By age forty, 50% of the Canadian population will have or have had a mental health disorder. (1) Could gluten be part of the problem?
It likely won’t surprise you to learn that depression is more common among those living with chronic illness. But is the depression a separate illness? Or, is it a symptom of living with chronic illness? And what role does gluten play in all of this?
What exactly is depression?
Feeling low or down in life is not an uncommon part of the human experience. But where do we draw the line between a bad month and depression? The Diagnostic and Statistical Manual of Mental Health Disorders, has created robust diagnostic criteria for the proper diagnosis of clinical depression. They call this the DSM-V – it is the most recent publication outlining classification and diagnosis of mental health disorders. Regarding depression, the DSM-V follows the following criteria for diagnosing depression: (2)
- Two to four of the following symptoms have been present during the same 2-week period:
- Dysphoria – Depressed mood most of the day, nearly every day
- Anhedonia – Markedly diminished interest or pleasure most of the day, nearly every day
- Significant appetite or weight change
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation (observable by others)
- Anergia – Fatigue nearly every day
- Thoughts of worthlessness or inappropriate guilt nearly every day
- Impaired concentration or memory nearly every day
- Recurrent thoughts of death or suicide, or suicide attempt
- At least one of the symptoms include dysphoria (depressed mood) or anhedonia (diminished interest or pleasure)
- The symptoms cause clinically significant distress of psychosocial impairment
- The symptoms are not due to to the physiologic effects of a substance, medication, or general medical condition
- Persistent depressive disorder (dysthymia) and cyclothymic disorder are not present
- The mood disorder does not occur exclusively during a psychotic disorder
So, the next time your doctor thinks you’re depressed, make sure she’s familiar with the above criteria. At the time of this writing, they’re the most robust and up to date.
For those of you that have celiac disease or gluten sensitivity, don’t a lot of the listed symptoms reflect the way you felt before adopting a gluten-free diet?
This is where diagnosis gets complicated. Do you actually have depression? Or, are your symptoms caused by a different disease altogether?
Are there different types of depression?
Yes, to further complicate the diagnostic picture, there is more than one type of depression. The above DSM-V criteria are specific to clinical depression. Other types of depression include:
- Persistent depressive disorder (dysthymia)
- This is a depressed mood lasting for at least 2 years.
- Perinatal depression
- This is a major depressive episode during or after pregnancy.
- For more information on gluten’s effect on pregnancy, please see this series of posts.
- Psychotic depression
- This occurs when clinical depression is combined with psychosis.
- I’ve written at length on gluten’s effects on schizophrenia and psychosis here.
- Seasonal affective disorder (SAD)
- SAD is characterized by a depression in the winter months when there is a decrease in natural sunlight.
At the time of this writing, there is no depression category unique to gluten intolerance or chronic illness. Both are generally classified under clinical depression.
Gluten and depression
Most of us are familiar with the effects celiac disease and gluten sensitivity has on our guts. But did you know that celiac disease has a wide range of additional symptoms? Some of which include mental health. In a previous post, I wrote in detail about the less-common effects of celiac disease and gluten sensitivity. Before receiving a proper diagnosis, those with silent celiac disease or gluten sensitivities often go years with unexplained symptoms.
Imagine if you suffered (for years) with fatigue, dull aches in your joints, itchy skin, headaches, and diarrhea/constipation. Each time you visit your doctor, he prescribes a medication to help with one of your symptoms – steroid cream for the itchy skin, painkillers for your joints and headaches, and a heartburn medication to settle your stomach. The medications help (temporarily) with your symptoms. But they always return. And, the medication has unwanted side-effects. Would you not start to feel depressed?
There is no blood test or marker we can measure for depression. After suffering for years with symptoms, those with undiagnosed celiac disease or gluten sensitivity often feel that this is their new normal. With this acceptance often comes feelings of depression. This is part of the reason many people with undiagnosed celiac disease or gluten sensitivity are placed on antidepressants.
Can gluten cause depression?
The exact effect gluten has on our mental health is a topic of research. At the time of this writing, there is no specific cause-effect relationship between gluten and depression. However, we do know that there are certain correlations between the two:
- Depression may be a reaction to the illness
- Some studies show that depression is a reaction to a chronic disease condition. (3)
- Patients with undiagnosed gluten sensitivity or celiac disease often have all the symptoms of irritable bowel syndrome (IBS). Sometimes, they even receive an IBS diagnosis before celiac disease. Those with IBS have been shown to have a much higher risk of developing depression. (4)
- Depression may be a reaction to the restrictive nature of a gluten-free diet
- One study found that the restrictive nature of a gluten-free diet caused depressive symptoms. (5)
- Depression may be due to the malabsorption of nutrients
- One study suggested that the malabsorption could interfere with the neurotransmitters that regulate mood. (6)
- Folate and vitamin B12 absorption is affected when the gut lining becomes inflamed or irritated. This is commonly the case with gluten sensitivities or celiac disease. Both folate and vitamin b12 deficiencies have been shown to cause neurological symptoms. One of which could be depression. (7)
- Depression may be due to chronic low-grade inflammation
- Cytokines are small proteins that communicate and coordinate actions between cells. (8)
- Chronic elevation of cytokines occurs in long-term inflammatory conditions. (9) The elevation of cytokines has been shown to contribute to the development of depression. (10)
- Those with gluten sensitivities or celiac disease that continue to consume gluten risk developing a chronic inflammatory state within their body. This chronic inflammation may contribute towards developing depression.
- Genes and their relationship to depression
- Having a first degree relative with depression will elevate your risk of developing depression.
- Almost everyone with celiac disease has either the HLA DQ2 or HLA DQ 8 gene variants. Researchers have not identified a gene specific to depression (yet) but since having a family history of depression increases your risk, we know there is a genetic component.
If you have depression, should you go gluten-free?
Let me ask you this:
If you have depression, why would you not try a gluten-free diet?
A gluten-free diet is a low-risk treatment option. Plus, you can do it from the comfort of your home. I certainly believe that the benefits of a gluten-free diet far outweigh the costs.
The one study that showed a connection between a gluten-free diet and increased risk of developing depression illustrated the potential for social isolation, and eating disorders to develop. This study was written in 2013. Since then, going gluten-free has gotten much easier. Most restaurants have at least a couple options for those following a gluten-free diet. Public acceptance of gluten-related disorders continues to improve as well.
Adopting a gluten-free diet has never been easier or as socially acceptable as it is today. The other studies all showed a plausible connection between depression and an undiagnosed gluten allergy/sensitivity. Suffice it to say, if you’ve struggled with depression, it’s worth trying a gluten-free diet.
How to start a gluten-free diet if you’re depressed
If you’re already bordering on overwhelm, the thought of a complete dietary overhaul can seem terrifying. This is often what stops us from starting. After helping hundreds of patients successfully transition to a gluten-free diet I’ve learned that success does not come overnight.
You do not have to be gluten-free by tomorrow. A slow, methodical pace towards achieving a gluten-free diet is ideal. For some, that may take a week. For others, six months. There is no rush. The key is creating new shopping, eating, and food preparation habits; and habits are not formed overnight.
The first step I recommend everyone follows is to first educate yourself on the products that contain gluten. I’ve written about these foods here. Some foods obviously contain gluten, like bread and pasta. Others are less intuitive, like soy sauce, canned beans, or instant coffee. Once you know what contains gluten, identify which foods in your diet make up 80% of your gluten consumption. For most people, it’s bread and pasta.
Now, it’s time to alter your shopping experience. When you’re first starting a gluten-free diet, purchasing gluten-free alternatives is the best place to start. Bread and pasta can be swapped with gluten-free varieties. Add these new additions slowly. Find gluten-free brands/products you enjoy the taste of. We want this transition to be sustainable.
With the simple change in bread and pasta, you’re likely already 80% gluten-free. All with little effort and no overwhelm. Removing the remaining 20% of gluten exposure is where it can get cumbersome. I recommend staying 80% gluten free until it feels effortless. Only then should you (slowly) begin making the push for removing the additional 20%.
To make the final push towards removing the last 20% of gluten in your diet, please see this post. It outlines all the places gluten hides and the aliases it goes by on ingredient lists.
Now, I want to hear from you!
What helped make your transition to a gluten-free diet comfortable and low stress?
Did removing gluten from your diet help improve your mood? How long did it take for you to notice a change?
Also published on Medium.