I frequently get questions about treatment for depression without using medication, or going off medication for depression without relapsing. I’m going to summarize what I know and give my point of view about this.
First and most importantly, nothing said here is treatment or a substitute for treatment. Major Depressive Disorder and related disorders can be life threatening. Prior to Covid-19, suicide was the tenth leading cause of death in the U.S. and for people in younger age groups ranks second. If you are feeling suicidal please contact the national suicide helpline at 800 273 8255 or in the San Francisco Bay Area (number reachable from anywhere, of course, but I want you to know what time zone it is in) 415 781 0500, both available 24 hours a day.
My experience with suicidal clients is that people can and do recover from suicidality and go on to have lives that are fulfilling– something that the person actually wants for themselves. My experience with people who completed suicides is that all of them were missed and grieved by loved ones. I can’t emphasize either of these points too much.
Equally important, if you are on medication do not make medication changes or go off medication without consulting with your prescriber and having a plan.
Here’s a quick list of topics covered:
- Talk therapies including–
- Cognitive and Cognitive-Behavioral Therapies
- Mindfulness and Mindfulness based Cognitive Therapy
- Interpersonal Therapy
- Diet, especially certain nutrients
- Thoughts on why DIY treatment may fail
- Light therapy for SAD
- Electrical stimulation therapies
I will not cover every topic in equal depth.
First, my point of view: medications may be necessary for successful treatment. Don’t reject them out of hand. At the same time, medications alone may be insufficient for successful treatment of depression, don’t reject other forms of therapy and don’t reject a broad based approach to treatment. Your life is not a science experiment; you want to get better. At the same time, medications may not be necessary for treatment but for that to work, you will have to be a lot more proactive in your approach to getting better. All these reasons add up to the main one which is that you should do this with a treatment professional, possibly with both a talk therapist and a psychiatrist, possibly other providers depending on your individual case.
Now let’s talk about non-pharmacological interventions for depression. The most obvious one is talk therapy. There are several types of talk therapy that have been evaluated for depression including Cognitive Behavioral Therapy, (CBT) Mindfulness Based Cognitive Therapy, and Interpersonal Psychotherapy. Interpersonal Psychotherapy is structured for relatively brief treatment and has been widely adapted for use, including by the World Health Organization. It is designed as a time-limited treatment and focuses on interpersonal issues, as the name indicates, and social functioning. It is considered an evidence based treatment and has been shown effective in studies.
There is research that has demonstrated that CBT can be equal to medication in treatment for depression. There are caveats to this– a cognitive therapist may have greater or lesser degrees of skill in providing treatment, whereas the uniformity of the medication is highly likely to be the same at every pharmacy. On the other hand, people who go off medication are more likely to have depression relapses than people treated with cognitive therapy. Probably the best known cognitive therapy book for general consumption is The Feeling Good Handbook by David Burns, MD. My experience with providing cognitive therapy is that although it can seem very simple and obvious to learn about the most common forms of cognitive distortions, it can be surprisingly hard for people to learn to spot them in their own thinking. After all, everything I do turns out badly. That’s not a cognitive distortion, just a fact, right? It can take a relatively protracted conversation with a therapist to discover that one has, perhaps, succeeded at something at one point in life and the statement is an example of all or nothing thinking.
There is also mindfulness based cognitive therapy of depression (MBCT) which has been shown to be helpful. My observation is that depression tends to focus on the past while anxiety is focused on the future. Mindfulness, of course, keeps focus on the present, which means that whatever I’m depressed about (or anxious about), there’s a lot less mental room for it to happen than when I include my entire past and my entire future– If only I had behaved better when I was in first grade! And what about the heat death of the universe billions of years from now… There are reports of people having negative experiences from doing mindfulness so that suggests one should not simply jump into mindfulness for depression without a therapist or meditation teacher. I have introduced clients to basic mindfulness practice with few to no negative effects reported, but that’s clinical experience, not a clinical trial or study.
There have been studies of exercise and depression, and it’s not surprising that there have been positive results. At a presentation I attended, representatives of the UCSF Depression Center were willing to specifically name walking and yoga as two practices shown to relieve depressive symptoms. I have not done a separate web search looking for studies. Interestingly, I had a clinical experience with a client who discounted exercise for depression saying, “It didn’t work. When I stopped walking I got depressed again.” No one has ever been surprised that when they went off medication depression returned, and we should remember that these kinds of interventions are likely to require regular practice to be of greatest effectiveness. I will discuss this more a little later.
A variety of research studies have suggested that diet may have an effect, especially supplementation with folate and omega-3 fatty acids, found in Salmon, walnuts, and other foods. There has been research into the role in vitamin D and its association with depression also. Many people have vitamin D deficiencies– I once asked my primary care doctor if I should be tested for a deficiency and his answer was, “No, everyone’s deficient. Take a supplement.” Another doctor I knew who was a child psychiatrist who did test his patients said that something like 95% were vitamin D deficient, but we are next to the ocean and get a lot of gray days.
Other research suggests that the gut biome has an influence on depression. The UCSF Depression Center is willing to recommend folate and omega-3’s for depression, but nobody is promoting dietary changes as a stand-alone treatment. The thing to be mindful of is that folate is found in leafy greens and is a water soluble vitamin. As such, if you stop eating your vegetables your levels will drop rapidly and any beneficial effect is likely to also drop equally rapidly. Omega-3’s, being more fat-based probably last longer in your system but again, ceasing to consume the foods or supplements will lead to the benefit disappearing. Vitamin D is a fat-soluble vitamin as such probably lasts longer in the system, but nothing lasts forever. The gut biome stuff that I’ve read leads me to think that it’s about getting fiber, but that research is a lot more complex. I’m not trained as a nutritionist and don’t claim special knowledge in this area.
So here’s the thing about diet and exercise from my point of view. Some of the practices have pretty good research support for being specifically helpful with depression. When you look at them from a more general nutrition point of view, getting more leafy green vegetables is clearly a recommended dietary practice, omega-3’s are recommended for a variety of potential health benefits, exercise also is known to have a wide variety of health benefits, so any time we start doing these with a specific goal of helping depression, we’re supporting the general goals of better health and improved self-care. There’s a clear cognitive and behavioral aspect to this– “Look! I’m taking better care of myself! I can effect positive change in my own life!” One label for this is self-efficacy. Another is self-compassion. It’s something that’s under my own control, and when I’ve done it, nobody can take it away from me.
If it’s all that easy, why is depression such a huge health problem? Lots of reasons, obviously. Let me give a brief clinical perspective. One thing is that none of these non-pharmacological interventions has immediate strong effects. Neither do antidepressant medications either, given that most of them take weeks to kick in. A trainer whose lecture I attended once pointed out that people going into detox for alcohol are mostly depressed, and that three weeks off alcohol would lift the depression for most of them– which is also the amount of time it takes for a lot of medications to take effect. So he always recommended what he called “a clinical trial of abstinence for depression” before putting anyone from detox on psych meds. Similarly, changes to diet, exercise, and general lifestyle take time to kick in, so it may be very difficult for someone attempting to self-treat for depression via the diet and exercise route to see progress, leading to a lapse in the lifestyle changes and a relapse to depression.
The other factor is that one of the most problematic symptoms of depression is what was labeled by one of my clients as “that feeling of… I don’t wanna.” If you like more sophisticated language you can call it motivational deficit. This is where feedback from a therapist can help kick start and maintain the change process. Behaviorism works by giving positive reinforcement to successive approximations of the desired behavior. The role of the therapist is to spot the approximation and reinforce it when the client may have discounted it. Client: “I didn’t exercise. All I did was go to the store.” Therapist: How did you get to the store?” Client: “I walked.” Therapist: “So you not only got out of the house and walked to the store, but you also got some groceries. That counts as exercise and self-care.” I knew a client whose discounting was so powerful that they could convince an entire therapy group plus an intern that they had done nothing for themselves when I was able to honestly and factually point out at least three things they had done for themselves that were part of their treatment goals.
For completeness I am including a couple more non-pharma interventions
There is light therapy for SAD (Seasonal Affective Disorder). I do not have clinical experience with this but have known people socially who lived in the Pacific Northwest and had good experience with it. This takes getting a for real diagnosis by a licensed practitioner and using a specially designed light source, usually in the mornings.
There is also transcranial magnetic stimulation and electroconvulsive therapy along with other brain stimulation therapies. I am including a link to these as they are non-pharmacological in nature, but the last time I read up one still had to fail at getting relief from medication to become eligible. Electroconvulsive therapy is still used in severe treatment-resistant depression. It has bad associations from misapplications and involuntary treatment that happened many years ago, but is no longer in use except on a voluntary basis. None of these are available as DIY projects for obvious reasons.
Photos copyright James Matter 2021