What if most of what we thought we knew about depression was wrong — or at least alarmingly limited?
I believe it is. After 40 years of work as a psychiatrist and integrative physician, and as someone who has personally moved through and beyond depression, I have come to believe the conventional psychiatric view of depression as a disease is deeply flawed.
I’m also concerned that the routine prescription of antidepressant drugs is inappropriate — and may be dangerous. My experience has taught me that there is a better, more effective way to understand and treat depression than to view it as the endpoint of a pathological process. I call it the Unstuck approach.
For me, and for the thousands of people with whom I’ve worked, depression is often a sign that our lives are out of balance and we’re stuck. It can actually be a wake-up call, and potentially the start of a journey that can help us change and become more whole — and happier than we have ever been.
Yet for this to happen, effective treatment needs to address the whole person, not just his or her depressive symptoms.
The Downside of Antidepressant Drugs
When a physician observes the signs and symptoms of major depressive disorder in someone — difficulty sleeping and eating, weight loss, absence of interest in a world that once pleased him or her, feelings of helplessness and hopelessness — the doctor is likely to prescribe antidepressant drugs.
Some 30 million Americans are currently using these drugs for premenstrual syndrome, chronic pain, and anxiety, as well as depression. And drug companies profit hugely from this avalanche of prescribing. In 2012, for example, the sales of one antidepressant, Cymbalta, amounted to $4.5 billion.[callout]Some 30 million Americans are currently using these drugs for premenstrual syndrome, chronic pain, and anxiety, as well as depression.[/callout]
When a patient asks questions about the need for drugs, she (I use the feminine to remind us that more than twice as many women as men are diagnosed with depression — an issue I address more fully below) is often told, “Depression is a biochemical disorder like insulin-dependent diabetes. Diabetics need insulin because their pancreas doesn’t work properly. And you need these drugs — selective serotonin reuptake inhibitors (SSRIs), like Paxil and Prozac — to raise your levels of serotonin.”
It sounds authoritative, appropriate, and effective.
Unfortunately, it’s inaccurate.
First of all, the biochemical disorder associated with depression has never been demonstrated. Some people with depression may have lower levels of serotonin, a neurotransmitter that helps calm the brain and balance many body functions. But the evidence suggests they are a minority. And what’s more, doctors usually don’t measure a person’s level of serotonin before prescribing drugs to affect it.
It’s also important to understand that alterations in serotonin levels are often the consequence of other psychological and physiological disturbances that need attention. Low levels of vitamin D, hormone imbalances (including inadequate estrogen), exposure to toxic chemicals (such as bisphenol A in plastic), psychological abuse, and long-term stress all can decrease serotonin levels.
Low serotonin is a symptom. In other words, the cause lies elsewhere.
Second, the SSRIs are not, in fact, selective. Serotonin-producing cells are distributed widely through the brain and body. The small intestine has the largest number.
And altering serotonin inevitably influences the level, action, and many functions of other neurotransmitters, including dopamine, the energizing, “feel good” neuro-transmitter that controls the brain’s reward and pleasure centers.
Because of their effects on dopamine and other neurotransmitters, SSRIs can produce a cascade of uncomfortable and sometimes dangerous side effects.
These include gastrointestinal upset; neurological problems such as headaches, muscle stiffness, and tremors; weight gain; and sexual dysfunction. And such side effects occur in up to 70 percent of those who take SSRIs.
Some of these side effects, as well as potentially disabling neurological symptoms, appear to result specifically from interference with the normal metabolism of pleasure-producing dopamine.
It’s also worth noting that in the early weeks of taking the drugs, a number of people — mostly young adults and adolescents — become more depressed and more suicidal.
A 2004 FDA study found that suicidal thinking increased in 4 percent of children and adolescents who took antidepressant drugs, as opposed to 2 percent in those taking placebos. This prompted the issue of a black-box warning for antidepressant packaging.
More important, neither the SSRIs nor the increasingly prescribed SNRIs (serotonin–norepinephrine reuptake inhibitors) do nearly as good a job at relieving depression as their manufacturers maintain.
Doctors have prescribed these and other antidepressants for more than 20 years because they believed the published studies that showed the drugs were 50 to 60 percent more effective for depression than the placebos with which they were compared.
It has since been revealed that those study numbers were seriously misleading.
The drug companies profit hugely from SSRIs and other antidepressants, so perhaps it is not surprising that, for the most part, they had published only the positive studies.
When researchers recovered the unpublished studies at the FDA, the results were quite different. Reviews of the previously unpublished studies in The New England Journal of Medicine, The Journal of the American Medical Association, and the online journal PLoS Medicine have since suggested that antidepressants are little, if any, better than placebos — except in a small minority of cases of serious depression.
All this doesn’t mean that antidepressants aren’t sometimes helpful. Even with their limitations and side effects, they can be.
What it does mean is that they should not be regarded as the treatment of choice, as they too often are. Instead, antidepressants should be a last resort.
The Unstuck Approach
My treatment of choice is what many call integrative. I think of it as a way to get unstuck, to help us move through and beyond depression and the other difficulties that our lives may bring us.
I describe this integrative, comprehensive approach in my book Unstuck: Your Guide to the Seven-Stage Journey Out of Depression. It combines conventional treatments, including various forms of psychotherapy, with other techniques that enhance a person’s emotional life, cognitive abilities, and physical health. Medication is sometimes used, but only when other combined treatments don’t work. “In extreme situations,” Hippocrates said 2,500 years ago, “extreme remedies.”
Though the integrative approach is safe and appropriate for everyone, including children (who are increasingly being diagnosed with depression and treated with drugs), it is especially useful for women, whose rates of depression are twice as high as those of men.
The research is unclear about the reasons for this difference, but it may be related to hormonal balance in the female body — particularly prior to menstruation and postpartum — and perhaps to a higher incidence of thyroid dysfunction.
In my opinion, it is almost certainly a byproduct of women’s more vulnerable social position. An approach that encourages women to take charge of their own treatment, and gives them the self-care tools to do it, helps transform this conditioned sense of powerlessness.
Working with a skilled therapist can be important, even crucial, in healing from depression, but that work can be exponentially enhanced by what you do for yourself.
The goal with the Unstuck approach is to learn to understand and help ourselves, so we can overcome the feelings of helplessness and hopelessness that are the hallmarks of depression. Here are the key elements. All have been demonstrated to relieve depression. Used together, each enhances the effectiveness of the others.
Mindfulness helps people become relaxed, aware, and firmly grounded in the present moment. I teach specific meditation techniques such as slow, deep, soft-belly breathing and mindful walking and eating, which have been shown to decrease levels of anxiety and stress, enhance mood and optimism, and promote greater emotional stability and more reliable judgment. (Try some “Soft-Belly Breathing” below, or download the PDF.)
[callout]Regular meditation increases the thickness of the cerebral cortex in parts of the brain associated with executive functions such as reasoning and responsiveness.[/callout]
Studies have found that focused and mindful meditations raise levels of the same neurotransmitters at which SSRIs and SNRIs are aimed. Even more impressive, neuroscientist Sara Lazar, PhD, of Harvard Medical School and Massachusetts General Hospital, has shown that regular meditation increases the thickness of the cerebral cortex in parts of the brain associated with executive functions such as reasoning and responsiveness.
Increase Movement and Exercise
Movement is central to an integrative approach. Exercise has been shown repeatedly to equal antidepressants in relieving symptoms of depression and raising neurotransmitter levels. A number of studies, including several done at Duke University by James Blumenthal, MD, and his colleagues, show exercise-triggered mood increases at least as great as those achieved with SSRIs — and sometimes better.
They suggest at least 30 minutes of daily exercise is optimal (this is much easier when it’s an activity you enjoy), but all of us should start with what we can do — and what we like to do. Walking a couple of blocks a day is a great beginning.
How we eat can be crucial in preventing, as well as treating, depression. People who are depressed may be deficient in one or more nutrients, including B vitamins, vitamin D3, selenium, magnesium, and omega-3 fatty acids. Some people are sensitive to gluten and other food substances that may cause inflammation, which has been implicated in depression.
Additionally, we are just now beginning to understand the complex relationship between the gut, the brain, and our emotional well-being. One of the intriguing recent findings is that probiotics, which normalize gut bacteria, may provide significant relief to people who have been diagnosed with depressive disorders. The supplement regimen I prescribe usually includes a daily probiotic — a combination of acidophilus and bifidus — with 2 to 3 billion live bacteria. (For more on the food-mood connection, check out “The Food-Mood Connection“.)
Stimulate Imagination and Intuition
Creative practices nourish the body and mind. I teach techniques like guided imagery, drawing, and spontaneous written dialogues with one’s symptoms, problems, and issues. These often help depressed and anxious people access their imaginations and use intuition to address emotional challenges.
For example, using a technique called Wise Guide, a 13-year-old boy with whom I was working closed his eyes and imagined himself in a safe place. When I suggested that he envision a “wise guide,” he visualized a large, kind dog named Friend. When the boy asked Friend how he could deal with his anxiety about tests and speaking in class, Friend advised him to imagine that he, Friend, was sitting next to the boy in school, and that the boy was hugging him. The image quieted the boy’s fears. He began to speak up in class, and his grades improved.
Many people find that being part of a group where they share experiences and learn skills multiplies the benefits of their self-care. In the Mind-Body Skills groups that we’ve developed at the Center for Mind-Body Medicine, professionals teach self-awareness and a variety of self-care skills. Participants are treated as students, not as damaged or ill patients. They often say they feel like pilgrims together on a journey toward greater understanding, health, and wholeness.
This group model has proved powerfully helpful to depressed and anxious medical students and professionals in the United States, and for war-traumatized and depressed children and adults in Kosovo, Gaza, Israel, and Haiti.
Connect to Something Greater
Using self-care techniques and living more meditatively often paves the way for us to connect with something greater than ourselves — God, nature, a higher power — and to find meaning and purpose in our lives. A sense of connection, meaning, and purpose is among the most powerful proven antidotes to depression. So, look for ways to tap into that feeling regularly, whether it’s developing a daily reflective ritual, attending a spiritual service, or volunteering to help those in need. As your sense of meaning and purpose expands, your vulnerability to depression will diminish.