Anxiety & Depression
What Are Depression and Anxiety?
Depression and anxiety can impact individuals of any age. People with depression frequently also suffer from anxiety.
The causes of depression and anxiety appear to be complicated. While there may be a biochemical cause, meaning that certain chemicals-neurotransmitters-in the brain may be low, it is not clear if the low level of the neurotransmitter is the primary cause of the depression, or simply a marker for the cause of depression. In addition to biochemical causes, there are also genetic, psychological, emotional, environmental, social, and spiritual factors that influence depression and anxiety.
Depression is the most common psychiatric disorder. It is a disabling condition that adversely affects a person's family, work or school life, sleeping and eating habits, and general health. In the United States, the incidence of depression has increased every year in the past century, and now one out of six people will experience a depressive episode.
Depression is typically characterized by low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Symptoms include:
- Sleep disorders (too much or too little)
- Shifts in appetite and weight (too much or too little)
- Irritability or anxiety
- Chronic physical symptoms, including pain, gastrointestinal disturbances, headaches, etc.
- Loss of energy and fatigue
- Feelings of persistent sadness, guilt, hopelessness, or loss of self-worth
- Thinking difficulties, such as memory loss, challenges concentrating or making decisions
- Thoughts of death or suicide
Some more facts about depression:
- Women suffer from depression at approximately twice the rate of men.
- Only 50 percent of people actively seek conventional treatment, even though more than 80 percent of cases can find alleviation of their symptoms through treatment.
- Depression causes unnecessary suffering and is a risk factor for suicide.
- Approximately 3.4 pecent of people with major depression commit suicide, and up to 60 percent of all people who commit suicide have depression or another mood disorder.
Anxiety is a normal reaction to stress, and it can serve as a prompt to deal with difficult situations. However, when anxiety becomes excessive, it may fall under the classification of an anxiety disorder. Almost one out of four people experience an anxiety disorder during their lifetime.
Anxiety disorder is characterized by emotional, physical, and behavioral symptoms that create an unpleasant feeling that is typically described as uneasiness, fear, or worry. The worry is frequently accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes.
While generalized anxiety disorder is the most common, there are other anxiety disorders, including obsessive-compulsive disorder, panic disorder, phobias, and post-traumatic stress disorder
What Are the Conventional Treatments for Depression and Anxiety ?
Just as no two people are affected the exact same way by depression and anxiety, there is no "one size fits all" treatment. What works for one person might not work for another. The best way to treat depression or anxiety is to become as informed as possible about the treatment options, and then tailor them to meet your needs.
There are many types of therapy available. Three of the more common methods used in depression include cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. Often, a blended approach is used.
Some types of therapy teach you practical techniques on how to reframe negative thinking and employ behavioral skills in combating depression and anxiety. Therapy can also help you understand why you feel a certain way, what your triggers are, and what you can do to stay healthy.
Interpersonal and cognitive/behavioral therapies are two of the short-term psychotherapies that research has shown to be helpful for some forms of depression. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving that are often associated with depression.
People suffering from anxiety disorders often participate in cognitive-behavioral therapy, which focuses on recognizing and changing thought patterns and behaviors that lead to troublesome feelings. This type of therapy helps limit distorted thinking by looking at worries more realistically.
Psychodynamic therapies are sometimes used to treat depression. They focus on resolving the patient's internal psychological conflicts that are typically thought to be rooted in childhood. Long-term psychodynamic therapies are particularly important if there seems to be a lifelong history and pattern of inadequate ways of coping (maladaptive coping mechanisms) in negative or self-injurious behavior.
Medications for Depression
- Selective serotonin reuptake inhibitors (SSRIs) are medications that increase the amount of the neurochemical serotonin in the brain. Brain serotonin levels are often low in depression, and as their name implies, the SSRIs work by blocking the reuptake of serotonin in the brain so it stays around. SSRIs have fewer side effects than many of the older generation antidepressants, such as the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Therefore, SSRIs are often the first-line treatment for depression. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro).
- Dual-action antidepressants. Some of the newer antidepressant drugs appear to have particularly robust effects on both the norepinephrine and serotonin systems and are called "dual-action." These drugs seem to be very promising, especially for the more severe and chronic cases of depression. Venlafaxine (Effexor) and duloxetine (Cymbalta) are two of these dual-action compounds.
- Atypical antidepressants are so named because they work in a variety of ways. Examples of atypical antidepressants include nefazodone (Serzone), trazodone (Desyrel), and bupropion (Wellbutrin).
- Mood stabilizers and anticonvulsants include Lithium (Eskalith, Lithobid), valproate (Depakene, Depakote), carbamazepine (Epitol, Tegretol), neurontin (Gabapentin), and lamictal (Lamotrigine). They have been used to treat bipolar depression.
- Tricyclic antidepressants (TCAs) were developed in the 1950s and 1960s to treat depression. They work mainly by increasing the level of norepinephrine in the brain. TCAs are safe and generally well-tolerated when properly prescribed. However, if taken in excess, TCAs can cause life-threatening heart-rhythm disturbances. Examples of tricyclic antidepressants are amitriptyline and desipramine.
- Monoamine oxidase inhibitors (MAOIs) are the earliest developed antidepressants. MAOIs can interact with over-the-counter cold and cough medications to cause dangerously high blood pressure. Because of these potentially serious drug and food interactions, MAOIs are usually only prescribed after other treatment options have failed.
Medications for Anxiety
Medicines used to treat anxiety disorder may be especially helpful for people whose anxiety is interfering with daily functioning. The medications most often used to treat anxiety are:
- Benzodiazepines. These medications are sometimes referred to as "tranquilizers," because they leave you feeling calm and relaxed. Common benzodiazepines include Xanax, Librium, Valium, and Ativan.
- Antidepressants, such as Paxil and Effexor.
Dependency on anti-anxiety medications is a potential complication of treatment. Other side effects of medications include sleepiness and sexual problems.
Electroconvulsive therapy (ECT)
In ECT, an electric current is passed through the brain to produce controlled convulsions (seizures). ECT is useful for certain patients, particularly for those who cannot take or have not responded to a number of antidepressants, have severe depression, and/or are at a high risk for suicide. In many people, ECT relieves depression within one to two weeks after beginning treatments. After ECT, some patients will continue to have maintenance ECT, while others will return to antidepressant medications. In recent years, the technique of ECT has been much improved.
What Lifestyle Changes Are Recommended for Depression and Anxiety?
Lifestyle changes are simple but powerful tools in treating depression. Sometimes they might be all you need. Even if you need other treatment as well, lifestyle changes go a long way toward helping lift depression. Lifestyle changes that can treat depression include:
Numerous well-designed studies have found exercise to be as effective as prescription antidepressants or psychotherapy, which are roughly equivalent to each other in their success rates for treating depression. The bulk of studies evaluating the impact of exercise on anxiety have found an improvement in symptoms with increased physical activity.
Exercise stimulates the body to produce serotonin and endorphins, which are chemicals in the brain (neurotransmitters) that alleviate depression. But that only partially explains the positive impacts of exercise on depression.
Participating in an exercise program can increase self-esteem, self-confidence, and sense of empowerment, as well as improve social connection and enhance relationships. All of these things have a positive impact on a depressed individual.
A number of studies have shown that a diet high in simple sugars or in caffeine (750 mg daily) is related to increased rates of major depression. In one small study, eliminating refined sugars and caffeine results in improved symptoms of depression within one week. Long-term use of caffeine has been linked with anxiety as well.
Longer term studies in this area are needed, but minimizing refined sugars and caffeine is currently an easy and logical recommendation.
Depressed populations also have more problems with alcohol use. People suffering from depression should stop drinking alcohol. If alcohol abuse underlies the depression, it is critical that it be addressed directly.
Poor sleep has a strong effect on mood. Make getting the amount of sleep you need a priority.
Strong social networks reduce isolation, a key risk factor for depression. Keep in regular contact with friends and family, or consider joining a class or group. Volunteering is a wonderful way to get social support and help others while also helping yourself.
Make changes in your life to help manage and reduce stress. Too much stress exacerbates depression and puts you at risk for future depression.
What Are Some Integrative Therapies and Healing Practices to Consider for Depression?
A 2001 large survey study of people in the U.S. who considered themselves anxious or depressed, found that more people used complementary and alternative therapies than conventional therapies. In fact, 53.6 percent of respondents suffering from severe depression reported using complementary and alternative medicine for treatment in the 12 months prior to the survey published in the American Journal of Psychiatry.
While people with depression perceive integrative therapies to be as effective as conventional medicine, the existing research literature does not necessarily confirm the effectiveness of integrative interventions. There is a significant lack of large, methodologically rigorous studies on integrative therapies for depression. However, that is not decreasing their popular usage.
Part of the reason people might be attracted to integrative care for depression or anxiety is the holistic perspective found in most integrative approaches. This perspective takes into account the complex nature of depressive disorders and the numerous reasons why people experience them.
Mind Body Practices
While there have not been many well-designed studies looking at relaxation training, meditation, hypnosis or imagery in the treatment of depression, these practices have been an important part of traditional healing approaches for millennia (e.g. Ayurvedic, Chinese, Tibetan). In addition, hypnosis is used by conventional psychotherapists.
Early studies in yoga, breathwork, stress reduction, and relaxation therapy are promising, but require further investigation. But given that it costs little to learn these practices and there is little risk, they are worth pursuing. Therapists often recognize the importance of simply doing something and creating a sense of control over some aspect of life, and these practices can provide that.
Music therapy involves actively listening to or performing music to promote health and healing. In an early, small study with an older population and depression, music therapy produced a significant positive impact. More and larger studies are needed before recommendations are clear, but given the low cost and risks, this may be a helpful approach for those individuals who have interest in this area.
The uniqueness of each person's biochemical processes is only just beginning to be appreciated. The evolving field of Functional Medicine attempts to take into account both the genetic information and the unique differences that occur in each person's metabolism, including their extra need for certain nutrients.
Current recommendations, as follows, come from a generalized understanding of human brain chemistry, without these individual considerations. Typical doses for each botanical are indicated below. However, you should talk with your healthcare provider before adding botanicals to your health regimen and ask about the right dosage for you.
- B-Vitamins are necessary for the production and regulation of neurotransmitters connected to depression. B-vitamin deficiency has been linked with mood disorders, including depression and anxiety. Elderly patients are at particular risk of B12 deficiency; and women on oral contraception or estrogen replacement are at increased risk of B6 deficiency. Thus, although long-term prospective studies have not been completed, it seems beneficial to take Vitamin B complex, with 100 mg each of the major B vitamins.
- Folic acid is low in one-third of depressed adults. Depression is also the most common symptom of folate deficiency. If there is a deficiency, some depression medications (i.e. SSRIs) are not as effective. Take 0.8-1 mg daily of folic acid.
- Omega-3 fatty acid deficiency, or an imbalance with omega-6, correlates with an increased rate of both anxiety and depression. Dosage range has not yet been clearly established, but studies have shown improvement in depressive symptoms with as little as 1 gram, or as much as 6 grams a day. Begin with 1 gram a day of fish oil, and go up to 6 grams a day if desired. Flaxseed oil, or ground flaxseed meal, (2 tbsp daily) is a vegetarian alternative.
- St. John's wort is a plant that impacts several neurochemical pathways in the brain and has been shown in numerous studies of mild to moderate depression to be as effective as conventional antidepressants. Take 900 mg daily in three divided doses, using a product standardized to a minimum of 2-5 percent hyperforin or 0.3 percent hypericin. There are potential side effects to this botanical, although the side effect rate is lower than that of prescription drugs. There are also potential herb/drug interactions, especially with blood thinners. St. John's wort should not be used in combination with SSRIs, and may interfere with oral contraceptives.
- S-Adenosylmethionine (SAMe) is a naturally occurring chemical substance intimately involved in the production, regulation, and action of many brain neurotransmitters. Multiple studies have found SAMe to be a safe and effective natural antidepressant that starts working faster than pharmaceutical antidepressants. An initial dose is 1,600 mg per day, divided into two doses; however, because of gastrointestinal side effects, it should be started at 200 mg twice daily and gradually increased. It is best to use this with the guidance of a professional, especially if combined with an antidepressant. It should not be used in bipolar disorders, like manic depression.
- Kava at 50 to 70 mg three times a day (standardized to either a 30 or 50 percent kava lactone concentration) has been found to help with anxiety disorder in seven small clinical trials, but has not yet been confirmed by a larger prospective study.
- Valerian is another botanical that has been used in Europe as a calmative agent and tranquilizer, especially for sleep disturbances. It has been tried in several small studies on anxiety, in combination with either passionflower or St. John's wort, with promising results. It may be tried clinically, if Kava has failed after six weeks, at doses of 150 to 300 mg in the monring and 300 to 600 mg in the evening for at least a six-week trial.
Naturopathy includes diet, exercise, natural botanicals and supplements, mind/body practice, hydrotherapy, and other tools. For those preferring natural approaches, treatment with a naturopath can certainly be partnered with psychotherapy of some kind.
Traditional Chinese Medicine practitioners work with an individual to optimize their nutrition, activity, and internal energetic balance, using herbs, acupuncture, movement practices (Qi Gong and Tai Chi), massage (Tui Na), and other techniques. Acupuncture for mild to moderate depression has been found to be promising in early studies, although larger prospective studies have not been completed.
Homeopathy is another systemic approach used by some individuals in combination with psychotherapy.
How to Use Integrative Therapies and Healing Practices in Depression and Anxiety
When suffering from depression or anxiety, it is critical to have a working relationship with a provider, or team of providers, who can help you navigate through this time. The provider can be a conventional physician, therapist, or other professional who is philosophically aligned with your perspective on your disease.
It is important to try to understand what is causing depression or anxiety. A depression triggered by a major trauma or loss may be a very appropriate response to a situation and should not be suppressed, although the individual may require supportive coaching or therapy to work through the situation. However, these responses should not be prolonged and should be examined after six months. Worry and anxiety can also be triggered by an underlying or unresolved situation or issue and may signal a need to explore where you need to make changes.
Depressions that do not appear to have a "cause" in everyday life may originate from a biochemical imbalance, but may also be part of a larger pattern of imbalance. A combination of self-care practices (e.g. exercise, healthy diet, alcohol abstinence, self-reflection, mind/body skills), psychotherapy of some type, and conventional medical supervision (with optional medication) seems to be the safest and most optimal scenario.
If any oral natural supplements (other than homeopathy) are used in combination with conventional prescription medications, it is critical for both the prescriber and the pharmacist to be aware of the supplements being taken.
If there are any thoughts of or plans for suicide, a conventional therapist, psychiatrist, or physician must be involved immediately, even if that necessitates the use of emergency medicine services. If someone doesn't willingly request help, the family or other supportive members of that person's social sphere may need to intervene and engage services.
The risk for suicide often increases after early improvement induced by either medications or supplements, as the individual finds more energy and a sense of self-control. Support during this time of treatment is critical.
References and Resources
Bourne, E.J. (2005). The Anxiety and Phobia Workbook. New Harbinger Publications.
Emmons, H., MD (2006). Chemistry of Joy. Fireside.
Forsyth, J.P., Eifert, G.H. (2007). The Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free from Anxiety, Phobias, and Worry Using Acceptance and Commitment Therapy. New Harbinger Publications.
Hammerly, M. (2001). Depression: The New Integrative Approach : How to Combine the Best of Traditional and Alternative Therapies (New Integrative Approach). Philip Lief Group
Shannon, S. Valerian.
Weintraub, A. (2003). Yoga for Depression: A Compassionate Guide to Relieve Suffering Through Yoga. Broadway Books.
Williams, M., Teasdale, J., Segal, Z., Kabat-Zinn, J. (2007). The Mindful Way through Depression: Freeing Yourself from Chronic Unhappiness. Guilford Publications.
Zuess, J.G. (1998). The Wisdom of Depression: A Guide to Understanding and Curing Depression Using Natural Medicine. Three Rivers Press.
Institute of Functional Medicine http://www.functionalmedicine.org/
National Center for Complimentary and Alternative Medicine - Naturopathy http://nccam.nih.gov/health/naturopathy/
Holistic On-line - Depression http://www.holisticonline.com/remedies/Depression/dep_home.htm
Depression handouts for patients from the University of Wisconsin http://www.fammed.wisc.edu/integrative/modules/depression