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The Natural Medicine Guide to Depression 1 What Is Depression and Who Suffers from It? Depression falls into the category of mood disorders, also known as affective disorders. It encompasses a continuum of disturbance in thoughts, feelings, behaviors, and physical health, with the prevailing characteristic of persistent sadness and despair. While some people experience depression to the point that they can no longer function in their lives, others may not even realize that they are depressed. An estimated twelve million people in the United States are not aware that they are suffering from depression,7 and 80 percent of primary care patients actually fit the criteria for a diagnosis of major depression.8 Melancholia, a former term for depression, has plagued humankind for at least as long as recorded history, and likely from the beginning of human existence. Written accounts of depression date back to 2500 B.C., with an ancient Egyptian papyrus relating a man’s despair and sense of emptiness as he contemplates suicide.9 One way of explaining the presence of mood in the human spirit is to regard it as an evolutionary adaptation.10 A depression in mood, for example, pulls us back from engagement with life, which we may need at that moment to keep us safe or to give us time to gain a perspective. Viewed in this light, one might say that there is a tremendous need today for safety and perspective, given that depression is a worldwide epidemic. This point gains validity when one considers the complexity, toxicity, and stress of modern life and the physical, psychological/emotional, and spiritual causes of depression, as discussed in chapter 2 and throughout the book. In the United States alone, thirty million people are taking Prozac, which is now in the top That translates to nearly one in ten people. One in eight adolescents and one in thirty-three children overall suffer from depression. One in four women will have clinical depression in their lifetime—twice the rate for men. (These rates reflect reported cases. The rate for men may actually be equal to that of women as societal factors contribute to men not seeking help.) Depression cuts across all ages, with more than one in six people over the age of 65 afflicted.12 While the devastation of depression cannot be measured solely in dollar amounts, its economic cost illuminates its far-reaching reverberations. The annual cost of depressive disorders in the United States is $43 billion, a total of the costs of direct treatment, absenteeism, lost productivity, and mortality.13 In Their Own Words “ What’s really diabolical about it is that if there were a pill over there, ten feet from me, that you could guarantee would lift me out of it, it would be too much trouble to go get it.”14 —Dick Cavett, on his severe depression Another tragic set of statistics reflects the profound human loss resulting from depression. A study by the World Health Organization (WHO) and the Harvard School of Public Health reveals that by the year 2020 depression will be the single leading cause of death around the globe.15 The risk of suicide is 30 times greater among people with depression than in the general population.16 In the United States alone, there are 30,000 suicides every year.17 Suicide among the teen population has increased 300 percent in the past 30 years.18 Among children between the ages of 10 and 14, the rate of suicide has more than doubled in the last 10 years. For youth between the ages of 15 and 24, suicide is now the third leading cause of death. For college students, it is the second leading cause.19 While the statistics on depression and its effects are grim, they reflect the fact that only one in three people with a major mood disorder seek help,20 and 50 percent of people with clinical depression turn to their primary care physician, who may or may not have the training needed to provide true assistance.21 The dismal nature of the statistics also reflects the fact that the vast majority of those who seek help for their depression are receiving conventional treatment, which does not have a good success rate (as the epidemic proportions of depression verify). The overwhelming emphasis in the conventional approach to depression is on antidepressant drugs. Despite the fact that psychotherapy is cited as a primary component in WHO and APA (American Psychiatric Association) standards for depression treatment, its use accounts for just eight percent of the money expended in treating depression.22 Unfortunately, the effectiveness of antidepressants is greatly overrated. In disregard of disturbing side effects and of research showing that they do not work for a third of the people who take them, and do no better than placebos for another third,23 these drugs continue to be dispensed widely and to be regarded as the panacea for depression. While in some cases of chronic severe depression, they may provide an important intervention to save a life, antidepressants are handed out far too freely. The prescription flurry is now extending to increasing numbers of children, despite the fact that Prozac and similar antidepressants are approved by the Food and Drug Administration (FDA) only for use in patients over the age of 18.24 Even for those people who get welcome relief from antidepressants, it is important to keep in mind that they are not getting a cure for their depression, in that the drugs do not address the underlying factors that caused the depression in the first place. Fortunately, there is a way out of this current state of affairs. The statistics of depression will change to a far more positive picture as more people learn about and gain access to natural medicine approaches to the disorder, which make profound and lasting recovery from depression a strong possibility. Meanwhile, the present statistics should put the medical profession on alert that changes need to happen in regard to the treatment of depression. The statistics also serve another important function: to highlight how important it is to determine if you are suffering from depression and to get help. The common subcategories of depression are major depressive disorder, dysthymia, and seasonal affective disorder. Major depressive disorder is also known as clinical depression, major depression, major affective disorder, and unipolar disorder. Dysthymia, being chronic moderate depression, is the type that many people fail to recognize as a mood disorder. Seasonal affective disorder, or SAD, results from the reduced light of the winter season, which explains why it is known colloquially as “the winter blues.” Bipolar disorder (formerly known as manic-depression) is another mood disorder involving depression. It is not covered in this book because another book in The Healthy Mind Guide series is devoted to that subject. See the -author’s The Natural Medicine Guide to Bipolar Disorder (Hampton Roads, 2003). A holistic approach does not use such diagnoses to determine the appropriate treatment course, focusing instead on the particular manifestations and underlying imbalances in the individual patient. Many people receive these labels, however, so it’s helpful to know to what they refer. For a diagnosis of major depressive disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the APA’s diagnostic bible for psychiatric disorders, a person must have one or more major depressive episodes, which are defined as depressed mood or loss of interest lasting at least two weeks and accompanied by at least four other symptoms of depression (see lists that follow). For dysthymia, the person must have experienced a depressed mood for more days than not over at least a two-year period, accompanied by other symptoms of depression, but the whole does not fit the diagnostic picture of major depressive disorder. SAD is depression that occurs on a seasonal basis and does not fit the criteria for any of the other depressive disorders that involve a seasonal pattern.25 The following are symptoms of depression:26 • significantly reduced interest or pleasure significant change in weight or appetite feelings of worthlessness or excessive or inappropriate guilt problems thinking, concentrating, or making decisions While these are the symptoms for diagnosis according to DSM-IV criteria, anxiety, even extreme anxiety, is another common symptom of depression.27 Since this fact is not well known, the anxiety can serve to mask the depressive disorder. irritability or anger without apparent cause loss of interest in formerly pleasurable activities, including sex In Their Own Words “ U ntil one has experienced a debilitating severe depression it is hard to understand the feelings of those who have it….It was the worse experience of my life. More terrible even than watching my wife die of cancer. I am ashamed to admit that my depression felt worse than her death but it is true.”28 —Lewis Wolpert, author of Malignant Sadness Depression can be a corollary of other medical conditions (see chapter 2) and there is a comorbidity factor with substance abuse, eating disorders, and obsessive-compulsive disorder (OCD). Comorbidity means that two disorders exist together. In the case of substance abuse in relation to depression, for example, alcoholism is a factor in 30 percent of all suicides.29 In addition to identifying whether or not you or a loved one is suffering from depression, it is also important to be aware of the warning signs of suicide, so you are forewarned and can act to prevent this tragedy from happening if the signs begin to manifest. A family history of suicide or a previous suicide attempt places one at increased risk of suicide. In addition, the warning signs of suicide are:30 feelings of hopelessness, worthlessness, anguish, or desperation preoccupation with death or morbid subjects sudden mood improvement or increased activity after a period of depression thinking, talking, or writing about a plan for committing suicide If you think that you or someone you know is in danger of attempting suicide, call your doctor or a suicide hotline or get help from another qualified source. Know that there is help and, though it may be difficult to ask for it, a life may depend upon it. In Their Own Words “Most days, when I was depressed, I just felt a serious lack of energy and connectedness. On medium-bad days I walked around in a quiet state of desperation. When the depression was really bad, well, it was really bad.”31 — Catherine Carrigan, author of Healing Depression References to depression (melancholia) as a medical condition date back to Greece in the fourth century B.C., with the writings of Hippocrates, the “father of medicine.” In ancient Greece, melancholy came to be considered an excess of black bile, one of the four humors of the body (blood, black bile, yellow bile, and phlegm) believed to regulate health. As black bile was also considered the driving force in creativity, melancholy had a positive association with the creative temperament. By pointing out the many poets, artists, politicians, Greek heroes, and philosophers, including Plato and Socrates, who were of a melancholic nature, Aristotle perpetuated a positive view of the condition that continued for centuries.32 As melancholy began to be viewed as a condition to cure, in the late fourth century, various methods, including bloodletting, were used to eliminate the excess black bile from the body. This approach lasted into the 1800s, when the humoral theory fell out of favor.33 In the late 1800s and early 1900s, the German physician Emil Kraepelin studied and documented mental illnesses, providing the foundation for modern psychiatry. Its focus on diagnosis and classification comes from Dr. Kraepelin.34 The belief that psychological factors were the cause of depression arose from the work of Sigmund Freud and began to gain cachet in the American medical establishment in the 1920s.35 The advent of antidepressant medications in the 1950s transformed the psychiatric field, shifting the focus of the causality of mental illness from psychological to biochemical, and turning the profession into a pharmaceutical industry. The idea that psychological factors may contribute to depression has not been completely dismissed, but the small percentage of money devoted to psychotherapeutic treatment in the total amount expended in the treatment of depression shows where the overwhelming emphasis lies. The current conventional medical view is that depression is a brain disorder caused by a deficiency in neurotransmitters, the brain’s chemical messengers that enable communication between cells. While there are many different kinds of neurotransmitters, the primary ones involved in the regulation of mood are serotonin, dopamine, epinephrine/norepinephrine, GABA (gamma-aminobutyric acid), and L-glutamate. Contrary to popular belief, serotonin is not found only in the brain. In fact, only 5 percent of the body’s supply is in the brain, with 95 percent distributed throughout the body and involved in many functions.36 Serotonin is similarly distributed throughout the brain, where it is “the single largest brain system known.”37 In addition to influencing mood, serotonin is involved in the regulation of sleep and pain, to name but a few of its numerous activities. Dopamine has a role in controlling sex drive, memory retrieval, and muscles, in addition to mood. GABA operates to stop excess nerve stimulation, thereby exerting a calming effect on the brain. Two important functions of L-glutamate involve memory and the curbing of chronic stress response and excess secretion of the adrenal “stress” hormone cortisol. Epinephrine (also known as adrenaline) and norepinephrine are hormones produced by the adrenal gland. Epinephrine is involved in the stress response and the physiology of fear and anxiety; an excess has been implicated in some anxiety disorders. Norepinephrine is similar to epinephrine and is the form of adrenaline found in the brain;38 interference with norepinephrine metabolism at certain brain sites has been linked to affective disorders.39 Serotonin, dopamine, and norepinephrine are monoamines (they are derived from amino acids) colloquially known as the “feel good” neurotransmitters.40 As such, they are the target of antidepressant drug action. Prozac, Paxil, Zoloft, Luvox, and Effexor are what is known as SSRIs, selective serotonin re-uptake inhibitors. They block the natural reabsorption of serotonin by brain cells, which boosts the level of available serotonin. SSRIs are relatively new arrivals on the antidepressant scene; Prozac was introduced on the market in 1987. Earlier categories of antidepressant drugs are tricyclics and monoamine oxidase inhibitors (MAOIs). Tricyclics such as Elavil, Adapin, and Endep inhibit serotonin re-uptake, but block norepinephrine re-uptake as well; thus, they are less selective than SSRIs. MAOIs such as Nardil and Parnate act by inhibiting a certain MAO enzyme that breaks down monoamines; the outcome is more available neurotransmitters.41 The theory that neurotransmitter deficiency causes depression is known as the “biogenic amine” hypothesis. While the model recognizes that imbalances in amino acids (neurotransmitter precursors) produce the deficiency, amino acid supplementation is not the conventional medical solution. “These amino acids have proven to be effective natural antidepressants,” states Michael T. Murray, N.D., author of Natural Alternatives to Prozac.42 Despite this, the focus of conventional treatment is expensive pharmaceuticals. “Perhaps the main reason [the biogenic amine] model is so popular is that it is a better fit for drug therapy,” notes Dr. Murray.43 Contrary to popular belief, the newer, more expensive antidepressants—Prozac, Zoloft, and Paxil—are no more effective than the older antidepressant drugs, according to a report issued by researchers for the U.S. Agency for Health Care Policy and Research and the U.S. Department of Health and Human Services. Not only that, but research has not established that any drug produces better results than psychotherapy as a treatment for depression, the report reveals.44 Antidepressant drugs are problematic for a number of other reasons as well. It is sufficient for the purposes of this book to cite only two. First, the adverse effects (euphemistically known as side effects) of antidepressants can range from uncomfortable to untenable, although some people who take the drugs experience no side effects. With Prozac, for example, adverse effects include nausea, headache, anxiety and nervousness, insomnia, drowsiness, diarrhea, dry mouth, loss of appetite, sweating and tremor, and rash.45 Flattened or dulled feelings and sexual dysfunction are common effects of taking SSRIs. In addition, the anxiety and agitation induced by SSRIs can result in patients increasing their use of alcohol and other substances for calming purposes.46 More serious, there has been very little research on the long-term effects of taking SSRIs. It is known, however, that they can produce neurological disorders, and permanent brain damage is a danger.47 Second, and perhaps most important, antidepressants do nothing to address the deeper causes of depression. Why are the amino acids and neurotransmitters out of balance? What caused that to happen? What are the other factors involved in the depression of this particular individual? Chapter 2 looks at the many causes of depression, which can serve as a starting point for answering these questions. 7. Ronald Hoffman, “Beyond Prozac: Natural Therapies for Anxiety and Depression,” Innovation: The Health Letter of FAIM (January 31, 1999), 10–11, 13, 15, 17, 19. 8. Bradford Weeks, M.D., “Mental Health,” available on the Internet at: 9. Bika Reed, Rebel in the Soul: A Dialogue Between Doubt and Mystical Knowledge (Rochester, Vt.: 10. Thanks for this idea goes to: Demitri Papolos, M.D., and Janice Papolos, Overcoming Depression: The Definitive Resource for Patients and Families Who Live with Depression and Manic-Depression (New York: HarperPerennial, 1997), 10. 11. P. Stokes and A. Holtz, “Fluoxetine Tenth Anniversary Update: The Progress Continues,” Clinical 12. National DMDA, “Consumer’s Guide to Depression and Manic Depression,” National DMDA (Depressive and Manic-Depressive Association), 730 North Franklin Street, Suite 501, Chicago, IL 60610-3526; tel: (800) 826-3632 or (312) 642-0049; website: http://www.ndmda.org. 13. Ibid. 14. Quoted in: Demitri Papolos, M.D., and Janice Papolos, Overcoming Depression: The Definitive Resource for Patients and Families Who Live with Depression and Manic-Depression (New York: HarperPerennial, 1997), 10. 15. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020 ed. C. Murray and A. Lopez (Cambridge: Harvard University Press, 1996). 16. NARSAD (National Alliance for Research on Schizophrenia and Depression), Research, “Conquering Depression,” NARSAD Research, 60 Cutter Mill Road, Suite 404, Great Neck, NY 11021; tel: (516) 829-0091; fax: (516) 487-6930; website: www.narsad.org. 17. Ibid., “Fact Sheet: The Warning Signs of Suicide.” 18. NAMI, “Understanding Major Depression,” NAMI (National Alliance for the Mentally Ill), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Alexandria, Va. 22201-3042; tel: (888) 999-NAMI (6264) or (703) 524-7600; website: www.nami.org. 19. NARSAD, “Fact Sheet: The Warning Signs of Suicide,” NARSAD (National Alliance for Research on Schizophrenia and Depression), 60 Cutter Mill Road, Suite 404, Great Neck, NY 11021; tel: (516) 829-0091; fax: (516) 487-6930; website: www.narsad.org. 20. Demitri Papolos, Md., and Janice Papolos, Overcoming Depression: The Definitive Resource for Patients and Families Who Live with Depression and Manic-Depression (New York: HarperPerennial, 1997), 10. 21. C. Brown and H.C. Schulberg, “Diagnosis and Treatment of Depression in Primary Medical Care Practice: The Application of Research Findings to Clinical Practice,” JMPT (Journal of Manipulative & Physiological Therapeutics) 21:7 (September 30, 1998), 504. 22. American Psychiatric Association, “Practice Guideline for Major Depressive Disorder in Adults,” American Journal of Psychiatry 150:4 supplement (1993). M. Olson and H. Pincus, “Outpatient Psychotherapy in the U.S.: Volume, Costs, and User Characteristics,” American Journal of Psychiatry 151 (1994), 1281–8. 23. Harvard Medical School, “Update on Mood Disorders: Part II,” Harvard Mental Health Letter 11:7 24. “Depression Drugs Widely Prescribed to Children,” Health Watch 4:2 (June 30, 1999), 2. 25. American Psychiatric Association, DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision), Washington, DC: American Psychiatric Association, 2000: 345. 26. Ibid., p. 356. 27. Ronald Hoffman, “Beyond Prozac: Natural Therapies for Anxiety and Depression,” Innovation: The Health Letter of FAIM (January 31, 1999), 10–11, 13, 15, 17, 19. 28. Lewis Wolpert, Malignant Sadness: The Anatomy of Depression (New York: The Free Press, 1999), vii, 29. NARSAD, “Fact Sheet: The Warning Signs of Suicide,” NARSAD (National Alliance for Research on Schizophrenia and Depression), 60 Cutter Mill Road, Suite 404, Great Neck, NY 11021; tel: (516) 829-0091; fax: (516) 487-6930; website: www.narsad.org. 30. Rita Elkins, Depression and Natural Medicine: A Nutritional Approach to Depression and Mood Swings (Pleasant Grove, Utah: Woodland Publishing, 1995), 16. Demitri Papolos, M.D., and Janice Papolos, Overcoming Depression: The Definitive Resource for Patients and Families Who Live with Depression and Manic-Depression (New York: HarperPerennial, 1997), 270. 31. Catherine Carrigan, Healing Depression: A Holistic Guide (New York: Marlowe and Company, 2000), 32. Lewis Wolpert, Malignant Sadness: The Anatomy of Depression (New York: The Free Press, 1999), 3– 33. Ibid, 5–6. 34. Demitri Papolos, M.D., and Janice Papolos, Overcoming Depression: The Definitive Resource for Patients and Families Who Live with Depression and Manic-Depression (New York: HarperPerennial, 1997), 32–3. 35. Catherine Carrigan, Healing Depression: A Holistic Guide (New York: Marlowe and Company, 2000), 36. Joseph Glenmullen, M.D., Prozac Backlash (New York: Touchstone/Simon & Schuster, 2000), 16. 37. E. C. Azmitia and P. M. Whitaker-Azmitia, “Awakening the Sleeping Giant: Anatomy and Plasticity of the Brain Serotonergic System,” Journal of Clinical Psychiatry 52:12 suppl. (1991), 4–16. Cited in Joseph Glenmullen, M.D., Prozac Backlash (New York: Touchstone/Simon & Schuster, 2000), 16. 38. Joseph Glenmullen, M.D., Prozac Backlash (New York: Touchstone/Simon & Schuster, 2000), 340. 39. Taber’s Cyclopedic Medical Dictionary, 17th ed. (Philadelphia: F. A. Davis Company, 1993), 662, 40. Joseph Glenmullen, M.D., Prozac Backlash (New York: Touchstone/Simon & Schuster, 2000), 16. 41. Michael T. Murray, N.D., Natural Alternatives to Prozac (New York: Quill/William Morrow, 1996), 4. 42. Ibid., 2. 43. Ibid., 2. 44. Maryann Napoli, “A New Assessment of Depression Drugs,” HealthFacts 24:7 (July 31, 1999), 4. 45. C. Pande and M. E. Sayler, “Adverse Events and Treatment Discontinuations in Fluoxetine Clinical Trials,” International Journal of Psychopharmacology 8 (1993), 267–9. 46. Peter R. Breggin, M.D., and David Cohen, Ph.D., Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications (Reading, Mass.: Perseus Books, 1999), 68. 47. Joseph Glenmullen, M.D., Prozac Backlash (New York: Touchstone/Simon & Schuster, 2000). Peter R. Breggin, M.D., and David Cohen, Ph.D., Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications (Reading, Mass.: Perseus Books, 1999), 46–7. 2003, Stephanie Marohn, all rights reserved. Excerpt from The Natural Medicine Guide to Depression published by Hampton Roads Publishing Company, Inc.

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