The first important step involves determining if your depression is short term or chronic...and if it is mild, moderate, or severe. Do some careful self-analysis: how often do you feel depressed? Most people experience some level of depression occasionally; it's just part of our biorhythm of emotional and mental activity. If you are depressed right now, how long has this been going on? Is it linked to a stressful external cause – a life event at work or in a relationship? Or does the depression seem to follow you most of the time, like your own personal dark cloud? A state of constant depression may suggest persistent stress or a biochemical imbalance.

There are varying degrees of depression, from mild to severe, from acute to long term. Physicians often define a condition as chronic if it has persisted more than a month or two. In the case of depression, if you have experienced an ongoing low for more than three months, it is likely a chronic condition and definitely warrants a consultation with a capable, insightful psychiatrist or therapist (or a nutritionally- oriented practitioner if you wish to be guided in a natural approach). Anti-depressant drugs are clearly one solution and have been helpful to millions.

Depression has many causes as well. Western medicine categorizes depression as endogenous, coming from within, and exogenous, coming from outside influences. Exogenous depression comes from reactions to life events and daily stresses, such as loss of a loved one, job problems, or family crises. We also may experience depression from inner conflict, or we may feel overwhelmed by responsibilities. Many drugs can cause low to mild levels of depression; these include blood pressure medications, estrogens as in birth control pills, steroids, and anti-anxiety drugs, like the benzodiazepines (Valium or Ativan). The remedy for many cases of exogenous depression often involves clearing the causative factor, or doing some counseling to better integrate our life experiences.

Endogenous depression we could call biochemical depression. It tends to run in families, as in genetic factors, and is generated by brain chemistry and imbalances of serotonin (one of the "feel good" hormones that helps us sleep) or other neurotransmitters. Most of the anti-depressant medications prescribed currently are chemicals that lmaintain or improve serotonin levels. Even the natural approach that utilizes diet, herbs, and amino acids is geared toward raising serotonin levels.

One of the most commonly prescribed class of drugs these days are the SSRIs, abbreviation for Selective Serotonin Reuptake Inhibitors, or those substances like Prozac, Paxil, Zoloft, and Effexor. These medicines slow the breakdown and clearing of this important brain chemical, thus leaving more available to brain function. This then improves the mood and motivation of its consumer. The problem is that there are many possible, often likely, side effects of these drugs rather than the "side benefits" of a natural approach. Common side effects of the SSRI drugs include weight gain, loss of sexual energy, and bouts of anger or anxiety.

A hidden problem that contributes to depression is hypothyroidism, both the classically low thyroid function that any physician can discover and "sub-clinical hypothyroidism," which is based on body/mind symptoms and body temperature. If you are sluggish, have a slow metabolism, feel cold all the time, and experience constipation, and some depression, you may have low thyroid function. Your thyroid numbers may be okay, but you could benefit from low-dose thyroid support, as some people who are stressed and fatigued feel much better with adrenal support. (Review the Q and A area on my website for more information on sub-clinical hypothyroidism.

For mild to moderate depression, it is wise to try a course of natural therapies. For severe or persistent depression, I suggest seeing a conventional or orthomolecular psychiatrist for evaluation and treatment. An integrated approach to any medical problem involves there areas of care: lifestyle (behaviors), natural remedies (diet and supplements), and pharmaceutical drugs as a last resort or for more acute and serious problems.

The approach to psychiatry, which incorporates the use of nutrients to rebalance brain chemistry, is described as orthomolecular therapy. Readers can obtain referrals to trained orthomolecular psychiatrists in the U.S. and Canada by calling Orthomolecular Health Medicine in San Francisco at 415-922-6462. Many physician members of ACAM (American College for the Advancement of Medicine) and most naturopathic practitioners also have training in the treatment of depression using nutritional supplements and herbs. ACAM referrals can be obtained by following the instructions at 800-532-3688.

Self Care
My general philosophy suggests that behavior involves motivation and attitude, both of which affect how we care for ourselves, such as whether we make healthy food choices or create and maintain a regular exercise program. My approach in medicine, and I think the highest calling of a physician (a philosopher-physician of the ancient Chinese tradition) is to inspire and educate patients to care for themselves – to live in a way that generates health rather than have a lifestyle that causes disease.

Self-image and self-love are important unconscious motivators that affect how we treat ourselves and whether we make the effort to maintain healthy habits.

Meditation is a tool of ultimate and major significance. Practiced in moderation, meditation can be a meaningful adjunct to any medical regimen.

Our inner dialogue is also important to our emotional health. (See Feeling Good by Burns, a classic about the importance of maintaining positive self-talk and the applications of Cognitive Therapy.)

Appreciation is another key to reestablishing joy. I encourage each of us to assess and appreciate what we have. At the same time, we can acknowledge the challenges we face and do everything in our power to identify and correct the medical and lifestyle approached that decrease our depression.

Self-image, our view of ourselves, has a lot to do with behavior and depression. If we feel unworthy of love, particularly self-love, we may not treat ourselves with respect, or with healthy habits. If we can feel proud of ourselves, and believe that we can improve and heal, and grow, we may be more able to rise out of our blues. It is common for people with depression to feel withdrawn and to look down, often with a hunched over back. Sit up, look up, and embrace life!

Exercise
Exercise activity is one way to prevent and chase away depression. Studies show that regular exercisers feel better and have a better mood and attitude toward life than those who don't. Cleansing of toxins from the blood and the body is one positive way that could moderate depression. In addition, there are positive effects on the brain chemicals from exercise, such as an increase in the uplifting endorphins. Work toward a balanced combination of activities that includes aerobic exercise 3-5 times per week for 30-45 minutes, weight training to improve strength and tone, and stretching to insure flexibility. I know this takes an effort, even in organizing your time in the busyness and demands of modern times. However, it is surely worth it. I realize that it may be difficult to begin, especially if you feel depressed, but once your routine is established, it will build and potentially moderate some of the depressed state naturally over the course of a week or two.

Fatigue, and sometimes anxiety and insomnia, frequently accompany depression. In these cases, it will challenge your creativity to work exercise into your life. Yoga and T'ai chi, taking classes or perhaps using a video, can be helpful and require less energy. Walking continues to be one of the forms of exercise found by patients, doctors, and research to be the most beneficial. 

If you are too tired to exercise:

• Be sure to seek the care of a health care professional.
• Explore some form of sitting Qigong or T'ai chi, such as that used by cancer patients in China with reported benefit, or explore simple yoga postures and deep breathing.

DIET
"Foods and moods" have been written about many times, and it is clear to me that individual foods as well as various types of diets contribute to how we feel. Food nutrients and chemicals (natural food and synthetic contaminants and additives) affect brain function and neurotransmitter levels, and this leads to experiences such as depression and anxiety, fatigue or insomnia. Food reactions, allergies and hypersensitivities, also affect energy levels, moods, and mental faculties. The False Fat Diet (by myself and Cameron Stauth) describes a broad range of mechanisms involving food reactivity, which can clearly contribute to and alter mental, physical, and emotional states. Many patients and readers of my books have improved their mental states and cleared up depressive states using the New Detox Diet and the False Fat programs. Remember that sugars – especially refined sugars and sweet foods as with sodas and candies – alter the glycemic index and are often associated with rapid mood changes and depression. See additional information on the Glycemic Index.

Diet Guidelines to Prevent and Benefit Mild to Moderate Depression:

• Get all the appropriate nutrients from wholesome foods and supplements
• Avoid chemicals and junk foods as much as possible
• Rotate your foods and avoid your reactive foods
• Watch your sugar and refined foods intake
• Eat adequate proteins along with fresh vegetables
• Consume fresh fruits and some nuts and seeds
• Eat whole grains and legumes and some sprouts

Supplements
There is a wide range of vitamins, minerals, amino acids, and herbs that can help alleviate depression. Many of them support brain function and specifically serotonin levels. Others support normal hormone balance, specifically of the thyroid and adrenal glands.

Let's start with the B vitamins and a few minerals. The most important is pyridoxine, vitamin B6. It assists many brain and neurotransmitter functions. Vitamin B12 along with folic acid supports nerve structure and functions, while pantothenic acid and vitamin C aid the adrenal glands and energy. Choline and inositol also aid the brain. Calcium and magnesium allow relaxation and better sleep when taken at night, and iodine support normal thyroid function. In general then, a good quality multi-vitamin/mineral product is a good start.

Amino acid support may be a valuable key to clearing or reducing depression. Adequate protein in the diet is a good beginning for obtaining needed levels of amino acids. In addition, several specific ones may be helpful. Phenylalanine seems to improve endorphin levels and reduce pain. Tyrosine is energizing and is needed for proper thyroid function; 500-1,000 mg can be taken in the morning and after lunch. Tryptophan is the most important since it directly makes serotonin and this substance seems to be low in most people suffering from depression. Tryptophan is currently available through compounding pharmacists with your doctor's prescription, or a precursor to tryptophan, namely 5-HTP (5-hydroxy-tryptophan), can be obtained at health food stores. The amount to start with is 50-100 mg taken at night, as it aids sleep, with an additional 50-100 mg in the morning. This is also helpful for those suffering from Fibromyalgia (as is magnesium malate or malic acid).

There are also several herbs that may be helpful in improving depression. St. John's Wort, or hypericum as the active ingredient, has been helpful both in research studies and in clinical practice. It needs to be taken consistently for a month to two to see the benefits and usually three times daily of 300 mg capsules of 0.3% hypericum. Other herbs can be used to handle other symptoms that go with depression. This might include valerian and hops for insomnia, and kava kava for anxiety. Ginseng (panax) can be used for energy and Siberian ginseng utilized more for stress. For women with PMS or menopause, or for men with libido changes, different herbal combinations might be beneficial.

Consider an integrated approach drawing on the experience of a naturally-oriented physician who can help you sort out your options. You may be able to get acceptable results without the use of prescription drugs. Acupuncture could be helpful, as could the use of homeopathic remedies. Massage and relaxation therapies may likewise offer improvement. Meditation can be of great value, as can regular exercise. As with so many diseases, getting involved in your own program and finding a way to make things right, and to make them work for you (becoming your own best doctor) is likely the highest art in health care. In other words, get involved in your health and feel empowered. Seek wisdom and guidance from those trained to help you make the best decisions for you. For your long-term care, develop a working partnership with your practitioner. A multi- faceted approach typically holds the greatest promise.

Read More in the following Books
Natural Healing for Depression: Solutions from the World's Great Health Traditions and Practitioners, edited by Nancy and James Strohecker, Perigee Books, 1999.

Depression Cured At Last, Sheri Rogers, MD. SK Publishing, 1997.

The Pain Cure, Dharma Singh Khalsa and Cameron Stauth. Warner Books. 1999. (Relevant in that it has good info on raising the brain's serotonin levels.)

The False Fat Diet Elson Haas, MD and Cameron Stauth, Ballantine Books, 2000.

The Brain Chemistry Diet, Dr Michael Lesser's forthcoming book, Putnam, 2001.

Research and Depression
A number of important nutrients are being used to treat depression. The range of approaches has been reviewed in the medical literature over the past decade.

Hypericum (The Active Component of St. John's Wort)
Hypericum is considered a very promising supplement for the treatment of depression - so promising that the NIH has initiated a major clinical trial to evaluate its potential effectiveness. A very thorough review of the research on St. John's Wort was conducted in Germany by top researchers, known for their work on homeopathy. Here's what they found:

• The researchers narrowed the data down to 10 studies that compared hypericum with other antidepressant or sedative drugs. The studies included 1123 participants with "mild to moderate severe depressive disorders."
• The hypericum preparations were found to be about 2 1/2 times more effective than the placebo (supplements that contained no hypericum).
• They were equally effective to single preparation antidepressants and 1 1/2 times as effective as combination antidepressants.
• Among patients taking the hypericum, about one fourth had side effects.
• Almost half (45%) the patients taking standard antidepressants had side effects.

Linde K, Mulrow CD. St John's Wort for depression. Cochrane Database Syst Rev 2000;(2): CD000448.

SAMe
A ten-week study at Massachusetts General Hospital in Boston look at the benefits of SAMe in the treatment of depression. They found significant decreases in depression scores - the scores went from more than 19 (very depressed) to less than 11. However, it is important to note that eight out of the 21 patients dropped out due to uncomfortable physical symptoms such as diarrhea and increased anxiety. Like many other forms of treatment, the last word is still not in.

Fava M and others. J Clin Psychopharmacol 1999 Aug;19(4):329-35

The Role of Serotonin and Treatment Using 5-HTP M
The connection between pain and low serotonin levels is emphasized in a review on fibromyalgia, "a musculoskeletal pain and fatigue disorder manifested by diffuse myalgia, localized areas of tenderness, fatigue, lowered pain thresholds, and non- restorative sleep."

The first step in treatment suggested is to identify low serum tryptophan and serotonin levels through testing.

The review also indicates that supplementing the "serotonin substrate" through either L-tryptophan (available only through compounding pharmacists) or through 5-HTP (5-hydroxytryptophan) has been shown to improve symptoms of depression, anxiety, insomnia and somatic pains.

Juhl JH. Alternative Medicine Review 1998 Oct;3(5):367-75

Genetic Links to Depression
Research suggests possible indirect genetic links to depression. A study of the effects of exercise on depression and hormone output evaluated 82 health male volunteers (age 18 to 26 years old), who used an exercise bicycle to achieve maximum exertion. The volunteers were tested regarding their mood using the Beck Depression Inventory, an anxiety scale, stress scale, and self-efficacy scale. Blood samples were tested to measure growth hormone, cortisol, and testosterone.

The finding – exercise increases your hormones. The researchers noted that "In the majority of subjects, physical exercise induced remarkable increases in blood levels of the hormones." However, in the participants with test scores that reflected some depression, "growth hormone response was virtually absent." This suggests both a role for growth hormone in stabilizing mood and a possible genetic link between individuals with low growth hormone output and the tendency to depression.

Harro and others. Psychoneuroendocrinology 1999 Jul;24(5):505-17

Amino Acids. S. Meyers. Use of neurotransmitter precursors for treatment of depression. Altern Med Rev 2000 Feb;5(1):64-71.

Calcium Levels. Thys-Jacobs S. J Am Coll Nutr 2000 Apr;19(2):220-7 Micronutrients and the premenstrual syndrome: the case for calcium. Research from St. Luke's-Roosevelt Hospital Center at Columbia University.

Glutamine Levels. Levine J and others. Increased cerebrospinal fluid glutamine levels in depressed patients. Biol Psychiatry 2000 Apr 1;47(7):586-93. Research from the Neurophysics Laboratory, School of Medicine, University of Pittsburgh.

Thyroid. For more information on the possible role of thyroid in depression and how practitioners are approaching treatment, see the web site of CERI - the Cognitive Enhancement Research Institute at www.ceri.com. To order the newsletter, call 1-650-321-CERI.

Remember – genetics is not destiny. With the right guidance and health plan, you can delay your pre-dispositions to certain diseases, from heart disease and cancer to depression. Take care of yourself, it's worth it!