Healthful Alternatives for Treatment of Depressionby Vin Miller, December 17th, 2011
Depression is a very common health care concern and is disabling for many people. In most cases, antidepressant medications are the chosen form of treatment, but they aren’t always effective and often have dangerous side effects. Although antidepressants have proven to be invaluable for some patients, they’re frequently recommended without prior consideration of safer and more healthful forms of treatment that can be just as effective.
Serotonin is a neurotransmitter that’s commonly cited as a cause of depression, and the most prominent class of antidepressants is believed to work by increasing its availability. However, the involvement of serotonin in depression is not universally accepted, and even if it was, the fact that serotonin activity can be influenced by basic dietary factors is often overlooked. This serves as a good example of the many opportunities to treat depression in a manner that promotes optimal health instead of detracting from it. And while it’s easy to place blame on our medical system for not making such opportunities more available, it would be much more productive to embrace the perspective that it’s your own responsibility to guide the direction of your treatment.
The Common Approach to Treating Depression
Based on data from 2007, it’s estimated that nearly 9 million Americans recieve treatment for depression.1 For a large majority of these people, the form of treatment is either a class of antidepressant medications called selective serotonin reuptake inhibitors (SSRIs), or a similar class called serotonin-norepinephrine reuptake inhibitors (SNRIs), both of which inhibit the reuptake of serotonin by nerve cells. All of these medications are prescribed based on the hypothesis that reduced serotonin availability causes depression. However, this hypothesis has not been proven, and as with most hypotheses, it’s surrounded by disagreement and controversy.2
Depression comes in a variety of forms, is characterized by a variety of symptoms, and can be caused by a number of different factors. As many of us already know, depression can even be a natural and expected reaction to difficult life circumstances.3 In addition, depression has been associated with a number of abnormalities in neurological function that are unrelated to serotonin.4 Despite this, the prescription statistics mentioned earlier indicate that most patients are being treated with medication based on a questionable assumption that their depression is caused by serotonin abnormalities.
Serious Risks Associated with SSRIs
Most people understand that medications can have dangerous side effects, and many of these people appreciate the potential risk for other unknown effects. SSRIs are reported to have very serious side effects including increased risk of heart attack5 as well as a controversial association with an increased tendency towards suicide.6 In addition, they can cause a potentially fatal collection of symptoms known as “serotonin syndrome.”7,8 And these are just a few of the potential side effects. For example, the U. S. National Library of Medicine lists the following side effects for Prozac which is one of the more popular SSRIs: nervousness, nausea, dry mouth, sore throat, drowsiness, weakness, uncontrollable shaking, loss of appetite, weight loss, changes in sex drive, excessive sweating, rash, hives, fever, joint pain, swelling, difficulty breathing, irregular heartbeat, severe muscle stiffness, hallucinations, and seizures. Also listed is a suicide warning for children, teenagers, and young adults up to the age of 24.9
Clearly, there’s plenty of incentive to use alternative treatment methods that don’t impose as much risk. Such alternatives are indeed available and have proven to be effective.
Surprisingly Simple Alternatives to SSRIs
Even for people who’s depression is indeed associated with serotonin abnormalities, there are safer and more logical treatments that can be used before prescribing an SSRI. Tryptophan, a precursor to serotonin, is an amino acid that’s readily available from most dietary sources of protein. Therefore, simply increasing protein intake can promote an increase in serotonin synthesis and potentially alleviate depression as a result. In addition, identifying and addressing digestive issues can help by increasing the availability of the tryptophan already in the diet.
If improvements in protein intake and digestion fail to have the desired effect, the use of supplementation is another option that can be considered. Because tryptophan competes with other amino acids for transport into the brain,10 supplementation of tryptophan by itself may be more effective than simply increasing overall protein intake. Although some might remember that tryptophan supplements were once banned by the FDA in the 1990s, the underlying concern was eventually attributed to contaminants from a single manufacturer rather than tryptophan itself.11 If you’d still prefer to avoid tryptophan or have found it to be ineffective, there is yet another option. Tryptophan is converted to 5-hydroxytryptophan (5-HTP) prior to being converted to serotonin.12 Supplementation with 5-HTP may therefore be more effective because it’s the direct precursor to serotonin, and it’s widely available in supplement form.
Although critics say that more thorough research is needed, supplementation with tryptophan and 5-HTP has been shown to be as effective as SSRIs.13 A Cochrane review, which is a standardized review of intervention trials that’s generally regarded as highly reliable and unbiased, identified 108 trials that used tryptophan and 5-HTP to treat depression.14 Although only 2 of the trials met the Cochrane inclusion criteria, they both found tryptophan and 5-HTP to be more effective than a placebo for the alleviation of depression.
Even if the quality of the supporting research doesn’t meet the standards of critics, I hope most people would agree that the risk of ineffectiveness is certainly a lot more appealing than the risk of heart attack, suicide, and other side effects, even if these risks are unlikely.
Supplements Aren’t Always Better than Drugs
Even though supplements are generally safer and more natural than medications, their use still imposes some unnecessary risk. For example, as with SSRI use, supplementation with the natural serotonin precursors tryptophan and 5-HTP can potentially cause serotonin syndrome.7,8 In conjunction with several points I’m about to discuss, I consider this a good reason to emphasize a diet and lifestyle based approach prior to considering supplementation.
First, because tryptophan is an essential amino acid, meaning that it can’t be produced by the body and must therefore be obtained from diet, it would be logical to evaluate protein intake prior to recommending supplementation.
Second, supplementation doesn’t account for the vitamin and mineral cofactors that are involved in the conversion of tryptophan and 5-HTP into serotonin. For example, iron is needed by the enzyme that converts tryptophan into 5-HTP, and vitamin B6 is needed by the enzyme that converts 5-HTP into serotonin.15 As such, supplementation with 5-HTP won’t have much of an effect if intake of vitamin B6 is insufficient.
Third, a patient’s depression may be caused by dietary factors that are unrelated to serotonin. For example, a group of neurotransmitters called the catecholamines, which consists of epinephrine (adrenaline), norepinephrine, and dopamine, have also been associated with depression.13 These neurotransmitters are derived from the amino acid tyrosine which is in turn derived from the amino acid phenylalanine.15 Obviously, supplementation with tryptophan or 5-HTP is not going to alleviate depression caused by a insufficiency of these amino acids and the neurotransmitters derived from them. In addition, the previous two points apply to phenylalanine just as much as they apply to tryptophan. Phenylalanine is an essential amino acid, and its conversion into neurotransmitters requires a variety of vitamin and mineral cofactors.
Fourth, depression may be caused by factors that need to be eliminated from the diet rather than added. For example, sugar consumption has been highly associated with major depression.16 Although this doesn’t prove causation, it’s certainly plausible that an excessive intake of refined foods may promote depression, and supplementation is highly unlikely to correct such a problem.
Finally, because it’s not always practical to test for all of the known nutritional factors relating to depression, and because there may even be factors that we don’t know of yet, the information needed to use supplements accurately and safely isn’t always available. When used in such circumstances, supplementation can result in excessive intake and be counterproductive, as is the case with tryptophan and 5-HTP supplementation causing serotonin syndrome. As such, a well balanced diet that provides an adequate intake of as many essential nutrients as possible is a safer approach and is also likely to address a much wider variety of factors relating to depression. In my opinion, the only time supplementation is a smart choice is after all reasonable opportunities to improve food selection have been exhausted. Even then, supplementation should still be guided by a thorough dietary analysis.
As Hippocrates is well known for saying, “let food be thy medicine.”
A Paradoxical Side Effect of SSRIs
One potential side effect of SSRIs not yet discussed provides an excellent illustration of the irony behind their high rate of use. Understanding this example requires a somewhat more detailed explanation of how SSRIs are believed to work and how serotonin is metabolized.
Neurons (nerve cells) release neurotransmitters, including serotonin, to transmit an instructional impulse to another cell, which in some cases may be another neuron. This is a fundamental aspect of how the brain and nervous system work. Neurotransmitters are released from an ending of a neuron into a space called the synaptic cleft where they can bind to receptors on the cell located at the other end. The neurotransmitters that don’t bind with the target cell may be reabsorbed by the neuron that released them. In regard to the treatment of depression, SSRIs appear to work by blocking the reabsorption of serotonin17 which provides more opportunity for it to bind with the target cell. However, this also creates additional opportunity for serotonin to be broken down and excreted in urine as 5-hydroxyindoleacetate (5-HIAA).
Urinary elevations of 5-HIAA have been associated with SSRI use which indicates that SSRIs reduce the amount of serotonin recycled and therefore also increase the amount lost from the body. As previously mentioned, the amino acid tryptophan is a precursor to serotonin. Therefore, the depletion of serotonin by SSRIs can also deplete the body’s supply of tryptophan and create an increased need for intake.15 Wouldn’t it make a lot more sense to avoid the risks associated with SSRIs and start with a dietary increase of tryptophan in the first place?
Other Alternate Approaches
Even when serotonin abnormalities aren’t an issue, there are still other alternatives to pharmaceuticals, and as with dietary approaches, they’re much more conducive to promoting optimal health.
A negative outlook on life has been associated with depression18 and theorized as a cause of it.19,20 This suggests that depression can be alleviated by developing the ability to perceive daily events and circumstances in a more positive manner. Although not easy, perception is something that can certainly be changed, and the benefits can extend well beyond depression. If this approach interests you, I highly recommend The Heart Math Solution or The Power of Now. The former is a practical approach to changing your perception of negative events while the latter is more philosophical and addresses perspective at a much deeper level.
Aerobic exercise has been shown to be just as effective as SSRIs as a treatment for depression,21,22 and a follow-up to one of these studies found that the medicated group had a higher rate of relapse after 10 months.23
Based on the variety of safe and health promoting treatment options that exist for depression, you may wonder why they’re not recommended more frequently. If you currently use antidepressants, you may even feel some anger and resentment in association with this question.
The most likely reason, in my opinion, why these treatments aren’t widely recommended is that the structure of our medical system doesn’t allow for it. The dependency of the medical system on the insurance industry dictates that visits with health care providers be kept brief, and it takes a lot more time to assess a patient’s diet and lifestyle than it does to write a prescription. In addition, because nutrition and lifestyle aren’t a significant aspect of medical training, except for nutritionists, not all health care providers will have the background to even offer such options. And seeking out an alternative health care provider may not be any more helpful because they may still follow the same conventional model of addressing symptoms rather than causes, but with the use of supplements instead of drugs. As I mentioned earlier, there are many cases in which supplements are probably not the best choice.
Despite the flaws in our medical system, it’s excellent in a number of other ways, and it’s not my intent to criticize it. Instead, I hope for you to understand its limitations and have the motivation (rage) to become more informed so that you can have more of an influence on the direction of your treatment. Ultimately, the only person truly responsible for your health and wellbeing is you!
Although self sufficiency is a great value and I’m a big believer in being proactive, it would be irresponsible to write an article like this without mentioning the following concern. If you’re already taking an SSRI, it’s important to know that there are serious concerns associated with discontinuing usage or even just reducing the dosage. In fact, this concern is prominent enough to be the basis for a named syndrome: SSRI discontinuation syndrome.24 If you do decide that you’d like to transition off of your medication in favor of a more healthful approach, please do so with the help of a physician who appreciates your intent. While it’s an admirable goal, it’s not advisable for everyone and can be dangerous to attempt without professional help.