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"In Part I and Part II of this series, we examined drug-free alternatives to treating depression including exercise, psychotherapy, light therapy, St. John&#8217;s Wort and acupuncture. We have learned that all of these treatments are at least as effective as antidepressants in the short term, and some (exercise and psychotherapy) are more effective in the long-term. All of these treatments have far fewer side effects, risks and complications than antidepressants. In fact, the only &#8220;side effects&#8221; of exercise and psychotherapy are positive ones: improved physiological and mental health!\nToday we will look at other lifestyle-based approaches to treating depression without drugs. As I mentioned in the previous article, because 70% of research is funded by drug companies, many of these non-drug approaches have not been studied as extensively as antidepressant medication.\nNevertheless, there is enough data from clinical and epidemiological studies to support the following strategies &#8211; especially since they are superior to antidepressants from a &#8220;cost/risk &#8211; benefit&#8221; analysis. In other words, though some of the approaches I will propose in this article have not been exhaustively proven according to the standards of Western science, there are several lines of evidence supporting their effectiveness and without exception they have beneficial side effects and improve the quality of patient&#8217;s lives.\nWhat&#8217;s more, all of these approaches can be combined together along with the treatments mentioned in the two previous articles to obtain the maximum effect. Based on the available evidence which we have extensively reviewed, these non-drug treatments should without a doubt be the first line of defense (as well as the second, third, fourth, etc.) in treating depression.\nNutrition\nAt some point in the future, I hope to dedicate an entire post (or perhaps more) to the subject of nutrition and depression. I personally believe that inadequate nutrition is a significant contributing factor to the continuously rising rates of depression in this country. Consequently, I also believe that proper nutrition can be one of the most effective treatments for depression.\nFor now, I will go over what I feel are the most important aspects of nutritional causes and treatment of depression, and hopefully address the subject in more detail later.\nSugar\nDiabetes is correlated with higher rates of depression. In 2005, researchers discovered a positive connection between higher levels of insulin resistance and severity of depressive symptoms in patients with impaired glucose tolerance, before the occurrence of diabetes. Based on these findings, it was suggested that insulin resistance could be the result of an increased release of counter-regulatory hormones linked to depression; however, this has not been confirmed.\nSugar can increase fasting levels of glucose and can cause reactive hypoglycemia. Sugar can also cause a decrease in your insulin sensitivity thereby causing an abnormally high insulin levels and eventually diabetes. Based on the study results above, this is one mechanism by which sugar could contribute to depression.\nThere is no doubt that increased sugar intake leads to hormonal changes that can lead to emotional instability. Therefore, people who are depressed (and all people, in fact) should significantly decrease their sugar consumption.\nOmega-6 : Omega-3 Ratio\nAnthropological evidence suggests that the intake of omega-6 (n-6) and omega-3 (n-3) polyunsaturated fatty acids (PUFA) during the Paleolithic era was roughly equal, whereas the present n-6 to n-3 PUFA in western countries has been estimated to be between 10 and 25 to 1. The n-6 to n-3 PUFA imbalance has been due mainly to the increase in vegetable and seed oil use and the rise in consumption of processed foods (which contain these oils).\nTwo major studies have provided direct evidence for the role of the n-6 to n-3 PUFA ratio in depression. The studies found that depression is associated with significantly decreased total n-3 PUFA and increased n-6 to n-3 PUFA ratio (Maes et al. 1996; Maes et al. 1999) . A supporting study carried out in 1998 also found a significant depletion in total n-3 PUFA, and in particular DHA, in the erythrocyte membranes of depressed patients.\nEpidemiological data show the trend in decreasing dietary n-3 PUFA consumption and the increasing evidence of depression, both over time and between nations (Hibbeln et al. 1995). Further investigation suggests that the significance lies in the increase in n-6 to n-3 ratio, rather than simply low n-3 intake alone, as these two fatty acids compete in binding to enzyme systems that produce chain elongation and further desaturation. A diet high in n-6 fatty acids prevents the incorporation of n-3 PUFA into cell membranes and phospholipids (Spector et al. 1985).\nAll polyunsaturated fatty acids &#8211; including n-3 PUFA &#8211; have been shown to make lipoproteins more vulnerable to oxidative damage (Reaven et al. 1991), and oxidative damage is a significant risk factor for heart disease, cancer and many other conditions. As mentioned above, n-6 consumption actually prevents the incorporation of n-3 into our cells. Therefore, rather than increasing our consumption of n-3 PUFA to treat depression, as is often suggested, it makes more sense to dramatically decrease our consumption of n-6 PUFA. This will help our bodies to incorporate the small, but adequate amount of n-3 PUFA we get in a whole-foods based diet.\nAvoiding n-6 PUFA (primarily found in vegetable and seed oils, and in animals fed vegetables high in n-6 like pigs and chickens) will not only alleviate depression, but also benefit our health in many other ways.\nVitamin D\nIn a 1998 controlled experiment, Australian researchers found that vitamin D (400 and 800 IU), significantly enhanced positive affect when given to healthy individuals. Forty-four subjects were given 400 IU cholecalciferol, 800 IU cholecalciferol, or placebo for 5 days during late winter in a random double-blind study. Results on a self-report measure showed that vitamin D3 enhanced positive affect a full standard deviation and there was some evidence of a reduction in negative affect. The authors concluded: &#8220;vitamin D3 deficiency provides a compelling and parsimonious explanation for seasonal variations in mood&#8221; (Landsdowne &amp; Provost, 1998).\nIn another study in 1999, the vitamin D scientist, Bruce Hollis, teamed up with Michael Gloth and Wasif Alam to find that 100,000 IU of vitamin D given as a one time oral dose improved depression scales better than light therapy in a small group of patients with seasonal affective disorder. All subjects in the vitamin D group improved in all measures and, more importantly, improvement in 25(OH)D levels levels was significantly associated with the degree of improvement (Gloth et al. 1999).\nAccording to the Vitamin D Council:\n\nTo further strengthen the case that vitamin D deficiency causes some cases of depression, evidence should exist that the incidence of depression has increased over the last century. During that time, humans have reduced their sunlight exposure via urbanization (tall buildings and pollution reduce UVB ), industrialization (working inside reduces UVB exposure), cars (glass totally blocks UVB), clothes (even light clothing blocks UVB), sunblock and misguided medical advice to never let sunlight strike you unprotected skin. All these factors contribute to reduce circulating 25(OH)D levels.\nKlerman and Weissman&#8217;s claim that major depression has increased dramatically over the last 80 years is one of the most famous (and controversial) findings in modern psychiatry. Something called recall bias (a type of selective remembering) may explain some of the reported increase, but does it explain it all?\n\nIf you suffer from depression, get your 25(OH)D level checked and, if it is lower than 35 ng/mL (87 nM/L), you are vitamin D deficient and should begin treatment. If you are not depressed, get your 25(OH)D level checked anyway. If it is lower than 35 ng/mL (87 nM/L), you are vitamin D deficient and should begin treatment.\nRecommended intake is up to 5,000 IU per day of vitamin D through exposure to sunshine and/or supplementation. See this article on vitamin D to learn to calculate how much vitamin D is produced given a certain amount of exposure to sunlight, and to learn more about vitamin D supplementation. It is important to remember that D works synergistically with A &amp; K2, so if you increase your intake of D you must also increase your intake of A &amp; K2 to avoid D toxicity.\nFinally, I&#8217;d like to share with you a comment I received from a reader about how he/she has cured depression with nutritional intervention. Note that I endorse just about every suggested step, with the exception of the significant increase in n-3 intake. Based on the evidence above, I suspect that his/her improvement was a result of the decrease in n-6 PUFA more than it was the increase in n-3 PUFA.\n\nI suffered from depression, for many years–it was so bad that often I thought that the only answer for my life would be to end it. Thoughts of suicide danced through my mind frequently.\nEarly March 2008 I changed my diet completely:\n–eliminated all processed foods\n–eliminated all white foods; most important, eliminated sugar, which is the “white devil”\n–eliminated all foods containing soy and corn; so I don’t eat the meat of animals that have been fed grains\n–two years prior to March 2008 I stopped drinking sodas/soft drinks\n–only meats that have been traditionally raised; meat from ruminants that have been grass fed; chickens that have been pastured (I get them with the head and feet); meat from pigs that have not been raised in confinement (I know the people who “produce” the pork that I eat–they feed their pigs food that is in season and local, and they allow their pigs to be pigs, and never slaughter them before their time)\n–eliminated all the bad fats\n–added good fats: coconut oil, palm kernel oil, [raw] butter from grass fed cows, lard (from the pigs described above), beef bone marrow fat (from grass fed and pastured cows), olive oil\n–eat a tin of sardines (with the skin and bones) weekly\n–eat wild Alaskan salmon weekly\n–cut out grains; although, occasionally, I have a jones for those carbs, so I’ll eat some brown rice; sometimes I’ll have a bowl of steel-cut oats, which I have soaked overnight, and when I eat it, I add lots of butter and raw cream to it\n–stopped eating out; I cook all of the meals that I eat\n–only eat raw milk cheeses\n–eggs from hens that have been pastured\n–drink this mixture daily: raw milk, raw cream, 4-6 raw egg yolks, some unsulphured organic blackstrap molasses\n–daily supplements of: cod liver oil, evening primrose oil, wheat germ oil, kelp powder, desiccated liver\n–vegetables and fruit\n–drink only when thirsty\n–stopped wearing sunblock/sunscreen lotions; get out in the sun daily for 20-plus minutes\n–exercise daily; I ride my bike everywhere (I live in San Francisco) or I walk\n\nFollowing the reader&#8217;s advice will not only relieve depression, it will dramatically improve all aspects of your physical, emotional and mental health.\nAdequate sleep and rest\nRecent studies have definitively linked insomnia with depression and increased suicidal behavior. A research abstract that was presented on June 12 at SLEEP 2008, the annual meeting of the Associated Professional Sleep Societies, found a link between poor sleep and suicidal behavior among children and adolescents with depressive episodes.\n83.8% of the depressed patients in the study had sleep disturbances, and there was a significant association between suicidal behavior and the presence of sleep complaints.\nAnother recent study confirmed the persistent nature of insomnia and the increased risk of subsequent depression among individuals with insomnia. According to the study, 17% &#8211; 50% of subjects with insomnia lasting just two weeks or longer developed a major depressive episode reported in a later interview.\nOther research has indicated that insomnia can cause depressed mood and adversely affect endocrine function (Banks 2007).\nMost Americans are chronically sleep deprived. The foundation&#8217;s 2001 national &#8220;Sleep in America&#8221; poll reported that almost seven out of 10 Americans experienced frequent sleep problems, and that most were undiagnosed. The same poll in 2003 found that 67 percent of older adults had frequent sleep problems and only one in eight had been diagnosed.\nThis alone could explain the epidemic increase in depression over the last several decades. But when sleep deprivation is added to other factors such as increased intake of n-6 PUFA, increased stress, the use of antidepressant drugs, the breakdown of family, community and other social support structures, it isn&#8217;t difficult at all to understand why so many of us are depressed.\nThe American Academy of Sleep Medicine (AASM) offers the following tips on how to get a good night&#8217;s sleep:\n\nFollow a consistent bedtime routine.\nEstablish a relaxing setting at bedtime.\nGet a full night&#8217;s sleep every night.\nAvoid foods or drinks that contain caffeine, as well as any medicine that has a stimulant, prior to bedtime.\nKeep computers and TVs out of the bedroom.\nDo not go to bed hungry, but don&#8217;t eat a big meal before bedtime either.\nAvoid any rigorous exercise within six hours of your bedtime.\nMake your bedroom quiet, dark and a little bit cool.\nGet up at the same time every morning.\n\nStress Management\nAn increasing amount of evidence (along with common sense) indicates that chronic stress directly contributes to depression. Please see my recent article for more information about this.\nI am not aware of any well-designed clinical trials examining the effects of stress reduction on depression. However, logic dictates that since stress is a cause of and contributing factor to depression, managing stress is an important aspect of treating depression.\nOne study published in 1995 showed that meditation can improve mood. Another small study demonstrated that mindfulness-based cognitive therapy (MBCT) significantly improved depression and reduced relapse. A series of studies and case studies have shown that biofeedback can also be effective for depression and mood disorders.\nThe reality is that there are many ways to manage and reduce stress, from yoga to meditation to mindfulness-based stress reduction to progressive relaxation techniques. The important thing is not which method you choose, but that you commit to something and do it on a regular basis.\nPrayer &amp; Spiritual Practice\nYou&#8217;re not going to see much scientific research into the role of prayer and spiritual practice in treating depression. Nevertheless, for as long as people have been &#8220;depressed&#8221; they have used their relationship with God, nature, a &#8220;higher power&#8221; or whatever guiding principles they embrace to get through difficult times.\nPeople who are depressed often feel isolated, alienated or alone. A strong faith in God or in the interconnectedness of all life can re-establish a sense of belonging and support. Prayer and spirituality can also re-frame the depression one is experiencing in a larger and less &#8220;personal&#8221; context.\nIn my previous article called The Heart of Depression, we examined how cultural, religious and spiritual beliefs in these traditional societies provide a context in which symptoms of depression and other mental illness can be understood outside of the label of medical disease or pathology. Possession and rites of passage are two examples of such contexts.\nThe words and labels we use to &#8220;frame&#8221; our experience have tremendous power. In the U.S. today, depression is viewed as a sickness that must be cured, as a pathology, as a &#8220;biological disease&#8221;. There is little doubt that the people who seek treatment for depression are suffering. But should psychological and emotional suffering always be viewed as “something to get rid of”?\nGreat religious and spiritual traditions from around the world view suffering as an avenue to greater understanding of oneself, life and God. Suffering can be viewed as a signal drawing our attention to issues in our life that need to be addressed.\nSpirituality and prayer can help people who are suffering to understand their experience in a more empowering and self-validating context than what is offered by mainstream medicine. When one views their suffering as an opportunity for growth and evolution, rather than as a disease requiring treatment with drugs, it is far more likely that lasting, positive change will occur.\nIn the next and final article (for a while, at least) in my series on depression and antidepressants, I will summarize everything we&#8217;ve covered so far and offer my recommendations for treating depression holistically."
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