Usually by the time a depressed person comes in to see me, it’s because what they’re doing hasn’t been working. Therapy hasn’t been helping, or they don’t have the time or finances to do therapy. So as a psychiatrist, I offer an antidepressant. And almost every day, people hesitate. They don’t hesitate because they doubt whether the medications work (a separate debate). They hesitate because they want to follow a “natural” lifestyle or philosophy.
Now I follow a principle of using as little medication as needed, recognizing a propensity in many colleagues to use more and chase every symptom with another medication. But I disagree that “natural” means better in healthcare, as the foundation of a lifestyle of “natural” and “organic” is at its core shaky, particularly when it comes to depression.
Behind this lifestyle lies a bias against “chemicals,” as if all “chemicals” = “poison.” As if there exists a homeostatic mechanism in humans that will protect them from disease if they remain “pure” enough. This demonizes medicine and perpetuates a false model that the human system (body/mind) is inherently self-healing and self-correcting (a philosophy perpetuated in many alternative health models). Disease occurs because the system isn’t working anymore, often despite a “natural” lifestyle. And yet like anyone entrenched in a belief system, when something isn’t working anymore, rather than doing something else people just do more of the same. More extreme of the same.
The “natural” lifestyle could be partially a backlash against the overmedicalization and overmedication of every condition. I understand that. I can only blame my own field, where the trend of using medications exclusively causes a distorted view of chemistry as a solution for everything. This comes at the expense of what many seek in therapy, which is someone to listen.
The backlash against overuse is underuse. Antidepressants are all too often given out for mild complaints, or temporary depression and anxiety. This leads to the myth that antidepressants are useless, and even that “depression is natural.” People get concerned about getting treatment for their catastrophic depression because “it’s natural to feel this bad in these bad circumstances.” They hesitate because maybe depression is adaptive. And it is, to a point.
There may be an evolutionary basis to depression (see research by Keller and Nesse). Crying may have been selected for as a mechanism to help a person get social support. The low energy and interest of depression may have been selected for as mechanisms to conserve energy in the face of an impossible goal that can’t be relinquished. In the way having sickle cell trait (a single copy of the gene) appears to protect against malaria, some genetic developments help support life in a milder form. But when the development is in a more extreme, it isn’t adaptive. Sickle cell disease (a more severe type with two copies of the gene) isn’t more helpful than sickle trait against malaria. A sickle cell crisis can even kill a person. Similarly severe depression may be an out-of-control version of something originally adaptive or beneficial. To follow a model of statistical normal distribution (the bell shaped curve), it’s an outlier, where the mechanism is causing harm rather than helping.
Of course there may be conditions that are environmentally caused. That is not in debate. Some cancers are definitively caused by chemical exposure. What is less clear is if “purification” leads to remission from environmentally caused problems. If it’s “stress,” can we realistically avoid all stress? Probably not. Avoidance with stress is almost never helpful. Just as “bed rest” for back pain is in fact harmful, not helpful. An alternative to avoidance should be to utilize alternative ways to handle the environmental problems.
Physicians, as a profession, are inherently anti-evolution, in its traditional sense. Evolution occurs through natural selection, where environmental stressors kill off the “unfit” or weak. Our job is to help those that might not function as well without help. We’re a modern social invention to assist more of humanity to survive. In the first world of plenty, there’s fewer selective pressures. So apparently people are constructing their own, letting their ideals get in the way of their lives.
Everything is chemical. The state of being depressed is chemical, in that there’s a chemical process going on in the brain. Medications change those chemicals. Therapy changes those chemicals. Food has chemicals. Herbs, often touted as “natural,” are just weak medications that are less regulated (so you don’t know how much you’re getting), and less studied (so we know even less if they help or hurt). The idea of ingesting “foreign” or unnatural chemicals ignores the reason medication exists. Medication does something for your body that it can’t do on its own. An antibiotic, which is a foreign, unnatural chemical, that gets through your entire body often into your brain as well (thus its utility), is necessary when your own body can’t fight off an infection on its own. Few people think twice about that. It’s acceptable, most likely because it’s temporary.
I hear all the time in passing people present the rationale “well if cave men didn’t do it, it must not be healthy.” Paleo diets, organic air fresheners. The evidence actually isn’t that good as to the life expectancy of ancient man, but we can be sure of one thing now: we’re living longer. So we’re doing something right. Modern medicine helps people live longer.
In primary care, usually people are unable or unwilling to make the necessary lifestyle changes to keep themselves healthy. They won’t exercise or quit smoking. In psychiatry it can be about the same issue, that of getting someone to admit that what they’re doing isn’t working, and that doing more of the same isn’t really a solution. This is an issue throughout all of life, not just medicine. If telling a patient to exercise more isn’t getting them to exercise at all, telling them more often isn’t going to make them do it.
If it can be done “naturally,” terrific. Therapy is great. I treat with psychotherapy as much as I do with medications. But if you’re waiting to see if being natural will help with depression or any other medical problem, determine where the “point of no return” is, where it’ll be too late to take advantage of the treatments right in front of you. Is it when death is near? Is it when you’re hurting those around you? Consider the point when following a lifestyle comes at the cost of your life.
