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Roads Less Traveled Out of the Dark

Complementary and alternative therapies treating depression are being widely integrated with traditional Western treatment, most commonly in the “cognitive feedback” category. This article discusses current and prospective CAM modalities for treating depression and other psychiatric disorders.

Synopsis

  • This research focuses on CAM integration into traditional Western treatment of depression (particularly psychiatry) in the United States and available CAM treatments.
  • Discussion of how diagnosed need for psychotropic drugs reduces likelihood of patient exposure to CAM therapy is also explored.


Introduction

The World Health Organization defines depression as a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. Complementary and Alternative Medicine (CAM) offers forms of cognitive feedback, oral medication and therapy to treat depression, with new forms continually emerging and evolving.

Emerging Complementary/Alternative Treatment of Depression

In recent years, CAM has become an increasingly popular, promising and practical medical field and form of treatment in the United States. Natural products, mind/body practices, and manipulative and body-based practices have become familiar methods in healing and preventing short-term and chronic illness. Common perceptions of CAM benefits range from strengthened immune system to muscle relaxation to chronic pain reduction. However, less is known about CAM in regard to mental/emotional wellbeing. Therefore, my research’s overall focus addresses how CAM is being integrated into traditional Western treatment of depression in America. Specifically, I wish to explore how and why a diagnosed need for psychotropic drugs affects the likelihood of receiving CAM treatment.

Beyond my own personal fascination with this research question, insight into the topic is relevant for several distinct groups: individuals suffering from dysthymia or major depressive disorder (MDD), the CAM community, mental health specialists, and the larger health-care community in the United States. For individuals suffering from depression, an analysis of CAM integration in mood disorder treatment provides an opportunity be become educated and proactive in personal treatment selection. Such patient participation can help avoid unwanted stagnation of healing, particularly for individuals taking antidepressants or other psychotropic drugs. For the CAM community, the successful integration of CAM depression treatments into mainstream U.S. psychological services—and the struggle to integrate CAM into psychiatric pharmacology—are areas in need of more reliable and abundant empirical data. Answers to this research question could likewise demonstrate to mental health specialists a weakness in services which achieve patient healing effectively long-term. Finally, this research is relevant to the larger health-care community as a potentially significant influence on depression treatment in relation to the influence the mood disorder has on overall health and wellness.

Literature Review

In the past, U.S. depression treatment generally combined anti-depressant mediation with psychotherapy (generally some form of verbal interaction with a psychologist/therapist attempting to recognize and alter negative thoughts). However scholars have evidence that, in the new millennium, CAM therapies are used more than conventional therapies by people with self-defined severe depression [3]. Research published in the American Journal of Psychiatry analyzed a nationally representative survey, which obtained information on the use of 24 complementary and alternative therapies used for the treatment of severe depression and anxiety. The survey found that 53.6 percent of respondents with severe depression used some form of CAM therapy. Yet the substantially lower percentage of CAM “oral medication” users compared to psychiatrist users (mental health professionals capable of writing anti-depressant prescriptions) in the survey led me to infer that a substantial portion of complementary and alternative therapy users still are advised by psychiatrists to take conventional anti-depressant medication as opposed to CAM equivalents.

Considering this possible relationship, the research question then turns to how and why a diagnosed need for psychotropic drugs affects the likelihood of receiving CAM treatment. Linde’s review specifically of St John’s wort concludes, “Current evidence regarding Hypericum extracts is inconsistent and confusing. [4]” Yet a similar review by Josey concludes, “Based upon limited studies, St. John’s wort appears to be an acceptable alternative to traditional antidepressant therapy. [2]”It thus becomes possible to conclude that one way a diagnosed need for psychotropic drugs affects the likelihood of CAM treatment is the psychiatric community’s unfamiliarity with these CAM medicines still in their infancy. The mainstream psychiatric and scholarly communities in the U.S. have not seen enough studies and/or evidence to prescribe CAM medications with the same comfort and confidence they do prescribing traditional antidepressants.

A second possible explanation of why a diagnosed need for psychotropic drugs affects the likelihood of CAM treatment can be found in Pritzker’s Metaphors of Depression. Pritzker writes, “The stigma associated with mental illness is alleviated by the notion, even in the psychologized West, that it is not your fault if ‘a problem is responsive to chemicals’ [7], while a problem responsive to psychotherapeutic dialogue is ‘a problem you should be able to overcome with simple rigor [7]’. The implication here is that when depression is seen as a solely chemically-based illness category, evidenced by response to treatment with antidepressants, it makes it somehow ‘okay’ to be depressed. [6]. As I will discuss more fully below, I argue that the need for antidepressants is viewed as a last resort—i.e. depression as a purely or primarily chemical problem unable to be managed or cured by therapy—not only by those diagnosed with MDD, but perpetuated by mental health professionals who prescribe patients psychotropic drugs for months or years on end without suggesting any complementary therapy.

Research Methods

My primary research for this article comes from an audio-recorded interview with S.D. (pseud.), the Director of the UCLA Counseling and Psychological Services (CAPS) which is the primary mental health center for UCLA students. The center provides individual and urgent counseling, psychiatry, therapy groups, and wellness skills programs. Our interview focused on the integration of CAM therapies to varying degrees within CAPS. The interview with S.D., aided by my background knowledge of the center, provided insights into the integration of CAM and Western psychological treatment, as well asexposed key areas where the center still struggles to do so.

Perhaps a hybrid between participant-observation and autoethnography, my own personal experience with MDD treatment at CAPS (particularly in psychiatry and individual counseling) has provided me with a fair amount of prior knowledge of the center’s handling of students with mood disorders; it has given me first-hand experience in the process of therapeutic and medicinal treatment at the center.

Welcoming CAM into CAPS

Several times throughout the course of our interview S.D. expressed that in the past decade, CAPS has consciously built a center with a spectrum of psychological services and treatment ideologies ranging from biomedical approaches to holistic approaches. “We want to offer a tailored approach to students,” S.D. said. “So if they are more comfortable with a traditional Western approach, we can provide that for them. If they are looking for more holistic-oriented treatment, we can now offer that as well.”

Traditional psychotherapy—the prominent treatment for depression for the better part of the 20th century, according to S.D.—focuses primarily on analysis of the thoughts and problems at hand. In order to offer an alternative therapy method, CAPS has integrated programs which emphasize the prominent CAM concepts of long-term wellness and prevention. One treatment method that frequently engages these concepts is the CAPS Therapy Group program. These small groups—on average 8 students and 2 counselors—engage holism, namely the mind-body-spirit connection, to promote prevention of emotional distress and long-term emotional wellness in the lives of students. Examples include “Cognitive Therapy for Insomnia,” “Breaking Free From Anxiety,” and “Being in the Moment: Mindful Awareness.” Another medium for this holistic-style therapy is the center’s Wellness Skills Program. This program similarly promotes a holistic mind-body-spirit connection, but places even greater emphasis on what S.D. called, “mindfulness and acceptance.” Examples include “Mindful Pathways to Wellness,” and “Biofeedback Training.”

The incorporation of these self-help groups and lifestyle intervention programs at CAPS positively correspond with the survey analysis discussed above, which shows “cognitive feedback” (including self-help groups) and “other therapies” (including lifestyle intervention programs) as the most commonly practiced complementary and alternative therapy forms by depression patients. Hence, the CAPS center’s incorporation of CAM therapies for depression seems to demonstrate the larger U.S. integration pattern.

However, S.D. made it clear that the integration has left psychiatry virtually untouched. Speaking about the holistic emphasis on mindfulness and acceptance noted above, S.D. went on to say, “Now, this is not so true for psychiatry. Psychiatry in the one area that has not changed much.” When asked why she thought this was the case, S.D. responded, “It reflects evidence of what is going on nation-wide. All of our psychiatrists at the Wooden West Center (the building where CAPS in located) have been trained in Western psychiatric practice. Alternative medicine just hasn’t infiltrated psychiatry yet.” S.D. seemed to imply, as discussed above, that the psychiatric community’s lack of familiarity with CAM medicines is due to lack of studies and/or concrete evidence of their effectiveness, and consequentially their lack of prominence in psychiatric use.

I would argue that emerging CAM-inspired depression therapy promoting long-term health and wellness (influenced by concepts of holistic mind-body-soul and mindfulness) and traditional psychiatry (perceived as a short-term chemical fix) are leading to a dichotomy in which a patient is either believed capable of healing and making lifestyle adjustments to prevent future depression periods without psychotropic drugs, or they are incapable of this and therefore require medicinal assistance as a last resort.

Cutting Cattle — Determination of medicinal need and the subsequent decrease in likelihood of CAM treatment

As opposed to the common 20th century view that the short-term combination of psychotherapy and psychotropic drugs was the most effective way to “cure” depression, modern ideology in the U.S. seems to be moving toward the belief that if you are prescribed antidepressants, then you need them chemically in order to not be depressed [6]. Pritzker seems to be referencing common social views of psychotropic drugs, and my research and personal experience has led me towards the conclusion that, based on the way many psychiatrists determine medicinal need, this may be the case. S.D. explained that, “medicine is a last resort. Two-thirds of students coming here seeking help for depression don’t take medication.”

S.D. continued to explain the process as a narrowing-down of students in need of medication and those who do not. This is done by analysis of distress and severity of traumatic experiences, then an attempt to find deeper meaning and peace within the situation. If this progress is unable to be made, medication becomes a viable option. Once students have been prescribed antidepressants or other related medications, this mode of treatment can easily continue for months or years on end with no form of complementary therapy ever utilized, as psychiatrists would not want to threaten taking away a student’s medication because he or she didn’t have time or did not wish to engage in therapy.

Finally, there is the kind of student who arrives at UCLA having already been prescribed antidepressants before college. Because of my background, I was skipped to the front of the medication line. Interestingly, I did not request to be placed back on medication. I simply met with a psychiatrist, told her about the anxiety I was experiencing as a freshman at UCLA, and was told it would be good for me to continue taking the same brand and dosage of antidepressant I had previously taken. I was never expected to attend or informed of the CAM-oriented group therapy programs being offered to non-medicated students. Nor was I expected to attend individual therapy appointments: just my monthly psychiatry appointments.

After speaking to S.D., I learned that I was not alone. In fact, S.D. stated that, “If they’re already prescribed, we’ll facilitate.” And while this may be a completely acceptable and common psychiatric procedure, the distribution of psychotropic drugs without any requirement, or even encouragement, to complement the chemical component with therapeutic components seems to suggest that some psychiatrists clearly accept long-term antidepressant use as an acceptable, necessary and emotionally stabilizing treatment for depression. But because of the simple chemical remedy along with the lack of  expectations for student proactivity, the message of “this is as good as it’s going to get,” and “your depression isn’t going anywhere, so we will mask it,” is signaled. Hence, likelihood of exposure to CAM-oriented therapy at this point is even less likely than it was for students who began medication in college due to a complete lack of expectation to engage in it after receiving medication.

Conclusion

Through this work, I have attempted to trace CAM integration into U.S. treatment of depression at one site.  I have tried to shed light on the inverse correlation between psychotropic drug usage and likelihood of CAM treatment due to the increasingly popular view that taking medicine for depression means one is simply chemically lacking.

It is necessary to acknowledge that analysis of one psychological services center can only provide a finite amount of information and evidence when drawing broad conclusions about nationwide psychological services. However, it is equally important to note that the transparent nature of CAPS as a leading public university entity, and as a service provider to young adults (many of whom are dependents of concerned and observant parents), the psychological services provided here are very unlikely to be particularly radical or controversial. For this reason—along with the reviewed literature and information provided by the Director or CAPS—the findings noted above should substantiate the broader implications argued throughout this work. In review, these arguments were:

  • Complementary and alternative therapies treating depression are being widely integrated with traditional Western treatment, most commonly in the “cognitive feedback” category. These include relaxation techniques, imagery, self-help groups, hypnosis and biofeedback.
  • The integration of complementary and alternative medicine into psychiatry in the U.S. has been generally unsuccessful due to insufficient studies and/or evidence of its effectiveness. Consequently, these CAM medicinal alternatives have not been able to compete with familiar psychotropic drugs in the psychiatric community.
  • Once prescribed psychotropic drugs, there is a general perception that the patient needs the drugs, exasperated both by social and psychiatric norms, results in belief by both patient and psychiatrist that continued therapeutic treatment is not vital, because it won’t make a chemical difference.
  • Over time, expectation and encouragement to participate in therapy continually diminishes. Therefore, the earlier one is prescribed psychotropic drugs, the less likely they are to be involved with CAM therapy.

The ongoing testing and review of CAM modalities for treating major depression is a crucial future inquiry. It appears from recently published academic articles that the tide is finally turning in legitimizing the benefits of these medications, particularly St John’s wort. I would assume, then, that the next few years will be vital in substantiating the image of complementary and alternative medicine’s effective treatment of depression.

by Melissa L. Martin

NOTE: This article was written originally as a paper for the UCLA upper division anthropology course Perspectives on Complementary/Alternative & Integrative Medicine, taught by Dr. Sonya Pritzker.  More information on the course can be found here.

 

References

  1. Freeman, MP. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force report. J Clin Psychiatry, pp. 669-81; 2010.
  2. Josey, ES, Tackett RL. St. John’s wort : A new alternative for depression? International Journal of Clinical Pharmacology and Therapeutics, Volume 37, No. 3, pp. 111-19; 1999.
  3. Kessler, RC. The Use of Cmplementary and Alternative Therapies to Treat Anxiety and Depression in the United States. Am J Psychiatry, pp. 289-94; 2001.
  4. Linde, K. St John’s wort for depression: Meta-analysis of randomised controlled trials. The British Journal of Psychiatry, pp. 99-107; 2005.
  5. “Mental Health: Depression.” World Health Organization. 2011. Web. 07 Dec. 2011. <http://www.who.int/mental_health/management/depression/definition/en/>.
  6. Pritzker, SE. The Role of Metaphor in Culture, Consciousness, and Medicine: A preliminary inquiry into the metaphors of depression in Chinese and Western medical and common languages.  Clinical Acupuncture & Oriental Medicine, Volume 4, No. 1, pp. 11-28; 2003.
  7. Solomon, A.  The noonday demon: An atlas of depression.  New York: Scribner; 2001.

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