What Should We Be Doing to Improve Treatment Outcomes for Depression?

Estimates of the prevalence of depression can vary, but it seems that approximately 20% of people will experience a depressive episode sometime in their life. This rate refers to a diagnosed DSM-5 depressive episode [1]. However, not everyone will meet the criteria for a major depressive disorder, so when we consider bouts of significant sadness and reduced pleasure from daily activities, this rate will rise substantially. From a psychological, lifestyle, biological, and environmental perspective, there are multiple causes or contributors to depression. Some of these are listed below:

• Psychological: unhelpful thinking patterns and belief systems, exposure to current/ past trauma
• Biological: genetic predispositions and polymorphisms, comorbid medical disorders, disturbances in the microbiome/ gut bacteria
• Diet and nutrition: unhealthy diet and eating patterns, nutritional imbalances, food allergies and intolerances
• Lifestyle and environment: poor sleep patterns, physical inactivity, exposure to environmental toxins, limited exposure to nature, inappropriate light exposure
• Social and spiritual: lack of social support, increased social strain, lack of meaning/ purpose

As the causes of depression are multifactorial, it can make the treatment of this disorder complex. Only minor improvements may occur if we incorporate a simple change that only targets one cause but neglects to target other factors that might impact one’s mood. For example, suppose a person treats their depression with only psychological therapy (e.g., cognitive behaviour therapy or CBT) that helps change unhelpful thinking patterns but fails to make changes in other potential drivers of their low mood such as an unhealthy diet, nutritional imbalances, comorbid medical conditions, poor sleep, and physical inactivity. In that case, only moderate improvement in their mood may occur. Research continually shows that CBT is an effective treatment for depression; however, for many people utilising this treatment, depressive symptoms remain. In fact, only 40 to 50% of people experience full symptom resolution after CBT [2]. These remission rates are similar to the widely popular pharmaceutical antidepressants. Dissapointly, despite the significant amount of resources allocated to pharmacological and psychological research for depression, treatment outcomes are not getting much better. In one review paper, it was demonstrated that the efficacy of CBT is worsening over time [3].

I would argue that a reason why our treatment outcomes are not getting better is that we continue to search for a single solution (or magic bullet) for the treatment of depression. As shown in the figure below, from a biological perspective, there are multiple physiological disturbances in depression. Because of this, a single solution is unlikely to normalise all these biological disturbances. We know that neurotransmitter activity, inflammation, oxidative stress, mitochondrial activity, and our stress response are influenced by the psychological, lifestyle, environmental, social, medical, and dietary factors I listed earlier. To lower inflammation, we must eat ‘anti-inflammatory’ foods, reduce/ manage life stressors, improve sleep, improve gut health, and engage in moderate physical activity. I have also completed several clinical trials on anti-inflammatory ingredients such as saffron, curcumin, probiotics, and ashwagandha, which have been demonstrated to help improve mood. Interestingly, many of these ingredients and other plants and nutrients help lower inflammation, oxidative stress, normalise our stress response, and increase mitochondrial activity (some of the physiological disturbances that occur in depression). While these nutraceuticals and phytoceuticals aren’t magic bullets, they should be considered to help improve mood and reduce depressive symptoms.

If we want to improve treatment outcomes for depression (and help prevent the onset of depression), then we need to utilise holistic/ integrative options that help treat the causes or drivers of depression. Such an integrative approach is most effective when treatment options are based on a person’s unique causes/ drivers of depression. Often, making several small changes in one’s life can significantly improve one’s mood.

References:

1. Hasin, D.S., et al. (2018) Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry. 75(4):336-346. doi:10.1001/jamapsychiatry.2017.4602
2. Cuijpers, P. et al., (2021) The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta‐analysis. Acta Psychiatr Scand. 2021 Sep; 144(3): 288–299. https://onlinelibrary.wiley.com/doi/10.1111/acps.13335
3. Johnsen, T. J., & Friborg, O. (2015). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin, 141(4), 747–768. https://doi.org/10.1037/bul0000015