I am not currently on medication, but my doctor is suggesting it. What are alternative treatments to medication?

Good question! Before delving into a list of alternatives, let’s first think about how to think about this decision.

It’s not about following a set of rules, or really even about following what the scientific evidence says—although scientific evidence can be helpful in assisting you to make an informed decision. It’s really about costs and benefits—costs and benefits to you. In making a decision, it helps to enumerate the costs, or risks, on the one hand and the potential benefits on the other. And this depends on your personal situation.

Let’s say the condition you’re working on is bipolar disorder, type I. Persons with this condition have had one, and typically several, manic episodes. These episodes cause extensive havoc, sometimes irreparable, in an individual’s life. Often, they entail hospitalization and sometimes even psychotic symptoms. And if you’ve had one manic episode, odds are you’ll have another one at some time in the future. Clearly there’s a lot of risk here, and the potential costs to you are enormous. And the evidence base is pretty clear that medications can help to treat and prevent manic episodes, as well as the episodes of depression that almost invariably accompany bipolar type I. So, there’s a lot of risk involved in going without medications.

Now at the other end of the spectrum, let’s say the condition you’re working on is a single, first episode of depression, without hospitalization, psychosis, or suicidality. Maybe there is even a clear and identifiable stress that brought it on, and maybe you’re able to “play with pain” and keep going in your roles at work and home. Here the risks are feeling miserable, and perhaps making yourself more prone to future episodes by not having medication treatment for this first episode (the evidence is not so clear about this last point). The benefits of treatment are, simply, feeling less miserable faster with some type of treatment, either with medications or with other alternatives.

These two scenarios are purposely oversimplified—real, individual situations are not often this clear. But the point is this: Treatment choice depends on potential costs to you and what the evidence says are the potential benefits of various treatment options.

Let’s say you’re hesitant to take medications. Are there evidence-based alternatives? Well, it depends on the condition. For bipolar disorder—either type I or type II, which has milder forms of mania called “hypomania”—the risks are typically high enough and the evidence of treatment benefit is strong enough that clinicians recommend medication in almost all cases. If you do your own cost-benefit analysis, you’ll likely see why. Also, if you battle severe or chronic or recurrent depressions, or depression with suicidal urges or psychosis, the cost-benefit typically favors medication. In both these cases, however, medication plus psychotherapy are optimal treatments.

In single episodes of depression, or recurrent depressions that are not extremely severe, there can be benefits from non-medication treatments. Cognitive-behavioral therapy and interpersonal therapy probably have the strongest evidence base as alternatives to medication for depression. There is also some evidence supporting family therapies, therapies oriented toward strengthening circadian (daily) rhythms, problem-solving therapy, and a group of approaches sometimes called “psychoeducation” that focuses on developing a better understanding of one’s symptom pattern and improving coping responses to symptoms. There is also some evidence that certain types of psychodynamic therapies derived from classic psychoanalysis may help. There are various self-guided books and apps and web programs based on these evidence-based psychotherapies, but rarely have they been tested in clinical trials. Shop carefully.

In terms of non-medication devices, electroconvulsive therapy (ECT), also called “shock therapy,” is probably the most effective form of treatment for severe or psychotic depressive episodes. Recently, a procedure called reverse transcranial magnetic stimulation (rTMS) has accrued some evidence for effectiveness in depression.

What of so-called “complementary,” “alternative,” or “integrative medicine” techniques? These include both dietary supplements or restrictions, and life-enhancing practices that are typically derived from eastern medicine or philosophy. This latter group includes such practices as yoga, tai-chi, qi-gong, acupuncture, acupressure, and certain types of meditation. None of these has a particularly strong evidence base for mood disorders, though some practices, such as yoga and related techniques, can be quite helpful physically and mentally in general. In terms of supplements or dietary restrictions, the question is more one of costs (including financially) and risks (in terms of toxicity and interactions with medications you may be taking). If you go this route, be sure to let your prescribers know exactly what you are taking and let them do a risk analysis.

It takes a partnership to make a good decision: You are the expert in your own situation and your own risk tolerance, and your clinician is the expert in the evidence. Put your heads together, jointly choose a path forward, monitor the results, and change plans if necessary.

About the Doc

About the Doc

Mark Bauer, M.D., is Professor of Psychiatry at Harvard Medical School, Associate Director of the VA Center for Organization, Leadership, & Management Research, and Director of the VA National Bipolar TeleHealth Program.  He is on staff of the VA Boston Healthcare System and has served on the DBSA Scientific Advisory Board since 1990.

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