This summer, I left the yoga studio I'd opened more than three and a half years earlier. Even though I wasn't paid for my efforts beyond the wages I earned teaching classes, I managed the studio Read
Depression may be the defining disorder of our time. This year 13 to 14 million Americans will be diagnosed with a “major depression,” a month or many months-long bout of hopelessness, fatigue, sleep disturbance and physical symptoms, including overeating or weight loss.
Another three million will receive the diagnosis of “dysthymic disorder,” a more chronic, low-grade version of depression. That means that this year, almost one tenth of our adult population will have a diagnosable, “clinical” depression.
Depression is almost always treated as a disease. The standard treatment, the so-called “treatment of choice,” is anti-depressant drugs, usually selective serotonin reuptake inhibitors (SSRI’s) like Prozac, Paxil, and Zoloft. These increase the amount of serotonin, a relaxing neurotransmitter, which is available to brain cells.
Serotonin norepinephrine reuptake inhibitors (SNRI’s) like Effexor and Cymbalta, are also used. They increase the amount of norepinephrine, a more energizing neurotransmitter, as well as serotonin.
This approach to depression is, in the vast majority of cases, unwarranted and considerably less successful than its proponents have claimed. It also has significant side effects. The anti-depressant drugs are often experienced as emotionally numbing.
About 70% of those who take them experience gastrointestinal disturbances, headaches, agitation, and/or weight gain, among other distressing symptoms.
There are far better ways to successfully address depression which do not have the negative side effects of drugs. These include a number of natural, non-pharmacological approaches coupled with the oldest and most successful of modalities — talking with another, skilled, sympathetic person.
In order to make use of this integrative and effective approach to depression, we need to free ourselves from myths that limit our options, myths that may make us unnecessarily fearful of not taking drugs, and keep us from pursuing what may be a more successful treatment strategy.
Here are five of those myths:
1. Depression is a disease.
Depression is routinely compared to type 1 (insulin-dependent) diabetes. The idea is that people who are depressed are deficient in serotonin and/or norepinephrine, just as those with type 1 diabetes are unable to manufacture insulin and are therefore deficient in it.
This analogy is false.
There are consistent and predictable pathological and physiological findings in type 1 diabetes. You can see changes in the kidneys, eyes, and arteries of people with type 1 diabetes at autopsy, and you can easily measure their blood sugar levels. It is a definable disease.
With depression, however, these kinds of obvious and observable changes don’t exist. There is no consistent anatomical damage in depression. Some depressed people may be deficient in serotonin or norepinephrine; most are not. In any case, no tests are routinely done to determine who is deficient and in which neurotransmitters.
2. Drugs are the treatment of choice for depression.
This has been, for some years, the standard psychiatric assumption and practice. However, it is not justified by the evidence. Recent authoritative reappraisals of the studies on SSRIS and other drugs that have been published in some of our most prestigious medical journals, including The New England Journal of Medicine, The Journal of the American Medical Association, and PLoS Medicine, paint quite a different picture.
Until these review articles appeared, assumptions about the effectiveness of drugs were based only on published studies — ones which were largely funded by drug companies. Not surprisingly, the drug companies had chosen not to publish the vast majority of unfavorable studies.
When researchers accessed Food and Drug Administration records and examined unpublished as well as published studies, the results were quite different. Anti-depressant drugs were little, if any, more effective than placebo sugar pills for mild to moderate depression, the kind the vast majority of us are diagnosed with.
Though two of these reassessments suggested the drugs were better than placebo for severe depression, the third one raised doubts about that as well. This doesn’t mean that the drugs are always ineffective. They clearly relieve symptoms for some people. It does, however, strongly suggest that they should not be the authoritative “treatment of choice.”
3. Psychotherapy is not an effective treatment for depression.
Psychotherapy of various kinds can indeed be effective. Studies on brief “interpersonal” therapy (which emphasizes current stressful events and better coping strategies) and cognitive therapy (which addresses our negative thoughts about ourselves and our lives) show that these approaches, by themselves, have benefits that are at least as impressive as those that may come from drugs.
In fact, as far as I’m concerned, talking with a skilled and sympathetic other person (individually or in a group) is the single-most effective way to move through these hard times. For most people, this “talking cure” as Freud called it, should be a foundational part of any comprehensive approach.
4. Only drugs can address the underlying biological imbalances in depression.
Some people who are depressed may indeed have biological imbalances. However, drugs are by no means the only way to address them.
Modern science teaches us that everything that affects our mind also affects our body. Chronic stress, and the depression that often follows it, have been found to decrease the functioning and number of cells in the hippocampus, an area of the limbic system, the emotional brain, involved in memory.
Both meditation and exercise stimulate growth of new cells in the hippocampus as well as improve symptoms of depression. We know as well that deficiencies in some vitamins and minerals (including vitamins B1, B6, and B12, and vitamin D3, and the minerals chromium, magnesium, and selenium) and in Omega 3 fatty acids may cause or contribute to depression.
Studies have shown that supplementation with these nutrients can indeed be beneficial. Other nonpharmacological approaches like yoga, acupuncture, and herbal therapies (Hypericum, or St. John’s Wort, has been most carefully studied) also have positive effects.
Each of these approaches has specific benefits. When we combine them in ways that are tailored to each person, they are likely to work together to be far more helpful. In addition, such an approach, which relies primarily on self-care, is itself powerfully therapeutic. When we act on our own behalf, we overcome the helplessness and hopelessness that are the hallmarks of depression.
5. One episode of depression is likely to be followed by others.
This is statistically true, but it is hardly a preordained outcome. Subsequent episodes may well occur because the original one was only treated symptomatically — usually with drugs — and its causes were never addressed.
An integrative approach that addresses causes, one which includes psychotherapy and the other strategies described above, can make fundamental changes in the biology and psychology of depressed people, and the way they relate to the world. This experience and the ongoing use of self-care strategies may give people who have been depressed the tools they need to prevent future episodes.
This doesn’t mean that if we are depressed, we won’t be sad and suffer. It does mean that we can learn to become far more capable of dealing with life’s inevitable sadness and suffering.
Instead of defining ourselves as patients in need of treatment, we can learn to see difficult times, including depression, as challenges rather than disasters. If we do, we can move successfully through, and beyond, depression.
As we free ourselves from the constraints of these myths, we ready ourselves to create a comprehensive and integrative program of care that rarely has to include drugs. You can find a comprehensive step-by-step description of how this integrative approach works and how you can use it yourself in my book Unstuck: Your Guide To The Seven Stage Journey Out of Depression (Penguin).
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