I don't like the name depression and try to avoid using it in my practice.

The name carries a negative social characterization which I feel is not well deserved.

I prefer to use the terms "dysthymia" or "anhedonia" which are Latin and Greek for "I feel lousy!" There are good prescription medicines for this condition; but many of my patients are interested in avoiding the prescriptions and using more "natural" therapies instead.

Below I have outlined some of these approaches, starting with herbs and supplements.

* HERBS & SUPPLEMENTS

The first CAM that comes to mind is herbal therapy, and the first herb that you would think of is hypericin, or St. John's wort. There is not consensus as to the mechanism of action of hypericin.

Many sources have expressed concern that there is an element of MAO-I function; however this has been shown not to be the case and there is not a concern of ingestion of tyramine while taking hypericin. A meta-analysis of 23 RCT's of hypericin published in the BMJ2 found it to be superior to placebo at decreasing mild to moderate depression symptoms (odds ratio = 2.7) and comparable to TCA's (odds ratio for the TCA's of 1.52)1 The same study found a side-effect rate of 19.8% for hypericin and 52.8% for TCA's.

The main potential side effect to watch for is increase photosensitivity while on the drug. There also can be some GI side effects such as bloating and constipation, sedation, and dry mouth. It should not be taken with L-dopa or 5-hydroxytryptophan, should not be taken with MAO-I's and with caution with SSRI's. Drugs that are metabolized by the cytochrome P450 system could have drug levels lowered by St. John's wort. The usual dose is 300 mg t.i.d although doses may go safely up to 2400 mg per day.

Regarding the quality control of herbs, there are a few herbal companies which stand out for their quality controls; Herb Farm, Eclectic Insititute and Phytopharmica. There is an independent laboratory similar to the Consumers Union Lab, called ConsumerLab.com which evaluates herbs and supplements. If you see this logo on a bottle of supplements you know that it has passed their quality standards. They now have assessed ginko biloba and saw palmetto.

Your patients will also be hearing about SAMe (S-adenosylmethionine) as an anti-depressant. There is research showing parenteral SAMe to effective to treat depression, but the oral absorption is erratic, and it is not appropriate to extrapolate that the oral for available at the health food stores is also effective. Additionally, its cost of about $240 per month is prohibitive.

A quick note on 5-HTP (5-hydroxytryptophan). 5-HTP is the immediate precursor to seratonin and some research shows that this may be effective in treating the symptoms of mild to moderate depression (doses of 150 to 300 mg/day).

* NUTRITION

First we should address caffeine and alcohol.

Believe it or not, caffeine has been shown to increase depression scores with moderate to heavy use3. There is even evidence that this effect is amplified if the caffeine is taken with sucrose4. Avoidance of alcohol in anything greater than minimal amounts is obvious in the treatment of depression. Alcohol acts as a neurodepressant, interferes with sleep architecture, increases adrenal output and interferes with other CNS cellular processes. Recommending a well-balanced diet rich in vegetable and fruits and low in sugar and fat should be a baseline in our recommendations. In addition there is good evidence to recommend supplementation with folic acid, vitamin B12 and B6, as well as omega-3-fatty acids (found in oily fish as well as supplements).

* EXERCISE

There is a plethora of literature articles documenting the impressive anti-depressant effects of exercise5. Many of these studies found exercise to be as effective as TCA's and psychotherapy. The types of exercise evaluated were aerobic exercise and strength training. It may be at times difficult to convince your dysthymic patients to undergo a regular exercise program but the efficacy of this is in fact the most well documented of the life-style and Integrative Medicine approaches to mild to moderate depression.

* OTHER ALTERNATIVE THERAPIES

There are many other alternative therapies which have been used to assist in the treatment of dysthymia.

Homeopathy, for instance, can be very powerful for mood disorders.

However, the selection of the appropriate homeopathic prescription requires an experienced homeopathic practitioner. Designing studies to evaluate the efficacy of holistic therapies such as homeopathy are difficult, since the prescription is so individualized for each patient. This is one of the obstacles to the creation of studies for many of the alternative medicine modalities. None the less, the CAM community is quite interested in doing just that.

There is, for instance, a double-blind, placebo-controlled study from University of Massachusetts evaluating homeopathy in the treatment of mild to moderate depression. This preliminary study is near the end of the data collection phase and hopefully will be available to us within a year or two. There is much interest in other CAM modalities related to dysthymia. Acupuncture, body word such as massage therapy and energy work such as Reiki Therapy have anictdotally been found by many to help their symptom and their overall sense of well-being.

INTEGRATIVE MEDICINE RESOURCES:
NIH Office of Complementary and Alternative Medicine.
NIH CAM search engine:
NIH Office of Dietary Supplements - IBIDS
ConsumerLab.com
Health World OnLine