A groundbreaking guide to sub-clinical depression, one of the most underdiagnosed conditions in women today, presents a simple eight-week program, which uses light therapy, moderate exercise, and vitamins, that is scientically proven to combat depression, overcome fatigue, and provide a greater sense of control, balance, and well-being. Reprint.

Marie-Annette Brown, Ph.D., R.N., is a professor in the School of Nursing at the University of Washington who is involved in research, teaching, and clinical practice. Dr. Brown has lectured widely and published more than 60 scientific papers. She is nationally certified as a family and psychiatric/mental health nurse practitioner and provides primary care at the University of Washington Women's Health Care Clinic. Jo Robinson is a New York Times best-selling author from Vashon Island, Washington, who specializes in books on mental health and nutrition. She is the coauthor of 11 popular books, including Getting the Love You Want, Hot Monogamy, and The Omega Diet. She collaborated with Dr. Brown in the design of the Levity study.

Chapter One

The Body Blues

Women's Number One Mood Problem

    At any given time, tens of millions of women are troubled by a syndrome for which they have no name. One of the most common complaints is feeling tired and sluggish much of the time. To their dismay, the women don't have enough energy to be the patient moms, supportive partners, or fun-loving friends they would like to be. Although they know that exercise would help revive them, they rarely have both the time and the motivation.

    Many women with this syndrome have sleep difficulties as well. They have trouble falling asleep or staying asleep--or they sleep too much. The common denominator is that they feel drowsy during the day, whether due to a lack of sleep or general drowsiness. Those times when they feel alert and energetic all day long are a welcome relief.

    Difficulty concentrating is another telltale sign of this disorder, especially in women 35 and older. The women have trouble focusing on tasks, absorbing complex information, or finding just the right words to say when they talk. Verbal slips and difficulty remembering names--even the names of people they know really well--can be a source of embarrassment. Curiously, these mental lapses can come and go. For days at a time, they feel mentally sharp. Then, for some unknown reason, theft thinking becomes fuzzy or scattered. It's as though their IQs had dropped 10 points overnight. Middle-aged women can be especially troubled by these mental symptoms because they fear they might have the early signs of Alzheimer's disease.

    Many of the women also feel stressed and irritable. They can be annoyed by simple things such as the sound of construction from a neighbor's house, a partner's eating habits, or being put on hold on the phone. Even when the pressure is off, some women find it hard to relax. A drink or two is a fast way to unwind, but relying on alcohol to relax can lead to alcohol dependency. A more common way to relieve stress is to watch TV or read a book. These two remedies work reasonably well, but they take away from the little time women have to be creative or take on ambitious projects.

    But the most common and vexing symptoms of this syndrome are overeating and weight gain. In the morning, most of the women have little trouble controlling their appetite. But sometime in the afternoon, they begin to snack. They also feel an urge to eat whenever they are feeling anxious, tired, or stressed. Women say that certain foods are more soothing than others, especially pasta, pizza, sweets, bread, and chocolate. In fact, a craving for sweets and starches is one of the defining characteristics of this syndrome.

    The logical result of feeling too tired to exercise and eating too much is being overweight. Some women manage to keep the pounds off through rigorous dieting, but most plateau at a high weight or continue to gain weight year after year. One reason being overweight is so troubling to them is that they can't cover it up. If need be, they can disguise the fact that they're sleeping poorly, forgetting names, or feeling irritable. But they can't deny that they're overweight. It's the one visible sign of their distress.

    There's another symptom that one might expect to find on this list--a depressed mood. But women who have this syndrome do not have serious mood problems. Unlike women with clinical depression, they do not feel sad or tearful all the time. They don't feel hopeless or think that the world would be a better place without them. When something good happens to them, they feel genuinely happy. Most of them perform well at work, even those with high-level, demanding jobs. Nonetheless, they can be very distressed by their fatigue, eating problems, irritability, confused thinking, or sleep difficulties. These symptoms interfere with their relationships, frustrate their ambitions, and rob them of the full enjoyment of life. It's as though their bodies were depressed, but not their minds. They have what I call the "Body Blues."

What Is the Body Blues?

    The textbook term for the Body Blues is vegetative depressive symptoms . A woman with this condition has three or more of the symptoms listed below to such a degree that they diminish her enjoyment in life and sense of well-being.

    · Eating too much and gaining weight

    · Low energy

    · Difficulty concentrating

    · Sleep difficulties

    · Irritability or tension

    · Daytime drowsiness

    · Decreased interest in sex

    · Mild anxiety

    · Mild depression

    · Heightened sensitivity to rejection or criticism

    A woman can have the Body Blues all by itself, or it can be a part of other disorders. For example, PMS could be viewed as the Body Blues plus bloating, cramps, or breast tenderness. Postpartum depression, or the "baby blues," could be seen as the Body Blues but with more severe mood problems. Menopausal symptoms could be characterized as the Body Blues plus hot flashes and physical signs of aging. Seasonal affective disorder (SAD), also known as winter depression, could be regarded as a seasonal siege of the Body Blues. Embedded in all these disorders is the same core group of symptoms listed above.

    Men can have symptoms of the Body Blues as well, especially those 40 or older. But the syndrome is far more common in women. First of all, most of the disorders that include symptoms of the Body Blues, such as PMS and the baby blues, are exclusive to women. But even the unisex disorders, such as SAD, are three or more times as common in women as men. For reasons I will explore in more depth in chapter 2, the Body Blues seems to go hand in hand with being female.

Joanne: A Portrait of the Body Blues

    In addition to being a professor and researcher at the University of Washington School of Nursing, I am a primary care provider for female patients at the university's Women's Health Care Clinic. Like most practitioners, I see a steady stream of women with the Body Blues. One of my patients (I'll call her "Joanne") has four of the most common symptoms--fatigue, irritability, low sexual desire, and weight gain. Although these problems bother her a great deal, few people would sense that anything is wrong with her. To the casual observer, she appears to be a competent, confident woman who happens to be slightly overweight.

    The primary reason that Joanne made the initial appointment is that she feels tired much of the time. On most nights, she gets 7 to 8 hours of sleep, but when she wakes up in the morning, she still does not feel refreshed. By early afternoon, she is overwhelmed by the need to take a nap. Because her office is in her home, she can lie down whenever she needs to, but she resents taking the time. Napping also makes her feel lazy. "I'm only 39," she told me, "I shouldn't have to take a nap! I feel like my grandmother! Before I had employees, I could nap and not feel guilty. Now I have to sneak around to get the rest that I need."

    Joanne also feels stressed and irritable much of the time. "My family bears the brunt of it," she told me. "My employees and clients soak up most of my patience during the day. My son gets what's left. My husband--I'm much more critical of him than I want to be. And for about 5 years, I've had much less interest in sex. Once I get aroused, I enjoy sex. I say, ‘Hey, Jim! That felt really good! Why don't we do this more often?’ But when I'm not making love, I have little interest in sex at all. Most nights, I'd rather read a book."

    Even though Joanne listed fatigue as her reason for making the appointment, I could see that she was even more concerned about her weight. At 5 feet 6 and 172 pounds, she is about 30 pounds overweight. "I have no problem controlling what I eat for breakfast and lunch," she told me during that first appointment, "but everything falls apart in the late afternoon. I eat before dinner, during dinner, and after dinner. It's like I'm on a diet for the first half of the day, then I blow it the second half. I do this day after day." The net result of her frequent snacking and low energy is that she has been gaining about a pound or two every month. Even though she is not obese, her weight troubles her a great deal. She is unhappy about how she looks and feels ashamed that she can't tame her appetite. "I know everything there is to know about losing weight," she said. "I've done it dozens of times. But I can't keep it off. When I've dieted myself out of my size 16 clothes, I've learned not to throw them away because I know I'll be needing them again in a few months. Right now, I'm back in my fat clothes."

    Although Joanne did not seem to be seriously depressed, I asked her some general questions about her mood just to make sure. She said her mood wasn't great, but she didn't think she was depressed. "I have my ups and downs," she said. "But most of the time, I feel okay."

    "How do you feel about yourself?" I continued. "Do you often feel worthless or inadequate?" Many women have low self-esteem, but it is very common in women with serious mood disorders. Joanne laughed. "My husband would say I have the opposite problem--grandiosity. Most of the time, I'm pretty high on myself." Then she paused. "Except for being so tired. And my weight. I can't seem to do anything about that. And the fact that I'm such a slob. My house is a mess. So is the car. I can haul four sacks of groceries into the house, but I don't go back that one last time to clean out the car. That bugs Jim to no end. When I drive his car, I clean it up. But I leave mine a mess."

    As I listened to Joanne, it seemed that she had high self-esteem except when it came to the symptoms of the Body Blues. She thought she was overweight because she lacked willpower. She had a messy house because she was a "slob." I find some measure of self-blame in virtually all women with this syndrome. "Why can't I stick to a diet?" "I know I should exercise. Why don't I do it?" "Why can other women keep the weight off?" "My husband eats everything in the house, and he's not overweight." "Why am I so tired all the time?" "Why do I have so little interest in sex?" "Why can't I remember the names of my best friend's children?" In addition to being troubled by their vegetative symptoms, these women are weighed down by feelings of shame and blame. In some of my patients, the self-criticism seems just as burdensome as the symptoms themselves. Very few women realize that their eating problems and feelings of fatigue, stress, and irritability are due, in part, to their biology.

    I asked Joanne if her symptoms got worse just before menstruation, and she said that they did. "But I don't feel great the rest of the month," she said. "It's just that I eat more and feel more tired and irritable just before my period." Normally, I would have asked if her symptoms were confined to the winter, indicating that she might have SAD. But this was the end of June, and she was still feeling sluggish and eating too much. People with SAD feel much better in the summer.

    Finally, I asked her some questions about her diet, exercise habits, family relationships, and social support system. As a nurse practitioner, I've been trained to look at the whole person, not just her symptoms. I noted nothing in Joanne's responses that suggested she was in need of personal, marital, or family therapy. At the end of the appointment, I ordered some blood tests to make sure that she did not have any of the physical problems linked with fatigue such as an underactive thyroid, diabetes, mononucleosis, hepatitis, or anemia. A few days later, when all her tests came back negative, I was not surprised. As I had begun to suspect during her first appointment, Joanne is one of the millions of women with the Body Blues.

Why Is This Syndrome News?

    The fact that women are prone to having this particular cluster of symptoms has been known for a long time. For example, in the 19th century, the Body Blues was called "neurotic" or "nervous" depression and was considered a "female problem." The Victorians blamed this disorder on a woman's fragile constitution, her childlike nature, or her willful deviation from traditional femininity. Women at highest risk were thought to be those who were too involved in intellectual matters.

    The 19th-century cures for the Body Blues seem just as foreign from our modern point of view. When a woman had problems with fatigue, for example, she was said to be "off her feet" and could be sent to bed for weeks on end. While sequestered in her dark room, she was to avoid having company or stimulating her mind--a cure that was in reality a recipe for depression! If a woman ate too much, she was said to be "eating like a ploughman." To tame her appetite, she might be subjected to bloodletting or leeches. If that didn't work, then her ovaries might be removed. Women who felt irritable or displayed "cussedness" were treated with laudanum--an addictive elixir of opium, sherry wine, and herbs guaranteed to cure anyone's ills.

    Today, the Victorian remedies for the Body Blues and the 19th-century terms for the disorder are safely tucked away in the history books. The psychiatric community has chosen the label vegetative depressive symptoms because people who have this disorder tend to feel slowed down, weighed down, and sleepy, and they eat too much. In other words, they seem to "vegetate." The modern slang term "to veg out" has many of these same connotations. By contrast, people with more "typical" symptoms of depression have little appetite and tend to lose weight--the opposite of the Body Blues.

    Until the 1990s, however, vegetative symptoms of depression were given scant attention. They were regarded as just another variety of depression that happened to be more common in women than men. Few people were aware that these symptoms could plague women throughout their reproductive years--first manifesting themselves as PMS, then as winter depression, followed by the baby blues, and then perimenopausal and menopausal symptoms. People were too busy focusing on each of these disorders as a separate entity to see what they all had in common.

The Prozac Phenomenon

    One phenomenon in particular highlighted the similarities between these conditions--the widespread use of Prozac, the popular antidepressant medication introduced in 1988. Prozac was the first in a family of antidepressant drugs designed to boost the activity of serotonin, the brain's primary feel-good chemical. This family of drugs is referred to as selective serotonin reuptake inhibitors, or SSRIs. Prozac proved to be just as good at treating depression as earlier medications, but with fewer side effects. Because the drug was so well-tolerated, researchers began to see whether it could treat other disorders as well.

    Starting in the mid-1990s, Prozac and other SSRIs were given to people with a wide variety of conditions--including sleep problems, anxiety, obesity, bulimia, fatigue, chronic pain syndrome, fibromyalgia, SAD, and PMS--as well as to women going through perimenopause or menopause. Surprisingly, the SSRIs helped relieve all of these seemingly unrelated problems. To the researchers, this suggested that a deficiency of serotonin must be one of their hidden causes. There was another factor that united all of these conditions--they were either exclusive to women or far more common in women than men. Did this mean that women are more likely than men to be deficient in serotonin?

The Estrogen-Serotonin Connection

    It now appears that the answer is yes. Before the 1990s, researchers found little difference in the amount of serotonin in the bloodstream of men and women. But as scientists learned more about brain chemicals in general and serotonin in particular, they began to discover some very important differences between the sexes. For example, men and women differ in the number and effectiveness of the receptors that grab on to serotonin and make it available to the brain cells. This means that a man and woman could have the same amount of serotonin in their brains, but men would make better use of the mood-elevating chemical.

    An even more important discovery, however, is that the serotonin activity in a woman's brain ebbs and flows with her production of estrogen. When women have high estrogen levels, they have more serotonin activity in their brains. When they have low or falling estrogen levels, they have less serotonin activity.

    When do women have low or falling levels of estrogen? They are most likely to have low or declining estrogen production (1) in the days before menstruation, (2) after giving birth, (3) while breastfeeding, (4) during perimenopause, and (5) during all the decades following menopause. These happen to be the very times when women are most likely to have vegetative symptoms of depression. One could almost say that low estrogen equals low serotonin equals the Body Blues.

Women, Stress, and Serotonin

    There's one more occasion when women are more likely to be deficient in serotonin than men--during periods of prolonged stress. It's been known for a number of years that when people are under stress, they go through their store of serotonin at a faster pace, requiring their brain cells to speed up production. But a startling new finding is that women may replenish their supply of this feel-good chemical more slowly than men.

    In a 1997 study, investigators used a sophisticated imaging technique called positron emission tomography, or PET, to peer inside the brains of male and female volunteers. The PET scans showed that the men were producing serotonin 50 percent faster than the women. Years ago, the fact that women might have a larger corpus callosum--the bridge between the right and left hemispheres of their brains--was the topic of much discussion. The new finding that men produce nature's antidepressant more rapidly than women could prove to be a much more significant discovery.

    Hampered with a slower production of serotonin, a woman becomes vulnerable to the Body Blues when she is under prolonged stress. Imagine, for a moment, a situation in which a woman and her husband are subjected to the very same stressful situation. Let's suppose that they receive a registered letter from the IRS saying that they have underpaid their taxes for 5 years and may be facing penalties and criminal charges. Once the initial panic subsides, the couple endures weeks of anxiety and pressure as they spend long hours with their tax lawyer, stay up late going through their financial records, and worry about the possible criminal charges. The constant stress uses up their serotonin at a faster-than-normal pace. But the woman makes up for the deficiency more slowly than her husband, making her deficient in serotonin for more of the time. When the matter with the IRS is finally resolved, it's not surprising that she has gained a considerable amount of weight and feels more stressed and depressed than her husband: She has been handicapped by a slower production of serotonin.

A Syndrome in Search of a Cure

    If one of the underlying causes of the Body Blues is low serotonin activity, then the obvious solution is for women to take drugs that boost this essential brain chemical. Hundreds of thousands of women are now following this course of action. But none of the medications now on the market is a comprehensive solution for the Body Blues. Typically, the drugs help with some symptoms but make others worse. For example, a drug that makes a woman feel happier and more energetic can interfere with her ability to have orgasms. Or a medication that tames a woman's appetite can make her feel jittery and disrupt her sleep. Or a drug that helps calm a woman's anxiety can cause her to gain weight--a side effect few women will tolerate.

    When one of my patients is seriously depressed or her symptoms are interfering with her ability to function, I recommend the use of appropriate medications. For some of my patients, antidepressants have proven to be lifesaving. But the Body Blues is not a life-threatening mood disorder. The syndrome is burdensome and annoying and erodes a woman's sense of well-being, but it is not a severe condition. Many of my patients with this syndrome have come to the same understanding. When I discuss various treatment options with them, including SSRIs, one of the most common refrains is "I'm not all that depressed." Other women have a strong preference for relieving their symptoms in a more natural way. They say to me, "I don't want to solve my problems with a prescription drug."

    In search of a more natural solution, many women turn to alternative remedies for relief. There are now hundreds of products on the market that promise to cure some aspect of the Body Blues. There are teas, tinctures, and supplements that promise to enhance your mood, help you lose weight, improve your memory, calm your anxiety, spark your sexual desire, or help you sleep like a baby. Because women with the Body Blues tend to have a number of these symptoms, some take a handful of supplements each day.

    I am open to the use of herbal treatments or dietary supplements in general. Some show signs of living up to their claims and have fewer side effects than prescription drugs. But many of the products now on the market have not been adequately tested for their effectiveness, quality, or safety. And there is some concern as to whether they even contain the amount of active ingredients specified on their labels. Even when the products contain the right ingredients in the advertised amounts, many women don't get the relief they are seeking. They try one remedy for a few weeks and then discard it for the newest and latest herbal cure. Or they keep taking the old products and add a new one on top of them. As one of my patients confided, "I don't know if any of them is working, so I take them all."

    As a rough estimate, I would guess that about one quarter of the millions of women with the Body Blues seek relief from antidepressants and another quarter turn to alternative remedies. But, sadly, the rest of the women do nothing at all for their vegetative symptoms. Many do not know that they have a treatable disorder, so they simply do their best to cope. Some are ashamed of their symptoms, so they don't make an appointment to discuss them with their health care practitioners. Typically, I first learn that one of my patients has vegetative symptoms when I ask general health questions during her annual cervical and breast exam. If I didn't know what to look for and which questions to ask, I would never know she is troubled by the Body Blues.

(Continues...)

Excerpted from When Your Body Gets The Blues by Marie-Annette Brown, Ph.D., R.N., and Jo Robinson. Copyright © 2002 by Marie-Annette Brown, Ph.D., and Jo Robinson. Excerpted by permission. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.