Positive Health Online

Most of us have watched a relative or friend struggle with depression – and many of us have experienced it ourselves. Even so, few people understand the different roots of depression, the huge impact it can have on our health beyond the common symptoms and the available range of successful complementary treatments.

Roots of Depression

Biological Factors

The underlying causes of depression are not well understood, although there are many clues suggesting various systems in the brain may cause depression or be affected by it. For example, major depression is characterized by excessive sleep. So, it is very likely that the brain stem, which controls sleep, plays a role in depression. Similarly, abnormalities in the cerebral cortex, which controls thinking, probably have something to do with the inability to concentrate and the negative thoughts that can be characteristic of depression.

There is a degree of consensus that imbalances in neurotransmitters seem to play a key role in depression. Research into the way antidepressant medications function has provided the greatest insight in this area. For example, certain medications used to treat depression have been shown to increase amounts of neurotransmitters, such as norepinephrine, dopamine and most widely known serotonin, in the brain. This suggests that a chemical imbalance in the brain causes depressive symptoms. Abnormalities in the neuroendocrine system of the brain also seem to play a role in depression, including abnormalities linked to the thyroid, pituitary and adrenal glands.

Genetic Factors

Individuals with a family history of depression have a greater risk of becoming depressed than the general population. Some researchers believe a 'single depression gene' exists, but there is mounting evidence to suggest that several genes may be responsible for causing depression.

However, research on twins has helped to provide some answers. Kenneth S Kendler and his colleagues at the Medical College of Virginia found in a study of 2,060 female twins that genetics might contribute to how women respond to environ-mental pressures. The researchers examined twins with and without a family history of depression; some twins in both groups had recently undergone a trauma, such as the death of a loved one or a divorce. The investigators found that among the women who did not have a family history of depression, stressful events raised their risk for depression by only 6 percent. But the same risk rose almost 14 percent among the women who did have a family history of depression. In other words, these women had seemingly inherited the propensity to become depressed in the wake of crises.

Social and Environmental Factors

Social and environmental factors also may cause depression, but there are many conflicting scientific studies concerning this issue. For example, some studies suggest that adverse life events, such as divorce, serious illness or multiple episodes of misfortune may cause depression. Other studies have found that no such relationship exists.

However, research into the Seasonal Affective Disorder (SAD) is increasingly showing that there is a link between seasonal changes, in particular the shift in the Northern Hemisphere to winter months and the onset of depression in many sufferers.

SAD is a specific type of major depression, which reoccurs at specific times of the year. The most common pattern is the onset of major depression in September through November and abating of the symptoms in late winter to early spring (March through May). The severity of the symptoms depends on the amount of sunlight received. While as many as 10% of the English population may suffer from SAD, only 2% of Californians do.

Impact of Depression on Health

The symptoms of depression are well documented and a list is seldom exhaustive. The most common symptoms of depression are:

* Change in appetite or weight
* Sleep problems
* Anxiety
* Lack of energy
* Diminishing sex drive
* Memory loss
* Inability to make decisions
* Problems concentrating
* Low self-esteem (feelings of worthlessness or guilt)
* Lack of interest in or enjoyment of activities
* Suicidal thoughts.

However, research is now showing that depression may be far more detrimental to our health than transitory symptoms and that a depressive episode may have a far-reaching impact on sufferers' health in both the long and short term.

The examples below are based on recent research and highlight the manner in which depression can impact on general health other than the well-documented symptoms.

Depression may Predict Back Pain

Each year, 10-15% of adults will have back pain of at least moderate intensity, and 70-85% of all people will have back pain at some time in their lives. Although most patients will recover within 3 months, for those who do not, the recovery process is slow, and their demand on the health-care system is large and costly. Back pain is a cause of substantial disability and absence from work.

Gunner Andersson highlights various cross-sectional studies that indicate an association between psychological factors and the occurrence of low-back pain. These factors include anxiety and depression and connected problems such as stressful responsibility, job dissatisfaction, mental stress at work, negative body image, weakness in ego functioning, and a lack of motivation. In some studies, various symptoms that indicate psychological distress predicted the development of back disorders among people who did not have previous back pain. The recurrence rate of low-back pain is so high that it seems to be part of its natural history. Lifetime recurrences of up to 85% were reported in some studies.[1]

Depression may be a Sign of Cardiovascular Disease

Research has shown that men who become depressed for the first time may be at risk for heart disease.

Brenda WJH Penninx and colleagues, National Institute on Ageing, Bethesda MD conducted a study of 3,701 men and women aged 70 and older.

The results indicated that older men, but not women, who became depressed for the first time had about double the risk of developing heart disease over five years compared with those who had never been depressed.

Previously, research by Sesso et al has demonstrated that psychological stress affects heart rate and blood pressure, increasing the risk of heart attack.[2]

Depression and Mortality in Women

Research has also demonstrated that depression is a significant risk factor for death from cardiovascular and noncancer, noncardiovascular diseases but not cancer, in older women.

Researchers from California conducted a propsective cohort study of some 7,500 women age 67 or older. Follow-up was for an average of six years.

Mortality during the 7-year follow-up ranged from 7% for women with no depressive symptoms, to 17% for women with three to five symptoms, and 24% for women with six or more symptoms, who had a 2-fold increased risk of death.

The association between depression and women's risk of death was strong for many diseases, most particularly from cardiovascular disease.[3]

Depression and Physical Decline

Research has indicated that depressed elderly people are less physically active. However, whether depression triggers physical decline in the elderly has until recently been unclear.

Dr Brenda WJH Penninx of the National Institute on Ageing in Bethesda MD and colleagues conducted a study with 1,300 elderly people aged 71 and older for four years to evaluate the relationship between depression and physical functioning. At the start, more than 10 percent of the group exhibited signs of depression.

Researchers found that over four years, symptoms of depression in elderly people resulted in a 55% greater decline in physical performance. Decreased levels of performance were most pronounced in those with severe symptoms of depression; however, similar effects were also observed in less severely depressed elderly people.

The greatest decline in performance was significantly greater for the oldest, less educated, unmarried people and those with coronary heart and lung diseases.

While much remains to be learned about depression and physical decline, Penninx and her colleagues emphasize that "prevention and treatment of depressive symptoms may be one of the most effective targets for interventions aimed at reducing physical decline and increasing number of years during which older people are free of disability."[3]

Depression and Perception of Pain

Researchers at the University of Connecticut Health Centre in Farmington analysed the medical records of 203 middle-aged people with Rheumatoid Arthritis (RA). Those with no history of depression or current mood problems had an average pain score of 40 on a scale of 100. However, those with a history of depression or who were experiencing current depressive symptoms had an average pain score of 62, significantly higher. Those with current symptoms of depression but no prior history of major depression had a score of 52. These results support the hypothesis proposed by some researchers that past or current depression 'primes' RA sufferers to experience greater pain.

The researchers urge physicians to be sensitive to the fact that people with depression may experience greater pain problems than others. They also say that doctors evaluating pain conditions should ask about current or past depression.[4]

Depression and Impotence

Researchers at the Massachusetts Male Ageing Study investigating mood and erection, found impairment in 1,709 enrolees (age 40-70, 71 percent high school graduates, 78 percent employed, 75 percent married). Participants were given a standard psychological test to gauge depression and were then surveyed regarding their health and well being. Those whose tests revealed depression were 82 percent more likely than those with normal mood to report impotence. The authors suggest that impotent men be evaluated for depression.[5]

Complementary Treatments for Depression

Complementary medicine and in particular the use of herbal remedies has been spearheaded by the clinical acceptance of St John's Wort for the treatment of depression. However St John's Wort is only one of several herbal remedies available and there are several other treatments, which have been found to be highly successful.

The Herbs

St John's Wort (Hypericum perforatum)

St John's Wort has now been licensed as a medicine in both Europe and the US. In both Germany and England it is more heavily prescribed than Prozac. In clinical trials it has been shown to be as effective as Prozac and many other anti-depressants and often to have less side effects (see also Research Updates, page 49).

A major recent study shows that St John's Wort is an effective antidepressant. 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% reported mood elevation. Among those who used St John's Wort, the figure was 55%, a highly significant difference. Among those who responded to St John's Wort, the relief obtained was similar to that experienced from pharmaceutical antidepressants.[6]

Ginkgo Biloba

Ginkgo helps to improves circulation in the brain. It is used in the recovery of stroke victims and as an aide to improve the mental faculties in elderly people. By virtue of its ability to normalize neurotransmitter levels, it can also help to treat depression. One research trial studied 40 elderly people suffering both from depression and poor cerebral blood flow. Following a trial period of several months of taking 80 mg of ginkgo extract three times a day, their depression lifted and measures of their mental acuity improved significantly.[7]

Kava Kava (Piper Methysticum)

Kava Kava was first discovered by Captain James Cook during his voyage into the Pacific in 1768. Native to the South Pacific, a beverage made from the rootstock of the plant has been used for centuries in ceremonies and celebrations because of its calming effect and ability to promote sociability. The Kava beverage is still used today by inhabitants of the island communities of the Pacific including Micronesia, Melanesia, and Polynesia.

Its main use is as an anti-anxiety remedy. Anxiety is one of the more serious symptoms of depression and recent research has shown that depressed patients who also suffer from anxiety will suffer from depression for longer and have a higher chance of recurrence.

Ginkgo Biloba

St John's Wort

Kava Kava

Further Information on Depression

Planet Rx – has put together an outstanding internet website, which contains a goldmine of research, clinical treatments, and a multitude of topics related to depression, both for sufferers and their carers.[8] See also WebWatch on page 8.

Other therapies

Exercise

Exercise helps treat depression by helping the body to control three chemicals in the body which effect depression. It releases endorphins, the body's own mood elevating, pain-relieving compounds. It reduces levels of the stress-depression hormone, cortisol, in the blood and it increases levels of serotonin.

Many studies demonstrate that exercise helps treat depression. One of the largest was carried out by the University of California-Berkeley School of Public Health. Researchers had been periodically assessing the health, mental health, and lifestyle of 6,000 residents of the San Francisco Bay Area since 1965. The ongoing survey clearly showed a strong association between a sedentary lifestyle and depression, and an equally strong association between becoming physically active and relief from depression.

More specifically, the 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.[9]

Acupuncture

Acupuncture has been endorsed as a treatment for depression by the United Nations World Health Organisation. John J Allen, Ph.D., assistant professor of psychology at University of Arizona, studied 34 women diagnosed with major depression who were not taking antidepressant medication. One-third met with the researchers but received no acupuncture; the second received acupuncture, but not on points recommended for treating depression (sham points). The third received acupuncture on genuine depression acupoints. Compared with the two control groups, the women receiving acupuncture on the depression points showed significantly greater mood elevation.[10]

Colour Puncture

This is a new treatment being offered in some clinics in Britain based on a practice perfected by the ancient Egyptians and based on surviving ancient Egyptian texts. It works on the principle that if the body lacks light it can cause health imbalances. Colour puncture puts light back into the body after diagnosing the type of light which is missing. Practitioners advocate that light has a direct effect on the pineal gland.

Colour puncture uses a powerful beam torch with different coloured graphite lenses. The focused high intensity light is shone directly onto acupuncture and other recorded points. There are different sequences, which work combining seven different colours, for different effects. Patients have reported leaving in mid-winter with the feeling that it is a sunny day.[11]

Cosmo Light

The Cosmolight is a new device that boosts immune systems and elevates mood through a pulsing light wave, which penetrates the skin by 3-7cm. At the end of the treatment, the Cosmolight light panels are placed on the soles of the feet. Here the light waves work on the reflexology points to speed up the blood flow through the body.

Dr Yubraj Sharma, a medically qualified private homoeopath in London says: 'This machine is its early stages and although its not the be all and end all to light therapy healing, it is certainly the most scientifically advanced method to date. The machine works by using quite intricate scientific principles which stimulate certain reflexes that can, among other things, help with depression and boost the immune system'.[12]

Conclusion

Depression is a debilitating illness affecting a significant proportion of the population. The most worrying trend is its effect on physical health beyond the usually cited symptoms. However, there are many gentle and effective complementary treatments available to sufferers, which have helped thousands deal with this illness.

Case Study

Miss S is a 45-year-old saleswoman from Manchester. She was very active and successful before a car ran her down at Christmas1997 and shattered her life. Her body mended quicker than her mind and emotions.

She was a very fit woman who wouldn't go on a holiday without packing her trekking boots. She had been on walking holidays to Canada, Spain, and France and had previously walked around the whole coastline of the UK.

At the beginning of December 1997 her job was going well with the housing boom. She had recently moved in with her boyfriend of 3 months and she was enjoying a good social life.

However, in mid December 1997, she was a pedestrian hit by a car as she crossed the road. The impact damaged her right knee and she cartwheeled 11 metres before landing on her face. She received 40 stitches in her nose alone. By the end of 1998 she had attended 71 hospital appointments.

She was unable to pursue her hobby of walking as her right knee had been too severely damaged. Her job in sales required a sunny disposition. But she was deeply depressed by this time. She would fall apart for the slightest reason and her work colleagues began to find the sight of Claire crying normal. Her relationship with her boyfriend broke up a few months later as he was unable to deal with the effects the accident had had on her.

During 1999 she began to feel an improvement in her physical condition. Her knee was getting better and her shoulder and neck no longer felt as stiff or twitched as much. But she was still depressed. Her doctor prescribed her anti-depressants, but after 3 months she had noticed no improvement. During the day she would lack energy or enthusiasm and felt tired all the time. But at night she would be unable to sleep. She suffered from nightmares about the accident, reliving the accident in her sleep. Her weight suffered as well. She was still swinging between binge eating, where she would consume as much food as she could, to a near starvation diet. Claire estimates that she had put on over 1/2 stone during her depression.

Then while shopping for multivitamins in a local health food store, she was told about St John's Wort and Kava-Kava. On the shopkeeper's advice she consulted a doctor who gave her permission to take these herbal medicines with her existing medication. After a week she felt calmer, was sleeping better, eating better, felt more energy and the best she had felt since the accident. After a few weeks she stopped taking her prescribed drugs, and relied solely on the herbal supplements.

She now feels a huge improvement. Her work is better. She is looking forward to walking holidays, and fully rebuilding her life after the accident.

References and Notes

1. Andersson GBJ. Lancet 354: 581. Aug 1999. For further information the author of the report Gunner B J Andersson, can be contacted at Department of Orthopaedic Surgery, Rush-Presbyterian-St Luke's Medical Centre, Chicago, IL 60612, USA. Tel +312 942 4867; Fax +312 942 2101.
2. Sesso HD, Kawachi I, Pantel S, Vokonas, Sparrow S. Depression and the risk of coronary heart disease in the normative aging study. The American Journal of Cardiology 82(7): 851-856. 1998.
3. Whooley MA et al. Association between depressive symptoms and mortality in older women. Archives of Internal Medicine 158: 2129-2135. 1998.
Penninx BWJH, Guralnick JM, Ferucci L, Simonsick EM, Deeg DJH and Wallace RB. Depressive symptoms and physical decline in community-dwelling older persons. JAMA 279: 1720-1726. 1998.
4. Fifield J. Past Depression Impacts Rheumatoid Arthritis Pain. Arthritis & Rheumatism 41(10). 1998.
5. Araujo AB, Durante R, Feldman HA, Goldstein I, McKinlay JB. The Relationship Between Depressive Symptoms and Male Erectile Dysfunction: Cross-Sectional Results From the Massachusetts Male Aging Study. Psychosomatic Medicine 60: 458. 1998.
6. Linde, K. et al. St. John's Wort for Depression: A Meta-Analysis of Randomized Clinical Trials. British Medical Journal 313: 253. 1996,
7. Castleman M. The Healing Herbs. Bantam Books. 1995.
8. www.depression.com – the website by Planet Rx, is an excellent source of information about many facets of depression.
9. Nicoloff G. and Schwenk TL. Using Exercise to Ward Off Depression. The Physician and Sportsmedicine 9: 44-56. 1995.
10. Steefel L. Treating Depression. Alternative and Complementary Therapies 1: 1-4. 1996.
11. The Feel Good Factory in Clapham offers colour acupuncture by trained practitioners. Tel: 020-7350 1600.
12. Treatments cost from approximately £35 for a 40-minute session. For details of nearest Cosmolight clinic telephone 020-7607 7475.

Advice from the Medicines Control Agency

St John's Wort may interact with certain medicines. If you are taking prescription medicines, it is important to always tell your pharmacist or doctor about any herbal remedy you are taking. Further information: call NHS Direct 0845 4647.