Thursday, 6 June 2013

Is Depression a Disease or an Opportunity?

Is Depression a Disease or an Opportunity?
A depression diagnosis does not have to be a life sentence. Often, it is a sign that our lives are out of balance and that we’re stuck. It is a wake-up call and, potentially, the start of a journey that can help us become whole and happy, a journey that can change and transform our lives.

When a physician observes the signs and symptoms of “major depressive disorder” in someone—the difficulty sleeping and eating, the weight loss, the absence of interest in a world which once pleased her, the feelings of helplessness and hopelessness—he is likely to prescribe anti-depressant drugs. When a patient asks questions about the need for drugs, she (I use the feminine to remind us that more than twice as many women as men are diagnosed with depression) is often told, “Depression is a biochemical disorder like insulin-dependent diabetes. Diabetics need insulin because their pancreas doesn’t work properly. And you need the drugs, the selective serotonin reuptake inhibitors (SSRIs), like Paxil and Prozac, to raise your levels of serotonin.”

It sounds authoritative, appropriate, and effective. Unfortunately it’s inaccurate.

First of all, the biochemical disorder has never been demonstrated. Some people with depression may have lower levels of serotonin, a neurotransmitter which helps to calm the brain and balance many body functions. But it seems that they are a minority. Doctors often don’t even measure the level of serotonin before prescribing drugs to affect it.

Second, the SSRIs are not, in fact, selective. Serotonin producing cells are distributed widely through the brain and body—the small intestine has the largest number—and altering serotonin inevitably alters the level and action and many functions of other neurotransmitters, including dopamine, which mediates pleasure. A cascade of uncomfortable and sometimes dangerous side effects result, including gastro-intestinal upset, neurological problems like headaches, muscle stiffness and tremors, weight gain, and sexual dysfunction—in up to 70 percent of all those who take the SSRIs. Indeed, in the early weeks of taking the drugs, a number of people, mostly young adults and adolescents, become more depressed and more suicidal.

In fact, neither the SSRIs, nor the serotonin–norepinephrine (norepinephrine is a neurotransmitter that may affect mood and activity level) reuptake inhibitors (SNRIs), which are increasingly prescribed, do a very good job. Doctors have prescribed these and other anti-depressants with great enthusiasm for more than twenty years—some thirty million Americans are currently using them for premenstrual syndrome, chronic pain, and anxiety, as well depression—because they believed the published studies which showed that the drugs were 60 to 70 percent more effective for depression than the placebos, the sugar pills, to which they were compared. These numbers were seriously misleading.

The drug companies, which profit hugely from SSRIs and other antidepressants, had, for the most part, only published the positive studies. When researchers went to the United States Food and Drug Administration and recovered the unpublished negative studies, the results were quite different. Reviews of the literature, which were published in our most prestigious medical journals—including The New England Journal of Medicine and The Journal of the American Medical Association—revealed that antidepressants were little, if any, better than placebos—except for a small minority of the most seriously depressed people.

All this doesn’t mean that antidepressants aren’t sometimes helpful. They can be, even with their limitations and side effects. What it does mean is that they should not be regarded as the “treatment of choice” as most physicians believe them to be, but instead as a last resort.

My treatment of choice is what many call “integrative.” I think of it as a way to get Unstuck, to help us move through and beyond the depression and the other difficulties that our lives may bring us. I describe this integrative, comprehensive approach in some detail in my book, Unstuck: Your Guide to the Seven Stage Journey out of Depression. It combines the best of conventional treatments, including various forms of psychotherapy, with a variety of other techniques that enhance each person’s emotional life and cognitive abilities as well as her physical health. Medication should be used only when this approach doesn’t work. “In extreme situations” Hippocrates said 2500 years ago “extreme remedies.”

The foundation for this Unstuck approach is a meditative or mindful one—which simply means that it is designed to help people to be relaxed, aware and self-aware, and firmly grounded in the present moment. The Unstuck approach includes specific meditation techniques like slow, deep “soft belly” breathing and mindful walking and eating, which have been shown to decrease levels of anxiety and stress, enhance mood and optimism, and promote greater emotional stability and more reliable judgment. Both focused and mindful meditation raise the levels of the same neurotransmitters at which SSRIs and SNRIs are aimed.

Movement and exercise, which have been repeatedly shown to at least equal anti-depressants in relieving symptoms of depression, and also to raise neurotransmitter levels, are central. It looks like about 30 minutes of daily exercise is optimal, but all of us should start with what we can do–walking a couple of blocks is a great beginning—and be sure to do something we hope to enjoy.

Nutrition may also be crucial in preventing, as well as treating, depression. People who are depressed may be deficient in B vitamins, Vitamin D3, Selenium, Magnesium, and the Omega 3 fatty acids that are present in fish oil. Others are sensitive to gluten and other food substances which may cause inflammation, which has been implicated in depression.

It is important to stimulate imagination and intuition as well as nourish the body. I teach techniques like guided imagery, drawings, and written dialogues to help depressed and anxious people to access more easily their imagination and to use their intuition and creativity to find answers to previously insoluble problems.

Work with a skilled therapist can be important, even crucial, but it is exponentially enhanced by what we can do for ourselves. Because they are grounded in self-awareness and self-care, each and every one of these techniques carries with it a general as well as a specific benefit. In acting to understand and help ourselves, we overcome the feelings of helplessness and hopelessness that are the hallmarks of depression.

Many people find they can multiply the effectiveness of self-care by being part of a group in which they learn together and share their experiences and themselves with one another. In the Mind-Body Skills Groups which The Center for Mind-Body Medicine has developed, participants feel less like damaged or ill patients, more like pilgrims together on a journey toward greater understanding, health, and wholeness.

Finally, symptom relief, the treatment of depression, and spiritual practice can be intimately connected. Using self-care techniques and living more meditatively often paves the way for us to connect with something—god, nature, a higher power—great than ourselves and to find meaning and purpose in our lives. And spiritual connection, meaning, and purpose are among the most powerful proven antidotes to depression.

James S. Gordon, M.D., a psychiatrist, is the author of Unstuck: Your Guide to the Seven-Stage Journey Out of Depression, from which part of this article was excerpted. He is the Founder and Director of The Center for Mind-Body Medicine, a Clinical Professor at Georgetown Medical School, and former Chair of the White House Commission on Complementary and Alternative Medicine Policy.

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