By the most recent estimates, as many as one in 10 Americans are taking antidepressant medication. Some experts say this pill-popping explosion is a sign that people are getting the help they need to fight a condition that can be debilitating and even deadly.
But others say that what many depressed people need is not drugs, but help changing their lives.
Clinical psychologist, professor and researcher Stephen Ilardi, author of The Depression Cure, The 6-Step Program to Beat Depression Without Drugs (Da Capo Press, 2009), is squarely in the second camp.
Ilardi says his research has convinced him that for most people, depression is a lifestyle illness. Making six specific changes, he says, can help most patients improve or recover completely. And because he's calling for better nutrition, more activity, sleep and positive thinking, it's an overall good-health regimen.
Not, he hastens to add, that this is a simple matter. Overhauling your lifestyle while in the midst of depression may require professional assistance. And, he cautions, nobody should abruptly stop any prescription medications without their physicians' knowledge.
But his message should encourage the many people who have tried multiple types of antidepressants without success.
"People often think they have to swallow a pill and ingest chemicals. The idea of my research was that we really need to do better," said Ilardi, who recently spoke to the Times from his home in Lawrence, Kan., where he is a professor of psychology and a clinical researcher at the University of Kansas.
How did you become interested in finding an alternative for patients?
I was trained in traditional psychotherapy, what's known as cognitive behavioral therapy or CBT, the most widely used form of psychological treatment. It's not bad. It's generally regarded as helpful for about half of patients with depression. Which is about as effective as antidepressants are.
In both cases, complete remission, meaning elimination of all major symptoms, is less common. Over my clinical research career, over two decades, I became increasingly concerned that for most depressive patients, traditional treatment doesn't lead to complete and lasting recovery. I wrote the book after three years of rigorous work to develop a lifestyle-based treatment for depression.
What does lifestyle have to do with depression?
There's a whole class of diseases that are regarded as diseases of lifestyle, of modernity, like obesity, diabetes, high blood pressure, allergies, asthma, it's a very long list. The interesting thing is these diseases rarely affect Aboriginal groups and are uncommon in people who live a more traditional agrarian lifestyle, a more 17th century lifestyle.
I was intrigued by capitalizing on the antidepressant elements of their lifestyle — the antidepressant habits that used to protect our ancestors, that were built into the fabric of their lives. How could we help people reclaim these things? Things that are now known to produce profound positive effects on neurochemistry like physical activity, bright light, healthy sleep, social support and not sitting around, brooding on negative thoughts.
Was it easy to develop the program once you identified the factors to focus on?
Identifying the lifestyle elements was easy. There's a lot of documentation on the effects of bright light and exercise and omega-3 fats and vitamin D and social support on the brain. The challenge was how do we develop a program that is doable for someone who is depressed, someone with low energy, whose ability to act on this program is low. How could we help them in the throes of illness?
Inertia is common in depression. So how can a self-help program ever work for someone who is depressed?
That was a big challenge. We knew it was important not to overwhelm them by asking too much all at once. There's research on the notion that we all have a limited reservoir of willpower. Once something new becomes a habit it's sustainable, but to pick up a new good habit, it takes willpower. We also know we can change one or two things at a time. So, one of the principles of the program is its simplicity: Focus on one thing at a time and then build on some easy things to give patients a sense of momentum and confidence.
What do you start with?
In week one, we ask them to make a change that takes about 20 seconds — take 1,000 mg of EPA omega-3 every day. It's easier to ask them to take a supplement than to ask someone to change their whole diet and eat three servings of fatty cold-water fish a day. It gets expensive, it's boring and it takes a lot of effort.
What about week two?
We focus on something most depressed people do, which is brooding on negative thoughts. It's toxic psychologically. It doesn't take a lot of effort to redirect attention, to interrupt the process of rumination.
Depression pushes our attention and our thinking in a negative direction. They rehearse negative thoughts, spinning them around and around, often for hours a day. As they do that, it intensifies their negative mood, revs up the brain-stress circuitry, which is the driver of clinical depression. We want to put the brakes on that runaway stress response and the bodies' reaction to it.
Is this a do-it-yourself project?
I try to make it clear in the book that many people will need professional help in implementing the program. Why? Because depression affects the brain in a sinister way, robbing us of our ability to translate our intentions into actions. Many readers have taken the book to their therapists and said, 'I want you to help me with this.' Practicing clinicians say to me, 'A patient put me on to this book and I'm finding it helpful in my practice.' That was a pleasant surprise.
Where do you stand on the use of antidepressants?
I'm not philosophically opposed to antidepressant medications. But they may be only slightly more effective than sugar pills. It's only in the most severely depressed patients that they outperform placebo. We're talking about people who can't function, those who can't get out of bed or manage personal grooming. That's a small subset of patients, about 10 to 15 percent.
But (antidepressant medications) clearly have not solved our depression epidemic. In the last two decades, depression has increased and antidepressant use has increased but hasn't made a dent in the depression epidemic.
What if someone is taking antidepressants and wants to give your program a try?
My approach is always to say let's get these lifestyle changes in place before considering any other change, like stopping antidepressants. If a patient wants to go off meds, they must consult with their prescribing physician.
What do you most want people to know about depression?
It is so misunderstood, partly because we use the word colloquially to refer to sadness, while clinicians use the word as shorthand for a debilitating illness. Someone will say, 'So you're sad, come on, I'll help you snap out of it.' That may be well intentioned but it's inadvertently cruel. Because for the sufferer, they are in agony. The disorder lights up the brain's pain circuits and the depressed person feels like, 'Don't you think I would snap out of it if I could?' Others will internalize it and think, 'It must be my fault. I must be really lazy for not doing things that could help me.'
You are part of an epidemic. It's not your fault. It's a mismatch between your ancient genes and your 21st century environment. Yet there are things you can do to make it better.
Irene Maher can be reached at firstname.lastname@example.org.