A Holistic Approach to Depression Treatment

Antidepressants appear to be effective only in 20-40% of people compared to placebo. Those with mild to moderate depression show the worst response rate.  I am not saying not to use antidepressants, they are helpful for some. However, for the majority of people who experience no real benefit or who continue to have residual symptoms, we need to explore other interventions instead of or in addition to antidepressants.

Many people I work with expect to start taking antidepressants and wake up one morning and spontaneously feel like Mary Poppins. It takes more than a pill to change their outlook, help them deal with life on life's terms.  If people are still viewing the world from a pessimistic perspective, having unhelpful thoughts (cognitive distortions), lacking coping skills, under a ton of stress and not taking care of their health, then they likely are not going to show a great response. We also still cannot pinpoint which neurotransmitter is out of balance and causing symptoms for any one person, so any one antidepressant may or may not work. Imbalances in serotonin, norepinephrine, dopamine and GABA are all related to depressive symptoms. Unfortunately, we cannot just give someone a pill to increase them all and hope for the best. 

Neurotransmitters exist in a very delicate balance. When you increase one, you cause the body to alter the levels of all of the rest. (Learn more about Neurotransmitter functions and interactions in Counselor Toolbox Podcast episodes 354-356;364.) Think of it like a good marinara sauce. Salt takes out the bitter and enhances the sweetness, so you need less sugar, but it may blunt the taste of the parsley, so you have to add more, but parsley can overwhelm the basil and so on. While I am on the topic, neurotransmitters exist throughout the body, and more than 80% are made in the gut. So, a urine test for a neurotransmitter level does little or nothing to indicate the levels of the neurotransmitter in the brain. It is a waste of time and money in most cases.

Many patients with seemingly "treatment resistant depression" often have underlying biological issues that are working against their best efforts. As clinicians we need to be better about asking the question, "What is causing the neurotransmitters to be out of balance?"  There are a myriad of other causes of depressive symptoms which antidepressants just do not help with including hypothyroid, leaky gut, testosterone or estrogen imbalances, cardiac problems, hypocortisolism, chronic inflammation caused by autoimmune disorders, poor quality sleep, inadequate nutrition, medication side effects, or chronically high cortisol from a stressful environment to name just a few. (Learn more about the many causes of depressive symptoms in Counselor Toolbox Podcast Episode 98 )

By the time people come to therapy for their depression, they usually are exhausted, have overwhelmed their coping skills, started having difficulty in their relationships and begun having unhealthy sleeping, eating and lifestyle behaviors. One of the first steps is to help them get the energy to do the work necessary for full recovery. It ain't easy!

All patients should have a complete physical including thyroid function, vitamin D and sex hormone levels and a cortisol challenge test (ACTH stimulation test) to address any hormonal or other biological causes of depression. 

They should also start keeping a food log (like the Spark People app) to ensure they are getting all of the nutrients they need. If they are having difficulty, a referral to a registered dietitian should be made. Neurotransmitters and hormones, among other things, are all created from the nutritional building blocks in the foods we eat. Nutrients in a bottle (supplements) are not nearly as bioavailable as nutrients from food. Like altering one neurotransmitter alters the balance of all the others, the body needs nutrients in a very special ratio. (Learn more in Counselor Toolbox Podcast Episode 100 ) In some recent studies, for example it was found that bodybuilders who used a lot of Branched Chain Amino Acids (BCAAs) (a particular type of proteins) were more likely to also have depression, as a result of a shift in the availability of other amino acids.  The take away message is that poor nutrition = poor health and mental health. 

Thirdly, since most patients with depressive symptoms report sleep disturbances, clinicians should review sleep hygiene with patients to ensure they are doing everything they can to get quality sleep. This includes eliminating caffeine 8 hours before bed and alcohol and nicotine 2 hours before bed, reducing blue-light exposure 2 hours before bed, having a sleep routine, and making sure the sleep environment is ergonomically sound and conducive to sleep (light, noise, temperature etc.). (Learn more in Counselor Toolbox Podcast Episode 99)

These relatively simple interventions can give a much more detailed picture of what is causing the depressive symptoms, and often greatly increases patient motivation. They start understanding the breadth of the problem and feeling more empowered to actually make changes in their lifestyle and do the work in therapy that will help them address underlying cognitive and interpersonal issues . Furthermore, they can assist us in helping a much greater percentage of people actually achieve moderate to full symptom remission.