me an email, lee at drleewarren.com,

with your name, your mailing address, and your zip code if you'd like to be

considered for one of the free copies. Please read his book.

Please check it out. there is an opposite of depression and it's not just feeling better.

It's learning how to flourish and there's hope in Christ. Friend, we'll talk to you soon.

God bless you. And don't forget to start today.

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