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The risks and rewards of alternative treatments for depression
By Caitlin Crawshaw

The camera pans across a dimly lit room to a middle-aged woman hunched over a kitchen chair, then a close-up of the golden retriever lying beside her, leash in mouth. It’s a portrait of a once-vibrant woman now melancholy, exhausted, and unmotivated―the hallmarks of depression.

The voiceover asks if you’re suffering from these symptoms and suggests you ask your doctor about brand X. Cut to a bustling street where the now-smiling woman strolls down the sidewalk, led by her bouncing dog.

Antidepressant ads are a common sight on television these days―no wonder, given how many of us are using them. A 2002 university study reported that Canadian spending on antidepressants jumped from $31.4 million to $543.4 million between 1981 and 2000. In 2007, that number had risen to $1.16 billion, reports the University of British Columbia’s Centre for Health Services and Policy Research. And in the United States, the numbers are even higher: In 2008, $9.6 billion was spent on antidepressants, and a recent study shows antidepressant use doubled between 1996 and 2005.

To medicate or not to medicate

Experts agree the trend is complex. It may be that more sufferers are seeking treatment nowadays, but Joe Wegmann, a New Orleans therapist and author of Psychopharmacology: Straight Talk on Mental Health Medications (PESI, 2008), figures the ads are a contributing factor.

“People are bringing the information from the ads in to their doctor’s office and saying, ‘Doctor, what do you think about this? I’ve been feeling sad, a lack of energy, and am not sleeping so well,’” he says. Time-strapped doctors often prescribe a drug without doing a thorough assessment.

Wegmann is both a licensed clinical social worker and a board-certified doctor of pharmacy specializing in psychopharmacology, which means he is able to counsel patients as well as prescribe drugs―though he’s reticent to do so.

For one thing, new patients who seem depressed could actually be in the depressive phase of bipolar disorder, and antidepressants can trigger manic episodes in these individuals. Medication is also unwise when depression stems from a medical condition, like an under-active thyroid gland, so he asks patients to get a health screening first.

But he’s also a conservative prescriber because, in his view, antidepressants are overrated.

Weighing the options

The efficacy of antidepressants is a controversial issue, as the literature is inconsistent. In Wegmann’s view, the most reliable data in the United States comes from the National Institute of Mental Health (NIMH), whose studies typically involve thousands of subjects. NIMH data suggests that the response rate to antidepressants is about 50 percent; sustained recovery is only attained by 43 percent.

Psychiatric pharmacist Wende Wood, of the Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario, is more optimistic. She says the literature shows 70 percent of patients have success on their first medication and, of the 30 percent who don’t find relief on the first try, 70 percent feel much better after a second drug. Yet she’s only a reluctant supporter of antidepressants. Drugs are tools that can help people do the things they need to heal, like go to therapy, but a single pill doesn’t solve the problem, she says.

Wood and Wegmann―and many other experts―recognize there are many different ways of treating the symptoms of depression, including so-called “alternative” treatments. Non-pharmaceutical treatments abound, but research on the benefits and risks is often inconsistent, incomplete, or confusing.

The common sense approach: Healthy living

While lifestyle changes don’t sound particularly “alternative,” for many North Americans, basic habits like sleeping and eating properly can be radical. As kids, we ate from the four food groups and went to bed at 8 p.m. As adults, we’ve somehow unlearned these habits, making us susceptible to physical illnesses like diabetes and cancer, and mental illnesses like depression.

In his book, The Depression Cure: The 6-Step Program to Beat Depression Without Drugs (Da Capo Press, 2009), University of Kansas psychology researcher Stephen Ilardi, PhD, advocates for six research-backed lifestyle changes to tackle depression, including: consuming more omega-3 fatty acids (two good sources are fish and flax), using engaging activity to resist ruminating, increasing sun exposure (in order to absorb more Vitamin D, as deficiency is linked to depression), connecting socially, and getting better sleep.

Ilardi says the root of our unhealthy lifestyles runs deeper than poor individual decisions. In his view, the modern world has evolved faster than we have. “We’re still very well adapted to the Pliocene―the stone age, the hunter-gatherer way of life. We’re also moderately adapted to an agrarian way of life. We’re poorly adapted to a 21st century post-industrial way of life.”

For most of human history, people were outdoors for hours a day and could absorb Vitamin D readily, Ilardi says. We lived in large communities, interacting with others constantly. We slept a lot, but were physically active. “We were never designed for the sedentary, indoor, sleep-deprived, socially isolated, fast-food laden, modern way of life. It’s just a bad fit for us.”

He says his book isn’t based on new ideas, but it does provide a novel framework for depressed people to make changes in their lives. After all, when you’re struggling to get out of bed, it’s not enough to be told, “Go for walks” or “Eat more fish” by your doctor. People often need every step laid out, along with specific directions. 

But, he adds, lifestyle changes aren’t necessarily better than drug therapy. “I’m not anti-medication, I’m anti-depression,” Ilardi says, but drugs alone “don’t represent a lasting cure for the majority of patients.”

The not-so-sweet sugar-mood connection

Twenty-nine-year-old James Hahn acutely understands the role that lifestyle plays in good mental health. For years, the Lansing, Michigan, salesman talked to therapists and priests to combat his depression and compulsive bingeing. Finally, on January 12, 2006, desperation sparked a decision to cut out sugary treats altogether. The weight melted off and, a few months later, Hahn was inspired to cut out starch, salt, and dairy for Lent. He chalked up a happy mood to the weight change, and 40 days later when Lent drew to a close, Hahn let loose at a family brunch, piling his plate high with waffles and syrup.

“When I got done with the meal, I sat there feeling so intensely satisfied … everything was going right until I started driving home and my blood sugar started to crash,” he recalls. Hahn descended into hostile despair, which didn’t lift after a long sleep. By midday, during an anxiety attack, “a light bulb went on.” After years of therapy, the problem was under his nose, literally, the entire time. It was sugar that was causing him to plummet.

Hahn swore off sugar and read all the books he could find on the sugar-mood connection. He’s come to believe that as a sugar-sensitive person, sugar wreaks havoc with his brain’s ability to regulate serotonin. He’s now a life coach, helping wean others off the sweet stuff.

There is research to support the relationship between sugar consumption and depression. British psychiatrist Professor Malcolm Peet recently conducted a cross-cultural study on diet and mental illness, finding a strong link between high sugar consumption and the risk of depression and schizophrenia. In his Psychology Today blog on the topic, Kansas researcher Ilardi writes that Peet’s study was so compelling that he now encourages depressed patients to try cutting sugar out of their diets, with good results.

The power of exercise

Like Hahn, bingeing was one of the first symptoms of Victoria Maxwell’s mood disorder, and it motivated her to seek counseling for the first time as a university drama student. However, it wasn’t until a psychotic break during a meditation class that she was diagnosed with rapid-cycling bipolar disorder. Now she takes her medications religiously and tries to keep her lifestyle in balance. Running is part of the equation for the Sechelt, British Columbia, resident, who laces up her running shoes three to five times a week. She says it helps her stay “more-or-less in remission” so that she can focus on her work as a performer and mental health advocate.

“It’s also just about self-confidence, self-esteem, and a sense of pride, too, that I’m doing this,” she says. “Exercise is not easy; if it was, we’d all be doing it all of the time.”

There’s a great deal of research backing exercise as a treatment for depression, says Ilardi. Countless studies show that exercise increases the brain’s transmission of both dopamine and serotonin, and that it “puts the brakes on the stress-response circuit in the brain.”

Though yoga has become a popular form of exercise in North America, there still isn’t much data on how yoga helps depression. That’s why David Shapiro, PhD, a UCLA researcher, opted to study the effects of Iyengar yoga on depressed patients in 2007. A long-time practitioner of Iyengar, Shapiro studied 27 women and 10 men with major depression in partial remission. Participants reported reductions in depression, anxiety, anger, and other related symptoms. Eleven of the 17 people who completed the 20 yoga classes achieved remission in their depression afterwards.
Shapiro says there are more yoga studies than ever before, but not enough. Medicine is conservative and slow to adopt new ideas, but there’s also a lack of financial support impeding work on complimentary therapies in general. 

Amy Weintraub started meditating when she was 19 to help deal with her depression, but it wasn’t until she began practicing yoga that the black clouds lifted. “I think for me, and for many people, we need an embodied practice,” says the Tucson, Arizona, yoga instructor.

Weintraub says practicing asanas (yoga postures), along with yogic breathing and meditation, can release emotions and memories contained within the body. That’s why depressed people especially should find a compassionate teacher who makes them feel safe.

“Your yoga mat can be your safe container, your sacred space, so you can feel your feelings,” she says.

But Weintraub isn’t selling yoga as one-stop shopping for depression. She also believes in psychotherapy and antidepressants. She’s also not selling her depression-oriented yoga method―Lifeforce Yoga―as the only solution. All traditions can help, she says. “No matter what you’re practicing, if you’re aware of breath and sensation in your body, that’s what creates presence, that’s what creates wholeness.”

Back to nature

Herbal treatments are generally divided into two categories: traditional Chinese medicine (TCM) and homeopathy, a European tradition. Both work very differently from Western medicine; Jennifer Yee, a naturopathic doctor in Edmonton, Alberta, explains that TCM doesn’t diagnose depression per se, but rather energy imbalances. As a result, treatments can be very different for different people.

Generally speaking, people with depression have “stagnant liver chi,” explains Steven Aung, MD, another Edmonton TCM doctor, who also practices Western medicine. He says that the energy that usually moves freely through your liver can get stuck, creating emotional disturbances.

Aung says the goal is open up the “gates” to release the energy. Usually, he uses a combination of acupuncture and TCM herbs, like Ginseng, Coshishandra, and Wuchaseng, but he isn’t opposed to Western pharmaceuticals if he believes they will help. Sometimes people need to be stabilized quickly, so drugs are crucial. But for long-term maintenance, herbs offer a gentler alternative to pharmaceuticals, which can have unpleasant side effects.

Despite TCM’s growing popularity, there are not many studies to support its efficacy. A 2007 literature review by Edzard Ernst, PhD, the world’s first professor of complementary medicine, examined many alternative treatments, including several TCM herbs. He found little evidence that Ginkgo biloba combats depression or that Valerian reduces anxiety. Kava, however, may be useful for anxiety.
Like TCM, homeopathy offers a personalized approach to care, targeting a patient’s symptoms―both physical and emotional―rather than a diagnosed condition. Whether a homeopath treats with an animal, plant, mineral, or synthetic substance, the active ingredients are diluted.

Created by an English physician and homeopath in the 1930s, Bach Flower Remedies is a somewhat modern incarnation of homeopathy, which uses dilutions of flower essences. Bach Flower Remedies education director Nancy Buono says treatments can be applied topically or ingested.

“The remedies are completely safe; they don’t interact with anything,” she says. “They’re also not a placebo. For this reason, people can treat themselves. Dr. Bach designed this as a self-help system.”

The fact that treatments are heavily diluted makes them quite safe, says Wood, but it also means it probably doesn’t work.

“To be honest, I believe homeopathy is 100 percent placebo effect,” she says. However, there has been extensive research on one specific herb used in the homeopathic tradition: St. John’s Wort. Generally, there are more European than North American studies confirming its efficacy as a treatment for depression, and those contacted for this article agree it does have a fairly good rate of success. Ilardi, however, cautions it isn’t any more effective than antidepressants.

Don't knock it if it works

The placebo effect is one of the reasons studies of depression treatments are so difficult to assess. Depressed subjects in a study can become cheerier just from interacting with researchers, even if formal therapy isn’t offered. It becomes difficult to tell whether it’s the treatment itself  or the increased socialization and care from others that is responsible for an improved mood.

But if you’re depressed, it might not matter what it is that’s giving you relief. If you think you’re feeling better as a result of omega-3 fatty acids, yoga, a new antidepressant, or cognitive behavioral therapy, that’s what counts. And for this reason, some experts think the placebo effect is underrated.

Ilardi, for instance, has conducted studies on his six-step protocol and finds that between the first evaluation and the start of the study, patients become a little sunnier. Study participation can inject optimism into a person’s life. It’s definitely a placebo effect, but patients and caregivers should capitalize on it.

Wegmann, too, thinks that the placebo effect can be a marvelous thing for patients suffering from depression. “If the patient is getting better, that’s all I need to know,” he says. “The intense power of the placebo effect should never be underestimated.”

So if patients want to try alternative therapies, even if they haven’t been shown to be effective, he’s not opposed to it. After all, if a person thinks it’s elevating his or her mood, then it is―for all intents and purposes―working. Wegmann, however, advises his clients start with lifestyle interventions like nutrition and exercise before trying things like herbals, and he tells his patients that it is imperative they tell him everything they’re taking, whether it’s prescribed medication or otherwise. In fact, he asks his patients to empty their medicine cabinet into a bag and haul it to a therapy session for him to evaluate.

Wood agrees that as long as the risks are minimized with good communication between a patient and his or her health care provider, it could be worth it to try new approaches.

“They used to have an old saying at a hospital I once worked at: ‘Whatever it takes.’ If it makes you feel better, good.” h

Caitlin Crawshaw is an Edmonton, Alberta-based freelance writer and editor. Visit her website at www.inkslingermedia.com.