Depression: Alternative Treatments

By: Garry Cooper, LCSW

Reprinted with permission from Psychotherapy Networker magazine. Copyright, Psychotherapy Networker, Inc.

 

Last November, Prozac made Fortune magazine’s list of the century’s top products. But despite the millions spent promoting it and other selective serotonin reuptake inhibitors (SSRIs), many therapists and members of the general public continue to turn to alternative physical and social approaches for mild to moderate depression. Hardly a month goes by without the appearance of an article in Newsweek, Health or another popular magazine touting the antidepressant benefits of eating fish, going to church, bathing in full-spectrum light, belonging, volunteering, taking St. John’s wort or SAM-e, getting acupuncture or starting an exercise program. And some of these alternatives have proven to be as effective in clinical trials as other current treatment strategies, especially in cases of mild depression and “the blues.”

In the June, 1999 Professional Psychology: Research and Practice, a metareview of 14 controlled studies concluded that regular exercise works as well as cognitive therapy in significantly alleviating symptoms of clinically diagnosed mild to moderate depression. Researchers Garry Martin and Gregg Tkachuk, both from the University of Manitoba, found that aerobic exercise, like running or swimming, and non-aerobic exercise, like weight lifting, worked equally well. And one-year follow-up studies showed that after even just a few sessions with a trainer or exercise physiologist, people who continued to exercise on their own maintained their improvements on depression scales.

If something as simple as exercise works so well, why don’t more therapists suggest it? “Therapists often think too narrowly within whichever model they practice, whether it’s cognitive, systemic or medical,” suggests Weston, Massachusetts, therapist David Treadway. Jacqueline Sparks, currently a researcher and Ph.D. candidate at Nova Southeastern University in Fort Lauderdale, suggests another explanation: only pharmaceutical companies widely publicize depression treatments, and they fund much of the current research. “The pharmaceutical companies can’t patent things like exercise,” she says, “and they can’t make money off them.”

And there are other approaches for counteracting depression that the pharmaceutical companies can’t patent. Sparks says she uses depression-fighting ideas that come from her clients themselves. Almost every depressed person, she says, has had some success in escaping depression, so she gets them to think about what worked before. Their solutions have included taking a yoga class, scheduling neighbors to stop by for coffee or simply reminding themselves, during immobilizing moments, to put one foot in front of the other. One therapist reports that a woman client bought a three-month supply of vitamins and told herself that when the bottle was gone, she’d be ready to resume a social life. “Each day I took a pill, I told myself I was feeling a little better,” she said. “On the 90th day, I was cured.”

The range of theories purporting to explain why alternative approaches work illustrates the relationship and continuing tension between biochemical and psychosocial views of depression. Some therapists theorize that just by making the decision to do something about depression, people feel more empowered, which alleviates the characteristic helplessness they feel. “Depression stalks our brain’s motivation center,” says Treadway, “and the trick is to find something, anything, that gets people feeling motivated.” Boston therapist Michael Elkin often encourages depressed clients to volunteer at teenage drop-in centers, nursing homes and homeless shelters. He believes that this can give clients the opportunity to matter and to make an impact. Taking care of others, he says, seems to activate a self-nurturing part of the self that can be deadened by depression. “People often find that by taking care of others, they’re also taking care of themselves,” he says.

Others theorize that all effective physical approaches to depression–be they light boxes, Prozac, acupuncture, ion generators or St. John’s wort–work by directly or indirectly affecting the brain’s biochemistry. One novel theory, by University of Washington psychiatrist Michael Norden, the author of Beyond Prozac, suggests that chronic stress (which, more than Prozac, may deserve the title of this century’s most important product) causes depression by repeatedly triggering short-term spikes in serotonin production. Norden thinks that, over time, the body’s ability to produce enough of the neurotransmitter becomes exhausted. But when stress is lowered through dance, exercise or meditation, serotonin can be replenished. Herbs and other physical alternatives, he suggests, also facilitate the biochemical reactions that help the body produce more serotonin.

One of the best researched of the biological alternatives is St. John’s wort, a low, shrubby plant with yellow flowers used by Europeans to chase away melancholy since the Middle Ages. Two recent metareviews of controlled studies of St. John’s wort (mostly conducted in Germany) have found it to be as effective as tricyclic antidepressants (one review of 23 studies involving 1,757 subjects was published in the August 1996 British Medical Journal; another review, examining 6 randomized, double-blind studies of 651 subjects, appeared in the September 1999 Journal of Nervous and Mental Disease). The evidence is so compelling that the National Institutes of Health has a study under way with 336 subjects at 12 sites around the United States. The NIH study is comparing St. John’s wort to placebos, psychotherapy and SSRIs.

The same purported benefits apply to the expensive supplement SAM-e (S-adenosyl-methionine), a naturally occurring biological compound now available over the counter in the United States. At $45 to $75 for a month’s supply, it’s as expensive as Prozac, and not covered by health insurance. Used as a prescription drug in Europe since the 1970s to treat depression and osteoarthritis, SAM-e is one of the biochemical building blocks for the neurotransmitters serotonin and dopamine. Although not yet studied as widely as St. John’s Wort, a handful of small trials suggests it may be as effective as the herb, with fewer side effects. “It’s not a quack prescription,” says psychiatrist John Markowitz of Cornell University, “but it may not be a wonder drug either.”

Because St. John’s wort and SAM-e aren’t regulated by the Food and Drug Administration, the amounts of active ingredients in doses may vary widely from pill to pill as well as from brand to brand. Another concern is that the compounds can interact with other medications, including antidepressants. And even “natural” alternatives” can have significant side effects: St. John’s wort users can become hypersensitive to sunlight and there are anecdotal reports that SAM-e can cause insomnia and send depressed bipolar people into mania.

Many therapists are handling the widespread promotion of St. John’s wort and SAM-e much as they have handled the marketing blitz for SSRIs–regarding them as additional possibilities in a wide array of choices. Because depression is an intricate weave of biochemical and psychosocial factors, almost everyone agrees there’s no magic bullet for it. Placebos, SSRIs, herbs, exercise, acupuncture, light boxes and cognitive, family and narrative therapy all seem to work for some clients and not for others. “The secret to treating depression,” says Treadway, “is to find each person’s idiosyncratic, individual road map.”