Depression generates a significant economic burden and untold human suffering not only on the individuals affected by it, but also for those around them, sometimes posing a threat to the stability of the family, workplace, friendships and life itself. Much of this suffering is unjustified in light of current treatment options and prospects.

Depression is a far more complex disorder than the condition once defined simply as melancholy, “the blues” or “having a nervous breakdown”.

A depressed mood (or simply a sad mood), which represents the emotional affective side of this disorder, represents only one aspect of a condition that is probably triggered by malfunctions in several areas of the brain that produce effects on a number of different mental and physical functions (Cassano, 2003).

A great deal of interest has been aroused by recent evidence to the effect that mental and physical stimuli can actually change the course, severity and duration of depression, with or without concomitant pharmacological treatment. Such findings open up promising prospects for alternative forms of treatment, as an alternative to the traditional approach which is based largely on the use of antidepressants associated with psychotherapy.

The treatment regimen proposed here is very much in line with this trend, which is gaining currency among psychiatrists who advocate a biological approach to mental disorders.

Depression is characterized by a low mood accompanied by a series of other mental and physical symptoms such as an overall decline in energy levels together with listlessness, exhaustion, inability to sustain the slightest physical effort, generalized lack of initiative and purpose in mental and physical pursuits, frequent desire for rest and isolation, low self-esteem, a pessimistic outlook on family, work, social environment and finances, right down to a catastrophic outlook that may lead to thoughts of self-injury (suicide).

Sleep disorders (difficulty falling asleep, interrupted sleep, early morning awakenings, diurnal drowsiness) are often also present, and sometimes appear long before the onset of other symptoms, along with restlessness and aggressive behavior (including irritability and explosive reactions).

Phobic, obsessive and persecutory thinking may be present. People with depression may interpret the attitudes of others as being inspired by or oriented towards negative actions or criticism towards them. However, the overall listlessness that dominates the symptoms causes an inability to react and often the result is an even more accentuated negative outlook and overall pessimism regarding the surrounding social environment.

Hypochondria and pathophobia are also a frequent finding, resulting from depressive people continuously and obsessively examining themselves as if “under a magnifying lens” or “under the microscope”, both physically and behaviorally, in an attitude also known as “rumination”. This relentless monitoring and “dissection” of themselves leads to over-emphasizing even the minutest imperfection or disorder, blowing it out of all proportion, and charging it emotionally to the extent that it may actually fuel suspicions of diseases of every kind, which a pessimistic catastrophic outlook will interpret as seriously health- and life-threatening.

On the affective level, this condition may initially cause further pain and accentuate the morbid mood states and anxiety that often accompany depression. But if the depressive condition worsens, then thoughts of a serious or even fatal disease may be tolerated without excessive preoccupation, especially when suicidal thoughts emerge.

The turning of the depressed individual’s attention onto himself eventually leads to a complete withdrawal and alienation from the outside world, in a process that may involve people who are very close, such as family members or caregivers and friends; the individual sometimes develops progressive dislike and disinterest for them.

In rare cases, persecutory delusions may lead to fearing conspiracies and plots against the individual, even on the part of people who support them and are closest to them; in this case thoughts of aggression and revenge may ensue. However, lack of purposefulness and confidence in their own resources and abilities (loss of self-esteem) frequently lead depressed people to give up such attitudes and become remissive, if anything developing more marked morbid moods and delusional thinking.

Common physical complaints include: marked tiredness and an inability to embark on any physical or mental activity or initiative (i.e. refusing to leave the house, get out of bed or up from an armchair, tendency to stay in the dark without opening windows or shutters) and the onset or worsening of muscle pain, joint pain (rheumatism), back pain, “cervical” pain and headache. In many cases the depressed person also complains of pain involving the mouth or face (neuralgia, and a stinging or tingling sensation in the cheeks or tongue), or even toothache (sometimes mimicking dental decay and gum disease).

The depressed individual may become obsessed with his mouth and teeth due to actual occlusive disorders (abnormal contact between the upper and lower teeth) which, due to oversensitivity (hyperalgesia/hyperesthesia) and paying excess attention to the mouth and face (hypervigilance) may cause latent preclinical conditions to become symptomatic.

Because the teeth, mouth and face are of particular importance in conceiving every person’s ego, depressed people may project pain or pathological attention on to them, giving rise to the following conditions:

• psychogenic pain without an underlying disease due to an altered pain threshold or to hypervigilance;
• aggravation of pain caused by existing disorders (dental, periodontal, arthritic or muscular);
• projection of pain from anatomically and functionally neighboring areas to the face (cervical region, maxillary sinuses, etc.);
• complaints of psychogenic (imaginary) pain associated with hysteria

A rather frequent and somewhat disturbing symptom that may result from the pharmacological treatment of depression is tremors. Tremors may affect the upper and lower limbs (restless legs syndrome), arousing serious concerns over neurological disorders such as Parkinson’s disease and syndrome. Other neuro-degenerative diseases that can seriously impair the ability to work may be preceded or accompanied by depression (link: headache).

In some cases, tremor affecting the teeth may present as mandibular dyskinesia (uncontrolled jaw movements with chattering of the teeth - oral/oromandibular dyskinesia).

Occlusive disorders are also frequent, with the person feeling distressed by the way the upper teeth come into contact with the lower ones (the sensation is of “malocclusion”), and consequently developing abnormal habits (parafunctions) like bruxism (grinding the teeth) when awake by the day, or during sleep (link: craniomandibular disorders).

For these individuals the clinical process is particularly tiring and often fruitless: the diagnosis may be difficult to make both specifically (malocclusive disease) and generally (depressive syndrome and somatization); moreover the treatment plan may be difficult to implement due to the poor cooperation of the patient who minimizes or rejects the possible psycho-somatic origin of the problem.

Tremors may occasionally become generalized, especially during drug treatment, and become associated with another frequent symptom represented by loss of balance and abnormal posture , ranging from simple instability to the inability to stand up or walk normally. Dizziness may be common, sometimes leading to fainting (lipothymia) when getting up from the seated or lying position. It may be difficult to walk a short straight line without wobbling.

These disorders may be well controlled right up to complete remission through a suitable regimen of physical activity.

If left untreated, these disorders often understandably accentuate the anxieties and concerns felt by the person about his health, further limiting his willingness and desire for regular working, social and recreational activity.

The depressed individual’s general mental and physical inertia is often mistakenly interpreted by those nearest to him, including family and friends, as signs of laziness or lack of will power. Consequently, they may develop ambivalent feelings of compassion and annoyance, frequently fuelled by a well meaning resolve to prod and stimulate the depressed individual who is considered to be failing to react to his condition.

Guilt feelings and deep frustration can thus be brought on in the depressed person, who is often genuinely aware of his inertia, and wants to react, but at the same time is totally unable to. A common mistake committed by those who live alongside people who are depressed is to constantly stigmatize their inertia, attributing it to lack of will power and a weak character, and relentlessly urging them to muster their resources, react to their condition, and activate an initiative (purposefulness and ideation) that is inconsistent or entirely absent.

The blame is therefore put on the depressed person if it proves to be impossible to involve him in initiatives and activities that he was previously interested in.

On the contrary, understanding and sympathy are necessary, along with reassurances that his real inability to undertake any kind of action or initiative is transient. He must be encouraged to choose whatever activities he may like or be willing to perform, even if he is not particularly enthusiastic or interested in them, provided they do not overly strain his condition but rather demand commitment and attention (distracting him from his “rumination”) even without satisfaction or particular enjoyment.

These activities serve to keep the depressed person’s “social communication” channels open and represent a vital “anchor” to prevent isolation.

The atmosphere of incomprehension and gradual marginalization that depressed people develop towards family members, aggravated by persecutory thinking (betrayal, disinterest, incomprehension, irritation, hostility) lead them towards latent or manifest conflicts with their spouse or partner, who is called upon to provide support and encouragement – a weighty task that is, however, essential for the recovery of the depressed person’s health.

Because of their privileged affective position, spouses and partners may contribute significantly towards preventing the condition from spiraling towards self-injurious behavior (suicide).

Sensory disorders (dysperceptions) and feelings that may not be so severe as to be disabling but may still aggravate the already altered perceptions that many depressed people have of themselves, are represented by cenesthesic abnormalities, generally involving smell and taste, and sometimes, though rarely, touch and sight.

Vision may be altered due to an apparent or actual decrease in visual acuity, which may cause anxiety or obsessive behavior. Impaired gustatory and olfactory function can be explained by the well known dominance of the hypothalamus, the brain center that is of primary importance in human emotional reaction. Such changes largely consist in altered perceptions of smells or tastes, and the recurring and unjustified perception of specific smells that may be pleasant, or so unpleasant as to become more intolerable than is generally the case under normal conditions.

These changes in taste may lead the depressed individual towards unusual eating patterns or behavior during crisis situations. There is often a craving for sweets, and a desire for food or beverages never previously enjoyed, or a refusal of old favorites.

Depressed people may seek specific psychoactive substances and become addicted to them if they are felt to ease the pain (alcohol, coffee, tea, drugs). Sometimes once the crisis has subsided, there is a return to customary eating habits and normal sensory responses, but it is not unusual for altered taste and smell to persist for prolonged periods, if not indefinitely.

As a result of altered taste and smell, there may be a tendency to modify eating habits both in terms of quantity and quality, with resulting changes in calorie intake. This may lead to weight loss (anorexia nervosa) or, more frequently due to reduced physical activity, to sometimes marked weight gain, which may in turn become an even stronger discouragement from undertaking physical activity.

One characteristics feature of altered tactile cenesthesic function in depression is intolerance of the cold. Warm baths and showers are seen as restorative and gratifying. It is reasonable to believe that a preference for warm environments and a desire to “cover up” is more than a mere “regressive” mental and physical aspect associated with a generic yearning for protection. Such behavior may be related to significant variations in the thermoregulatory system, caused by neuro-endocrinologically based metabolic changes (the psycho-neuro-endocrinology of depression).

Indeed, the hormonal profile of the depressed person shows characteristic variations, albeit of uncertain diagnostic value, such as elevated cortisol levels, possibly a sign of impaired regulation of the adrenal-hypothalamus-pituitary/hypothalamus-pituitary-thyroid axes. In depressed people, sexual desire may weaken considerably to the point of total impotence (loss of libido and erectile capacity)

At the cognitive level, depressed individuals display a series of disorders such as the inability to concentrate, memory flaws, inability to mentally organize thoughts and plans, with an apparent and sometimes genuine reduction in information processing and problem solving skills, often with underlying anxiety.

Impaired intellectual skills may have a major negative impact on self-esteem and the confidence to tackle with life normally (study, work, private and social relations), fuelling the downward spiral towards suicide.

On the emotional plane, the depressed often feel the need for comfort yet at the same time have negative feelings of mistrust leading to hostility towards those around them, causing a further withdrawal into themselves, and the tendency to underestimate or criticize those offering help.

Dysthymia is a less severe form of depression. It involves long-term (chronic) symptoms that do not disable yet prevent the affected person from enjoying a fully satisfying life. People with dysthymia often also experience episodes of major depression during their lifetime.

Major depression is characterized by a combination of symptoms that interfere with the ability to work, sleep, study, eat and enjoy once-pleasurable family and social relations.

Disabling episodes can be isolated and occur only once in the course of a lifetime, or recurrent, when they are more frequent.

Bipolar disorder (manic depression) is characterized by periods of depression and euphoria. Sometimes the mood swings are dramatic and sudden, but most often they are gradual. During the depressive phase, the individual displays all the typical signs and symptoms of depression, whilst in the manic phase energy levels are abnormally high and hyperactivity may appear in different forms (extreme irritability, restlessness, loquacity and garrulousness with a tendency to monopolize conversations), along with overly assertive and overbearing behavior, exaggerated extroversion, increased sexual desire and activity, excessive generosity and a tendency to underrate risks and dangers, excessive self-esteem and confidence in one’s own resources, grandiose notions, narcissism.

There may often be a reduced need for sleep. The individual may be affected by poor judgment and lack of self-criticism, and display inappropriate social behavior including exhibitionism.

There is a condition defined as hypomania, in which only a few of the symptoms of manic episodes are present, or if many are present, are much attenuated.

In short, the most frequent symptoms of depression are:

• persistent feelings of sadness/melancholy
• recurrent anxiety, agitation and restlessness
• pessimism, lack of confidence
• feelings of guilt, uselessness
• loss of interest and pleasure in activities that were once gratifying, hobbies, sex
• loss of energy, fatigue, exhaustion, feelings of slowing down
• difficulties in concentrating, remembering, decision-making
• altered sleep patterns (insomnia or hypersomnia, early-morning awakening, difficulty falling asleep, interrupted sleep
• increased or decreased appetite, generally with weight gain
• negative thoughts (death and disease) and self-injurious behavior (suicide)
• short-temperedness and irritability
• appearance or worsening of physical symptoms that often fail to respond to treatment such as headaches, oro-mandibular dysfunctions, digestive disorders (indigestion, constipation), and chronic somatic pain (often musculoskeletal or rheumatic, involving the back and neck)

The most common symptoms of mania:

• abnormal loquacity
• excessive irritability
• reduced need for sleep
• grandiose notions
• profligacy
• exaggerated self-esteem and confidence in one’s own possibilities, narcissism
• under-estimation of risks and dangers
• lack of self-criticism
• inappropriate social behavior.

Bipolar disorder and manic depressive syndrome may present with the same characteristics, for which a specific genetic profile has in fact been identified.

However, it is not true that persons displaying a genetic vulnerability to the disease will necessarily develop it. A series of concomitant factors (environmental, etc.) are responsible for its emergence and these depend primarily on external environmental causes (i.e. stresses at home, work or school etc.).

People with low self-esteem and a pessimistic personality who display vulnerability to stress are particularly prone to depressive illness and much of their early life may have been influenced by a mild (preclinical) form of depression.

It has recently been demonstrated that several organic diseases (such as stroke, heart attacks, cancer, Parkinson’s disease, endocrine disorders) can give rise to depressive disorder, which negatively impacts the course, duration and response to treatment of the underlying disease (through refusal of treatment, apathy and non-compliant behavior).

The loss of loved ones, difficult social relations (in particular in the home and workplace), financial difficulties, stressful life events including those most strongly desired like the birth of a child, or sudden changes in habits and lifestyles can all trigger a depressive episode. It is likely that the cause of depressive disorder lies in the interaction of genetic, psycho-social and environmental factors.

Later, even minor stressful events may trigger depressive episodes.

Women also frequently face greater responsibilities than men both at work and at home (caring for children, elderly parents, housework and a career).

Post-partum depression (“the baby blues”) is particularly threatening, in that hormonal and physical changes occur together with the added responsibility of a new baby. Treatment of this condition requires the involvement of a sensitive physician and the emotional support of the family, amongst others.

Depression in men presents less frequently than in women, but may be more severe, leading to a four times higher rate of suicide among men, though women tend to display more “suicidal tendencies”.

Suicide occurs most frequently in the elderly (peaking between the ages of 70 and 85). The mental and physical involvement seems to be more intense in men, also because serious cardiovascular problems such as heart disease and stroke appear most frequently in this age group.

Depression in men may be masked by alcohol or drugs, or by behavior like anger, irritability, discouragement, and overwork. Men are often less willing to seek help and support, so it may be difficult to recognize and treat depression.

Some people argue that the elderly frequently display depressive symptoms because of their shorter life expectancy and less satisfying quality of life. This belief is biased and mistaken in most cases, since older people are generally satisfied with their lives; today, the elderly can look forward to a longer, happier and more comfortable life than in days gone by.

However, unless diagnosed and treated appropriately, depression may cause unwarranted suffering for the elderly person, the family and caregivers. Often the symptoms described are physical, since older people tend to be reluctant to discuss feelings of hopelessness, sadness, loss of interest in activities that were once pleasurable, or grief after the loss of a loved one.

It is crucial to recognize this attitude in order to correctly diagnose depression in the elderly. Once identified, the older person will benefit from the usual treatment options for depression based on medication, brief psychotherapy (“talk therapy”) or cognitive/behavioral therapy. Psychotherapy can be a viable alternative when medication cannot or will not be taken (for example, because of slower drug washout and turnover rates, impaired kidney and liver function, a more vulnerable nervous system, and so on).

Psychotherapy has proven to be effective in providing psychological support in particularly difficult times such as terminal disease, advanced age and disability.

The concept of depression in children as a specific pathology has only developed relatively recently (in the 1980s). The depressed child may pretend to be sick, refuse to go to school, cling to a parent, or fret over the prospect of a parent falling ill or dying.

Older children may sulk, fall back at school, be negative, cranky, and feel misunderstood. Since normal behaviors change from one childhood stage to the next, it may be difficult to understand whether a child is genuinely depressed or simply going through a difficult phase in normal development.

Occasionally the parents are concerned about changes in the child’s behavior, or a teacher may mention to the parents that the child is having problems at school, or performing below his usual standards.

The National Institute of Mental Health (NIMH / Bethesda), a highly distinguished American body, recommends considering the use of medications for treating childhood depression in selected cases (NIMH-supported Research Units on Pediatric Psychopharmacology-RUPPs).

Despite the fact that RUPPs studies advocate the use of drugs in the treatment of depressed children, under the supervision of the child’s doctor, there is growing opposition to this recommendation. Recently, controlled trials have generated numerous reservations on the safety of medications in children, and even the latest generation SSRIs appear to cause serious adverse effects on the child’s mental and physical development.

Many disease states can co-exist with or simulate depression, including iatrogenic conditions (i.e. disorders due to the undesirable side effects of drug treatments, including antidepressants and mood altering medications).

Only when the physical causes have been ruled out should a psychological problem – primary depressive disease – be suspected.

The diagnostic evaluation must include:

• patient history, to
  • identify the nature, frequency and duration of symptoms
  • evaluate previous clinical conditions (i.e. psychiatric disease or suggestive signs and symptoms)
  • investigate any conditions previously diagnosed and treated
  • probe and assess possible family history of depression or preclinical states
  • enquire about the use of alcohol or drugs
  • identify thoughts of suicide or death
  • evaluate the patient’s mental status, cognitive functions, and in particular, speech, thought patterns and memory
  • examine the affective profile of the patient (personality);
• an essential neurological examination
• if physical disease is suspected, in specific cases:
  • diagnostic imaging exams (Computerized Tomography/CT, Nuclear Magnetic Resonance/NMR and Positron Emitting Tomography / PET)
  • blood chemistry (lab tests), (Russel Vickers, IASP, Sydney, 2005)

There are a number of conventional treatment options available that involve the use of antidepressant medications and psychotherapies (support, cognitive behavioral, etc.). In some milder forms, psychotherapy alone may produce satisfactory results, while in moderate to severe cases the use of antidepressants in association with psychotherapy is generally recommended.

When people fail to respond to conventional treatment, and particularly if they display suicidal tendencies, or when there is a contraindication for such treatment, many centers advocate and perform Electroconvulsive therapy (ECT), also known as Electro-shock therapy. The Italian psychiatrist by the name of Cerletti is credited with formulating this type of treatment.

ECT produces an actual electric shock. Electrodes are placed at precise locations on the head to deliver short electrical impulses (30 seconds), which the patient does not consciously experience.

Today ECT treatment is far less traumatic for the patient, who is first given a muscle relaxant or brief anesthesia; for best results, several sessions of ECT are usually required at the rate of three per week, on an in-patient basis. Hospitalization is always recommended whenever there are suicidal or self-injurious tendencies and the individual needs to be kept under close observation.

Parenteral (intravenous) medications may be given more easily to in-patients and hospitalization also facilitates the choice of an effective treatment protocol, and close monitoring of the outcome.

The latter (chiefly Prozac) are more recent medications that date to the 1980s. Since they are presumed to be more effective and produce fewer side effects, the belief has spread among the general population that depression is a common easily treatable psychosocial disorder. People tend to regard it as separate from other mental diseases, and are more willing to take medication even if they were once mistrustful or hostile towards drug treatments.

The presumed relative harmlessness of SSRIs has also led to these medications being used on pediatric patients.

However, it is often necessary to try several drugs before finding the most effective medication for the individual patient. Sometimes the dose levels have to be increased to be effective. Although some improvements may appear very quickly, even after a week, it generally takes at least three or four weeks before the full therapeutic effect can be observed.

This slow time-to-effect sometimes makes the patient think the treatment is not working, and ask for it to be replaced, especially if side effects aggravate the typical symptoms of depression such as feelings of fatigue, lack of energy and blunting.

Some of the typical side effects of tricyclic antidepressants may be:

• gastrointestinal – dry mouth, nausea, vomiting, constipation
• visual – reduced visual acuity, scotoma
• olfactory and auditory – hallucinations or dysperceptions
• neurological and otoneurologal (impaired concentration, memory and thinking, drowsiness/lethargy, tremors, loss of balance, dizziness)
• sexual (loss of sex drive)
• urinary (difficult urination, pollakiuria)
• arthromuscular (joint pain and the appearance or aggravation of rheumatic and musculoskeletal pain)

Symptoms that are characteristic of SSRI antidepressants include:

• headache and orofacial pain
• nausea
• restlessness and sleep disorders
• tremors and loss of balance

The onset of side effects such as these without any appreciable reduction in affective symptoms may worsen the depression and cause patients to stop taking the medication or to develop an even more negative view of their condition.

In other cases, if the medication is effective, patients are often tempted to stop taking it too soon.

Once an improvement has been noticed, the medication must be taken for at least 4-9 months, to prevent recurrences of the depression; in any case the decision to discontinue or modify treatment must be taken by the physician, not the patient.

Antidepressants of any kind can be discontinued only following a rational dose reduction schedule (called controlled “wash-out”).

In some cases such as bipolar disorder (manic-depressive disorder), medication (such as Lithium salts) may need to be maintained indefinitely.

When taking antidepressants, a number of activities and habits will be prohibited or restricted. These may include alcohol and certain medications that may reduce the effectiveness of the antidepressant, driving the car, and tasks that require precision and responsibility, due to the risk of synergic effects causing a decline in alertness and slower, less well controlled mental and physical reflexes and responses.

Hypericum Perforatum (St John’s Wort) is used extensively throughout Europe and has recently aroused interest also in the United States.

The plant, which is a shrub that produced yellow flowers in the summer, has been used for hundreds of years in folk remedies. St John’s Wort is the most popular antidepressant currently used in Germany.

Though the National Institute of Health has conducted controlled trials sponsored by three NIH branches – the National Institute of Mental Health, the National Center for Complementary and Alternative Medicine, and the Office of Dietary Supplements – no evidence exists to suggest that St. John’s Wort is as effective as some SSRIs (e.g. Sertraline). In February 2000, the US Food and Drug Administration (FDA) published a Public Health Advisory, indicating the proven efficacy of Hypericum Perforatum in modifying the metabolic pathways of a series of drugs used for treating AIDS, cardiovascular disease, depression, seizures (epilepsy), certain tumors and rejection of transplants (immunosuppressive drugs).

These interactions must be taken into serious consideration by those who prescribe and take these herbal remedies.

Other popular herbal supplements those efficacy has not been proven include ginko biloba, ginseng, ephedra and echinacea.

Talking therapies, together with exercises that can be performed at home, can be useful in behavioral therapy, helping patients to gain insight into the possible causes of their condition, and teaching them to “reprogram” their attitudes and emotional affective reactions (thinking) towards disturbing thoughts and situations associated with depression.

Psychodynamic therapies are sometimes used in depression to analyze and resolve emotional conflicts, though these therapies are more effective when the symptoms of depression are starting to diminish. However, the use of medication is generally recommended and, in non-responders, relapses and under special conditions, ECT may be used along with or before psychotherapy.

• behavioral choices
• lifestyle choices
• exercise and physical therapy

Depression brings on negative thoughts and pessimism, hopelessness, helplessness, worthlessness and a feeling that external help and care are pointless.

Until the chosen treatment begins to take effect it is essential to try and break the vicious circle of negative thoughts with a series of behaviors that should be adopted in all cases, including situations that are at risk for depression and recurrences:

Behavioral choices

• set realistic goals in relation to the degree of depression and assume a reasonable amount of responsibility
• prioritize commitments in terms of their importance and urgency, and if possible, break tasks down into smaller ones that can be coped with more easily
• try not to become socially isolated, and seek the support of reliable people
• participate in activities and initiatives that at least provide some distraction, if not enjoyment and satisfaction. Look for activities that might be potentially gratifying (social or church work, etc.)
• prepare for a gradual improvement, rather than a sudden change, and accept that cognitive behavioral strategies will be effective in the long run (use positive thinking and “anchoring”)
• postpone important decisions and commitments until after the depression has eased (new job, changes in marital status, etc.)
• if possible, discuss choices and problems with people who are trusted and emotionally close
• encourage and be open to the help of family and friends
• rationally opt for positive thoughts and goals (cognitive behavioral strategies/self-help) and isolate them from the generally negative views that are typical of depression.

Lifestyle choices

Different lifestyle choices may make a significant difference:

Exercise and physical therapy

Introduce a rational program of exercise and physical therapy, including:

The methods described here for undertaking physical therapy and activity to treat anxiety, depression and other affective disorders and forms of dependence are the following:

including:

in water at temperatures ranging from 10 to 20 degrees Celsius (average temperature 15ºC)

Both of these treatments act on the neurophysiologic and neuroendocrine systems that regulate sleeping and waking rhythms, and produce/release psychoactive chemicals (neurotransmitters) involved in mood fluctuations, affective disorders, anxiety and depression.

According to this distinguished Committee, which has published the results of its in-depth analysis of the scientific literature on the subject in highly reputable magazines (Science, issue 303, 2004, Psychological Medicine, issue 35, 2005), chronotherapy (light and wake therapy) plays a fundamentally important role, in SAD (stress, anxiety, depression), and could indeed represent a viable alternative to conventional treatments relying on antidepressants and psychotherapy (e.g. cognitive behavioral therapy)

The World Health Organization (WHO) recently reported that in the industrialized world, depression as a disease dramatically increasing; by 2020 it is expected to become the second most common illness after cardiovascular disease (heart failure and stroke); today, depression ranks fifth. This finding stems from a study based on mortality and Disability Adjusted Life Years (DALYs) (Scientific American, September 2005).

The WHO recommends that the scientific community prove that such treatments proposed for depression are not only effective and sustainable (i.e. well tolerated) but also easy to deliver via simple protocols (Chrisholm, 2004).

The costs associated with prolonged and sometimes lifelong conventional therapies, in terms of financial expenditure and physical side effects, represent an evident limitation, at least for a large percentage of the population.

Therefore, to comply with the recommendations of the World Health Organization, effective treatment strategies must be found as an alternative to medication and psychotherapy.

The development of the ideal drug, capable of achieving effective results with a shorter time to effect than the current 2-3 weeks on all aspects of depression, with no adverse side effects and at an affordable cost is unfortunately still on everyone’s wish list, and the proven efficacy of psychotherapy in association with medication nevertheless still comes at a very high price.

The interest displayed by official research and science in treatments such as these as an alternative to conventional medication is obviously limited by the immense interests surrounding drug therapy for affective illnesses. However, the opportunity to make a more targeted and rational use of medication when combined with alternative treatments should suggest including chronotherapy among currently available remedies, at least for those members of the psychiatric community who are more ethically aware and inclined towards less aggressive treatments for depression (Wirz-Justice; Science, issue 303, 2004).

Chronotherapy, based on the principles of circadian rhythm and sleep physiology, offers mental health specialists (psychologists, psychiatrists, neurologists, patho-physiologists and others) involved in treating all forms of depression, a series of modalities for monotherapy or as an adjuvant to conventional medication (multimodal therapy), combining supplemental light exposure and sleep deprivation with traditional medication (SSRIs, Lithium salts and other antidepressants such as MAOIs or tricyclics).

Recently, it has also been proven that “light therapy” is likely to be effective also in other illnesses such as:

• major depression (Non Seasonal Disorder/NSD) and forms of bipolar affective disorders (Yamada, 1995;Lam, 1998)
• premenstrual depression (Lam, 199199)
• post- and ante-partum depression (Epperson, 2004)
• bulimia nervosa (Blonin, 1996;Lam, 1998;Braun, 199199)
• sleep disorders (delayed and advanced sleep phase syndromes)(Abbot, 2003; Reich, 2004)
• Alzeimer’s disease (Alzeimer dementia, Skjerve, 2004).

The efficacy of “light therapy” in major depression was supported by Yamada in 1995 and by Benedetti in 2004, and for bipolar forms by other researchers.

Recent controlled trials appear to prove the efficacy of “light therapy” when combined with the use of Selective serotonin reuptake inhibitors (SSRIs), by reducing time to effect, prolonging effect duration, reducing dose levels and enhancing efficacy (Benedetti, 2004).

According to Kripke (1992), drug latency times drop to just one week when they are used in association with “light therapy” and this theory is currently the object of an in-depth analysis (meta-analysis) (Tunnainen, 2004); Golden, awaiting publication)

Light therapy is particularly useful because it reduces time-to-effect to under a week in seasonal depression (autumn-winter or recurrent depression), when light is provided in the early hours of the morning (dawn light) for no less than half an hour a day for at least five consecutive days, with illumination of at least 5000 Lux, Color Temperature ranging from 4500 to 8000 Kelvin, and a frequency spectrum (electromagnetic wavelength) over 480 A, at the blue-green end of the scale.

The only undesirable effects that could be attributed to Light therapy concerns potential retinal damage (macular degeneration at frequency spectrum values shorter than 480 A (blue-green light).

Optimal exposure times could carry some risk when associated with unusually long treatment cycles.

The recommendation to choose artificial lighting with a spectrum primarily focused in the green band is not beneficial since these lamps do not guarantee the same levels of efficacy and require considerably longer exposure times.

However, it should be noted that there are different types of depression, each stemming from different causes (i.e. genetic, environmental, social, stress, etc.).

Spontaneous Internal Desynchronization may be one cause (or a concomitant cause) of some of these depressions. Light Therapy is particularly effective when used to treat seasonal depression (Seasonal Affective Disorder/SAD).

The use of light with a wavelength longer than 480 nm (because shorter wavelengths could cause retinal damage) is discouraged by some authors, who while admitting that blue light is harmful to the retina, observe that all the evidence points to the fact that the damaging wavelengths are around 450 nm or less. Recent studies show that blue light with a wavelength of 464-480 nm has the greatest impact on the human circadian system (Tosini. Personal Communication, 2005; Brainard et al., 2001, J. Neuroscience) and for treating specific forms of depression (Glickman et al., 2005, Biol Psychiatry).

If this treatment is compared to the two weeks that represent the minimum response time to conventional medication-based treatment, the response, which is positive in 60% of cases, is astonishing, and can begin to appear within hours of initiation (Wu e Bumey,1990; Liebenlaft e Wehr, 1992; Wirz Justice e Vander Hoofdakker, 199199; Berger, 2003).

The main drawback of “wake therapy” is represented by the transient nature of the remission with symptoms often reappearing after even a short compensatory sleep (or nap). It is also obviously difficult to manage the treatment at the individual clinical level.

“Wake therapy” is effective even in forms of major depression. Certain drugs like Lithium and Pindolol (5HT-antagonists) appear able to enhance and prolong the duration of symptom control exerted by “wake therapy” and seem to work synergically.

Kites are flown in the open air, on sunny days with moderate winds (‘light therapy’), in beautiful locations near beaches or lakes (wind therapy).

“Body drag” kites can be physically gratifying because it combines kite flying with only moderately challenging physical exertion, and is highly satisfying if practiced safely and without difficulty;

The physical exertion required to fly kites varies considerably depending on the type of kite used and whether it is used for fun or exercise (work-outs featuring “body drag”, “kite buggy”, “kite surfing”).

Kite flying demands solutions to unconventional problems (unraveling wires, untangling knots, straightening lines). Solving these problems requires discipline, commitment and attention, but also a level of skill and dexterity that is entirely within the reach of the depressed individual.

The concentration associated with kites constitutes a powerful distraction from the depressed person’s characteristic condition of self-affliction, isolation and “rumination”.

Though the family is a fundamental environment in which to communicate and share thoughts and feelings, it may not always be the ideal environment (i.e. conflicts, isolation, fragmentation).

There are people, institutions and groups that can significantly help depressed individuals to come out of their depression or at least tolerate it more effectively, and above all to avoid turning inward towards more negative thoughts of disease and death.

Such resources include:

• the family doctor;
• specialists (psychologists, psychiatrists and neuro-psychiatrists);
• social workers;
• mental health centers and facilities;
• psychiatric clinics and wards in public and private hospitals;
• medical and psychiatric societies;
• websites on depression (providing useful links and addresses). These can easily be found by entering keywords like “depression/care/support/scientific associations” in search engines.