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Depression

Depression or affective disorder is a family of diseases characterized by changes in mood, and are of two basic types: the melancholia of unipolar depression, and the manic elevation and desperate lows of a bipolar affective disorder. The prevalence of unipolar depression is fairly equally distributed, but bipolar disorders seem to affect more women and young adults.

The fourth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides the diagnostic criteria for a major depressive episode. At least five of the following symptoms must be present in the same two week period, and also must include either (a) or (b):

  • Depressed mood
  • Diminished interest or pleasure
  • Significant weight loss or weight gain
  • Insomnia or excessive sleep and lethargy
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Feelings of worthlessness
  • Diminished ability to think or concentrate; indecisiveness
  • Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide

There are a number of predisposing factors in depression, including:

  • grief due to the illness or loss of a loved one
  • the recent diagnosis of a severe medical condition, e.g. cancer, multiple sclerosis
  • chronic pain and disability
  • nutrient deficiencies, e.g. vitamin B12
  • mood changes in the elderly, and in particular, depression associated with aging and in particular diseases associated with aging that affect quality of life, including arthritis, Alzheimer’s disease, Parkinson’s disease, and stroke
  • endocrinal disorders, e.g. hypothyroidism, Addison’s disease, Cushing’s disease, hyperthyroidism, prolactinomas, hyperparathyroidism
  • side-effects from drug therapy, e.g. antihypertensive medications (especially ?-blockers, reserpine, methyldopa, and calcium channel blockers); steroids; medications that affect sex hormones (e.g. estrogen, progesterone, testosterone, gonadotropin-releasing hormone [GnRH] antagonists); H2 blockers (e.g. ranitidine, cimetidine); sedatives; muscle relaxants; appetite suppressants; chemotherapy agents (e.g. vincristine, procarbazine, L-asparaginase, interferon, amphotericin B, vinblastine).
  • substance use, abuse, or dependence, e.g. alcohol, cocaine, amphetamines, marijuana, sedatives/hypnotics, and narcotics
  • post-partum depression
  • seasonal affective disorder (SAD)
  • anxiety disorders, including panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, posttraumatic stress disorder, and phobia
  • eating disorders, e.g. anorexia nervosa, bulimia
  • borderline personality disorders
  • psychosis (Berkow 1992, 1594-95)

The physical signs and symptoms of depression can be mild to acute. Most patients present with a relatively normal appearance, but with severe symptoms may show an inattention to personal appearance and hygiene. There may be a general decline in spontaneous movements, often commensurate with a flattening of emotional expression, evidenced by speaking patterns that are slow, monotonic, or lacking in spontaneity and content. The patient may have gained weight recently, or lost a significant amount of weight, and may suffer from vertigo and poor coordination, fatigue and lethargy. Psychological symptoms may include:

  • sadness
  • a feeling of heaviness
  • emotional numbness
  • irritability
  • mood swings
  • a loss interest or pleasure in their usual activities
  • difficulty concentrating
  • decreased motivation
  • feelings of worthlessness, hopelessness, or helplessness
  • suicidal or homicidal ideation

While there are no objective criteria to examine for depression a number of laboratory tests may be undertaken to rule out underlying factors, including thyroid-stimulating hormone, vitamin B12, liver function tests, toxicology and EEG.

Medical treatment of depression

From a neuropharmacological perspective, depression is primarily correlated with a disturbance in CNS serotonin, and to a lesser extent problems related to norepinephrine (NE) and dopamine (DA) function. The role of serotonin in depression is supported by clinical trials that have suggested the efficacy of serotonin reuptake inhibitors (SSRIs), as well as other studies that demonstrate an acute, transient relapse of depressive symptoms in tryptophan. The idea that it is a deficiency of serotonin that causes depression is a perspective that has become strikingly popular among medical professionals such that these drugs account for a significant percentage of profits enjoyed by the drug companies that produce them. It is a recipe that is convenient and ideally suited to a clinical practice where a doctor may spend only a few minutes with a patient before arriving a diagnosis of depression and prescribing a serotinergic therapy. Unfortunately SSRIs have multiple negative side-effects including weight gain, loss of libido and headache, and are notorious for interacting with other drugs. The drug companies appear to be very aggressive in protecting their market share however, and have published a few studies indicating that often used alternatives to SSRIs such as St. John’s Wort (Hypercium perforatum) are no better than placebo. In one double-blind placebo-controlled clinical study of 340 patients suffering form mild to moderate depression for example, a positive response to St. John’s Wort (SJW) was only found in 23.9% of the patients, compared to 31.9% for placebo (Hypericum Depression Trial Study Group 2002). What the press release failed to mention however is that the study also examined the efficacy of sertraline (Zoloft®), which accounts for upwards of two billion dollars in sales, and found that not only was this drug no better than St. John’s Wort in treating mild to moderate depression (with a 24.8% response). Despite the fact that SJW was never traditionally used for depression per se, other clinical trials have consistently shown the benefit of SJW over placebo, and is at least equivalent or more effective than drugs such as fluoxetine (Prozac®) (Behnke et al 2002; Schulz 2002; Schrader 2000).

Pharmacotherapy

Pharmacotherapy for depression usually consists of a two to six week introductory period, during which time the benefits of the drug will begin to be seen. Among the different drugs are:

  • selective serotonin reuptake inhibitors (SSRIs): fluoxetine (Prozac®), paroxetine (Paxil®), sertraline (Zoloft®), fluvoxamine (Luvox®), citalopram (Celexa®), and escitalopram (Lexapro®). SSRIs block the reuptake of serotonin with little effect upon norepinepherine. Common sides effects include anorexia, nausea, headache, fatigue, insomnia, sexual dysfunction, drowsiness, dizziness and agitation.
  • serotonin noradrenergig reuptake inhibitor (SNRI): venlafaxine (Effexor®). Venlafaxine inhibits the reuptake of both serotonin and noradrenaline. Side effects include sedation, nausea, headache, and sexual dysfunction.
  • serotonin 2 antagonist/reuptake inhibitor (SARI): trazodone (Desyrel®). Trazodone affects serotonin and noradrenaline secretion, increases REM sleep and promotes sedation. Prominent side effects include a dry mouth, sedation, dizziness, and nervousness.
  • norepinepherine dopamine reuptake inhibitor (NDRI): bupropion (Wellbutrin®). Bupropion is a weak inhibitor of the neuronal uptake of serotonin, norepinephrine and dopamine, but the specific mode of action is not known. Side effects include headache, insomnia, agitation and seizure.
  • noradrenergic/specific serotinergic antidepressants (NaSSA): mirtazapine (Remeron®). Mirtazapine increases noradrenergic, dopaminergic and serotinergic activities. Side effects include sedation, increased appetite, weight gain, dizziness and dry mouth.
  • tricyclic antidepressants (TCAs): amitriptyline (Elavil®), nortriptyline (Pamelor®), desipramine (Norpramin®), clomipramine (Anafranil®), doxepin (Sinequan®), protriptyline (Vivactil®), trimipramine (Surmontil®), and imipramine (Tofranil®). Tricyclic antidepressants are so-called because of their 3-ring chemical structure. Generally speaking, TCAs increase the activity of norepinepherine and serotonin by blocking neuronal uptake, with increased stimulation of postsynaptic receptors. Their relative lack of specificity however leads to anticholinergic effects and cardiotoxicity. The most common side effects include sedation (antihistamine H1 blockade), dry mouth, constipation, urinary retention, blurred vision, orthostatic hypotension, dizziness, and weight gain.
  • monoamine oxidase inhibitors (MAOIs): phenelzine (Nardil®) and tranylcypromine (Parnate®). MAOIs allow inhibit the enzymatic degradation of monoamines neurotransmitters including norepinepherine, dopamine and serotonin, increases post-synpatic stimulation. Side effects include dizziness, anxiety, tremors, insomnia, weight gain, and sexual dysfunction, and have many drug interactions. With the concomitant consumption of foods rich in tyramine (e.g. fermented foods such as aged cheeses, red wine, prepared meats, coffee etc.), TCAs, and SSRIs, MAOIs can promote a life-threatening hypertensive crisis.

Non-pharmacotherapeutic medical options

In addition to drug therapy, a variety of non-drug options may be used instead of or in conjunction with standard drug treatments.

  • Electroconvulsive therapy (ECT): ECT or “electroshock” involves the application of electrodes placed above each temple or above the temple of one side of the brain and in the middle of the forehead (unilateral ECT). An electrical current is then passed through the brain via the electrodes, inducing a grand mal epileptic seizure. Prior to the application of the electrical current the patient is anesthetized with an intravenous injection of a barbiturate or an anaesthetic, and the muscles are temporarily paralyzed with a drug such as succinylcholine, preventing the violent jerking motions that can cause bones to break. Risks include those associated with anesthesia, as well as post-treatment confusion, short-term memory difficulties, and death. ECT is typically used when a rapid antidepressant response is prescribed, when drug therapies have failed.
  • Light therapy: Broad-spectrum light exposure has long been shown to be effective for SAD, with some recent evidence indicating that it may be helpful in nonseasonal depression.
  • Psychotherapy: Psychotherapies employ a belief that unconscious conflicts and distortions are at the heart of depression. Through a dialogue with a skilled practitioner, the aim of psychotherapy is to help the patient to create a new perception and relationship with the world. In some cases psychotherapy may involve many years of treatment.

Holistic treatment of depression

At the heart of affective disorders is the human condition. Life, for all that it offers, has long been recognized as a source of pain and suffering. Entropy seems to be an inevitability, where matter and consciousness are engaged in a downward spiral of dissolution and meaningless. The reality of suffering is reflected in many of the religious and philosophical teachings of the world, from suffering of the Jews recounted in the Bible, to the painful crucifixion of Jesus. These teachings show us however that suffering is not only an inevitable reality, but that it is a vast storehouse of wisdom and knowledge.

The Yogic and Buddhist teachings of India suggest that life is an infinite wheel of birth, death and rebirth called samsara. When each of us are born, we are taught that we have an identity and a place within society. We are encouraged to develop this identity, into a career, into social and personal obligations, and soon we invest a great deal in supporting and protecting this sense of individuality. Somewhere down the line however, the existential realities of life cause a disruption of this ego-complex, and he who was once a powerful CEO soon becomes an old man that has to be tended to like a baby. The heart of the issue is this identification with the ego-complex, that we attach such an enormous significance to that which is transient, impermanent and subject to decay. We think we know who we are, and we have our many preferences and aversions to support it. But, in the end, we lose it all. Did our investment pay us any return?

Buddhist teachings tell us that it is this conditioned ignorance, perhaps necessary for survival, binds and confines our unconditioned inner natures to a narrow and specific circumstance. Yogic teachings posit that we are holograms of God, a microcosm of the macrocosm, and it is this persistent belief that the self exists independently of God that binds us to the wheel of samsara. Viewed in this context depression is something quite natural: coming face to face with the face that isn’t there. Who are you with no face, with no identity? Depression is the precursor to the next stage of spiritual development, where we escape the limitations of identity and learn to realize our unconditioned existence and merge with the bliss of the Infinite.

Holistic therapies treat a broad range of possible causes of depression, including emotional disturbances, chronic stress, fear, low self-esteem, loneliness, nutritional deficiencies, food allergies, hypothyroidism, obesity, candidiasis, heavy metal toxicity and hypoglycemia. In many cases of depression there is a concurrent issue of immune dysfunction. Depressed levels of circulating Vitamin D3 in the blood can have a significant effect upon a sense of well-being.  In women who are obese, hirsute and depressed, there is a strong possibility of polycyclic ovarian disease, or at the least, a relative androgenization and deficient progesterone. In such cases it is helpful to assess hormone levels, either through laboratory testing or by asking the woman to keep a symptothermal chart if she is pre-menopausal.

In Ayurvedic medicine depression is a symptom of an underlying imbalance of the doshas. Thus treatment is centered around balancing or pacifying the affected doshas. Vataja depression is noted by concomitant symptoms of fear, anxiety, being “spaced-out” and confusion, with physical symptoms of coldness, dryness, numbness and fatigue. Pittaja depression is manifest as emotional irritability, rage, intense anger, and violence, with physical symptoms of heat and flushing. Kaphaja symptoms are recognized by feelings of worry, grief, and sentimentality, with physical symptoms of catarrh, heaviness, lethargy and coldness. Combined symptom pictures are recognized as a combination of the doshas.

Caution is warranted when withdrawing antidepressant drugs in patients that has been on these drugs for more than eight weeks. Withdrawal symptoms include headaches, dizziness, restlessness, tremors, insomnia and diarrhea. To avoid these symptoms wean the patient off the drugs over a period of two weeks, gradually increasing the dosage of alternative remedies. Avoid the use of botanicals with an MAOI activity (e.g. Peganum harmala, Banisteriopsis caapi) with any antidepressant or tyramine-rich foods.

Botanicals

  • Thymoleptics, to allay sadness and promote happiness: St John’s Wort (Hypericum perforatum), Lemonbalm (Melissa officinalis), Pasqueflower (Anenome pulsatilla), Vervain (Verbena hastata), Passionflower (Passiflora incarnata), Kava (Piper methysticum), Chai Hu (Buplerum chinense), Reishi (Ganoderma lucidum), Ashwagandha (Withania somnifera)
  • Antimanics, for rage and aggression, manic depression: Passionflower (Passiflora incarnata), Skullcap (Scutellaria lateriflora), Sarpagandha (Rauwolfia serpentina), Yellow Jessamine (Gelsemium sempervirens)
  • Nervine trophorestoratives, for neurasthenia (fatigue, nervous exhaustion): Milk Oats (Avena sativa), Brahmi (Bacopa monniera), Jatamamsi (Nardostachys jatamansi), Gotu Kola (Centella asiatica), Sweet Flag (Acorus calamus), Damiana (Turnera diffusa), Ashwagandha (Withania somnifera), Ginseng (Panax ginseng), Wu Wei Zi (Schizandra chinensis), Siberian Ginseng (Eleutherococcus senticosus), Licorice (Glycyrrhiza glabra), Jujube date (Zizyphus jujuba), Reishi (Ganoderma lucidum)
  • Cholagogues, for emotional stagnation; detoxification: Gentian (Gentiana spp.), Dandelion root (Taraxacum officinalis), Barberry (Berberis vulgaris)
  • Stimulants, for lethargy and mental confusion: Cayenne (Capsicum frutescens), Pippali (Piper longum), Ginger (Zingiber officinalis), Prickly Ash (Zanthoxylum spp.), Rosemary (Rosmarinus officinalis), Holy Basil (Ocimum sanctum)
  • Cerebrovascular stimulants, for the aged: Ginkgo (Ginkgo biloba), Bilberry (Vaccinium myrtillus), Rosemary (Rosmarinus officinalis), Holy Basil (Ocimum sanctum)
  • Entheogens, e.g. Banisteriopsis caapi and Peganum harmala, Psychotria viridis, Diplopterys cabrerana, Desmanthus illinoensis. USE ONLY UNDER EXPERIENCED SUPERVISION

Supplements

  • vitamin B complex, 200 mg daily, with B12 and folic acid, 800 mcg each
  • vitamin C, to bowel tolerance
  • chelated multiminerals with trace minerals
  • chromium, to control blood sugar, 200 mcg t.i.d.
  • EPA/DHA, 1000 mg each daily
  • L-tryptophan (taken with B vitamins)
  • 5-hydroxytryptophan

Topical

  • cold water showers in manic states; paste of Sandalwood powder mixed with cool milk applied to forehead (pitta)
  • warm oil massage in asthenic conditions (vata)
  • Ayurvedic udvartana (herbal powder massage) and garshana (massage with raw silk gloves) (kapha)

Diet

  • remove food allergens with an elimination-challenge diet
  • eliminate methylxanthines, in coffee, tea, chocolate and certain medications
  • avoid alcohol: regular alcohol consumption can reduce serotonin levels
  • rule out hypoglycemia
  • rule out aluminum, lead, mercury and heavy metal toxicity

Aromatherapy

  • Lavender, Rose, Vetivert, Sweet Marjoram, Bergamont, Lemon, Clary Sage, Myrrh, Frakincense, Sandalwood, Cinnamon (Vata)
  • Chamomile, Lavender, Rose, Gardenia, Honeysuckle, Ylang, Vetivert, Jasmine, Sandalwood (Pitta)
  • Cedar, Pine, Rosemary, Basil, Frankincense, Myrrh, Eucalyptus, Cajeput, Camphor, Ginger, Clove (Kapha)

Flower Essences

  • Cerato (self-esteem), Mimulus (fear), Gorse (hopelessness), Mustard (melancholy), Red Chestnut (worry), Rock Rose (panic), Sweet Chestnut (despair)

Other

  • regular exercise
  • following the daily regimen
  • meditation, tai chi, hatha yoga
  • shamanic journeying
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