I am not a psychiatrist, but throughout my career as an internist, I have managed a number of patients with depression. It has always proven challenging, not only from a clinical viewpoint, but philosophically as well.
On the one hand, we have been trained to view depression-especially severe depression-as a medical condition warranting treatment with pharmaceuticals. From a different point of view, though, mild to moderate depression may indicate that a patient's "life systems" are not working well. In our well-intentioned effort to treat symptoms with medications, herbs or other interventions, are we missing an opportunity to help our patients make important life changes and learn new psychosocial skills? Are we encouraging quick pharmaceutical fixes at the expense of deeper personal growth?
These questions hit me close to home this past year, when a close family friend of ours, Alex, was suffering from a fairly deep depression. Alex is the single father of a six-year-old girl, and he was having trouble keeping work. The last time I saw him; he was on his couch with the lights off and had a severe migraine. His entire outlook on his life was colored by depression.
"I specifically remember thinking for certain that I was just never meant to simply enjoy life. I assumed that at nearly thirty years of age, if I had never discovered a way to make things work for me in a way that made sense, then I was never meant to do so, and that the universe never intended me to," said Alex. "After coming out of a long difficult abusive relationship I had felt anger, extreme loss of motivation, lack of creative desire, unending sadness, self blame, self pity, and a general over bitterness and distrust in the world."
If it weren't for a very strong family support system, his mother living nearby, and his brother living with him, I would have been extremely concerned for Alex's survival.
At the time, I recommended anti-depressants. My view was that drug therapy would get him off the couch and re-engaged in life. But like many patients, Alex refused to take anti-depressants drugs or herbs. "I had shared with many people about my depression, and was advised by some to get on some anti-depressants or perhaps St. John's Wort, just to help get me over the hump. For some reason, though, I never took anti-depressants nor did I ever feel comfortable with the idea. Intuitively I had always felt as though they would only be coating my symptoms and not treating my causes. As dark and as hopeless as I felt, I still declined the idea of pills."
Ultimately, Alex decided to enter a program called the Hoffman Quadrinity Process. This is an intensive residential program, aimed at improving the participants' sense of spirituality and well-being. It focuses in on patterns of behavior that often develop early in childhood and are learned by a child as he/she attempts to gain the love and recognition of his or her parents.
The process guides the participant through multiple techniques, scenarios and experiences in order to identify, confront, and gain clarity about these behavior patterns. Through the week-long program, a participant moves from anger to acceptance to forgiveness around these core issues. Having done this program myself, I knew that it was safe and would provide good support for Alex.
The Hoffman method was developed by Robert Hoffman in the late 1960s, based on the idea that healing deeply ingrained negative behaviors, relationship problems, feelings of worthlessness, and internalized injurious beliefs requires careful attention to how learned behavior in childhood affects the four fundamental dimensions of a human being: the intellectual, emotional, physical and spiritual, hence the "quadrinity." The method is a carefully structured program of guided visualizations, journaling work, and controlled catharsis. The Hoffman Institute has established centers in 13 countries, and the therapeutic method has been in steady use for 35 years.
The Hoffman Process was the subject of a recent study that showed it could markedly decrease depression scores, while increasing scores on measures of spirituality and forgiveness. It was demonstrated, in a group of 99 participants with mild depression, that these effects were maintained over one year after completing the 7-day program, and that the sense of forgiveness and spirituality mediated the 'anti-depression' effect. Additional, sustainable improvements were also seen in mastery, empathy, emotional intelligence, life satisfaction, overall health and well-being. What was most interesting to me was that there was a direct correlation between spiritual well-being and diminished depression (Levenson MR, et al. Explore: The Journal of Science & Healing, 2006; 2 (6): 498-508).
A few days ago, I spent the day with Alex, and he certainly seemed to echo the experiences of the participants in the study. He is now happy, engaged, ambitious and back 'in life' again. He has started on a screenwriting project and is simply enjoying his life.
"What occurred for me was nothing like I could have ever imagined. I was given tools to deal with defects in my being that I had been experiencing for my entire life. The recent events of my breakup that had been dragging me down seemed to melt away and I was able to approach that, and everything else that had really affected me, with a level of compassion and understanding that I never had before. Everything in my past that had seemed like a horrible dark curse blossomed into a beautiful learning experience," said Alex. "For once in my life, I truly felt free and given a second chance to enjoy life, not just survive it. The valuable tools I learned have affected me in all areas of my life. Someone I met during the process said something that really resonated with my experience: "I came here looking for a life preserver, what I found was a ship."
Alex's experience certainly raises a big question: Is it feasible; that a one-week program that involved no pharmaceutical interventions could shift someone from a relatively deep depression into a state of conscious well-being? This definitely goes against conventional medical thinking about depression as a medical illness, and it raises another important question for us as holistic physicians: What is the appropriate treatment for mild to modest depression?
I still believe that anti-depressant drug therapy is reasonable for those with profound depression. But as a holistic practitioner, I also believe that this should always be combined with "lifestyle" therapies that include changes in diet, increased exercise, and strategies aimed at improving self-esteem and social contact.
We need to bear in mind that while pharmacotherapy can sometimes be life-saving in severe depression, it can also negate the possibility of personal growth, especially if the pharmacologic approach is used without psychotherapy or other introspective work.
Mild-to-moderate depression may be a signal that someone does not have appropriate psychosocial tools to manage his or her life situations. This is not something you can fix with drugs, and it is why cognitive behavioral therapy and other psychotherapeutic approaches to depression are often highly effective. These therapies help people evaluate their lives and teach them new tools to cope. Pharmacotherapy can sometimes end up dis-empowering someone with depression, blocking the individual's ability to gain a sense of control and self-reliance.
I do not mean to dismiss the important idea that depression has treatable biological components. But it is equally important to recognize that the ways we define health and illness are profoundly influenced by cultural and commercial factors. This point was well-illustrated in a 2004 New York Times article entitled, Did Antidepressants Depress Japan? Author Kathryn Schulz points out that before 1999, when pharmaceutical companies identified a vast potential market, there was no word for mild to modest depression in the Japanese language.
Japanese doctors, of course, recognized severe depression, which was typically treated and spoken of as a form of psychosis. But the condition we label as mild-to moderate depression was viewed as simply a diminution in life energy, treated with meditation, self care, or retreat. The problem was not seen as a "disease," per se, but a call to self-care and self-growth. This began to change quickly once drug manufacturers began to market anti-depressants in Japan. The Japanese now have a term for mild depression: Kokoro no kaze, which means something along the lines of "Your soul catching a cold." Like a respiratory infection, one should, of course, treat these "soul colds" with medicine. With the 'popularization' of anti-depressant drugs, their use has grown phenomenally.
Are the Japanese following us down a road toward a society that overvalues medical "cures" and undervalues self growth and self awareness? This seems to be the case, and I believe it would be a very unfortunate outcome.
For profound depression, there is no doubt that pharmacotherapy is a valid option when combined with appropriate counseling. But as a holistic physician, I believe that in prescribing an anti-depressant to an individual with mild to moderate depression that is willing to do personal work, we may actually be doing harm.
By relying on pharmaceutical fixes, we may inadvertently decrease an individual's likelihood of spiritual and personal growth. Anti-depressants should be considered as a 'back-up' or temporizing agent, used in conjunction with self-evaluative work and talk therapy. After all, holistic medicine should serve as a bridge towards psycho-spiritual well-being. Nowhere is the opportunity greater than in the context of depression.
Lee Lipsenthal, MD, ABHM is Past-President of The American Board of Holistic Medicine and President of Finding Balance in a Medical Life. He is also founder and director of the Finding Balance in a Medical Life program and leads workshops for individual physicians, their families, their practices as well as large medical IPAs and hospital systems. For information see HealthClassics.com or call 1-800-769-0638.