Depression, Melancholia, Bipolar Disorders

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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From 1994 to 2008, the prescription of antidepressants to teens and adults in the United States rose 400 percent, despite controversy concerning real effectiveness, as well as significant risks when taken during pregnancy, where more than 13 percent of pregnant women continue to depend on antidepressants. The underlying causes of depression are not addressed by antidepressant medication, and this taking of a medication without also taking a proactive approach to understanding and correcting the problem of depression, as well as anxiety mood disorder, which often precedes depression, is not a sensible approach to this health problem. Integrating Complementary Medicine, as well as Cognitive and Behavioral Psychology, into the treatment protocol provides a more thorough and holistic treatment plan, and the potential to stop depressive mood disorders, not just dull them.

Depression is a term that is widely used and misunderstood medically and socially. There are various medical conditions that we term depression, depressive disorders that are secondary to other health conditions, common emotional depressions that may not be part of a significant physiological disorder, and depression that is cyclical and tied to a predominant anxiety disorder. There is much concern now that denial of real care to treat emotional disorders has led to an equating of emotional imbalance with depression and anxiety mood disorders, and that there is a failure to see that emotions are not a sign of disease, but a part of a healthy human life, and emotional intelligence and balance are essential to a successful and fulfilled existence, not something that needs to be suppressed with drugs. The subject of depression is not simple, and there are no real simple solutions.

Understanding your depression is the first step in treating it successfully and emerging a better and healthier person. Bipolar disorder is also now a familiar term as well, signifying alternating periods of depression and mania, which is an abnormal state of increased activity and elevated mood, characterized by various combinations of the following symptoms: abnormally increased energy and activity level, inappropriate elation, increased irritability, insomnia, grandiose notions, disconnected and racing thoughts, increased sexual desire, poor judgment, and/or inappropriate social behavior. Depression may be characterized by feelings of worthlessness and self-loathing, difficulty concentrating, restlessness, problems with decision making, fatigue, low energy, weight changes, poor sleep patterns, with both insomnia and somnolence, body aches, and thoughts of suicide or death. Each individual may experience a different array of symptoms in depressive mood disorders, and syndromes with depressive mood as part of the dysfunction. Often, the term depression is used to describe all of these diseases and syndromes, both primary depressive disorders and depression secondary to another health problem, and the treatment is often standardized for not only all individuals with these problems, but for subsets of patient with various depressive disorders. A one-size-fits-all approach for symptoms of depressed mood is not logical, and in recent decades, experts have agreed that a more comprehensive treatment protocol is necessary, as well as a better differential diagnosis. Such disorders are serious and should always be treated with a thorough integrated approach, utilizing various specialties to achieve a cure, not just a medicated state.

A growing awareness of the prevalence of depressive and bipolar mood disorders exacerbated by fluctuations in the neurohormonal homeostasis of the menstrual cycle, and perimenopausal fluctuations, is finally leading to the acknowledgement that much misdiagnosis and overprescription of mood-stabilizing drugs has occurred with premenstrual syndromes (PMS) and premenstrual dysphoric disorder (PMDD), as well as perimenopausal changes. Prominent clinics devoted to this subject, such as the Women's Mood and Hormone Clinic at the University of California San Francisco (UCSF), founded by Dr. Louann Brizendine, author of The Female Brain, have found that standard mood-stabilizing drug prescriptions do not work with these mood disorders caused by dysfunctional hormonal fluctuations. While problems with the menstrual cycle are often treated with synthetic hormones in the form of contraceptive medication, these synthetic hormones do not effectively treat the mood disorders accompanying neurohormonal dysfunction, and in fact, studies have found that even the newer class of contraceptive hormone medications, such as the NuvaRing, Yasmin or Yaz, and the Ortho Evra, actually exacerbate mood disorders rather than alleviate them. The Product Monograph for NuvaRing by the manufacturer, Merck Canada, Inc., on February 7, 2011, stated: "Patients with a history of emotional disturbances, especially the depressive type, may be more prone to have a recurrence of depression while using combination hormonal contraceptives...Women with a premenstrual syndrome (PMS) may have a varied response to combination hormonal contraceptives, ranging from symptomatic improvement to worsening of the condition." While clinics are now suggesting that SSRI medications may be used premenstrually in short courses to immediately inhibit the enzyme 3-beta-HSD (hydroxysteroid dehydrogenase) from metabolizing progesterone, maintaining higher levels to stabilize the mood, a better approach would be to try to stabilize the menstrual hormonal imbalances and restore a healthy homeostasis with Complementary and Integrative Medicine, and consider going off of synthetic hormonal contraceptives for a period of time to achieve this effect. Bioidentical hormonal lotions, herbal and nutrient medicines, and acupuncture may be combined to restore normal balance of steroidal hormones, such as progesterone in the premenstrual cycle.

In 2013, the first of four studies concerning sleep disorders and depression was completed and the results published. The U.S. NIH National Institutes of Mental Health commissioned these studies, the first of their kind, to explore the role of sleep disorder, itself a poorly studied and ignored aspect of human health, on both the onset and worsening of depressive mood disorders. Experts at Ryerson University, in Toronto, Canada, found that 87 percent of patients that resolved issues of insomnia with cognitive and behavioral therapy in just 8 treatments, attended twice per week, saw their symptoms of depression resolve in 8 weeks, both with concurrent antidepressant medication, and with a placebo pill. These rates were twice those of patients with clinical depression that could not resolve their sleep disorder, or insomnia. Colleen E. Carney Ph.D., the reports lead author, and director of the University's Sleep and Depression Laboratory, notes that treatment of sleep disorder involves more than just taking a sleeping pill, which may alter healthy sleep cycle patterns. Dr. Carney notes that poor sleep often becomes chronic when a person focuses too much on how much they sleep, and the patterns of waking, as well as the consequences of poor sleep experienced during the day, such as fatigue, concentration problems at work, and negative mood. When a person becomes preoccupied with sleep, and the worry about these daytime consequences, they may try too hard to sleep. Dr. Carney notes that this is the one health problem where trying too hard is counterproductive. She recommends that understanding the physiology of sleep and fatigue is itself an effective way to treat insomnia, and so cognitive and behavioral therapy incorporated into a holistic treatment protocol provides great promise in treating depression. This study provides sound data to back up this claim. Once again, treating the individual holistically and addressing these issues underlying the depressive mood disorder, such as hormonal imbalance and sleep disorder, may provide the means to cure the depression, rather than relying on antidepressant medications forever, and living with the long-term adverse health effects of these drugs.

Research at Stanford University School of Medicine, in Palo Alto, California, headed by Rachel Manber Ph.D., a professor of psychiatry and behavioral medicine, also confirms the findings that insomnia doubles a person's risk of developing depression, and resolving sleep disorder with cognitive and behavioral therapy will resolve symptoms of depression in a great majority of patients. In her randomized, controlled human clinical trials, 60 percent of patients receiving such therapy, focused on sleep hygiene understanding, were able to fully resolve their depression, about double that of patients just taking an antidepressant. Complementary Medicine, with acupuncture, herbal and nutrient medicine, and even physiotherapy, may also provide much help in treating and resolving sleep disorders (see a separate article on this website entitled Insomnia and its implications). Besides sleep disorder, chronic pain has been found to be highly associated with both sleep disorder and depression, and treatment of this aspect of health could also increase success in treatment of depressive mood disorders greatly. Complementary Medicine, in form of acupuncture and physiotherapy in the medical specialty of Traditional Chinese Medicine, offers an effective way to address both chronic pain and insomnia in a short course of therapy.

Not only healthy sleep quality, emotional balance and healthy expression of emotions, as well as hormonal balance, are proven to be very important in preventing and treating depressive mood disorders, but dietary habits and gastrointestinal health is proving to be integral to healthy mood and brain function as well. In 2014, experts at the Harvard Medical School and the famed Massachusetts General Hospital, along with experts at the British Columbia Women's Hospital and Health Centre in Vancouver, published their findings explaining how traditional diets with a variety of fermented foods, which promote a healthy gut microbiota, are now proven to be integral to psychiatric care and mental health. The human Biome provides a wealth of chemicals needed to maintain mental health, affecting the nervous, hormonal and immune systems, metabolic health, and of course regulating the balance of microbial life to prevent low-grade pathogenic infection. We have seen from the explosion of research in microbiomics that the Biome actually directly provides neurohormones when needed as well. These dietary considerations in mental health extend to more than the use of probiotcs and fermented foods, though, as this research also shows that fresh local organically grown foods provide a rich source of microbial life that is destroyed in processed food. To treat depression and prevent recurrence of mood disorders we need to do more than just pop a pill. To see this important study in nutritional psychiatry, just click here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904694/ . One can also go the the article on this website entitled Deep Tissue Massage and Its Many Benefits to see research that reveals that treatment with soft tissue mobilization, such as TCM Tui na, provides a host of direct benefits to mental health as well, increasing healthy hormones, neurotransmitters and metabolic chemicals, immune cells, and an improved homeostatic balance. The importance of this holistic approach to psychiatric medicine is proving to be enormous, but we will see whether this scientific evidence is enough to change the treatment outlook in standard medicine, where the monetary incentive steers our medical doctors to just prescribe more and more expensive pharmaceutical drugs with an enormous number of adverse health effects, euphemistically called "side effects" despite the numerous warnings being generated concerning health risks and injury from this protocol, as well as the failure of the current drug protocol to actually take care of the problem in most cases.

Traditional Chinese Medicine, and Complementary and Integrative Medicine (CIM/TCM), offers the patient an individualized proactive approach to regaining a healthy control of mood and correcting underlying imbalances in one's health that contribute to the diseases of depressive disorders. Treatments don't just block chemicals activities, but actually restore the patient's health, and a variety of treatment protocols are tailored to each individual disorder. Acupuncture, herbal/nutrient medicine, and patient counseling are now recognized as important adjunct therapies in an integrated multifaceted treatment of a variety of depressive disorders and related underlying health problems, such as insomnia and chronic pain, as well as hormonal imbalances.Treatment with soft tissue physiotherapy, or Tui na, has also been proven valuable in both relieving pain related to depression, and improving biochemical parameters associated with mood disorders, and a landmark 2010 study of these effects at Cedars-Sinai Medical Center and the UCLA David Geffen School of Medicine led Dr. Mark Rappaport, the lead author of the study, to remark that he would perhaps rethink his approach to mood disorders after this study.

There is still a stigma attached to the diagnosis of Depression despite the recognition that this is a widespread societal health problem. It is possible that 100 percent of the population suffers from some sort of depressive episodes at some time in their life. The degree of dysfunction that results from these depressive episodes and their chronicity is what determines the need for treatment. The failure of society to accept the prevalence of depression and to deal with it in an open and healthy manner may be key to the prevalence of clinical disorders and dysfunctional states. The failure of patients to treat depressive episodes and discover the underlying health problems related to these episodes leads to the development of clinical dysfunctional disorders. Looking at your condition objectively, and not giving in to a purely subjective emotional response to depressive disorders, is an important step in treating these health problems early and effectively. Early treatment with Complementary and Integrative Medicine (CIM) and TCM holds much promise in preventing depressive episodes from becoming severe enough to require medication.

The World Health Organization (WHO) has determined from study that treatment for depressive disorders is so prevalent now that it consumes more than 1% of gross domestic product in Europe. The WHO is looking to find more effective treatment strategies to curb the rising costs of clinical depression, both to individuals and to society as a whole. An example of such treatment focus is the area of dysfunctional neurogenesis, which is a term applied to deficiency of brain function and physiology brought about by chronic stress and emotional depression, or constraint. Areas of the brain affected by problems with dysfunctional neurogenesis include the prefrontal cortex, amygdala, hippocampus and neocortex. Physiological problems objectively measured with fMRI study include reductions in neuronal volume, size and density, changes in blood flow, changes in glucose metabolism, and reduction in glial cell support. These various physiological problems are not addressed in standard pharmaceutical therapy. New approaches in medicine are needed as new research unveils the physiological aspects of depressive disorders.

The WHO has found a number of novel treatment strategies proven helpful in neurogenesis stimulation, or the formation of new healthy nerve and nerve support cells. Standard medicine, until recently, insisted that nerve cells in the brain could not be regenerated. This has been found to be patently untrue. The motivations for perpetuation of the myth that brain cells could not be regenerated are being explored, and many believe that this prevalent theory was promoted by profit motives in the pharmaceutical industry. Helpful tools in the stimulation of neurogenesis include increased daily exercise, new learning activities, hormonal balancing, resolution of metabolic dysfunctions, stress reduction, treatment of accelerated aging mechanisms, and neurotransmitter bioavailability promoted by natural precursors to neurotransmitters. The WHO studies found that both acute and chronic stress inhibits neurogenesis and gliogenesis, predominantly in the hippocampus, as well as the prefrontal cortex. Since there are 100 times as many glial (support) cells in the brain than actual neurons, reduced gliogenesis may be the key to reduced neurogenesis. Glial cells have been found to possess cellular receptors that are stimulated by both neurotransmitters and hormones. This type of research points to the explanation of how a complex and holistic strategy with Complementary and Integrative Medicine (CIM) could have a profound effect over time on the success of treatment of Depressive Disorders. To better understand how acupuncture stimulation affects the brain, go to an article on this website entitled Brain Health and Function: utilizing Complementary Medicine. Of course, research has uncovered many ways that herbal and nutrient medicines directly aid brain tissue and function as well, and a comprehensive treatment approach may improve this aspect of the depressive mood disorder pathology.

A crisis of noncompliance with standard drug therapy for depressive disorders, and a drive to find improved treatment protocol

Why is there such a problems with noncompliance in standard drug therapy with Depressive Disorders? Long term studies of SSRIs and SSNRIs (selective serotonin and norepinephrine reuptake inhibitors) have produced some alarming statistics of side effects, and the lack of effectiveness has also played a part in many patients being discouraged and failing to consistently take the drugs. The problems with withdrawal, though, usually create a need to resume medication. Physicians themselves are starting to become alarmed due to the number of health problems linked to SSRI and SSNRI medication. Large class action lawsuits have been generated due to the number of studies linking SSRIs, such as Paxil, to a wide range of birth defects, including heart, abdominal wall, skull shape, lung and blood pressure abnormalities. A 2004 study linked SSRI use to suicidal thoughts and actions, prompting strict FDA warnings, and bans or limits on prescription in a number of countries. Many studies have identified neurotoxicities resulting from chronic use. In 2009, the Japanese Ministry of Health revised the warning labels on SSRI antidepressant medication to read "There are cases where we cannot rule out a causal relationship (of hostility, anxiety, and sudden acts of violence) with the medication." Other studies have linked depressed bone health to the hormonal and metabolic changes associated with chronic SSRI use. Researchers at the University of Minnesota reported that "women taking SSRIs lost twice as much bone density at the hip compared to other antidepressants or none at all." (Diam el al, 2007). SSRI-induced sexual dysfunction has also been a subject of much concern. All of these studies point to an underlying mechanism that inhibits normal homeostatic regulation in the body and has large implications for general health as well. Patient concern has become high, and many patients are exploring a broader protocol for dealing the the underlying mechanisms that cause depression, melancholia and bipolar depressive disorders. For these patients, simply suppressing symptoms is no longer enough, and a restoration of health is sought. Complementary and Integrative Medicine serves as a proven effective adjunct to standard treatment, and also serves to decrease risks and side effects, support homeostatic health, and make standard protocols work better, in a safe, effective and healthy way.

In recent years, prominent experts in the field of psychology and psychiatry voiced doubts about the efficacy of antidepressant drug therapy itself. Irving Kirsch, a professor of psychology at the University of Hull, United Kingdom, and professor emeritus at the University of Connecticut, United States, wrote a book entitled The Emperor's New Drugs: Exploding the Antidepressant Myth, suggesting that the whole array of data on antidepressant drug trials shows that these drugs barely outperformed placebos for mild to moderate depression. Dr. Kirsch has been a reknowned researcher of both antidepressants and the placebo effect, and is the originator of response expectancy theory, influencing analysis of clinical trials and official treatment guidelines. Marcia Angell M.D. is the first woman to serve as editor-in-chief of the New England Journal of Medicine, and is currently a senior lecturer at Harvard Medical School. Dr. Angell also has now written extensively on the failures of drug therapy for depression, and also on the fact that psychiatrists lead the pack of medical specialties in taking money from drug companies. Her article in The New York Review of Books, entitled The Illusions of Psychiatry, suggests that pharmaceutical companies invested heavily to transform psychiatry to a drug-intensive specialty and rewrite diagnostic guidelines to increase drug prescription despite the lack of objective tests or signs in mental illness. Dr. Angell's views on the controversies of antidepressant drug use, including her view that the defining of depression and other psychiatric disorders by the often relatively small beneficial effects seen in clinical trials, can be read by clicking this link to her article entitled, The Epidemic of Mental Illness: Why?: http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/. More and more experts in the field are suggesting that the patient should consider an integrative approach to treatment for mild to moderate depression, utilizing an array of therapies besides standard drug protocols to quiet symptoms and reestablish a healthy neurocognitive function.

The failure of anti-depressant medications is also spurring a large push in the area of new technology to treat depression and anxiety disorders. The physiological problems in these pathologies involve more than simplified neurochemical imbalances. David Anderson, a professor of biology at the California Institute of Technology, does research with optogenetics, a promising field of therapy that seeks to use fiber optic implants to exert direct effects on neural firing, or even exogenous light beams that affect chemically sensitized neurons in specific areas of the brain. While still in early stages of development, these technologies involve brain studies that reveal much about the physiological problems in depression and anxiety disorders. Dr. Anderson states that: "Psychiatric disorders are probably not due only to chemical imbalances in the brain. It's more than just a giant bag of serotonin or dopamine whose concentrations sometimes are too low or too high. Rather, they likely involve disorders of specific circuits within specific brain regions." Dr. Anderson compares the current drug strategies to a sloppy oil change, stating that if you dump oil over your engine, some of it will get to the right place, but a lot of it will end up doing more harm than good. The notion of more harm than good is now gaining a broader acceptance in standard medicine, and even in the patient population. Restoration of brain function is more sensible approach to these problems, and current research is finding quite the role for therapies in Complementary Medicine to help achieve this goal of restoring neuroplasticity and function (see the article entitled Brain Health and Function on this website).

The most prevalent focus to address widespread non-compliance with standard drug therapy in depressive disorders is to expand the treatment protocol and include therapies that proactively engage the patient in their care, as well as afford the possibility of decreasing drug dosages enough to diminish side effects and risks to an acceptable level. The two areas that are being promoted heavily in this new strategy are cognitive-behavioral therapies and Complementary and Integrative Medicine.

Large studies to prove efficacy with these strategies have been, and are being, conducted across the world. Of course, there are problems applying the type of clinical study used to judge pharmaceuticals, where the effects are simpler and a placebo is easily substituted by creating a dummy pill. There are no real placebos possible in the study of cognitive-behavioral therapies and acupuncture, and these treatments work best when individualized and nuanced to each patient by the treating physician. The array of effects of Complementary and Integrative Medicine are also broad, and thus difficult to apply to standard studies. Nevertheless, these randomized, double-blinded and supposedly placebo-controlled studies have been widely conducted, and have shown efficacy. This fact alone shows the public how serious medicine is in incorporating these strategies into a more effective multifactorial set of protocols. Designing treatment guidelines and integrated protocols that meet standardized guidelines will be a challenge, but many patients have become educated to these approaches and now seek out physicians that integrate therapeutic disciplines and show knowledge and clinical experience. This array of scientific study is helping such phsyicians as Licensed Acupuncturists and herbalist to also utilize more objective information in their practice, which has greatly improved results.

In 2014 the Obama administration proposed changing the rules that protect the sale and prescription of 6 classes of drugs, including antidepressants, antipsychotics, and immunosuppressants. This rule required all insurers to cover all, or substantially all, of these drugs, and this has led to a huge increase in the number of prescriptions, often to the detriment of other therapies that could more effectively and safely treat patients with depression and anxiety disorders. There is much concern that enormous amounts of money were spent to include antidepressants and antipsychotics in this realm of drugs necessary for public health, and this created a guaranteed market in the industry that led to overprescription. The new proposal would not change the requirement protecting cancer drugs, drugs to treat HIV/AIDS, and anti-seizure medications, but would solve the alarming problem of overprescription of drugs intended for those that really need them acutely, but were instead marketed to anyone who complained of health problems needing other therapies. The legal guarantee of payment for these antidepressants and antipsychotics led to them becoming the highest selling drugs on the market, and 85 percent of the most popular drug, atypical antipsychotics such as Abilify, prescribed for problems where the drug was not FDA approved. Finally, the mounting data on overprescription of antidepressants, and the addition of antipsychotic drugs with cute names like Abilify, Seroquel, and Zyprexa, which come with many serious long-term adverse health effects, is leading to significant action to protect the patient population. Not only are these drugs too easily prescribed by medical doctors who are not psychiatrists, but are the focus of fraudulent practice and fraudulent marketing crimes settled out of court for many billions of dollars, and involving systematic overprescription to helpless patients in nursing homes. Of course, the industry, and their lobbyists, are staunchly objecting to these changes, claiming that they are affecting an area of healthcare that is not broken. Many experts in the field, though, are stating that this aspect of our healthcare protocol is broken.

In 2014, in response to a growing concern with antidepressant SSRI use during pregnancy and numerous long-term studies showing not only acute adverse effects on the fetus, but long-term adverse effects as well, the U.S. Food and Drug Administration (FDA) issued strong warnings about evidence of birth defects associated with use of Paxil. Research summarized in a September 2, 2014 article in the New York Times, entitled Pills May Put Babies at Risk, revealed that now up to 14 percent of pregnant women in the United States take antidepressants during pregnancy, and multiple studies now show that these women are more likely to give birth prematurely, and that a number of future diseases, increased risk of attention deficit and hyperactivity disorder, autism, lower language competence by age 3, and other long-term developmental defects have been revealed in large studies across Europe and the United States, including studies at Harvard Medical School and Johns Hopkins University Medical School. Neurotransmitters such as serotonin play a large role in fetal development, and SSRI medications may impact the fetal development, yet they have not been discouraged from use in standard medicine. A new more holistic outlook on these health problems and treatment utilizes a neurohormonal approach, recognizing that the nervous system, the endocrine system, our immune systems, and our genetic expressions all interact in a complex manner, not as separate systems. Of course, if the Depressive Mood Disorder is severe the patient may need to stay on medication during pregnancy, and if the patient becomes pregnant while on SSRI medication, the drug should not be suddenly discontinued, as rebound effects often occur. It has been found that continuous use of SSRI medication during pregnancy has resulted in SSRI withdrawal symptoms for the newborn infant, with disruption in sleep patterns essential for the health of the infant. All of these factors should be considered by the primary treating physician. Complementary and Integrative Medicine (CIM) provides another treatment protocol that can be integrated to help achieve the goals of reduced or gradual discontinuation of antidepressant medication during pregnancy.

One practical solution to the problems of antidepressant medication noncompliance, as well as the health concerns about long-term prescription, is the integration of Complementary Medicine and psychotherapies, especially cognitive and behavioral therapy, into a protocol of gradual drug withdrawal once a stabilization of the depressive or bipolar disorder is seen. The problems with withdrawal of these drugs, especially sudden withdrawal, involves both the chemical dependence as well as the negative effects of the drugs themselves. Gradual tapering of dosage over a period of several months is now the normal guideline for withdrawing these drugs, and an increasing number of MDs that prescribe them are finding that an adjunct therapeutic protocol during this withdrawal period, such as the use of acupuncture, herbal and nutrient medicine, as well as cognitive and behavorial counseling, effectively reduces the negative effects of withdrawal, and provides the patient with an alternative maintenance support therapy to prevent relapse. Studies have also shown that about 10% of patients with depressive disorder treated or withdrawn from antidepressant therapy acquire a bipolar depressive disorder, or initiation of a manic phase to the disorder. Use of Complementary and Integrative Medicine may provide for a modulatory, or balancing, physiological effect that could prevent many of these unipolar depressive disorders from advancing to a bipolar disorder. Traditional Chinese Medicine (CIM/TCM) offers a rich history of effective treatment protocol for these depressive and bipolar disorders and is relatively inexpensive, as well as being very safe and free of negative effects. It is not an alternative medicine, but a specialty that can be integrated with standard care and cognitive and behavioral therapy. Patients often adopt attitudes of belief in just one of these medical approaches, which is not helpful. Utilization of this TCM practice when withdrawing from antidepressant and antianxiety medication, along with tapering of the drug dosage, is proving to be a remarkably beneficial and effective protocol.