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Comment: with all the stumbling blocks we have today in our lives, a lot of us face periodic depression and unhappiness. Here’s an article from my favorite site – Women to Women – it’s good for men too – about depression that’s worth reading.

Antidepressants and alternative treatments for depression

Marcelle Pick, OB/GYN NP discusses antidepressants and alternative treatments for depressionby Marcelle Pick, OB/GYN NP

Topics addressed in this article:

Jackie was just 42 when she came to Women to Women for help. She had gone to her prior healthcare provider complaining of fatigue and “feeling low” two weeks out of every month. She had two active children, kept house, helped her husband with his business, and cared for her aging parents. No wonder Jackie was tired. But her doctor put her on Prozac.

Almost 75% of the new patients at our medical practice come to us on antidepressants prescribed by their prior healthcare provider. There are often other underlying issues needing to be balanced, and few of them suffer from major depression, the one diagnosis that clearly justifies their use.

Some of these women went to their primary care provider’s office with situational mood disorders like seasonal affective disorder (SAD) or post partum depression. Others were in a minor depressive state brought on by emotional or physical stress. Many had common symptoms of hormonal imbalance such as PMS or hot flashes. Like Jackie, many suffered from fatigue, insomnia, or simple aches and pains. But all left their doctor’s office with a prescription for antidepressants.

If you go to a conventional healthcare provider, the odds are pretty high that you will be prescribed antidepressants at some point in your life. Should you take them? And if you’re on them now, what are your alternatives?

Antidepressants: a brief overview

Chances are, either you or someone you know has a prescription for an antidepressant. They have become conventional medicine’s default drug of choice: when in doubt, you’re probably depressed.

There are three different families of antidepressants, each with a different chemical mechanism. (Here’s a list of common antidepressants.) All of these drugs work with your neurotransmitters — the brain chemicals that regulate mood, sleep, and appetite, among other things.

In the 1960’s and 1970’s it was thought that norepinephrine, epinephrine and dopamine were the primary affectors of mood. The first two families of antidepressants, MAOI’s and tricyclics, were developed to increase available levels in the brain, but it turns out that they can burn out the brain’s receptors within several weeks. They also have very strong side effects. As a result, physicians have come to prescribe them with care just to people who really need them.

At about the same time, some scientists began to view another neurotransmitter — serotonin — as the missing link in treating mood disorders. In the 1980’s a new family of antidepressants — SSRI’s, or selective serotonin reuptake inhibitors — was developed, and appeared to deliver results in regulating mood without the more serious side effects of its predecessors.

Due to the seemingly attractive risk/benefit ratio of SSRI’s, physicians expanded antidepressant use exponentially: in the 1990’s, spending on antidepressants grew by 600%! Today the various classes of antidepressants under such tradenames as Prozac, Paxil, Zoloft, Celexa, Lexapro, Wellbutrin, Effexor, Cymbalta, and Sarafem are among the most widely prescribed drugs in the world. And while we know now that diminished serotonin reuptake does factor heavily into the mood regulation equation, SSRI’s and their pharmaceutical cousins are not the magic bullet pharmaceutical companies would have us believe.

The depressing truth about antidepressants

Can so many of us have the major form of depression that warrants such rampant drug use? Of course not.

This doesn’t mean that a lot of you don’t feel depressed, or have symptoms that could be related to depression. Such symptoms are usually related to some kind of stress — emotional and/or physical — that can be resolved without pharmaceutical drugs. This is especially true when it comes to subclinical forms of mood disorders such as SAD, PMS, or post partum depression. It’s also true for many situational or reactive depressions.

Some studies have shown that antidepressants are no more effective in treating this kind of mild to moderate depression than a placebo. (In a clinical trial half the participants are given the real drug; the other half are given an inactive pill called a placebo.) Furthermore, depending on how one defines depression, as many as one-third to a half of depressed patients do not show significant improvement with prescription medication, while as many as half of those who receive no such treatment improve anyway.

Numerous recent studies also tell us that regular exercise — 20–30 minutes, three to six times a week — can be a powerful antidote to mild or moderate depression. Even small amounts of exercise can make all the difference in the world (though we will generally benefit more from a higher amount). Most of us have heard of the mood lift that accompanies the endorphin surge or “runner’s high” that occurs with exercise. These studies show that sticking to a regular workout provides long-term mood stabilization, especially when combined with other antidepression measures, such as talk therapy.

In fact, antidepressants are contraindicated for short-term treatment of minor depression — something the drug companies don’t want publicized. Clinical practice guidelines indicate that SSRI’s need to be prescribed for at least six months for minimal treatment of major depression — longer than most episodes of minor depression last.

So with such doubt about their efficacy, why are so many doctors (most antidepressants are prescribed by PCP’s, not psychiatrists) handing out prescriptions for an ever-growing list of symptoms — such as headaches, insomnia, PMS, menopausal symptoms — that are not exclusively linked with severe depression?

Managed care and antidepressants

To get a clearer picture, it’s important to understand how the healthcare system works. Under managed care, when you feel unwell your first stop is your primary care physician (PCP), not a specialist. To figure out the real issues requires a lot of time. One must look at the person’s unique history and presentation. PCP’s have very little time to spend with you and they are usually not experts on mental health or natural methods.

PCP’s are well-intentioned, but antidepressants may be the best option they have for you. They may believe that antidepressants, particularly SSRI’s, provide an adequate solution with relatively little risk (at least in the short term). And antidepressants often will help you feel better — if you don’t mind the side effects.

Certain chronic pain conditions that primarily affect women, such as fibromyalgia, endometriosis and rheumatoid arthritis, can cause mild depression and multiple trips to the doctor’s office. While your primary care doctor may be unable to resolve your chronic pain, he or she can help make you happier about living with it. If they can satisfy you and the HMO with a prescription, they feel they’ve done their job.

Off-label use of antidepressants

While doctors are under pressure from the managed care system on the one hand, the influence of the pharmaceutical companies who make antidepressants is truly pervasive.

Drug companies typically get a new product approved by the FDA for a specific diagnosis for a limited period of use based on the results of clinical trials. The companies then use a range of tactics to support the use of that drug for other diagnoses and for longer periods of time. This is referred to as off-label use, and it is an enormous source of sales and profits for Big Pharma, as the pharmaceutical industry is sometimes called.

Years ago a tactic used to promote off-label use of antidepressants was to suggest to doctors that women’s complaints have no medical basis — i.e., “it’s all in her head” — and won’t go away without a mood-altering drug.

Today Big Pharma’s tactics are subtler. They fund research, conferences, and speakers and direct free samples and sales efforts toward physicians in support of off-label use of their products, including antidepressants. Not to mention the multimillion-dollar direct-to-consumer advertising campaigns. A 2003 study found that over 70% of surveyed patients reported exposure to these persuasive advertising efforts.

One specific recent tactic in recent use is the widespread promotion of antidepressants as a “safe” substitute for synthetic HRT. When the WHI studies on the dangers of HRT were published in 2001, about 13 million women were taking those drugs. Many of these women were put into a panic by the news about the health risks of HRT.

The drug companies seized this opportunity to promote antidepressants for menopausal symptoms, especially hot flashes. Millions of women were switched directly from Prempro to Prozac or other SSRI’s. Unfortunately, in our clinical experience, they don’t work for very long, particularly in their use for hormonal, inflammatory issues, and women aren’t being told enough about their health risks and side effects.

Side effects of antidepressants, known and unknown

We must not forget that these products are drugs — very powerful, significant chemicals that alter your hormonal balance and perhaps permanently change your brain’s biochemistry. No one knows what the long-term effects of antidepressants are because most clinical trials to date study 3– to 5–year outcomes of a single drug at a time — never a combination.

There is evidence now that SSRI’s actually decrease levels of serotonin over time. Some kind of disruption of the neurotransmitter pathways occurs, because SSRI’s don’t create a new equilibrium: at some point in time the patient must be moved to a new drug to maintain the same effect.

The side effects of SSRI’s include weight gain or loss, intense restlessness, insomnia, fatigue, sexual dysfunction, panic attacks, and anxiety. And these are not rare side effects: for example, studies indicate that 18–50% of patients experience sexual dysfunction.

Other studies show an increased risk of bleeding disorders, such as GI bleeding, bruising and nosebleeds, with use of SSRI’s. Although recent studies and anecdotal evidence strongly suggest an increase in suicidal behavior in children and adolescents, the data do not present a clear picture. Despite years of analysis, this link remains highly complex and not well understood. SSRI’s also carry strong potential for drug interactions. Clearly, more research needs to be done on all fronts.

In short, for all but those suffering from major depression, antidepressant use carries the risk of serious side effects to address what is, in most cases, a temporary problem. SSRI’s were just introduced in 1988. Synthetic HRT was used for 60 years before government studies finally showed their health risks. Who knows what the next 50 years will reveal about the risks of extended use of antidepressants?

A new view of ordinary depression

What makes this all so frustrating is that many forms of depression are natural, normal and temporary — rather like menopause. Indeed, the philosophically minded might simply attribute many of these feelings to the human condition. Likewise, they can be relieved through safe, gradual methods using your body’s natural mechanisms.

As with other symptoms of imbalance, depression is your body’s way of sending you a signal that something is awry. Antidepressants don’t address the underlying problem; they drown it out with a booming Don’t worry—be happy! But for how long? What happens when you want or need to come off antidepressant medications?

Think for a moment about how SSRI’s work. The idea is that you don’t have enough serotonin, so the drug conserves the limited amount in your body, blocking it from being changed into the next substance on its metabolic pathway.

At Women to Women, we look at the problem differently. We ask, “Why isn’t your body making more serotonin? And what can we do about that?” Moreover, we question the simplistic view that depression is solely the result of low serotonin — the real biology is probably more complex, arguing for a holistic solution that supports the whole neurotransmitter cascade.

I’ve seen so many of my patients turn their lives around — naturally — who never thought they’d be free of depression. You can, too. But first you have to know what you’re dealing with.

How depressed are you?

I want to be clear about one thing. If you have major depression, you need to stay on your antidepressants. We are not recommending that anyone with this diagnosis quit their medication cold turkey (some patients have severe reactions when they get off SSRI’s too quickly). However, we want every woman who is on or thinking about taking an antidepressant to know what her choices are.

Depression includes a range of normal negative emotions. But clinical depression differs significantly from minor or situational depression or mood disorders, even though the symptoms can be the same. The difference is that in mild depression the symptoms ebb and flow and eventually lift, while in major depression they spiral down into a full-blown, entrenched mental health crisis.

Most forms of depression are characterized by overwhelming, persistent feelings of grief, anxiety, guilt or despair; a sense of numbness or hollowness; and a loss of interest or pleasure in activities that were once enjoyed, including sex. Dullness, decreased energy, difficulty concentrating or making decisions, and disrupted sleep patterns are also symptoms, as well as overeating and weight gain, or loss of appetite and weight loss. Suicidal thoughts or attempts and obsessing about death are serious warning signs that need to be addressed immediately.

If you’ve been feeling any of these symptoms consistently for over a month, you should immediately seek out medical advice, preferably from a trained psychiatrist, psychologist, or social worker.

Chronic physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and pain can be an indication of depression, but may be symptoms of an underlying physical condition that warrants further testing. Before taking antidepressants you should get a second opinion. Integrative medical practices (those that combine alternative and conventional medicine) are very successful at finding the true source of mysterious ailments. (For more information see our article on how to make alternative medicine work for you.)

The social stigma of depression

If you think you may have minor depression, you’re in good company! Everyone has normal, sometimes extended bouts of melancholy or grief, particularly after a trauma or loss. But pain and anguish aren’t often talked about. Our culture doesn’t like “downers,” so many of us put on a brave face and perhaps wonder why we can’t be happy like everyone else.

The truth is that sadness and grief are normal, and psychotropic drugs may interfere with our grieving or mental processing. Before going to the pharmacy, think about the possible reasons why you’re feeling blue. In many cases, you have good reason: death, health crises, financial woes, divorce, break-ups, moves, and other big transitions are common causes of situational depression. Even joyful events like weddings and births can bring on depression by resurfacing unresolved emotional experiences from your past.

Minor depression may stem from individual physical stresses such as jet lag, poor nutrition, illness, insomnia, low carbohydrate levels, carbohydrate addiction (more on that below), hormone imbalance, yeast or wheat sensitivity, allergies, and environmental pollutants. Many suffer from a downward cycle of poor health that creates life problems that in turn are depressing.

Then there’s the cast of well documented subcategories of depression that affect millions of people, such as post partum depression (PPD), post traumatic stress syndrome (PTSD), and seasonal affective disorder (SAD). They can be devastating while they last, making doctors quick to prescribe pharmacological solutions. Sometimes medications are needed and can be a useful bridge back to wellness, but it’s important to know that there are other, more natural options that work quickly, too.

And of course, there are those emotional issues we all grow up with. Sometimes we’re blissfully unaware of them until we run smack into them. I know a woman who at 47 had a sudden nervous breakdown. For a year she hid in her house, cried all the time, and stopped caring for her children. Today she’d be on antidepressants in a heartbeat. While they might have helped her get out of the house and to the therapist’s office (a good thing for sure), they would not have identified or resolved her underlying emotional issue: Her father had died tragically when he was 46. By outliving him, she fell unwittingly into a deep well of unconscious guilt and grief. With time she was able to work that through and her depression resolved.

The good news is that most forms of mild to moderate depression will respond very well to positive changes in diet, exercise and lifestyle habits and nutrient support. Why? The key is the connection between serotonin and cortisol levels, which are directly influenced by diet and stress.

Serotonin, melatonin, cortisol, and depression

While all of your neurotransmitters are important, serotonin is the star when it comes to your mood. When your serotonin receptors are in sync, you feel good: you sleep and eat well, and you awake refreshed and energized. Contrast this to an abnormal serotonin state in which you suffer all the symptoms of depression.

Serotonin is synthesized in the brain and the digestive tract, which is also the source of its precursors. This is yet another reason why what you eat and how well you digest are crucial to how you feel! L–tryptophan, an essential amino acid found in food and supplements, is converted in your body into 5–hydroxytryptophan (5–HTP), and then into 5–hydroxytryptamine ( 5–HT), which is the chemical name for serotonin.

Importantly, serotonin is the “parent” for the hormone melatonin, which regulates our circadian rhythm, or sleep cycles. If you have insufficient serotonin, your melatonin levels become imbalanced and your sleep gets disrupted. This can be a downward spiral, leading to further disruption of serotonin function.

Sudden changes in serotonin levels cause irritability, fuzzy thinking, and anxiety. Stimulants like coffee, sugar, simple carbohydrates, nicotine, and recreational drugs can release a flood of serotonin for a few hours, creating a pleasurable effect. When the stimulants wear off, serotonin levels plunge and we crave another “hit.” A reliance on stimulants puts your body and mind on a vicious up-and-down treadmill, resulting in chronic serotonin pathway dysfunction — not to mention weight gain.

Maybe you’ve heard the recommendation to eat a potato at night to help carbohydrate cravings and depression. This may sound silly, but potatoes and turkey contain L–tryptophan, that important building block of serotonin.

Stress is truly big here, too. When we are stressed, our body releases the hormone cortisol. A surge in cortisol is always accompanied by a surge in serotonin — and the inevitable dip a few hours later. Women who suffer from fatigue and cravings for carbohydrates in the late afternoon are probably on the high-cortisol/low-serotonin rollercoaster. And guess what? They usually feel depressed.

So what can you do?

Once you see the connection between nutrition, stress, and serotonin levels, it gets easier to understand how simple lifestyle and diet changes will make huge improvements in your mood — and overall health — without resorting to drugs. What you eat affects your brain chemistry. I can’t say it more simply.

Many women with mild to moderate depression don’t feel they have the energy to make dietary or other changes in their health habits. They’re discouraged and tired. I tell them to just give it two weeks: you can do that for yourself. And the lift you’ll feel in your energy will be remarkable. You’ll have the strength to keep going with other changes. Here’s how to get started:

  • Limit consumption of carbohydrates, especially simple carbohydrates, including alcohol. (Don’t eliminate all complex carbohydrates, however. Too few carbohydrates will cause serotonin levels to plummet because the brain is not being fed properly.)
  • Eat a balanced diet and take a rich nutritional supplement. Many factors that contribute to low serotonin production are created by nutritional deficiencies. Similarly, if you suffer from digestive problems, find an alternative practitioner to help you. We put all our patients on a pharmaceutical–grade nutritional supplement, like those we offer in our Personal Program. (Click here to read more about Essential Nutrients.)
  • Reduce stimulant use and known physical stressors to help balance out serotonin levels.
  • Exercise is a good way to reduce stress and enhance mood. It releases endorphins — which create a natural euphoria — and reduces cortisol levels. You don’t have to join a gym, even a daily walk to the mailbox is a good place to start. Experts recommend beginning slowly, working up to 30 minutes, six times a week. Or just start with burst training — one minute four times a day, three times weekly. Combining some weight-bearing exercise with aerobic activity (like walking or biking) provides the most relief.
  • Get moderate sun or full-spectrum light exposure year-round. A real connection exists between vitamin D deficiency and depression. It’s commonly known that light exposure, especially sunlight (which stimulates vitamin D production), is a very effective treatment for SAD. Same with supplements of vitamin D. Future research will tell us more about this link (as well as low vitamin E levels). I am now testing my patients regularly for vitamin D deficiency. This is yet another good reason to take a medical-grade daily nutritional supplement every day: to prevent or compensate for vitamin D deficiencies.

If these steps don’t help, find a practitioner who’s experienced with neurotransmitter testing and have your serotonin levels checked. While this is controversial, we have found it helpful to gain a picture of your levels at a moment in time. At Women to Women I provide a customized combination of 5–HTP or St. John’s wort, tyrosine, other amino acids, vitamins, and minerals for such patients, based on their test results and response over time.

St. John’s wort works by inhibiting the reuptake of not only serotonin, but also dopamine and norepinephrine. Supplemental 5–HTP, which is more easily converted into serotonin than L–tryptophan, can be especially effective (but it should be used with caution as it can cause increased anxiety in patients with high cortisol levels).

These support measures are useful whether or not you are taking an antidepressant. Many of my patients use our protocol to help wean slowly off their meds. Remember, it’s wise to seek guidance from an experienced professional when it comes to weaning off antidepressant medications.

Last, but definitely not least…

The natural remedies outlined above are remarkably effective, but won’t work for long without dealing with the emotional experience that lies behind depression. That requires work on the emotional factors that affect you: childhood trauma, relationships, work, memories, fears.

Patterns of behavior and negative reactions that trigger bouts of depression are usually so deeply ingrained — and hidden — that it takes professional help to weaken them.

We always recommend that our patients talk about their emotional issues and combine any physical treatment with counseling. We’ve found Gestalt–type therapy to be especially effective in connecting your current emotional state to past experience and thereby getting at a fundamental cure. So much depends on the skill of the therapist, so we recommend you keep looking until you find a therapy and therapist that are effective for you.

If this sounds more complicated than popping a pill — it is! But taking a pill involves complications, too. It is my hope that you can use this knowledge and perspective to rediscover and sustain your capacity for joy safely, effectively, and without a lifetime of powerful drugs.