Mental Health Disorders, Depression & Anxiety:
Pharmaceutical Treatments Compared to Integrative Treatments
If you’ve ever considered your options for treatment of depression or anxiety using pharmaceuticals and/or integrative approaches, we wanted to offer an educational essay on some of the comparisons of consideration from the perspective of what happens chemically and biologically in the body.
“Depression’s treatments have morphed over time, as has the disease itself, reminding us that suffering is never stagnant, that even discrete illnesses take the shape of the culture’s currents.” Lauren Slater
Mental healthcare in our society has become a touchpoint of awareness through not only self-awareness of individual mental health, but also through family influences, friends, colleagues, peers, and even through the increase in social influence through media and social platforms. Mental health effects a sense of self, relationships with others, physical health, and also an individual’s ability to maintain and balance stability, resilience and coping throughout one’s life. According to the World Health Organization, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.” (WHO)
Mental health, as an attribute of the state of health, can branch into many conditions, disorders, and disturbances with a very broad number of diagnoses. The clinical definition of a mental health disorder according to the Diagnostic & Statistic Manual (DSM) is, “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” (DSM) An individual’s diagnosis of a mental health disorder can evolve throughout an individual’s life, but overall, the most common diagnoses for mental health conditions fall into the categories of depression and anxiety. The World Health Organization has announced that Depression is now the #1 Illness, with 300 million people worldwide suffering from this condition. (Depression) Clinical symptoms of depression include a depressed mood on a daily basis, a diminished sense of pleasure in activity, weight loss or gain, lack of sleep, agitation, feelings of restlessness, fatigue, feeling unworthy, and recurrent thoughts of death.
Anxiety disorders in comparison, relate to a collective number of mental health disorders that are characterized by not only anxiety, but also fear, worry and panic. Anxiety disorders can include generalized anxiety disorder (GAD), panic disorders, phobias, social anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). According to the Anxiety & Depression Association in America, “Generalized anxiety affects 6.8 million adults, or 3.1% of the U.S. population. Panic disorders affects 6 million adults, or 2.7% of the U.S. population. Social Anxiety Disorder affects 15 million adults, or 6.8% of the U.S. population. Obsessive-Compulsive Disorder (OCD) affects 2.2 million adults, or 1.0% of the U.S. population. Posttraumatic Stress Disorder (PTSD) affects 7.7 million adults, or 3.5% of the U.S. population.” (ADAA) Clinical symptoms of anxiety can vary based on the specific category of diagnosis, but in general can include excessiveness in anxiety and worry, difficulty controlling the worry, restlessness, fatigue, inability to concentrate, irritability, muscle tension, and sleep disturbances.
Depression and anxiety disorders can be diagnosed and treated through the application of mental health counseling and therapy, pharmaceutical medication, preventative tools accessed through self-treatment, herbal therapy, nutritional supplements, and also integrative approaches such as meditation, breathwork, sound therapy, somatic movement, and yoga.
Antidepressant pharmaceuticals aim to extend the actions of the neurotransmitters, norepinephrine, and serotonin. It is theorized that the brain is the site where these two neurotransmitters are deficient. SSRI’s are antidepressant drugs that “inhibit serotonin reuptake, have 300-3000 fold greater selectivity for serotonin transporter, and have little blocking activity at specific receptor sites.” (Whalen 135)
Serotonin is a monoamine neurotransmitter found in the gastrointestinal tract, nervous system and blood platelets of animals and responsible for the feeling of happiness and wellness. It is derived from tryptophan and also referred to as 5-HT due to its chemical composition. Its chemical formula is C10H12N2O as represented in Figure 1:
SSRI’s stands for Selective Serotonin Reuptake inhibitors and include pharmaceuticals such as Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), and Paroxetine (Paxil).
Fluoxetine is an antidepressant belonging to the SSRI group and used in the treatment of major depressive disorders. Common trade names include Prozac, Adofen, and Sarafem. Also referred to as N-methyl-3-phenyl-3-[4-(trifluoromethyl)phenoxy] propan-1-amine, a name derived from its chemical composition C17H18F3NO represented by Figure 2 below.
Sertraline is an antidepressant drug used in the treatment of depression and anxiety disorders (U.S. National Library of Medicine, 2018). Its chemical formula is C17H17Cl2N as represented in the structure below. The drug is in the SSRI class of drugs and sold under the trade name Zoloft.
Citalopram is an antidepressant agent of the SSRI class, and its chemical structure varies from that of other drugs in the level, but it has the same pharmacological action. Its chemical formula is C20H21FN2O and represented by the structure below.
Paroxetine is an antidepressant of the SSRI class used in the treatment of various depression disorders that include a social anxiety disorder and panic disorder. (U.S. National Library of Medicine, 2018). Its chemical structure is C19H20FNO3 and represented by the structure below. The drug sells under the trade names Paxil and Seroxat.
“During the 1990s, mainstream psychological and pharmacological treatments of anxiety disorders were developed and tested, leading to an initial algorithm that is similar for all major anxiety disorders. In general, clinicians choose between CBT (Cognitive Behavioral Therapy) and an SSRI and then try another SSRI if the first one did not work or was not tolerated. None of the SSRIs has shown superiority to another. The choice of an SSRI is usually based on the side-effect profile, pharmacokinetic and pharmacodynamic properties, and potential interactions with co-administered medications.” (Bystritsky) Another interesting point about SSRI’s was discovered when researchers began to look at past studies on the efficacy of drugs and drug studies through information made available in the Freedom Information Act, “it was discovered that in 47 trials on six antidepressants (Celexa, Effexor, Paxil, Serzone, Zoloft and Prozac) that the drug outscored the placebo in only 20 of the time-which was fewer than half.” (Slater 172)
Anxiolytic Drugs are anti-anxiety drugs that offer a sense of dulling, calming or numbing to the nervous system. Anxiolytic drugs include Benzodiazepines such as Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium), and Lorazepam (Ativan). “The target for benzodiazepines are the y-aminobutyric acid (GABA) receptors, wherein GABA is an inhibitory neurotransmitter in the central nervous system.” (Whalen 121) Side effects of benzodiazepines can include a high ability to become dependent, withdrawal, restlessness, insomnia, tension, drowsiness, cognitive decrease, amnesia, and liver disease.
Gamma-Aminobutyric acid is an inhibitory neurotransmitter in the central nervous system. Its chemical formula is C4H9NO2, and it is represented by the structure below.
Benzodiazepines are drugs in the psychoactive class of drugs with its chemical structure being the fusion of benzene and diazepine rings. (U.S. National Library of Medicine) The drug is used in the treatment of many different types of anxiety and sleep issues. Its chemical formula is C9H8N2, and it is represented by the structure below.
Alprazolam is classified as a psycholeptic, anxiolytics and benzodiazepine derivative. It is used to treat anxiety and produce sedation. It’s chemical formula is C17H13ClN4 and is represented in the structure below.
Clonazepam is a synthetic benzodiazepine that is used as an anticonvulsant for seizures and epilepsy. It is used to treat anxiety and produce sedation. It’s chemical formula is C15H10ClN3O3 and is represented in the structure below.
Diazepam is classified as a benzodiazepine that is anticonvulsant, anxiolytic, and acts as a sedative, and muscle relaxant. It’s chemical formula is C16H13ClN2O and is represented in the structure below.
Lorazepam is classified as a benzodiazepine that acts as a hypnotic and anticonvulsant and is used to treat anxiety and insomnia. It’s chemical formula is C15H10Cl2N2O2 and is represented in the structure below.
Antidepressants and anxiolytics create a change in mood by affecting brain chemicals, such as Serotonin Reuptake Inhibitors (SSRIs), Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs), Monoamine oxidase inhibitors (MAOIs), Serotonin and norepinephrine reuptake inhibitors (SNRIs), and Gamma-Aminobutyric acid (GABA). SSRI’s can begin to improve mood and take effect from between 2 weeks, up to 12 weeks, with the possibility of some drugs not making any impact and possibly still causing side effects, which can include nausea, anxiety, drowsiness, insomnia, sexual dysfunction and drug interactions. More intense side effects can include cardiac arrhythmias, suicidal ideation, seizure, and changes in mental status. (Whalen 137) Further studies regarding SSRI’s and their effectiveness and safety indicate that “serotonin reuptake inhibitors (SSRIs) have immediate effects on synaptic levels of serotonin but their therapeutic effects are often delayed. This delay has been suggested to reflect the time required for new learning and therefore that SSRIs might be having effects on the learning process.” (Msetfi) But even further testament to the challenges and side-effects of SSRI’s, research indicates, “despite considerable improvements in toxicity and acute side-effect profile when compared to tricyclic antidepressants and monoamine oxidase inhibitors, SSRIs are still associated with significant long-term side effects that affect treatment adherence and quality of life.” (Baldwin)
In comparison to pharmaceuticals, an integrative approach in the treatment of depression that may include meditation, biofeedback, guided imagery, and progressive relaxation, all help teach the patient “how to relax and consciously control their own autonomic functions, as well as improve cardiovascular function, reactivity to stressors, immune function, and even be able to stop or reduce the use of medication.” (Khalsa 42) As proof of the effects of meditation on the brain, a research study utilized techniques to record the brain and found that, “medical imaging studies have successfully demonstrated that meditation may counteract or prevent the physiological cause of depression by decreasing amygdala activity and increasing grey matter volume and activity of the hippocampus, prefrontal cortex and other brain regions associated with attention and emotional self-regulation.” (Annells) Clinical psychologist Richard Miller says of the treatment of depression with pharmaceuticals, “We cannot simply address the chemical component of depression and expect that depression will be alleviated.” (Weintraub 6)
The brain fires electrical signals each day, and these brainwave patterns can be measured to understand emotions, sleep, and feeling and thought sensations. Brainwaves are the action of the millions of neurons in the brain connecting and firing together. These connections can build patterns and waves that relate to certain conditions or feelings. Meditation has been shown to help increase alpha level brainwaves, which help create a sense of relaxation internally and naturally. “Alpha waves (8 to 12 Hz) are present when your brain is in an idling default-state typically created when you’re daydreaming or consciously practicing mindfulness or meditation, whereas Beta waves (12-30 Hz) typically dominate our normal waking states of consciousness and occur when attention is directed towards cognitive and other tasks. Depression and anxiety have also been linked to beta waves because they can lead to “rut-like” thinking patterns.” (Psychology Today) A study done in Scandinavia found that yoga increased the alpha waves in the right temporal lobe and theta waves. (Mapping) Still another study that considered meditation for the treatment of depression found that, “meditation has two major principles: reduction in reactivity and abolishing thought patterns….and meditative training can help to prevent depressive relapses, and reduce the levels of depressive and anxiety symptoms.” (Srivastava)
In consideration of alternative approaches to elevating serotonin levels, an article in the Journal of Psychiatry & Neuroscience noted, “nonpharmacologic methods of raising brain serotonin may not only improve mood and social functioning of healthy people — a worthwhile objective even without additional considerations — but would also make it possible to test the idea that increases in brain serotonin may help protect against the onset of various mental and physical disorders.” (Young) Such nonpharmacologic methods may include exercise, movement, meditation, diet and even bright light. Movement and exercise such as yoga, is an approach that the patient can use to help manage and control their depression symptoms. In this same article, it was further indicated that, “several lines of research suggest that exercise increases brain serotonin function in the human brain….including research that found physical activity increased 5-HIAA, … exercise increases extracellular serotonin and 5-HIAA in various brain areas, including the hippocampus and cortex..which accounted for two different mechanisms of involvement with motor activity increasing the firing rates of serotonin neurons, which resulted in increased release and synthesis of serotonin, and an increase in the brain of the serotonin precursor tryptophan that persists after exercise as well.” (Young)
Research studies about yoga and stress with depression have considered the impact, “and found that a regular yoga practice decreased the dominance of the parasympathetic system for some people. But there was an important difference in this study: The 17 adult participants were all clinically depressed. The participants practiced Iyengar Yoga three times a week for eight weeks. At the end of the study, 11 participants were in remission from depression.” (McGonigal)
Applying and using integrative techniques in the management and control of mood disorders can offer an option of care that is starkly contrasting to the utilization of pharmaceutical medications for the same use. Stated so beautifully from someone who has suffered from depression and now teaches and educates others on integrated approaches, yoga teacher, Amy Weintraub says, “Yoga offers an alternative to the problems of conventional medical treatment for depression. It does not have detrimental side effects; it has side benefits for the body and mind. Yoga practices address the root cause of depression.” (Weintraub) The natural effect and change that one notices after moving through exercise or yoga is a self-induced sensation stimulated by the brain and the body through stretching, movement and an internal shift to balance. Clarified by Dr. Khalsa, an anesthesiologist, “you are stimulating your pituitary gland to release endorphins. Your peripheral glandular system is producing adrenaline and norepinephrine-type compounds that travel to the brain and give you that mild stimulating effect. You are stimulating the relaxation response.” (Weintraub 59)
The use of yoga as a modality of treatment for anxiety provides a different action in the human body towards relieving anxiety in comparison to using a pharmaceutical. The physical activity of yoga movement improves the quality of heart rate variability, increases the relaxation response, reduces blood pressure, deepens the action of breathing, and offers the body a general state of calm. Breathing as a practice by itself can offer a shift in attitude and ease from anxious thoughts. Says, Yoga psychologist David Coulter, “breathing is one of the most remarkable functions of anatomy and physiology. It is the only biological activity which can be brought under full conscious control and yet functions semi-automatically twenty-four hours a day.” (Weintraub 134) In considering the side effects of pharmaceuticals to those of integrative techniques, the differences are physically altering from a biological perspective as well as a physical perspective. As testament to this, “a meta-analysis of several hundred studies of transcendental meditation found that it exceeds the relaxation response in reducing psychophysical arousal due to stress, decreasing anxiety, increasing mental health and decreasing drug use.” (Khalsa 8) Whereas antidepressant drugs have numerous side effects ranging from dependence, withdrawal symptoms, amnesia, digestive issues, headaches, insomnia weight gain and sexual dysfunction, integrative approaches like meditation and yoga offer minimal side effects more of lack of ability to commit to the daily prescription of action.
Significant differences can be noted between the mode of action experienced in using pharmaceutical drugs in comparison to more natural, integrative approaches such as meditation and yoga in treating mental health disorders. Chemical pharmaceuticals interact with brain chemicals, such as serotonin or norepinephrine and can result in a direct shift and impact on an individual’s emotional state within, as well as the emotional state of being. Pharmaceuticals may help ease some cases of anxiety and panic by influencing the neurotransmitters and their action on the brain, but not without consequence and side effects to one’s physical and mental health. The integrative approaches of meditation and yoga more directly and actively affect the levels of brain chemicals, but do so in a natural and safe way, encouraging homeostasis from within.
ADAA. Facts & Statistics. (n.d.). Retrieved from https://adaa.org/about-adaa/press-room/facts-statistics
Annells, S., Kho, K., & Bridge, P. (2016). Meditate don’t medicate: How medical imaging evidence supports the role of meditation in the treatment of depression. Radiography, 22(1).
Baldwin, D. S. (2006). The importance of long-term tolerability in achieving recovery. International Journal of Psychiatry in Clinical Practice, 10(Sup1), 31-37.
Bystritsky, A., MD Phd, & Khalsa, S., MD Phd. (2013). Current Diagnosis and Treatment of Anxiety Disorders. P&T, 38
Depression. (n.d.). Retrieved from http://www.who.int/en/news-room/fact-sheets/detail/depression
DSM. Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Arlington, VA: American Psychiatric Association.
Khalsa, D. S., Stauth, C., & Borysenko, J. (2002). Meditation as medicine: Activate the power of your natural healing force. New York: Fireside.
Mapping the brains activity after Kriya Yoga. (n.d.). Retrieved from https://www.yogameditation.com/reading-room/mapping-the-brains-activity-after-kriya-yoga/
McGonigal, K. (2011, February 14). Change Your Stress Response. Retrieved from https://www.yogajournal.com/health/tame-stress
Msetfi, R. M., Kumar, P., Harmer, C. J., & Murphy, R. A. (2016). SSRI enhances sensitivity to background outcomes and modulates response rates: A randomized double blind study of instrumental action and depression. Neurobiology of Learning and Memory, 131, 76-82.
Psychology Today. Alpha Brain Waves Boost Creativity and Reduce Depression. (n.d.). Retrieved from https://www.psychologytoday.com/us/blog/the-athletes-way/201504/alpha-brain-waves-boost-creativity-and-reduce-depression
Slater, L. (2018). Blue dreams: The science and the story of the drugs that changed our minds. New York: Little, Brown and Company.
Srivastava, Malini. Meditation for the management of adjustment disorder anxiety and depression.
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Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Pharmacology. Philadelphia: Wolters Kluwer.
WHO, W. Mental health: Strengthening our response. Retrieved from http://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response
Young, S. (2007). How to increase serotonin in the human brain without drugs. Journal of Psychiatric Neuroscience, Nov(32), c.