Do you feel sad, empty, fatigued? Are you experiencing a loss of interest in everyday activities, do you suffer from insomnia or sleep excessively, have you noticed significant changes in your weight? Do you feel worthless, hopeless, lonely, apathetic and miserable? These can all be symptoms of depression. If you feel this way, the good news is – you don’t have to!
This article is an overview of what depression is, and what can be done to treat it. It’s a summary of how depression should be approached from a multi-faceted perspective (with help from and under the supervision of professionals, of course).
WHAT IS DEPRESSION?
In psychopathology, depression falls into the class of disorders known as mood disorders. These disorders are categorised according to type, duration and frequency of episodes. In general, depression is more prevalent in women than in men. A brief outline of the medically recognized mood disorders follows. It is adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition,¹ and will help us gain a better understanding of depression. Note that it is abbreviated, and there are many more factors involved in diagnosis.
THE MOOD DISORDERS
The following episodes are the ‘building blocks’ of the mood disorders.
Major depressive episode
Five or more of the following must be present in the same 2-week period and represent a change from previous functioning:
- depressed mood most of the day, nearly every day (subjective or observed by others)
- markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (subjective or observed by others)
- significant weight loss when not dieting, or weight gain (more than 5% changes), or decrease or increase in appetite nearly every day
- insomnia or hypersomnia nearly every day
- psychomotor agitation or retardation nearly every day (observable by others)
- fatigue or loss of energy nearly every day
- feelings of worthlessness or excessive or inappropriate guilt nearly every day
- diminished ability to think or concentrate, or indecisiveness, nearly every day (subjective or observed by others)
- recurrent thoughts of death, recurrent suicidal thoughts or a suicide attempt.¹ For a diagnosis of a major depressive episode the symptoms must cause clinically significant distress or impairment in social, occupational or other important areas of functioning. The symptoms must not be due to the direct physiological effects of a substance or a general medical condition, must not be better accounted for by bereavement, and must not meet the criteria for a mixed episode (see below).¹
A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week. During this period three or more of the following symptoms have persisted:
- inflated self-esteem or grandiosity
- decreased need for sleep
- more talkative than usual, or pressure to keep talking
- flight of ideas or racing thoughts
- increase in goal-directed activity or psychomotor agitation
- excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. sexual indiscretions, spending sprees, foolish business investments). ¹
The symptoms must not meet the criteria for a mixed episode, and must not be due to the direct physiological effects of a substance or a general medical condition. The mood disturbance must be sufficiently severe to cause marked impairment in occupational functioning, social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there must be psychotic features.¹
For a mixed episode the criteria for both a manic episode and a major depressive episode must be met every day during a period of at least a week.1 Otherwise the same criteria as for a manic episode apply.¹
Three of the same criteria as for a manic episode need to be met. However, the symptoms only need to last 4 days.¹
The episode is associated with a change in functioning that is uncharacteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. In this case the episode is not severe enough to cause marked impairment in functioning or to necessitate hospitalisation, and there are no psychotic features. The symptoms must not be due to the direct physiological effects of a substance or a general medical condition.¹
THE MAIN TYPES OF DEPRESSION AND MOOD DISORDERS
The main types of depression and mood disorders are:
- The person has had one or more major depressive episodes not better accounted for by another psychiatric disorder.
- There has never been a manic episode, a mixed episode or a hypomanic episode.
More specific features are often identified at this point.¹
- There are six different criteria sets of bipolar I disorder, each describing the most recent episode (all types include at least one manic episode or mixed episode, and some include major depressive episodes and/or hypomanic episodes as well).
- Bipolar II disorder includes major depressive episodes with hypomanic episodes (when there has never been a manic episode or a mixed episode).¹
A depressed mood is present for most of the day, for more days than not (subjective or through observation), for a minimum of 2 years, during which two or more of the following are present:
- poor appetite or overeating
- insomnia or hypersomnia
- low energy or fatigue
- low self-esteem
- poor concentration or difficulty making decisions
- feelings of hopelessness.1
During the 2-year period the person has not been without the above symptoms for more than 2 months at a time. There has never been a manic or hypomanic episode. No major depressive episode has been present during the first 2 years. The symptoms must not be due to the direct physiological effects of a substance or a general medical condition.¹
This is diagnosed when there have been many periods of hypomanic symptoms and periods of depressive symptoms that don’t meet the criteria for a major depressive episode for a minimum of 2 years, the person has not been without symptoms for more than 2 months at a time, and no major depressive episode, manic episode or mixed episode has been present during that time.¹
Other commonly occurring types of depression
- Seasonal affective disorder
- Postpartum depression
- Mood disorder caused by an underlying medical condition. A common example is hypothyroidism.
HOW TO MANAGE DEPRESSION
It’s not possible to examine all the neurological pathways that may impact on depression in this article, so it is sufficient to say that not all depression is a result of reduced activity of serotonin; rather, there are many different pathways, and treatment must be individualised.²
Milder depressive episodes that do not meet the criteria for a full-blown disorder, or depression linked to a temporary situation or nutritional deficiency, also need to be acknowledged and treated, and this is likely to be where the management techniques discussed below will be extremely useful.
In some cases allopathic medicine is an absolute necessity, but in others natural remedies, nutrition and diet can all play a significant role, and psychiatric medicines can be avoided. However, if you are on allopathic medicine, the dosage must never be altered without strict medical supervision.
Psychotherapy involves the patient seeing a psychologist on a regular basis in order to build up a relationship with him or her, from which point the psychologist can assist the patient in working through some of the issues relating to the depression as well as helping develop effective coping strategies. It has been shown to be useful in many cases of depression.
Diet can play an important role in depression. Here are some useful points.
- Avoid stimulants such as caffeine and alcohol, as they tend to adversely affect mood.
- Concentrate on balancing blood sugar by eliminating refined carbohydrates, eating small frequent meals and avoiding sugar.
- Eat mainly unprocessed foods (whole foods) and avoid preservatives and colourants.
- Include cold-water fish that are high in omega-3 fats, such as salmon, tuna or mackerel, in the diet. Include nuts and seeds (specifically flax seeds, pumpkin seeds and walnuts) and free-range eggs.
- Eat plenty of fresh fruits, vegetables and whole grains every day. In short, eat food that is as natural as possible, nutrient rich and delicious.
St John’s wort (Hypericum perforatum). For milder depression St John’s wort has been shown to be as effective as tricyclic antidepressants, yet it has considerably fewer side-effects.3,4 St John’s wort should not be taken with other psychiatric medications, or if you are on the contraceptive pill. St John’s wort often takes a couple of weeks to work. Dosages vary between 300 and 1 200 mg per day (usually divided into two or three doses and containing about 0.3% hypericin), depending on the supplement and the individual patient’s needs.2-4
Sceletium (Sceletium tortuosum) , a plant found in southern Africa, is known for its antidepressant and mood-enhancing effects. It is thought to act as a natural selective serotonin release inhibitor (SSRI)5 and is also used for anxiety disorders and to lessen the withdrawal effects of alcohol, nicotine and drugs. Do not take it with other psychiatric medications or with cardiac medications. It is available in 50 mg tablets and 100 mg capsules.6
5-hydroxytryptophan (5-HTP) is made from the seeds of the griffonia plant. The precursor to serotonin, it is formed in the body from the amino acid tryptophan and has been found to be very useful in the treatment of depression, particularly depression that is linked to too little serotonin activity or that has a seasonal pattern.2 5-HTP is not effective for everyone, and although it is widely used, more scientific research is needed.7 Do not use it if you are on other psychiatric medication. Dosages vary, usually being around 50 – 150 mg per day, and it should be administered under supervision.7
Multivitamins and minerals are a good place to start. Try to choose a product with the optimal amounts of each nutrient rather than one that covers the bare necessities. It’s advisable to add a vitamin C supplement (between 1 000 and 2 000 mg) and a B-complex (dosage dependent on the strength of the multivitamin and the quality of the diet; some really good multivitamin and mineral supplements do not need an added B-complex).
Deficiency of omega-3 fatty acids has long been linked to depression. B-vitamins are necessary for enzymes to convert essential fatty acids into prostaglandins, which increase the brain’s serotonin and other neurotransmitter production.2 This is why cold-water fish and plenty of nuts and seeds should be included in the diet, and ideally these ‘healthy fats’ (including omega-6 and omega-9 as well as omega-3 fatty acids) should mostly be obtained from the diet. Supplementation of omega-3 fatty acids has also been shown to be effective.8 Dosages vary, but usually 1 – 2 capsules of a high-quality fish oil supplement high in EPA (somewhere between 200 and 400 mg per capsule) and DHA (120 – 3 000 mg per capsule) are taken daily.
Magnesium deficiency is fairly common in today’s Western society and has been linked to depression, among many other things.2,9 Ensure that the diet is rich in magnesium (by eating plenty of dark green leafy vegetables) and possibly supplement with magnesium if the deficiency seems severe. If you are taking calcium supplementation extra magnesium is a necessity as this may aggravate an imbalance. Take the two minerals at different times.² The dosage is usually between 200 and 500 mg of magnesium citrate per day.²
Folic acid deficiency can lead to depression. The optimal daily dose is 400 – 800 mcg per day.²For severe or chronic deficiency take 1 200 mcg of folic acid along with 100 mg vitamin B6.³ These two vitamins increase the production of SAMe,² another antidepressant naturally formed in the body that also improves brain function. SAMe can also be supplemented if necessary at 200 mg per day.³
Special note: Some people have high blood histamine levels (histadelia). In these cases too much folic acid can stimulate even more histamine production and make the depression worse.³ This brings us back to the point that not all depression is the same, so not all treatment is the same.
Phenylalanine is the precursor to tyrosine. It can also be converted to phenylethylamine (PEA), which has a stimulating and antidepressant effect. It is particularly helpful for depression that is linked to too little noradrenaline, dopamine or endorphin activity in the brain.² The dosage is usually 500 mg per day in the L-phenylalanine form.²
Tyrosine is produced in the body from phenylalanine. It too has an antidepressant effect, thought to be due to its ability to increase dopamine and noradrenaline in the brain.² Tyrosine is also useful when depression is due to hypothyroidism. The dosage is usually 500 mg 2 – 3 times a day.²
Note: This list is by no means comprehensive; other nutrients that are highly useful in treating depression include GABA, glutamine, vitamin A, inositol, choline, vitamin D, vitamin E and co-enzyme Q10. I have highlighted some of the most popular ones.
Raw cacao is the bean that chocolate is made of; it is an amazing superfood that is worth a mention here as it has wonderful antidepressant effects. The unprocessed, unheated organic product is rich in minerals and has many benefits, and is particularly good for depression. Cacao is high in magnesium, which is needed for serotonin production and balancing brain chemistry. It also contains PEA (mentioned above) and anandamide (known as the bliss chemical) as well as tryptophan (the precursor to 5-HTP). Snack on it, or make your own raw food delights – just make sure that the product is raw and organic.
Exercise. Studies have shown that as little as 30 minutes of exercise (e.g. brisk walking) three times a week can help to relieve depression due to increased levels of serotonin and endorphins.² It is important that the exercise is continued on a long-term basis.2,8 Light exposure. Increased exposure to sunlight can positively affect mood.
Laughter. There is no doubt that laughing elevates the mood (by releasing endorphins). Watch funny movies, spend time with children, play games, discover what makes you laugh and use it!
Spending time in nature increases exposure to negative ions, which leave you feeling tranquil and energised. Go to the beach, visit a waterfall, enjoy a hike, have a family picnic.
Touch has also shown to be useful in treating depression, whether the depressed person is being touched or doing the touching.²Give those around you hugs, shake a stranger’s hand, and go for massages and other touch therapies as often as possible.
Sleep. Lack of sleep affects mood, as we all know from experience. There are remedies that can assist with falling asleep. Try and go to bed at a similar time every night in order to establish a routine. Make sure the room is dark, and cut back on stimulant use during the day.²
Reduce stress. There are many ways of doing this. Take time for yourself, have a bath, read a book, spend time in nature, enjoy a treatment, do yoga, and just be. Various techniques can be learnt to help reduce stress. Cultivate your spirituality as well, as this can also play an important role.
Nurture relationships. The importance of family and friends should not be underestimated when dealing with depression. A good support structure, a shoulder to lean on, and the feeling of being loved and needed all contribute to alleviating and preventing depression. A depressed person should work on nurturing or repairing their close relationships.
We have looked at the wide range of natural treatments for depression, but it is still advisable to seek the advice of a health professional when undergoing these treatments. The supplements and herbs are not all meant to be taken simultaneously; your health practitioner will select those most relevant to your condition. Anyone suffering from depression should adhere to the recommended lifestyle factors and dietary advice. Last but not least, always remember that help is available and that there is sunshine at the end of the tunnel!
Editor's note: There is more hope for healing depression. Please read the article Saffron for Emotional Health by Dr Peter Bongiorno and the article by Veronica Haupt on Energy Psychology for Depression.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.
- Cousens G, with Mayell M. Depression-Free for Life. New York: Harper-Collins, 2000.
- Holford P. Optimum Nutrition for the Mind. London: Piatkus, 2003.
- Linde K, et al. St John’s wort for major depression (Review). The Cochrane Collaboration, Issue 4. John Wiley and Sons, 2009.
- Stafford GI, et al. Review on plants with CNS effects used in traditional South African medicine against mental diseases. J Ethnopharmacol 2008; 119(3): 513-537.
- Big Tree nutraceutical product information.
- Turner EH, et al. Serotonin a la carte: supplementation with the serotonin precursor 5-hydroxytryptophan. Pharmacol Ther 2006; 109(3): 325-338.
- Ravindran AV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. V. Complementary and alternative medicine treatments. J Affect Disord 2009; 117: Suppl 1, S54-64.
- Eby GA, Eby KL. Rapid recovery from major depression using magnesium treatment. Med Hypoth 2006; 67(2):362-370.