Gluten and Depression
Celiac disease, gluten sensitivity and your emotional health
For much of her childhood and teen years, Hilary,* now 47, thought she was lazy. While other kids were out riding bikes, she was home napping. She was very bright but it wasn’t apparent in her grades.
“I couldn’t start a school project or assignment,” she says. “I had crippling procrastination. I’d wait until the last minute, panic and then put together something sloppy.”
Hilary felt a deep sense of guilt and self-contempt about her chronic underachievement. “I’m unworthy,” she’d often find herself subconsciously repeating. Sometimes: “Why am I even alive?”
It wasn’t until she finished her freshman year of college that Hilary realized she was depressed. That spring, she was homesick and her grades slipped.
“I wasn’t well,” she recalls. “I think it was pretty obvious to my parents what was going on.”
Her father, who’d suffered with depression himself, sat her down for a heart-to-heart talk.
“My parents, now in their 70s, don’t talk about things like depression—to them, it’s shameful, like depression is a moral failing—so when he opened up to me, it was a big deal.”
For Hilary, it came as a relief to hear that what she viewed as chronic laziness was not the result of a personality flaw but a treatable disease.
Over the next 15 years, she tried psychotherapy, antidepressants, exercise, acupuncture and various homeopathic remedies. Although some of them helped her better understand her depression and better function with it, none of them fundamentally changed it. The sense of hopelessness, guilt and self-hatred was always there.
In 2001, when Hilary was in her 30s, she stopped eating wheat. Previously, she’d tried stints with vegetarian, sugar-free and dairy-free diets.
“I was always looking for something to boost my ever-waning energy level,” she says. Cutting out wheat was something she started almost on a whim but she stuck with it. In an unexpected turn of events, her depression began to gradually ease—over the course of two years or so.
“Improvements happened so slowly that I actually didn’t connect them with the wheat until I read about a link between gluten and depression,” she says. “I immediately cut out every bit of gluten in my diet.”
At first, Hilary wasn’t careful about cross-contamination—she’d use a friend’s toaster or an unwashed colander—and within hours she’d notice that her mood had changed.
“Things would once again feel very difficult. My voice came out like a whisper but I felt like I was shouting. I would feel like a horrible person and wonder why I was alive. Then about three days later, I was back to normal—my new normal. Unpleasant as they were, these incidents were instructive. Each was a realization that yes, this is working!”
Within a year of starting the gluten-free diet, Hilary’s symptoms cleared beyond what she says she could ever have imagined.
“It’s much easier to wake up in the morning. I have energy to do my work. I feel competent and capable and smile for no reason but because life is enjoyable.”
For Hilary, it’s very black and white: she’s depressed when she eats gluten and not depressed when she doesn’t. But is gluten really to blame?
Gluten and Depression
Depression is a generic description of a number of mood disorders, from postpartum depression to bipolar disorder, says James Greenblatt, MD, a child and adult psychiatrist who has a special interest in integrative therapies for mental health.
“We know there’s a genetic predisposition for depression—it may run in a family,” he explains. “But we don’t really know the underlying cause or causes of depression. Many biological, environmental and psychological factors are thought to probably also contribute.”
That could, in some cases, include gluten. At least two gluten-related disorders—celiac disease and non-celiac gluten sensitivity—have been linked to depression.
Depression, fatigue and “brain fog” are frequently reported by people diagnosed with non-celiac gluten sensitivity, also called gluten sensitivity. These individuals don’t meet the diagnostic criteria for celiac disease but notice an improvement in their health when they avoid gluten. Little else is definitively known about gluten sensitivity. However, one of the recent studies that helped put it on the map revealed that gluten-sensitive individuals experience more fatigue when they eat gluten. This finding suggests there’s some neurological involvement but it doesn’t provide any clues as to a mechanism, says Peter HR Green, MD, director of The Celiac Disease Center at Columbia University.
Considerably more is known about celiac disease and depression.
“Celiac disease is not just a gastrointestinal disorder but a multisystem disorder with manifestations in almost any organ, including the brain,” says Green. “Not only do we see neurological manifestations, particularly seizures in children and neuropathy in adults, there have been studies that depression and anxiety are more common in those with celiac disease than in the general population.”
That goes for children, too. Greenblatt recently treated a 12-year-old girl suffering from depression, anxiety and an eating disorder. A deeper investigation revealed she had celiac disease. After treatment with the gluten-free diet and psychotherapy (talk therapy), her eating disorder, anxiety and depression resolved.
In celiac disease, the lining of the small intestine becomes damaged. This can lead to various nutritional deficiencies, which may, in turn, play a role in depression. Certain nutrients are necessary to create essential chemicals (neurotransmitters) in the brain, such as serotonin, explains Greenblatt. Depressed individuals often have lower-than-normal levels of serotonin.
“Antidepressants work to raise levels of serotonin and other neurotransmitters,” says Greenblatt. “But these medications may be less effective in people with celiac disease who simply don’t have enough raw materials—nutrients—to start with.” Not responding to antidepressants can suggest, among other causes, celiac disease, he says.
Severe nutritional deficiencies aren’t as common in celiac patients as they once were, however, says Green. He points to other features of celiac disease, such as the presence of inflammation in the body. Inflammatory proteins called cytokines may be able to cross the blood-brain barrier and contribute to various neurological conditions, including depression. Researchers are beginning to look more broadly at the possible connection between inflammation and depression. A small study recently showed that the powerful anti-inflammatory drug, Infliximab, which is used to treat inflammatory disorders like rheumatoid arthritis, was also effective in reducing depression in a number of patients, particularly those with certain markers of inflammation.
Cross-reactivity between celiac-related antibodies and other proteins in the brain is one more possibility that could contribute to depression, adds Green. “When we look at individuals with depression, schizophrenia, autism and ADHD, we find increased levels of anti-gliadin antibodies.”
Anti-gliadin antibodies indicate an immune response to gluten but they don’t necessarily mean a person has celiac disease. “The significance of these antibodies isn’t entirely clear because the gluten-free diet doesn’t necessarily improve all these disorders—but it’s a gut-brain connection we’re actively exploring,” Green says.
Hilary was never tested for celiac disease. At the time she went gluten free, she didn’t know there were blood tests to screen for it. Now she says it’s too late—she’s not willing to eat gluten again, even for a few weeks in what’s known as a “gluten challenge.” (Accurate testing for celiac disease requires regular exposure to dietary gluten.)
She strongly suspects she has celiac disease. Several of her relatives have related autoimmune disorders (type 1 diabetes and thyroid disease) and Hilary has suffered telling gastrointestinal symptoms much of her life—gas and painful bloating.
“When I went gluten free, my stomach was no longer clenched,” she recalls. “I never realized it was supposed to be soft.”
She says she’s frustrated that in the 15 years she actively worked with counselors, psychotherapists, psychiatrists and naturopaths, no one ever mentioned celiac disease.
Laura Bowman, LCSW, a mental health counselor who herself has celiac disease, isn’t surprised. Working in inpatient and residential settings since 2004, Bowman has seen many patients with depression, but not one of them had a diagnosis of celiac disease.
“Part of the problem is how varied the symptoms of celiac can be—I’ve seen lists with over 100 possible symptoms,” she says. “There’s a lot of overlap between these symptoms and various unrelated conditions, including psychological ones.”
People with depression or anxiety may have celiac-like symptoms but not have celiac disease, she explains. A case in point? Fatigue goes hand-in-hand with depression but it’s also very common in celiac disease. Diarrhea, nausea and other stomach problems may be associated with anxiety or celiac disease.
“In some fields—pediatrics or gastroenterology—diarrhea may be a red flag for celiac disease but mental health professionals may be quick to link these symptoms directly to the psychological condition and not think of celiac disease,” she explains.
Yet there are indications that depression is very common in celiac disease. A 2012 study that combined data from over a dozen studies on celiac disease and depression in adults found that celiac disease increases the risk of depression by about 20 percent. Based on statistics recently put out by the Centers for Disease Control and Prevention—that one in ten Americans report depression—it’s possible as many as one in eight adults with celiac disease suffers from depression at some point.
Road to Recovery
Treatment for depression commonly involves a combination of antidepressants and psychotherapy. Depression in individuals with celiac disease is not typically treated any differently, says Greenblatt. However, some studies have found certain supplements may be beneficial. Celiacs who took vitamin B supplements had better overall health and reduced anxiety and depression symptoms, according to a recent study. In addition, carnitine, a substance that helps the body turn fat into energy, has been shown to fight fatigue in celiacs who have a carnitine deficiency.
Dr. Peter Green recommends talking to your doctor before starting any supplement regimen as it’s possible to take too much. Green says he’s actually seen neurological problems develop in those with celiac disease as a result of vitamin B6 toxicity. Celiacs may absorb B6 (also known as pyridoxine) more readily, he says.
Although some patients like Hilary experience a big improvement on the gluten-free diet, celiac experts caution against relying on the diet alone to treat depression. Some studies suggest that treatment with a gluten-free diet can improve depression but these studies are small and it’s difficult to draw any certain conclusions, says Jonas Ludvigsson, MD, associate professor of pediatrics at Orebro University Hospital in Sweden.
“If depression in celiac disease occurs independently from nutritional deficiencies or inflammation, it may be difficult to modify by a gluten-free diet,” he says.
“The bottom line is depression is a serious mental health condition,” says Green. “In some cases, it’ll improve on the gluten-free diet but in many, it won’t. For these reasons, depression should be managed independently from celiac disease.” This means finding a licensed mental health practitioner to develop an appropriate treatment plan.
Although depression is common before a celiac diagnosis—months or even years of feeling sick can certainly contribute—it may develop after the diagnosis, too. As with other serious medical conditions, learning you have celiac disease can be a stressful life event, says Laura Bowman, LCSW, and stress can be a trigger for depression in susceptible individuals. With its diet-based treatment, she adds, a diagnosis of celiac disease may initially bring up a lot of emotions.
“When I first learned I had celiac disease, I remember a lot of tears,” she recalls. “How would this affect my social life? Would I ever eat out again?”
At her dietician’s suggestion, Bowman joined a local support group. With an educational focus (how to avoid gluten, where to eat out and gluten-free recipes), the group was helpful but it never touched on emotional health.
“I think many of us could benefit from groups where people share their emotional experiences and find support from others who are dealing with the same challenges. Some people have gone undiagnosed their entire lives and have trouble putting their anger to bed. Others have children with celiac disease and need an outlet for feelings of guilt and other stressors,” she says.
Bowman may be onto something. In 2004, an Italian study found celiacs who received psychological support (counseling) were significantly less depressed and had better adherence to the gluten-free diet than those who didn’t.
More recently, a team at The Celiac Disease Center at Columbia University Medical Center studied a group of 100 people with celiac disease who had persistent celiac symptoms—they weren’t getting better. The findings were surprising: Psycho-social factors, like stress and depression, had a greater negative impact on participants’ health, including worsening gastrointestinal symptoms, than the typical measures of disease activity, such as celiac-related antibodies or intestinal damage (flattened villi). The same phenomenon has been shown in irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).
Thus celiac disease may be better managed using a “bio-psycho-social approach,” write the researchers. This would include psychological support, in addition to the gluten-free diet, to reduce emotional distress and improve coping skills.
It’s been almost six years since Hilary went gluten free and gained the upper hand over her depression. She now owns her own business and a co-op apartment—goals that were at one time unthinkable. Today she DJs local dances, leads group hikes in the mountains near her home and has volunteered as a tax preparer this spring. She’s no longer afraid of being debilitated by her depression.
“It doesn’t stop me from things,” she says. “Before I got better, I always imagined ‘not depressed’ meant ‘I seldom feel so bad that I wonder why I’m alive.’ What I’ve learned is that ‘not depressed’ really means that I actually like myself. Waking up doesn’t feel like I have to first move a concrete wall off my chest. Simple things aren’t overwhelming—doing the laundry or paying bills are just things to do or not do.”
Life isn’t perfect, she emphasizes. She’s worried about how to pay an unexpectedly high bill coming up, her building is undergoing some disruptive renovations and she doesn’t have a romantic relationship.
“But I’m interested in how I’m going to solve things and in seeing how they come out,” she says. “Most days, I can honestly say I am aware of being happy—truly happy.”