Treating depression without drugs – Part I

August 12, 2008 in Depression | 11 comments


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.

{ 11 comments }

Mona November 13, 2008 at 6:06 am

I have used both medication and non-medicinal methods for treating my depression.  The first time I went through a depression, it was overwhelming.  I was a full-time student and working part-time in a Biotech lab with grad students so I had to stay focused.  I was a little scared at the ease of actually getting a prescription for antidepressants.  It was a list of questions that qualified me as a candidate (if the patients says yes to any of these then they qualify).  

I started them at low doses and read the warning label.  (Warning:  if you stop using this medication without doctors consent, you may have suicidal tendencies.)  I did a lot of drugs when I was younger and can honestly say that the first few days were like taking ecstasy but only a bad trip.  I wanted to stop taking it because I felt chittert and high all the time.  Then the effects subdued.  I didn’t care about anything anymore so nothing bothered me.  It was hard to care about studying for test too but I got through my semester.  It was better than trying to study and go to work without sleep and not eating all day.  I was an advocate for antidepressants for that very reason. 

But my problem was never solved.  After the cause of my depression was a distant memory, the same cycle started again.  I was depressed all over again with the same symptoms.  I was a little older and tired of the cycle so I did some research on my own.  I self-diagnosed myself as codependent and started therapy, exercising, and group therapy.  Exercising was great but the effects are not instantanious like you would expect.  It took time for my adrenaline levels to reach their peak, like weeks.  Then I felt great.  I was strong physically and mentally.  (And I looked great too.)  People started to notice the change which made me feel better .  Likewise, therapy helped me treat the problem, not just the symptoms.  

I still get sad, angry, and frustrated but each episode is shorter and less intense than the last.  My most frequent lasted only one afternoon.          

Chris November 13, 2008 at 11:32 am

@Mona:

Thanks for your comment, Mona. I’m glad you’ve learned some non-drug strategies that have helped you to be more resilient.

Chris

Tam July 20, 2009 at 2:19 pm

I am just starting this journey of depression/anxiety treatment. I am seeing a counselor which helps a little. I think therapy would be more effective if the couselor/patient match was better. She recommended that I take antidepressants and scheduled me to see a Nurse Practitioner who gave me sample doses of Lexapro to try for 3 weeks. That was a week ago and I have yet to take the first pill. There is just some sense of apprehension inside me not to do so, even before researching the side effects, which, by the way, the nurse didn’t share with me.
I am hoping that my condition is temporary and related to a number of major changes I have experienced in the past couple of years and will eventually get better. I am going to try some of the recommendations in this article. I used to practice yoga, meditate and run regularly but stopped doing so once this depression set in. I am going to do my best to start these practices again. I’m also going to try eating healthier as I find I eat lots of junk food in response to stress. That can’t be helping the cause!
My dad committed suicide 2 years ago. My main fear is that I will end up like him.

Ralph Taite January 17, 2010 at 6:13 pm

I know you’re trying to bring healthy skepticism to all branches of medicine, but I think you need to be careful when discussing recent claims that antidepressants are no better than placebo. 

Remember, prior to SSRIs like Prozac, antidepressants had such a bad side effects profile that only people with true biological depression were being treated.  And we know from that period that the MAO inhibitors and tricyclics did in fact save lives and reduced depression as compared to placebo.

And that’s with crappy first generation drugs.

Where we’re running into problems now is SSRIs are being prescribed to people who are just upset about a divorce or a death in the family.  Of course, in that instance, they would be no more effective than placebo since life event depression (without a biological enforcer) typically goes away in 6 months anyway.   

I have used Prozac and I come from a family which definitely has biological markers for depression and anxiety.  When I first had depression, it did provide relief better than anything I had tried previously.  I have since learned there are natural things (i.e., GABA and its derivatives, valerian root, D-phenylalanine, high omega 3 fish oil, etc), but to say that antidepressants have no role in treating biological depression is simply false.

The brain and nervous system is a chemical messaging network.  Just as computers use electronic 0′s and 1′s to communicate messages between subsystems, the brain uses messaging chemicals to communicate information between neurons.  In some people, those systems don’t work properly.  I know this because I can see how supplements and drugs affect my moods and my mental state. 

My depression was made worse by the exercise which you describe as a treatment.  I would have a panic attack after a heavy workout thinking, like you, that I could treat this thing with exercise alone.  It turned out that Prozac helped me get over the panic attacks so I could buy some time to learn other methods of depression management.

To Tam, I hope you do learn more about depression and don’t simply read blogs which suggest that exercise and psychotherapy will cure it.  For people who have depression in their genetic makeup, drugs can help a lot and may save your life.  I hope you do learn about the major mood neurotransmitters like serotonin, norepinephrine (adrenaline), dopamine and GABA and how drugs which target each system can help you manage your depression.

Also, people who have gone through traumatic events may have altered brain function.  They may be overly sensitive to adrenaline — as I believe our family has a genetic tendency toward — and it may take a while for the brain’s receptors to “down regulate” (meaning reduce their sensitivity).  People who have post traumatic stress disorder often have just had too much adrenaline pumped through their systems to the point that their bodies do not react to it properly.  GABA acts like a big stop sign to overactive neurons and supplements which enhance GABA transmission in the brain can help calm the symptoms of PTSD.

I am a firm believer that we do need chemical intervention at times to deal with depression.  If you get right down to it, food itself is a chemical fuel and we already know our choices of food can affect mood and depression.  The most important thing is to educate yourself about both sides of the issue.

By the way, I do agree with the blog author that cholesterol appears to not be the big risk factor in coronary heart disease — however, oxidated LDL does — and therefore we must learn how to control oxidation in the body.

Which, once again, is a chemical process.

Ralph :)

Tam April 23, 2010 at 7:54 am

First let me say thank you Ralph for your personal response.  I hope you are doing well.
It’s been 9 months since my previous post on this site. I did not take the SSRI prescribed to me in 07/2009.  I started seeing a new counselor who is a better match for me. She is actually teaching me things which are helping me tremendously.  I have started taking better care of me by doing things I used to love: running, yoga, meditation.  I have been certified in first degree Reiki and am taking the second degree Reiki class tomorrow. Reiki has been wonderful for me; it relaxes and calms me like nothing else. I’ve learned to speak up for myself instead of constantly feeling like a victim. My self-esteem is getting stronger. I’m learning about myself and why I act and react the way that I do and how to change those actions that are less than desireable. I’m learning that it’s okay to feel unhappy, sad, mad, happy, glad, etc. I’d put myself into a spiral of guilt because I thought I should be happy all the time. My life is really good so why would I feel sad? I realized that I was/am grieving the loss of my single life after I got remarried a year and a half ago to a wonderful man with a lot of baggage in the form of an ex-wife, 2 children and an overly involved mother! No wonder I was unhappy! ha!
Anyway….what I want to say is that I am glad I didn’t go the medication route. For me it was not the best treatment.  I am not even sure that I was really depressed. Yes, I displayed some symptoms of depression but I think I was in mourning. Mourning the “death” of my previous lifestyle.
I can’t say that I agree or disagree with the treatment of depression with medication. I guess if the disease is debilitating and the person doesn’t respond to any other treatment then okay. I am blessed and grateful that I am not in that situation.
Peace and blessing to all that are.

Ralph Taite April 23, 2010 at 12:09 pm

Tam,

That’s great news.  I support any therapies which bring you the results you desire.  For me, it must be a combination of psychotherapy and supplements or medication to address the underlying neurological disorder.  If psychotherapy in the form of meditation, Reiki, yoga, etc works for you, then I concur with you that you should utilize them first.

I think you are correct that your depression was a result of a big life change and not indicative of an underlying psychiatric disorder.  My point to the author of the blog was that some people do have serious psychological issues which won’t be cured by exercise, meditation or diet alone. 

Ralph

Joan April 28, 2010 at 11:09 pm

I am 60 yrs old and have taken SSRI steadily for the past 13 yrs.  My first experience with antidepressants was at age 34 when I took a TCA for 3 months -  I was reluctant to see what I was experiencing as Depression (ie meeting DSM3 (at that time) criteria but was persuaded to try a TCA just for a couple weeks to see if I got any response.  I did, and it started on about the 7th day.  It was like a miracle.  Profoundly helpful.  I had every side effect in the book and successfully went off the medication after 3 months which was what was recommended at the time.
I continued to be highly reluctant to take medications to treat subsequent episodes of depression.  I have tended, since I have studied pharmacology, and do have a healthy degree of scepticism, to want to avoid drugs when ever possible.  I have suffered through periods of depression without meds but with substantial costs in my family life, and costs in terms of personal suffering.
I have worried that I  might be doing harm to myself by not treatment depression chemically.   Several years after developing a chronic illness (autoimmune) that i decided to take drugs if they helped.  So now I have taken Celexa for 13 yrs.  At times I have reduced the dose form 40 to 20 mg, but have not done that for at least 6 years.
There is multigenerational suicide and depression in my family -and I have felt very lucky to live in a time when antidepressants are available.  I have accepted that I do have a genetic tendency toward depression.  I do light therapy in the winter as I do also have SAD.  Aerobic exercize is not a possibility for me.
I am concerned re long term side effects of Celexa and do want to get off of it.  So,I am planning to do another trial of reduction of dose.  I will of course go slow.
What suggestions do you have for things I can do to mitigate against the disruption I am bound to experience with a brain that has become accustomed to Celexa for so long?
 
Thanks,
Joan
 
 
 

Chris Kresser April 29, 2010 at 7:42 am

Joan,

All of my recommendations are contained in the “Treating depression without drugs” articles, Part I – Part III. Remember, it’s essential to have qualified medical supervision if you try to reduce the dose of your antidepressant. Diet is crucial, as I point out in the articles.

Gia July 29, 2010 at 3:18 pm

Ralph – maybe you missed the point.  There are some people that suffer from true biological depression, like Joan.  And from her statement anti-depressants improved her mental health and quality of life.  That’s a good thing.  But these ‘serious’ medications are being scripted out like candy.
When I was prescribed an SRRI (3 different ones at 3 different times) I had the ‘rare’ reaction.  I became angry and emotionally aggressive.  The “doctor’ that prescribed them got frustrated with me and we ceased our relationship.  I found ways to cope.  But they have yet to find a solution.
It is difficult to get medical doctors to look for an underlying cause for the depression many people are suffering with.  They just recommend you off to a shrink doctor, who then puts you on the anti depressant medication.  If the medication doesn’t make you feel better, they label you ‘difficult’ and move on to the next patient.
This is not effective medicine… just sayin’

Kim February 16, 2011 at 5:19 pm

@Mona

I was struck by your comment, “I didn’t care about anything anymore so nothing bothered me”. This appathetic condition caused by anti-depressants is known as “flatlining”. You don’t feel the highs and lows of normal emotions anymore. This is one of the many negative side-effects of these drugs that most don’t realize.

I went through a depressive episode about 10 years ago. It was a “life event” type of depression which is true of many people. It is NORMAL for a person to feel depressed when bad things happen. I recently learned that the scientists have discovered that the pain of depression is actually the brain trying to rewire itself to solve the problem that is making them so depressed. The drugs actually short-circuit the process and make things worse in the long run. I’m glad that I didn’t succumb to drugs even though my doc offered them. At one point, things had progressed so that I had lost a significant amount of weight due to the fact that I hadn’t eated much in a few months. I finally had a conversation with myself and said if I wasn’t going to eat properly, I at least needed to choke down some vitamins and other supplements like amino acids. The honest truth is, after I took them the first time, I woke up the next day feeling much better. I had allowed myself to get nutritionally deficient and that compounded the problem.

I wonder how many people who are depressed are really just deficient and depleted of key nutrients that would make them feel better than drugs? Remember, you’re not depressed because you have an SSRI deficiency! One of the things I ended up taking was Sam-e in very small does of 50-100 mgs in the mornings. I only did it for about 1-2 months but it really helped. a recent Harvard study confirmed it’s anti-depressant benefits. There are other things as well but if you’re on drugs, you absolutely must consult with a doc about adding supplements like this since they can interfer and cause bad side-effects.

And speaking of the drugs, I found a website not long ago that specifically deals with helping people get off RX drugs especially anti-depressants, benzos, ADD, etc. I hope it’s ok Chris to post this link, if not feel free to remove it. http://www.pointofreturn.com/index.html My nephew was diagnosed with OCD (not sure if it’s really the case, tho) and he’s only 15 but has been on some pretty powerful drugs for years and I can see the change in his personality. I’d like to see him get off them. I hope this helps people here.

Ryality March 10, 2011 at 2:47 pm

Hi everyone. TY Chris.

Drugs should always be a last resort, in all cases, with all problems, because drugs ussually do not work on the cause but the effect. I appreciate that Chris has this POV. Psychotherapy, meditation, excercise, spirituality are life long pursuits they are needed in different amounts to different people but always help. I’ve come to believe that we are chemicals first. We can affect those chemicals with the least amount of side effects by diet combined with the things listed above. What we know changes as we grow. Had I known about paleo and all the things I do now prior to my life long battle with anxiety that peaked witha year and a half very intense constant anxious state I might have not taken 25Mg’s of Zoloft daily. Looking back the peak, the thing that finnally made me go see a doctor was probably caused by too much alcohol and poor diet (SAD high carbs). Leading up to my decision to take it I excercised, I read every book i could, and talked to everyone that would listen. I even tried following the normal type diets that everyone says are healthy. I quit smoking for 3 months. I felt no improvement. When I got to the point when I could find no peace ( I don’t mean joy and elation I mean simply being ok being alive type peace) I went to a Dr. and took Zoloft. It was a good experience for me. I did care less about stuff, but it wasn’t terrible. I didn’t become a robot. I did suffer some sexual side effects, but they were worth it. After a year I was able to look at my anxiety and say to my self…if chemicals changed it then chemicals caused it…and I’m not going to die. Through a continued effort of the steps I mention above combined with this understanding I took my self off the medication. I did get the brain shivers feeling…it was weird, but ended after a month or so. I’ve been off Zoloft for almost 2 years now and I’m good, things are good. I still have a tendency to become anxious or think very dark thoughts, but I get it now, its ok, and it doesn’t persist.

One of the main and important things I got from Chris’s article was that if a person is not interested in fixing the cause and only lowering the effect they are going to trap them selves into this dependancy for life. There are people who need the drug. There are people who do not need it. We are better off without it if we can be, with every drug. the people who have the most trouble in life are the ones who take a drug frist approach whether its pot, oxycontin, alcohol, or anti depressants. The way to know the difference is through wisdom and seeking peace. For those people who are on it. I would follow the diet Chris reccomends, as well as look for other spiritual and psychological methods like the ones Nora Gedgaudas talk about with Neurofeedback, with the intention and effort to grow grow grow…learn learn learn. I hope that those on it are able to find or reach peace, or enough peace, because its terrible being depressed and anxious.

-R

Previous post:

Next post:

Designed by Evan Haas & Soy Pak