Treating depression without drugs – Part II

lightbox

In the first article in this three-part series on treating depression without drugs, we established that several non-drug treatments are at least as effective in treating depression than antidepressants – with few, if any of their side effects. Specifically, we learned that both psychotherapy and exercise compare favorably with antidepressants for treating even serious depression in the short-term, and are both more effective than antidepressants in the long-term.

Today we will examine three other drug-free treatments for depression: light therapy, St. John’s Wort and acupuncture. In the final article, we will look at lifestyle-based treatments such as nutrition, adequate sleep and rest, stress management, pleasure and bibliotherapy (prayer or spiritual practice).

Light Therapy

Researchers at the National Institute for Mental Health are credited for the idea that perhaps more people are apt to become depressed during dark, dreary winter days than on bright, crisp spring days because they are not getting enough light. Since then, people around the world have begun to use “light therapy” to overcome Seasonal Affective Disorder. However, light therapy is also being used to successfully treat major depression at any time of the year.

Beginning the day sitting in front of a fluorescent light box that typically emits about 10,000 lux units of light has helped many people who might otherwise struggle with depression throughout the day. Bright light has been shown by numerous studies to act as a specific antidepressant in depressed patients. In a recent meta-analysis of published studies on light therapy and depression which appeared in the April 2005 issue of the American Journal of Psychiatry, the authors found that bright light treatment for nonseasonal depression is efficacious, with effect sizes equivalent to those in most antidepressant studies.

Once again, as was the case with both exercise and psychotherapy, the combining light therapy with antidepressants was no more effective than light therapy alone.

In contrast to exercise and psychotherapy, bright light therapy does occasionally have some side effects, including headache, eye strain, nausea and agitation. But these are very mild when compared against the side effect profile of antidepressants.

It is very important to note that some psychotropic medication (and psychotropic herbs such as St. John’s Wort) may increase sensitivity to light, so light therapy should probably not be combined with St. John’s Wort or antidepressants.

Some critics of light therapy have pointed out that it could be a placebo and there is no way to prove otherwise. It is not possible to keep someone from knowing whether they are being exposed to very bright light or the placebo (dim light). Therefore the “blind” is broken and patients will know whether they are receiving the active or “inert” treatment. Could it be that the positive effects of bright light are simply due to the assumption or expectation of the patients that they will improve, rather than a result of the bright light itself?

Sure it is. But perhaps a more important question is, “does it matter?” If we use Antonuccio’s criteria for evaluating a potential treatment (i.e. 1) first do no harm, 2) cost-benefit analysis) then it becomes clear that light therapy compares very favorably with antidepressants even if it is “merely a placebo”. As you will know if you’ve been following my blog, antidepressants could also be referred to as placebos because they have been shown to be no more effective than placebo in treating depression. The criteria for whether a drug gets approved or not by the FDA is that it must outperform placebo; otherwise, it is simply considered a placebo itself.

Although light therapy may have some side effects, they pale in comparison to those of antidepressants and, unlike antidepressants, light therapy poses no significant risks or long-term complications. A typical light therapy device costs between $200-$300, so over the long-term it is much more cost-effective than medication. Finally, light therapy is just as effective as pharmacotherapy for treating depression.

When all of this is taken together, light therapy is superior to antidepressants – even if it is a placebo.

St. John’s Wort

St. John’s Wort (Hypericum) is an herb that can be used to make tea, or the “active ingredients” with the herb that can be extracted and put into capsules. In Europe SJW is widely prescribed as an antidepressant, but in the U.S., it is available over-the-counter.

St. John’s Wort has repeatedly been shown to work as well as or better than antidepressants in double-blind, placebo-controlled studies. For example, compared to Paxil, depression scores fell more (56.6% vs. 44.8%) and side effects were less (Szegedi et al. 2005). Similar results were found for Prozac (Schulz 2002). A comparison with both Zoloft and Celexa found St. John’s Wort again performed as well as the antidepressant drug without as many side effects (Gastpar 2005; Gastpar 2006).

While St. John’s Wort is clearly as effective as antidepressants, the number of adverse effects is ten times less – being essentially equivalent to taking a placebo. The most common adverse events (1 per 300,000 treated cases) concern reactions of the skin exposed to light (due to potential increased photosensitivity caused by SJW and other psychotropic substances).

Please do note that St. John’s Wort is contraindicated for concurrent use with certain medications, including antidepressant drugs, coumarin-type anticoagulants, the immunosuppressants cyclosporine and tacrolimus, protease and reverse transcriptase inhibitors used in anti-HIV treatment and with certain antineoplastic (cancer) agents.

However, these potential interactions can be easily avoided with proper supervision from a health-care professional who is experienced with the use of St. John’s Wort.

Once again, to be accurate we must point out the possibility that St. John’s Wort is merely a placebo. If it is roughly as effective as antidepressants, and antidepressants are themselves placebo, then it follows that St. John’s Wort may also be a placebo. However, the same analyses that we used for light therapy applies here. The question is, how does St. John’s Wort compare against the primary treatment for depression – antidepressants? As we have seen, SJW is just as effective as antidepressants with only a fraction of the side effects, so there is absolutely no reason not to choose it over a synthetic antidepressant.

Before we move on to acupuncture, nutrition, rest and other lifestyle-based treatments for depression, I want to briefly discuss the criteria we’ve used so far for evaluating the effectiveness of a treatment. As I’m sure you’ve noticed, I am primarily basing the determination of the effectiveness (or lack thereof) of a treatment on well-designed, placebo-controlled, double-blind scientific studies.

I obviously have great respect for this method of inquiry and it has led (and continues to lead) to many important advances in medicine. However, it must be pointed out that this standard of proof has limitations. For example, 2/3 of medical research is funded by pharmaceutical companies. This means that the lines of investigations most often pursued in scientific research are those that are likely to lead to new therapies that can be monetized by the drug companies. There is little incentive for a drug company to dedicate research dollars to a study on how nutrition affects depression, unless there’s a product they can imagine marketing based on the study results. The result is that there are relatively few studies evaluating the effect of nutritional intake on depression.

Another limitation of double-blind, placebo-controlled research is that it is difficult (if not impossible) to maintain that standard with treatment modalities that depend on the unique interaction that happens between a practitioner and a patient. Western science is often skeptical, of course, that this interaction that occurs influences the treatment in any way. They do not understand how the interaction could influence the treatment, and what Western science does not understand, is often dismissed as “new-age fluff”.

What is remarkable about this is not just the arrogance of such a position, but also the ignorance it demonstrates. Over the last two decades, research into the placebo effect and growing understanding of how the nervous, endocrine and immune systems are inter-related have proven beyond a shadow of a doubt – according to the most rigorous Western scientific standards – that the interaction between a doctor or clinician and their patient absolutely influences the outcome of the treatment. In fact, many studies have shown that this interaction may be more important than the treatment itself; or, perhaps more accurately, the interaction is the treatment.

With this in mind, it becomes clear that the efficacy of acupuncture as a treatment for depression – or anything else – can never be accurately measured in a double-blind, placebo-controlled study. As much as Western science hates to admit this, we are not machines that respond in entirely an predictable manner given the same circumstances. There is no way to “standardize” the interaction that happens between an acupuncturist (or any healing professional) and a patient, because each person and, therefore, each relationship is unique.

Acupuncture

Considering all of the caveats above, can acupuncture help with depression? According to the Cochrane Database Systematic Review (the gold standard for medical research reviews today), “there is no evidence that medication was better than acupuncture in reducing the severity of depression.” In many of the studies they reviewed, acupuncture and electro-acupuncture either cured or remarkably improved depression scores, performing just as well as synthetic antidepressants.

However, it must also be noted that the studies were few in number, often poorly designed and did not have enough subjects to draw definitive conclusions. The authors of the review concluded that there was “insufficient evidence to determine the efficacy of acupuncture compared to medication”.

And of course, we always have the issue of placebo. It is possible that the benefit the patients are receiving comes from the interaction with the practitioner and their expectation that they will improve – rather than as a result of the needles themselves.

Once again, though, if we evaluate acupuncture based on a “cost-benefit” analysis, it compares very well against antidepressants. It has been shown to be at least as effective as medication in many studies as noted above, and the side effects are minimal when compared with antidepressants. Acupuncture has also been shown to be effective in treating other conditions that may occur alongside of depression, such as pain and stress.

Stay tuned for part III of this series which will consider lifestyle-based treatments such as nutrition, adequate sleep and rest, stress management, pleasure and prayer.

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Comments Join the Conversation

  1. Ken Lawler says

    I have a theory that camp fire light somehow served the same purpose for our ancestors. They used fire to cook and extend their daylight and starting one on a cold morning for heat and cooking was probably a priority most days in colder latitudes. The trouble is the literature says there is no impactful vitamin D production from sitting in front of fire. (I’ve read that the wavelength of the light is different than that of the sun) I doubt our ancestors suffered the same rates of depression that we do today. Obviously their environments were less problematic for humans than ours and that could fully explain it but I think there has to be something to extending exposure to light via fire – and I doubt it’s a placebo effect. Thoughts?

    • Luke says

      I’m not sure that firelight has the effect on SAD that you suggest.

      However Iliard explains in his TED talk that sun light even on a cloudy day is sufficiently bright to balance mood and reset our body clock.

      He is promoting a book so you might want to remain skeptical but he links depression to modern lifestyle.

  2. says

    Chris, I love it that you are promoting light therapy for mood disorders. I do hasten to add though, that it would be very helpful to warn against this treatment without supervision, if the person has any history of mania or hypomania or has bipolar disorder. These people do get good results but they need to be medically supervised. CET.org is an incredible resource for people interested in light therapy for mood, sleep and circadian rhythm problems.

  3. Kim says

    If the whole brain chemistry imbalance is a myth then why would St. John’s wort work? It’s thought to
    treat mood problems due to it’s inhibition of MAO, thus raising Serotonin, Epi, Dopamine, etc.
    Just playing devil’s advocate here.

  4. Ewa says

    I have been taking St.John’s Wort for almost a year already, with very good results. I know it works every time I try to take a break from my regular 900mg/day and already after 1-2 days of no-treatment my mood and energy sink down rapidly, I become anxious and extremely reactive to any sign of social rejection and I just stop wanting anything at all, become apathetic.

    One concern I have that I hope you may be able to address and whether I can continue taking SJW during pregnancy. In a few months we’d like to start trying for a baby and I’m concerned that either SJW may cause problems to my pregnancy or that without it, I will go out of my mind (both of which will be bad for the baby!). What is your stand on SJW and pregnancy?

    Thank you!

  5. Kevin says

    I would recommend that the author investigate SAMe for the treatment of depression, and add his findings to an updated version of this article. SAMe is far more efficacious than the likes of St. John’s Wort, especially for treatment-refractory depression, and it is also a natural substance with many collateral health benefits (e.g., liver and joint protection).

  6. Cassandra Quandt says

    Interesting side note about Hypericum-St. John’s Wort enhances liver detox, hence the theoretical fears about mixing St.John’s with oral contraceptives. Traditionally depression was not associated with the brain at all but rather the liver. Galen referred to “black bile” as causing melancholy.

  7. says

    St. John’s wort like most herbs works best in a formula oriented towards the patttern of depression.  But for seasonal affective disorder, the combination of St. John’s wort and lemon balm is far better than either alone.
    As for acupuncture, I have successfully used NADA protocol with PTSD and depression, and I have seen a variety of Sun Si Miao ghost treatments do amazing things within a single session for people with all kind of serious issues.  In one case a woman whose mother and daughter had both committed suicide, walked into the clinic bent over, not meeting anyone’s eyes, complaining of depression.  Post ghost treatment she looked right in our eyes, stood tall and in future visits dressed well and continued the change.

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