Clinical Brief – Music and depressive disorders – do they go hand in hand?

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It may be cliched’ to label musicians as tortured, yearning, more interesting than average, extremely creative, wild, hypersexual, prone to addiction and prone to mental health issues.

But when I looked into the research on the subject of depression disorders in the music industry I was surprised to see some of the statistics actually support the idea that musicians may be more prone to depression and anxiety.

As it turns out, there is a charitable organization in the UK called “Help Musicians” and they conducted a pilot study to help musicians who suffer from mental health issues such as anxiety and depression. In that study, they surveyed over 2200 people and roughly the same amount of men and women in 12 different occupations in the musical industry. Researchers asked them about working conditions and how they felt these conditions affected their mental wellbeing. They found that 71% of the people polled reported that they had suffered from panic attacks and/or high levels of anxiety, and 69% of them reported that they had previously suffered from depression. Contrast these rates to data collected in the UK in 2010 that showed a depression rate of 1 in 5 or 20% in the general population. According to this data, professionals in the music industry in the UK would be 3 times more likely to suffer from depression than someone who is not. An interesting thing to note here is that 39% of the subjects were the musicians themselves and the rest were employed in the industry. Respondents in the study listed the following reasons for their depression:

• difficulty of sustaining a living;
• anti-social working hours;
• exhaustion and the inability to plan their time/future;
• a lack of recognition for one’s work and the welding of music and identity into one’s own idea of selfhood;
• musculoskeletal disorders;
• balancing work and family commitments;
• Sexist attitudes and sexual harassment.

Few would argue that being a professional musician is an easy vocation. But if you dissect the explanations above you can make a case that the general population would list many of the same reasons for their struggles. These are issues that most of us deal with every day and the truth is, many professional musicians are subject to expectations that are often unrealistic. But let’s explore some of the explanations they listed above and see why these reasons may be applicable. I found an article written by Dan Masterson on quora.com that addresses a few of these points beautifully. By the way, Dan is a professional musician and songwriter. This is what he had to say: On the difficulty of sustaining a living: “… Then you get a royalty check from Spotify for 3020 spins: WOW 3000 spins! Fat $0.52 check. Does this seem worthwhile when that album cost $6000.00 to produce? …Know this: many musicians never recoup their costs on recordings, they turn a profit by playing live, selling merchandise with lower overhead costs, and working sponsorships.”  The competition for listeners ears and getting gigs is more difficult than ever and the “starving artist” cliche is definitely real.= On working hours and inability to plan their time/future: “Ex. Wednesday night: gig 9p–12am. Thursday 2–6pm, teach lessons, no gig. Friday: 7am radio show, 10am meeting with agent, 2–4pm record store appearance, gig 10pm–1am. What time do you go to bed Thursday? Still reeling at midnight? Nightcap? Hit the bowl? This is part of why touring is so difficult. The hours are irregular, unpredictable, and you’ve probably got adrenaline, caffeine, alcohol, and time zones screwing up your whole system. “ On balancing work and family commitments: “Imagine you work 60 hours a week honing your craft, performing, and sending work-related email. How many close friends did you talk with that week?….The successful ones [musicians] who go on the road spend weeks at a time disconnected from the people who truly know them. By the time they return from a tour, sometimes months have passed, and it’s hard to preserve relationships in that kind of environment.” On a lack of recognition for one’s work: “Musicians spend most of their careers being derided, ripped off, and unacknowledged.” Underappreciation for the work you do, especially in the form of underpayment can lead to high levels of stress and dissatisfaction and eventually cause symptoms of depression and anxiety. Musculoskeletal disorders I’ll address this one because I see it in my practice frequently. If you’re working 60 hours a week you likely don’t have time to add in a fitness program to keep your body in shape.  On top of that, throw in repetitive motions or postures for hours on end for 200 nights a year and hours of practice each day. This is a breeding ground for tendinopathies or repetitive motion injuries which are very difficult to get rid of, if the motions are continually performed. Pain increases stress and leads to hormone imbalance, and predisposes one to addictive behaviors. In many cases can cause depression and anxiety over the inability to escape the condition. Sexist ideas and sexual harassment In this survey, the percentage of women or men who reported this as a potential reason for their symptoms was not listed but I would guess that most of the complaints were from women who were themselves exploited or knew someone who was. As with any industry, sexism and sexual harassment is still a big problem. In an article called “Women in the music industry: Mind the Gender Gap” Lara Baker states:  “With discrepancies like this it is no surprise that depression is rampant in the industry. Experiencing  a feeling of helplessness is just one of the major indicators and causes of depression.” After going through the reasons the study subjects listed I’m going to propose a few of my own ideas on why I think musicians may suffer to a greater degree when it comes to depression and anxiety: Intelligence and depression often go together Viatcheslav Wlassoff, PhD wrote an article titled: “Does High IQ Increase the Risk of Depression and Mental Disorders?” In this article he articulately describes the interface of depressive disorders and people with exceptional intelligence: “People with high IQ tend to have fertile inner lives where they recreate the world to fit their dreams and preferences. They also have more intensified and enduring reactions to stimuli than their less-gifted counterparts. This means that when reality clashes with their perception of what is “real,” they feel at a loss and are unable to cope..…….“Highly intelligent people are also very sensitive and tend to be socially withdrawn. It may be because they are too busy with their own mental chatter or do not find someone to whom they can relate on an intellectual and emotional plane. Whatever may be their reason for feeling alienated from the world at large, people with high IQ lack support systems or creative outlets to help them cope with their blues.” Social withdrawal and isolation are very common behaviors seen in depressive disorders and I would argue that creative and artistic people tend to isolate themselves more often than the general public because it is often in isolation where art is produced. Overall, musicians tend to be creative and more intelligent than average. Gibson et al examined creativity and frontal lobe activity in musicians and demographically similar non-musicians. What they found is that the musicians showed enhanced creativity and enhanced divergent thinking, and greater bilateral frontal activity during divergent thinking compared with non-musicians. In addition, many other studies have observed differences in musical and nonmusical populations. Is it reward seeking? Sex, drugs, and alcohol are available to anyone who’s looking. Professional musicians are no exception, and many musicians agree that the opportunities are plentiful in the music industry.  Any intense event where people collaborate to put on a great show creates a feeling of comradery and those activities give extra space for celebratory events and often reward-seeking behaviors. Current scientific evidence tells us that the dopamine and opiate systems are primarily responsible for reward-seeking. Opiates are the reward, and dopamine is the neurotransmitter that drives us to continually seek reward and reinforces behaviors that are pleasing to us. It’s all in the genes…or is it the environment? One important thing to keep in mind when looking at potential causes of depression and anxiety in a population, is that no single cause exists in isolation. We are born with genetic propensities that dictate our biochemistry but we know that behavior changes protein synthesis and genetic expression of our genes. So we inherit our biochemistry and as we develop through childhood and beyond, our genes change to accommodate our environment. Genetic change sometimes occurs rapidly but it can also happen over the course of time with repetitive behaviors. If we know that our biochemistry changes with environmental influence, then we can see how constant influence from any source can also produce a change. Could it be that creative, intelligent people who possess elevated capacity for music, who tend towards depression and anxiety, and, who, are exposed to musical opportunity at an early age be attracted to careers in music greater than those who do not? Addressing brain function Let me start by saying that we know very little about how the brain works! Granted, neuroscience is arguably the hottest area of scientific research at this time, and so much valuable data has been generated. But good, objective data from scientific studies is hard to come by. Many of the studies conducted in the industry are generated by pharmaceutical companies who’s sordid relationship with the FDA, allows them to be heavily biased. The drug therapies we currently use for depression will, in 20 or 30 years be a joke in the minds in scientists of the future. Several books have addressed the idea that antidepressant medications are no better than placebo in the treatment of depression and anxiety and that these medications actually create more problems in the brain than they solve. (reference here) If the above is true then we should understand that information we consider factual now, will likely be partially true in the future. Scientific achievement in neuroscience in the last two decades is nothing short of remarkable. With that said, we still have a very limited understanding about the brain and how it works. Many of the medications used to alter neurochemical function are poorly characterized and understood. However,  in our quest to know more, we go with what we know. Current knowledge tells us that the neurotransmitters play a central role in brain function and we have a relatively good understanding about how a handful of them work. What are neurotransmitters and what role do they play? Neurotransmitters are chemicals produced by nerve cells that act as messengers of communication from one nerve cell to another.There are more than 80 known neurotransmitters in the human body and researchers continue to learn new information about them. The major neurotransmitters are dopamine, serotonin, norepinephrine, acetylcholine, and GABA. These brain chemical messengers are produced in nerve cells, and constantly being released when the body demands it. When they are released, they leave the cell, bind to receptors on another nerve cell, which perpetuates the signal. When these neurotransmitter systems are functioning well, we have a sense of well being, and bodily functions are carried out in an efficient and productive manner. When the neurotransmitter systems are not working well, it can create all kinds of unwanted symptoms in the body including depression and anxiety. Serotonin is the “feel good” neurotransmitter and when the serotonin system is working well, we generally feel confident and safe. When it’s not, we can lose the sense of well-being and become depressed. It is less well-known that depression is associated with low dopamine signaling. One study looked at the connection between dopamine signaling and motivation for reward seeking in mice and it found that when it is low in certain parts of the brain, passive coping mechanisms are activated, indicating an increase in depressive-like behaviors. Conversely, they showed that increasing dopamine cell firing can help prevent depressive-like behaviors. So we can see that both serotonin and dopamine are involved in depression mechanisms that tie into reward-seeking behaviors. If this is true then I think it would plausible to say that the perceived rewards of going into the music industry may be enough to attract people who both sought the rewards of fortune and fame and all that comes with it. Music in and of itself can provide enough of a reward to keep mild depression at bay but for many people, notably the ones in the UK who participated in this study and are still reporting depression and anxiety, it hasn’t done the trick. Below I would like to offer some ideas for musicians and people in the general population who suffer from depression and anxiety. Address psychological issues: The following information from an article on the Taking Charge of your Health and Wellbeing website offers some very helpful information on the types of therapy that can be used to help with depression and anxiety. Interpersonal therapy Focuses on the patient’s disturbed personal relationships that both cause and exacerbate the depression. Cognitive/behavioral therapy Focuses on recognizing and changing thought patterns and behaviors that lead to troublesome feelings. Helps patients change the negative styles of thinking and behaving that are often associated with depression and limits distorted thinking by looking at worries more realistically. Mindfulness-Based Cognitive Therapy Combines cognitive behavioral therapy with principles of mindfulness. Designed for people who experience “repeated bouts of depression or chronic unhappiness”. Dialectical Behavioral Therapy (DBT) –A very effective therapy that was developed to help manage borderline personality disorder. Psychodynamic therapies Focuses on resolving the patient’s internal psychological conflicts that are thought to be rooted in childhood. Long-term psychodynamic therapies may be useful if there is a lifelong history and pattern of inadequate ways of coping (maladaptive coping mechanisms) in negative or self-injurious behavior. Eye Movement Desensitization Resolution (EMDR) Frequently recommended for people who have experienced trauma or suffer from post-traumatic stress disorder (PTSD). Involves an 8-stage approach that includes recalling upsetting memories while engaging in side to side eye movement or other sensory input. Somatic therapies, including Hakomi and Somatic Transformation Body-centered practices that focus on the relationship between the body and mind. Based upon the belief that thoughts and emotions have a physical impact on the body, and vice versa. Interpersonal and Social Rhythm Therapy (IPSRT) – Designed to help people improve their moods by understanding and working with their biological and social rhythms. A compelling adjunctive therapy for people with mood disorders, emphasizing techniques to improve medication adherence, manage stressful life events, and reduce disruptions in social rhythms. Teaches patients skills that let them protect themselves against the development of future episodes.

Other potentially beneficial therapies that address lifestyle issues:

Movement Yes, I avoided the word exercise here because it conjures up images of going to the gym. How many musicians have time to do that? I bet if you polled for that question you’d get a single digit value in the yes column. Movement, however, is something most of us can pull off even if it requires focused effort and time. Carving time out of your schedule for this will pay dividends far beyond what you’d expect. It is well known that movement (exercise) is beneficial for overcoming and staving off depression for months at a time but of course this is very dependent on what is causing your depressive symptoms. Movement can mean involve walking, rock climbing and anything or between. My favorite form of movement is a combination of the following:

1. CARS and PAILS/RAILS exercises 3 days a week – if you have a floor you can do these.  They are a prerequisite for the exercises below.  If you don’t move well, do these for 8-10 weeks before starting the others types of exercises. See micro.university for the CARS course that I’ve put together for my patients and anyone else who wants to use it. These exercises can also help you get rid of all the aches and pains you have from the silly postures required to play an instrument.
2. Resistance training twice weekly – If you don’t have access to weights, who cares?. This can be done with just bodyweight for resistance. Do a search for Functional Movement Exercises and you’ll find plenty of exercises to get you started.
3. Interval Training one to two times a week – sprint/rest intervals of 30 seconds max effort followed by rest until your heart rate is back to resting. It can include biking, running (in place or anywhere else), using equipment designed for aerobic exercises.
4. Rest – Yes, rest and recovery are just as important as the exercises themselves. My rule of thumb when you’re starting out is at least one day of rest in between resistance training and interval training.

Sleep Sleep is the most important thing you can do to keep yourself from becoming depressed and anxious.  Getting 7-9 hours of sleep is more important than you will know.  A lack of sleep causes depression, anxiety, and destroys creativity and relationships. Sleep hygiene is so important. I’m not going to talk about it now but google it and you will get a few tips on what to do. Let’s move on for a minute and talk about natural body rhythms and what they have to do with sleep. Our metabolism goes through two main states throughout a 24 hour period: Catabolism and Anabolism. Catabolism starts in the wee hours of the morning and ends in the late afternoon. Catabolism is about breaking down nutrients and stored energy so that we can make it through the day and be productive. Anabolism starts in the afternoon and goes until the early morning hours. Anabolism is about recovery. Circadian rhythms are the natural rhythms our bodies follow for being awake and being asleep. If you superimpose our Circadian Rhythms on top of our metabolic states, you see that catabolism is paired with the waking part of the cycle (and sunlight) and the anabolic state is paired with sleep. It’s pretty logical that our bodies do recovery when we are at rest and do breakdown when we are active. Lastly, if you superimpose dark and light cycles on the circadian rhythm and their corresponding metabolic states you can see that it makes no sense to be sleeping during the daytime when the sun is up – it jacks everything up. So what do you do if you’re a musician who plays late night gigs and keep a late night schedule?   Here’s what you can try: Buy a quality pair of earplugs and eye covers or a sleep mask to block out the light. Melatonin is secreted when light levels are low. If you are trying to sleep when there is light penetrating your eyelids, you aren’t going to make enough melatonin and you won’t feel like going to sleep and your body rhythm will be off. Dietary modifications Simply put, the food you eat can make you feel depressed, tired and anxious. Coffee is the # 1 cause of food induced anxiety because it stimulates the release of cortisol, adrenaline, and the excitatory neurotransmitters. If you are one of the unlucky folks with a genetic disorder that inhibits your ability to metabolize caffeine, then you should avoid coffee, because it can make you crazy and turn you into a real asshole. That’s just one example. Your comeback will be something like this: Hey pal, I need that coffee to wake up and get going. My answer to that is: I tried this strategy for years and ended up in the Dean’s office in medical school because my test anxiety was so bad I couldn’t perform any longer. Quit the coffee and your body will thank you. See my supplement recommendations below for a healthy substitute. The ingestion of carbohydrates, sugars and fats cause your brain to secrete neurotransmitters, specifically serotonin and dopamine. When we get depressed, we crave foods that stimulate the release of the neurotransmitters that are depleted. Sugar and fat is a great one/two punch to increase dopamine and serotonin but you will pay for it after the high is over. Take simple carbohydrates and sugar for example. If you eat too much or eat them without protein or fiber,  you’ll feel like shit and your body will hate you. Look up the definition of simple carbs if you want to, but basically your body uses them just like sugar and you shouldn’t eat them and expect your body to thank you after the dopamine, serotonin rush wears off. I can tell you without fail, that if you eat a balanced diet that’s right for your body, you will feel good and you can rule that out as a possible cause of your depression and or anxiety. Supplementation: Supplementation is important for two reasons: 1). It is used for absolute and relative nutritional deficiencies; 2). It provides compounds that are used to create a desired effect in the body. An absolute nutritional deficiency is defined as a deficiency of a specific nutrient in the body. A relative nutritional deficiency can be defined as a deficiency created by the increased need for a specific nutrient or nutrients due to adverse or suboptimal conditions the body is exposed to. If you have an absolute nutritional deficiency, your body won’t work the way it was intended to and it will create backup mechanisms if the required nutrients aren’t in place but it usually comes at a cost. Absolute deficiencies can create relative deficiencies if the necessary nutrients are not present for a long period of time.

Examples of absolute deficiencies:

1. Omega 3 fatty acids  they have proven over and over to be beneficial to brain health and specifically can help reduce depression in individuals who are deficient. Most people take about 1-3 grams of high quality fish or Krill oil to meet these levels;
2. Vitamin D3 – This is also critical for those with depression. Most people that I’ve tested in northern climates are vitamin D3 deficient. Taking a minimum of 5000 IU of vitamin D3 along with 1 mg of vitamin K2 per day is what I’ve found it takes to get most people to a healthy level in blood tests;
3. Vitamin and mineral deficiencies –  Deficiencies in any of the vitamins and minerals can force the body to come up with other less effective ways to achieve to carry out metabolism but like I said above it usually comes at a cost.

Examples of absolute and/or relative nutritional deficiencies:

Methylation defects – If you’ve never heard of methylation defects (or MTHFR defects) you will know all about them before too long. Methylation defects are inherited from your parents. Basically, when you have a methylation defect, you have an enzyme that helps your body carry out processes that build and repair DNA, break down biochemicals and carry out the process of detoxification. If you have at least one copy of the gene, you will not be able to carry out those processes effectively and you are at an increased risk for depression. This defect will determine your need for more “methyl groups” found in the active form of folic acid, methylcobalamin and trimethylglycine to name a few. Testing can be done at a number of places but we recommend doing this with a qualified practitioner. Amino acids – If you don’t eat enough protein you will be deficient in certain amino acids. This is a problem for some people who just don’t eat enough but is also common in those who have a condition called malabsorption syndrome of Pancreatic Insufficiency. Amino acids are used by the body to make more protein and they are also used to make neurotransmitters in the nervous system. Physical or emotional trauma, build up of compounds that are toxic to the brain or disease processes can cause a relative nutritional deficiency that increases the bodies’ need for more of these nutrients than normally required. We use a combination of amino acids that are used to help restore balanced function within two weeks. It can be found here. (hypertext link here please) Taking meds when they are necessary and discontinuing them when they are not If you have been diagnosed with depression or anxiety and you need to take medicines to keep you off the ledge. There are times when drug therapy is absolutely necessary and we will prescribe them in our clinic when we feel that a person is at risk to harming themselves or others. Most of the time, however, a person can use nutrients to help bring their bodies back into a balanced state. References:

Creative & Cultural Skills report that the gender divide across all music industry related jobs is 67.8% male to 32.2% female. PRS for Music report that their membership of over 95,000 songwriters and composers is only 13 per cent female.

Exercise for Mood and Anxiety, Proven Strategies for Overcoming Depression and Enhancing Well-Being, by Michael W. Otto, PhD, and Jasper A.J. Smits, PhD (Oxford University Press, 2011)

Kumar AM1, Tims F, Cruess DG, Mintzer MJ, Ironson G, Loewenstein D, Cattan R, Fernandez JB, Eisdorfer C, Kumar M. “Music therapy increases serum melatonin levels in patients with Alzheimer’s disease.” Altern Ther Health Med. 1999 Nov;5(6):49-57.

Tye KM1, Mirzabekov JJ, Warden MR, Ferenczi EA, Tsai HC, Finkelstein J, Kim SY, Adhikari A, Thompson KR, Andalman AS, Gunaydin LA, Witten IB, Deisseroth K.

Nature. Dopamine neurons modulate neural encoding and expression of depression-related behaviour. 2013 Jan 24;493(7433):537-41. doi: 10.1038/nature 11740. Epub 2012 Dec 12.

https://www.takingcharge.csh.umn.edu/manage-health-conditions/anxiety-depression/what-types-psychotherapy-are-helpful-anxiety-and-depress

https://www.helpmusicians.org.uk/assets/publications/files/can_music_make_you_sick_summary.pdf

http://www.huffingtonpost.co.uk/lara-baker/women-in-the-music-business_b_3472612.html

https://www.quora.com/Why-do-successful-musicians-almost-always-do-hard-drugs

http://bjp.rcpsych.org/content/199/2/92

http://www.azlyrics.com/lyrics/smiths/iknowitsover.html

http://www.nme.com/list/50-songs-about-depression-1109

http://www.nature.com/neuro/journal/v14/n2/full/nn.2726.html

https://news.vanderbilt.edu/2008/10/02/musicians-use-both-sides-of-their-brains-more-frequently-than-average-people-65577/

http://musicpsychology.co.uk/musicians-brains-locked-in-from-the-start/

https://www.ncbi.nlm.nih.gov/pubmed/10550905

http://brainblogger.com/2014/12/18/does-high-iq-increase-the-risk-of-depression-and-mental-disorders/

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