depression, diet, exercise, holistic, life style, nursing, nutrition, recovery program



  1. Meyer, Bonnie L. MS, RN
  2. Taylor, Elizabeth Johnston PhD, RN


Given the prevalence of major depressive disorder (MDD) and its significant economic and personal costs to society, families, and those with MDD, and given the frequent failure of contemporary therapeutics to treat MDD, it is imperative that nurses explore holistic approaches to managing MDD. My story provides a case study for how several approaches can be blended to holistically manage MDD. The approach that is effective for me requires faithfully attending to diet, exercise, sunlight, sleep, and spirituality, as well as continuing to receive psychological and social support.


Article Content

Each year, 13 million to 14 million adults (6.6% of the population) in the United States suffer with major depressive disorder (MDD).1 Likewise, the 16% lifetime prevalence rate for MDD indicates how pervasive an illness it is.1 Not only does this illness cause severe symptoms and impaired function, it costs US society tens of billions of dollars each year.2


Therapeutics for major depression is infrequently curative. Data from a large national survey indicate that only 22% of persons with MDD receive adequate treatment.1 Another large study of persons with depression demonstrated that those accepting pharmacological treatments have only a 21% to 30% chance of achieving a remission.3 Even the 55% to 86% possibility of remission after receiving electroconvulsive therapy alongside medication is tempered by the fact that there is a significant 40% chance of relapse within 6 months even with this treatment approach.4 Various psychological therapies have been found to be efficacious in treating MDD, yet even persons responding to such therapy can often relapse.5 For example, a meta-analysis of relapse rates after cognitive-behavioral therapy showed MDD recurred 54% during the 2 years after cognitive therapy.6 For many, MDD is a chronic illness.


Given the prevalence of MDD and its significant economic and personal costs to society, families, and those with MDD, and given the frequent failure of contemporary therapeutics to treat MDD, it is imperative that nurses explore other holistic approaches to managing MDD. My story provides a case study for how several holistic approaches can be blended to successfully manage MDD. Although my story offers only an N of 1, it describes an inexpensive, extremely successful treatment that has brought me not only healing of mind but also healing of body and spirit. And this, without negative side effects.



I have struggled with depression on and off throughout my life. My first experience with MDD occurred in 1995 after the end of a deeply troubled marriage. I began taking medication for depression at that time and continued until after implementing the holistic approaches presented here. I worked as a nursing professor for over a decade while managing my depression with this medication. Then, while consulting with a nutritionist to help me lose weight, it became apparent that my junk food craving and emotional eating reflected a deeper, underlying disorder.


By 2004, I spent many of my days in bed. My home had become a filthy, dirty mess. My 14-year-old son would wake me and beg me to go to the store to get food. Flashbacks of abuse I had experienced and witnessed increased. My anxiety created chest pain and days of throwing up. Worthlessness and guilt plagued me constantly. When I did go to work, my ability to function became increasingly limited. Finally, I could no longer even answer my e-mail. Yet, if I met my boss in the hall I would smile and say I was fine because I did not want anyone to know. I did not even understand myself how bad things had gotten.


I began seeing a therapist who diagnosed me with MDD. Because my condition required more help than he could give alone, I entered a partial hospital program at a behavioral medicine center. Moreover, I went on disability. I attended the program for two 3-month sessions. These sessions provided me with a solid intellectual awareness of the principles of cognitive-behavioral therapy. I also suffered through the unpleasant experience of living under the influence of the several different medications that were tried. Although I improved somewhat from this help, my primary therapist and psychiatrist (as well as several other psychiatrists) recommended electroconvulsive therapy. I declined, fearful of the side effects.


Frightened for my life, I accepted a monetary gift that allowed me to attend a healthy lifestyle program. In fact, I attended 2 different lifestyle programs during the 2005 summer. This lifestyle program began the healing process. The second lifestyle program was a comprehensive depression recovery program (DRP), which catapulted me toward health.


I arrived for the 3-week program feeling sick, tired, scared, and worthless. When I got to my room, I curled up in the overstuffed chair and cried and cried. I had already had months of therapy. Yet, I still felt like a messed-up failure. I was not able to care for son. I kept obsessing about being a failure as a mother and as a person. I was confident that no one would be able to help me. I thought I might as well just give up. But I could not do that. My mother had spent a lot to send me to the DRP. I had to stay because I could not waste her money!!



An Internet search for "depression recovery programs" indicates programs touting a holistic approach exist. While a few involve an intensive, live-in program with extensive assessment and personalized medical supervision, most are contained in books, audiotapes, or some product available for purchase. The programs requiring attendance all include extensive psychotherapy, as well as attention to physical fitness (eg, Feldenkreis, walking), nutrition (eg, organic meals), and spirituality (eg, meditation, yoga). Although a PubMed search revealed no empirical study about the effectiveness of these comprehensive approaches to MDD, one nursing study does suggest that a program of vitamin supplementation, exercise, and bright light can improve mood and well-being among women with subthreshold depression.7


Because of the paucity of evidence regarding holistic treatments for MDD used in concert, my story offers not only a personal description but also anecdotal evidence for its effectiveness. The unique program that influenced my recovery most was the DRP, developed by Neil Nedley, MD. After an exhaustive review of the depression literature, Nedley identified numerous factors that can contribute to depression.8 Although the factors that cause depression for 1 person can be different for another person, instituting lifestyle changes that minimize or correct for these various precipitating factors is the focus of Nedley's DRP.


The DRP I attended involved a 3-week live-in stay at a lifestyle center. The daily schedule included private therapy (mainly cognitive-behavioral therapy and problem-solving therapy), group therapy, instructional sessions explaining the rationale for treatments, exercise (mandatory), physical therapy (hydrotherapy, massage), time for spiritual reflection, and special meals and cooking classes (given diet is pivotal to depression management). At the beginning and weekly thereafter, I was medically evaluated by Nedley. I received a fitness evaluation at the start and end of the DRP.


During my stay, I was able to taper off my alprazolam (Xanax) and mixed amphetamine salts (Adderall XR). During the subsequent few months, I tapered off my citalopram (Celexa) and trazodone (Desyrel), per a regimen recommended by Nedley. Following Nedley's regimen also naturally meant losing weight. I lost 18 lb during the 2-lifestyle programs and eventually over the next year lost a total of 60 lb. Likewise, my scores on anxiety and depression inventories fell from severe to mild and normal. At the conclusion of the DRP, I was healthy enough to self-manage my illness: I had a plan for managing my chronic illness and had a plan for myself were I to relapse. These outcomes occurred, although I had a significant relapse just before entering the DRP.



With good nutrition and a healthy lifestyle, I learned we care not only for our bodies but also for our brains. A healthy body contributes to a healthy brain. A healthy brain is more resistant to depression. Furthermore, because depression is almost always caused by multiple factors, multiple approaches to its treatment are efficacious.8 My experience illustrates how depression management requires a holistic approach including


* psychotherapy and avoiding negative thinking,


* social support,


* diet,


* physical exercise,


* religious or spiritual experience,


* regular restful sleep, and


* bright light.



To manage my MDD, I have to follow dietary guidelines, exercise, sleep, and get light. Omitting any one of them for more than 1 week, I start slipping. To make my self-management manageable (especially during those first few months of recovery when I had to put 1 foot in front of the other), I placed a checklist of these approaches in my day planner. Daily, I would check off what I had done or eaten.


Of course, pharmacotherapy is often a beneficial treatment. Likewise, having a social network for support is paramount. It is important to remember that diet and lifestyle changes should not be used alone to treat moderate or severe depression. I do not want to mislead by suggesting that if one just eats right and takes walks, he or she will be fine and can stop other treatments. Whereas these other approaches have been effective for me and others, they should be seriously considered as additional components of depression treatment. Because psychosocial therapies for depression are well described in the literature, I will focus on the other holistic approaches the DRP emphasized which I continue to implement today.



Depression has been linked with diets low in n-3 polyunsaturated fatty acids (n-3 PUFAs, or omega-3 fats), tryptophan (or diets containing large amounts of amino acids that block tryptophan transport to the brain), folic acid, and vitamin D and several B vitamins including vitamin B12.7-12 High levels of homocysteine, which can be lowered by folic acid, have also been linked to depression.11 Although poor diet is a commonly overlooked factor contributing to depression, many persons in Nedley's practice experience improved mood with dietary changes. Nedley observes that, after implementing diet changes, it takes roughly 7 to 10 days before one notices an improvement in mental function. Peak improvement occurs after 3 to 6 more months of brain healthy eating.


The DRP dietary guidelines7 include the following.


1. Eat fruits, vegetables, beans, nuts, and whole grains. Avoid, or at least limit, refined foods. Although the brain needs carbohydrates to function, eating refined carbohydrates and sugars (especially by themselves, not in connection with a meal) causes the pancreas to secrete extra insulin. Such insulin surges contribute to depression. Craving sweets is common among depressed people because sugar temporarily increases serotonin, which helps the person feel better. Unfortunately, indulging in sweets makes depression worse in the long run. A variety of fruits and vegetables provide vitamins, minerals, and antioxidants that are also important for brain performance and overall health.


2. Eat plant sources of tryptophan. Tryptophan is required to make the neurotransmitter serotonin, which combats depression. Animal sources have high amounts of other amino acids that compete with tryptophan in traveling to the brain. Although milk is often thought of as a great source of tryptophan with 46 mg/100 g, it is actually a poor source compared to various seeds and nuts, gluten flour, flax seed, and tofu (747 mg/100 g).


3. Eat foods rich in n-3 PUFAs (or omega-3), at least 1 meal per day. (A 9-g/d supplement is also recommended by Nedley.) Even a high-fat diet can be too low in omega-3. Although fish are famous for providing omega-3 fats, they are also known to harbor concentrated toxins such as mercury, dioxin, pesticides, heavy metals, and so forth. Therefore, Nedley advocates plant sources of omega-3 fats. Extremely rich sources include flaxseed, canola, walnuts, and soybeans-especially when condensed into oil. For example, a tablespoon of flaxseed oil has more than double the amount of omega-3 than does a 3.5 oz serving of halibut (7520 mg vs 3160 mg). My preference, however, is to use whole foods or nonrefined sources rather than the oils for my source so that I can get the tryptophan simultaneously.


4. Eat foods providing adequate folic acid and B12. The recommended daily intake of folic acid is 400 [mu]g, easily consumed if eating legumes and dark green leafy vegetables. Yet, a deficiency of folic acid has been identified as 1 cause of depression.9 Nedley finds that persons with depression due to folic acid deficiency are also those who tend not to respond to standard antidepressants. Likewise, B12 has been linked to depressed mood. Fortified cereals and soy milk, as well as organically grown foods, are good vegetarian sources of B12.




Studies have suggested that regular exercise (eg, 20-60 min/d, at least 3 times per week) can deter and reduce depression.13-15 Exercise fights depression, in part, by activating neurotransmitters, enhancing memory, and combating anxiety and fatigue. At the DRP, Nedley recommended that I do 60 minutes each day of interval training. That is, I walk at a comfortable pace, speed up so I feel I am really working out for a few minutes, and then I slow down again (and repeat the cycle). Nedley warned me that it would take at least a week before the depressive symptoms would wane. For me, it took several weeks. I still strive to walk an hour every morning or during my lunch break and then do stretching and strength training twice a week. Now I find if I do 30 minutes at least 3 times a week I remain well. When I have extra stress, I do better if I up my exercise again.


Bright light

Research findings suggest that bright light hitting the retina increases serotonin production; it may also improve sleep by increasing nighttime melatonin levels and restoring circadian rhythm.16,17 Thirty minutes of daily sunlight, which is significantly greater in intensity than indoor lighting, and morning sunlight are especially effective in diminishing depression and aiding nighttime sleep. Therefore, I aim to walk, read, eat, or relax with classical music or deep breathing, outside at least half an hour each day. When it is difficult to get outside, I use an artificial light box.


Spiritual or religious experience

Numerous studies have observed indirect relationships between mental health (often measured as depression) and spirituality or religiosity.18-20 For example, a large study of 1000 depressed cardiac inpatients in the Bible Belt found that religiosity (ie, attending religious services frequently, praying, studying the Bible, and having strong inner motivations for one's religiosity) predicted a 53% increased speed of remission from depression.21 Thus, my process of recovery has included efforts to reexamine my spiritual beliefs, to study the Bible to keep me thinking, and to memorize its verses that offer me comfort. My wake-up routine includes prayer and listing 5 things for which I am grateful.



Studies have shown poor sleep to both contribute to and result from depression.22-24 Instituting good sleep hygiene such as those found in nursing texts (eg, warm bath prior to bedtime) is helpful for persons with MDD. Exercising in late afternoon or early evening rather than right before bedtime and avoiding a large evening meal are additional measures to encourage a sound sleep.8 I eat my main meal at lunchtime and often either skip dinner or eat a light supper of simply fruit. I also started to "count my blessings instead of sheep."


Other approaches

In addition to psychotherapy and social support, other less substantiated approaches to MDD such as listening to classical music (or music conveying a positive message or experience), hydrotherapy, and deep breathing are encouraged by Nedley's DRP. For example, a memorable point at the beginning of my recovery occurred when a therapist went walking with me. After her literally brief therapy on the road, she counseled me to sing a hymn or song that gave me a sense of worth-while I continued to walk!! And, of course, social support, counseling, and abstaining from abusive drugs and alcohol are imperative as well.


These approaches, followed closely and faithfully, have allowed me to successfully manage an extremely deep depression. When I returned home, my family joyfully greeted me and noted that for the first time in years, my eyes looked "happy."



I follow the program closely. I did have one significant relapse. It started with my thoughts. I started saying to myself that it is not fair that I have to work so hard to keep ahead of my depression. Other people can stay up late, never exercise, and eat all the junk food they want. Why did I have to always take care of myself? I slacked off for 2 weeks and the depression, poor concentration, and related symptoms set in with a vengeance. I was scared. I got help quickly. I had to work hard for a week.


I have had many smaller relapses. As my therapist says, "depression is my default mode." Whenever I slack off on following my program, I start having symptoms. Initially I would panic. Because I had a strong support system that helped me through the panic, I could get back on track. Now, I am less likely to panic because I am able to figure out what to do. My support people, however, are still there when I need them.


When I experience stress, I have to consciously choose to continue to follow my program. I have discovered that it is not stress that triggers the relapse. Rather, it is slacking off on my program. When I do face stress, if I am even more rigorous about following my program, I remain well. That is a real challenge, though, because when I am facing stress, I usually do not feel like following the program. Choosing to readhere to this holistic approach, however, helps me manage the depression.


I am now able to see that my depression can be my blessing. My prayer for others is that they might have the faith to understand that the pain of today can be the triumphant story of tomorrow.



Although I had received months of individual and group psychotherapy, I was unable to integrate or be changed by what I learned in therapy until after I entered the DRP. It was after the 3-week general lifestyle program and 1 week of the DRP that I finally began to grasp what my therapists had been trying to teach me. It was as though my body was not physically able to mentally understand the teachings. I also believe that learning how to care for your mind and body is not what changes you. It is doing it. As I actively participated in mending my body, my mind slowly began to heal. Furthermore, until the DRP, I had blamed my problems on biochemistry. I did not understand that caring for my body physically and changing my thoughts would change my biochemistry. I thought that that was something I could not change.


Although persons with depression may not discuss their use of complementary or alternative therapies, they do use them.25 A study of women with depression found that half of them used complementary or alternative medicine (CAM).26 These women desired a "natural approach" to depression that was congruent with their values and void of negative side effects. How well I understand this!! Nurses need not only become aware of what complementary or alternative medicine and lifestyle approaches to MDD are used, but which ones are effective.


Nurses can play a central role in educating individuals and communities regarding these holistic approaches to MDD. Indeed, nurses are pivotally positioned to ensure this holistic approach for depression. As coordinators of care, nurses can bring together the expertise of physicians, psychotherapists, dieticians, physical or exercise therapists, and chaplains to provide holistic care for persons with MDD.




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