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Mild Depression:
Medical Illness or Invitation for Self-Growth?
by Lee Lipsenthal, MD, ABHM
Spring 2007 | Holistic Primary Care
 I
am not a psychiatrist, but throughout my career as an internist,
I have managed a number of patients with depression. It has always
proven challenging, not only from a clinical viewpoint, but philosophically
as well.
On the one hand, we have been trained to view depression-especially
severe depression-as a medical condition warranting treatment with
pharmaceuticals. From a different point of view, though, mild to
moderate depression may indicate that a patient's "life systems"
are not working well. In our well-intentioned effort to treat symptoms
with medications, herbs or other interventions, are we missing an
opportunity to help our patients make important life changes and
learn new psychosocial skills? Are we encouraging quick pharmaceutical
fixes at the expense of deeper personal growth?
These questions hit me close to home this past year, when a close
family friend of ours, Alex, was suffering from a fairly deep depression.
Alex is the single father of a six-year-old girl, and he was having
trouble keeping work. The last time I saw him; he was on his couch
with the lights off and had a severe migraine. His entire outlook
on his life was colored by depression.
"I specifically remember thinking for certain that I was just
never meant to simply enjoy life. I assumed that at nearly thirty
years of age, if I had never discovered a way to make things work
for me in a way that made sense, then I was never meant to do so,
and that the universe never intended me to," said Alex. "After
coming out of a long difficult abusive relationship I had felt anger,
extreme loss of motivation, lack of creative desire, unending sadness,
self blame, self pity, and a general over bitterness and distrust
in the world."
If it weren't for a very strong family support system, his mother
living nearby, and his brother living with him, I would have been
extremely concerned for Alex's survival.
At the time, I recommended anti-depressants. My view was that drug
therapy would get him off the couch and re-engaged in life. But
like many patients, Alex refused to take anti-depressants drugs
or herbs. "I had shared with many people about my depression,
and was advised by some to get on some anti-depressants or perhaps
St. John's Wort, just to help get me over the hump. For some reason,
though, I never took anti-depressants nor did I ever feel comfortable
with the idea. Intuitively I had always felt as though they would
only be coating my symptoms and not treating my causes. As dark
and as hopeless as I felt, I still declined the idea of pills."
Ultimately, Alex decided to enter a program called the Hoffman
Quadrinity Process. This is an intensive residential program, aimed
at improving the participants' sense of spirituality and well-being.
It focuses in on patterns of behavior that often develop early in
childhood and are learned by a child as he/she attempts to gain
the love and recognition of his or her parents.
The process guides the participant through multiple techniques,
scenarios and experiences in order to identify, confront, and gain
clarity about these behavior patterns. Through the week-long program,
a participant moves from anger to acceptance to forgiveness around
these core issues. Having done this program myself, I knew that
it was safe and would provide good support for Alex.
The Hoffman method was developed by Robert Hoffman in the late
1960s, based on the idea that healing deeply ingrained negative
behaviors, relationship problems, feelings of worthlessness, and
internalized injurious beliefs requires careful attention to how
learned behavior in childhood affects the four fundamental dimensions
of a human being: the intellectual, emotional, physical and spiritual,
hence the "quadrinity." The method is a carefully structured
program of guided visualizations, journaling work, and controlled
catharsis. The Hoffman Institute has established centers in 13 countries,
and the therapeutic method has been in steady use for 35 years.
The Hoffman Process was the subject of a recent study that showed
it could markedly decrease depression scores, while increasing scores
on measures of spirituality and forgiveness. It was demonstrated,
in a group of 99 participants with mild depression, that these effects
were maintained over one year after completing the 7-day program,
and that the sense of forgiveness and spirituality mediated the
'anti-depression' effect. Additional, sustainable improvements were
also seen in mastery, empathy, emotional intelligence, life satisfaction,
overall health and well-being. What was most interesting to me was
that there was a direct correlation between spiritual well-being
and diminished depression (Levenson MR, et al. Explore: The Journal
of Science & Healing, 2006; 2 (6): 498-508).
A few days ago, I spent the day with Alex, and he certainly seemed
to echo the experiences of the participants in the study. He is
now happy, engaged, ambitious and back 'in life' again. He has started
on a screenwriting project and is simply enjoying his life.
"What occurred for me was nothing like I could have ever imagined.
I was given tools to deal with defects in my being that I had been
experiencing for my entire life. The recent events of my breakup
that had been dragging me down seemed to melt away and I was able
to approach that, and everything else that had really affected me,
with a level of compassion and understanding that I never had before.
Everything in my past that had seemed like a horrible dark curse
blossomed into a beautiful learning experience," said Alex.
"For once in my life, I truly felt free and given a second
chance to enjoy life, not just survive it. The valuable tools I
learned have affected me in all areas of my life. Someone I met
during the process said something that really resonated with my
experience: "I came here looking for a life preserver, what
I found was a ship."
Alex's experience certainly raises a big question: Is it feasible;
that a one-week program that involved no pharmaceutical interventions
could shift someone from a relatively deep depression into a state
of conscious well-being? This definitely goes against conventional
medical thinking about depression as a medical illness, and it raises
another important question for us as holistic physicians: What is
the appropriate treatment for mild to modest depression?
I still believe that anti-depressant drug therapy is reasonable
for those with profound depression. But as a holistic practitioner,
I also believe that this should always be combined with "lifestyle"
therapies that include changes in diet, increased exercise, and
strategies aimed at improving self-esteem and social contact.
We need to bear in mind that while pharmacotherapy can sometimes
be life-saving in severe depression, it can also negate the possibility
of personal growth, especially if the pharmacologic approach is
used without psychotherapy or other introspective work.
Mild-to-moderate depression may be a signal that someone does not
have appropriate psychosocial tools to manage his or her life situations.
This is not something you can fix with drugs, and it is why cognitive
behavioral therapy and other psychotherapeutic approaches to depression
are often highly effective. These therapies help people evaluate
their lives and teach them new tools to cope. Pharmacotherapy can
sometimes end up dis-empowering someone with depression, blocking
the individual's ability to gain a sense of control and self-reliance.
I do not mean to dismiss the important idea that depression has
treatable biological components. But it is equally important to
recognize that the ways we define health and illness are profoundly
influenced by cultural and commercial factors. This point was well-illustrated
in a 2004 New York Times article entitled, Did Antidepressants Depress
Japan? Author Kathryn Schulz points out that before 1999, when pharmaceutical
companies identified a vast potential market, there was no word
for mild to modest depression in the Japanese language.
Japanese doctors, of course, recognized severe depression, which
was typically treated and spoken of as a form of psychosis. But
the condition we label as mild-to moderate depression was viewed
as simply a diminution in life energy, treated with meditation,
self care, or retreat. The problem was not seen as a "disease,"
per se, but a call to self-care and self-growth. This began to change
quickly once drug manufacturers began to market anti-depressants
in Japan. The Japanese now have a term for mild depression: Kokoro
no kaze, which means something along the lines of "Your soul
catching a cold." Like a respiratory infection, one should,
of course, treat these "soul colds" with medicine. With
the 'popularization' of anti-depressant drugs, their use has grown
phenomenally.
Are the Japanese following us down a road toward a society that
overvalues medical "cures" and undervalues self growth
and self awareness? This seems to be the case, and I believe it
would be a very unfortunate outcome.
For profound depression, there is no doubt that pharmacotherapy
is a valid option when combined with appropriate counseling. But
as a holistic physician, I believe that in prescribing an anti-depressant
to an individual with mild to moderate depression that is willing
to do personal work, we may actually be doing harm.
By relying on pharmaceutical fixes, we may inadvertently decrease
an individual's likelihood of spiritual and personal growth. Anti-depressants
should be considered as a 'back-up' or temporizing agent, used in
conjunction with self-evaluative work and talk therapy. After all,
holistic medicine should serve as a bridge towards psycho-spiritual
well-being. Nowhere is the opportunity greater than in the context
of depression.
Lee Lipsenthal, MD, ABHM is Past-President of The American
Board of Holistic Medicine and President of Finding Balance in a
Medical Life. He is also founder and director of the Finding Balance
in a Medical Life program and leads workshops for individual physicians,
their families, their practices as well as large medical IPAs and
hospital systems. For information see HealthClassics.com or call
1-800-769-0638.
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