Depression is still a mystery in medicine. It is considered a diagnosis, but it is actually just a symptom ... with many potential causes. Antidepressants are controversial, leading many people to wonder if there are other options for treating depression. There are.
Being diagnosed with depression requires more than just feeling blue. The official diagnostic criteria come from the DSM-IV - the Bible of Psychiatry - and are fairly specific. They require that for at least two weeks, you suffer from at least five of the following: loss of interest in pleasure, depressed mood, weight or appetite change, sleep change, lack of energy, physical slowing, feelings of worthlessness or guilt, inability to concentrate, and thoughts of death or suicide.
Many kinds of Depression
Depression is not a diagnosis. It is a symptom. This is the most obvious evidence of a simple truth that does not seem to be given enough attention in the medical literature or the popular press: that the profession of psychiatry is still in its infancy and we know almost nothing about the brain.
These are not physiologic measurements. They are feelings. They do not suggest a specific chemical or body part - or even remotely point to the cause of your problem. They simply describe what you feel. The equivalent in another branch of medicine would be something like 'stomach pain'.
We already know that depression can be caused by hypothyroidism, folic acid or vitamin B12 deficiency, seizure disorders, brain tumors, head injury and other rare biochemical disorders. It is very likely that as our understanding of the brain continues to advance, we will realize that there are many other reasons for this symptom to occur.
One promising frontier is the field of neurofeedback and quantitative EEG. This aims to diagnose your problem not based on what you are feeling, but rather on what the pattern of electrical activity in your brain looks like. Another interesting approach is taken by Julia Ross MD whose book The Mood Cure describes several types of depression - all based on a different chemical that is missing from the brain. We consider these approaches on a case-by-case basis.
Antidepressant drugs - the truth
This completely subjective diagnosis makes it no surprise that people respond very differently to antidepressant drugs. At best, a gifted psychiatrist can choose one that suits your symptoms the best to maximize your chances of success. At worst, it can be considered complete guesswork. What is worse, antidepressants made headlines when it was suggested that many of them don't work as well as we once thought.
When the FDA reviewed all the clinical trials that were registered with them, they found that 31% of them were never published - and almost all found that the drugs in question did not work. This is called publication bias, and it happens because drugmakers are not keen to publish studies suggesting that their products are useless. Incredibly, they are under no obligation to publish this negative data.
The whole sordid affair was published in the Jan 18 2008 issue of the New England Journal of Medicine. It is very helpful to review the evidence - drug by drug:
Celexa - two studies say it works - three say it doesn't
Cymbalta - 4 studies say yes - 4 studies say no
Effexor - 6 studies say yes - 3 studies say no
Paxil - 9 studies say it works - 10 studies say it doesn't
Prozac - 4 studies say yes - 1 study says no
Remeron - 5 studies say yes - 5 studies say no
Serzone - 3 studies say yes - 3 studies say no
Wellbutrin - one study says it works - two say it doesn't
Zoloft - one study says it works - 4 studies say it doesn't
This is an embarrassment to science. These medications are being used by millions of people around the world, based on scientific evidence that is only half the truth. The scientific truth was hidden by drugmakers so they could convince doctors to prescribe their drugs. To be fair, this kind of publication bias exists for any treatment - including some CAM therapies - but rarely to such an extent as this. If you take antidepressants and are not sure if they are making any difference, ask your doctor if you really need them.
Omega-3 fats
This is the first treatment that should be considered for anyone suffering from depression, anxiety or any other psychiatric symptom. The human brain is believed to have evolved a great deal when our ancestors moved from the plains of Africa to the East African coast - and started fishing. These fats are believed to alter the fluidity of the membranes of nerve cells, improving their function. In a meta-analysis of all the clinical trials studying omega-3 fats in depression, the overall conclusion was that they work. We have seen this time and time again in our patients, but what is needed now is a large, multicentred trial to convincingly prove this once and for all.
St John's Wort
This plant has been used as a brain tonic for centuries. It is mentioned in some of the oldest of the world's herbals and is still one of the world's biggest selling medicinal plants. I am not so sure that it is all it is cracked up to be. A recent review found 37 clinical trials of this plant, but results were confusing. In most cases, it was found as effective or more effective than antidepressant drugs. We know now that this is not saying much. An additional problem is that studies have shown that the amount of active ingredient in commonly sold bottles can vary by up to 200 times. So make sure you buy St John's Wort that you can trust. When we realize that depression is still a mystery and we don't know much about the brain, it is not very appealing to me to use St John's Wort as a natural band-aid - this is not much better than using pharmaceutical band-aids.
5-HTP
We have had good results with 5-HTP. One of the chemicals that is often missing in patients with depression is serotonin. Serotonin is made from 5-HTP. Enough said. Without understanding why serotonin is missing, we cannot fully address the problem - so it is always important to ensure that gut function is healthy and that nutrition is adequate. But if your symptoms are consistent with a serotonin deficiency, then 5-HTP is a good bet. There have only been a few small studies done on this treatment, but they have shown promising results.
SAM-e
S-adenosylmethionine is involved in many chemical reactions. Without adequate SAM-e, your body cannot make enough dopamine, norepinephrine or serotonin - all very important neurotransmitters in the brain. It has been studied in 7 trials - two of which were randomized, controlled trials - involving a total of 186 patients. In all seven studies, patients reported improved scores on the standard measure used in research - the Hamilton Depression Scale. Larger studies are needed to support these promising early results, but we have had good success with some patients using SAM-e.
Other approaches
Get away from your computer. Call a friend. Go for a walk in the woods. Join a yoga class. Watch funny movies. Lift weights. Meditate. Get a pet. Buy some plants and water them and talk to them while you listen to Mozart. All of these might offer as much benefit as the drugs marketed for the treatment of depression. The conventional medical approach to the treatment of mental disorders is the best evidence that medicine itself needs to be healed.
We also look behind the veil with our patients. We investigate for imbalances in intestinal bacteria, toxic metals, food allergies and mineral deficiencies. We treat with B vitamins, intravenous amino acid infusions and other leading-edge approaches that are shared at conferences and symposia with like-minded physicians around the world.
If you are depressed, consider your options.
