Depression
Written by: Dr. Madeleine Clark. ND
Depression is a mood disorder which can lead to a loss of interest, an inability to experience pleasure and a persistent feeling of low mood. Typically we look for this to persist for beyond two weeks (beyond a situational circumstance that may be sad), and it may be associated with the following symptoms:
Sleep disturbances (either insomnia or sleeping more than normal)
A change interest or pleasure (a reduction in either or both)
Feelings of guilt or worthlessness
A drop in energy, fatigue
Difficulties with concentration and attention
Changes to appetite and/or weight
Psychomotor disturbances; either a slowing down of movements or a speeding up/visible agitation.
Suicidal thoughts or thoughts of self harm
Depressed mood
How common is depression?
The presence of depression is often dependent on the age category. Younger patients aged 18-29 have a three times higher likelihood of depression than patients over 60 years of age. Women are also more likely to experience depression - about 1.5-3 times more likely than men.
What causes depression?
Historically depression has been thought to be due to a reduction in neurotransmitters (like serotonin, dopamine) due to the fact that medications that increase these levels, such as our first line therapy selective serotonin receptor inhibitors (SSRIs), can improve symptoms in patients. There has also been research that shows when we reduce the amount of serotonin in patients, they may experience a relapse of their depression - but typically only in those patients who have experienced a depressive episode before. What further complicates the picture, is not everyone improves with SSRI medication, making us realize the cause of depression is likely due to a combination of factors.
What are those factors?
Neurotransmitter and & receptor availability
Serotonin and serotonin receptor availability play a role in mood, but it’s also been found that other neurotransmitters such as; brain derived neurotrophic factor (BDNF), glutamine, dopamine, and norepinephrine all contribute.
Hormones & Hormonal windows
Women have a higher likelihood to experience depression in windows of hormonal change - such as post-partum or during the perimenopause/menopause transition.
HPA dysregulation
Our hypothalamic pituitary axis, or “stress” axis which controls the hormonal influences of stress on our bodies. Chronic stress, or early exposure of stress in life, will cause these hormones to impact the expression of certain genes tied to depression, can influence and change the structure of our brains.
Psychosocial Stress & exposure to recent stress or ongoing stress
Psychosocial stress (especially exposure early in life) is predictive for depression. These may include stressful life events, such as death of a loved one, divorce, illness or injury, major transitions (moving), abuse, and financial hardship. These stressful life events may activate the HPA axis, causing a disruption to neurotransmitters, brain structure and function, blood flow, the immune system and increase inflammation. If this stress continues to persist, it may put an individual at risk for a depressive episode.
What else do we want to evaluate?
Your health care provider may want to run blood work to rule out any nutritional or endocrine cause of depression, especially if you are experiencing a lot of fatigue.
This may include looking at the following blood work
Complete Blood Count (CBC)
This looks at our hemoglobin and helps us rule in or out anemia that may be caused from low b12 or iron deficiency.
Ferritin
A measure of iron storage which tells us if you are iron deficient
Vitamin B12
Testing vitamin B12 in the blood can help us understand your levels and if we need to adjust supplementation or injections. Low B12 can be linked to fatigue.
Thyroid Stimulating Hormone (TSH)
TSH helps us understand how your thyroid, and organ implicated in metabolism is functioning. When our thyroid is underfunctioning, such as in hypothyroidism, we may experience low energy, depression, and weight gain.
Vitamin D
Low vitamin D is sometimes associated with lowered mood and energy. We can test vitamin D through the blood and adjust dosing accordingly.
What are our treatment options depression?
Treatment for depression depends on the individual, duration and severity of what is going on. Some patients may find that one intervention works best than the other, and some patients may need a combinatory approach (using multiple treatments) for different parts of their care (maintaining remission from depression vs. active or acute treatment).
Psychotherapy
There are many different types of talk therapy that have been found to be helpful for depression when it is “acute” - or when we are currently experiencing a depressive episode, or when we are looking to maintain our mental health. Talk therapy is beneficial in that it is drugless - and can be used even if an individual is on other medications or pregnant, it can be delivered in a variety of ways (online or in-person, individual or group settings etc.) there are no side effects, and it is not addictive. However, talk therapy can take longer to take effect, may not support those who are dealing with severe depression, is a large time commitment, and may be expensive or difficult to access if there is not an acute problem on going.
Cognitive Behavioural Therapy (CBT)
CBT is a type of therapy that helps individuals focus on negative beliefs and unrealistic thoughts about themselves that can create depression and re-informace it. To complete CBT, individuals talk with a psychotherapist and may complete homework that helps them challenge these negative thoughts and change them.
Canadian Network for Mood and Anxiety Treatments (CANMAT) indicates the evidence for CBT in the acute phase of depression, and in the long term maintenance of mental well-being is strong for both situations.
Interpersonal Therapy (IPT)
Interpersonal therapy is a system of talk therapy that looks at the impact your relationships with others and how that may create or reinforce depressive feelings or thoughts. CANMAT classifies IPT to be helpful in active depression treatment (with a strong recommendation) , however in the maintenance the evidence for IPT is only considered medium.
Behavioural Activation (BA)
Behavioural Activation is a type of treatment that looks at changing an individuals activities to be more active, identifying fun things and how to include those in your life. It may mean working with the psychotherapist to identify the problems and subsequent behaviours that help. It has been shown like the other two therapies to be helpful in the treatment of active depression (strong recommendation), but like IPT, long term maintenance of mental health using BA has only been deemed to be a “medium” strength recommendation by CANMAT.
Medications
Anti-depressant medications work as well as psychotherapy for most patients. In severe cases of depression, medication may be used first as it typically works faster. Depending on the individual you may find a combination of psychotherapy and medication works best for you. With any medication, it make take time to find the right medication and dose for you. Talk with your prescribing health care provider about what treatments make sense and how to navigate dose changes, side effects and medication changes.
Lifestyle Medicine
Exercise
Regular physical movement can improve your mood. Although we don’t think that exercise works better than psychotherapy or medication. As exercise is a foundation part of a healthy lifestyle, we typically encourage all patients to strive for the Canadian guidelines of physical activity minimums, which is to partake in aerobic exercise (cardio) for 150 minutes per week (or 3-5x a week of 45-60 minutes) at a moderate to vigorous intensity, incorporate 2 bouts of strength training per week and to reduce or interrupt sitting as much as possible. Having a hard time starting? Both cardio and strength training have shown a benefit for reducing depressive symptoms, so getting started with whatever is easiest it your best bet. We want the activity to be done over the long term, with the changes to depressive symptoms being seen around the 10 week mark.
Why does exercise help depression?
We think that exercise helps depression via biological factors such as increased neurotransmitter turnover, the release of endorphins, changes in neurotrophic factors (like BDNF) and reduced cortisol levels. Exercise may also increase feelings of self-efficacy providing a psychological benefit.
Light therapy
Light therapy uses a specific wave length of light (lux) to help restore chemicals in your body that impact and improve mood. Using light therapy may also help regulate the sleep‐wake cycle. Light thereapy is often used in seasonal depression or seasonal affective disorder (SAD). It can be combined with medications and has minimal side effects.
Yoga
Yoga does not have robust research showing it improves depression on it’s own, however it is often added to other treatments (like medications and talk therapy) We think that yoga benefits our neurobiology in depression by increasing the turnover of dopamine and GABA levels in specific brain regions, regulating the hypothalamic-pituitary-adrenal axis, and normalizing our heart rate variability. These effects can contribute to improved mood and reduced depressive symptoms
Acupuncture
Acupuncture can be a supportive add-on treatment in depression. Our western explanation of how acupuncture works is by modulating the nervous system, hormonal system, immune system and altering blood flow. You can read about the traditional eastern approach in our blog here.
Supplements
Supplements can be supportive as add-on therapy, or on their own in mild-moderate cases of depression. Always consult with a naturopathic doctor or health care provider before taking supplements as they may interact with your medication or not be right for you.
St. John’s Wort
St. John’s Wort is an herb that contains a compound called hypericin. This compound act’s similarly to SSRI or serotonin influencing medications, and increases serotonin levels which can alleviate depressive symptoms. St John’s Wort is a supplement that can be considered as a stand alone treatment in mild-moderate depressive cases in some circumstances. Talk to your health care provider about if St. John’s Wort could be an option for you.
Omega-3
Omega-3 Fatty Acids are found in fish oils and certain nuts and seeds. Some research shows positive results for managing depression with omega‐3 fatty acids, with both EPA and DHA, components of Omega-3 fatty acids supporting. Omega-3s should be used as an add-on therapy to standardized treamtents.
S‐Adenosyl Methionine (SAM‐e)
SAM‐e is naturally made in your body and is involved in the regulation of hormones and mood. It can be used by itself or with antidepressants. SAM-e is a potentially useful add-on therapy for depression, as the results in research can be mixed on whether it is effective. Talk to your health care provider about if this is a good option for you.
Want to learn more?
Curious about your own health circumstance and what treatments might make sense for you? We encourage you to book a consultation with one of our naturopathic doctors, acupuncturists, or our psychotherapist to explore what makes sense for you.