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person sleepingIn Part I and Part II of this series, we examined drug-free alternatives to treating depression including exercise, psychotherapy, light therapy, St. John’s Wort and acupuncture. We have learned that all of these treatments are at least as effective as antidepressants in the short term, and some (exercise and psychotherapy) are more effective in the long-term. All of these treatments have far fewer side effects, risks and complications than antidepressants. In fact, the only “side effects” of exercise and psychotherapy are positive ones: improved physiological and mental health!

Today we will look at other lifestyle-based approaches to treating depression without drugs. As I mentioned in the previous article, because 70% of research is funded by drug companies, many of these non-drug approaches have not been studied as extensively as antidepressant medication.

Nevertheless, there is enough data from clinical and epidemiological studies to support the following strategies – especially since they are superior to antidepressants from a “cost/risk – benefit” analysis. In other words, though some of the approaches I will propose in this article have not been exhaustively proven according to the standards of Western science, there are several lines of evidence supporting their effectiveness and without exception they have beneficial side effects and improve the quality of patient’s lives.

What’s more, all of these approaches can be combined together along with the treatments mentioned in the two previous articles to obtain the maximum effect. Based on the available evidence which we have extensively reviewed, these non-drug treatments should without a doubt be the first line of defense (as well as the second, third, fourth, etc.) in treating depression.

Nutrition

At some point in the future, I hope to dedicate an entire post (or perhaps more) to the subject of nutrition and depression. I personally believe that inadequate nutrition is a significant contributing factor to the continuously rising rates of depression in this country. Consequently, I also believe that proper nutrition can be one of the most effective treatments for depression.

For now, I will go over what I feel are the most important aspects of nutritional causes and treatment of depression, and hopefully address the subject in more detail later.

SUGAR

Diabetes is correlated with higher rates of depression. In 2005, researchers discovered a positive connection between higher levels of insulin resistance and severity of depressive symptoms in patients with impaired glucose tolerance, before the occurrence of diabetes. Based on these findings, it was suggested that insulin resistance could be the result of an increased release of counter-regulatory hormones linked to depression; however, this has not been confirmed.

Sugar can increase fasting levels of glucose and can cause reactive hypoglycemia. Sugar can also cause a decrease in your insulin sensitivity thereby causing an abnormally high insulin levels and eventually diabetes. Based on the study results above, this is one mechanism by which sugar could contribute to depression.

There is no doubt that increased sugar intake leads to hormonal changes that can lead to emotional instability. Therefore, people who are depressed (and all people, in fact) should significantly decrease their sugar consumption.

OMEGA-6 / OMEGA-3 RATIO

Anthropological evidence suggests that the intake of omega-6 (n-6) and omega-3 (n-3) polyunsaturated fatty acids (PUFA) during the Paleolithic era was roughly equal, whereas the present n-6 to n-3 PUFA in western countries has ben estimated to be between 10 and 25 to 1. The n-6 to n-3 PUFA imbalance has been due mainly to the increase in vegetable and seed oil use and the rise in consumption of processed foods (which contain these oils).

Two major studies have provided direct evidence for the role of the n-6 to n-3 PUFA ratio in depression. The studies found that depression is associated with significantly decreased total n-3 PUFA and increased n-6 to n-3 PUFA ratio (Maes et al. 1996; Maes et al. 1999) . A supporting study carried out in 1998 also found a significant depletion in total n-3 PUFA, and in particular DHA, in the erythrocyte membranes of depressed patients.

Epidemiological data show the trend in decreasing dietary n-3 PUFA consumption and the increasing evidence of depression, both over time and between nations (Hibbeln et al. 1995). Further investigation suggests that the significance lies in the increase in n-6 to n-3 ratio, rather than simply low n-3 intake alone, as these two fatty acids compete in binding to enzyme systems that produce chain elongation and further desaturation. A diet high in n-6 fatty acids prevents the incorporation of n-3 PUFA into cell membranes and phospholipids (Spector et al. 1985).

All polyunsaturated fatty acids – including n-3 PUFA – have been shown to make lipoproteins more vulnerable to oxidative damage (Reaven et al. 1991), and oxidative damage is a significant risk factor for heart disease, cancer and many other conditions. As mentioned above, n-6 consumption actually prevents the incorporation of n-3 into our cells. Therefore, rather than increasing our consumption of n-3 PUFA to treat depression, as is often suggested, it makes more sense to dramatically decrease our consumption of n-6 PUFA. This will help our bodies to incorporate the small, but adequate amount of n-3 PUFA we get in a whole-foods based diet. Avoiding n-6 PUFA (primarily found in vegetable and seed oils, and in animals fed vegetables high in n-6 like pigs and chickens) will not only alleviate depression, but also benefit our health in many other ways.

VITAMIN D

In a 1998 controlled experiment, Australian researchers found that vitamin D (400 and 800 IU), significantly enhanced positive affect when given to healthy individuals. Forty-four subjects were given 400 IU cholecalciferol, 800 IU cholecalciferol, or placebo for 5 days during late winter in a random double-blind study. Results on a self-report measure showed that vitamin D3 enhanced positive affect a full standard deviation and there was some evidence of a reduction in negative affect. The authors concluded: “vitamin D3 deficiency provides a compelling and parsimonious explanation for seasonal variations in mood” (Landsdowne & Provost, 1998).

In another study in 1999, the vitamin D scientist, Bruce Hollis, teamed up with Michael Gloth and Wasif Alam to find that 100,000 IU of vitamin D given as a one time oral dose improved depression scales better than light therapy in a small group of patients with seasonal affective disorder. All subjects in the vitamin D group improved in all measures and, more importantly, improvement in 25(OH)D levels levels was significantly associated with the degree of improvement (Gloth et al. 1999).

According to the Vitamin D Council:

To further strengthen the case that vitamin D deficiency causes some cases of depression, evidence should exist that the incidence of depression has increased over the last century. During that time, humans have reduced their sunlight exposure via urbanization (tall buildings and pollution reduce UVB ), industrialization (working inside reduces UVB exposure), cars (glass totally blocks UVB), clothes (even light clothing blocks UVB), sunblock and misguided medical advice to never let sunlight strike you unprotected skin.All these factors contribute to reduce circulating 25(OH)D levels.

Klerman and Weissman’s claim that major depression has increased dramatically over the last 80 years is one of the most famous (and controversial) findings in modern psychiatry. Something called recall bias (a type of selective remembering) may explain some of the reported increase, but does it explain it all?

If you suffer from depression, get your 25(OH)D level checked and, if it is lower than 35 ng/mL (87 nM/L), you are vitamin D deficient and should begin treatment. If you are not depressed, get your 25(OH)D level checked anyway. If it is lower than 35 ng/mL (87 nM/L), you are vitamin D deficient and should begin treatment.

Recommended intake is up to 5,000 IU per day of vitamin D through exposure to sunshine and/or supplementation. See this article on vitamin D to learn to calculate how much vitamin D is produced given a certain amount of exposure to sunlight, and to learn more about vitamin D supplementation. It is important to remember that D works synergistically with A & K2, so if you increase your intake of D you must also increase your intake of A & K2 to avoid D toxicity.

Finally, I’d like to share with you a comment I received from a reader about how he/she has cured depression with nutritional intervention. Note that I endorse just about every suggested step, with the exception of the significant increase in n-3 intake. Based on the evidence above, I suspect that his/her improvement was a result of the decrease in n-6 PUFA more than it was the increase in n-3 PUFA.

I suffered from depression, for many years–it was so bad that often I thought that the only answer for my life would be to end it. Thoughts of suicide danced through my mind frequently.

Early March 2008 I changed my diet completely:

–eliminated all processed foods

–eliminated all white foods; most important, eliminated sugar, which is the “white devil”

–eliminated all foods containing soy and corn; so I don’t eat the meat of animals that have been fed grains

–two years prior to March 2008 I stopped drinking sodas/soft drinks

–only meats that have been traditionally raised; meat from ruminants that have been grass fed; chickens that have been pastured (I get them with the head and feet); meat from pigs that have not been raised in confinement (I know the people who “produce” the pork that I eat–they feed their pigs food that is in season and local, and they allow their pigs to be pigs, and never slaughter them before their time)

–eliminated all the bad fats

–added good fats: coconut oil, palm kernel oil, [raw] butter from grass fed cows, lard (from the pigs described above), beef bone marrow fat (from grass fed and pastured cows), olive oil

–eat a tin of sardines (with the skin and bones) weekly

–eat wild Alaskan salmon weekly

–cut out grains; although, occassionally, I have a jones for those carbs, so I’ll eat some brown rice; sometimes I’ll have a bowl of steel-cut oats, which I have soaked overnight, and when I eat it, I add lots of butter and raw cream to it

–stopped eating out; I cook all of the meals that I eat

–only eat raw milk cheeses

–eggs from hens that have been pastured

–drink this mixture daily: raw milk, raw cream, 4-6 raw egg yolks, some unsulphured organic blackstrap molasses

–daily supplements of: cod liver oil, evening primrose oil, wheat germ oil, kelp powder, dessicated liver

–vegetables and fruit

–drink only when thirsty

–stopped wearing sunblock/sunscreen lotions; get out in the sun daily for 20-plus minutes

–exercise daily; I ride my bike everywhere (I live in San Francisco) or I walk

Following the reader’s advice will not only relieve depression, it will dramatically improve all aspects of your physical, emotional and mental health.

Adequate sleep and rest

Recent studies have definitively linked insomnia with depression and increased suicidal behavior. A research abstract that was presented on June 12 at SLEEP 2008, the annual meeting of the Associated Professional Sleep Societies, found a link between poor sleep and suicidal behavior among children and adolescents with depressive episodes. 83.8% of the depressed patients in the study had sleep disturbances, and there was a significant association between suicidal behavior and the presence of sleep complaints.

Another recent study confirmed the persistent nature of insomnia and the increased risk of subsequent depression among individuals with insomnia. According to the study, 17% – 50% of subjects with insomnia lasting just two weeks or longer developed a major depressive episode reported in a later interview.

Other research has indicated that insomnia can cause depressed mood and adversely affect endocrine function (Banks 2007).

Most Americans are chronically sleep deprived. The foundation’s 2001 national “Sleep in America” poll reported that almost seven out of 10 Americans experienced frequent sleep problems, and that most were undiagnosed. The same poll in 2003 found that 67 percent of older adults had frequent sleep problems and only one in eight had been diagnosed.

This alone could explain the epidemic increase in depression over the last several decades. But when sleep deprivation is added to other factors such as increased intake of n-6 PUFA, increased stress, the use of antidepressant drugs, the breakdown of family, community and other social support structures, it isn’t difficult at all to understand why so many of us are depressed.

The American Academy of Sleep Medicine (AASM) offers the following tips on how to get a good night’s sleep:

  • Follow a consistent bedtime routine.
  • Establish a relaxing setting at bedtime.
  • Get a full night’s sleep every night.
  • Avoid foods or drinks that contain caffeine, as well as any medicine that has a stimulant, prior to bedtime.
  • Keep computers and TVs out of the bedroom.
  • Do not go to bed hungry, but don’t eat a big meal before bedtime either.
  • Avoid any rigorous exercise within six hours of your bedtime.
  • Make your bedroom quiet, dark and a little bit cool.
  • Get up at the same time every morning.

Stress Management

An increasing amount of evidence (along with common sense) indicates that chronic stress directly contributes to depression. Please see my recent article for more information about this.

I am not aware of any well-designed clinical trials examining the effects of stress reduction on depression. However, logic dictates that since stress is a cause of and contributing factor to depression, managing stress is an important aspect of treating depression.

One study published in 1995 showed that meditation can improve mood. Another small study demonstrated that mindfulness-based cognitive therapy (MBCT) significantly improved depression and reduced relapse. A series of studies and case studies have shown that biofeedback can also be effective for depression and mood disorders.

The reality is that there are many ways to manage and reduce stress, from yoga to meditation to mindfulness-based stress reduction to progressive relaxation techniques. The important thing is not which method you choose, but that you commit to something and do it on a regular basis.

Prayer & Spiritual Practice

You’re not going to see much scientific research into the role of prayer and spiritual practice in treating depression. Nevertheless, for as long as people have been “depressed” they have used their relationship with God, nature, a “higher power” or whatever guiding principles they embrace to get through difficult times.

People who are depressed often feel isolated, alienated or alone. A strong faith in God or in the interconnectedness of all life can re-establish a sense of belonging and support. Prayer and spirituality can also re-frame the depression one is experiencing in a larger and less “personal” context.

In my previous article called The Heart of Depression, we examined how cultural, religious and spiritual beliefs in these traditional societies provide a context in which symptoms of depression and other mental illness can be understood outside of the label of medical disease or pathology. Possession and rites of passage are two examples of such contexts.

The words and labels we use to “frame” our experience have tremendous power. In the U.S. today, depression is viewed as a sickness that must be cured, as a pathology, as a “biological disease”. There is little doubt that the people who seek treatment for depression are suffering. But should psychological and emotional suffering always be viewed as “something to get rid of”?

Great religious and spiritual traditions from around the world view suffering as an avenue to greater understanding of oneself, life and God. Suffering can be viewed as a signal drawing our attention to issues in our life that need to be addressed.

Spirituality and prayer can help people who are suffering to understand their experience in a more empowering and self-validating context than what is offered by mainstream medicine. When one views their suffering as an opportunity for growth and evolution, rather than as a disease requiring treatment with drugs, it is far more likely that lasting, positive change will occur.

In the next and final article (for a while, at least) in my series on depression and antidepressants, I will summarize everything we’ve covered so far and offer my recommendations for treating depression holistically.

lightboxIn the first article in this three-part series on treating depression without drugs, we established that several non-drug treatments are at least as effective in treating depression than antidepressants – with few, if any of their side effects. Specifically, we learned that both psychotherapy and exercise compare favorably with antidepressants for treating even serious depression in the short-term, and are both more effective than antidepressants in the long-term.

Today we will examine three other drug-free treatments for depression: light therapy, St. John’s Wort and acupuncture. In the final article, we will look at lifestyle-based treatments such as nutrition, adequate sleep and rest, stress management, pleasure and bibliotherapy (prayer or spiritual practice).

Light Therapy

Researchers at the National Institute for Mental Health are credited for the idea that perhaps more people are apt to become depressed during dark, dreary winter days than on bright, crisp spring days because they are not getting enough light. Since then, people around the world have begun to use “light therapy” to overcome Seasonal Affective Disorder. However, light therapy is also being used to successfully treat major depression at any time of the year.

Beginning the day sitting in front of a fluorescent light box that typically emits about 10,000 lux units of light has helped many people who might otherwise struggle with depression throughout the day. Bright light has been shown by numerous studies to act as a specific antidepressant in depressed patients. In a recent meta-analysis of published studies on light therapy and depression which appeared in the April 2005 issue of the American Journal of Psychiatry, the authors found that bright light treatment for nonseasonal depression is efficacious, with effect sizes equivalent to those in most antidepressant studies.

Once again, as was the case with both exercise and psychotherapy, the combining light therapy with antidepressants was no more effective than light therapy alone.

In contrast to exercise and psychotherapy, bright light therapy does occasionally have some side effects, including headache, eye strain, nausea and agitation. But these are very mild when compared against the side effect profile of antidepressants.

It is very important to note that some psychotropic medication (and psychotropic herbs such as St. John’s Wort) may increase sensitivity to light, so light therapy should probably not be combined with St. John’s Wort or antidepressants.

Some critics of light therapy have pointed out that it could be a placebo and there is no way to prove otherwise. It is not possible to keep someone from knowing whether they are being exposed to very bright light or the placebo (dim light). Therefore the “blind” is broken and patients will know whether they are receiving the active or “inert” treatment. Could it be that the positive effects of bright light are simply due to the assumption or expectation of the patients that they will improve, rather than a result of the bright light itself?

Sure it is. But perhaps a more important question is, “does it matter?” If we use Antonuccio’s criteria for evaluating a potential treatment (i.e. 1) first do no harm, 2) cost-benefit analysis) then it becomes clear that light therapy compares very favorably with antidepressants even if it is “merely a placebo”. As you will know if you’ve been following my blog, antidepressants could also be referred to as placebos because they have been shown to be no more effective than placebo in treating depression. The criteria for whether a drug gets approved or not by the FDA is that it must outperform placebo; otherwise, it is simply considered a placebo itself.

Although light therapy may have some side effects, they pale in comparison to those of antidepressants and, unlike antidepressants, light therapy poses no significant risks or long-term complications. A typical light therapy device costs between $200-$300, so over the long-term it is much more cost-effective than medication. Finally, light therapy is just as effective as pharmacotherapy for treating depression.

When all of this is taken together, light therapy is superior to antidepressants – even if it is a placebo.

St. John’s Wort

St. John’s Wort (Hypericum) is an herb that can be used to make tea, or the “active ingredients” with the herb that can be extracted and put into capsules. In Europe SJW is widely prescribed as an antidepressant, but in the U.S., it is available over-the-counter.

St. John’s Wort has repeatedly been shown to work as well as or better than antidepressants in double-blind, placebo-controlled studies. For example, compared to Paxil, depression scores fell more (56.6% vs. 44.8%) and side effects were less (Szegedi et al. 2005). Similar results were found for Prozac (Schulz 2002). A comparison with both Zoloft and Celexa found St. John’s Wort again performed as well as the antidepressant drug without as many side effects (Gastpar 2005; Gastpar 2006).

While St. John’s Wort is clearly as effective as antidepressants, the number of adverse effects is ten times less – being essentially equivalent to taking a placebo. The most common adverse events (1 per 300,000 treated cases) concern reactions of the skin exposed to light (due to potential increased photosensitivity caused by SJW and other psychotropic substances).

Please do note that St. John’s Wort is contraindicated for concurrent use with certain medications, including antidepressant drugs, coumarin-type anticoagulants, the immunosuppressants cyclosporine and tacrolimus, protease and reverse transcriptase inhibitors used in anti-HIV treatment and with certain antineoplastic (cancer) agents.

However, these potential interactions can be easily avoided with proper supervision from a health-care professional who is experienced with the use of St. John’s Wort.

Once again, to be accurate we must point out the possibility that St. John’s Wort is merely a placebo. If it is roughly as effective as antidepressants, and antidepressants are themselves placebo, then it follows that St. John’s Wort may also be a placebo. However, the same analyses that we used for light therapy applies here. The question is, how does St. John’s Wort compare against the primary treatment for depression – antidepressants? As we have seen, SJW is just as effective as antidepressants with only a fraction of the side effects, so there is absolutely no reason not to choose it over a synthetic antidepressant.

Before we move on to acupuncture, nutrition, rest and other lifestyle-based treatments for depression, I want to briefly discuss the criteria we’ve used so far for evaluating the effectiveness of a treatment. As I’m sure you’ve noticed, I am primarily basing the determination of the effectiveness (or lack thereof) of a treatment on well-designed, placebo-controlled, double-blind scientific studies.

I obviously have great respect for this method of inquiry and it has led (and continues to lead) to many important advances in medicine. However, it must be pointed out that this standard of proof has limitations. For example, 2/3 of medical research is funded by pharmaceutical companies. This means that the lines of investigations most often pursued in scientific research are those that are likely to lead to new therapies that can be monetized by the drug companies. There is little incentive for a drug company to dedicate research dollars to a study on how nutrition affects depression, unless there’s a product they can imagine marketing based on the study results. The result is that there are relatively few studies evaluating the effect of nutritional intake on depression.

Another limitation of double-blind, placebo-controlled research is that it is difficult (if not impossible) to maintain that standard with treatment modalities that depend on the unique interaction that happens between a practitioner and a patient. Western science is often skeptical, of course, that this interaction that occurs influences the treatment in any way. They do not understand how the interaction could influence the treatment, and what Western science does not understand, is often dismissed as “new-age fluff”.

What is remarkable about this is not just the arrogance of such a position, but also the ignorance it demonstrates. Over the last two decades, research into the placebo effect and growing understanding of how the nervous, endocrine and immune systems are inter-related have proven beyond a shadow of a doubt – according to the most rigorous Western scientific standards – that the interaction between a doctor or clinician and their patient absolutely influences the outcome of the treatment. In fact, many studies have shown that this interaction may be more important than the treatment itself; or, perhaps more accurately, the interaction is the treatment.

With this in mind, it becomes clear that the efficacy of acupuncture as a treatment for depression – or anything else – can never be accurately measured in a double-blind, placebo-controlled study. As much as Western science hates to admit this, we are not machines that respond in entirely an predictable manner given the same circumstances. There is no way to “standardize” the interaction that happens between an acupuncturist (or any healing professional) and a patient, because each person and, therefore, each relationship is unique.

Acupuncture

Considering all of the caveats above, can acupuncture help with depression? According to the Cochrane Database Systematic Review (the gold standard for medical research reviews today), “there is no evidence that medication was better than acupuncture in reducing the severity of depression.” In many of the studies they reviewed, acupuncture and electro-acupuncture either cured or remarkably improved depression scores, performing just as well as synthetic antidepressants.

However, it must also be noted that the studies were few in number, often poorly designed and did not have enough subjects to draw definitive conclusions. The authors of the review concluded that there was “insufficient evidence to determine the efficacy of acupuncture compared to medication”.

And of course, we always have the issue of placebo. It is possible that the benefit the patients are receiving comes from the interaction with the practitioner and their expectation that they will improve – rather than as a result of the needles themselves.

Once again, though, if we evaluate acupuncture based on a “cost-benefit” analysis, it compares very well against antidepressants. It has been shown to be at least as effective as medication in many studies as noted above, and the side effects are minimal when compared with antidepressants. Acupuncture has also been shown to be effective in treating other conditions that may occur alongside of depression, such as pain and stress.

Stay tuned for the third-part of this series which will consider lifestyle-based treatments such as nutrition, adequate sleep and rest, stress management, pleasure and prayer.

bicyclistThe most widely prescribed drugs in the U.S. are not for pain management, cholesterol lowering, heartburn or hypertension.

They’re for depression.

Last year doctors wrote $232.7 million prescriptions for antidepressants. That’s an increase of 25 million prescriptions since 2003 and translates into an estimated 30 million patients in the United States who spent $12 billion on antidepressants in 2007.

With numbers like these, a person might make these assumptions:

  • Antidepressants are effective treatments for depression
  • There are few, if any, effective alternatives to antidepressants

As reasonable as these assumptions would be based on the popularity of antidepressants, they are both wrong.

In my preceding articles in this ongoing series on depression and antidepressants, I’ve presented clear evidence that antidepressants are not effective for treating depression.

In this article and the following two, I will present evidence that several non-drug treatments for depression are at least as effective as antidepressants, with few (if any) of their side effects, risks and costs.

As you may recall from the previous articles in this series, recent meta-analyses have shown that antidepressants have no clinically meaningful advantage over placebos. What I have not yet pointed out is that the effectiveness of antidepressant drugs has probably been overstated due to methodological factors in the studies.

In the studies performed on antidepressant drugs, the people taking the drugs also received supportive weekly visits with doctors or researchers along with the medication. The resulting “therapeutic alliance” may have enhanced the efficacy of these drugs and given an inaccurate picture of their effectiveness in a managed care environment where antidepressants are often delivered in conjunction with infrequent visits to a physician or mental health professional.

We know from placebo research that the contact which occurs between the patient and practitioner can be a powerful treatment in itself. Therefore, the supportive visits that patients received during the drug trials could have easily amplified the effect of the drug and made it seem far more effective than it would be in a “normal” clinical situation where visits to a physician or psychiatrist are not regular or frequent.

With this in mind, it is very likely that antidepressants are less effective than placebos in normal clinical practice. Indeed, researcher Joanne Moncrieff has repeatedly pointed out that the term “antidepressant” is a misnomer. The drugs collectively referred to as “antidepressants” do not specifically treat depression (any more than placebo), and therefore should not be called “antidepressants” at all.

What are the alternatives, then, to treating depression? Imagine having a choice between five treatments. Treatment A produces a therapeutic response but also a large number of adverse effects including diarrhea, nausea, anorexia, sweating, forgetfulness, bleeding, seizures, anxiety, mania, sleep disruption and sexual dysfunction. Treatments B, C, D & E produce therapeutic responses similar to Treatment A, but with far fewer adverse effects and costs. Treatments B & C, in fact, have no adverse effects at all and have been shown to be significantly more effective than Treatment A in the long-term.

This is not, of course, simply a hypothetical question. Treatment A corresponds to the selective serotonin reuptake inhibitors (SSRIs) that have become so overwhelmingly popular. Treatment B is psychotherapy, which is as effective as antidepressants in the short term (even for serious depression), and is more effective in the long term. Treatment C is exercise, which has been reported to have lasting therapeutic benefits in the treatment of major depression with no “side effects” except for improved physiological and mental health. Treatment D is light therapy, which has been recently assessed in several clinical studies and is just as effective as antidepressant medication. Treatment E is St. John’s Wort, an herb that has been extensively studied and shown to be similar in efficacy to antidepressants with 10 times fewer adverse effects.

As depression researcher David Antonuccio points out, “whether one subscribes to the Hippocratic dictum ‘first do no harm’ or takes a cost-benefit approach to treatment, it is impossible to ignore the fact that antidepressants are not medically benign treatments. Antidepressants have serious side effects (listed above) as well as medical risks (including increased risk of dying) when combined with other medications – as is often the case in clinical settings. Antidepressants have been shown to cause potentially permanent changes to the brain that can predispose a patient to depression in the future, and the withdrawal symptoms of SSRIs are substantial for many, if not most, patients.

A frequent argument made by supporters of antidepressants is that patients with serious depression need antidepressants to stave off suicide. However, there is no evidence whatsoever that antidepressants reduce the risk of suicide or suicide attempts in comparison with placebo in clinical trials. On the contrary, in a recent analysis of the data that compensated for erroneous methodologies, Dr. Grace Jackson found that antidepressants increased the risk of suicide by two to four times in adults, and by three times in children (Jackson 2005, p.122)

It has also been demonstrated that recent sharp increases in antidepressant use have been accompanied by increased prevalence and duration of depressive episodes and rising levels of sickness absence (Patten 2004). Naturalistic studies have also shown that depressive episodes are more frequent and last longer among antidepressant users than among nonusers, and that sickness absence is more prolonged (Moncrieff 2006). Finally, long-term follow-up studies show very poor outcomes for people treated for depression with drugs, and the overall prevalence of depression is rising despite increased use of antidepressants (Fombonne 1994).

Please allow me to summarize the research and simplify the preceding paragraphs:

Antidepressants don’t work. If anything, they make things worse.

Now that we have firmly established the ineffectiveness and dangers of antidepressants, let’s look more closely at the alternatives. We will evaluate each treatment based on Antonuccio’s criteria above:

  • Does the treatment do any harm?
  • How do the “costs” compare with the “benefits”?

and we will also compare their efficacy with that of antidepressants.

Psychotherapy

Several studies show that psychotherapy (particularly cognitive therapy, behavioral activation, and interpersonal therapy) compares favorably with medication in the short-term, even when the depression is severe, and appears superior to medications over the long term (Antonuccio 2002). When medical cost offset, relapse and side effects are considered in a cost-benefit analysis, psychotherapy can be very cost-effective – particularly in a psychoeducational (e.g. therapist-assisted bibliotherapy) or group format (Antonuccio et al. 1997). Finally, studies show that most patients prefer psychotherapeutic intervention to drugs when given the choice. (Unfortunately, they are rarely given the choice; today, fewer than 10% of psychiatrists offer psychotherapy to their patients.)

It is important to note that several studies have shown that combined treatment (psychotherapy + medication, exercise + medication) produces inferior results when compared to the non-drug modality alone (Hollon et al. 1992). The failure of this combined approach is not surprising when one considers the counter-productive effects of invasive chemical interventions (e.g. suppression of REM sleep, elevation of cortisol, induction of mania).

Unfortunately, the mental health profession remains largely ignorant to this “tragedy of its own making”:

“Some investigators have argued that the relatively high relapse rate after drug treatment indicates that depression should be treated like a chronic medical disease requiring ongoing, long-term medical treatment indefinitely. This logic appears tautological: Drug treatment results in a higher relapse rate than cognitive-behavioral therapy; therefore, the patients should be maintained on drugs to prevent relapse.” (Antonuccio 1995)

Exercise

Several studies have shown that aerobic exercise is at least as effective as antidepressants in treating depression. For example, one recent study published in the American Journal of Preventative Medicine in 2005 indicated that the “public health dose” (5x/week frequency burning 17.5 kcal/kg/week) of exercise led to remission rates of 42%. For the sake of comparison, the Collaborative Depression Study, conducted by the National Institute for Mental Health, indicated remission rates of 36% for cognitive behavioral therapy and 42% for antidepressant medication.

A frequent criticism of exercise as a treatment for depression is the supposed lack of compliance in patients. The argument is that people who are depressed are too depressed to exercise. While this may be true in some cases, adherence rates in exercise studies were comparable to many medication trials, where rates vary from 60%-80%. Thus, evidence does not support the notion that exercise is not a feasible treatment for depressed patients.

Another benefit of exercise as a treatment for depression is that the only “side effects” are improved physiological and mental health. In contrast to antidepressants, exercise has no adverse effects whatsoever. Instead, it has a moderate reducing effect on anxiety, can improve physical self-perceptions and in some cases global self-esteem, and can enhance mood states and – in older adults – improve cognitive function.

In a study published in Psychosomatic Medicine in 2000, another important advantage of exercise over antidepressants was revealed. Participants in the exercise group were less likely to relapse than participants in the two groups receiving medication. Other studies have confirmed this effect, demonstrating that aerobic exercise is especially helpful in the prevention of relapse and recurrence of depression.

Once again, as was the case with psychotherapy, there was no benefit when combining antidepressant drugs with exercise. In fact, the opposite was the case, at least with respect to relapse for patients who initially responded well to treatment. According to the authors of the study:

“This was an unexpected finding because it was assumed that combining exercise with medication would have, if anything, an additive effect.

The authors go on to speculate on why antidepressant drugs would decrease the exercise’s beneficial effects on depression:

“One of the positive psychological benefits of systematic exercise is the development of a sense of personal mastery and positive self-regard, which we believe is likely to play some role in the depression-reducing effects of exercise. It is conceivable that the concurrent use of medication may undermine this benefit by prioritizing an alternative, less self-confirming attribution for one’s improved condition. Instead of incorporating the belief “I was dedicated and worked hard with the exercise program; it wasn’t easy, but I beat this depression,” patients might incorporate the belief that “I took an antidepressant and got better”.

It is also possible that the metabolic and physiological effects of antidepressants described above (suppression of REM sleep, elevated cortisol levels, etc.) could counteract the positive benefits of exercise to a certain degree.

In part II of this article I will discuss light therapy, St. John’s Wort and acupuncture as treatments for depression. In Part III I will examine other lifestyle modifications that can both prevent and treat depression, such as proper nutrition, stress management, getting adequate sleep, the experience of pleasure and prayer or spiritual practice.

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