Overcoming Depression
Half of Americans will suffer from at least one bout of Clinical Depression (Major Depressive Disorder, or MDD) in their lives. In this article we’ll look at how that diagnosis is made. When someone says, “I feel depressed,” it’s easy to jump to the conclusion that they “have” MDD. At any particular point in time, 6.5% of American women suffer from MDD and 3.3% of men. Overall 5.3% of adults and 4% of adolescents suffer from MDD according to the National Institutes of health.
Causes of Depression
Depression is caused by inner and outer stresses, by genetics, brain chemistry, nutrition, and even by the amount of sunlight we get. The biological basis of depression is our neurotransmitters, the chemicals in our brain that allow one nerve cell to communicate with the next one. There are numerous neurotransmitters. The ones most commonly implicated in depression are serotonin and norepinephrine.
When I meet a new patient who says to me, “I have depression,” it’s likely that my response will be, “Let’s start off by saying that you feel depressed. When people say that they have depression, they have already bought into the disease model. A diabetic might say, ‘I have diabetes, or I’m diabetic.’ They have a disease.” The vast majority of people who feel depressed do not have MDD. People can feel depressed for a number of reasons, including: normal grief, unresolved conflict, feeling “blue,” and a strong reaction to acute severe stress, such as losing one’s job. A depressed mood can also be caused by problems with physical health such as: adrenal stress, hypothyroid, hypoglycemia, chronic viral infections, Parkinson’s Disease, brain tumors, stroke, CFS/ME (chronic fatigue syndrome/myalgic encephalopathy), and diabetes. Ten percent of pregnancies are followed by depression. A significant number of people who have had open-heart surgery will develop post-cardiotomy syndrome, which can include depression. Poor nutrition and protein deficiency can also cause depression.
Depression can also be caused by medications, including: minor tranquilizers, sedatives, birth control pills, high blood pressure medication, steroids like prednisone, and at least 50 other drugs. If you feel depressed and are taking any medication, ask your doctor about it, or Google it to see if it causes depression.
PTSD (post-traumatic stress disorder) can cause severe depression, whether the trauma occurred during childhood or during war. The underlying mechanism of depression in PTSD is not at all the same as in Major Depressive Disorder, and drugs don’t work well with PTSD.
In writing about depression for a column on alternative medicine, I would be remiss if I made this discussion only about alternatives to conventional treatments, including anti-depressant medications. We’ll get to as many nooks and crannies of depression as possible in this “depression series.”
While scientific data shows that half of us will suffer from MDD in our life, what is not discussed is that perhaps 99% of the population has felt depressed at some point. I’ve met about 5 people who have never experienced depression and have no idea what it is. Depression is not simply a disease that, when diagnosed, requires treatment with drugs. Depression (and anxiety) is part of the Western mind and personality. Anyone who has visited small villages around the world is struck by the lack of stress, anxiety and depression on the villager’s faces. Depression is the “culture-bound” disorder of the West.
DSM-IV
Let me explain why it is so important to know if your case of the blues is MDD or not. If you see a doctor and tell him you feel depressed, you will be prescribed an anti-depressant and the chances are very high that it will be an SSRI such as Prozac, Paxil, and Zoloft. A recent meta-analysis reviewed the efficacy of anti-depressants. A meta-analysis is a review of many scientific studies, perhaps 25–50 studies, in which conclusions are made from the large numbers of people treated for depression in all the combined studies. The meta-analysis showed that, when treating mild to moderate depression, anti-depressant medication is no more effective than placebo. The treatment of moderate to severe depression with anti-depressants is far more effective than placebo. Drugs aren’t bad. They are just prescribed incorrectly to millions of Americans. However in treating severe Major Depression, anti-depressant medication truly saves lives.
The Bible for psychiatric diagnosis is the DSM (Diagnostic and Statistical Manual). The current version is DSM IV. Now, let me help you plow through the DSM criteria for MDD. In order to make this understandable, I’ll do some paraphrasing.
“A person having a Major Depressive Episode: 1) has felt depressed for at least two weeks and 2) has had a noticeable drop in overall functioning. 3) They may have lost interest or pleasure in life. They feel depressed most of the day, every day. 4) They suffer from insomnia or hypersomnia (sleeping too much), and may have had 5) significant weight loss without dieting. 6) People with MDD have “psychomotor retardation,” which means that things are slowing down. They walk and talk more slowly. These changes are not only subjective; others see these changes. 7) Fatigue all day long is common. 8) Decreased ability to think and concentrate, 9) Feelings of worthlessness or excessive guilt (not merely self-reproach or guilt about being sick), 10) Recurrent thoughts of death and recurrent suicidal ideation, 11) The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.” Not all 11 of these criteria are required to diagnose MDD.
As a psychiatrist, I’m happy with the amount of detail in the DSM required to make the diagnosis of MDD. Let’s continue, by looking at what the DSM has to say about what is not MDD.
“It’s not MDD if: 1) There is a clear medical condition; 2) There are delusions or hallucinations; 3) Drug or alcohol abuse are present; 4) A medication the person is taking can cause depression; 5) The symptoms are better accounted for by bereavement after the loss of a loved one; 6) The patient does not have a major mental disorder such as schizophrenia.”
The good news about the DSM criteria for Major Depressive Disorder is that it is very thoughtful and thorough. The bad news is that, in my experience, few doctors who are writing anti-depressant prescriptions have carefully interviewed the patient and have found that they clearly meet DSM criteria. For simplicity, I’ll refer to one anti-depressant, Paxil, when referring to “anti-depressant medication.” If you visit a doctor and even mention feeling blue, down, or depressed, the chances are high that you’ll walk out with a prescription for Paxil. And psychiatrists are writing these prescriptions, right? Wrong. It has become very common practice for primary care doctors to prescribe Paxil for a wide array of medical problems, whether or not the patient is depressed or not. While psychiatrists are over-diagnosing MDD without sticking to the DSM criteria, primary care doctors truly are not qualified to be treating depression — at all! And I believe it’s unlikely that most primary care physicians have anything more than a cursory understanding of the DSM.
Drug Trends
In the ’60s and ’70s, the drug of choice for treating just about everything was Valium, a minor tranquilizer, or anti-anxiety drug. When abused, Valium is a problem. But the vast majority of people took Valium (or Ativan, Xanax, and Klonopin) as it was ordered, and did not turn into Valium addicts. Valium went from a main drug in the doctor bag to a “sinful drug.” Valium is not free of problems and should be discontinued very slowly (10 weeks if you are taking 10 mg a day). Prozac (and then Paxil) took the place of the Valium Trend.
I think that conventional medicine has fewer and fewer real solutions for chronic illness, while alternative medicine has more and more good options for chronic illness. But, doctors like to “do something,” and if they don’t know what to do, writing a Paxil order is a frequent, but highly faulty, recommendation. Thirty years ago we knew that 30 minutes of aerobic exercise is a powerful anti-depressant. From 1978 until today, I ask every patient about their exercise, and will help people get moving, whether they have to start by walking a few blocks, then walking further, then jogging, cycling or swimming.
The old family doctor frequently prescribed fluid and rest for a lot of problems, and exercise for depression. People visiting doctors today expect to “get something.” Doctors feel that pressure and have succumbed to “doing” before “being with their patient” and spending the time to make a careful, educated diagnosis.
In this series, we’ll be looking at when and how to use anti-depressants, how to deal with grief, how to scientifically test for neurotransmitter problems, and how to treat through nutritional medicine. We’ll look at cognitive behavioral therapy, ECT, light therapy, as well as the anti-depressant qualities of having a strong spiritual connection as well as a sense of meaning and purpose.
For now, if you (or someone close to you) are sad and blue, see if you fit the criteria for Major Depressive Disorder. If not, Paxil may not be your doorway to peace of mind.
David Gersten, M.D. practices Nutritional Medicine and Integrative Psychiatry out of his Encinitas office and can be reached at 760-633-3063. Please feel free to access 1,000 online pages about holistic health, amino acids, and nutritional therapy at www.aminoacidpower.com and www.imagerynet.com.