Written by Cyndi Collen, LCSW-S | MSSW, Clinical Director

Holistic treatment for depression

Taking an anti-depressant and still feel depressed? Or feeling down or anxious and considering taking a medication to help you feel better?  While short-term anti depressant use can get people through dark, hopeless episodes they do not treat the root cause.  However, holistic treatment for depression does target root cause(s).   Holistic options for people feeling depressed or anxious considers all of you, not just one neurotransmitter called serotonin.

Myth: Depression is caused by a chemical imbalance

The marketing slogan ‘depression is caused by a chemical imbalance’ has zero research supporting it as evidence-based. However, many people have heard their doctor or someone close say this. This phrase implies a person’s fatigue, chronic hopelessness or disinterest can be simply fixed by taking a medication. Even though human beings are the most complex beings on the planet, somehow a modern medicine miracle figured out an easy way to defeat depression. The neurotransmitter ‘serotonin’, according to the pharmaceutical industry, is the root cause of your depression. They say you do not have enough of it. You need to take medication so you can have more serotonin and then, voila, your brain chemicals will be balanced.

This reductionist perspective dismisses other possible influences on depression. Through this lens, healthcare professionals do not have to ask if anything traumatic has happened or if you have had some awful childhood experiences. Dismissing factors that could be contributing to or causing depression such as recent events or life changes, activity levels, sleep quality or diet, is efficient. Even if a healthcare professional, such as a primary care doctor, was curious about your symptoms of depression, the eight minute appointment leaves no extra time to ask important questions.

SSRI’s

The class of medications targeting serotonin are called SSRI’s — Selective Serotonin Reuptake Inhibitors.   We are told that these medications work by blocking the reabsorption (reuptake) of serotonin in the brain, thereby increasing the availability of serotonin in the synaptic gaps between neurons.  Originally advertisements and doctors were telling people they need more serotonin to regulate their mood.  When this ‘theory’ was challenged, the narrative shifted to how SSRI’s improve neuroplasticity, which improves mood.   But, the phrase ‘depression is a chemical imbalance’ stuck even though there is no evidence to support the validity of the phrase.

The truth is that human moods and emotions are not easy to ‘fix’. There is no evidence that people with depression have less or more serotonin then people who are not depressed.(1)  While I wish our human bodies were this simple and that we could cure people’s depression by adding a ‘chemical’ to balance the imbalance this is not the case.   Receiving holistic treatment for depression can get to the root cause(s) of depression; an SSRI cannot.

Myth: Mental health screenings improve mental health outcomes

All patients going to a primary care doctor for anything are given a PHQ-9 questionaire. The nine question quiz is meant to replace a thorough mental health assessment by a licensed mental health professional. In less then two minutes, your ‘yes ‘and ‘no’ answers can lead to a diagnosis of major depressive disorder. Modern science is so awesome, right? You go to the doctor for a physical or a chronic sinus headache and you find out that you have a mental illness. But no worries, there is a pill that can fix that. No need to see a trained mental health professional. Just take one nanosecond out of your day to swallow a pill and just like that, depression is gone … poof!

Since the COVID pandemic there has been an significant increase in depression (2). The leading medical organizations believe the solution to cure depression is to increase mental health screenings. This mean giving this this 9-question quiz, the PHQ-9, to everyone.

Is mental health improving?

If the medications were working wouldn’t less people have symptoms of depression? Since psychotherapy or talk therapy is effective at decreasing mental illness episodes, why aren’t doctors or nurses sending patients to therapy first instead of prescribing a pill that has lots of side effects and low efficacy.

Pharmaceutical-aligned organizations like NAMI will counter that the screenings identify depression when someone is unaware they are depressed. By asking 9 questions to diagnose major depressive disorder organizations like NAMI will claim they are saving lives. In this simplistic scenario, prescribing an SSRI for someone who didn’t know they were depressed could save their life. Period. In this perspective, human beings that answer ‘yes’ to five out of nine questions could take their life at any moment. This perspective views the human condition as fragile and prone to hopelessness and suicide. If this was really true, how did our species manage to populate to the tune of over 8 billion people worldwide?

Root cause(s) not part of mental health screenings

Mental health professionals with training in diagnostic assessment know the importance of gathering personal information before diagnosing a mental illness. We know we need to ask many questions, gather context, and see the patient over a few weeks in order to objectively assess and categorize their symptoms. Anyone that has had sleep disruption, stress at work or with finances or a recent tragedy could answer ‘yes’ to five out of nine questions on the PHQ-9. The passage of time, the restoration of sleep or time with close friends (or a therapist) can turn a ‘yes’ into a ‘no’ in a short period of time.

If a patient receives a diagnosis of major depressive disorder from a medical professional most will trust this is correct. The promise of a better mood with just one pill is held out like a diamond carrot, making it feel so easy to reach. The risks of sexual dysfunction, chronic fatigue, and emotional disconnection from yourself and others in your life are, usually, not mentioned.

Psychotherapy is rarely brought up as the first line of treatment. This is ironic as according to an abundance of research it is THE most effective treatment for depression. Instead, the 2-minute quiz asking you nine questions about your mental health is used to skip over treatments that work. Your answers on the quiz can put you into a decades long relationship with the pharmaceutical company of your doctors’ choice. Holistic treatment options for depression, such as psychotherapy, can shorten or sever a pharmaceutical company relationship.

Psychotherapy is safe and effective

There is an abundance of data on how therapy, such as Cognitive Behavioral Therapy (CBT),  is effective at reducing symptoms of depression.  A simple ‘CBT therapy for depression’  search on PubMed returned over 2,000 research articles.   Systematic reviews, such as this one, found 100% of the articles reviewed showed psychotherapy had a positive effect in reducing symptoms of depression. (3)

However, patients that score five ‘yes’ answers on the PHQ-9 are rarely referred to psychotherapy as the first treatment recommendation.   We know this as psychotherapists; it is rare a client is referred to us by a conventional doctor or psychiatrist.

On the contrary, many integrative, functional and holistic doctors, nurse practitioners and nutritionists do refer patients to aligned psychotherapists for treatment.   Their training and experience encourages them to look for root causes.   If a patient has symptoms of depression due to unresolved trauma, adverse childhood events or dysfunctional relational patterns they understand that an SSRI cannot ‘fix’ these wounds.

Psychotherapy can help to uncover these wounds over time.   Through the trusted therapeutic relationship, a trauma-informed psychotherapist can join the client in processing painful experiences.  And help to integrate them with tender acceptance. Psychotherapy that is trauma-informed is an important facet of holistic treatment for depression.

Trauma – Therapy or Medication ?

Traumatic experiences, whether they be big or small, cannot go away with medication.   An SSRI might help someone disconnect from internal pain, shame or hopelessness. It can dull or numb internalized suffering allowing one to navigate the day with less pain.   It can help someone function and disconnect from intense feelings of hopelessness.  But the awful emotions or experiences do not go away. They remain held within, waiting to be felt and soothed.

Psychotherapy on it’s own, without medication, helps to make space for negative feelings and experiences.   When we talk open and honestly about these with a non-judgmental therapist, our nervous systems sense we are not alone and the wound(s) start to show up.   Therapists that use treatments such as IFS, EMDR, ACT or mindfulness-based models can help clients make a container for the painful stuff.   By safely containing pain and shame and shoring up internal resources and resilience, held experiences can be explored with curiosity.

By bringing in compassion and connection, negative experiences and feelings can be soothed and resolved.    The pain may show up again but it will be softer and not as intense.  The experience(s) and emotions can be accepted and integrated.   Therapy can bring all of your experiences together, even the negative ones, to inform your authentic identity.     On the other hand, medication can lock these negative feels into a dungeon behind a concrete wall.   You may not feel it, it may not be triggered.  However, the stuff that happened is still within you. And until it is let out of the dungeon, it can influence your mood and nervous system state in a negative way.

Sleep, Activity, & Nutrition

Most medical visits allow about eight minutes with the doctor.   Before the doc comes in you interact with a nurse or medical assistant.   They give you quizes, such as the PHQ-9, forms to fill out about medications and family medical history.  You will be asked if you’ve received a flu vaccine.   You will be weighed and your blood pressure and body temperature will be measured.  Important data to collect but not to help assess if you have major depression disorder.

A primary care doctor is suppose to be your first go-to for basic medical ‘maintenance’ yet they do not collect basic primary data.   For instance, there is no form asking questions about your sleep quality and sleep routine.  No quizes about your physical activity, bowel movements, water intake or how many meals you eat a day. From a holistic and integrative mental health perspective, asking about sleep, activity, elimination, hydration and meal frequency is key data.   If any one of these are not ideal, depression and/or anxiety symptoms can easily pop up.  All of the integrative mental health training courses I have taken review the influence of sleep, activity and nutrition on mood. True holistic treatment for depression would include exploring these basics along with past experiences and emotional regulation.

Sleep

For example, a meta-analysis in 2020 linked ‘problematic cellphone usage’ to poor sleep quality, depression and anxiety. (4)    Yet quizes like the PHQ-9 do not ask about your cellphone usage at night. Doctors or medical assistants do not ask about cellphone use while you are there in the office. If you have symptoms of depression and your cellphone usage at night keeps you awake past 10:30pm, shifting sleep hygience habits could be more effective in lessening symptoms than an SSRI.  Holistic therapists can help guide you towards sleep habits that could improve your mood and energy levels.

Physical Activity

Human beings have been physically active since the beginning but this activity decreased with the industrial and technology revolutions.   Work, play and meal preparation can all be done while sitting in front of a screen.  Convenience is a priority, physical activity is not.   Older generations did not need to go to the gym.   Their employment and the chores for cooking and cleaning all required physical activity.   Mental health professionals have known about the influence activity has on mood for decades.   But when SSRI’s came on the market the narrative shifted.  Depression was related to the brain, not the body; a statement not supported by evidence.

A meta-analysis covering fifteen studies and nearly 200,000 participants found “relatively small doses of physical activity were associated with substantially lower risks of depression.” (5)  Just 2.5 hours a week of walking can lower the risk of depression compared with no walking.    Prescribing a daily 20-minute dog walk to a patient could be more efficacious at reducing depression than an SSRI.

Nutrition

All of us have had the experience of eating too much and feeling tired and lazy afterwards.   It isn’t just the tryphophan in turkey on Thanksgiving that does this. Our digestive systems are challenged to break down the massive quantity of  mashed potatoes, pies, and cheesy appetizers.   When digestion slows down, we slow down.

The connection between diet and mood has been researched for decades.   For instance, eating a mediterranean diet  rich in healthy fats, veggies and fruits lowered the risk of depression in Swedish women over a 20 year span. (6)  But due to everyone’s unique, genetic design, nutrition’s influence on mood and the brain can differ.  It is not a one-size fits all diet that will decrease symptoms of depression.

For example, the Center for Nutritional Psychology was created in 2005 and has over 3,200 written summaries about nutritional psychology.    As a psychotherapist I get to know my clients really well over many months.   I can weave in nutritional shifts that align with their uniqueness; the results are remarkable.  They not only feel better they feel empowered.   They did not rely on a pill; they relied on nourishing themselves with guidance from a trusted professional.

Making dietary and nutrition changes is not easy and it is best to work with a certified integrative mental health professional or medical professional specializing in nutrition.

Food – Mood Connection

The connection between food and mood is real.   Our enteric nervous system is also called the ‘second brain’.   Our gastrintestinal tract is connected to the brain through the vagus nerve; it’s functioning influences physiological states that inform our thought patterns and behaviors.   This topic is so complex and widely studied that a search on ‘enteric nervous system second brain’ at PubMed Central came back with over 24,200 results!

Summary

Circling back to the neurotransmitter serotonin, neuroscience identifies the gut as the largest producer of serotonin. (7)  If serotonin actually plays a role in depression then treatment focused on supporting a healthy gut is a no-brainer (pun intended).

Symptoms of depression such as feeling hopeless, disinterested or tired do need to be addressed.  It is a message from your body letting you know something is off.   If your first treatment option choice is taking an SSRI, I am not judging that choice.   But the human body is truly an amazing conglomeration of complex interdependent systems; it needs more than an SSRI if your goal is to feel good and authentically you.  Exploring how your past experiences, physical activity, sleep habits and nutrition impact your mood can offer life changing mental wellness.   If you are in Texas reach out to us to schedule a free 15-minute phone call to see how we can help.

References

(1) Moncrieff, J., Cooper, R.E., Stockmann, T. et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry 28, 3243–3256 (2023). https://doi.org/10.1038/s41380-022-01661-0

(2) https://www.nami.org/about-mental-illness/mental-health-by-the-numbers/

(3) Zhang A, Franklin C, Jing S, Bornheimer LA, Hai AH, Himle JA, Kong D, Ji Q. The effectiveness of four empirically supported psychotherapies for primary care depression and anxiety: A systematic review and meta-analysis. J Affect Disord. 2019 Feb 15;245:1168-1186. doi: 10.1016/j.jad.2018.12.008. Epub 2018 Dec 11. PMID: 30699860.

(4) Yang, J,  Fu X,  Liao, X, Li, Y.  Association of problematic smartphone use with poor sleep quality, depression, and anxiety: A systematic review and meta-analysis,
Psychiatry Research 284, (2020), 112686.  ISSN 0165-1781, https://doi.org/10.1016/j.psychres.2019.112686.

(5) Pearce M, Garcia L, Abbas A, et al. Association Between Physical Activity and Risk of Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2022;79(6):550–559. doi:10.1001/jamapsychiatry.2022.0609

(6) Yin, W., Löf, M., Chen, R. et al. Mediterranean diet and depression: a population-based cohort study. Int J Behav Nutr Phys Act 18, 153 (2021). https://doi.org/10.1186/s12966-021-01227-3

(7) Shajib, S, Baranov, A, Khan, W. Diverse effects of gut-derived serotonin in intestinal inflammation.  ACS Chemical Neuroscience (2017) 8 (5), 920-931.  DOI: 10.1021/acschemneuro.6b00414