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ConditionsDepression: cutting through the darkness

Depression: cutting through the darkness

Depression is one of the least well understood and least welltolerated (by others) emotional states in our culture

Depression is one of the least well understood and least well tolerated (by others) emotional states in our culture. Broadly speaking, there are two types: unipolar, characterised by low moods only; and bipolar, characterised by extreme highs and lows, sometimes called manic-depression. Within these two broad categories are varying levels of severity and regularity. For instance, some may experience depression only in the winter months, as in the case of seasonal affective disorder (SAD); others may experience moderate depression which doesn't appear to be linked to any external occurrence. Mild depression is sometimes called dysthymia. It is chronic, but so mild that it is often difficult to distinguish from a personality trait. Yet, up to 25 per cent of those who go on to develop major depression are already suffering from mild depression.

What are usually presented as the more scientific, more sophisticated cures - drugs or ECT - aren't scientific at all. We don't understand enough about how the brain works to label drug treatment as either scientific or proven, especially for the majority of depressed individuals who suffer mild-to-moderate symptoms. The same, of course, can be said for many alternative treatments. Depression is an emotional state which practitioners and patients sometimes have to feel their way through.

The good news is that depression does not have to be a lifelong problem. There are effective alternative means of dealing with it and relapse is not always inevitable (Behav Res Ther, 1993; 31: 325-30). What's more, far from being a sign of failure or hypochondria, the high placebo response in depressed individuals (as much as 50 per cent) indicates that taking action is better than not taking action. If that action can be in the form of self-help, so much the better, since depressed individuals often feel there is nothing effective which they can do for themselves.

Among herbal preparations, St John's wort (Hypericum perforatum) has received a great deal of publicity, following an analysis of 23 studies published in the British Medical Journal demonstrating that it is as effective as most antidepressants, but with far fewer side-effects (BMJ, 1996; 313: 253-8). Many studies demonstrate its efficacy (Forstch Med, 1995; 113: 404-8; Therapiewoche, 1995; 45: 106, 108, 110, 112; J Geriatr Psychol Neurol, 1994; 71: 6-8, 9-11, 15-8; Lakartidningen, 1997; 94: 2365-7). One, for example, showed that 66.6 per cent of depressed patients experienced positive effects from taking Hypericum compared with 26.7 per cent of those who took a placebo (Fortsch Med, 1993; 111: 339-42).

Hypericum has been compared with conventional drugs singly and in combination, and found to be at least as effective. In a study comparing it with maprotiline (J Geriatr Psychol Neurol, 1994; 71: 24-8, 44-6), it demonstrated greater efficacy. Though improvement showed earlier in maprotiline patients, long-term side-effects, such as tiredness, dry mouth and heart complaints, were common with the conventional drug. In a randomised, double-blind study of Hypericum and the drug imipramine, the herbal remedy performed equally as well (J Geriatr Psychol Neurol, 1994; 71: 19-23).

In another randomised, placebo-controlled study, a regime of 300 mg of Hypericum three times daily resulted in 70 per cent of the treatment group being symptom-free within four weeks (J Geriatr Psychol Neurol, 1994; 71: 12-4). Hypericum is also of benefit to those suffering from SAD (J Geriatr Psychol Neurol, 1994; 71: 29-33).

Overall, according to the BMJ review, less than a fifth of patients suffer side-effects from Hypericum, compared with more than half of patients taking drugs.

According to Frankfurt University's Professor Walter Mueller, who has studied the effect of Hypericum in different biochemical models, Hypericum works by apparently boosting levels of three neurotransmitters - noradrenaline (norepinephrine), serotonin and dopamine, which are known to be low in sufferers of depression. This effect is unlike any other antidepressant he's ever studied; at best, the latest antidepressants, like mirtazapine, raise levels of serotonin and noradrenaline, while drugs like Prozac raise serotonin levels alone.

Unusually, the psychiatric community has responded to the Lancet studies with an 'if you can't beat 'em, join 'em' bonhomie, embracing Hypericum as the latest and most interesting magic bullet for depression. Psychiatrists attending the 10th International Congress on Neuropharmapsychology heard evidence that standardised Hypericum extracts are justified as a first-line treatment for depression. This is the first time a herbal preparation has been recognised and recommended at such a prestigious event. Leading lights in the psychiatric community, such as Dr Norman Rosenthal, of America's National Institute of Mental Health, Professor Siegfried Kasper, of Vienna University's department of general psychiatry, and Dr Yves Lecrubier, from the World Health Organization, were unanimous in their belief that Hypericum extracts appeared to be a safe and effective alternative to antidepressants. In Germany, Hypericum is the country's leading antidepressant, according to the Hypericum Information Centre.

Now that the psychiatric world has bestowed its blessing upon this herb, the worry, of course, is that drug companies will muscle in and attempt to isolate the active ingredients in a synthetic version. Nevertheless, it's clear that it is the natural form which is most effective. In a study comparing the biological response to Hypericum compared to a synthetic version, it was concluded that the two, though structurally similar, are substantially different (J Geriatr Psychol Neurol, 1994; 71: 47-53).

The other worry about magic bullet substances like Hypericum is that practitioners or patients could create an overreliance on a single substance to lift mood, rather than dealing with the life crises which may have brought on the depression.

Other herbs have also shown promise. Forskolin given intravenously to depressed and schizophrenic patients produced a transient elevation in mood in all four depressed patients and two of five schizophrenics (J Neural Trans, 1996; 103: 1463-7).

Siberian ginseng has consistently demonstrated an ability to increase feelings of wellbeing in those suffering from a variety of psychological disturbances, including depression and insomnia. It has been shown to increase the monoamine content in the brain (Econ Med Plant Res, 1985; 1: 156-215).

To the standard psychiatric community, which only believes in drugs or shock treatment, any sort of 'talking cure' is strictly in the alternative camp.

Two similar therapeutic approaches have received the bulk of researchers' attention: cognitive and behavioural. Cognitive theory believes that much of depression originates from faulty thinking, such as pessimism, and loss of hope and self-worth. It aims to alleviate depression by changing the way the person perceives himself and the world around him. Behavioural therapy ignores moods and other internal states, and concentrates instead on rewarding and reinforcing the positive aspects of an individual's life. For instance, many depressed individuals get rewarded with attention when they are low. Behavioural therapists would seek instead to reward them not for being helpless or passive, but for being self-reliant and positive.

The efficacy of talking cures, as compared to drugs, is well established, yet many physicians still consider this a fringe treatment. In one trial, patients were allocated to one of five treatment groups - diazepam, dothiepin, placebo, cognitive-behavioural therapy, or self-help. The results of the study showed that self-help and cognitive-behavioural therapy were at least as effective as drugs (Lancet, 1988; ii: 235-40). In addition, those who had therapy took fewer drugs over the study period.

Cognitive-behavioural therapy may be of more benefit to those who are not severely depressed (J Consult Clin Psychol, 1995; 63: 997-1004), though psychological intervention may take longer to show results (Arch Gen Psychiatr, 1996; 53: 913-9). When elderly patients, diagnosed as having major depressive disorders, were randomly assigned to problem-solving therapy (PST), reminiscence therapy (RT) or a waiting-list control group for 12 weeks, both therapy groups showed significant reductions in depressive symptoms, although those in the PST group experienced significantly less depression than those in the RT group (J Consult Clin Psychol, 1993; 61: 1003-10).

A review of cognitive-behavioural treatment showed that as many as 82 per cent will improve with this therapy as opposed to 73 per cent with relationship training. It's particularly interesting to compare this high success rate with the improvement rate for tricyclic antidepressants, which was only 29 per cent. These improvements were irrespective of the patient's expectations for the success of the treatment (Psychol Rep, 1995; 77: 403-20). Other studies show the effectiveness of cognitive-behavioural therapy in improving depression, hopelessness, anxiety and levels of self-esteem (Arch Psych Nurs, 1993; 7: 277-83), and these improvements seem to last over a period of time. In one study, a follow-up at 2.25 years showed that behavioural therapy patients were still significantly improved in areas of mood, personal productivity and social activity (J Consult Clin Psychol, 1990; 58: 482-8).

Psychotherapy, in general, seems to work better for those patients who do not have personality disorders (Br J Psychiatry, 1993; 162: 219-26). Those who are taking antidepressants may find that having therapy as well will alleviate many depressive symptoms and improve their chances of longer-term recovery (Br J Psychiatry, 1990; 156: 73-8).

Cognitive-behavioural therapy may be of less benefit to those whose symptoms stem from difficulties with interpersonal relationships. In one study, 120 white-collar, professional and managerial employees with major depressive disorders were assigned to either cognitive-behavioural (prescriptive) therapy or exploratory therapy. Results suggested that both therapies resulted in substantial clinical improvements, but that exploratory therapy helped improve interpersonal relationships (Br J Med Psychol, 1990; 63: 97-108). Other studies indicate that it is not the therapy, but the personality which influences the outcome. For instance, in one study comparing cognitive-behavioural therapy, interpersonal therapy, placebo and imipramine, those who were self-criticising and perfectionistic fared consistently worse than those who were not (J Consult Clin Psychol, 1995; 63: 1125-32).

Hypnotherapy may be an effective, if underused, treatment (Psychol Rep, 1986; 58: 923-9). The hypnotic state is similar to a state of deep relaxation, and this may be why it can be so effective in treating a wide range of disorders, including depression, anxiety, and stress (Am J Clin Hypn, 1989; 32: 110-7).

Homoeopathy and psychoanalysis have much in common since both disciplines place a high value on the personality and temperament of patients. Also, both believe that symptoms can be part of a self-healing response. The use of individually selected homoeopathic remedies has a long history in the treatment of depression (Br Homeop J, 1978; 67: 239-47). In one study of 12 adults who had major depression, social phobia or panic disorder which had responded poorly to conventional drugs, more than half improved with individually selected homoeopathic remedies. Treatment periods ranged from seven to 80 weeks (Alt Ther Health Med, 1997; 3: 46-9).

Depression is often coupled with anxiety, and homoeopathy has shown itself in several small trials to be effective in treating both. A homoeopathic remedy referred to as 'anti-anxiety' was tested in a double-blind, placebo-controlled trial on sufferers of anxiety. Those taking the remedy showed improvement in sleeplessness and anxiety over those taking the placebo (J Appl Nutr, 1996; 48: 2-6).

Homoeopathy is also a safe and effective way to combat anxiety at certain times of life, such as during pregnancy and afterwards (Prof Car Mother Child, 1994; 38:185-7).

A comprehensive review in the British Homeopathic Journal (1990; 79: 39-44) outlined the main remedies used to treat the symptoms of depression, but also argued that depression can be reactive. Treating the broader categories of emotional disturbance - anger, resentment, jealousy, weepiness and indifference, for instance - of which depression can be a symptom, can also produce excellent results.

Aromatherapy massage
Most of the research into the efficacy of massage has been done on elderly institutionalised patients and those who are severely ill, often with significant results. In one study of elderly patients, massage was shown to more effective than conversation alone (J Adv Nurs, 1993; 8: 238-45).

The right essential oils appear to play a significant part in the success of massage therapy. If citrus fragrance is used during massage, it is likely to raise both mood and immune system function. In one study, it has been shown to be more effective than antidepressants (Neuroimmunomodulation, 1995; 2: 174-80). Lavender is known to have sedative effects (Complement Ther Med, 1996; 4: 52-7), but in one study using oil from two different species of lavender, one produced significantly better effects than the other (Nurs Times, 1993; 89: 32-5). Other studies also show positive effects with aromatherapy. In one, cancer patients massaged with essential oils experienced a greater reduction in anxiety than those massaged without essential oils (Int J Pall Nurs, 1995; 1: 67-73). This result was repeated in another study, which showed that a 20-minute foot massage with neroli oil elevated the mood of heart-surgery patients whereas massage with simple vegetable oil failed to produce the same results (Complement Ther Med, 1994; 2: 27-35). Weekly massage with Roman camomile has also been shown to
decrease both anxiety and depression in elderly individuals (Int J Pall Nurs, 1995; 1: 21-30).

Massage brings with it a sense of connectedness to others, often missing in the depressed individual's life. In one study involving hospitalised depressed children, the group which received a simple 30-minute back massage experienced better nighttime sleep and decreased depression and anxiety, compared to controls, who were given relaxing videotapes to watch (Am Acad Child Adolesc Psychiatr, 1992; 31: 125-31).

Full-spectrum light
We now recognise that some depression is seasonal, as in seasonal affective disorder, or SAD (Psych Ann, 1987; 17: 664-9). Light is thought to significantly modify the processing of serotonin signals in the brain (Nature, 1997; 385: 123). Those with SAD can experience irritability, fatigue, sadness and sleep changes. Both adults and children can be affected. Early administration of full-spectrum light can help prevent seasonal depression from developing into full-blown depression (J Affect Disord, 1991; 23: 75-9). Most studies have been small, but the outcomes seem remarkably positive (Am J Psychiatr, 1986; 143: 356-8; Aust NZ J Psych, 1989; 60: 508-10; Univ Lond Inst Psychiatr Psychol Med, 1989; 19: 585-90).

Acupuncture can cause a decrease in delta-wave activity and increase in fast alpha-wave activity of the brain (J Trad Chin Med, 1994; 14: 14-8), resulting in significantly decreased anxiety and better sleep patterns.

When depression is linked to pain, such as facial pain, electroacupuncture can provide both pain relief and relief from depression (Med Hypoth, 1986; 19: 397-402). Laboratory experiments suggest that acupuncture is capable of accelerating the synthesis and release of serotonin (5-HT) and norepinephrine (noradrenaline) into the central nervous system and, thus, is as effective a means of treating chronic depression as tricyclic drugs (Int J Neurosci,1986; 29: 79-92; J Trad Chin Med, 1985; 5: 3-8).

Relaxation techniques
Even short (15-minute) relaxation programmes daily can prove effective in combating milder forms of depression (J Occup Med, 1993; 35: 1123-30). More extensive work with psychiatric inpatients has also shown that following a progressive relaxation programme can produce significant elevations in mood (Psych Rep, 1993; 72: 1267-74).

Music may also be helpful. In one study, 30 older adults were randomly assigned to one of three eight-week programmes. In one, patients learned music-listening stress-reduction techniques with weekly home visits by a music therapist. The second group followed the same programme on a self-administration basis with a weekly phone call for additional support. The third remained on a waiting list without intervention. Those who listened to music performed significantly better than controls in standardised tests of depression, self-esteem and mood. The improvements were clinically significant and maintained over a nine-month follow-up (J Gerontol, 1994; 49: 265-9).

In another study, 36 volunteers suffering from symptoms of anxiety, nervousness, fatigue, insomnia and sleep disturbance were randomly assigned to one of three groups - relaxation and meditation; relaxation and meditation plus a 10-week follow-up, with instructions to practice daily using meditation tapes; or a pseudorelation control group. Both practice groups improved significantly when compared to the control group, and the improvement was sustained over the follow-up period (Psychother Theory Res Pract, 1982; 19: 512-21).

Exercise and movement can also be relaxing and have a positive effect on moods and sleep patterns. In one small study, what was described as movement therapy had a positive effect on moods across many different measures, challenging the concept that movement is recreational, but not therapeutic (Arch Psych Nurs, 1994; 8: 22-9).

Useful addresses:
* Hypericum Information Centre, PO Box 21, Godalming, Surrey GU7 2SS Tel: 0990 168 151

* Outside In (for full-spectrum lighting), Unit 21, Scotland Road Estate, Dry Drayton, Cambridge, CB3 8AT Tel: 01954 211 955 Fax: 01954 211 956

Between 25 and 75 per cent of depressed people may have depressed thyroid function. The thyroid gland influences growth and sexual development, and controls the body's basal metabolic rate - the rate at which it consumes energy while at rest. The hypothalamus and pituitary glands regulate thyroid activity in the same way they regulate the adrenal glands. The hypothalamus produces thyrotropin-releasing hormone (TRH), which causes the pituitary to secrete thyroid-stimulating hormone (TSH). In depressed individuals, the TSH response to TRH is abnormally feeble. This is sometimes called hypothyroidism or Hashimoto's disease, after the Japanese physician who first recognised it in 1912.

It is thought that up to 20 per cent of cases of chronic depression may be associated with low production of thyroid hormones. A University of North Carolina study found that, among women with mildly decreased thyroid function, the rate of those who had suffered depression at least once in their lives was almost three times as great (56 per cent versus 20 per cent) as those with normal thyroid function (Ann Rev Med, 1995; 30: 37-46).

Underactive thyroid may be the result of environmental influences. Many countries iodise salt regardless of whether the soil in that area is rich in iodine. Consuming too much iodine can produce both under- and overactive thyroid with all the attendant symptoms (Lancet, 1996; 335: 99-107). Smoking, which can decrease thyroid function (N Engl J Med, 1995; 33: 964-9), has been linked to more than double the risk of depression (JAMA, 1990; 264: 1546-9). An indiscriminate diet can also play a role in depression and thyroid malfunction, so it seems that some of the coping strategies which we use to defeat depression and anxiety (such as bingeing on chocolate) may actually contribute to the problem.

An individual's emotional state also plays a part. Thyroid is especially susceptible to emotional blows such as bereavement or divorce (Acta Endocrinol, 1993; 128: 293-6).

Thyroxine replacement therapy may be an unnecessarily aggressive solution, especially in milder cases of underactive thyroid. Safer alternatives include consuming iodine-rich foods such as Japanese seaweed and kelp. The homoeopathic remedy Iodum provers can increase levels of circulating thyroid hormones (Homeop J, 1988; 77: 152-60) and the herb Lithospermum officinale will also regulate thyroid function (Endocrinology, 1984; 115: 527-34). Other helpful treatments for thyroid problems include osteopathy or aerobic exercise (In J Biometerology, 1994; 38: 44-7).

* Histadelia. According to the Institute of Optimum Nutrition, the majority of depressed patients are histadelic, which means they have high levels of histamine (which is released by the mast cells during the allergic response).

Clues to histadelia are if you sneeze in bright sunlight, can hear your pulse in your head on the pillow at night, get frequent backaches, stomach aches and muscle cramps, have regular headaches, seasonal allergies, abnormal fears and compulsive rituals or suicidal thoughts, and are unable to tolerate large amounts of alcohol and other downers. Supplementation with vitamin C and B3 - so often given as part of an antidepressant nutritional regimen - will not work. Instead, you might benefit from a low-protein, high-complex-carbohydrate diet and supplements of calcium, 500 mg twice daily, and the amino-acid methionine, 500 mg twice daily. Avoid folic acid since it can raise histamine levels. The prognosis even for severely depressed patients can be good, but only if they stick like glue to the regime. Once off the programme, you risk having depression return with a vengeance.

* Supplements. If you have ruled out being histadelic, a general programme of supplements should be considered. Depressed individuals are most likely to be low in B vitamins, with folic acid deficiency being the most common (BMJ, 1980; 281: 1036-42; Biol Psych, 1989; 25: 867-72). Supplementation can produce significant improvements (Lancet, 1990; 336: 392-5). B6 deficiency is also common (Nutr Rep Int, 1983; 27: 867-73; Br J Psych, 1979; 135: 249-54). B2 (riboflavin), B1 (thiamine) and B12 deficiencies can also result in depression.

Increasing vitamin C can also lift depression (J Orthomolec Med, 1987; 2: 217-8; Br J Psych, 1963; 109: 294-9; Br J Psych, 1984; 145: 477). Your magnesium and potassium levels may also be low.

* Dietary adjustments. The modern trend for low-fat diets may be doing more harm than good since it has been clearly demonstrated that low-cholesterol diets can lead to feelings of depression and even suicide (BMJ, 1996; 313: 649-63, 644; J Orthomolec Med, 1990; 5: 20-1). High caffeine and sugar intakes are also associated with higher rates of depression.

* Amino acids. Neurotransmitters are chemicals which act like messengers between the brain and the nerve cells. The neurotransmitters serotonin and norepinephrine (noradrenaline) help to regulate our moods. Instead of suppressing these or substituting for them with drugs, give your body a chance to manufacture its own. Tryptophan is an essential amino acid from which serotonin is derived. Studies show that depressed individuals are often low in this amino acid (Psychol Med, 1978; 8: 49-58; Arch Gen Psych, 1990; 47: 411-8) and that taking supplements of tryptophan can be as effective as antidepressants (Neuropsych, 1988; 20: 28-35; Wurtman & Wurtman, Nutrition and the Brain, vol 7, NY: Raven Press, 1986). Given that tryptophan is one of the least abundant amino acids in foods, it is unfortunate that it is not currently available as a supplement. But you may be able to boost your tryptophan levels to some extent by eating amino acid-rich foods.

Norepinephrine is derived from L-phenylalanine, another essential amino acid. L-phenylalanine is also converted into phenylethylamine, or PEA (the same stimulant found in chocolate) when the body is low in vitamin B6. In one study, a group of people with major depression were found to be low in PEA. As soon as they began taking L-phenylalanine and B6, their moods lifted (J Clin Psych, 1986; 47: 66-70).

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