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Monday, September 04, 2006

Treating Depression - Holistic versus Traditional Treatment Approaches

Introduction:
The traditional medical model of depression emphasizes biochemical diagnosis and treatment which can lead to feelings of helplessness among those diagnosed with depression. This may result in further complication of the disease process as loss of control has been correlated with increased risk and severity of depression. The holistic model of depression accounts for the whole individual and contributes to the perception of control by identifying numerous points of impact or intervention.
Traditional Treatment
Traditional treatment of depression typically includes hospitalization, psychotherapy, medication, and electroconvulsive therapy (ECT). Currently the most widely used treatment for depression includes pharmacological interventions such as Prozac, Zoloft, and Paxil which act as selective seratonin-reuptake inhibitors (Franklin, 1997). Pharmacological intervention is regarded as the most cost effective and quickest form of treatment for depression but may have negative side effects or secondary symptoms. When depression is the result of other drug usage (both legal and illegal), pharmacological intervention may by contraindicated (Public Citizen, 1989). As Health Maintenance Organizations (HMO’s) and other insurance providers attempt to minimize healthcare expenditures, drug therapy is replacing other forms of treatment.
Psychosomatic Findings
Depression demonstrates the complexity of the “mind/body” interaction and is at the forefront of exploration into the holistic determinants of health and disease. Despite the widespread use of “anti-depressants” in the treatment of depression, “talk therapy” or psychotherapy has been shown to “have essentially the same success rate as medication- around 60 or 70 percent” (Franklin, 1997). Researcher at the University of California at Los Angeles used Positron Emission Transmission (PET) scans to demonstrate that “talk therapy” resulted in identical changes in brain metabolism as Prozac (Franklin, 1997). Furthermore, researchers studying the impact of “learned optimism” found statistically significant risk reduction for depression among college students (APA, 1995), and the use of cognitive-therapy techniques may actually prevent the onset of depression among children high at risk for depression (DeAngelis, 1996).
Risk Factors Associated with Depression
Numerous individual, sociological, and situational factors are associated with an increased risk of depression. Individual factors include an external loci of control, low self-esteem, cognitive distortion (defined as exaggerated, overgeneralized and personalized negativity), helplessness, hopelessness, and loneliness (Hammond and Romney, 1995). Poor physical health, the recent birth of a child, and irregular schedules also have been found to contribute to an increased risk of depression. Sociological factors include poor family relations (Garber, Robinson, and Valentine, 1997), certain work environments... especially those which require a great deal of “emotional labor” (Erickson and Wharton, 1997), and other contextual arrangements including housing, unemployment, crime rate, and debt (Lewis, 1997). The central theme is perceived loss of control. Once again, the traditional medical model may reinforce feelings of helplessness associated with the disease process.

Overview:
According to the National Institute of Health Office of Alternative Medicine, worldwide only 10 to 30 percent of health care is delivered by conventional medical practice. As the United States becomes more culturally diverse, the interest and understanding of other treatment modalities has increased. Corresponding to this is the need for lower medical/health care costs, increased personal responsibility, and intervention where other methods have failed. Unfortunately the consumer is often unaware of valid alternative therapies.
Professionalized Health Care Systems
According to the NIH/OAM, professionalized health care systems are characterized by:
1. A theory of health and disease
2. An educational system to teach major concepts
3. A delivery system involving practitioners
4. A material support system to produce medicine/therapeutic devices
5. A legal and economic mandate to regulate practice
6. Cultural expectations about the systems roles
7. A means to confer professional status on approved providers
Professionalized medical systems include traditional oriental medicine, acupuncture, Ayurvedic medicine, homeophathy, anthroposophy, naturopathy, and environmental medicine (NIH/OAM, 1997). Each of these is sub-divided into specialties, for example, traditional oriental medicine may include diverse methods of treatment such as acupuncture, herbal medicine, or even massage.
Pharmacological and Biological Treatments
Another example of holistic treatment alternatives include pharmacological and biological treatments not yet recognized by traditional medicine. This may include neural therapy where a local anesthesia is injected into nerve cell bodies for the management of chronic pain... to the use of biologically guided chemotherapy including the administration of medication during specific times of an individuals circadian rhythm. Alternative diets, orthomolecular medicine, and dietary supplements are widely used treatments.
Individual Mind-Body Interventions
According to the NIH/OAM, one of the most promising areas of treatment include the mind-body interventions; including psychotherapy, support groups, meditation, imagery, hypnosis, biofeedback, yoga, dance therapy, music therapy, art therapy, and prayer and mental healing. If wisely selected and appropriately applied, many of these therapies have been found to be cost-effective and safe alternatives for the treatment, management, and prevention of disease. Additionally, these therapies encourage a proactive approach to personal health care. This is of particular importance in the treatment of depression.
Health Education:
Health education is able to provide health care consumers with information regarding alternative means of treatment; and methods to evaluate the integrity, worth, and value of the treatment regimen in relation to a specific disease. Alternative therapies can be used as a primary intervention. For example, biofeedback is used to reduce stress and tension thereby lowering blood pressure whereas visual imagery is used in conjunction with surgery or chemotherapy as a supportive therapy. Information itself is a powerful intervention capable of changing behavioral patterns, attitudes, and perceptions related to disease. As morbidity and mortality trends demonstrate the increased rate of chronic and behavioral based disease, education and holistic intervention is increasingly deemed an appropriate and effective alternative. Traditional medicine concentrates on the treatment of disease rather than prevention, and oftentimes lacks the ability to meet the needs of chronic disease patterns where illness is not viewed as an opportunity for growth. Emotion and motivation specifically impact the role of health education in holistic health, especially in the treatment of depression.
Emotion and Motivation
Beginning with the earliest stages of human development, emotional expression provides a powerful system of communication. Newborns enter the world with the ability to express surprise, distress, and pleasure...followed by anger, fear, or shyness (National Institute of Mental Health, 1997). Evolutionary adaptation is quickly reinforced by social learning; society soon teaches the newborn to repress emotions. This constant state of repression is associated with mental illness, poor individual and social adjustment, and high levels of physical illness.
Emotion Based Research Findings
Literature is rich with findings related to the emotional aspects of personality, illness, and perception. Research with non-human subjects suggests it is necessary to have a sense of control over environmental events. Infant monkeys raised with control over food choices were found to have less fear in novel situations whereas monkeys raised without control over food choices exhibited anxiety and fear. Research with children has found that the emotional development of children is strongly related to increased risk for emotional problems and mental disorders including clinical depression, conduct disorder, and attention deficit/hyperactivity disorder. This is attributed to the mental/emotional impact from family members, for instance, mothers with chronic depression tend to be less receptive than other mothers in interaction with their children (NIH, 1997). Negative thought patterns have been associated with increased risk for depression among children and adults (APA, 1995; Azar, 1996; DeAngelis, 1996; Franklin, 1997). This cognitive vulnerability to depression has been tested by Teasdale and Dent who found that in depressed mood, there is a greater activation of the underlying cognitive structures related to the negative aspects of self schema in persons at high risk for depression. The dysfunctional cognition’s that become activated when people are mildly depressed determine the extent/severity of “full-blown” depression (Myers, 1995).
According to the NIH, research has consistently demonstrated that negative qualities elicit more attention than positive qualities:
¨ When considering decisions, losses are given greater weight than potential gains
¨ Socially one negative personal characteristic more greatly influence feelings about a person in spite of numerous positive characteristics
¨ Negative experiences are reported to have more impact than positive experiences among married couples
¨ Subjects who were described with an equal number of positive and negative adjectives were subsequently able to recall more negatives.
These tendencies are found throughout the population, however, depressed persons are found to exhibit a more dramatic response to these stimuli. For example, when the average person thinks about mildly emotional topics, tension increases in facial muscles. One group of facial muscles is associated with positive emotional thoughts whereas another group is associated with negative emotional thoughts. According to the National Institute for Mental Health, “when people with depression recall happy thoughts, the facial muscles normally associated with happiness show little activity. Another study with depressed patients revealed that as their depression lifts, activity lessens in the currogator muscle, a large muscle in the forehead that Darwin referred to as the “grief” muscle.” (NIMH/NIH, 1997).
These emotional response patterns not only assist in the diagnosis of depression but also suggest possible treatment options. Researchers have found that the frontal regions of both hemispheres are involved in the interpretation and expression of emotion: negative emotion is processed mainly in the right hemisphere and positive emotion is processed mainly in the left hemisphere. The relative amount of electrical activity in the left versus the right hemisphere is used to measure the level of negative emotion... especially depressed mood. While sitting quietly with their eyes closed, persons with clinical depression show more activity in the right hemisphere (particularly in the frontal temporal area), self report more negative feelings, and have a lower immune system response than persons with a normal pattern. The chronic activation of the right hemisphere suggests a higher risk for the development of depression and other illness (NIMH, 1997). Other studies have also found brain abnormalities associated with depression including a significant decrease in brain tissue, decreased blood flow of the prefrontal cortex (PSL, 1997), low levels of seratonin and melatonin (Murray, 1997), and greater levels of stress related hormones including cortisol, norepinephrine and epinephrine (Azar, 1996). The relationship between the mind-body interaction is believed to be the biological basis for depression. According to the NIMH, “many severe mental disorders, such as clinical depression, involve disturbances in mechanisms underlying basic biological motivations, including those involved in behaviors that preserve individual life... or preserve the species” (NIMH, 1997). Depression is characterized by the loss of these essential motivational factors; biologically, emotionally, and socially based.
A Holistic Approach to Depression:
The holistic perspective of the treatment of depression recognizes the multidimensional aspect of depression. Rather than treat the chemical imbalances alone, a combination of psychotherapy and cognitive restructuring, melatonin and light therapy, herbal and other interventions, are being successfully employed for the treatment of depression.
Psychotherapy and Cognitive Restructuring
The efficacy of psychotherapy and cognitive restructuring have demonstrated similar results as obtained through the use of Prozac and other SSRI’s (Franklin, 1997) and have even been found to offer a potentially preventative measure against the development of depression (DeAngelis, 1996). Whereas traditional medicine often reinforces the perception of loss of control, psychotherapy and cognitive restructuring focus on the individuals ability to control their own feelings, thoughts, and environment. Specifically, achievement goals, loci of control, and motivational factors are targeted. These are supplemented by technological innovations such as biofeedback or even video-taped interviews designed to provide the individual insight into their emotional functioning (NIMH, 1997).
Melatonin and Light Therapy
According to the NIMH, the cycle of waking and sleeping is one of the most significant indicators of disturbed behavioral regulation. Not only does sleep involve the bodies chemistry, mental outlook, behavior, and emotion; but the physical and social environment as well. Sleep is vital to proper functioning. Deprived of sleep, laboratory rats die within two to three weeks...similar to the time they die without food (NIMH, 1997). Researchers have found that more than 80% of people with depression experience sleep disturbances (PSL, 1997) and the normal patterns of sleep are altered. People with clinical depression “often wake up involuntarily in the early hours of the morning and cannot return to sleep. Even when they do sleep, the structure of sleep is often abnormal; they tend to enter the REM sleep stage much sooner after falling asleep than do other people” (NIMH, 1997). Closely related is research on manic depressive disorders. Depressive episodes are characterized by fatigue and excessive sleep whereas manic episodes are characterized by activity with little sleep. The dramatic changes have led researchers to examine the biological clock responsible for regulation of brain and body rhythm. The NIMH reports recent research “suggests the circadian pacemaker, which regulates cycles that recur daily, is indeed unstable; it is constantly resetting itself to a slightly different time in patients with manic depressive illness. The pacemaker also seems to be readily disrupted in patients with clinical depression. Levels of the hormone melatonin...are lower in their brains than in the brains of other people (NIMH, 1997).
Melatonin is a natural hormone released by the pineal gland which helps regulate the body’s “biological clock”. The level of melatonin in the body is low during the daytime and high at night in response to retinal photoreceptors (Guver, 1994). According to a recent bulletin by the National Institute of Health, both light and temperature have been found to regulate the human biological clock (Brody and Asher, 1997). Supplements of melatonin have been found to assist the regulation of the body’s secretion of melatonin which may decrease as a person ages. Research has found that melatonin is effective in assisting people to sleep more easily and more soundly, however, it is believed this may be more pronounced among the elderly than younger persons due to the variations in naturally occurring melatonin levels (Guver, 1994). The use of artificial lighting alternatives has also demonstrated positive results by increasing the body’s own levels of melatonin, thereby decreasing sleep disturbances associated with depression.
Herbal Alternatives
One of the major areas of research conducted by the NIH Office of Alternative Medicine into the field of depression is the efficacy of St. John’s Wort. St. John’s Wort (also known as Hypericum perforatum) is widely used in Europe for the treatment of depression although officially mandated clinical trials have just begun in the United States.
The National Institute of Health is funding a $4.5 million, three-year study to be conducted by Duke University, into the effectiveness of St. John’s Wort as compared to a placebo and Zoloft. This is after a study published by the British Medical Journal found that data from 23 randomized trials comparing the herbal extract to a placebo or standard drug, found the herb to demonstrate statistically significant results. In the 13 trials comparing the herb to a placebo, 55% of the patients taking St. John’s Wort improved compared to 22% of the patients who received a placebo. In the studies comparing the herb to standard antidepressant, it was found 64% of the patients receiving St. John’s Wort improved compared to 59% of those receiving antidepressants. Also, only 20% of St. John’s Wort recipients reported side effects compared to 36% taking antidepressants (Okie, 1997). It should be noted that St. John’s Wort is not a “cure all” for depression and may in fact be contraindicated when taking other medications, in the case of allergies, and skin sensitivity after sun exposure (Gormley, 1996).
Summary:
Depression is one of the most common and potentially debilitating conditions in the U.S. with an estimated one in every ten men and one in four women suffering from depression at some point in their lives. The cost of treatment and lost productivity due to depression is approximately $44 billion dollars a year (Murray, 1996). The holistic mind-body interaction is clearly demonstrated in the disease process of depression and particularly suited to not only treat, but potentially prevent, depression.
Traditional medicine treats depression with hospitalization and the administration of antidepressants designed to realign the chemical imbalances associated with depression. Psychotherapy has been found to elicit similar changes in brain chemistry, as well as reinforce the individuals perception of self control by concentrating on numerous points of impact or intervention. Cognitive restructuring is used to identify areas in need of assistance such as negative or intrusive thought patterns, repressed hostility and other emotions, and physical symptom recognition of those emotions. Other alternative treatments are exploring the importance of regulating sleep and biological cycles in the treatment of depression, with some practitioners concluding that depression and other forms of mood disorders may result from imbalances of the individuals biological rhythm. Studies addressing the use of light therapy and melatonin have provided positive results. Finally, the use of St. John’s Wort is being studied in the hope of finding a less expensive, more gentle, and effective means of treating depression.















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