Depression and Treatment

"There is a paradigm shift. We're starting to listen to the people we treat."
"We're increasingly realizing that there is a proportion of patients who are either unwilling for philosophical reasons [to take antidepressants] or find it difficult to tolerate them."
"It's not the uneducated people who resort to these kinds of alternative therapies, but well-educated sophisticated patients who suffer from depression or anxiety."
"There will always be [psychiatrists] who will be more dogmatic about it. But I think there is room for all options, and I think we owe it to our patients to have a more broader perspective on this [mental health treatment options]."
Dr. Arun Ravindran, senior scientist, Centre for Addiction and Mental Health, Toronto

"Instead of taking a pill, you're going to do yoga, that's great too. [But St.John's wort? I think] the fish stuff has been oversold."
"You need to watchfully wait. Explain that [mild, transient depression] is normal, that people have ups and downs. And if it persists, then it may need treatment."
Dr. Allen Frances, psychiatrist, founding editor: the Journal of Personality Disorders and the Journal of Psychiatric Practice

Jim Young/Reuters

There is no disagreement between these two mental health experts. Both agree that severe forms of depression will require that antidepressants continue to be prescribed as part of therapy to help people cope with the degree of their illness. Dr. Frances was the lead author in the fourth edition of The Diagnostic and Statistical Manual of Mental Disorders, the veritable tome of mental illness that mental health care professionals have become reliant upon for its illness identification guidelines and recommendations.

Yet a growing group of psychiatrists is now becoming increasingly comfortable with a more flexible approach in treating the various gradients of depression. Mild to moderate depression, they feel, can be successfully treated and perhaps unsurprisingly, with physical action. Jogging, swimming, dancing, brisk walking; in fact any form of aerobic exercise that effectively increases breathing and heart rate. Yoga is particularly noted for its efficacy in this regard, for treatment of moderate depression.

The latest edition of the Canadian Journal of Psychiatry issued from the Canadian Network for Mood and Anxiety Treatments goes so far as to recommend exercise as a first-line treatment for mild to moderate depression for adults. An additional recommendation is use of the herbal remedy, St. John's Wort. Both recommendations can be identified as 'folk remedy', for people have long recognized the utility of exercising the body to enhance both physical and mental health.

A second-line, add-on therapy notes the usefulness of yoga and omega-3 fatty acids. This represents a turnaround in conventional treatments, conventionally heavily reliant on prescription drugs, in a treatment environment that has long been skeptical of the use of and usefulness of alternative medicine "in a blanket kind of way", observed Dr. Ravindran, admitting the time has come to take heed of what people suffering from depression have themselves divined as reliable first-stage remedies.

Guidelines still focus on conventional therapy as best practise for people suffering with major depressive disorders. Drugs and/or psychotherapy should come first to mind in consideration, followed by complementary or alternative treatment. Conventional drug treatment is not particularly beloved by many. With use of the Prozac-type drug class SS-RIs [selective-serotonin reuptake inhibitors] as example, sexual dysfunction comes in at 30 to 40 percent.

Aside from which evidence is increasing that medication for mild depression has little advantage over placebos "and it brings all the side effects", noted Dr. Frances, adding that "the literature is clear that exercise helps". Behind all the misery of depression, there is stress brought by life-events. Sadness and stress, commented Dr. Francis, reflect life; mild, transitory depression will in most instances, improve on its own, over time.

Canadians are among the greatest users  of antidepressants worldwide. Two years ago, 47.1 million antidepressant prescriptions were filled, resulting in pharmaceutical sales of $1.91 billion in that class of drugs. Family doctors prescribe the major proportion of the antidepressants for their patients resulting in an estimated 11 percent of the Canadian population on an antidepressant. In tandem, alternative therapy use has grown in prevalence.

The last word from Dr. Frances is that life is not a predictable constant, and people living normal lives are exposed to vicissitudes of fortune, some good some not. In response, people have their 'ups' and their 'downs' expressed in depression brought on by events beyond their capacity to prevent, or sometimes in unforeseen consequence of their actions. It is if and when that depression persists that professional treatment may be required.