Non drug therapy

Cognitive Therapy

In 1976, Philadelphia psychiatrist David Burns, M.D., became the father of a son, David Erik. The birth was normal, but something was clearly wrong with the newborn. His skin looked blue. He had difficulty breathing and he gasped for air. The obstetrician reassured Burns and his wife that David Erik’s condition did not appear serious, but he explained that the infant’s bloodstream wasn’t getting enough oxygen. As a precaution, the obstetrician said he wanted to send David Erik to the intensive care nursery for extra oxygen.  Dr. Burns consented—then suddenly became depressed and panicky. Intensive care meant something was terribly wrong. His baby son wasn’t getting enough oxygen. That meant that his brain wasn’t getting enough. He could be brain damaged. Burns flashed on a future ruled by the needs of a severely handicapped child. He wondered if he could love such a child, and imagined that people would think the less of him for having a handicapped son.  Feeling himself becoming overwrought, Dr. Burns decided to try the disarmingly simple therapeutic technique his colleague, Aaron Beck, M.D. had pioneered. It involved writing down negative thoughts and then seeing if they were really true or somehow illogical. But the moment the idea occurred to him, Dr. Burns dismissed Beck’s program as absurd: It was fine for his patients. They were imagining their problems. His problem was real. Of course, Dr.  Burns’ patients had often made the identical comment to him, so he told himself what he always told them: Just try it. What do you have to lose?

It didn’t take the depressed psychiatrist long to identify his negative thoughts: Intensive care meant the worst. His son was brain damaged. His life would be ruined caring for a handicapped child. And his child’s problems would diminish him in others’ eyes.

Next, Dr. Burns looked for fact or fallacy in his stated feelings—and found major distortions.  The obstetrician had said intensive care was a precaution, that David Erik’s condition did not look serious. By assuming the worst, he’d “mentally filtered” the information available to him, seeing only the most dire possibility, when his son was probably fine. Thinking that his son was brain damaged, he’d “jumped to a conclusion” that was unjustified. Even if his son were handicapped, he’d “magnified” the problem by assuming it would ruin his life. Plenty of people live full, rich, rewarding lives despite their children’s—or their own—handicaps. Finally, by assuming that others would think the less of him because his son was handicapped, he’d engaged in “over-generalization.” On reflection, he realized that his friends would judge him for himself, just as he judged them independent of their children.  This simple exercise immediately calmed Dr. Burns, and improved his mood. Soon after, he learned that David Erik was breathing normally and that his skin had turned a healthy pink.  Subsequently, he learned that the boy’s brain was fine.

In addition, Dr. Burns, a professor of psychiatry at the University of Pennsylvania Medical Center in Philadelphia, learned that the technique he’d used could benefit not just those with major psychiatric problems, but anyone dealing with emotional negativity. He went on to write Feeling Good: The New Mood Therapy, and The Feeling Good Handbook , pioneering popular guides to cognitive therapy. “Cognitive” refers to thought processes.  Cognitive therapy is a powerful self-help technique for dealing with depression and other negative emotions by consciously changing the way we think.

What Causes Negative Feelings?

The cause of negative emotions—depression, anxiety, anger, impatience, frustration, guilt, irritability—is a matter of opinion. To Freudian psychoanalysts, they are the result of repressed feelings that typically date back to childhood relationships with parents. To

biological psychiatrists, they stem from chemical imbalances in the brain. To cognitive

therapists, they represent distorted thinking. Cognitive therapy is comparatively new to the mental health profession, but it’s approach was first espoused more than 2,000 years ago by the Greek philosopher, Epictetus, who said, “People are not disturbed by events themselves, but rather by the views they take of them.” Shakespeare put it well in Hamlet: “There is nothing either good or bad, but thinking makes it so.”

Some emotional turmoil is clearly the result of problems early in life, for example childhood abuse, and Freudian-style talk therapies can help. “But most people don’t have to spend a great deal of time understanding the past to improve how they react to potentially depressing situations in the present,” says psychologist Mark Sisti, Ph.D., associate director of the Center for Cognitive Therapy in New York City.

Some mental health problems are caused by chemical imbalances in the brain, and for severe depression, antidepressant medication is clearly the way to go. Antidepressants may also help people with mild to moderate depression, but for these conditions, Dr. Sisti says, “cognitive therapy is also quite effective.”

Insert neuropeptides

The 10 Forms of Twisted Thinking

Dr. Burns has documented 10 types of distorted thinking. How many of these depressing emotional traps have you fallen into?

1.      All-or-Nothing Thinking. You see things as black or white. If you’re not perfect, you’re a total failure. You make one mistake at work, and decide you’re going to be fired. You get a B on a test, and it’s the end of the world. Your husband reprimands you for not checking the oil when you got gas, and you decide he doesn’t love you.  “Like many people, I was a perfectionist,” Dr. Burns explains. “Either I was terrific, or I was nothing. Either I pleased my boss, spouse, parents, or friends, or else I was good for nothing. It made me terribly anxious, and I spent a good deal of my life ashamed of myself because, of course, I wasn’t perfect.”

2.      Labeling.  An extension of all-or-nothing thinking. You make a mistake, but instead of thinking I made a mistake, you label yourself: I’m a jerk. Your girlfriend breaks up with you, but instead of thinking she doesn’t love me, you decide: I’m unlovable. Dr. Sisti felt himself slipping into labeling during a six-hour professional licensing exam. When he came to a section he found difficult, his first thought was: This is really tough. I must be an idiot. “But then I took a deep breath, and realized that I’d completed other sections that weren’t so hard, and that everyone else in the room was probably having as tough a time as I was.”

3.      Over-generalization. The tip-offs are the use of the words “always” or “never.” You drop something and think: I’m always so clumsy. You make a mistake and think: I’ll never get it right.

4.      Mental Filtering. In complicated situations that involve both positive and negative elements, you dwell on the latter. Your mother clearly enjoys the dinner party you throw in her honor, but comments that the cake was a bit dry. You filter out all her positive comments and whip yourself for being such a lousy baker.  “As a perfectionist,” says Bruce Zahn, M.A., director of psychology and cognitive therapy at Presbyterian Medical Center in Philadelphia, “I sometimes slip into mental filtering. I usually get good feedback on my job and in my personal relationships, but when people give me minor criticism, I’m apt to think the worst: They don’t love me. They’re going to fire me. Then I realize, no, this is a minor criticism, and all I have to do is correct it.”

5.      Discounting the Positive. The tip-offs here are phrases: “That doesn’t count,” “That wasn’t good enough,” or “Anyone could have done it.” You do well on a test, and think: It doesn’t count. Your colleagues praise a presentation, and you think: It wasn’t good enough. You win a commendation and think: Anyone could have done it.

6.      Jumping to Conclusions. You assume the worst based on no evidence. In “mind-reading,” you decide that another person is reacting negatively to you. Two of your coworkers are chatting at the coffee machine at work, but as you approach, they fall silent. Chances are they’d simply finished their conversation, but you assume they’ve been criticizing you behind your back. In “fortune-telling,” you predict the worst possible outcome. A test is difficult, so you decide you failed. The sky is cloudy before you lawn party, so you decide a thunderstorm must be imminent.  Dr. Sisti slipped into fortune-telling recently when he realized he’d lost his automatic teller machine (ATM) bank card: “My blood pressure shot up as I imagined that I’d lose all my money. Then I thought: What’s the worst thing that could happen? Someone might use my card. But no one could—not without my personal identification number. But what if I’d left it in the machine? Then someone could withdraw $250. That would have been a loss, but not a terrible one.”

7.      Magnification. You exaggerate the importance of problems, shortcomings, and minor annoyances. Your toilet backs up, and you believe you need your entire plumbing system replaced. You forget to close a window before it rains, and imagine that you’ll return to a flooded home. A neighbor’s dog tramples a few flowers and you decide your garden is ruined.

8.      Emotional Reasoning. You mistake your emotions for reality. I feel nervous about flying, therefore, it must be dangerous. I feel guilty about forgetting my brother’s birthday, therefore, I’m a bad person. I feel lonely, therefore, I must not be good company.

9.        “Should” and “Shouldn’t” Statements. You play well in the company volleyball tournament, but miss one shot and berate yourself: I should have made that shot. I shouldn’t have missed. You eat a donut and think: I shouldn’t have done that. I should lose 10 pounds.  Other self-demanding tip-offs include: “must,” “ought to,” and “have to."

10.  Personalizing the Blame. You hold yourself personally responsible for things beyond your control. Your child misbehaves at school and you think: I’m a bad mother. “Occasionally, I’ve been late for an appointment because of heavy traffic,” Dr. Sisti says, “and I’ve felt tempted to personalize it, as in: I must be irresponsible. But then I’ve realized that I’d allowed what should have been enough time, and that the traffic jam is beyond my control. People understand if you get stuck in traffic. It happens to everyone.”

Seven Ways to Untwist Your Thinking

“When you feel badly,” Dr. Burns explains, “your thinking becomes negative. This is the ABC of emotion: ‘A’ stands for the Actual event, ‘B’ for your Beliefs about it, and ‘C’ for the Consequences you experience because of your beliefs.”

Suppose the actual event is a divorce. You might believe many of the charges your ex leveled

against you: You’re selfish, uncaring, vindictive, and lousy in bed. The consequences of these

beliefs might be deep depression. Cognitive therapy tries to change the “B’s” so you don’t experience the “C.”

How can you change your beliefs about the slings and arrows of outrageous fortune? Dr.

Burns recommends subjecting any negative belief to the following tests:

  • ·        What would you say to a friend? “People are generally much harder on themselves than

they are on others,” Dr. Burns says. Suppose a friend were getting divorced, and felt like a

selfish, uncaring, vindictive failure. What would you say? Probably something like: You’re not

a failure simply because your relationship ended. Many marriages end in divorce, just like

many winning teams lose games. It’s rough to endure a divorce, and break-ups never bring

out the best in people, but I’ve known you for years, and you’re a warm, kind, caring person.”

  • ·        Examine the evidence. Your ex says you’re lousy in bed, but are you, really? Until you

learned of you ex’s unfaithfulness, you had a good sexual relationship. Of course, after your

heart was broken, you didn’t have any energy for sex, especially with the person who’d rejected and betrayed you. That’s not being lousy in bed. That’s a normal reaction to your situation.

  • ·        Experiment. You ex called you selfish for wanting to keep the house, but are you really? If

you were truly selfish, you wouldn’t give to charity, wouldn’t help friends in need, and

wouldn’t share credit for your group’s accomplishments at work. Test your reactions the next

time a charitable solicitation arrives, or a friend calls with a problem, or your group’s efforts

are recognized. If you write a check, offer to lend a hand, or praise a coworker, you’re not

entirely selfish. You may not be as magnanimous as you’d like to be, but you’re not the ogre

your ex says you are.

  • ·        Look for partial successes. Instead of thinking your marriage was a “complete failure,”

consider how it was successful. You took turns putting each other through school, and now

both have much more fulfilling careers than you had when you met. You have two great kids,

and the problems that led to your breakup have given you valuable new insights into the kind

of person you’ll look for in your next relationship.

  • ·        Take a survey. You ex insists that your refusal to take the kids for an extra day after a

holiday weekend proves you’re vindictive. You maintain that you’re open to rescheduling time

with the children, but not when it means allowing your ex to jet off to a luxurious resort with

the new lover. You feel justified, but after a screaming argument on the phone, your

confidence is shaken. Perhaps you are a vindictive SOB. That’s the time to call a few friends

and solicit their views. Chances are they’ll say you’re justified.

  • ·        Define your terms. You had no idea your ex was having affairs. You were blind. Define

“blind.” The dictionary says “completely without sight.” That wasn’t you. You saw that your

ex had withdrawn from you, and was spending an enormous amount of time “working late.”

You weren’t blind, just too trusting of someone you had every reason to believe was trustworthy.

  • ·        Solve the problem. You blew up when you came home early and found your ex, who’d

moved out months ago, unexpectedly in your house. Since that ugly scene, you’ve been

thinking that your “terrible temper” has turned you into a “monster.” Possibly, but the problem

here is that you ex still has keys to your house. Maybe it’s time to change the locks.

Seven Steps to Feeling Better

Six steps may not sound like many, but “simplicity is one of cognitive therapy’s major

strengths,” Dr. Sisti explains. It’s quick and easy, and once people understand the basic

concepts, almost anyone can practice it.” Sometimes, though, cognitive therapy’s very

simplicity puts people off. They say: “It’s so simple, it can’t possibly work.” When that

happens, Dr. Sisti points out that they’re jumping to a conclusion, and urges them to try the

steps and see if the process has value:

  • ·        Step 1. Get pen and paper. Write everything down. “The act of writing automatically puts

some distance between you and your negative thought,” Dr. Sisti says. “Jotting things down

provides perspective and helps people detect distorted thinking more easily.” If you can’t put

pen to paper, Dr. Sisti recommends saying things out loud.

  • ·                    Step 2. Identify the upsetting event. What’s really bothering you? Is it simply the fact that you got a flat tire? Or is it that you soiled your outfit changing it? Or that you knew you needed a new tire, but didn’t replace it? Or that the flat made you late for your daughter’s soccer game?
  • ·        Step 3. Identify your negative emotions. You might feel annoyed about the flat, frustrated

that replacing it soiled your outfit, angry at yourself for not replacing it in time, and guilty for

being late to the soccer game.

  • ·        Step 4. Identify the negative thoughts that accompany your negative emotions.About

failing to replace the tire: I always procrastinate. I never take care of things in time. About

soiling the outfit: I’m a slob. I can’t go anywhere and look okay. About being late for the

game: My daughter will make a scene. She’ll think I don’t love her. And the other adults there

will think I’m a bad parent.

  • ·        Step 5. Identify distortions and substitute rational responses. About the tire: I don’t

always procrastinate. I juggle my job and family, and accomplish just about everything that

has to get done. I would have replaced that tire in time, but I had to deal with an emergency

at work, and the tire just got by me. About the stained outfit: I’m not a slob. I’m usually very

careful about my appearance, more so than most people, which is why things like this upset

me. About the tardiness: My daughter knows I love her. She knows that if I’m late, whatever

detained me was beyond my control. She’s unlikely to make a scene, but if she does, the

other adults there will comfort her. I’ve done the same for their kids, and never thought them

to be bad parents. No one will think the worse of me.

  • ·        Step 6. Reconsider your upset. Are you still heading for an emotional tailspin? Probably not. But you still feel annoyed about getting the flat.
  • ·        Step 7. Plan corrective action. As soon as the game is over, we’re getting that tire. That

will take the time I’d planned to spend cooking dinner, so I’ll pick up some take-out instead.

Have More Fun

Start by smiling. We smile when we’re happy. But the link between smiling and positive emotions is a two-way street. “Smiling helps makes us happy,” says psychologist Robert Cooper, Ph.D., of Ann Arbor, Michigan. Smiling transmits nerve impulses from the facial muscles to the limbic system, the part of the brain that plays an important role in emotions.  Smiling tilts the body’s neurochemical balance away from depression and toward mood elevation. Try it: Smile right now. Not a little, corners-of-the-mouth smile, but a big, full-face, ear-to-ear grin. Don’t you feel happier?

Beyond smiling, do something—anything—that makes you feel happy. “Happiness requires action,” says psychologist Jennifer James, Ph.D., author of Women and the Blues.  Try not to mope. Visit a friend. Get a massage. Care for a pet. Redecorate your home. Go to a concert. Volunteer your time helping the less fortunate. Take a class in something that interests you. Take a vacation. If nothing feels fun, do things you used to enjoy.

 Count Your Blessings

“A major task of adulthood is to balance striving to do your best while accepting your limits,”

Dr. Burns says. “Cognitive therapy has helped me accept my limits without feeling ashamed.”

“Cognitive therapy is simply a more organized way to implement traditional psychological

self-care advice,” says New York psychotherapist Alan Elkin, Ph.D. “It boils down to

counting your blessings. Most depressing or anxiety-producing events are not inherently

awful. What makes them feel distressing is the way we react to them. Counting your blessings

forces you to step back, get some perspective, and see challenges in a larger context. The problem with ‘count your blessings’ is that it’s vague. Cognitive therapy is a step-by-step program, and when you feel depressed or stressed by negativity, an organized program helps.”

Selected Sources:

NIH Depression Awareness, Recognition, and Treatment (D/ART) Program. Cooper, Robert. Health and Fitness Excellence

The Feeling Good Handbook by David D. Burns, M.D.

Exercise as Therapy

Exercise helps treat depression in four ways:

1.It releases endorphins, the body’s own mood-elevating, pain-relieving compounds.

2.It reduces levels of the stress-depression hormone, cortisol, in the blood.

3.It helps provide perspective on life.

4.It provides a feeling of accomplishment, which enhances self-esteem.

Many, many studies demonstrate that exercise helps treat depression. Here are summaries of just afew:

  • ·        At the University of Illinois, researchers surveyed 401 adults about their health, mental health, andlifestyle. The more time the respondents spent in strenuous exercise, the less depression, anxiety,and insomnia they reported.
  • ·        At Harvard University, researchers divided 32 mildly-to-moderately depressed individuals over age60 into two groups. Half continued to live as they had. The other half enrolled in a weight-liftingclass. At the end of 10 weeks, everyone in the control group was still mildly-to-moderately depressed. But among the exercisers only two of 16 still were.
  • ·        At the University of California, at Berkeley, School of Public Health, researchers have been periodically assessing the health, mental health, and lifestyle of 6,000 residents of the San FranciscoBay Area since 1965. The ongoing survey clearly shows a strong association between a sedentarylifestyle and depression, and an equally strong association between becoming physically active and relief from depression.
  • ·        University of Nebraska researchers tested 180 college students for depression and then divided them into three groups. A control group continued to live their lives as they had. One test group enrolled in a swimming class that met twice a week for an hour. The other test group enrolled in an hour-long weight-training class that met twice a week. Seven weeks later, the researchers re-tested all the students for depression. Compared with the controls, both exercise groups were significantly less depressed, and showed improved self-esteem.
  • ·        At LaTrobe University in Bundoora, Australia, researchers tested 33 people’s mental health, and then enrolled them in a two-month tai chi class. Tai chi is a gentle, non-strenuous, dance-like, Chinese exercise program. After the class, the people were tested again. They were less depressed,  anxious, tense, and fearful.
  • ·        Other studies have shown that for mild-to-moderate depression, regular aerobic exercise helps about as much as talk-based psychotherapy.

Which kind of exercise is best? Whatever you like. Do something that appeals to you personally. It doesn’t matter what you do as long as you do something physical for a half hour or so three or more times a week, ideally every day: take walks, ride a bike, swim, play volleyball, garden, go bowling, play golf—anything. Just do something. If no physical activity appeals to you, think back to when you were a kid. What kind of physical play did you enjoy? Bicycling? Roller skating? Jumping rope? Try your childhood favorites again. You might still enjoy them.

The most accessible exercise program is walking. You already know how to do it, and there’s no outfit or equipment to buy, no gym to join. Just open your front door and put one foot in front of th eother. In recent years, walking has become Americans’ most popular form of exercise.It takes about a month of regular exercise to notice a significant mood-elevating effect. Be patient. Stick with it, and you’ll feel better.

Also, be patient about your workout ambition. This isn’t a competition. Your exercise program should be enjoyable. Take it nice and easy. Don’t increase the strenuousness or duration of your workout more than 10 percent a month. Exercise shouldn’t be a chore. It should be fun.

Selected Sources:

NIH Depression Awareness, Recognition, and Treatment (D/ART) Program.

Nicoloff, G. and T.L. Schwenk. “Using Exercise to Ward Off Depression,” The Physician and

Sportsmedicine. 9-95, 44-56

Ross, C.E. and D. Hayes. “Exercise and Psychological Well-Being,” American J. of Epidemiology (1988)


Jin, P. “Changes in Heart Rate, Noradrenaline, Cortisol, and Mood During Tai Chi,” J. Psychosomatic Research (1989) 33:197


Support Groups

Support groups turn life around wonderfully. They take depression, or any other illness or

challenge, things that usually leave people feeling sad, frustrated, and isolated—and turn them

into the sole criterion for membership. In this powerful way, people can come together with

dignity, compassion, and cooperation to lighten the burdens of depression, disability, bereavement—whatever. Typically, the results are better information about surviving the situation, and profound healing.

“Doctors and psychologists can’t be all things to all people,” says Edward Madara, M.S.,

director of The American Self-Help Clearinghouse in Denville, New Jersey. “When you sit

down with others who have shared your experience—no matter whether it’s depression, diabetes, multiple sclerosis, or an unfaithful spouse—you feel a sense of comfort and closeness no professional relationship can match.”

Many scientists were skeptical of support groups until the 1970s and the development of

pyschoneuroimmunology, the study of how emotions influence the central nervous system and

the immune system. Now we know that social support has profound psychological benefits

that can help anyone who feels depressed.

Over the last 25 years, many studies have shown that social isolation releases a flood of

stress hormones into the blood that trigger many psychological and physiological changes,

including: feelings of depression and anxiety, increased heart rate, higher blood pressure, and

impaired immune function.

“These hormones normally ebb and flow,” says David Spiegel, M.D., a professor of

psychiatry at Stanford University and director of the Psychosocial Treatment Laboratory

there. “But when social isolation becomes chronic, they remain consistently high, impairing the

body’s ability to cope with depression, emotional stress, and physical illnesses.”

On the other hand, well-developed social networks dam the flood of depression-stress

hormones, minimizing their presence in the bloodstream, and allowing the body to heal more

efficiently and cope with stress more effectively.

“The relationship between social isolation and early death, including suicide, is as strong

statistically as the relationship between dying and smoking or having high cholesterol,” Dr.

Spiegel says. “It’s as important for mental health to have a strong network of family and

friends as it is for physical health to quit smoking. Unfortunately, medical science has greatly

underestimated the value of social support.”

In previous generations, social support came largely from family and the communities where

most people spent their entire lives. But in mobile America, family and old friends may be

thousands of miles away. To replace the support they provide, hundreds of thousands of support groups have mushroomed across the United States.

Beyond fellowship, support groups can provide important information about depression: the

names of good psychiatrists and psychotherapists, first-hand accounts of antidepressant medication side effects, and self-care tips about surviving the depression.

The camaraderie, laughter, and back-and-forth bantering support groups encourage help

banishes feelings of isolation. When you ask, “Has anyone every felt--?” Or, “Has this ever

happened to you?” The answer is almost invariable “Yes.” Support groups legitimize members’ feelings and experiences. They provide a welcome framework for coping.

Since the helper and beneficiary are peers, everyone can be both. This exchange of support

has a special meaning, and some believe it’s therapeutic in itself, especially for those who feel

depressed, because helping others boosts self-esteem. “There are a lot of selfish reasons to be altruistic,” says David Sobel, M.D., the San Jose-based director of preventive medicine for the Kaiser Permanente Health Maintenance Organization of Northern California. “You get the personal satisfaction of making a real contribution to someone else’s life. But you also get other benefits—emotional uplift, perspective on your own problems, significant stress reduction, and as a result, better physical and mental health yourself.”

“Support groups reduce isolation,” Madara explains. “They’re empowering and comforting.

They teach practical coping skills. Sometimes they change laws and public perceptions. And

usually, they’re low cost.”

Selected Sources:

NIMH Depression Awareness, Recognition, and Treatment (D/ART) Program

American Self-Help Clearinghouse. The Self-Help Sourcebook. St. Charles-Riverside Medical

Center, Denville, NJ.

Spiegel, David. Living Beyond Limits. Fawcett-Columbine, NY, 1993.

Herbal Medicine

Several medicinal herbs have antidepressant effects. The most powerful is St. John’s wort, a

natural MAO inhibitor. In addition, ginkgo, and caffeine may also help.

St. John’s wort. “Wort” is Old English for “plant.” St. John’s wort was named for John the

Baptist, whose birthday, June 24, falls around the time this plant produces its yellow flowers.

St. John’s wort (Hypericum perforatum) has been used in traditional herbal medicine for

centuries, primarily for wound healing. Some years ago, German scientists discovered that the

plant is also a monoamine oxidase (MAO) inhibitor, one class of antidepressant medication.

A major recent study shows that St. John’s wort is an effective antidepressant. The 1996

report published in the British Medical Journal, was compiled by researchers at the Audie

Murphy Veterans Hospital in San Antonio, Texas, and colleagues in Germany, who

conducted a meta-analysis of the herb’s effectiveness. Meta-analysis is a sophisticated

statistical technique that allows studies with small numbers of subjects to be mathematically

combined as if they were all part of one big study. Size is important because the larger the

group tested, the more reliable the results. The researchers combined 23 methodologically

sound studies of St. John’s wort that had a total of 1,751 participants. Among those who

took the placebo, 22 percent reported mood elevation. Among those who used St. John’s

wort, the figure was 55 percent, a highly significant difference. Among those who responded

to St. John’s wort, the relief obtained was similar to that experienced from pharmaceutical antidepressants.

In Germany, where herbal medicine is more mainstream than it is in the U.S., doctors often

prescribe St. John’s wort for mild-to-moderate depression.

On the plus side, the herb costs only about $10 a month, considerably less than

pharmaceutical antidepressants, and it does not appear to cause the side effects of other

MAO inhibitors, notably hazardous interactions with foods containing tyramine, among them:

cheeses, yogurt, sour cream, liver, sausage, bologna, pepperoni, salami, game meats, meats

prepared with any tenderizer, caviar, salted or pickled herring, shrimp paste, beer, ale, red wine, sherry, vermouth, distilled spirits, avocados, bananas, figs, raisins, sauerkraut, soy sauce, miso soup, tofu, fava beans, coffee, tea, colas, chocolate, and ginseng.

On the minus side, MAO inhibitors have been largely replaced by newer drugs, and some

people find these newer medications more effective. In addition, St. John’s wort may cause

side effects: upset stomach, dry mouth, fatigue, dizziness, rashes, and itching. Finally, anyone

taking St. John’s wort should err on the side of caution and observe the food restrictions required of those who use other MAO inhibitors.

Do not take St. John’s wort if you are already taking a pharmaceutical antidepressant. Do not

use the herb if you are pregnant or nursing, or planning to become pregnant while taking it.

Ginkgo. Ginkgo improves blood flow through the brain, accounting for its major uses as an

aid to stroke recovery and mental acuity in the elderly. But it also appears to normalize

neurotransmitter levels, and as a result, can help treat depression. In one study, European

researchers recruited 40 elderly individuals who had both depression and poor cerebral

blood flow. After a few months of taking 80 mg of ginkgo extract three times a day, their

depression lifted and their mental faculties improved significantly. If you use gingko, don’t

take more than 240 mg/day or you might develop diarrhea, restlessness, and irritability.

Caffeine (coffee, tea, colas, chocolate). Coffee is the nation’s most popular “pick-me-up.”

In addition to waking people up in the morning, it also has a mild, but noticeable

antidepressant effect. Caffeine’s mood-elevating action plays a role in two of its proven, but

lesser-known effects—pain relief and weight loss. The addition of caffeine to aspirin has been

shown to produce better pain relief than aspirin by itself. Caffeine is not known to have any

pain-relieving action, so researchers believe its mood-elevating action accounts for its

pain-relieving benefit. (Excedrin is a combination of aspirin and caffeine.) Caffeine has also

been used in some physician-supervised weight-loss programs with modest, but statistically

significant success. The drug has no known appetite-suppressing action, so scientists attribute

its action to its mood-elevating effect. If you use caffeine, do not exceed your own individual

tolerance or you may experience insomnia, agitation, restlessness, and irritability.

Selected Sources:

Linde, K. et al. “St. John’s Wort for Depression: A Meta-Analysis of Randomized Clinical Trials,”

British Medical Journal (1996) 313:253.

Castleman, M. The Healing Herbs. Bantam Books, 1995.

Duke, J. The Green Pharmacy. Rodale, 1996.

Dietary Supplements

Certain vitamin deficiencies can cause depression:

Vitamin B6. Even a minor B6 deficiency can reduce the availability of serotonin, a neurotransmitter involved in depression, according to Karl Goodkin, M.D., an associate professor of psychiatry and neurology at the University of Miami School of Medicine.  Several studies show that depressed individuals tend to have low blood levels of this nutrient.

As little as 10 mg of supplemental B6 a day can relieve depression. In one study, 19 depressed women with low B6 levels were given a supplement. Sixteen of them reported improved mood.

Other B vitamins. At the University of Arizona, researchers divided 14 elderly people

taking antidepressant drugs into two groups. In addition to their regular medication, one took

a placebo, while the other took 10 mg each of vitamins B1, B2, and B6. The supplement group showed greater relief from depression.

Folic acid. Folic acid, another B vitamin, also helps elevate a depressed mood. Several

studies have shown that depressed individuals tend to have low blood levels of this nutrient.

Other studies have shown that supplementation helps relieve their depression. In one, 24

people with major depression and low blood levels of folic acid were divided into two

groups. One received a placebo, the other, 15 mg a day of folic acid. After three months, the

folic acid group was significantly less depressed.

The Weil regimen. Andrew Weil, M.D., is a professor at the University of Arizona College

of Medicine. He is also a noted advocate of non-drug therapies. Here’s what he recommends

for depression: Upon waking, take 1,500 mg of DLPA (DL-phenylalanine), an amino acid

available at health food stores that increases synthesis of neurotransmitters. In addition, take

500 mg of vitamin C, 100 mg of B6, and a small piece of fruit or glass of juice. In the evening

take another round of vitamins C and B6. Dr. Weil says his supplement regimen can be used

by people taking antidepressant medication.

Selected Sources:

Bal, I.R. “Vitamins B1, B2, and B6 in Augmentation of Tricyclic Antidepressant Treatment,” J. Am.

College of Nutrition (1992) 11:159.

Andrew Weil’s Self-Healing, 1-97.

Godfrey, P.S.A. et al. “Enhancement of Recovery from Psychiatric Illness by Methylfolate,”

Lancet (1990) 336:392.

Werbach, M. Nutritional Influences on Illness. Third Line Press, 1991.


The United Nations World Health Organization endorses acupuncture as a treatment for

depression. At the University of Arizona, John J. Allen, Ph.D., an assistant professor of

psychology studied 34 women diagnosed with major depression who were not being treated

with antidepressant medication. One-third met with the researchers but received no

acupuncture. The second received acupuncture, but not on points recommended for treating

depression. The third received acupuncture on the depression points. Compared with the two

control groups, the women receiving acupuncture on the depression points showed significantly greater mood elevation.

Source: Steefel, L. “Treating Depression,” Alternative and Complementary Therapies, 1-96, 1-4.

Music as Therapy

In the Bible’s Book of Samuel, King Saul shows classic symptoms of depression: persistent

sadness, listlessness, and irritability. To ease his melancholy, the future King David plays music for him.

David had the right idea. In one study, people suffering serious depression received one of

the following: weekly visits from music therapists who played music and taught them stress

management techniques; taped music to play on their own, with weekly phone calls from

music therapists; or no music. Compared with the control group, participants in both music

groups showed significantly improved mood.

Source: Hanser, SB, et al. “Effects of a Music Therapy Strategy on Depressed Older Adults.”

Gerontology (1994) 49:P265.

Massage as Therapy

Touch is the only sense human beings cannot live without. Children born blind or deaf can

lead normal lives. But infants deprived of touch become withdrawn, listless, and stop smiling,

classic symptoms of depression. If touch deprivation continues unchecked, it may prove fatal.

At the Touch Research Institute at the University of Miami Medical School in Florida, psychologist Tiffany Field, Ph.D., had massage therapists give 20-minute Swedish massages twice a week to women hospitalized for serious post-partum depression. Their blood levels of stress hormones decreased, and they reported improved mood.

Source: Steefel, L. “Treating Depression,” Alternative and Complementary Therapies, 1-96, 1-4.

Relaxation Response, Meditation, and Visualization as


People who meditate (or who practice the very similar Westernized, secular relaxation response) often report mood elevation and feelings of enhanced well-being.

In a study of 154 women who felt depressed because they were being treated for breast cancer, British researchers met with one-third, the controls. They taught another third a combination of the relaxation response and visualization therapy using pleasant, relaxing imagery. The final third were taught progressive muscle relaxation, another meditative technique. Before and after tests showed that the control group remained depressed, but both relaxation therapies significantly improved the women’s mood.

“Many studies have shown mood elevation in depressed people who regularly elicit the

relaxation response,” notes Herbert Benson, M.D., the Harvard researcher who popularized

the relaxation response, and introduced meditation into American medicine.

Selected Sources:

Bridges, LR et al. “Relaxation and Imagery in the Treatment of Breast Cancer,” Br. Med. J. (1988)


Benson, H. “The Relaxation Response,” in Mind-Body Medicine, Consumer Reports Books, NY,

1993, p. 250.


Phototherapy is the use of bright artificial light to treat winter depression, or seasonal affective

disorder (SAD). It was discovered in the early 1980’s, when researchers noticed that SAD

sufferers who went south for winter vacations experienced relief that persisted for a week or

so after they returned home.

This observation led to the development of devices that produce bright artificial sunlight

(full-spectrum minus the ultraviolet, which causes sunburn and increases risk of skin cancer).

You sit in front of one of today’s bright light appliances as you have breakfast, and by the time you’ve finished, you’re protected from SAD for the day.

SAD symptoms typically begin to lift about a week after the start of phototherapy. But they

return shortly after discontinuing treatment, which is why authorities urge SAD sufferers to

use their bright light appliances daily from October through April.

In the mid-1990’s, scientists discovered that for some people with winter blues, ultrabright

light might not be necessary. Devices that simulate dawn often work just as well. Dawn

simulators are night lights fitted with timers and dimmers. At 4 a.m. the timer turns the light on,

bathing the sleeping winter-blues sufferer in the faint glow of an artificial dawn. The light

brightens over two or three hours until the person awakens. In one early study, six of eight

SAD sufferers experienced substantial relief after two weeks of awakening to simulated sunrises. Since then, other studies have confirmed the effect.

Light therapy’s success in treating SAD has led to studies of its effectiveness for nonseasonal

depression—with promising preliminary results. At the University of California at San Diego,

psychiatry professor Daniel F. Kripke, M.D., divided 50 men with severe nonseasonal

depression into two groups. Half spent seven consecutive evenings in a room illuminated with

1,600 watts of bright light. The other half spent the time in a room with the lights turns low.

Compared with the dim-light group, symptoms in the bright-light group improved 18 percent.

Bright-light boxes and dawn simulators may be necessary for some seasonal blues sufferers,

but if you feel blue, experts in phototherapy offer other suggestions as well:

Get more natural sunlight. Trim the bushes around your windows and keep your curtains and blinds open. Use bright colors on walls and upholstery.

Sit near windows whenever possible. Do this at school, at work, on public transportation, and when dining out. If you exercise indoors, work out near a window.

Take a walk. People with SAD often spend unusually little time outdoors in winter. A Swiss

study showed that a one-hour walk in midday winter sunlight can significantly lift the spirits.

For winter blahs and winter doldrums, a daily outdoor winter walk may be all that’s necessary.

Take a winter vacation. Head for a sunny destination. “With a diagnosis of SAD,” Dr.

Freeman quips, “it might even be tax-deductible.”

Selected Sources:

Society for Light Treatment and Biological Rhythms, P.O. Box 478, Wilsonville, OR 97070.

NOSAD, the self-help group for people with SAD. P.O. Box 40133, Washington, D.C. 20016.

The SunBox Company, 19127 Orbit Dr., Gaithersburg, MD 20879.

Apollo Light Systems, 352 West 1060 South, Orem, UT 84058.

Drug Therapy for Depression

An Introduction to Antidepressant Medications

All antidepressant medications are equally effective. They elevate mood in 60 to 80 percent

of people who use them as directed.

It usually takes two to four weeks to feel any benefit.

The first antidepressants, monoamine oxidase (MAO) inhibitors, were discovered

accidentally during the 1960’s by researchers who were trying to develop new drugs to treat

tuberculosis. MAO inhibitors didn’t help TB, but they elevated mood.

Since then, many other types of antidepressants have been developed. The newer drugs are

safer and for most people, have fewer side effects.

While all these medications are equally effective, some work better for different combinations

of symptoms than others. It’s important to tell your doctor about your symptoms in detail so

that your symptom cluster can be matched to the medication that works best for it.

But if the first antidepressant you try does not provide sufficient relief, don’t despair. Another

probably will. Many depression sufferers must try several different medications before they

find the one that works best for them.

Antidepressants are usually prescribed by themselves, but some psychiatrists combine them

with other drugs to increase their effectiveness.

What’s it like to take an antidepressant? In What You Need to Know About Psychiatric

Drugs, Stuart Yudofsky, M.D., Robert Hales, M.D., and Tom Ferguson, M.D. say, “We tell

our patients that it’s just the opposite of drinking alcohol. With alcohol, you get the enjoyable

effects right away. The hangover doesn’t appear until the next morning. With antidepressants,

most people experience the unpleasant side effects first, while the benefits may take four to

six weeks to appear.”

Having to wait a month or six weeks to feel better can be very frustrating. Be patient. You’ll

feel better soon.

As for the side effects, most subside after a few weeks of using the medication.

The first side effect most people notice is a dry mouth. It helps to drink more water and juice,

eat more juicy fruits (oranges, etc.), and suck on hard candies. By about the third week, dry

mouth and some other initial side effects (e.g. constipation and headache) typically subside.

The different antidepressants have different effective dosages. It’s important to note that the

dose you take has nothing to do with the severity of your depression or your hopes for

recovery. The number of milligrams (mg) is irrelevant. Some antidepressants work at 15 mg a

day, others at 200 mg a day. That’s just the way these drugs are formulated.

It often takes a while to get used to taking antidepressants. Most physicians start people on a

low dose, and slowly increase it over a few weeks or months. Again, having your dosage increase has nothing to do with the severity of your depression or your prognosis.

Antidepressants are not addictive. But overdosing on some antidepressants (notably, the

tricyclic and tetracyclic compounds) can be fatal. Because any depressed individual is

potentially at risk for suicide, the possibility of fatal overdose is a major disadvantage of the

tricyclic and tetracyclic drugs.

How long will you take antidepressants? That depends on how many depressive episodes you’ve had.

First episode. For a first episode of clinical depression, drug treatment typically lasts six to

nine months. But it’s important to understand that a first episode increases your risk of a

second. You face about a 50 percent chance of becoming seriously depressed again within

five years.

Second episode. A recurring depressive episode usually requires one to two years of medication, and the chance of another episode within five years increases to 70 percent.

Third episode. A third serious depression virtually guarantees more recurrences (95 percent

chance). As a result, people in this situation typically take antidepressants for life. There is

nothing hazardous about taking antidepressants long-term. Think of your medication as a diabetic thinks of insulin. You need it to function.

Do not drink alcohol while taking antidepressants. Alcohol is a powerfully depressant drug.

Don’t stop taking antidepressants abruptly. If you do, you may experience a variety of flu-like

withdrawal effects. When you’re ready to stop taking your medication, you physician can help you taper off.

Will antidepressants affect your sex life? Possibly. Depression typically changes sexuality.

Some people lose their libidos. Others become hyper-sexual. Once the depression clears up,

sexuality usually returns to normal.

Some antidepressants have been associated with sex problems. Among people taking the

Prozac family of medications (SSRI’s), some 40 to 50 percent report sexual impairment: loss

of libido in both sexes, difficulty ejaculating in men, and loss of orgasm in women. If you

believe that your medication is causing sex problems, don’t suffer in silence. Call your doctor.

Wellbutrin and Serzone cause very few sex problems.

How do antidepressants work? The physical basis of depression involves neurotransmitters in

the brain. Neurotransmitters are chemicals that carry messages from one nerve cell to another. Nerve cells do not touch. There are microscopic gaps between them called synapses. For a nerve impulse to travel from one nerve cell to another, the sending cells releases a tiny amount of one of the neurotransmitters, which transmits the signal to the second cell, and so on around the body. After a nerve impulse has been sent across a synapse, special enzymes clear away the neurotransmitter so that another impulse may be sent.

Depression is strongly associated with abnormally low levels of certain neurotransmitters,

among them: serotonin, epinephrine, and norepinephrine. Antidepressants increase the levels

of these chemicals by interfering with the enzymes that eliminate them from the synapses, a

process called “reuptake inhibition.” The different types of antidepressants have different

effects on the various neurotransmitters. The various antidepressants may act on the same

neurotransmitter(s), but each has a subtly unique action, which distinguishes them from one


The choice of one drug over another depends on your symptoms. Describe your symptoms

clearly and completely to your doctor so that you can receive the medication best suited to

your individual situation.

Selected Sources:

Yudofsky, Stuart, M.D., Robert Hales, M.D., and Tom Ferguson, M.D. What You Need to Know

About Psychiatric Drugs. Grove Widenfield, NY, 1991.

Drug Facts and Comparisons, 1998. Facts and Comparisons, St. Louis.

Prozac, Zoloft, and Paxil (Selective Serotonin

Reuptake Inhibitors, or SSRI’s)

The first SSRI, Prozac, was approved by the FDA in 1988. The other SSRI’s were approved as follow: Zoloft, 1991; and Paxil, 1992.

SSRI’s are as effective as the other antidepressants, but no more so. They help 60 to 80 percent of those who use them as directed.

In addition to treating depression, SSRI’s may also help treat panic, obsessive-compulsive disorder, and bulimia.

Typically, it takes several weeks of regular use to obtain the full antidepressant effect.

Side Effects

SSRI’s often cause sexual side effects. Depending on the study, 40 to 50 percent of SSRI

users complain of one or more sexual side effects, mostly, inability to have an orgasm, but

also decreased desire and arousal, erection impairment in men, and loss of lubrication in women.

SSRI’s also disrupt sleep. They often cause “micro-awakenings.” Users usually remain

unaware of these sleep disruptions, but they appear clearly in sleep studies of SSRI users,

and contribute to the fatigue some users cite as a reason for dissatisfaction with these drugs.

Other possible side effects include:

For Prozac: nausea (21% vs. 10% of those taking a placebo), nervousness (15% vs. 9%),

insomnia (14% vs. 7%), drowsiness (12% vs. 6%), diarrhea (12% vs. 7%), and tremor (8%

vs. 2%).

For Zoloft: nausea (26% vs. 12% of those taking a placebo), diarrhea (18% vs. 9%), dry

mouth (16% vs. 9%), insomnia (16% vs. 9%), drowsiness (13% vs. 6%), dizziness (12% vs.

7%), tremor (11% vs. 3%), sweating (8% vs. 3%), and indigestion (6% vs. 3%).

For Paxil: nausea (26% vs. 9% of those taking a placebo), drowsiness (23% vs. 9%), dry

mouth (18 % vs. 12%), weakness (15% vs. 6%), constipation (14% vs. 9%), dizziness

(13% vs. 6%), insomnia (13% vs. 6%), diarrhea (12% vs. 8%), sweating (11% vs. 25), and

tremor (8% vs. 2%).

Instructions to Users

SSRI’s may cause dizziness or drowsiness. Be extra-careful when driving or operating machinery until you are confident that your SSRI does not interfere.

Do not drink alcohol while taking an SSRI.

If you take or plan to take other drugs while taking an SSRI, discuss the issue with your physicians and/or pharmacist. Hazardous drug interactions are possible.

If you are pregnant or breastfeeding or plan to become pregnant while taking an SSRI, discuss your situation with your doctor.

SSRI’s may cause sensitivity to sunlight. Avoid prolonged sun exposure, wear protective clothing, and use sunscreen until you determine your level of sun sensitivity.

Consult your doctor if you develop hives, a rash, or any unusual reaction while taking any



Prozac: The recommended initial dose is 20 mg/day. If necessary, it may be increased up to

80 mg/day (lower in the elderly).

Zoloft: The recommended initial dose is 50 mg/day. If necessary, it may be increased up to

200 mg/day (lower in the elderly).

Paxil: The recommended initial dose is 20 mg/day. If necessary, it may be increased up to 50 mg/day (40 mg/day in the elderly).

Mechanism of Action:

Prozac, Zoloft, and Paxil block the recapture of the neurotransmitter serotonin by nerve cells.

Selected Sources:

Yudofsky, Stuart, M.D., Robert Hales, M.D., and Tom Ferguson, M.D. What You Need to Know

About Psychiatric Drugs. Grove Widenfield, NY, 1991.

Drug Facts and Comparisons, 1998. Facts and Comparisons, St. Louis.

Physicians’ Desk Reference, 1996.

“SSRI’s Cause Sexual Dysfunction in Many Patients,” Medical Tribune, 6-6-96.

“Sex Problems Related to SSRI’s May Be More Common Than Believed,” Family Practice News,


Armitage, R. et al. “A Multicenter, Double-Blind Comparison of the Effects of Nefazodone and

Fluoxetine on Sleep Architecture and Quality of Sleep in Depressed Outpatients,” J. of Clinical

Pharmacology (1997) 17:161.

Gillin, J.C. et al. “A Comparison of Nefazodone and Fluoxetine o Mood and on Objective,

Subjective, and Clinician-Rated Measures of Sleep in Depressed Patients: A Double-Blind,

Eight-Week Clinical Trial,” J. Clinical Psychiatry (1997) 58:185.

Sharpley, A.L. et al. “ The Effects of Paroxetine and Nefazodone on Sleep: A Placebo-Controlled

Trial, “ Psychopharmacology (1996) 126:50.

Feiger, A. et al. “Nefazodone Versus Sertraline in Outpatients with Major Depression: Focus on

Efficacy, Tolerability, and Effects on Sexual Function and Satisfaction,” Journal of Clinical

Psychiatry (1996) 57(suppl 2):53.