OUT OF THE BLUES
by Randi Henderson

Ask someone the best way to treat depression and you're likely to get the answer 'medication.' But a host of alternative therapies tell a different story.

Shelley Wallace didn't know what was wrong with her, but she knew that the way she was feeling in the months following the birth of her first baby couldn't be normal.

"I couldn't seem to get myself in a good mood," recalls Wallace, 29, a Maryland mother of two young children. I slept a lot, but I was tired all the time. I had panic attacks if I had to leave the house. I couldn't concentrate. I couldn't make dinner. Cleaning the bathroom, I'd stand there and not be able to figure out whether to clean the sink or tub or toilet first. Then I'd break down in tears and it wouldn't get done." One day when she was at the doctor's office with her husband and child for a well-baby check, her husband pointed to a poster on the wall listing the symptoms of depression. "Honey, this sounds like you," he told her. The next day Wallace saw a newspaper ad for a depression screening at the local hospital. She went, filled out a questionnaire, and was told she was severely depressed.

Wallace's family doctor started her on Zoloft, which made her feel cranky. Paxil was no better, so she moved on from her family doctor to a psychiatrist, who prescribed Effexor. One of the newest generation of antidepressants, Effexor increases levels of serotonin and norepinephrine, chemicals thought to be inadequate in people with depression. It made Wallace feel numb. All the drugs, and she was still so depressed she was suicidal. Eventually she was hospitalized. When her doctor started talking to her about electroconvulsive therapy (ECT), she felt her soul recoil and knew she needed to get on another track.

Wallace checked out of the hospital against medical advice and weaned herself from antidepressants. As the months went by, she felt her depression lifting. She started working part-time for a computer company-and found out she was pregnant again. She was excited about her pregnancy and not overly concerned about another episode of what she had come to understand was a severe postpartum depression.Within a few months of her second baby's birth, however, the dark cloud once again settled and Wallace was barely functional. "This is too much for me-I'm going to have to go back on the drugs," she told her husband, but he suggested she try an alternative. He had a coworker who was an herbalist, on whose advice Wallace started taking a combination of Chinese herbs: dong quai, valerian, and ginkgo. Dong quai, one of the most widely used herbs in China, is referred to as the "female herb"; the herbalist told Wallace it might help with the hormonal swings that are believed to influence postpartum depression. Valerian is used to combat anxiety and improve sleep, and ginkgo seems to aid concentration.

Wallace used the herbs for a month and felt better almost immediately. When she ran out of them, she tried doing without, but the depression once again descended. She began taking the herbs again and started feeling better. She also tried one session of acupuncture and found that it lifted her mood for days. Says Wallace: "The herbs and acupuncture helped me more than any antidepressant or shrink ever did."

Shelley Wallace is one of thousands in the United States and millions worldwide who use alternative treatments for depression and get better results than they've gotten from traditional medications and psychotherapy. Alternative approaches-from herbs to nutritional therapy to physical exercise to homeopathy to spiritual healing-often not only provide dif ferent treatment tools for depression but also challenge basic assumptions about this condition.

Depression is one of the most prevalent disorders diagnosed in the United States today. Nearly 5 percent of the adult population has diagnosable depression within a one-year period, says Ronald Manderscheid, chief of the Survey and Analysis Branch of the U.S. Center for Mental Health Service. Other studies put that number even higher, and as much as 20 percent of the adult population are thought to have experienced depressive symptoms at some time in their lives.

The current standard psychiatric understanding of depression is that its origins are biochemical, possibly genetic. Endogenous depression which comes from within-is usually differentiated from exogenous depression, which is a reaction to external circumstances and is more transient. But many alternative practitioners question this clear-cut diagnostic distinction and emphasize that depression must be treated not as a compartmentalized disorder but as one that is integrally related to an individual's life and culture.

"We have to honor depression-it tells you where you are," says John Welwood, a San Francisco clinical psychologist and associate editor of the Journal of Transpersonal Psychology. "It tells you of your disconnectedness, of where your life is out of balance." Says psychiatrist James Gordon, director of the Center for MindBody Medicine in Washington, D.C.: "The first thing I tell my depressed patients is it's not a disease. Once you get out of that mode, you have a whole range of treatments open. You can turn anything into a disease. The question is, is it useful to view it that way? There are examples of all kinds of diagnostic folly. In the 1840s many Americans viewed drapetomania as a disease-it's the uncontrollable urge of a slave to run away." Gordon calls conventional treatment of depression by pharmacotherapy only inadequate but also counterproductive." Nevertheless, treating depression medically has become a billion-dollar industry. Last year physicians presented, recommended or administered antidepressants 28 million times. The two classes of drugs that have been used for more than 30 years, and + (MAO) inhibitors, have been eclipsed in the 1990s*++ by the increasingly popular selective serotonin reuptake inhibitors (SSRIs). as the name indicates, block the reuptake of serotonin in the chemical pathways of the brain, increasing the availability of this neurotransmitter, which is associated with feeling good and is thought to be in short supply in the brains of depressives.

SSRIs became popular because for most people they seem to have fewer and milder side effects than other antidepressants as well as less potential for addiction. Prozac, the first and still the most commonly prescribed SSRI, quickly achieved celebrity status, appearing on the covers of Time and Newsweek. Within two years of its introduction in 1988, more than 650,000 prescriptions per month were being written. By the early '90s, sales of Prozac accounted for $1 billion of the $8 billion antidepressant market. The increase in the use of SSRIs has leveled off after a rapid upward spiral in the early to mid-'90s. Still, in 1996 Prozac and Zoloft were the number-three and number-five drugs sold in this country in terms of total dollar sales. Often SSRIs are prescribed not by psychiatrists but by primary-care physicians like Shelley Wallace's, who may take less than five minutes to come up with a diagnosis and write a prescription. Many orthodox psychiatrists raise a skeptical eyebrow at the way SSRIs are prescribed. "It's mad medicine," says Paul Wender, M.D., cofounder of the National Association for Depressive Illness and a professor of psychiatry at the University of Utah School of Medicine. "Prior to SSRls, you had to titrate the doses [calculate an exact measurement to achieve a certain result] and help patients through the side effects. With Prozac, Zoloft, and Paxil, if you have the IQ to write 'one pill per day/ you can write a prescription for it."

Many people respond favorably to antidepressants, although it is still not clear that any of the drugs does a better job than talk therapies. A recent survey of the scientific literature concluded that "psychological interventions, particularly cognitive-behavioral therapy, are at least as effective as medication in the treatment of depression, even if severe." The review also noted that "effective non-drug strategies are often ignored by medical practitioners."

Most alternative practitioners- naturopaths, homeopaths, acupuncturists, body psychotherapists, transpersonal psychiatrists, and others-while critical of the widespread use of chemical antidepressants, are also careful to leave a place for them, particularly for their most serious patients. In fact, the most widely touted alternative treatment for depression is another chemical, although one that comes from a plant rather than a lab. Saint Johnswort ("wort" is from the Middle English for "plant"), an herb with bright orange-yellow flowers, has been known since antiquity for its curative powers. Contemporary medicine may be suspicious of ancient healing lore, but Saint Johns Wort (botanical name hypericum perforatum, or hypericurn for short) is holding up under the scrutiny of modern scientific investigation.

In August 1996, the British Medical Journal published a review of 23 randomized trials testing the effects of hypericurn compared with those of pharmaceutical antidepressants. "Hypericum extracts were significantly superior to placebo," the reviewers found, "and similarly effective as standard antidepressants." Two years earlier, the journal of Geriatric Psychiatry devoted an entire issue to hypericurn research. The cumulative result of the research was improvement in 80 percent of the 3,250 mildly to moderately depressed patients who took the herb, including many who said they were symptom-free after a month on Saint Johns Wort.

The herb-available in healthfood stores in tablets, capsules, drops, and tea-also produces considerably fewer side effects than most pharmaceuticals. The only potentially serious side effect of hypericurn is an increased sensitivity to sunlight that has been observed in light-skinned animals (sheep) but not in humans. In the 3,250-patient sample, only 2.4 percent reported any side effects, and these were primarily mild gastrointestinal irritation, allergic reactions, or fatigue.

The hypericurn research is "a real integration between traditional medicine and what used to be called alternative medicine," says Harold Bloomfield, a psychiatrist practicing in Southern California and the co-author of Hypericurn and Depression. "None of us learned about herbal medicines in med school." Bloomfield became aware of hypericurn a couple of years ago when he researched a previous book, How to Heal Depression.

Bloomfield admits he was skeptical at first. "I had a bias against herbal medicine, thinking it was on the fringe, with a placebo effect at best. Now I realize that attitude was very foolish. Most of our medicines come from plants-digoxin, penicillin, morphine. It's very important to pay attention and see if there is anything of value here."

Saint Johnswort contains a number of active chemicals, and much remains to be learned about the mechanism of action. "Many streams make one river," Bloomfield notes. "Hypericum and pseudohypericurn appear to have an SSRI effect. The advantage in having multiple chemicals working is that there is a more holistic response than there would be to one chemical, and less troublesome side effects."

Truen Bergen, 48, is one of Bloomfield's patients, who managed for years to keep a smile on her face while feeling disconnected and isolated. She limped through a life she describes as "laced with depression" since childhood. She remembers getting some relief from biofeedback, and intermittently she'd see a therapist or physician. "They'd prescribe Valium and say I'd be okay," she recalls, "but I wasn't."

About 15 years ago, she began seeing Bloomfield. She resisted the diagnosis of depression but tried the anti-anxiety medications Ativan and Xanax, and then Paxil, Zoloft, and Effexor. She also tried meditation, tai chi, yoga, and exercise, which had minimal effects on her depression. The SSRIs did not agree with her: She felt manic and out of control on Paxil, Zoloft caused a feeling like an electrical charge going through her, and Effexor made her jaw and neck feel so tense she thought she had lockjaw.

Bergen felt that she was looking at the world through a thick, smoky glass, with all the happiness and sunlight on the outside. She decided on her own to try Saint Johnswort after reading Bloomfield's book about it. She bought the capsules at a health-food store and started taking a couple a day. She laughs as she remembers the herb's initial impact. "I remember exactly when it hit me. I'd been taking it about three weeks and was driving along this canyon and felt this amazing feeling of balance and well-being." At first she didn't relate the feeling to Saint Johnswort, but when she went out of town for a few days without the herb, she started to sink back into darkness. Within a week of resuming Saint Johnswort, she felt better again. Bergen continues taking Saint Johnswort, three 300-milligram capsules, one at each meal. "The end result isn't anything outstanding," she says, "but I don't have this deep dread in my heart that dictated my life and daily experience in the past."

While the medical establishment is looking with interest at Saint Johnswort, homeopathy generally attracts little more than raised eyebrows from the main stream. There is little or no scientific rationale for this system of medicating with tiny quantities of substances that in larger quantities might induce the same symptoms a person is experiencing. The philosophy that "like cures like" seems counterintuitive. However, results tell a different tale, and many people report successful outcomes using homeopathic treatments for a number of conditions, including depression. "In homeopathy you don't treat a disease; you treat a syndrome, of which depression is a part," explains Dana Ullman, a homeopathic educator and the author of The Consumer's Guide to Homeopathy. This holistic approach, which characterizes most alternative treatments, is coupled with individualized strategies for each patient. "Each depression will have important and subtle differences," Ullman says. "There is no one remedy."

He mentions one treatment, aurum, which is made from minute particles of gold dust. "It is a classic remedy for dark depression," he notes, "resembling-at least mythically-the gold standard of light, the sun." Another often effective treatment is natrurn muriaticum, which is sodium chloride-salt. "What is interesting about salt is that it is one of the primary ingredients within the tear," Ullman points out. "People who benefit from this are often people who have experienced some type of grief or loss." For Neva Trenis, a 37-year-old Virginia woman, it was neither gold nor salt but another homeopathic remedy-sepia-that lifted a depression that had plagued her intermittently for years, since the birth of her first child. Sepia is the dye that comes from the fluid emitted by the cuttlefish. "I studied biochemistry-I have the same reaction as anyone," says Trenis. "Why does the ink of the cuttlefish, in these minute doses, take away my depression?"

The bottom line for her, though, is that it does work, and has changed her life. Trenis was treated by Wayne Jonas, one of a number of physicians who are incorporating alternative approaches into their practices. Trenis credits the individualized attention she received from Jonas as part of the reason for her success in treatment. "This homeopathic medication just allows me to feel normal," says Trenis, who continues a daily maintenance dose with the eventual goal "to get my body to do this on its own."

Jonas has moved on to direct the Office of Alternative Medicine (OAM) at the National Institutes of Health (NIH). OAM's mission is to employ "appropriate, high-quality scientific methods" to "evaluate and investigate complementary, alternative, and unconventional medical practices." Founded in 1991, the office funds a range of studies looking at medical problems from AIDS to diabetes to lower-back pain, cancer to premenstrual syndrome to brain injury. So far, OAM has commissioned only two projects on depression, a study of the use of acupuncture and a study of Saint Johnswort. The acupuncture study looked at 34 severely depressed women for 16 weeks, and researchers concluded that the results were promising enough to justify further trials.

Notice of alternative medicine by the NIH is no doubt a result, at least in part, of the attention and study that have trickled up from grassroots health-care providers who see more and more patients turning to alternative treatments and an increasing number of colleagues incorporating alternative techniques or referring to alternative practitioners. "I get referrals from other doctors all the time," says Elson Haas, M.D., director of the Preventive Medical Center of Marin, in San Rafael, California, and author of Staying Healthy with Nutrition and three other books on nutrition and medicine. "Western medicine doesn't have the answer for so many chronic problems."

But a solid contingent of physicians remain skeptical. Psychiatrist Paul Wender expresses a notuncommon attitude. "It's all garbage," he says of the panoply of alternative approaches. Solid scientific data supports the effectiveness of antidepressants and ECT to treat depression, he says, and until a similar body of evidence validates alternatives, he cautions against using unproved treatments. "We're not talking about treating depression the ordinary human emotion," he says. "We're talking about depression the potentially lethal disease."

EIson Haas is one of a number of holistic practitioners who report success in alleviating depression with nutritional therapy. Nutritional therapy focuses on food and dietary supplements, the fuels that power the body, with an approach that involves the exclusion of certain foods, the inclusion of others, and the addition of vitamins and other supplements such as amino acids. Haas works with patients to "detox" them from substances such as caffeine, sugar, and alcohol "and get someone on a cleaner, more vital diet with more fresh foods and whole grains and fewer packaged, refined foods and dead animals." Nutritional supplements are helpful, Haas adds, "particularly vitamin B6, which seems to help the metabolism of all the macronutrients and amino acids. We'll probably find out in the future that depression is related to amino-acid imbalance."

Nutritional therapy is generally used in conjunction with other treatments, particularly herbs and lifestyle changes. But sometimes the results of dietary changes can be quite convincing. Haas describes one patient, a 35-year-old man who suffered a succession of low-level physical complaints, a sore throat, an upset stomach, and mild to moderate depression. "We put him on a multivitamin and a sugar-free diet," Haas says. "We got him away from a couple foods he was habitually using, like too much bread and dairy products. Then we added L-tyrosine." Within a week, improvement was noted-"the improved energy that is often typical of getting off sugar," Haas says. The patient also started taking hypericurn with continuing good results.

Joel Robertson, a Michigan pharmacologist and the author of Natural Prozac: Learning to Release Your Body's Own Anti-Depressants, is another advocate of nutritional therapy for depression, but he warns that each prescription must be individualized. He stops short of suggesting his approach as a way to treat major depression, but he sees it as a preventive measure that is effective in less severe cases.

"We go beyond just calories and low fat; we go right into specific food types and specific food when to eat, why, and how often," he explains. The precise dietary recommendations are based on a detailed behavioral questionnaire that he says provides the necessary profile to analyze brain chemistry and to point in the direction of necessary adjustments. For example, he proposes specific dietary guidelines "to increase serotonin as quickly as possible, while gently and gradually increasing norepinephrine and dopamine." These include eating whole-grain foods at every meal and for snacks; eating low-fat, high-protein foods such as fish or white-meat chicken twice a week; eating daily servings of vegetable-protein foods such as beans or tofu; and reducing or eliminating high-fat animal products and caffeine from the diet. These modifications are combined with recommendations regarding exercise and behavior, which also influence brain chemistry.

An element incorporated into most alternative treatment plans for depression is attention to the benefits of regular aerobic exercise to prevent or alleviate the condition. "It's hard to be depressed when you're exercising," Haas says. "I'm not talking about walking around mowing the lawn. I'm talking about getting your heart rate up to 135 or so for a half-hour or 45 minutes a day."

Various studies have found that regular aerobic exercise increases levels of serotonin as well as dopamine and norepinephrine, the other neurochernicals associated with feelings of well-being and the ability to enjoy life. A recent study found that even short bursts of strenuous exercise resulted in lessened feelings of depression. And exercise can produce profound psychological effects as well: It takes a person away from problems and promotes a sense of achievement, of completion of a prescribed task. The physiological and psychological combination can be euphoric.

However, exercise is not a cure all. One recent study found that runners have depression rates as high as those of the general public. And for many people, physical activity is easier recommended than accomplished. A caveat of the exercise prescription is not to set people up for failure with unrealistic goals. "Depression is often accompanied by low energy," says Barbara Goodrich-Dunn, a body psychotherapist in Silver Spring, Maryland. "If you throw someone who is really depressed into an exercise program, they'll think, 'I'll just fail.' Starting an exercise program can just be too much. So start with very modest goals-to just stand up for two minutes a day or to walk a half a block."

Body psychotherapy represents a different physical approach to treatment-it is not exercise, not massage, not physical therapy, Goodrich-Dunn points out. Rather, it is "a way of approaching the psyche by looking at how someone is holding their body," she explains. "The energy patterns of the body say a lot about what is going on with the psyche." Not only can posture, stance, and gait speak of what is happening in the mind, but treatments can be based on them. There are a number of different approaches to body psychotherapy: Some use meditation, some use movement, some use physical expression of emotions such as anger. "We work on drawing" he notes, although patients are often concerned about this. He tells of one patient, a man in his 50s who was a "numbers cruncher" and said he couldn't draw.

"Think of your grandchildren and how they draw spontaneously if you put crayons in front of them," Rosen counseled. "You have to meditate and get out of the part of you that says you can't draw. In kindergarten, everyone can draw." Rosen takes his patients inward to treat what he calls the "existential/spiritual factor" of depression, but he also appreciates the necessity of addressing the other, more outward facets-the biological, psychological, and sociocultural aspects.

For his part, John Welwood speaks more of the cultural origins of depression as he describes the journey on which he takes his patients. "The word 'depression' says 'pressing down/ the feeling that wants to come up when you are cut off from life, a sense of loss and grief," he says. "In our culture we don't know how to relate to that very well; we don't understand it. Grief makes us feel down, and we want to feel up. Depression comes from the longing, the disconnection that people don't want to feel."

Welwood, like Breggin, stresses the need for empathy. "The place to start is to help people feel what they feel. People need kind understanding, starting with themselves. If you are depressed, approach it with kind understanding: 'I feel down. Why do I feel down? What's the matter? What do I need?"' Asking those questions, he says, is likely to lead to an answer like: "I don't have a community, my relationships aren't good, I'm working too hard, I don't have time to relax and enjoy life. No wonder I'm feeling depressed." Moving from these understandings to "learning how to be present with your experience" is the next step Welwood describes. "I'm not saying if you express your emotion, it will cure the symptom," he explains. "I'm talking about being open with your experience. It takes a capacity to just allow it and feel it directly without having to express, analyze, or fix it. In opening to our experience in that way, we actually start to connect with our being."

The process is individualized and the duration variable, Welwood says. "Some people can do this when they walk through the door, some people take months, some you can never reach. You can't change the world or give them community, but at least you can help them see the elements that are missing from their lives. Often you can help them change their lives."

Welwood laughs softly when he considers where a discussion of depression should begin. “Let's start with Plato," he suggests. "You almost have to go back to the most basic assumptions about what people understand about life. It's a long history. Depression is endemic in this culture, and that's not accidental, because this culture doesn't really teach people how to live. And it's accelerating now, with the capitalistic frenzy that is sweeping society. All kinds of cultures are getting cut off from their roots. It's not happening just in the U.S."

With depression rampant, and exacerbated by the contrast between individual feelings of despair and a culture where so many external stimuli emphasize feeling good, people are eagerly seeking healing solutions. Prozac and its cousins, so shiny with promise a few years ago, are clearly not for everyone. Saint Johnswort was the next media darling, but the hope it offers is also limited. Alternatives expand the menu of treatment choices, but the selections must be tailored for each user. While there is not enough scientific proof to dictate that we abandon Western medicine for alternatives, there is ample historical and clinical evidence suggesting that we pay attention to these alternatives, and acknowledge the paths they point to.

Randi Henderson is a writer in northern Maryland. She wrote about the effects of Ritalin on children in the May/June 1996 Common Boundary

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