Depression

Depression

The conventional antidepressant approach

Antidepressants are the most commonly prescribed treatment for depression. Research supports that they help reduce depressive symptoms for some people.

 

However, depression should be considered in a broader context that considers the drugs' risks and limitations as well as the many evidence-based nondrug options available. This full view helps individuals and their practitioners make the most informed choices about care. 

In that spirit, the following infographic summarizes statistics on the challenges of antidepressants extracted from a number of gold-standard scientific studies.

See Infographic Footnotes.

In addition, antidepressants have many other potential side effects that may persist even after you stop using them. These include gastrointestinal issues, weight gain, cardiovascular issues, and Parkinsonian-like involuntary movements. [1]​

Do antidepressants work?

Yes, but their benefit is almost entirely placebo effect

After reviewing the evidence, the U.S. FDA states that antidepressants work only slightly better than placebo (sugar pills). [2]  

 

This startling conclusion is found in the clear evidence of many independent gold-standard drug trials. Overall, placebos eliminate 38% of depressive symptoms while antidepressants alleviate 46%. [3] This 8% difference is so small that researchers assert that, "the potential small beneficial effects (of antidepressants) seem to be outweighed by harmful effects." [4]

Is the chemical imbalance theory valid?

Experts say, "no".

One reason for the relatively poor outcomes with antidepressants is that the underlying chemical imbalance theory of depression - the theoretical foundation upon which antidepressants are based - is now considered flawed and untenable. [5] 

 

For many years low levels of serotonin (a brain chemical) were thought to cause depression. To address this suspected deficiency, serotonin-increasing antidepressants were prescribed. However, it was found that drugs that increase serotonin had the same impact as drugs that decrease serotonin - both providing relief only slightly better than placebo. [6]

Additionally, the FDA has issued a black box warning – the most serious warning for prescription drugs – for antidepressants, because of the doubling of the frequency of suicidal thoughts of children and young adults on antidepressants. [7]  Antidepressant use by children is also associated with almost a tripling of aggressive behavior. [8]

Are antidepressants effective in the long term?

The answer appears to be "no"

Real-life outcomes of long term antidepressant use are not promising. Those on antidepressants show significantly worse depressive symptoms at 9-year, [9] 20-year, and 30-year [10] follow-up visits as compared to similar groups of depressed people not given these drugs.

 

In addition, one of the largest gold-standard studies shows that only 3% of people taking antidepressants achieve a non-depressed state and stay that way until their one-year follow-up.[11]

Your health, your choice

The risks and limitations of antidepressants combined with their slim margin of benefit over placebo make their risk/reward profile much less favorable than most people think.

 

Doctors and patients alike want the transparent sharing of the pros and cons of drugs so people can make informed trade-off decisions on their care. 

Unfortunately, two surveys found the information flow inadequate. 64% of people received no information from their doctors on the risks or side effects of antidepressants, nor adequate guidance on their withdrawal difficulties. [12]

 

But as this information is used to inform clinical care, both doctors and patients are becoming more cautious in using antidepressants, especially for the developing brain and personhood of children.

 

With no game changing drugs on the horizon, it's fortunate that there are a growing number of evidence-based non-drug options that show promise. Nearly all can be used with drugs, they typically have far fewer and milder side effects than drugs, and their use can often help reduce - and in some cases eliminate - the need for drugs. 

 

This is an important step forward since our mind, body, and emotions require a more holistic, integrated, and complete solution than pills can provide. 

An integrated wellness approach

Thousands of studies show that non-drug approaches help mental health recovery. In fact, there are 27 broad non-drug approaches that have proven effective. Many are useful for depression (download free monograph).

 

There are many non-drug options for depression, separated into four categories of care.

The "higher" in this diagram we operate (toward Preventive), the better, since these are the approaches that help us sustain mental wellness. However, once we develop depressive symptoms, it may be helpful to use techniques in multiple categories simultaneously to maximize recovery. 

 

Preventive care

Preventive approaches include a number of common sense health practices we can adopt that often have a significant impact on mental health. Often called wellness basics, many of these approaches have been proven very helpful for depression including proper diet, aerobic exercise, mindfulness, controlled breathing, ensuring gut-health, social interaction, being in a bright natural light, mind-body disciplines (especially yoga) and more.

 

Restorative care

Restorative approaches address root-causes and direct influencers of mental health symptoms. They come in two varieties: biomedical and psychosocial. Since our body and mind interact so deeply, it is often helpful to address both simultaneously.

 

Biomedical practitioners help identify your unique bio-individuality through blood/urine and other testing, using detailed biomedical test panels. These tests can uncover nutrient imbalances, hormonal issues, amino acid irregularities, food allergies, pathogens, inflammation, toxicities, or other causative factors. To help you locate integrative biomedical practitioners, review our practitioner finder

 

Biomedical testing is important since over 25% of the time, mental health symptoms are caused by or significantly influenced by physical issues. [14] This figure rises to about 50% for those of lower socioeconomic status.

 

Walsh-protocol nutrient therapy has been shown in open label trials to be a particularly effective biomedical treatment for depression: over 70% of people who use customized Nutrient Therapy for six months return to normal without antidepressants. In nearly all the remaining 30%, symptoms can go into remission with lower antidepressant dosages. [15] Funding is being sought to build the evidence-base for this approach in randomized controlled trials. In the absence of individualized testing, EPA Omega-3 fatty acids and SAM-e - both natural substances - have proven effective. 

Nutrient Therapy for Depression with Dr. William Walsh, PhD 

Courtesy Walsh Institute.  www.WalshInstitute.org.

Psychosocial practitioners can help identify and address an individual's past trauma, stress, social challenges, emotional difficulties and unhelpful thinking patterns that can cause or influence depressive symptoms. 

 

Cognitive Behavioral Therapy and individual psychotherapy are two approaches that are superior to drugs for depression. [16] In addition, peer support - from those who have experienced similar mental health challenges and recovered - offers a unique "been there" perspective and personal sensitivity that can be invaluable. Directories of therapists, psychologists, peer specialists and other psychosocial practitioners are usually available in your community.

 

Symptom relief care

Symptom relief approaches seek to address any residual symptoms that are not removed by preventive and restorative care. Although antidepressants are by far the most common treatment for depressive symptom relief, various herbs (including St. John's wort), sensory therapies and very low charge electrical stimulation have been shown effective.

 

Over-care avoidance

Over-care avoidance is limiting the use of psychiatric drugs and other medical interventions to only what is necessary. Practitioners often work to minimize the use of psychotropic drugs because of their side effects, withdrawal difficulties, and inability to cure.

 

Increasingly, many leading psychiatrists are developing de-prescribing plans to help clients reduce and sometimes eliminate psychiatric drugs as they gain sustainable benefit from non-drug options. [17]  

 

This is important since excessive drug use can not only be expensive, but harmful - long-term psychiatric drug use is associated with a variety of worsening outcomes. Over-prescribing is an especially important issue for children, the elderly, and other vulnerable populations. The American Psychiatric Association and a variety of public health organizations are working to curb over-care practices.

However, some people find psychiatric drugs helpful. When using drugs, they should be taken in minimum effective dosages - no greater than the amount needed to gain significant symptom relief and for no longer than is required.

Resources

Footnote references are removed in the mobile version of this page to respect small screen sizes. They can be found in the desktop version.

 

Please see disclaimer.

Work with trusted integrative practitioners

Your doctors and practitioners are your trusted guides. Work closely with them as you evaluate and choose your options of care. Many are joining the paradigm shift to Integrative Mental Health, a discipline with a much larger menu of recovery options that spans the best of conventional and non-drug treatments.

 

Leading voices in mainstream psychiatry support this paradigm shift. Dr. Kenneth Duckworth, Medical Director of the National Alliance on Mental Illness (NAMI), is clear: "... psychiatric medications... are rarely enough to promote recovery alone... Use of non-medication strategies is crucial for most clinical situations." [13] 

Unfortunately, your current doctors may not offer the full combination of treatments you need. In that case, consider expanding your team with integrative practitioners.

 

Instead of looking only at symptoms and drugs that can reduce them, integrative practitioners often probe to find markers of known causative factors of depression. This results in personalized treatment customized to your unique bio-individuality and needs.  

Even though Integrative Mental Health shows great promise, non-drug options aren't a panacea. But the expanded menu of options of integrative care offers you many more avenues of recovery and much stronger reasons for hope.

References:

[1]  Carvalho AF et al, The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature, Psychother Psychosom. 2016, https://goo.gl/wiPzR9. 

[2]  Laughren T, Treating Depression: Is there a placebo effect?, CBS News, 60 Minutes broadcast, 2012, https://goo.gl/ug78Av.  

[3]  Khan, A et al, Antidepressants versus placebo in major depression: an overview. World Psychiatry, 2015, PMCID: PMC4592645.

[4]  Jakobsen, JC et al,  Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis,2017, BMC Psych, https://goo.gl/FF9lqo

[5]  Lacasse J et al, Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature, PLOS Medicine, 2005, https://goo.gl/q2oIQa; Cowen P et al, What has serotonin to do with depression?, World Psychiatry. 2015, PMCID: PMC4471964

[6]  Wagstaff AJ, Tianeptine: a review of its use in depressive disorders, CNS Drugs. 2001, PMID: 11463130, https://goo.gl/brq2r7. 

[7]  Nat’l Institute of Health, Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers, copied 1/5/17 https://goo.gl/nicPm8. 

[8]  Sharma T et al, Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports, BMJ. 2016, PMCID: PMC4729837.

[9]  Vittengl JR, Poorer Long-Term Outcomes among Persons with Major Depressive Disorder Treated with Medication, Psychother Psychosom. 2017, PMID: 28903116

[10]  Hengartner MP et al, Antidepressant Use Prospectively Relates to a Poorer Long-Term Outcome of Depression: Results from a Prospective Community Cohort Study over 30 Years, Psychother Psychosom. 2018, PMID: 29680831

[11]  Pigott HE et al, Efficacy and Effectiveness of Antidepressants: Current Status of Research, Psychother Psychosom 2010, PMID: 20616621

[12]  All-Party Parliamentary Group for Prescribed Drug Dependence, Antidepressant Withdrawal: a Survey of Patients’ Experience by the All-Party Parliamentary Group for Prescribed Drug Dependence, 2018, https://goo.gl/aFXv3o;  All-Party Parliamentary Group for Prescribed Drug Dependence, The Patient Voice: an analysis of the personal accounts of prescribed drug dependence and withdrawal submitted to petitions in Scotland and Wales, 2018, https://goo.gl/nYEhJd. 

[13]  Duckworth K, The Sensible Use of Psychiatric Medications, NAMI Advocate Magazine, Winter 2013,  https://goo.gl/GMIuSU.

[14]  Koranyi EK et al, Physical illnesses underlying psychiatric symptoms, Psycho Psychosom. 1992, PMID: 1488499, http://goo.gl/V9Wi23.; Koran L, MEDICAL EVALUATION FIELD MANUAL, 1991, http://goo.gl/TPNL9t, copied 10/30/2013.; Hall RC, Physical illness manifesting as psychiatric disease. II. Analysis of a state hospital inpatient population, Arch Gen Psychiatry. 1980, PMID: 7416911.

[15]  Walsh W, Nutrient Power Heal Your Biochemistry and Heal your Brain, Skyhorse Publishing, 2014, http://goo.gl/DxoIvQ

[16]  Vaswani A,  Non-Pharmacological Treatments (NPTs) for Depression Are Effective, Mad in America, https://goo.gl/Zrlvjh; Khan, A et al, Antidepressants versus placebo in major depression an overview. World Psychiatry (Figure 1, Blinded studies), 2015, PMCID: PMC4592645;  Farah WH et al, Non-pharmacological treatment of depression: a systematic review and evidence map, Evid Based Med. 2016, PMID: 27836921.

[17]  Gupta S, A Prescription for "Deprescribing" in Psychiatry, Psychiatr Serv. 2016 PMID: 26975524.  Ontario Pharmacy Evidence Network, Deprescribing Guidelines, https://goo.gl/8VpYFx. Grudnikoff E et al, Deprescribing in Child and Adolescent Psychiatry—A Sorely Needed Intervention, Am J Therapeutics, 2017, PMID: 28059976. Gupta, S et al, Deprescribing antipsychotic medications in psychotic disorders: How and why? Betham Science, 2018, https://goo.gl/mR9jJ1. 

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