Holistic Solutions For Anxiety & Depression in Therapy - Peter Bongiorno
Holistic Solutions For Anxiety & Depression in Therapy - Peter Bongiorno
Holistic Solutions For Anxiety & Depression in Therapy - Peter Bongiorno
PETER B. BONGIORNO
W. W. NORTON & COMPANY
New York London
This book is dedicated firstly to the patients who teach me something valuable everyday.
Their courage is my inspiration. I want to also dedicate this book to the mental health
practitioners that I have the honor to work with in order to create a true team care
approach. Together, we have learned that working in an integrative fashion truly creates
the best results. Finally, this book is co-dedicated to the tireless laboratory and clinical
researchers running trials and pouring over statistics to learn how lifestyle and natural
medicines work. Without that hard and often unrewarded work, the information for this
book would not be available.
Contents
Acknowledgments
Introduction: Why Holistic Care for Anxiety and Depression?
ONE
ARE HOLISTIC APPROACHES RIGHT FOR YOUR CLIENT?
TWO
ASSESSING CONTRIBUTING LIFESTYLE FACTORS
THREE
ASSESSING CONTRIBUTING INTERNAL FACTORS
FOUR
EFFECTIVE SUPPLEMENTS FOR ANXIETY AND DEPRESSION
FIVE
MIND-BODY MEDICINE
SIX
WORKING INTEGRATIVELY WITH MEDICATIONS
SEVEN
MAKING RECOMMENDATIONS AND DESIGNING TREATMENT PLANS
APPENDIX ONE
Top Seven CAM Recommendations You Can Offer Your Clients
APPENDIX TWO
Blood Test Recommendations
APPENDIX THREE
CAM Referrals and Resources
APPENDIX FOUR
Supplements for Anxiety and Depression
APPENDIX FIVE
Homeopathics Commonly Used for Depression and Anxiety
APPENDIX SIX
Example Diet and Lifestyle Diary
References
Index
Introduction
Why Holistic Care for Anxiety and Depression?
Insanity: doing the same thing over and over again and expecting
different results.
About a year before writing this book, I worked with a 42-year-old father of two;
lets call him Jason. Jason came in for his sixth monthly follow-up visit. He had
been dealing with depression for most of his adult life. An avid athlete in his youth,
by the time he was twenty-four he began to experience low mood and low-grade
depression. This was around the time he started having severe difficulties in his
family life, specifically discussing difficulties with his drug-addicted brother and
aging alcoholic parents. He suddenly began to have a very hard time playing
soccer, a game he loved. For almost two decades he avoided athletic events and
fought the dark cloud, as he put it, that kept him from enjoying sports, going out
dancing, or even just being social with friends. While functional at his job as an
engineer, he was labeled dysthymic by his psychiatrists and bounced from
medication to medication, with equivocal results. At the time we began to work
together, he was also working with a psychotherapist, as well as a
psychopharmacologist, and believed he would always be somewhat depressed, for
that was his nature.
Jasons most recent therapist decided to refer him to me for a more holistic
view and to see if there were any physical reasons that might be contributing
Jasons mood challenges. After taking his full history and completing a round of
blood tests, we learned that Jasons vitamin D and ferritin (iron storage) levels
were abysmally low. We also found out through the blood tests that he had a lowgrade reaction to gluten (a protein from wheat) that was likely contributing to the
slightly high inflammation in his body. I referred him to a hematologist and
gastrointestinal doctor to check on the low iron. Once it was clear that no
gastrointestinal or hematologic problems were the cause of low iron, I encouraged
him to eat more iron-containing foods and gave him low doses of an easy-toabsorb iron supplement with herbs that help absorption. I also recommended
vitamin D3 and had him avoid all gluten and wheat products. We also adjusted his
sleep schedule and added more vegetables and anti-inflammatory foods (e.g., fish
and olive oil) to his diet. After working with these recommendations for about 4
months, his mood gradually lifted. He even went back to working out, and now he
is excitedly considering getting back on a local mens soccer team this coming
summer. I suspect he will be able to wean off his current medications within the
next few months.
Jason had difficulty absorbing iron. His vitamin D was low because he avoided
the sun after his medical doctor told him sunlight would cause skin cancer, even
though he had no known increased risk for skin cancer. Because he did not have
digestive issues, laboratory tests for gluten sensitivity were never performed. After
we added a gentle but absorbable iron, his red blood cells ability to carry oxygen
improved, which helped both Jasons mood and energy. Giving him vitamin D
likely balanced inflammation in his body and supported his mood. Having Jason
eliminate gluten foods and adding anti-inflammatory foods also lowered
inflammation in the body. Inflammation in the body translates to more brain
inflammationa contributor to poor mood in susceptible individuals.
At our last visit, Jason asked me a very reasonable question: fter almost 20
years of going from doctor to doctor, why didnt anyone think to check and do these
things? My answer was simple: Because conventional care rarely looks at the
body as a whole. Often, when we look at the body holistically, we can elicit much
more information to help support the bodys healing ability.
Jasons story is an example of a type of patient I typically work with: someone with a
long-term mood disorder who has tried many forms of medication and has had limited
success. I am lucky, for in my New York practice I work alongside like-minded therapists,
social workers, psychologists, and psychiatrists who look to me to assess, from a more
holistic perspective, the physical reasons for a persons mood issues. In a team care spirit,
I rely on them for their expertise to monitor patients safety, work on improving their
psychological well-being, and consider pharmaceutical options when absolutely necessary.
Together, we create a full complementary and alternative medicine (CAM) perspective
that allows patients full opportunity to heal and provides a small community in which
patients feel safe to share concerns, change patterns, and heal.
Most therapists I have the honor to work with in this team care approach tell me that
most of their clientele are either interested in or are already using some type of natural
remedy or holistic modality. However, I have also heard that, whether it be the latest diet
craze, acupuncture, fish oil, vitamin D, St. Johns wort, or some new miracle mood cure,
often the therapist does not feel familiar enough with these remedies to give an opinion,
and some have confided in me their concern for drug-nutrient-herb interactions. Even
more overarching is the safety concern that their clients may inappropriately use these
remedies in lieu of more potent and necessary conventional care. This book will help
orient you regarding these concerns and give you a holistic framework to help see where
safe and effective use of CAM can fit with your clients concerns.
As a clinician, you probably have noticed that anxiety and depression rank as the top
reasons that people are sick and go to the doctor. Anxiety disorders are the most common
of the psychiatric illnesses in the United States, with approximately 30% of the population
experiencing anxiety-related symptoms in their lifetime (Kessler et al., 2005). Eighteen
percent of the U.S. population have been diagnosed with anxiety disorder.
According to the U.S. Centers for Disease Control and Prevention (2010), 9.1% of the
population meet the criteria for current depression, including 4.1% who meet the criteria
for major depression. A report from the World Health Organization tells us that depression
has become the second most burdensome disease in the worldit causes more lost time
and money than any other condition except heart disease (Ferrari et al., 2013).
Anxiety and depression are generally inextricable disorderseach often occurring
with the other. About 58% of patients with lifetime major depressive disorder have anxiety
disorder, while 48% of patients with generalized anxiety disorder also experience
comorbid depression (Lieberman, 2009). Patients who suffer from both seem to have more
severe, chronic types of anxiety. These patients also have more social and work
challenges, as well as greater rates of alcoholism and substance abuse. Most unfortunate,
patients with both are less likely to benefit from conventional care (Lydiard 2004). While
the Diagnostic and Statistical Manual of Mental Disorders, version 5 (American
Psychiatric Association, 2013) does not acknowledge nxious depression as a distinct
diagnosis, it is a very common presentation of mood disorder. In holistic circles, many
practitioners consider anxiety and depression a continuum, where certain stressors, as well
as sleep, environmental, and lifestyle factors, will help decide whether a particular degree
of anxiety, depression, or both may manifest.
Despite decades of drug dominance, many patients are now realizing that they prefer
something elsepossibly to avoid toxicity of these drugs, or maybe because they realize
their medication is not fixing the problem. In 2007, over 38% of adults sought out some
kind of natural or CAM support in the United States (Barnes, Bloom, & Nahin, 2008), a
significant increase from the previous decade. In many cases, this CAM support may
involve an anxious person going to the health food store to find a mineral, such as
magnesium, to help with sleep. Or possibly a person with depression might try a
supplement like tryptophan to lift mood. Other people may start regular acupuncture
treatments or yoga therapy. Or they may visit a naturopathic doctor like myself, who may
individualize lifestyle changes, recommend specific supplementation, and organize a
holistic plan.
You have probably noticed this interest in CAM with your own clientsmore and
more are asking about this vitamin or that diet. Thus, a basic working knowledge of
available CAM modalities and their efficacy is becoming an essential part of health care
education. A general natural medicine knowledge base is becoming essential for any
health care practitioner who wants to communicate and participate effectively in a health
care strategy with his or her client.
Alternative Medicine
The term alternative medicine refers to various medical and health care systems,
modalities, and recommendations that are not presently considered to be part of the typical
conventional medical model. These remedies are called lternative because they are used
in place of conventional medical care. When defining alternative care, the key here is
understanding that, by definition, lternative medicine replaces mainstream medical
protocol.
Instead, I prefer to employ the term complementary and alternative medicine (CAM).
CAM is a system that employs alternative modalities alongside conventional care. It does
not necessarily replace conventional care but, rather, keeps all methods of care in mind
when creating a plan of action for a particular patient (National Center for Complementary
and Alternative Medicine, 2013a). In my experience, neither conventional nor alternative
methods are superior. I prefer CAM because it is not mutually exclusive and allows the
opportunity to use whichever treatment might be best for a patient at a given time. Using
both conventional and alternative medicines together is termed integrative medicine.
CAM practitioners may be physicians of conventional medicine (e.g., medical doctors
and osteopathic physicians) or physicians of naturopathic medicine like myself. Also
considered part of the CAM world are nutritionists, herbalists, Chinese medicine and
acupuncture practitioners, chiropractors, energetic healers, and so forth. Therapists who
work with standard psychotherapy along other modalities such as yoga would also be
under the CAM umbrella.
CAM therapies may incorporate nutrient therapies, botanical medicines, Native
American healing, dietary changes, Ayurvedic medicine (ancient medicine from India),
energy healing, hypnosis, acupuncture, spinal manipulation, animal-assisted therapy,
physical medicines, and many other types of therapies.
Holistic Medicine
CAM and integrative medicine are, at their best, a type of holistic care. Holistic medicine
is a system of medicine that fully appreciates the multiple factors that affect a persons
health. It considers each person to be a unified whole. This contrasts the biomedical
approach of fragmenting the body into parts and specialties such as a nervous system,
digestive system, hormonal system, and so forth. For example, when you have a stomach
problem, you see a gastroenterologist. If you have skin issues, you see a dermatologist. In
contrast, a holistic practitioner may recommend focusing on supporting the digestive tract
to help the skin issues.
Biomedicine too often does not consider how tweaking one body system may affect
the whole person. Lets take the common example of reflux, a condition affecting 60
million Americans every month. Common conventional treatment includes a proton pump
inhibitor drug such as Nexium, which may help decrease symptoms and avoid discomfort.
However, in the long term, such treatments can cause poor nutrient absorption, which
leads to body deficiencies and risk of osteoporotic fracture (Fraser et al., 2013). A CAM
and integrative approach may consider a drug like this in the short term only if really
needed for symptom reduction or to heal a dangerous ulcer. In the meantime, a CAM
approach will work on the underlying factors, such as balancing a patients stress
response, changing diet, modifying meal timing, improving sleeping habits, and using
herbs and nutrients to heal the digestive tract liningtreatments I find work extremely
well in practically all cases.
As the word reflux does not tell us why a person is having digestive discomfort; so too,
the words anxiety and depression do not really tell us much about the underlying causes of
a persons mood issues. When we hear of people with anxiety and/or depression, we know
they are involved in an experience where they do not feel like at their best and are likely
challenged to function optimally in their life. But we dont know why. Holistic medicine
seeks the reason why and to help adjust various factors, such as sleep, movement,
digestion, psychology, and spirit, as well as nutrient and supplement intake, to help the
body balance itself.
SAFETY FIRST
Groucho Marx once said, Be open mindedbut not so open-minded that your brains fall
out. Please remember that while we focus on natural medicine and holistic remedies,
patient safety is always paramount. The complementary aspect of this approach reminds
us that sometimes drugs can also be a friend to the patient, and using natural therapies
instead of needed urgent care can cause harm. Any good clinician considers risk and
benefits with any treatment option and should choose safety first.
In cases where patients are severely impaired (e.g., patients with severe depression,
suicidal ideation, or completely debilitating anxiety), first-line therapy may need to
include medication and sometimes hospitalization for monitoring. In these cases, I
ONE
Before diving head first into exploring complementary and alternative medicine (CAM),
we first need to decide if holistic care is the right choice right now. Good practitioners use
their knowledge and experience to help guide their clients to decide which path is worth
taking and which do not make sense at that time. This chapter should help you answer that
question in regards to holistic care. It gives some statistics about anxiety and depression
and describes how to broach the idea of complementary care. It presents some basic
clinical questions you may want to ask your client in order to determine whether natural
and integrative medicines are appropriate. It will also help to identify safety issues that
may suggest the need for medication, or contraindications that would suggest that, at the
moment, it may be best to avoid holistic or more integrative care in order to focus on
conventional biomedicine.
efficacy of antianxiety medication has not been shown (Committee on the Review of
Medicines, 1980). Addiction to antianxiety medications is also another problem, as druginduced changes in brain function lead to need for higher dosage, withdrawal symptoms,
and greater disability (Mugathan et al., 2011). To sum up, antianxiety medications can
help in the short term but pose clear dangers of addiction, likelihood of withdrawal
problems, and increased risk of death.
Medication Withdrawal
The experience of discontinuation syndrome (the medical term for what really is
withdrawal) is a major challenge for both antidepressant and antianxiety medications.
Symptoms include depression, anxiety, confusion, irritability, dizziness, lack of
coordination, sleeping problems, crying spells, and blurry vision. And these symptoms
herald a larger concern, for research shows that withdrawal itself evokes a major
behavioral stress response (Harvey, McEwen, & Stein, 2003) and can cause significant
neurologic damage through pathways that create nervous system overexcitement. Thus,
the system we are trying to help can end up more damaged and unable to work in the long
term.
As clinicians, we have all witnessed patients who have, unfortunately, stopped their
own medications cold turkey, or could not get a hold of a refill in timethey are not
happy people. Jean Paul Sartres famous existential play No Exit features three characters
with a fear of the unknown. They have a group dynamic of perpetual anxiety, which leaves
them with no ability to flee their situation. In many ways, anxious and depressed patients
given these medications too often have a sense of not being able to ever stop medication
and flee, without serious withdrawal effects. This takes their power away, leaving them
feeling trapped. Holistic care can help bring a sense of power and control back into their
lives.
Psychotherapy Benefits
While I am likely preaching to the choir on this one, I do want to note that psychotherapy
has clearly been shown to be at least as beneficial as drugs in most cases (Cuijpers et al.,
2013). Instead of suppressing symptoms, psychotherapy helps the underlying cause, by
addressing the fundamental thinking that contributes to anxiety and depression. These
thoughts and negative messaging prompt the primitive center of the brain known as the
hypothalamus to overexcite the hypothalamic-pituitary-adrenal (HPA) axis. Short-term
upregulation (increased activity) of the HPA axis can ready the body and help flee danger,
and it is hoped, in the process, learn to protect against future danger. However, sufferers of
anxiety and depression often have long-term upregulation, which leads to chronic
symptoms of anxiety and depression and even increases risks for many diseases, such as
cardiovascular illness, autoimmune disease, and bone loss. In the case of depression,
research clearly shows that relapse rates with psychotherapy are much lower than with
antidepressants (31 percent vs. 76 percent, respectively) (Hollon et al., 2005). Chapter 3
discusses dysregulation of the HPA axis.
yes: Have you ever devised a plan or do you have a plan to do this?
2. Is the anxious or depressed client not able to function in a capacity necessary to
perform basic functions (e.g., going to and being effective at work) and is thus
unable to feed or house himself or herself or dependents? An example of this may
be a single parent whose responsibility is to take care of his children but he cannot
leave his bed and, as a result, is placing the children in jeopardy.
If threat of immediate harm is suspected in either of these considerations, then medication
and supervision of the patient may be needed and should be considered to first to stabilize
your client. Two possible exceptions are cases of pregnancy and breast-feeding, which
should be treated on a case-by-case basis.
If no threat of immediate harm is suspected, then the following questions will help
assess whether holistic care should be first-line therapy:
1.Does your mood stop you from taking care of yourself where you do not bathe or eat
regularly?
2.Does your mood stop you from going to work and doing the basic things you need to
do for yourself?
3.If you have children or people who depend on you, does your mood stop you from
taking proper care of them?
4.Would you prefer trying natural methods to help balance your emotions?
If your client answers yes to any of questions 13, then conventional medication should be
first-line therapy, with natural medicine as an adjunct when possible. If the answer to
question 4 is no, then it is much less likely that holistic therapies will be of value to this
particular client, and you may want to focus on conventional care, for patient preference is
an important predictor of effective care.
If medications are needed help stabilize the patient, natural medicine therapies that
address lifestyle and psychology/spirit, as well as nutrient and supplemental therapies, can
then be considered for the longer term. Chapter 7 reviews how to make recommendations
and design treatment plans to support a patient using medication.
When using pharmaceutical medications, team management by the patients
prescribing doctor, therapist, and CAM provider (naturopathic doctor or other holistic
practitioner) as a core team will afford the best overall care and allow the comanagement
needed to consider future discontinuation of medications when appropriate. This
possibility will be more appropriately realized once other lifestyle, psychological,
physiologic, and nutrient factors are successfully addressed.
As described in the introduction, the team-care approach of a prescribing doctor
(psychiatrist or psychopharmacologist), therapist, and holistic practitioner is the best of all
worlds regarding optimal patient care. Once a decision is made that the patient does not
meet the criteria outlined above that necessitates first-line pharmaceutical intervention, in
team-care fashion, holistically minded recommendations should begin, while remaining
vigilant to changes in the clients condition that could lead him or her to fulfilling the
ego at the door and help the patient find what he or she is looking for, even if it doesnt
include my help.
TWO
OK, great. Now we are moving into the reasons you are reading this book: to identify the
underlying causes of anxiety and depression. Understanding the underlying causes helps
the holistic practitioner pair treatments that are well researched, effective, and safe, as well
as individualized to your client. As a naturopathic physician, I am most excited about
understanding the underlying causes, for this understanding is the key to creating the best
plan. In the alternative medicine world, there are so many treatment solutions: diets to
follow, herbs, vitamins, detoxifications the list is endless. It is seemingly impossible
choose among them all. As a result, holistic care can become a guessing game to the tune
of this herb didnt work, now lets try this vitamin. This shot-in-the-dark approach ends
up frustrating both the patient and the practitioner.
Getting the lay of the land and understanding in depth the details of a clients life will
help to ultimately ferret out underlying issues and make sense of it all, in order to make
the best choices.
Anxiety and depression are typically not caused by one factor. If there were only one
cause, modern medicine would already have a drug or procedure to fix it. As you are
probably already aware, anxiety and depression stem from multiple factors. This chapter
discusses the most important lifestyle factors, to help you organize them in your mind and
ferret out which are the most salient for your clients needs.
to stop his Nexium, without having a return of reflux symptoms. This is likely
because the increased sleep gave his digestive tract more time to heal. Within two
months on the new plan, he stopped using his Xanax. Within 6 months, he weaned
off the Lexapro. I believe that, combined with the psychotherapy he was doing, the
adjustment to sleep helped his digestion. Better digestion helped his
neurotransmitters balance. And the exercise helped burn excess stress hormones.
All these helped him create mood balance.
SLEEP
All animals (including human animals) require sleep. Studies on human sleep deprivation
show how inadequate sleep function increases risk of viral illness, weight gain, problems
with blood sugar imbalance, slowed cognition, and increased brain inflammation
consistent with problematic mood. For instance, Cohen et al. (2009) showed having that
less than 7 hours of sleep each night raises the risk of contracting respiratory viral illness
by 300 percent compared with those who had 8 or more hours of sleep.
Despite the importance of sleep, most of us are not getting enough. People are
sleeping, on average, 20 percent less than we did 100 years ago. For people predisposed to
anxiety and depression, sleeping problems will make mood worse. Sleep challenges
typically precede and occur concomitantly with mood challenges. Insomnia is a wellknown symptom of depression (Ringdahl, Pereira, & Delzell, 2004) and often heralds its
onset or recurrence (Ford & Kamerow, 1989; Buysse et al., 1997). Sleep disturbances are
highly prevalent in anxiety disorders (Staner, 2003); an estimated 90 percent of depressed
patients have insomnia, and about half the population is losing sleep due to anxiety and
stress.
The underlying cause of sleep disorder is different for each person. Typically, there is
no one underlying cause. Instead, a few unbalancing factors are typically at play at the
same time. Unless a person has an exceedingly rare condition called fatal familial
insomnia, people with insomnia can usually fix their sleep patterns with individualized
holistic care. We will go over some of these care options.
it is not, your client may end up with a circadian rhythm disorder. Characteristic
symptoms of this often undiagnosed problem include sleep onset insomnia (I cant get
sleep at night) and waking up multiple times throughout the night, or waking too early in
the morning. Generally people with DSPS feel more alert at night than in the morning
these are the self-proclaimed night owls. Many suffer then from inability to wake up
early enough to get their day goingthese people want to keep sleeping, and then once
they are up, they experience immeasurable and sometimes debilitating fatigue during the
day. By the time night rolls around, they get a second wind that keeps the bad sleep
cycle going. The prevalence of depression and personality disorders in people with DSPS
is very high (Smits & Pandi-Perumal, 2005). Up to 10 percent of high school students
have DSPS and suffer chronic sleep deprivation because their schedule dictates they go to
sleep earlier.
I Snore a Lot
Some patients (or, more often, their sleeping partners) will complain about snoring. While
only about 6 percent of the general population struggle with a type of disturbed sleep
known as sleep apnea where there are irregular breathing cessations of breathing
throughout the night, 20 percent of people with depression have sleep apnea. So,
especially for your clients with depression, you may want to keep this in the back of your
mind. It is best to speak with a sleep specialist or pulmonologist to properly diagnose this
condition. Natural methods to treat this include melatonin (see p. 20), avoiding food
sensitivities (discussed in Chapter 3), and weight loss. If these are not effective, it is worth
considering a continuous positive air pressure (CPAP) machine or possibly surgical
procedures to help open the airway. Patients who have hypertension or are falling asleep
during the day may need to consider the CPAP or surgery sooner for safety reasons
(Milleron, et al., 2004).
needed to help (see more about melatonin with step 7 below and in Chapter 4).
2. Create an evening ritual
I recommend my patients start dimming the lights by 9:00 to 9:30 p.m. and shut down the
TV and computer. My computer has an application called f.lux which is a free
downloadable program that changes the screen light to a less melatonin-suppressing amber
hue in the early evening, which will help curb melatonin suppression while still using the
computer in the early evening. Sipping a calming tea such as chamomile or lavender is
also smart choice at this time. It is best to make a small cup and sip slowly. This way the
bladder does not fill and cause wakefulness during the night. As people create their own
healthy sleep rituals, they will find comfort in consistency, and their body will learn to
calm in preparation for sleep.
3. Lower the lights 30 minutes before bed
Avoid using any bright lights at this time. This includes shutting any computer and e-mail
work, texting, tablet computers, and so forth. Bright light suggests to the body that it is
daylight, which suppresses the release of melatonin. Reading calming literature using a
lamp with an orange light bulb is also helpful to avoid melatonin suppression.
4. Keep the room dark and cool
Melatonin, human growth hormone, and other hormones are needed for repair and
detoxification. These are suppressed when the room is too bright and too warm. If your
client can see their hand when held one foot in front of the face, then the room has too
much light. Consider covering all light sources (like cable boxes, clocks) and keep the cell
phone charging in another room. I also recommend using completely occlusive blinds.
Some of my patients install automatic openers that open the blinds gradually at the right
time in the morning to assure a slow introduction of light. Keeping the temperature around
68 F assures optimal melatonin secretion.
5. Ask about food and blood sugar
Occasionally, eating too late and having too much food in the stomach can inhibit the
natural ability to fall asleep. I have noticed certain patients are also quite sensitive to
individual foods (common ones are wine, spicy foods, and dairy products), which can
keep them up.
Alternately, when people have low blood sugar before bed, it can be equally hard to
fall asleep. When blood sugar is low, this signals our animal brain to go hunt for food and
trigger the release of stress hormones. If this is suspected, eating a small amount of protein
and carbohydrate together (e.g., a little turkey with an apple slice, or nut butter with a rice
cracker) right before bed can be helpful.
6. Journal before bed
Many of us lead very hectic lives and often do not have one quiet moment during the day
until the moment we decide to go to bed. At this time, the brain gets us alone and says,
OK, Ive got you. Lets go over some things, and wants to start processing lots of things,
over and over. This is the moment all the thoughts flood in at one time: family problems,
relationship issues, job stress, financial worries, worries about nuclear war, and so on.
These come at us at once and become overwhelming. Placed in stress mode, the brain and
body cannot shut off.
In these cases, it is a valuable practice to pause for a minute right before bed and jot
down a to-do list for the next day, and/or write down the top issues that are of concern,
and then fold over the paper and put it to the side, to let go of them until the next day.
As a clinician, you may find it valuable to review this written list with your client, to see
what comes up during those nighttime hours. Walt Whitman said: I do not think until I
read what I write. Although jotting them down may not fix the issues of concern, it can
help create some balance by processing them before going to sleep.
7. Natural Remedies for Sleep, If Needed
I encourage patients to try the above steps for two weeks and see if sleeping improves. If it
does not balance out completely, then natural medicines can be amazing to finish the job.
Here are the top natural remedies I will typically use.
Magnesium
Magnesium deficiency is common and is associated with chronic inflammatory stress
(Nielsen, Johnson, & Zeng, 2010). Deficiency will increase dysfunction in the brains
biological clock areas of the suprachiasmatic nuclei and pineal gland (Durlach, 2002) and
disorganize sleep patterns (Murck, 2013). This nontoxic mineral has been shown helpful
in clinical trials for sleep efficiency, sleep duration, sleep onset latency, and early morning
awakening (Abbasi et al., 2012).
Dosing is usually in the range of 400500 mg/day. Many patients will take 250 mg
twice a day, with the last dose right before bed. I often recommend the magnesium
glycinate form, for glycine is an amino acid known for its own calming effect. While there
is no known toxicity associated with magnesium, some sensitive individuals can have
loose bowel movements with extra magnesium intake. In this case, the dose needs to be
scaled back.
Melatonin
Studies from the 1980s have shown that low or delayed melatonin levels can contribute to
depression (Beck-Friis et al., 1984) and anxiety (Toffol et al., 2014). A powerful
antioxidant, it protects brain and nervous tissue (Garcia et al., 1997). As a supplement, it
was originally known to fix jet lag and is now known to help fight cancer (Al-Omary,
2013) and may even increase efficacy of chemotherapy (Lissoni, 2007).
Melatonin supplements are sold in dosages from 0.5 mg up to 20 mg. Regular (nontime-released) melatonin is best to help calm the body and let it know when it is time to
fall asleep. Time-released (also known as sustained released) melatonin can be used for
trouble falling asleep that occurs with difficulty staying asleep. Melatonin is quite safe and
nonaddictive and is even used with children. A typical adult dose is 13 mg a half hour
before the desired bedtime. Studies with DSPS have used very low melatonin doses of
0.125 mg in the late afternoon and evening, each dose 4 hours apart (e.g., at 4 p.m. and
again at 8 p.m.). If your client finds using a single before-bedtime dose is not working,
then try the low doses given at 4 and 8 p.m. Adolescents with DSPS have been given
doses of 0.35 mg (Alldredge et al., 2012) to help retrain normal sleeping patterns. If a
client is having trouble staying asleep, but not falling asleep, time-released melatonin in
doses of 36 mg may help to keep a person from waking during the night.
While melatonin has no toxicity in the doses described above, it is best to scale it back
if the patient feels groggy in the morning after use. Some research suggests that elevated
melatonin levels are associated with exacerbations in nocturnal asthma, so melatonin
should be avoided in someone who has nighttime asthmatic symptoms (Sutherland et al.,
2003).
Melatonin versus sleep medications
Studies comparing hypnotic medication with melatonin found that melatonin caused no
postural instability in seniors, whereas zolpidem (Ambien) impaired stability and caused
body sway, a strong risk factor for falling (Otmani et al., 2012). Two studies comparing
melatonin with Ambien found that melatonin had sleep benefits without the next-day
cognitive, attention, psychomotor, or driving impairments reported with the zolpidem
(Wesensten et al., 2005; Otmani et al., 2008). In my practice, it is common to use both
melatonin, and sleep medications like zolpidem, especially when the sleep drugs stop
working. While most research combining melatonin and zolpidem show no negative
interactions, some research with extended-release zolpidem (Ambien CR) showed
increased psychomotor impairments (Otmani et al., 2008). As a precaution, it is best to
start on low doses of melatonin (around 1mg) and increase as needed until desired effect is
achieved, while monitoring for daytime sleepiness and any impairment.
Natural food sources of melatonin
Oats (Avena sativa) are known to have a calming effect on the body and contain very
small amounts melatonin. However, to get the same amount of melatonin that is found in a
supplement pill, one would need to eat about 20 bowls of oats. Montmorency tart cherries,
ginger, tomatoes, bananas, and barley also contain very minute amounts of melatonin
(Iowa State University Extension and Outreach, 2009). One study of tart cherry juice
found a modest effect on sleep (Pigeon et al., 2010), and it might work well for mild
insomnia issues.
L-Tryptophan
L-Tryptophan is a naturally derived amino acid that serves as a precursor to serotonin.
Depletion of tryptophan contributes to generalized anxiety and panic attacks (Klaassen et
al., 1998), and L-tryptophan levels are significantly lower in depressed subjects than in
normal controls (Maes et al., 1997c). Low levels of tryptophan do not allow the body to
manufacture enough serotonin. Lowered levels of serotonin can be a reason for poor sleep,
especially for staying asleep.
Dosage at bedtime is usually 5001,000 mg, while some patients may need up to 2,500
mg. For best absorption to the brain, it is best to take with a slice of simple carbohydrate
(like an apple slice), because the carbohydrate will increase insulin levels, and insulin will
Valerian
Valerian is the best-studied herbal medicine for sleep. The root word valere comes from
the Latin term for good health. Please note that valerian has no relationship to Valium,
except for the fact that both names share the same first three letters. Valerian is especially
helpful for people who focus stress in their gut (nervous stomach) and when there is a
strong anxiety component accompanying inability to sleep. This herb has constituents that
act to inhibit sympathetic nervous system neurons by enhancing levels of gammaaminobutyric acid (GABA), a brain-calming neurotransmitter. The sympathetic nervous
system activates the stress response in our body, sometimes called the flight-or-flight
response.
A meta-analysis of 18 randomized controlled clinical trials suggests benefit using
valerian (Fernndez-San-Martn et al., 2010). In one randomized, triple-blind, controlled
trial of 100 postmenopausal women, 530 mg of concentrated valerian extract given twice a
day for 4 weeks resulted in better sleep quality compared with placebo. While most
studies report positive effects, one randomized trial did not find benefit, although this
study was in a small group of 16 women and used suboptimal dosing of 300 mg once a
day before bed (Taibi et al., 2009). It is possible that using higher doses typically
recommended may have showed benefit.
Valerian can also help with staying asleep when trying to wean off anxiety
medications. In rat studies, valerian has been shown to help alleviate withdrawal
syndrome resulting from the removal of diazepam (Valium) following prolonged periods
of administration (Andreatini & Leite, 1994), while not showing any toxic effects (Tufik et
al., 1994). A team out of Brazil had a similar notion when they prescribed valerian (100
mg three times a day, with 80 percent didrovaltrate, 15 percent valtrate, and 5 percent
acelvaltrate from valerian root) to help patients with insomnia tolerate withdrawal from
benzodiazepines. These 19 patients (averaging 43 years of age) were using
benzodiazepines every night for an average of 7 years but still had poor sleep and were
matched to 18 control subjects. Electroencephalogram patterns were studied during sleep
while still on the benzodiazepines, and then for 2 weeks after while taking either valerian
or placebo. The patients taking valerian reported significantly better subjective sleep
quality than those on placebo after benzodiazepine withdrawal, despite the presence of a
few withdrawal side effects from the medications. At the end of 2 weeks, there was a
significant decrease in nighttime waking time after sleep onset in valerian subjects
compared with placebo subjects. Nonetheless, valerian-treated patients did show increased
alpha waves (corresponding to more difficulty falling asleep) as well as longer blocks of
sleep latency than did control subjects. Despite subjective improvement, sleep data
showed that valerian did not actually produce faster sleep onset, which was likely due to
the medication withdrawal hyperarousal (a state where the withdrawal of the medication
keeps the patient in a more awake state). The authors concluded that, overall, valerian was
well tolerated and had a positive effect on withdrawal from benzodiazepine use, with no
interactions between the two (Poyares et al., 2002).
Typical dosage of valerian is 450600 mg about 2 hours before bedtime. Patients with
daily anxiety or needing more sleep support may add an early afternoon dose. In many
cases, valerian works best when taken over a few weeks rather than acutely. While safety
has been shown in trials of children (Francis & Dempster, 2002) and in the senior
population, it has not been evaluated in pregnancy. The active components of valerian may
increase benzodiazepine activity and should be monitored by a physician if used with
these medications.
Supplements in combination?
While any of the above supplements can be of value alone, CAM practitioners typically
combine some of these for even better results. For example, one double-blind study from
Italy used 5 mg melatonin and 225 mg magnesium taken 1 hour before bedtime. Results
showed significant improvements in sleep scores, as well as quality sleep, and alertness
the following morning (Rondanelli et al., 2011). Very often I will start by recommending
one supplement at a time and then add others after a few days if the one supplement does
not create the full effect.
FOOD
If you have a dog with anxiousness, inflammation, digestive issues, or virtually any
problem, when you bring the dog to a veterinarian, what is the first thing the vet asks?
What are you feeding this dog? This is because the vet is trained to know that what the
So, how much protein should your clients be getting? To help understand how much
protein a person generally needs, you can use the formula
[weight (lb)/2.2 lb] 0.8 g = grams of protein you need per day.
For example, a 120-pound person will require about 44 g protein. (Note that elite athletes
should multiply by 1.2 g instead of 0.8 g; a person with kidney disease may need to
decrease protein intake below the formulas recommendation.)
The healthiest protein sources are beans, raw nuts and seeds, tofu, fish and natural
poultry, and grass-fed meats.
Fish and healthy oils
There is ample evidence showing correlations between low seafood consumption and
higher rates of mood disorder. Conversely, solid research also tells us that higher intake of
fish may help prevent and treat anxiety and depression.
Seafood intake is shown to lower both anxiety and depression. One study showed that
the likelihood of anxiety was 43 percent higher for those who rarely or never ate dark and
oily fish compared with those that ate it one to three times a week or more (Vaz et al.,
2013). A thorough review spanning 13 countries demonstrated that there is an inverse
relationship between intake of fish and depression (Hibbeln, 1998).
There are two main types of healthy omega-3 fatty acids in fish: eicosapentanoic acid
(EPA) and docosahexanoic acid (DHA). It is believed that these substances help balance
inflammation in the body and brain and lower the likelihood of mood disorder. These
omega-3 fats are especially high in wild salmon, striped bass, mackerel, rainbow trout,
halibut, and sardines. While science is still trying to understand whether EPA or DHA is
more important, it is clear that individuals with anxiety and depression who eat less fish
show marked depletions in omega-3 fatty acids in blood cell fats compared with people
who do not have these mood disorders (Jacka et al., 2013), and these lower levels correlate
with more anxious and depressive states.
The standard American diet (with the apt acronym SAD) tends to be quite low in
healthy omega-3 fish oil and high in omega-6 oils. Omega-6 fatty acids are found in
saturated fats and red meats. It is well established that diets with high omega-6 to omega-3
ratios increase the risk of heart disease, as well as contribute to mood problems. Swedish
researchers looked at senior patients and found that depressive symptoms and markers of
inflammation increased with higher ratios of omega-6 to omega-3 fatty acids. They
concluded that diets with high ratios can increase the risk of not only cardiovascular
disease but also depression (Kotani et al., 2006).
Because the brain and nervous system are made of mostly fats and water, it stands to
reason that healthful dietary fats are crucial for the mood of your clients. While we focus
on the omega-3 fats, healthy oils such as cold-pressed extra virgin olive oil (which consist
healthy omega-9 fats or oleic acids) and flax oils are also highly recommended. Organic
and natural foods and wild fishes are preferred due to the lower levels of pesticides,
neurotoxins, and metals that may play a role in some mood illnesses.
germs boost mood in two important ways: they generate a brain-calming neurotransmitter
called gamma-aminobutyric acid (GABA), and they enhance the brain receptors for
GABA. GABA is calming amino acid, known to calm areas of the brain that are
overactive in anxiety and panic.
Bravo et al. (2011), working with mice, showed those mice that ingested probiotics
were, in general, more chilled out than the control mice. The probiotics-fed mice had
lower levels of corticosterone in response to stresscorticosterone is the mouse version of
the human stress hormone cortisol. High levels of cortisol are common in both anxiety and
depression. These mice were fed a broth either with the probiotic strain Lactobacillus
rhamnosus or without these bacteria. The lactobacillus-fed animals showed significantly
fewer stress, anxiety and depression-related behaviors than those fed with just broth.
Human studies have also corroborated these mouse findings. Messaoudi et al. (2011),
in a double-blind, placebo-controlled, randomized parallel group study, learned that giving
humans specific strains of Lactobacillus and Bifidobacterium for 30 days yielded
beneficial psychological effects, including lowered depression, less anger, hostility, and
anxiety, and better problem solving, compared with the placebo group.
While a healthy microbiome will contribute to good mood, an unhealthy one full of
Candida albicans (yeast), and all the toxins associated with it, may also contribute to
mood disorder. Presence of yeast will alter the ability to absorb nutrients and push
hypersensitivity reactions to toxin by-products, which translates to inflammation in the
body. Inflammation will greatly contribute to depression, anxiety, and poor mental
function (Rucklidge, 2013).
Unhealthy microbiome yeast buildup toxic by-products hypersensitivity
reactions inflammation mood problems (anxiety and depression)
While Messaoudi et al. (2011) gave a supplement, there are also many wonderful
natural foods full of probiotics. These include natto (a traditional Japanese fermented
food), kimchi (Korean-style fermented vegetables), yogurt, kefir, tempeh, fermented milk
(e.g., buttermilk), miso, and nonbaked cheeses (e.g., aged cheese). Sauerkraut is also a
good probiotic source, however, store-bought sauerkraut has less of the healthy probiotics
due to pasteurization and preservative content, so obtaining freshly made versions may be
best.
Crunchy vegetables
Notice how most people get pleasure from crunchy foodsthe idea that someone cant
eat just one? Theres a scientific reason why we go for these. Its because crunching
makes people feel happier (when they are doing the crunching themselvesnot so much
when someone right next to you is the cruncher). Hoch et al. (2013) used enhanced MRI
technology with rats given either regular chow or crunchy snacks to figure out the reasons
behind hedonic hyperphagia (which means eating to excess for pleasure). He found that
crunchy snacks activate many more brain reward centers than the noncrunchy chow. Other
research suggests that the crunching sound allows pleasure centers to release more
endorphins. Because crunchy food calms, this can be used to help anxiety.
That said, when people eat too many calories from junky-crunchy foods, they tend to
feel even worse. So, instead of unhealthy chips and cookies, we will want to recommend
healthful crunch foods, such a carrots, celery, and peppers. Also, a number of healthy lowtemperature-baked snacks, such as flax meal crackers and high-bran-fiber crackers, can
also do the job. Nuts are great, too, but should be raw (see below for why).
Foods to Avoid
As healthy foods can help support a health nervous system and good mood, poor-quality
foods will work against the best health of your client. This discussion about food started
with foods that are healthy, for this is the best place to start. With most patients, often it is
not effective to begin by focusing on what they should not eat. I have learned that if we
start with foods to avoid, patients will feel deprived and sometimes angry, and they may
have the opposite reaction, eating even more of the unhealthy foods as a way to gain a
sense of control or as a type of backlash reaction.
As such, it is best to start by having your client add foods that are healthful. For
example, if a client eats fast foods three times a day, a movement it the right direction
might be to suggest he or she eat a rib of celery between breakfast and lunch and an apple
between lunch and dinner. As the patient accomplishes these small tasks, then you can add
others (e.g., a cup of greens with dinner and a glass of water in the morning). In my
experience, as patients feel healthier and more empowered, eventually the unhealthy foods
start to decrease without the sense of being deprived.
Also, it is important to check patient taste preferences. Research shows that the brain
reacts similarly to both something morally violating and a taste that is unpleasant, so
among the healthy foods, pick ones that the patient finds palatableunpleasant tastes may
exacerbate negative mood.
High glycemic foods
Sugary foods (juices, cakes, cookies, candy) and simple carbohydrate foods (breads, pasta,
rice) are known as high glycemic foods. These foods contain higher levels of easily
absorbed sugar, which triggers any disease to which someone may be predisposed, and
contributes in the long term to diabetes, dementia, heart disease, and cancer.
Specific to mood disorder, high consumption of sugars and carbohydrates causes
depletion of important minerals, such as magnesium (Barbagallo & Resnick, 1994;
Pennington, 2000). Minerals are important cofactors for the production of
neurotransmitters and help minimize the effect of toxic burden (see more about minerals
in Chapter 4).
High-glycemic foods also trigger release of excess insulin. Insulin drives
inflammation. Brain inflammation contributes to mood problems. Higher insulin levels
also will drop blood sugar below normal values, making someone hungry. Hunger and
hypoglycemia (low blood sugar) are primitive signals known to set off the stress response
in a person. In people who are predisposed, anxiety and depression can be common segues
to this stress response.
Unhealthy fats
Which foods are most damaging to mood? In contrast to the benefit of healthy fats,
hydrogenated oils, highly heated vegetable oil, fried foods, and non-grass-fed animalbased saturated fats are best avoided. While the healthy fats keep nervous system
membranes fluid and calm inflammatory pathways in the body, unhealthy fats will replace
the good fats in cell membranes and make them rigid, not allowing toxins to clear or
nutrients to get in. Immune system cell membranes that lack fluidity also contribute to
inflammation.
Foods additives
Food additives such as artificial colors, glutamate, and artificial sweeteners have all been
linked to mood problems. While there are strict FDA guidelines for food additives, the
safety of these not been rigorously proven, with most studies being conducted by the
companies that produce them.
Artificial colors. Color additives have been linked to conduct and mood disorders (Schab
& Trinh, 2004) and attention issues in children. A study by Kamel and El-lethey (2011) in
animals showed that those taking in both low and high doses of tartrazine (as FD&C
Yellow no. 5) exhibited increased hyperactivity, with significant promotion of anxiety
responses. Depression responses were also greatly heightened compared with animals not
exposed to tartrazine. The authors concluded that the study points to the hazardous
impact of tartrazine on public health. Human studies have also linked anxiety to these
chemicals (Rowe & Rowe, 1994). Tartrazine is used in colored foods, candies, and even
medications used for mood.
Glutamate. Glutamate is an excitatory neurotransmitter our brain produces in small
physiologic amounts as a by-product of everyday cell metabolism. Monosodium glutamate
(MSG) is the salt form of glutamate. While this compound does occur naturally in some
foods (including hydrolyzed vegetable protein, yeasts, soy extracts, protein isolates,
cheese, and tomatoes), the additive MSG is used in high amounts primarily to enhance
taste. While the FDA considers the additive MSG as to be generally recognized as safe
(GRAS), it can be toxic to the brain and mood. In fact, excess glutamate is more cytotoxic
to neurons than is cyanide (Mark et al., 2001), and studies show that levels of glutamate in
patients with depression are significantly higher than in healthy people (Kim et al., 1982).
Many people react to Chinese food, which often has a large amount of added MSGthese
people probably have a larger stores of glutamate already and/or are not able to detoxify it.
While the brain uses a very sophisticated system to remove glutamate, inflammation and
heavy metal burden can decrease its ability to remove it. People with anxiety and
depression should avoid taking it in altogether.
Artificial sweeteners. Artificial sweeteners (e.g., saccharin, aspartame, sucralose,
acesulfame potassium) are also known to possess toxic effects on the nervous system and
may directly assault the neurotransmitters of mood. A study by Yokogoshi et al. (1984)
revealed that aspartame may contribute to abnormal balance in the neurotransmitter
serotonin. Anxiety relief has been reported in numerous cases by removing ingestion of
aspartame, with recurrence upon reexposure (Roberts, 1988). One large study (Butchko et
al., 2002) did find aspartame as safe with no unresolved questions regarding its safety;
it should be noted this study was funded by the NutraSweet Company.
As the most-used psychoactive drug of all time, coffee is an interesting case. Studies show
some wonderful positive health effects for coffee. It can decrease a prediabetics risk for
developing diabetes, lower incidence of bile tract and liver cancer, and even help prevent
heart attacks after a meal. In fact, a review of larger epidemiologic studies (Bhatti et al.,
2013) shows regular coffee consumption to reduce mortality, both for all-cause and for
cardiovascular deaths. Coffee is associated with lower risk of dementia and Alzheimers
Disease, with the lowest risk (a 65% decrease) was found in people who drank 3 to 5 cups
per day from mid-life onward (Eskelinen et al., 2009). In addition, coffee intake is
associated with lower rates of heart failure, stroke, diabetes mellitus, and some cancers.
As far as mood is concerned, coffee can be both beneficial and harmful. So what about
your client? As with many questions in holistic medicine, the answer here is, It depends
on the individual.
The positive mood effects of coffee lie in caffeines ability to increase a sense of
euphoria, as well as increase sense of energylikely by helping the brain produce
dopamine in the brains prefrontal cortex, an area important for mood regulation. In a 10year cohort study of more than 50,000 older women, investigators found that, compared
with those who drank 1 cup or less of caffeinated coffee per week, those who drank two to
three cups per day had a 15 percent decreased risk for depression, and those who drank
four cups or more had a 20 percent decreased risk (Lucas et al., 2011). For people
predisposed to depression, daily intake may make good sense.
However, there is a threshold for coffees benefit. Tanskanen et al. (2000) found that,
although the risk for suicide decreased progressively for those consuming up to seven cups
of coffee per day, the risk started increasing when consumption exceeded eight cups a day.
Also noteworthy is that decaffeinated coffee, caffeinated tea, and chocolate did not have
positive effects.
Whether coffee is best for your client really depends on his or her particular situation.
Long-term coffee use can contribute to burnout in people who are already depleted and
deficient. Also, caffeine at high doses can encourage loss of minerals, such as magnesium,
which is an important cofactor in brain neurotransmitters. Coffee may also contribute to
fluctuations in blood sugar, which can raise anxiety levels. Caffeine-sensitive individuals
may see more insomnia. As discussed above, poor sleep will promote both anxiety and
depression in predisposed individuals.
Coffee and green tea research out of Japan was also very positive for depression
support. In a study of 537 people by Pham (2014), among the green tea drinkers, those
drinking two to three cups a day were 41 percent less depressed than those who drank one
cup or less. Among coffee drinkers, those who drank more than one cup per day had a 26
percent lower chance of becoming depressed, and those drinking more than two cups had
a 40 percent decreased risk. In both groups, higher caffeine correlated with lower
depression risk.
Originally used by the Chinese over 4,700 years ago, green teas first well-known use
was by monks, who used it to attain a state of relaxed wakefulness while meditating.
While the caffeine content is likely responsible for this effect, two other components may
account for the relaxation effect. Studies in animals suggest that the green tea polyphenol
epigallocatechin gallate can induce anxiolytic (anxiety relieving) activity via interaction
with brain GABA receptors (Vignes et al., 2006)receptors that are exploited with
anxiety-relieving drugs like alprazolam (Xanax). Green tea also has theanine, a naturally
occurring amino acid that has anxiety-improving and blood-pressure-lowering effects,
even in people who had high blood pressure increases in response to stress (Yoto et al.,
2012b).
It seems that coffee is beneficial for those susceptible to low mood, low motivation,
and depression, but it can often be disruptive for people with anxiety and should probably
be avoided in anyone who is osteoporotic or has a tendency for insomnia. Green tea can be
helpful for both anxiety and depression, but I would caution its use in people with anxiety
who are especially caffeine sensitive.
Foods to Avoid:
High glycemic foods (sugary foods and simple carbohydrates).
Unhealthy saturated fats
Foods additives: MSG, dyes, FDA colors, artificial sweeteners
Coffee: best for depressive mood, avoid with anxiety and insomnia
Green tea: OK for depression and in anxiety patients who are not caffeine sensitive
EXERCISE
Known since the times of Hippocrates as a mood balancer, exercise protects the brain
areas needed for stable mood. Experts believe it may be the most effective treatment for
both anxiety and depression. Exercise has been shown to reduce anxiety and depression
and to slash negative mood, while simultaneously improving self-esteem and even
memory (Callaghan, 2004; Coventry et al., 2013).
Exercise has also been shown to maintain the brains hippocampus, an area vital to mood,
spatial relationships, and memory. A study of 120 older adults with dementia by Erickson
et al. (2011) showed the after 1 year, subjects who performed moderate-intensity aerobic
exercise 3 days a week increased hippocampal volume by 2 percentand effectively
reversed any age-related loss in brain volume. Expected brain loss was seen in the group
who did not exercise aerobically, but instead did only stretching and toning work.
SUNLIGHT
Hippocrates, the father of medicine, also recognized that people with mood challenges
needed plenty of sunlight. Three ways healthful exposure to sunlight can help mood is by
keeping healthful levels of serotonin, balancing circadian rhythm, and building up vitamin
D stores. John Denver sang Sunlight on my shoulders makes me happy. While I am not
sure he ran a clinical trial on this, he did seem to have a clear understanding of sunlights
benefit on mood.
Figure 2.1.
studies have also shown how serotonin transporters, which will bind up and inactivate
serotonin, are more plentiful in the brain during dark periods (Praschak-Rieder et al.,
2008). Darkness sends a signal to our bodies to stay low.
Figure 2.3.
One fascinating medical outcome study by Ulrich, Lundn, and Eltinge (1993)
compared the recovery from gall bladder surgery among patients who had a bedside
window view of either trees or a brick building wall and those with no nature view. Those
with the nature view had shorter hospital stays and suffered fewer minor postsurgical
complications, such as persistent headache or nausea. Furthermore, patients with the view
of trees were more frequently reported by hospital staff as in good spirits. Those in the
wall view group elicited far more negative evaluations, including the patient is upset
and patient needs much encouragement. Even more impressive, the patients with tree
view needed far fewer doses of strong narcotic pain drugs.
In Japan, there is a practice called Shinrin-yoku (forest bathing), which is known for
its health benefits, including mental health and support of the immune system. Forest
bathing involves visiting a forest for relaxation and breathing in the air, which has
molecules given off by the trees. A 2007 paper from Nippon Medical School looked at 12
healthy males 3755 years of age who took a three-day and two-night trip through nature
while researchers took blood and urine samples at various intervals. On the first day,
subjects walked for two hours in the afternoon in a forest field. On the second day, they
walked for two hours in the morning and afternoon, respectively, in two different forest
fields. Blood was sampled on the second and third days. Natural killer cells and other
intracellular anticancer proteins were significantly higher (about 50%) on the forest
bathing days than before. Moreover, levels of natural killer cells stayed elevated for 30
days after the trip. In addition, the study found that levels of the stress hormone
adrenaline, which the body releases in response to anxiety, had dropped after forest
bathing trips (Li et al., 2007).
Factors from the plant kingdom that may provide beneficial physiologic effects
include the aroma of plants, as well as such various factors as temperature, humidity, light
intensity, wind, and oxygen concentrations. It is suggested that the natural aromatherapy
found in the forest in the forms of antimicrobial organic compounds called phytoncides
may signal the brain to help release immune-related compounds. Other corroborating
studies in seniors have found that forest exposure helps lower cortisol, blood pressure,
heart rate, and inflammation, while enhancing parasympathetic activity (Mao et al., 2012).
Parasympathetic activity refers to the relaxation response of the autonomic nervous system
and is sometimes called the rest and digest response.
Two Ways to Get into the Light: Nature Cure and a Light Box
Probably the simplest nature cure therapy is to get out into nature. Encouraging clients to
take an early morning walk outside or sitting or moving in the park is a great start. When
the weather is amenable, it is healthful to try to get at least 50 percent of the body exposed
to the sun for 1020 minutes a day. One journal reports that 12 min of exposure of 50
percent of body skin to noontime sun on a clear day is equivalent to oral intake of 3,000
IU vitamin D3 (Garland et al., 2007). For most people, this will not cause damage but will
start the vitamin D process. It is a good rule to get out of the sun if one starts to see the
skin turning pink or red. Any fair-skinned people or those with personal or family history
of skin cancer may need to check with their doctor first and consider vitamin D
supplementation or a phototherapy light box.
A second step, if needed, would be phototherapy, or light box therapy. While this is
most often used in depressive illness and seasonal affective disorder, many of my patients
with anxiety and insomnia patients who have imbalanced cortisol patterns (where cortisol
is up at night, and low during the day) tend to see benefit as well. Typical light box
therapy uses a 10,000-lux full-spectrum white light for at least 30 minutes every morning.
Smaller-power light boxes do not seem to provide the same benefit.
HYDROTHERAPY
Mankind used to spend much more time outdoors, exposing ourselves to variations of
temperature in certain geographic regions, especially when submerged in water.
Hydrotherapy (also known as water therapy) may be defined as the application of water
for the maintenance of health or the treatment of disease (Barry & Lewis, 2006).
Hydrotherapy has been employed since ancient times as a way to balance the body and
mind. According to Hippocrates, water therapy llays lassitude.
Therapeutic water therapy applies water at temperatures above or below the body
temperatureand this can help change our physiology and mood. When humans take a
cold swim, once over the initial shock of the cold, it is usually very invigorating. This is
because wet and cold causes our surface vessels to vasoconstrict (tighten up), making
blood move from the surface of your body to the core, as a means to conserve heat. It not
only conserves heat but also reflexively bathes the brain and vital organs in fresh blood, as
well as gently detoxifying the body. Throughout our millions of years of evolution,
primates have endured physiologic stressors like temporary cold and heat temperature
changes as a part of daily life. Hydrotherapy is designed to take advantage of the natural
body reaction. It has been theorized that brief changes in body temperature like a cold
swim or warm bathing could help brain function.
Medical research has supported the use of hot and cold baths as well. Decreases in
cortisol levels have been reported with water bathing (Toda et al., 2006), likely because
the affinity of the serotonin transporter increases (Marazziti et al., 2007). Warm footbaths
have been shown to induce relaxation by decreasing both sympathetic nervous function
and serum cortisol levels (Yamamoto et al., 2008).
While used extensively for hundreds of years as a part German water cure, relatively
little clinical research has been done to study hydrotherapy for mood. One study suggests
that patients with anxiety can benefit from the mechanisms of hydrotherapy.
Balneotherapy (using water baths for healing) was compared with paroxetine (Paxil), a
leading selective serotonin reuptake inhibitor, by Dubois et al. (2010). In a randomized 8week multimember study, 117 of 237 patients with generalized anxiety disorder were
assigned randomly to balneotherapy, and the remainder to paroxetine. The balneotherapy
treatment consisted of weekly medical visits and daily bath treatments using natural
mineral waters (containing sodium, calcium, magnesium, and sulfates) for 21 days. Every
morning, patients were immersed in a bubbling bath (37C for 10 min). Next, they took a
shower with a firm massage-like pressure targeting the abdominal, paravertebral, and
cervicobrachial regions (for 3 min), and then their legs as well as cervicoscapular and
paravertebral areas were massaged under water (10 min). Sounds nicer than taking a drug
for sure! The mean change in HAM-A scores showed an improvement in both groups,
with a clearly superior result of the water therapy compared with the effect of the drug.
Sustained response rates were also significantly higher in the hydrotherapy group
(respectively, 19 percent vs. 7 percent, and 51 percent vs. 28 percent). The water therapy
was found to be safe and without side effects as well.
One group of researchers suggest that hydrotherapy may be useful to treat cancer and
chronic fatigue (Schevchuk & Radoja, 2007) and depression (Schevchuk, 2008). For the
treatment of depression, it is suggested that cold exposure therapies may be the best
choice. Because the density of cold receptors (the structures that sense cold) in the skin is
thought to be 310 times higher than that of warm receptors (Iggo & Iggo, 1971), the
simultaneous firing of all skin-based cold receptors caused by jumping into cold water
may result in a positive therapeutic effect. Lowering the temperature of the brain is known
to have neuroprotective and therapeutic effects and can relieve inflammation (Arrica &
Bissonette, 2007), a known mechanism in depressive illness (see Chapter 4 for more on
inflammation). In addition, exposure to cold has been shown to activate the sympathetic
nervous system, increase blood levels and brain release of norepinephrine (Jedema et al.,
2001), and help increase production of beta-endorphin, a feel good molecule that gives a
sense of well-being (Vaswani, Richard, & Tejwani, 1988).
It has also been analogized that cold hydrotherapy may have a mechanism similar to
that of electric shock therapy, another proven antidepressant treatment that has long been
used to treat drug-resistant forms of depression. These effects may well help depressed
patients, especially those who do well with increased release of norepinephrine, such as
patients who respond well to duloxetine, or other serotonin-norepinephrine reuptake
inhibitors that help increase the neurotransmitter norepinephrine.
I recommend patients with depression to use brief whole-body exposure to cold water
in the form of a cold shower. Patients can start a shower at a comfortable warm
temperature and slowly cool the water over a 5-minute period down to 68F, at which
point you can sustain for 23 minutes, using a thermometer to check the temperature. This
can be performed once or twice a day and may be continued for weeks to several months
(Shevchuk, 2008). Although mild cold stress seems to help the brain work better, animal
research has shown that extreme cold stress may actually impair cognitive function
(Mahoney et al., 2007)suggesting too cold is not good.
The Brain on TV
T. S. Eliot said, The remarkable thing about television is that it permits several million
people to laugh at the same joke and still feel lonely. Televisions role in influencing the
mental and physical state of our society has been profound. Most people seem to enjoy
coming home at night and turning on the TV. Like any opiate, it is a way for many to get
away from the stress of our day. And, in fact, in the short term TV seems to have a
relaxing effect. Studies using functional MRI during TV viewing have determined that
humorous television programming can activate the insular cortex and amygdala, which are
brain areas activated and needed for balanced mood (Moran et al., 2004).
Unfortunately, longer-term use of TV seems to create problems; for instance, watching
television over 2 hours per day and eating while watching television are each associated
with obesity (Johnson et al., 2006). In our country, two-thirds are overweight or obese
(Ogden et al., 2012), and obesity is a leading cause of a lower life expectancy,
cardiovascular disease, cancer, and diabetes. Even more, it is setting us up for mood
disorder early: each extra daily hour of television watching among children is associated
with an 8 percent increase in developing depressive symptoms by young adulthood
(Primack, et al., 2009). Television time is also taking us away from more healthful
activities: although many people report lack of time as a major barrier to doing regular
exercise, the average American adult spends over 4 hours each day watching television.
Analysis of over 30 years of U.S. national data shows that spending time watching
television may contribute to viewers happiness in the moment, but the longer-term effects
are not good. In a study by Robinson and Martin (2008), participants reported that on a
scale from 0 (dislike) to 10 (greatly enjoy), TV watching was nearly an 8. Despite these
high marks, it seems that the enjoyment from TV was very short lasting, and eventually
gave way to discontent. Unhappy people reported watching 25 hours of television a week,
compared with 19 hours for happy peoplea 30 percent difference (but still quite an
alarming number). These results held even after taking into account education, income,
age, and marital status. These data from nearly 30,000 adults led Robinson and Martin
(2008) to conclude that
TV doesnt really seem to satisfy people over the long haul the way that social involvement or reading a
newspaper does. We looked at eight to ten activities that happy people engage in, and for each one, the people
who did the activities morevisiting others, going to church, all those thingswere more happy. TV was the
one activity that showed a negative relationship. Unhappy people did it more, and happy people did it less. The
data suggest to us that the TV habit may offer short-run pleasure at the expense of long-term malaise.
social phobia, panic disorders, and anxiety, those who used online CBT showed about a 50
percent improvement (Andrews et al., 2010), which is pretty good result for a single
medical therapy. I was most struck by a comment by Dr. Gavin Andrews, a psychiatry
professor from Australia who headed the study: There was no hint of relapse reported in
any study, which is just foreign to my experience. Depression is supposed to be a relapsing
and recurring disorder. What on earth is it doing just disappearing after someone does
CBT over the Web? This is not what any of us were trained for (Andrews et al., 2010).
A study by DMello (2011) recounted the experience of 26 patients hospitalized for
severe depression from an adult in-patient psychiatry unit. These subjects mood states
improved significantly after using one 60-minute computer-assisted CBT session. It is
pretty astounding that only one session could have any effect at all, for severely depressed
patients from an in-patient ward are the toughest to treat.
THREE
perspective there are many tests that can help a holistic clinician care for a patients best
mood by explaining some aspects of physiology that may be contributing to the
underlying causes of the mood issues. It is true that a single test never cured anything by
itself, but using lab testing wisely can help the holistic practitioner understand, in part,
how to create and individualize a holistic treatment plan.
think about suicide. Maes et al. (1997a), looking at HDL levels and mood, concluded that
HDL cholesterol can be used as a marker for major depression and suicidal behavior. No
correlations with low HDL and anxiety are known.
How to treat low HDL. If HDL cholesterol levels are in the low range (usually <40 mg/dL
for men and <50 mg/dL for women), holistic recommendations such as stopping smoking
(Dwyer et al., 1998), exercise (Hata & Nakajima, 2000), and intake of fish oil (Peterson et
al., 2002), as well as moderate alcohol consumption (one to two drinks a day; Ellison et
al., 2004), are all known to help naturally increase HDL cholesterol levels. Foods that can
help include oranges, dark chocolate, extra virgin olive oil, and hibiscus and black teas.
The fiber supplement beta-glucan can also raise good cholesterol levels.
Homocysteine
Derived from sulfur and methionine, homocysteine in high levels is directly related to
depression. It is a well-known marker of inflammation and an independent risk factor for
cardiovascular disease (Sun et al., 2009), and it may be a more accurate marker of
cardiovascular risk than cholesterol. In a large study of 3,752 men 70 or more years of
age, an increase in plasma homocysteine was associated with a significantly increased risk
of depression. Research shows that approximately 4555 percent of patients with
depression develop significantly elevated serum homocysteine. There is evidence
suggesting that lower levels of homocysteine may decrease the incidence of depression in
the elderly (Almeida, 2008). B vitamin treatment of celiac patients with high
homocysteine lowered homocysteine, which correlated with significant improvement in
well-being, most notably anxiety and depressed mood (Hallert et al., 2009).
Homocysteinemia may have anxiogenic effects, too (Hrnc i et al., 2013). High
homocysteine in the blood causes a decrease in S-adenosylmethionine (SAMe), a
compound made out of the amino acid methionine that has been shown to specifically help
depression. (SAMe is discussed in Chapter 4.) Having inadequate amounts of SAMe
impairs your bodys ability to make brain neurotransmitters. There is a strong correlation
between high homocysteine and trauma of the endothelium (inner lining) of the blood
vessels, leading to atherosclerosis and cardiovascular disease. High homocysteine will
also activate N-methyl-D-aspartate (NMDA) receptors in the brain. This activation will
lead to higher glutamate levels in the brain, negatively affects neuronal structure, and
increases oxidative stress in the brain, encouraging mood disorders (Karakula et al., 2009).
This may explain the link between cardiovascular disease and depressive disorders.
(Danner et al., 2003) and women (Cizza et al., 2009). Episodes of depression also are
predictive of higher CRP levels (Copeland et al., 2012a).
How to Address high CRP. Exercise in the form of interval training, an aerobic training
using high intensity interspersed with lower intensity, has been shown to be effective in
lowering CRP and blood pressure in patients with hypertension. Lamina and Okoye
(2012) looked at 245 males with mild to moderate high blood pressure. Half of these men
performed 8 weeks of interval training programs between 45 and 60 minutes, at intensities
of 6079 percent of heart rate reserve. The control group remained sedentary during this
period and did not find the benefits in blood pressure or CRP that the active group
enjoyed.
Reduce the intake of highly cooked food. Chemicals called advanced glycation endproducts (appropriately called AGEs) from foods that are cooked at high temperatures will
increase CRP levels (Uribarri et al., 2005). For instance, a study on potato chip eating
revealed eating those delicious little chips for 4 weeks increased both the oxidation of
LDL and CRP levels (Naruszewicz et al., 2009). Eating more raw foods, and minimally
cooked foods (e.g., using boiling, poaching, and slow cooking) is best.
Because the majority of the immune system is in the digestive tract, eating plenty of
fiber, especially in the form psyllium husk, will help douse the CRP fire by whisking it
away with a bowel movement. Studies of using 28 g fiber a day, either as a psyllium
supplement or in a high-fiber diet, showed clear CRP-lowering benefits in patients whose
total fiber intake was only around 12 g a day (King et al., 2007). One teaspoon of psyllium
husk as about 5 g fiber and can be mixed in 8 ounces of water, in the morning and
evening, with the remaining 18 g satisfied by eating good-quality fruits, vegetables, and
flax meal throughout the day.
CRP can also be lowered by taking fish oil and vitamin C. Patients with end-stage
renal disease given 2 g of fish oil supplements showed significant lowering of CRP versus
the control group (Bowden et al., 2009). I usually recommend 1 teaspoon of a highquality, molecularly distilled fish muscle oil a day for balancing inflammation in the body.
In a randomized trial of 396 healthy nonsmokers, Block et al. (2008) found that,
among participants with CRP indicative of elevated cardiovascular risk, 1,000 mg vitamin
C reduced the median CRP by 25.3 percent versus placebo. Taking 500 mg vitamin C two
or three times a day should be effective in lowering CRP.
Complete blood count and iron panel
A complete blood count (CBC) records the numbers of red and white blood cells. An iron
panel looks at the amount of iron available in the blood (serum iron) and how much is
stored (ferritin). Red blood cells carry oxygen throughout the body to keep all tissues alive
and energy up. Iron forms the center of the hemoglobin molecule and helps carry oxygen.
The term nemia applies to anyone who has low red blood cell number or volume, low
hemoglobin, or low serum iron or ferritin.
With anemia, fatigue and mood problems are quite common for not enough oxygen
gets to the various parts of the body, which enhances the stress response. If a person is
anemic and they are predisposed to anxiety or depression, these will more likely manifest
(Bokemeyer & Foubert, 2004). The lassitude can be debilitating and has been shown to
contribute to lost work, decreased physical and emotional well-being, and interference
with clear thought.
Verdon et al. (2003) looked at a total of 134 very fatigued women, most of whom had
low ferritin. Half of the group received iron supplementation every day for 4 weeks, and
the other received a placebo. The level of fatigue after 1 month decreased 29 percent in the
iron group versus only 13 percent in the placebo group. Although the iron group benefit
was double that in the controls, not all the women improved, likely because other issues
beyond iron were also at playpossibly digestive issues, sleep, blood sugar issues, and so
forth. It may be a good to time to mention that the purpose of this book is to underscore
how multiple factors can contribute to mood issues. Fatigue caused by low iron may just
be one of many contributing factors. The study by Verdon et al. (2003) suggests that for 29
percent of the women in the treatment group, iron was likely the sole issue, but for the
other 70 percent, other factors still needed addressing. Nevertheless, getting 30 percent
improvement with the simple recommendation of iron was pretty good.
Any cases of anemia should be worked up by a physicianespecially when it happens
in men and nonmenstruating women, for blood loss elsewhere in the body or bone marrow
issues may need to be addressed. If the cause is simply low intake or absorption of iron or
B12 (which helps build red blood cells), then a supplement is appropriate. One study on
anemic schoolchildren found that giving a multiple vitamin with iron increased
hemoglobin and reduced anxiety (Zhang et al., 2013).
For iron-deficient anemia I usually recommend a patient start with the following:
1. Check CRP levels, for those with high CRP are at increase anemia risksuggesting
inflammation may be a causative factor (Eisele et al., 2013).
2. Check nutrient intake for adequate amounts of iron and B12. This may be especially
challenging in the vegetarian and raw food population.
3. If intake is adequate, consider working on digestive health (see next section) for
better absorption of nutrients.
4. Take an iron supplement, starting 25 mg/day with food and increasing to 25 mg
three times a day with food. I usually use the gentler iron succinate or iron fumarate
forms, which are easier on the stomach and tend to cause less constipation. Also, it
is helpful to take about 500 mg vitamin C with the iron for best absorption. With
some cases of anemia I recommend the herbs nettles and yellow dock for supporting
and absorption effects. Food sources of iron include grass-fed beef, dark turkey
meat, dark leafy greens, and using an iron skillet for cooking.
5. Vitamin B12: A patient can ask his or her doctor for B12 shots or can start with a
methylcobalamin lozenge, using 1,000 g once a day. Sublingual lozenges or shots
tend to help increase B12 levels more effectively over capsules or tablets.
Thyroid panel (TSH, T3, T4)
endocrinologists do not prefer natural replacement, stating that it is not well standardized
from batch to batch. This is based on old studies from the 1970s, before newer techniques
were available to keep consistency. My experience suggests that patients have done quite
well on it. Holistic practitioners generally prefer natural thyroid hormone for it contains
thyroid gland, which includes not only active T4 but also T3 and other lesser known
thyroid hormones that may have a role in supporting the thyroid system. If using natural
thyroid replacement, the doctor should check pulse and symptoms before starting, and
recheck once a week to see how the pateint feels, as well take blood tests every few weeks
to recheck thyroid levels. If natural thyroid replacement is not helping the patient feel
better, you can also try the synthetic thyroid replacement thyroxine (T4). Synthetic thyroid
is actually bio-identical, for it is the same molecule our body makes, and is generally
without side effects when used at the proper dose. With any thyroid replacement, the
clinician should watch for excess signs of palpitations and heart racing, increased
temperature, excessive sweating, and/or weight loss. Some patients fare better with natural
thyroid, while others are more compatible with synthetic thyroid. As such, both should
remain as options.
If T3 is low, consider working with a prescription for Cytomel: Cytomel is pure active
T3. Usual starting dose is 5 g in the morning, increasing by 5 g every 3 days until
symptoms improve. It is best not to take more than 60 g total if the patient is over 55
years of age, or 125 g if younger. Reasons to discontinue or lower dose include racing
heart, excess sweating, shakiness, anxiety, or fast-paced thought patterns.
Parathyroid (PTH)
The parathyroid glands are four little pea-sized organs placed directly in the midst of the
thyroid gland. Primary hyperparathyroidism (an overfunctioning parathyroid gland) will
show a high PTH number on blood tests. This high PTH is frequently accompanied by
high blood calcium and a reflexive vitamin D deficiency. High PTH can cause digestive
issues and bone problems, as well as many mood symptoms, including anxiety, obsessioncompulsion, interpersonal sensitivity, depression, hostility, and psychoticism. Low vitamin
D can contribute to depression and poor mood. Depressive disorders and anxiety can
normalize after treatment of hyperparathyroidism (Peterson, 1968; Watson & Marx, 2002;
Solomon, Schaaf, & Smallridge, 1994), which may include surgical removal of one or two
of the four glands. While PTH is not routinely checked, it is worth checking if vitamin D
is consistently low, especially if supplementation doesnt bring it up in a timely manner.
DHEA and DHEA sulfate
Considered a neurosteroid, dehydroepiandrosterone (DHEA) and DHEA sulfate are
molecules produced by the adrenal gland and somewhat related to testosterone. Low levels
have been related depression severity (Goodyer et al., 2000), anxiety, and even
schizophrenia (Strouss et al., 2003).
DHEA may protect against the adverse effects of stress, especially the ravages of the
stress hormone cortisol. Like exercise, DHEA can increase neuronal growth in the
hippocampus and will protect new nervous tissue from getting destroyed by stress
hormones (Karishma & Herbert, 2002). Levels naturally decrease with age, and with it,
physical health and mood may be affected. Unfortunately, DHEA is known to decline with
psychological challenge and stress (Wang et al., 2009).
Supplemental DHEA has been clinically assessed for safety and effectiveness. A study
by Alhaj, Massey, and McAllister-Williams (2006) treated 24 healthy young men with a 7day course of high-dose oral DHEA (150 mg twice a day) in a placebo-controlled doubleblind, randomized, crossover study. Researchers found that memory was significantly
improved after taking DHEA. DHEA was shown to encourage hippocampal activation and
early differential activation and neuronal recruitment of the anterior cingulate cortex, and
to decrease evening cortisol levels. Reduced function of the anterior cingulate cortex can
contribute to behavioral disorders, including diminished self-awareness, depression, and
aberrant social behavior (Devinsky, Morrell, & Vogt, 1995).
DHEA seems to be supportive to balance anxiety. A randomized, double-blind
controlled study giving heroin addicts 100 mg for one year to help with withdrawal found
statistically significant improvement in the severity of withdrawal symptoms and in
depression and anxiety scores, while the control groups deteriorated in all measures,
suggesting that DHEA might benefit this particular population (Maayan et al., 2008).
Studies of adolescent girls with adrenal insufficiency caused by brain malfunction
found 25 mg DHEA helped improve anxiety scores (Binder et al., 2009), although another
analysis in adrenal-deficient women found benefit for depression and quality of life but
not for anxiety (Alkatib et al., 2009).
A number of studies report the benefit of DHEA supplementation for its antidepressant
effects (Gallagher et al., 2008). Specifically, DHEA may be effective for midlife-onset
minor and major depression. One placebo-controlled, randomized trial of a double-blind,
crossover treatment study looked at 23 men and 23 women 4565 years of age with
midlife-onset major or minor depression. These patients were randomized to either 6
weeks of DHEA therapy, using 90 mg every day for 3 weeks and then a whopping 450 mg
every day for 3 weeks, or 6 weeks of placebo followed by 6 weeks of the other treatment.
The subjects did not receive any other antidepressant medications during the study. DHEA
treatment for 6 weeks was associated with improvement in both primary outcome
measures compared with both baseline and 6 weeks of placebo. After DHEA treatment, 23
subjects had a 50 percent or greater reduction in depression rating scores, as did 13
subjects after placebo treatments. The treatment with DHEA was well tolerated. The
response to DHEA did not seem to differ between men and women. Larger doses did not
seem to confer any additional benefit (Schmidt et al., 2005).
How to work with low DHEA. Work on stressstress lowers hypothalamic-pituitaryadrenal (HPA) axis function and will imbalance DHEA status. Although supplementation
is discussed next, in most cases stress is the culprit, and dealing with this will help in the
long term. Of course, working with psychotherapy is a must. Also consider yoga,
meditation, and other relaxation work.
For supplementation, DHEA is available as over-the-counter hormonal therapy. When
needed, taking DHEA appears to reduce stress hormone concentrations and can improve
mood. Though many studies have used 50450 mg given every day in divided doses, in
my opinion it is best to first check blood levels. If low, or low-normal, start with 510 mg
every day for women and 1025 mg for men. When beginning supplementation please
check blood levels every 23 weeks. If mood does not improve, and/or the level of
hormone does not increase, then you increase in increments of 510 mg while continuing
to monitor with blood tests. The only known food source for DHEA is from the wild yam,
but these levels are too low for any clinical effect (Araghiniknam et al., 1996).
Cautions with DHEA. DHEA levels should always be checked before starting
supplementation. Taking too much may cause problems by increasing levels of other
hormones like testosterone and estrogen. I am especially concerned with the effect of too
much DHEA in women, due to the theoretical potential to exacerbate or initiate hormoneresponsive tumors. While I do not find women complaining of side effects often, the most
commonly reported side effects in the literature include male hormone-like skin effects
such as greasy skin and hair, acne, scalp itching, hair loss, and facial and body hair
(especially along the midline of the lower abdomen) (Wiebke, 2006). Men with prostate
cancer or benign prostatic hyperplasia (BPH) should check with their doctor before
starting DHEA.
Serum testosterone: Free and total testosterone
Testosterone is the hormone most associated with being male. However, both men and
women need it to keep up a good mood. Low testosterone levels may cause flattened
mood, anxiousness, low sex drive, loss of motivation, fatigue, and general loss of wellbeing in both women (Davis 2002) and men (Carnahan & Perry, 2004). Testosterone
administration in 15 females resulted in reports of reductions in unconscious fears in a
placebo-controlled, double-blind crossover trial (van Honk, Peper, & Schutter (2005)).
Low testosterone is often underdiagnosed due to the nonspecific symptoms that may
appear identical to clinical depression or anxiety states and should be tested in anyone
with these symptoms. Testosterone replacement has also been shown to help cases of
drug-resistant depression helping antidepressant medication work (see Chapter 6).
I have observed that males with low testosterone often (but not always) have a bit of
belly fat around their middle that is hard to lose, along with low mood, or irritable mood
(the curmudgeonly type of fellow). Please consider having your client check
testosterone, and if it is low, have him talk to his doctor about taking a small amount and
monitor mood, while checking for levels monthly. The occasional female may also fit this
picture, although not as often.
What to do if testosterone is low. For testosterone replacement, oral, short- and longacting parenteral, and transdermal patch and gel formulations are all available.
Transdermal patches are a better choice because oral prescriptions that go through the
liver at first pass can cause the liver to send out a binding protein (called sex hormone
binding globulin), which can lower the availability of a number of hormones and create
imbalances in thyroid, reproductive, and adrenal function.
As a note, it has been shown that serotonin reuptake inhibitors (SSRIs), the most
commonly prescribed antidepressant medication, can cause infertility by lowering
testosterone and sperm levels. So, if a depressed man with normal serotonin and low
testosterone is given an SSRI, it is possible to make his depression even worse.
Cautions with testosterone. Too much testosterone can cause excess body and facial hair,
as well as acne. Testosterone replacement is thought in some studies to exacerbate prostate
cancer risk, while others suggest low testosterone may increase risk as well. Recent
studies also suggest giving extra testosterone in senior men may increase cardiovascular
risk up to 30 percent (Vigen et al., 2013). Testosterone replacement should be regularly
monitored by a doctor using blood tests and by checking for clinical excess signs and may
be best avoided if there is heart disease risk.
Serum estrogen and progesterone
Low levels of estrogen have long been considered a factor in mood disorder. Estrogen is
the predominant female hormone known for its ability to affect the levels of serotonin in
the brain, by changing the ability of nerve cells to recognize this important mood
transmitter, as well as lowering levels of an enzyme called monoamine oxidase, which
breaks down serotonin (Carrasco et al., 2004).
While some menopausal patients using estrogen report reduction in mood symptoms
(Miller et al., 2002), the majority show no benefit (Demetrio et al., 2011). One study in
115 seniors older than 70 years showed no benefit when given a 20-week course of highdose estrogen to help cognitive function, mood, or quality of life (Almeida et al., 2006),
and another in 417 women 6080 years of age given 2 years of low-dose transdermal (skin
patch) estradiol also did not see any improvement (Yaffe et al., 2006). Women taking the
high-dose therapy also had double the adverse events versus the placebo group.
Like testosterone therapy, estrogen replacement therapy may actually improve the
effects of conventional antidepressants (Schnedier et al., 2001), which is discussed further
in Chapter 6.
The research on progesterone replacement suggests that it may block estrogen effects
and actually support breakdown of serotonin in the brain. Optimal levels of progesterone
are known to help calm the brain, improve sleep, and improve libido.
Progesterone treatment given without estrogen, such as the synthetic drug depot
medroxyprogesterone acetate (Depo-Provera) has been shown to worsen depression in
women who already have a tendency toward or clinical signs of depression (Jelovsek,
2009; Fraser & Lobo, 1999). However, other research does not corroborate this. One study
looking at the birth control implant levonorgestrel (Norplant), another synthetic
progesterone, showed the depression scores of the women most depressed actually
improved during the study period (Westoff et al., 1998). While a number of preclinical and
animal studies data suggest a positive antianxiety effect of progesterone (Auger & ForbesLorman, 2008), very few studies have been conducted reviewing the effects on mood. One
study of 176 postmenopausal women found that taking oral micronized progesterone (a
natural form of hormone replacement) resulted in significant improvement in vasomotor
symptoms, somatic complaints, and anxiety and depressive symptoms over using the
synthetic form of medroxyprogesterone acetate (Fitzpatrick, Pace, & Wiita, 2000).
The take-away from these studies of hormones is that hormonal replacement may help
if given to the right person, but more than likely, it is only one piece of the puzzle. This is
the reason it is important to address foods, lifestyle, sleep, exercise, and nutritional
supplementation to create a CAM approach that will work for the depressed or anxious
patient.
If estrogen and/or progesterone is low: As a point of caution, the use of any hormones,
synthetic or natural, should not be taken lightly, and should done with the care of a
knowledgeable practitioner. Often, I will not recommend these unless other more basic
care is addressed first (e.g., balancing the diet, exercise, sleep, work). It has been my
experience that, in most cases, when these basics are addressed, women do not necessarily
need hormones, or lower doses can achieve desired results.
If it is decided to consider replacement therapy, I recommend considering natural
hormone replacement therapy instead of conventional synthetic hormones. Although much
less research is available for natural therapies, it is likely that they will have fewer side
effects due to the bodys ability to recognize these compounds over their synthetic sisters.
The above study by Fitzpatrick, Pace, & Wiita, (2000) also suggests the effect may be
better as well.
If estrogen is going to be used, it is a good idea to also use some progesterone to
protect the tissues in the body that may be susceptible to cancer risk (e.g., breast and
uterus). Progesterone itself may be most useful in cases where there is much anxiety with
the depression. For cases of insomnia, I would also recommend using a nighttime oral
dose of micronized progesterone, which is helpful to potentiate gamma-aminobutyric acid
(GABA) in the brain, an effect elicited by benzodiazepines (Babalonis et al., 2011).
Compounding pharmacies are the best source for natural hormones and will formulate
these specific to the needs of the patient. These are usually prepared as oral preparations,
transdermal creams, suppositories, or subdermal pellets and can include estrogen,
progesterone, testosterone, and DHEA individually dosed.
Celiac panel
Parallel to the massively increased consumption of gluten and grain products, there has
been a dramatic rise in the past 50 years in the incidence of celiac disease, an
inflammatory reaction to the gluten component of wheat or spelt grain. According to a
National Institutes of Health panel, celiac disease is considerably underdiagnosed, with
estimates suggesting about 1 in 100 persons is affected (U.S. Department of Health and
Human Services, 2004).
There is a correlation between overt gluten allergy (celiac disease) or gluten sensitivity
and mood disorder in adults (Jackson et al., 2012) and behavioral issues in children
(Hernanz & Polanco, 1991). In addition, people with the undiagnosed disease have a 4fold increased risk of death (Rubio-Tapia et al., 2009).
A celiac panel comprises four different tests: anti-gliadin antibody IgG, anti-gliadin
antibody IgM, tissue transglutamase, and secretory IgA. Although not a perfect test, it has
typically an 8090 percent accuracy (Fasano & Catassi, 2001). The gold-standard test for
Celiac disease is biopsy of the small intestines jejunum. For the blood test, it is helpful to
be eating gluten products regularly a few weeks before the test, otherwise the antibodies
may not be found in a patient who is truly celiac.
What to do if celiac positive: Simply stated, it is best to avoid all gluten proteins, which
occur in wheat, rye, barlely, and spelt. Gut linings can heal in 36 months. There are
naturopathic herbs, such as geranium and marshmallow, that can also aid in healing. In my
clinical experience, mood issues can improve within as little as 2 weeks. Most other
grains, like rice, quinoa, amaranth, millet, and wild rice, are perfectly fine to eat. Oats are
fine if the manufacturer assures they are processed away from other wheat and gluten
products. For patients with severe depression, it is best to slowly lower gluten intake, for
completely avoiding it at one time can induce a withdrawal effect and contribute to even
worse mood. Like any drug we are addicted to, gluten can also cause an ugly withdrawal
when removed too fast.
Serum carnitine
Serum carnitine is an amino acid cofactor that serves to help turns fats into energy.
Carnitine also plays a neuroprotective role in mood by acting as an antioxidant and antiinflammatory (Soczynska et al., 2008). L-Carnitine has been shown to help mood, fatigue,
and depression in patients with cancer (Cruciani et al., 2006) and hepatic encephalopathy
(Malaguarnera et al., 2011). While administration of carnitine in rats have shown
antianxiety benefits (Levine et al., 2005), no trials have studied anxiety benefit in humans.
Another form of carnitine called acetyl-L-carnitine (ALC) is similar in structure to the
neurotransmitter acetylcholine and acts as a cholinergic neurotransmitter. ALC has also
been shown to have epigenetic effects (see the section Behavioral Epigenetics below) on
production of receptors in the hippocampus and prefrontal cortex, to contribute to a rapid
antidepressant effect (Nasca et al., 2013). An MRI study in geriatric depressed patients
found that imbalances in the prefrontal cortex were resolved using doses of ALC
(Pettegrew et al., 2002). For senior patients, the ALC form may be best for
supplementation.
In a randomized double-blind placebo-controlled trial in 82 patients with amyotrophic
lateral sclerosis (ALS) taking the drug riluzole, patients taking 3 g ALC daily had a
median survival of 45 months, versus 22 months for the placebo groupan astounding
improvement in the treatment of ALS (Beghi et al., 2013).
If carnitine is low: I recommend starting with 500 mg L-carnitine twice a day, preferably
away from food for best absorption. I also would recheck carnitine blood levels in 6 weeks
to look for improvement. If there is no improvement, consider doses up to 3,000 mg/day
while looking into digestive support (see the section Digestive Health below), to help
absorb nutrients better. Levels of 3,000 mg/day have not shown any toxicity. Effective
dosages of ALC in most clinical trials range from 1 to 3 g/day, given in divided doses
(Gaby, 2011). For cognitive issues with depression, ALC may be the better choice.
L-Carnitine natural food sources. As the word carnitine comes from the Latin word
carne, which refers to meat, it is not surprising that the highest concentrations of this
amino acid are in red meats. Other relatively higher amounts are found in dairy products,
nuts, and seeds, and lesser amounts are found in beans, vegetables, and grains.
Serum folic acid and vitamin B12
Known best for preventing the neurologic disorder spina bifida in newborns, folic acid
also plays a key role in the production of the neurotransmitters dopamine, norepinephrine,
and epinephrine (Stahl, 2008). Vitamin B12 is a cobalt-containing molecule is known to
help support production of red blood cells, the manufacture of DNA and nervous tissue
and to play a role in normalizing the SAMe and homocysteine pathways, as well as
helping in the synthesis of serotonin. Both vitamin B12 and folic acid can help patients
when antidepressants do not work on their own (see Chapter 6).
Low folate status is noted in about 33 percent of people with depression. Conversely,
people with diets high in green vegetables full of folate tend to have high levels of folate
in their blood and less major depression ( Coppen & Bolander-Gouaille, 2005).
Studies using B complex formulas that include 1,0002,000 g methylfolate and 260
420 g vitamin B12 have found significant and more continuous improvements in
depressive and anxiety symptoms in depressed patients compared with placebo, with
improvements in Beck Depression and Anxiety Inventories (Lewis et al., 2013).
Steps to take if folic acid and/or B12 is low: Taking both folic acid (800 g up to 15 mg
daily) and oral vitamin B12 (1,000 g daily) will help. B vitamins like folic acid and B12
are water soluble and generally safe. For folic acid, the methyltetrahydrofolate version is
the most natural form. Regular folic acid should be avoided. Methylcobalamin is the
preferred form of vitamin B12.
If B12 and folic acid levels are normal: If levels are normal but symptoms of anxiety or
depression are present, it may still be prudent to supplement with extra B12 and folic acid,
especially if medication treatments are not working (see Chapter 7). It is quite possible
that some people may have deficiency in their body tissues while still showing reasonable
levels in the blood. For example, some genetic research suggests that transporters which
bring vitamin B12 to the central nervous system may not function well, leaving B12 levels
higher in the blood but still deficient in the brain. Additionally, other lab abnormalities,
including high homocysteine and low red blood cells, may be suggestive of B12
deficiency. Mutations in the MTHFR (methylenetetrahydrofolate reductase) gene also
suggest the need for taking in extra methyltetrahydrofolate (see next section about the
MTHFR gene tes).
Dietary sources of folate and B vitamins. Excellent sources of folate are spinach,
asparagus, romaine lettuce, turnip greens, mustard greens, calfs liver, collard greens, kale,
cauliflower, broccoli, parsley, lentils, and beets. And vegetable sources have the
methyltetrahydrofolate form. Excellent sources of B12 are snapper and calfs liver; other
sources include venison, shrimp, scallops, salmon, and beef. Vegetarian sources have
significantly lower available B12, and the best of these are sea plants (e.g., kelp), algae
(e.g., blue-green algae), brewers yeast, tempeh, miso, and tofu.
MTHFR gene test
There is a relatively new genetic test for the MTHFR gene that is gaining widespread
attention in both the holistic and conventional medical world. MTHFR is found on the
short arm of chromosome 1 codes for an enzyme (methyltetrahydrofolate reductase)
needed to process folic acid into its most useful form, methyltetrahydrofolate (MTHF). If
someone has a mutation in the MTHFR gene, it is usually best to supplement with extra
folate. And the best form to take is MTHF, not regular folic acid. MTHF dosage is often
15 mg a day, which is much higher than what is found in a multiple vitamin or most
prenatals. MTHF has a strong relationship to both anxiety and depression (Almeida et al.,
2005). Studies in treatment-resistant depression dose up to 15 mg folic acid (Fava et al.,
2010). More about MTHF for this use is discussed in Chapter 6.
25(OH)vitamin D or serum vitamin D
Well known for bone strength, vitamin D is a steroid molecule with receptors that
recognize it all over the body. Vitamin D deficiency is implicated in autoimmunity,
cardiovascular diseases, cancers, and chronic pain (Straube et al., 2009). One metaanalysis suggested that all causes of death might be lowered by giving supplemental
vitamin D (Autier & Gandini, 2007).
Mice genetically altered to lack vitamin D receptors show greatly increased anxiety
behavior (Kalueff et al., 2004). Vitamin D deficiency is linked to both anxiety and
depression in people with fibromyalgia (Armstrong et al., 2007). One study of 1,000 older
adults found mean levels of serum vitamin D were lower in those with minor depression
and major depression compared with controls (Hoogendijk et al., 2008).
Low levels of vitamin D are likely involved in mood in several ways. Vitamin D
affects nerve growth factor, which is important for brain and neuronal repair and growth
(Wion et al., 1991). Vitamin D also helps production of serotonin, testosterone, and
thyroid hormone (Stumpf, 1995). Hypothalamic brain centers are responsive to the
presence of vitamin D, and low levels will affect the HPA axis as well, contributing to
poor mood (Eyles et al., 2005).
Increased depressive symptoms are found in the adults born from women with low
vitamin D while pregnant (OLoan et al., 2007), suggesting that it may be possible to head
off mood disorder in the next generation by checking vitamin D in prepregnant and
pregnant women. Preventing mood disorder in the next generation would be the ultimate
in preventive care!
Research demonstrates that dosages of 4,000 IU vitamin D per day in depressed
patients tend to improve well-being (Vieth et al., 2004). A small study evaluated 44
healthy participants during the wintertime, when vitamin D levels are low. They were
randomly assigned to 5 days of treatment with 400 or 800 IU of vitamin D3 or a placebo.
Compared with placebo, both doses of the vitamin increased positive mood and decreased
negative mood (Lansdowne & Provost, 1998). A Norwegian study of 441 overweight
people measured serum 25-hydroxyvitamin D levels. Those with levels <40 nmol/L (16
mg/dL) were shown to be more depressed on the Beck Depression Inventory. These
subjects were then given 20,000 IU, 40,000 IU, or placebo once a week. Those given
40,000 IU had a 33 percent reduction in depression scores, those given 20,000 IU had a 20
percent reduction, and the placebo group had a 5 percent decrease (Jordea et al., 2008).
These results are modest and suggest that vitamin D plays a role, but deficiency may not
be the sole cause of mood issues.
Dosing vitamin D. Vitamin D ranges in the normal adult between 30 and 100 ng/mL. An
ideal level of vitamin D is around 50, and in my experience very few patients come in
with normal levels, unless they are already supplementing. Sunlight exposure is the
method nature prescribed for humans to keep up vitamin D levels, as there are few food
sources, and even eating large amounts are not enough to raise levels of vitamin D.
Garland et al. (2007) reported that 12 min of exposure of 50 percent of body skin to
noontime sun on a clear day is equivalent to oral intake of 3,000 IU vitamin D3.
As discussed in Chapter 2, some sun is very healthful. Unless there is a clear
immediate skin cancer risk, remaining in the sun long enough to allow the skin to pink a
bit (not burn) is enough to help convert vitamin D without allowing excessive radiation
damage to skin cells.
If supplementing with vitamin D, I recommend 2,000 IU/day of vitamin D3 for every
10 ng/mL we are looking to increase. For example, if a patient is at 20 ng/mL, and we
would ultimately like to achieve 50 ng/mL, then 6,000 IU/day is a reasonable dose, and
we will recheck blood levels in 3 months to monitor.
Food sources of vitamin D. The best dietary source of vitamin D is fish. Much of the
literature ascribes the mood benefit of fish to their essential fatty acids (Hibbeln, 1998),
but vitamin D may also play a role. Eggs, butter, mushrooms, and parsley have small
amounts of D.
Vitamin D toxicity. Vitamin D is a fat-soluble steroid molecule that can be toxic in high
levels. Hypervitaminosis D may lead to high calcium in the blood, kidney issues, and
excessive bone loss. It is not known what supplemental amount may be problematic.
Likely, this number may vary from patient to patient, which is why it is best to run lab
tests to check pre- and postsupplementation. Studies of patients given long-term treatment
of 14,000 IU/day orally seemed to have no toxicity and did show significantly decreased
depression relapse rates (Burton, 2009).
One study suggests hypervitaminosis may start at regular 20,000 IU/day dosing (Vieth,
1999), with other research suggesting blood levels should not exceed 100 ng/mL (Hollis &
Wagner, 2004). One meta-analysis suggests that long-term ordinary dosages of 400800
IU/day are not associated with adverse effects (Autier & Gandini, 2007).
Conflicting information spurs the question of which form of the supplement is better:
vitamin D2 (ergocalciferol) or D3 (cholecalciferol). Plants manufacture vitamin D2,
whereas vitamin D3 is synthesized by humans in the skin when it is exposed to ultraviolet
B rays from sunlight. Clinically, I have used vitamin D3, which shows efficacy for raising
blood levels, as well as improving mood. For patients not finding benefit with vitamin D3,
vitamin D2 may be a consideration.
One note about vitamin D tests. Although there are a few forms of vitamin D in the body
that can be tested, the test indicative of true vitamin D status is the 25-
hydroxy(OH)vitamin D test, and it is the best test for making clinical decisions regarding
dosing.
Serum mercury
High mercury levels in the blood and body tissues can contribute to many nervous system
disorders, mood disorders, and cardiovascular disease. I recommend running this test to
see if there has been recent exposure to this deadly heavy metal. It may also be ordered to
monitor those who are regularly exposed to mercury. In my practice over 10 years, I have
seen six patients with depression and neurologic challenges who had high serum mercury
due to high intake of tuna and sushi. Please note, this test does not tell you if you have had
a long-term exposure to mercury that has accumulated in the body tissues over a long
period of time.
In patients with sudden onset of depression with possible exposure, is worth checking
mercury levels. I have also seen in middle-age and senior patients that the initiation of
osteoporosis can release stored mercury and other heavy metals from bone into the body.
This sudden release of these metals can contribute to mood challenges, nervous system
changes, and high blood pressure. We will talk a little more about how to treat both acute
and long-term mercury and other metal poisonings in the section on detoxification at the
end of this chapter.
DIGESTIVE HEALTH
Its a gut feeling
There are butterflies in my stomach
The way to a mans heart is through his gut
My hearts in my stomach
How often have we heard about the association between ones feelings and the digestive
tract? More than we can countwe see it in literature, art, and mass media. Nevertheless,
modern psychiatry has still all but ignored the strong association between the
gastrointestinal system and mood.
Naturopathic doctors have an old saying: If you dont know what is wrong or what to
treat, then treat the gut. Digestion is the default system to focus on for difficult-to-treat
cases. For decades it had been observed by holistic practitioners that improved digestion
can lead to better overall health, including mood. Modern science is starting to catch up to
this concept.
Conventional biomedicine has relegated mood disorders solely to the realm of the
psychiatrist. The preceding section touched on the realms of the hematologist,
endocrinologist, neurologist, cardiologist, toxicologist, and nutritionist. This section
discusses why the gastroenterologist should be getting involved, too.
Healthy digestion is critical for mood. Michael Gershons book The Second Brain
(1999) took a new perspective regarding the digestive system: not just as a means for
nutrient absorption and elimination, but also as a neuroendocrine organ. He explained to a
mass audience for the first time that lying within this organ system is a robust nervous and
hormonal output that rivals production found in the central nervous and hormone systems
themselves. Called the enteric nervous system ( enteric refers to the digestive tract), the
gastrointestinal tract is the main source of neurotransmitters in the body. For example, one
of the neurotransmitters, serotonin, is an amine that is produced from food sources of
tryptophan in the digestive tracts ubiquitous enterochromaffin cells and enterochromaffinlike cells. Poor digestive function (often due to stress, poor diet, sleep problems, and
toxins) creates inflammatory issues and lowers the ability to absorb tryptophan. In patients
who have celiac disease, chronic inflammation leads to poor nutrient absorption (Mki &
Collin, 1997). Additionally, irritating foods will spur the digestive tract to send copious
amounts of serotonin into the digestive system as a protective mechanism, where it
encourages fast motility as a means to empty out the gut. This is a likely cause of diarrhea
in people who have mood disorders, poor diet, and/or accompanying high stress.
Evidence shows that bowel disorders are correlated with mood. In fact, 20 percent of
patients with functional bowel disorders such as irritable bowel syndrome have
diagnosable psychiatric illness (Agazzi et al., 2003). Almost one-third of patients with
major depression are thought to have constipation, and patients with irritable bowel
syndrome are more prone to both anxiety disorders and depression (Kabra & Nadkarni,
2013).
How often do you work with women who have self-esteem challenges? Well, bowel
movements are intimately linked with feminine self-esteem, as well as being able to
maintain a relationship. An interesting study by Emmanuel, Mason and Kamm (2001)
compared 34 women 1945 years of age who had significant constipation for at least five
years with women who did not have constipation. The constipated group had poorer health
scores, had difficulty forming close relationships, and described themselves as less
feminine. The constipated women also had reduced rectal blood flow, which was strongly
associated with anxiety and depression, as well as negative body symptoms and impaired
socialization. The authors concluded that a womens individual psychological makeup
alters the function of the involuntary nerves that link the brain to the gut. Reduced activity
of these nerves slows down gut function, resulting in constipation. Because it is known
that most neurotransmitters needed for healthy mood are made in the digestive tract,
slowed gut function likely plays a role in how a woman feels about herself and how she
responds in a relationship.
body. Stress will also increase the likelihood of immune response by inhibiting proper
enzymatic production, which allows macromolecules to reach the intestines without being
properly broken down and provoke a greater inflammatory response.
The concept of leaky gut suggests that excess inflammation over a long period of time
will significantly compromise both the structure and repair mechanisms of the digestive
tract. Under this inflammatory fire, tight junctions known to hold digestive tract cells
together begin to deteriorate. When these structures break down, material in the lumen of
the gastrointestinal tract now has greater access to the blood stream. This is known by the
more technical term of gut permeability or what many people simply call leaky gut.
Particles that escape from the digestive tract will travel to the rest of the body and
contribute to global inflammatory effects and eventually to disease. As discussed in the
last section, if someone has a predisposition to disease, leaky gut and its accompanying
inflammation will increase the likelihood this disease will manifest.
When there is leaky gut, the intestinal inflammation and leaked particles travel through
the hepatic portal system, spur upregulation of hepatic Kupffer cells (immune cells in the
liver), an trigger upregulation of brain microglia (immune cells in the brain). Inflammation
in the brain will result in brain degeneration and poor mood. The likelihood of this
cascade of events is far greater with leaky gut than if the intestines are intact (Maes et al.,
2009).
While intestinal permeability/leaky gut is fairly well recognized in natural medicine
and CAM circles, conventional biomedicine has spurned this concept, calling it laughable,
unproven, and the work of pseudoscientists. In fact, the National Health Service of
England (2013) echoes the sentiment of mainstream medicine regarding leaky gut:
There is little evidence to support this theory. While it is true that certain factors can make the bowel more
permeable, this probably does not lead to anything more than temporary mild inflammation of an area of the
bowel. Some scientists and sceptics believe that people who promote leaky gut syndrome are either misguided
and read too much into the theory, or are deliberately misleading the public to make money from the treatments
they sell.
It also goes on to state: Generally, it is wise to view holistic and natural health
websites with skepticismdo not assume that the information they provide is correct or
based on scientific fact or evidence.
Although standard in the conventional medical world, this opinion seems to fly in the
face of medical research, as emerging information suggests leaky gut syndrome is indeed
quite real and is a strong contributor to disease, including mood disorder (Maes, Kubera,
& Leunis, 2008). Maes et al. (2008) looked at the serum concentrations of IgM and IgG
antibodies in chronic fatigue patients. The presence of these antibodies is indicative of the
presence of gram-negative enterobacteria in the bloodeffectively serving as a marker of
a leaky gut situation. Forty-one of these patients were given a leaky gut diet and
prescribed natural anti-inflammatory and antioxidative supplements, such as glutamine, Nacetyl cysteine, and zinc. After an average of 1014 months, 24 patients showed a
significant clinical improvement or remission and normalization of the IgA and IgM
responses.
Leaky gut has also been elucidated and implicated in other disor-ders, such has gall
bladder and liver disease (Reyes et al., 2006; Hartmann et al., 2012), heart disease (Rogler
& Rosano, 2014), kidney disease (Anders, Andersen, & Stecher, 2013), vascular problems
(Hunt, 2012), type I diabetes (Vaarala, Atkinson, & Neu, 2008), and autoimmune disease
(Fasano, 2012), to name a few.
HYPOTHALAMIC-PITUITARY-ADRENAL AXIS
The HPA axis is composed of central parts of the brain (hypothalamus and pituitary) along
with the adrenal glands, which sit on top of the kidneys. These vital structures act
collectively as a nexus for the hormonal and nervous systems (known collectively as the
neuroendocrine system) with the immune system. It is primarily among these structures
that stress responses are coordinated. Impaired functioning of the HPA axis has been
associated with several physical and psychiatric disorders, such as the metabolic syndrome
(Bjorntorp & Rosmond, 2000), fibromyalgia, depression (Holsboer, 2000), and
posttraumatic stress disorder (Yehuda, 1997).
Found deep in the center of the primitive brain, the hypothalamus is implicated in the
pathogenesis of mood disorder. Postmortem studies reveal greatly altered levels of the
neuropeptide corticotropin-releasing hormone (CRH; formerly called corticotropin
releasing factor) in individuals with anxiety and depression (Meynen et al., 2007). CRH
moderates the neuroendocrine, autonomic, and behavioral responses and is considered the
main mediator of the response to stress.
Changes in the hypothalamus affect the amygdala, a brain area very much involved in
the fear and emotional responses. The amygdala expresses high levels of CRH receptors in
chronically stressed individuals, making it more reactive in times of stress. Stress-induced
changes within the amygdala are a likely critical step in the pathophysiology in the
development of chronic anxiety states. It is further proposed that such a change in the
limbic neural circuitry (composed of the brains hippocampus, hypothalamus, and
thalamus) is involved in the transition from normal vigilance responses to hypervigilant
pathologic anxiety, manifesting in panic and posttraumatic stress disorders (Shekhar et al.,
2005).
The limbic system, made up of a number of brain structures including the
hippocampus, hypothalamus, thalamus, cinglulate gyrus and amygdala. It is the area of the
brain involved with emotion, behavior, motivation, and memory.
Figure 3.6. Three phases of the HPA: acute stress, chronic stress, and exhaustion.
2009 and found that stressful life events clearly increased the risk of depression. However,
the short 5-HTT allele did not show a relationship to increased risk for major depression,
alone or in interaction with stressful life events. Risch et al. concluded that there is no
evidence of an association between the serotonin gene and the risk of depression, no
matter what peoples life experience was. This substantiates other research suggesting
there is no relation-ship between serotonin and depression. Even more, the drug tianeptine
(Coaxil), a serotonin reuptake enhancer, which works completely opposite of SSRIs by
helping break down serotonin at faster rates, has been shown to be as effective as SSRIs in
depression and more effective than some at lowering anxiety (Wagstaff, Ormrod, &
Spencer, 2001).
Other candidate genes being considered as playing possible roles in anxiety and
depression include those for the dopamine receptor D4 (DRD4) and catechol-Omethyltransferase (COMT). Dopamine is highly implicated in anxiety, depression, and
attention-deficit challenges. The DRD4 receptor is a target for drugs that treat
schizophrenia and Parkinson disease. Polymorphisms of the DRD4 gene are associated
with anxiety disorders, including obsessive compulsive, avoidant disorders and depression
(Tochigi et al., 2006). The COMT gene is mostly considered in relationship to anxiety. It is
involved with helping to breakdown dopamine. People who had variations in the COMT
gene showed more anxiety when given personality tests and had higher startle responses
when given uncomfortable scenes to watch. Generally, those with the COMT variation are
higher-level thinkers, with higher levels of anxiety. It is possible that people with this
genetic change may keep higher levels of dopamine, epinephrine, and other
neurotransmitters around and are less able to take their attention away from unpleasant
pictures and sounds (Montag et al., 2008).
NEUROTRANSMITTERS
A neurotransmitter is a chemical signal released from one end of a nerve fiber (usually
called the presynaptic nerve terminal) into the synaptic cleft (space between neurons) that
transfers an impulse to the next nerve fiber. The theory of brain neurotransmitter action
has been the underpinning of psychiatric treatment for much the past 60 years.
The tricyclic antidepressant imipramine has been utilized since 1948 for the treatment
of depression, although its mechanism of action was not understood. In 1965, the biogenic
amine hypothesis suggested that reduced levels of the neurotransmitter norepinephrine
were associated with depression (Schildkraut, 1965). This partly explained the reason why
imipramine seemed to help some people with depression and motivated the continued
interest in using drugs to manipulate neurotransmitters for depression.
Conventional care began utilizing tranquilizers for anxiety disorder in the 1950s as a
means to calm anxious patients. In 1955, chlordiazepoxide (Librium) became the first
benzodiazepine antianxiety drug. Benzodiazepines help calm the brain by binding to
receptors for the neurotransmitter gamma-aminobutyric acid (GABA). GABA is the main
inhibitory neurotransmitter in the brain and calms overall brain activity. Most of todays
anxiety and sleeping medications still rely on this benzodiazepine effect.
Antianxiety and antidepressant medications rely on the neurotransmitter theory.
However, I hope this book has already clued you in that your clients anxiety and
depression are not as cut-and-dried as simply modulating levels of neurotransmitters.
When it comes to anxiety treatment, pharmaceutical therapy is clearly superior to
placebo in all antianxiety drug categories. Benzodiazepines (e.g., alprazolam, lorazepam,
and diazepam), which work on boosting the neurotransmitter GABA, and azapirones (e.g.,
buspirone), which upregulate serotonin and dopamine, were both shown equally effective
(Mitte et al., 2005). When selective serotonin reuptake inhibitors (SSRIs) are used for
anxiety, these also seem to have an effect greater than placebo, although they are not as
effective at symptom management as the benzodiazepines. While antianxiety medications
are effective and widely prescribed medications, they are best used in the short term. As
discussed in the introduction of this book, long-term use of benzodiazepines for anxiety
does not fix the underlying causes. Long-term use eventually leads to dependence,
resistance, withdrawal syndromes, and increased rates for all-cause mortality. This is a
reason that psychological therapy and holistic modalities are so important.
Both side effect profiles and efficacy are not good for antidepressants. They are linked
to greater likelihood of headaches, insomnia, rashes, muscle aches, gastrointestinal
symptoms, sexual problems, teratogenic effects, and even depression and suicidal thoughts
(Hyman, 1996). Even more, antidepressants may not actually work in most cases, for
evidence suggests that depression is likely not solely a neurotransmitter issue. This would
explain why antidepressant medications are not more effective than placebo (both have
~30 percent efficacy rate) in all but severe cases (Fournier et al., 2010).
Dopamine
Dopamine is considered a monoamine and catecholamine and specifically is the precursor
to epinephrine. It is implicated as a feel good neurotransmitter, where its release causes
euphoria, focused attention to pursue a goal, and a sense of reward.
Evidence from clinical investigations supports the finding that depressed patients have
reduced cerebrospinal levels of homovanillic acid, which is the main metabolite of
dopamine (Robinson & Donald, 2007). Neuroimaging studies of medication-free
depressed patients have found a functional deficiency of synaptic dopamine. Animals
exhibiting learned helplessness behavior show dopamine depletion in the brain areas of
the caudate nucleus and nucleus accumbens. This depletion can be prevented by
pretreatment with a dopamine agonist. In the forced swim test, another animal model of
depression, the immobility of animals can be reversed by administration of the dopaminenorepinephine reuptake inhibitor nomifensine, as well as by tricyclic antidepressants.
Dopamine antagonists have been shown to block the beneficial effects of antidepressants
in animal models (Meyer et al., 2006). (Agonists are molecules that can dock to receptors
and turn on an effect; antagonists bind to a receptor and block any effect from happening.)
Dopamine also plays an important role in fear and anxiety by modulating the medial
prefrontal cortex activity on the output of the brains amygdala. The amygdalas role is to
help connect life situations with helpful emotional reactions. Dopamine has an important
influence on the movement of impulses between the basolateral and central nuclei of
amygdala (de la Mora et al., 2010). Adequate dopamine effects on the amygdala, and
greater ability of the amygdala to store dopamine, seem to help it communicate best with a
part of the prefrontal cortex called the anterior cingulate cortex, which keeps trait and
baseline anxiety lower (Kienast et al., 2008).
Epinephrine and norepinephrine are stress hormones made in the bodys adrenal glands.
The word epinephrine translates to on the kidney (epi- + nephros), in reference to the
adrenal glands anatomic location. Known as catecholamines, epinephrine and
norepinephrine (called adrenaline and noradrenaline in the United Kingdom) are made in
the outer cortex of the adrenal gland during stress and are responsible for feeling awake,
alert, and motivated. Triggers of epinephrine include danger, surprises, light, temperature,
and excitement. Epinephrine spurs the release of norepinephrine in the brain, which
imparts psychological effects.
Epinephrine and norepinephrine were the first neurotransmitters to be considered in
the mechanism of depression. According to the catecholamine theory of mood, the major
symptoms of depression arise primarily from a deficiency in catecholamine
neurotransmitters between nerve cells in the brain. Increasing catecholamine availability
improves mood and has antidepressant effects (Millan et al., 2006). However, studies on
middle-age adults found that higher levels of depression and anxiety symptoms are related
to increased 24-hour urinary norepineph-rine excretion, showing that depression and
anxiety are associated with increased sympathetic nervous system activity (Hughes et al.,
2004). In my experience with patients, those who exhibit depression over many years
usually have low catecholamine levels, while those who have depression with anxiety, or
recent-onset depression, usually have higher catecholamines.
Traditional antidepressants such as the tricyclic antidepressants and the seldom used
monoamine oxidase (MAOI) inhibitors increase concentrations of catecholamine
neurotransmitters in the brain by inhibiting either neurotransmitter reuptake or their
breakdown. The catecholamine theory seems to have some validity, for it has been shown
that these drugs have no effect in mice that cannot make any of their own norepinephrine.
Glutamate
While GABA is the main calming neurotransmitter, the neurotransmitter glutamate is one
of the main excitatory neurotransmitters and also the most common neurotransmitter in
the brain and a major mood player. Glutamate is also a player in the inflammatory process,
where its buildup leads to toxicity and neuronal cell death, contributing to the
pathophysiology of both anxiety and depression. The brains frontal cortex coordinates
planning, decision making, and problem solving. Autopsy studies found elevated
glutamate levels and more inflammation in the frontal cortex of depressed patients
(Czyzewski, 2007) compared with those without depression. Stress will disrupt normal
balance and clearance of glutamate. High-carbohydrate diets lead to impaired glutamate
signaling and increased oxidative damage in the brain.
Glutamate binds to the N-methyl-D-aspartate (NMDA) receptor. Drugs that block
NMDA receptors have a strong antidepressant effect. Ketamine is an anesthetic drug that
has hallucinogenic properties. Known on the street as special K, ketamine is an NMDA
glutamate receptor antagonist, which effectively blocks NMDA receptors. Besides its
recreational effects, ketamine has been shown to have an amazing antidepressant effect
within 3 days of use (Berman et al., 2000)the quickest-acting antidepressant known.
Unfortunately, ketamine has a very high side effect profile and is limited by
psychomimetic side effects (psychosis, delusions, and delirium) and high abuse potential.
Oxytocin
Oxytocin is the neurotransmitter best associated with feelings of love, meaningful touch,
cuddling, and combating anxiety. Oxytocin helps reduce hyperactivity of the amygdala (a
fear center of the brain) and helps block the perception of a threatening environment. High
levels of oxytocin are consistent with bonding experiences, regular community interaction,
and consistent social engagement. Oxytocin can even be released by petting a dog. Those
who trust are able to release appropriate amounts of oxytocin, whereas humans who have
social anxiety disorder have dysregulated oxytocin.
Oxytocin may play a dual role in the effect of social situations, reinforcing both
positive and negative experiences. Adults who were abused in early life show lowered
levels of oxytocin (Heim et al., 2009). Mice tested in stressful situations that did not have
oxytocin receptors seemed not to show fear when the events were repeated, whereas those
with working oxytocin receptors remembered interactions with aggressive mice and
remained fearful (Guzmn et al., 2013).
Intranasal administration of oxytocin has shown to substantially increase trust among
humans (Kosfeld et al., 2005). Oxytocin preparations are currently being tested as
antianxiety drugs in several clinical trials (Hofman, 2013).
Serotonin
The focal point for many antidepressant and anxiety drugs, serotonin (5hydroxytryptamine, 5-HT) has a widespread cellular distribution in the body and brain. It
is considered to be calming and important for best sleep and appetite. Gaining confidence
and feeling respect also trigger serotonin. High levels can promote agitation.
Interestingly, serotonin was originally discovered as the molecule that allowed the
clam adductor muscle to remain chronically tight to keep its shell closed while expending
minimal energy. Serotonin is found in many tissues, including blood platelets, intestinal
mucosa, and the central nervous system. Some biologists called this molecule enteramine
(entera refers to the gut) due to its high levels in squid and octopus digestive tracts; other
researchers who found it in the blood named it serotonin. About 90 percent of our
serotonin supply is found in the digestive tracta likely connection between mood
disorder and digestive dysfunction. With this pleiotropism (effects throughout the body),
serotonin is implicated in many physiologic effects, including inhibition of gastric
secretion (stopping enzymes needed for digestion), stimulation of smooth muscles (which
can lead to diarrhea), vasoconstriction (tightening vessels for higher blood pressure), brain
communication, and mood effect.
While there are numerous receptors for serotonin, this section focuses on 5-HT1A, the
receptor for anxiety. Studies in mice showed that without the receptor they were much
more prone to anxiety as adults (Donaldson et al., 2014). People may be predisposed to
anxiety if serotonin levels are low. Serotonin is a likely factor in oxytocin levels, as there
is evidence that oxytocin exerts anxiolytic (anxiety-relieving) effects via oxytocin
receptors expressed in serotonergic neurons (Yoshida et al., 2009). SSRI (selective
serotonin reuptake inhibitors) antidepressants preferentially increase serotonin levels by
inhibiting its breakdown.
Serotonin was linked to depression in a landmark study by Coppen et al. (1965), who
postulated serotonins involvement in depressive illness. Serotonins involvement may be
due to low production, downregulation of its receptors, inability of serotonin to reach the
receptor sites, or a shortage of tryptophan substrate (tryptophan is the amino acid the body
uses to make serotonin). But serotonin is not the only actor on the depression stage. Some
research suggests that synaptic depletion of serotonin may promote a fall in
norepinephrine levels. Prange et al. (1974) wrote about the possibilities that alterations in
mood were due to a deficit of serotonin plus either a deficit or excess of norepinephrine.
This dual neurotransmitter approach lives on today in the debate as to whether single
(SSRIs) or dual (serotonin-norepinephrine reuptake inhibitors) uptake blockers are
actually more effective in treating depression. Interestingly, the serotonin hypothesis of
depression presumes that depression is caused by a serotonin deficiency. It is not well
known that this has actually never been shown to be true. In fact, to confuse the situation,
tianeptine, a medication that acts as a serotonin antagonist and decreases serotonin effects,
is as effective as the SSRIs (Maas et al., 1984; Wagstaff et al., 2001). This tells us we still
have a lot to learn about serotonin.
treating metal toxicity because clear evidence does not warrant this approach except in
clear-cut massive exposures. Nevertheless, this is a subject worth discussing. Emerging
information reveals that toxic exposures can accumulate insidiously over time to cause
slow degeneration of brain and nervous system tissue, resulting in more subtle mood
dysregulation in predisposed individuals. Long-term heavy metal exposure may lead to
apoptotic events (neuronal suicide) in susceptible brain and nervous system tissue. In an
epidemiologic study, Stokes et al. (1998) compared 281 young adults who had
environmental lead exposure as children with 287 nonexposed control subjects. Exposed
subjects had significantly more neuropsychiatric symptoms 20 years after initial exposure.
The metals most commonly associated with depression are cadmium, lead (Shih et al.,
2006), and mercury (Siblerud, 1989). These heavy metals are very common in our
environment. Industry, dental amalgams, welding work, cigarettes, and galvanized water
pipes are common sources. Natural medicines have even been implicated, as
contamination of Ayurvedic (Saper et al., 2004) and Chinese herbs (Ko et al., 1998) has
caused documented heavy metal exposures. Some preparations, such as rinchen rilbu
(Precious Pills) used in Tibetan medicine purposefully contain trace amounts of
hundreds of ingredients, including mercury, gold, and iron.
Heavy metals create clear mechanistic changes in physiology. They deplete
antioxidant reserves, which leads to inflammatory reactions and oxidative stress (Flora,
Mehta, & Gupta., 2008). These metals have high affinity for thiol (sulfur) groups found
within enzymes and proteins and impair cell function by inhibiting their normal metabolic
workings. Metals that are lipophilic (able to go across fat membranes) are able to cross the
blood-brain barrier easily and attach themselves to fatty myelin sheaths, as well as cell
membranes (Nagamura et al., 2002). For example, if we eat oils or fish with heavy metals,
these can easily get into the body and the brain. Once there, inflammatory levels in the
brain skyrocket and contribute to mood disorder. In a cyclic fashion, inflammation further
makes brain cells more vulnerable to a number of toxins.
The brain uses a very elaborate system to remove glutamate, a neurotransmitter that
can be very toxic to brain cells. Mercury, aluminum, and other toxins can easily damage
the reuptake proteins the brain uses to remove glutamate, thus rendering the brain cells
more easily damaged (Aschner et al., 2007; Allen, 2002). Inflammation causes excess
immune cytokine production, which can also affect these reuptake proteins, allowing
smaller amounts of toxin to have a greater effect. This creates a cycle of toxicity,
oxidation, and inflammation that becomes hard to break.
Symptoms of anxiety and depression caused by heavy metals
Exposure to mercury can give rise to the symptoms and traits often found in autistic
individuals (Bernard et al., 2001). Heavy metals may contribute to anxiety as mercury is
known to inhibit COMT, the enzyme discussed above that is needed to break down
epinephrine. Evidence suggests that mercury will also inactivate the methionine/SAMe
pathway needed to produce healthy neurotransmitter levels. (The SAMe pathway is
discussed in Chapter 4.)
Self-registered symptoms of patients with mercury intolerance have revealed many
commonalities with serotonin dysregulation (Mills, 1997), although test tube (in vitro)
studies of mercury do not clearly show how mercury may regulate serotonin regulation to
correlate to the psychosomatic symptoms (Marcusson, Cederbrant, & Gunnarsson, 2000).
It may involve more inflammation and glutamate upregulation than serotoninmore
needs to be learned.
Careful clinical history and presentation of specific symptoms may help the
practitioner suspect toxicity. History of clinical exposure preceding symptoms would be a
simple clue. Below is a short list of the most common symptoms. Certain compounds are
specifically associated with other comorbidities, which may clues in the practitioner as to
which metal may be playing a role (Bongiorno, 2010).
metal. It is important to note that these tests are not controlled and do not suggest a
reliable reference range. As such, it is unclear how accurate this is as a test for body
burden. Unlike blood sugar tests, where there is a known standard and reference range,
these chelation tests do not necessarily tell us whether a persons burden is
supraphysiologic and pathologic to the level of causing disease (Hibbs, J., personal
communication, 2013). Much more research and calibration are needed before these tests
reliably assess metal body burden in a way that allows us to use this test as truly
diagnostic. Nevertheless, for a patient with depression or anxiety that has not been helped
by other dietary, lifestyle, and supplemental means, metal testing and detoxification may
be a valuable next step.
If it decided to try to remove heavy metals from the body, chelation choices include
foods and supplements with chelation properties, oral chelation, intravenous chelation, and
rectal suppository chelation.
The characteristics of an ideal chelator include the following:
Affinity for the toxic metal
Low toxicity itself
Ability to penetrate cell membranes
Rapid elimination of metal
High water solubility
It should be noted that some vitamins have a known protective role during metal
chelation. In theory, when a person is being administrated chelation, release of the heavy
metals may increase oxidant burden. Vitamin E (tocopherols and tocotrienols) is a fatsoluble vitamin known to be one of the most potent endogenous (made-in-the-body)
antioxidants. Tocopherols and tocotrienols comprising vitamin E are potent, lipid-soluble,
chain-breaking antioxidants that may prevent the propagation of free radical reactions.
Vitamin C is a water-soluble antioxidant occurring in the body as an ascorbic anion that
acts as a scavenger of free radicals and plays an important role in regeneration of the
tocopherols. Supplementation with ascorbic acid and alpha-tocopherol has been known to
alter the extent of DNA damage in arsenic-intoxicated animals (Ramanathan et al., 2005).
Coadministration of antioxidants with another chelating agent has shown to improve
removal of toxic metals from the system, as well as achieve better and faster clinical
recoveries in animal models (Flora, Mittal, & Mehta, 2008).
There is unfortunately scant human clinical research studies supporting the use of
chelation for any disease at this time. Anecdotal reports of patients (including a number I
have seen myself) who have had chelation for mood care have noted less depression, more
alertness, and better memory. As of this writing, there are no known published studies of
chelation to treat any mood disorder. While a systemic review by Seely, Wu & Mills
(2005) found that controlled scientific studies did not support chelation therapy for heart
disease, the National Institutes of Health (NIH) Trial to Assess Chelation Therapy (TACT)
begun in 2003 and completed six years later did find a very modest benefit for heart
disease. This trial used a treatment originally used to remove lead from the body: officebased, intravenous disodium ethylenediaminetetraacetic acid (Na2EDTA), a chelating
substance that binds to lead and other heavy metals and removes them from the body
through the urine. Post-heart-attack patients older than 50 who were administered 40
chelation infusions experienced 18 percent fewer cardiovascular events (a nonsignificant
value) versus placebo in five years, and chelation was found to be safe (Lamas et al.,
2013). This is interesting, for there are a number of underlying factors common to
depression, anxiety, and cardiovascular diseaseparticularly regarding inflammation in
the blood. Unfortunately, these studies did not track mood changes. Hopefully, future
studies will look at possible mood benefits.
Chemical Toxicity
Besides the ubiquity of metals, another environmental concern is the various chemical
assaults that may also lead to depression. These often hail from the use plastics,
insecticides, herbicides, and the thousands of other industrial and household chemicals.
These chemicals are known contributors to diabetes, obesity, cancers, and hormonal
challenges. These chemicals, found in the plastics that line our food packaging, receipts,
water pipes, and medical tubing, are easily brought into the body and enter directly into
the blood.
Bisphenols
Often referred to as endocrine disruptors, bisphenols occur in plastics and act as synthetic
estrogens, increasing anxiety and depression, especially in kids. Females exposed
prenatally to high levels of bisphenol A (BPA) are more likely to be anxious, depressed,
and hyperactive by age 3 (Perera et al., 2012). Exposure in the womb or during early
childhood in boys correlates with anxiety issues by age 7. Exposure by age 5 correlates
with hyperactivity, internalizing challenges, anxiety, depression, inattention, and attentiondeficit hyperactivity disorder in both girls and boys by age 7 (Harley et al., 2013). Boys
were affected with greater levels of aggressive behavior. These effects are comparable to
those found in other research on high exposure to toxins such as lead, mercury, and
pesticides.
Pesticides and solvents
The primary toxic action of pesticides and solvents is disrupting healthy neurologic
function. In addition to being neurotoxic, these compounds are particularly harmful to
both the immune and endocrine (hormonal) systems (Crinnion, 2000). As discussed in
Chapter 4, the production of the methyl group donor SAMe is integral for neurotransmitter
production and mood regulation. SAMe pathway function is inhibited by both heavy
metals and pesticides,. Vitamin B12 is a necessary component of the SAMe pathway and
is itself reliant on the master body antioxidant glutathione for its own methylation. Excess
oxidative stressors like pesticides and heavy metals deplete glutathione, which places B12
production in jeopardy (Watson, Munter, & Golding, 2004). Insufficient B12 production
eventually leads to insufficient production of neurotransmitters. According to the World
Health Organization, higher concentrations of a class of pesticides called
organophosphates correlated with regions with higher rates of suicide and severe anxiety
disorders (Zhang et al., 2009).
Table 3.1 Sources of Toxins and How to Avoid Them
Agent
Heavy metals
Pesticides
Bisphenol A
Sources
How to avoid
Shoes
Pollution
Fish
Cigarettes
Dental fillings
Water pipers
Drinking water
Rice
Salt
Vaccines
Antiperspirants
Foods
Lawn
Plastics
Receipts
Packing
FOUR
accomplished by Celexa), and works well for depression and anxietyshe fit the
picture perfectly for this particular natural remedy. We started at 50 mg three times
a day between meals for the first week and went up to 100 mg three times a day. By
the third week, she was 90 percent betterand claimed it would be a 100 percent,
but her job stress was high at the time. Within two months, her job stressed passed,
she stayed at 100 percent, and began weaning off her medications over the course
of two months. Within six months she no longer needed the 5-HTP and kept feeling
well using diet, lifestyle, good sleep, and meditation.
As Deanna already knew, there are a plethora of effective and promising supplements for
the patient with anxiety and depression. There are more choices than the average patient
could possibly try or tolerate. It is confusing to both practitioners and patients alike when
deciding which may be the best. This chapter is designed to summarize both the available
research-based evidence and the traditional use of these natural medicines. It will also, in
naturopathic fashion, underscore particular clinical facets of each remedy to help best
match the therapy for anxiety and depression.
When considering a supplement for the client with anxiety or depression, it is vital to
keep in mind that supplementation should rarely be the focus of any holistic therapeutic
regimen. This book has already outlined the overall determinants for health: sleep, diet,
exercise, lifestyle, and toxin consideration. With Deanna, we had to reset her diet and
lifestyle a bit. Even though the 5-HTP was the clincher, the setup of diet and lifestyle were
a likely key to help the 5-HTP works its best. The determinants of health help balance and
treat the myriad underlying causes of anxiety and depression. Like drugs, supplements by
themselves will not likely get to the underlying cause. Having said this, choosing the right
supplements for the right patient may prove to be mood balancing and create the desired
health effect with much less chance of side effects than their pharmaceutical mates.
According to Your Dictionary (2013), supplement is defined as something added, esp.
to make up for a lack or deficiency. This is a succinct and effective definition, for it
emphasizes the reasonable use of supplementation when deficiency is suspected. In
comparison, the word medication is defined as substance for curing or healing, or for
relieving pain. So, to compare the two, a supplement helps mitigate deficiency, whereas
medications can be used to cure. Depending on the use of a supplement, it may satisfy
either or both criteria. Supplements are typically used to correct a deficiency or for
optimization of nutrient levels. However, certain supplements in proper doses may also act
more like medication, often when prescribed in larger pharmacologic, rather than
physiologic, doses.
Please note that most supplements described in this chapter also have food sources
listed. If a patient is suspected to need a specific amount of a supplement, I encourage the
holistic provider to also give that patient a list of healthy, whole foods, when available,
that also focus on that nutritional element. As the patient learns to enjoy these foods, he or
she will need to rely less and less on supplementation. It should always be noted that
supplements, like drugs, should not be viewed as the cure but merely one step, of many
healthful steps, to return the body and mind to balance.
The tables in appendix IV summarize the various supplements that can be considered
for patients with anxiety or depression, which are described in further detail below. In
particular, Table IV.1 lists general supplementation that should be considered for all
patients with anxiety or depression.
Fish Oil
Fish oil is an important source of essential fatty acids and can be used to help form healthy
brain and nervous tissue, and thus healthy mood. Numerous works have acknowledged
likely benefit of using fish oil as first-line therapy or adjunctive care for anxiety and/or
depression. Fish oil helps normalizes the membranes of brain tissues and simultaneously
supports and calms the adrenal system during anxious and stressful times (Delarue et al.,
2003), as well as encouraging a healthy cardiovascular system. Fish oil supports the
nervous system by increasing nerve growth factor, a protein needed for the growth and
repair of brain and nervous tissue (Thuret et al., 2007). Fish oils contain omega-3 fatty
acids known as eicosapentatoic acid (EPA) and docohexanenoic acid (DHA). EPA and
DHA have a long list of attributes that support mood and the nervous system (Song,
Zhang, & Manku, 2009).
One of the most potent effects of fish oil is as global (throughout the body) antiinflammatory. All cell membranes, including those of the immune system, are made of
fats. Ingestion of too many saturated fats (the kind from grain-fed red meats and fried
foods, sometimes referred to as omega-6 fats) make these membranes too rigid and
inflexible. When they are too rigid, they can break off and cause greater inflammation in
the body. Fish oils have unsaturated fats and create an immune system that is less able to
get over inflamed.
between these two debilitating diseases (Severus, Littman, & Stoll, 2001).
Positron emission tomography (PET) in depressed subjects has shown low fatty acid
content in specific brain regions that suffer from insufficient glucose metabolism. In an
uncontrolled study of 29 unmedicated depressed subjects, in which those subjects with
lower levels of EPA and DHA had relatively poor glucose usage in the brains
temporoparietal lobe, Sublette et al. (2009) posited that low fatty acids discourage proper
glucose metabolism in the temporoparietal area and may have an effect on depressionrelated cognitive problems, such as decision making and conflict resolution. The study
also suggested that low levels of DHA promoted hyperfunction of the anterior cingulate
and prefrontal cortex, areas known to be overactive in people with both depression and
anxiety. DHA can calm these areas.
Fish oil studies in humans
People without diagnosed anxiety are shown to benefit from the anxiolytic (anxietybreaking) properties of fish oil in times of stressa reason we should probably all be
taking some. Medical students are a well-known stressed-out group. Supplementation of
2.5 g/day of fish oil (2,000 mg EPA and about 350 mg DHA) or placebo given to 68
chronically stressed medical students in a placebo-controlled, double-blind, randomized
controlled trial showed 14 percent lower levels of inflammatory cytokines, such as
interleukin-6, and a 20 percent reduction in anxiety symptoms versus those who took a
placebo over a 12-week period. It is not known if longer-term supplementation would
increase the beneficial results. I give many talks at medical schools throughout the
country, where I have presented this information and challenged the skeptical students to
give it try. Numerous students have later reported how they really did feel the difference
after taking fish oil.
A number of clinical studies support the use of fish oil for depression (Freeman, 2000).
One 8-week, double-blind, placebo-controlled trial by Su et al. (2003) gave 28 depressed
patients 6.6 g/day of fish oil or placebo, in addition to typical pharmaceutical and/or
psychotherapy treatments. Patients taking the fish oil showed significantly improved
ratings with the Hamilton Depression Inventory versus the placebo group. Su et al.
suggested one reason for the benefit is fish oils ability to install itself into neuronal
membranes and support healthy electrical signal movement.
In a randomized double-blind controlled trial of 22 patients with major depressive
disorder, Nemets et al. (2002) found highly significant benefits with the addition of the
omega-3 fatty acid compared with placebo. These benefits were apparent by the third
week of treatment. In a double-blind placebo-controlled pilot trial (da Silva et al., 2008),
31 Parkinsons patients with depression took omega-3 fatty acids for 3 months along with
their antidepressant pharmaceutical therapy. Patients taking fish oil showed a clear
increase of omega-3 fatty acids in red blood cell membranes, and these patients showed
clear improvements in depressive symptoms. Tajalizadekhoob et al. (2011), in another
double-blind, randomized, placebo-controlled study, gave low-dose fish oil therapy in 66
senior patients (1,000 mg total, breaking down to about 300 mg each of EPA and DHA),
who showed clinical benefit and much greater effect over placebo, and clear differences in
the Geriatric Depression scales after removing confounding factors such as body mass,
thyroid dysfunction, and cholesterol. While omega-3 fatty acids have a clear albeit modest
effect on anxiety, an 8-week trial using 1,050 mg/day EPA and 150 mg/day DHA
suggested that those depressed patients without comorbid anxiety symptoms had a better
positive response than patients who also exhibited anxiety (Lesprance et al., 2011).
Double-blind placebo-controlled studies have also shown that omega-3 consumption is
associated with a longer remission period in depressed patients (Parker et al., 2006).
For other mood-related disorders, Peet et al. (2002) found that 2 g/day of ethyl-EPA
was the optimal dose for schizophrenia, another difficult-to-treat mood disorder. Fish oil
also showed the ability to greatly reduce distress symptoms and basal cortisol secretion in
abstinent alcoholics (Barbadoro et al., 2013), and 2,000 mg EPA lowered anxiety and
anger scores in substance abusers (Buydens-Branchey et al., 2008). A 12-week study of
bipolar depression showed that 1 or 2 g/day of ethyl-EPA significantly outperformed
placebo based on the Hamilton Rating Scale for Depression and Clinical Global
Impression Scale (Frangou, Lewis, & McCrone, 2006). Research is often completed on
patentable forms of natural substances, such as ethyl-EPA, so that the compound can be
treated as a drug and be called FDA approved. They thus can garner a higher price, as
well as prescription status. As of this writing, it is not clear that ethyl-EPA has any greater
benefit over high-quality, more natural fish oil versions.
There is also evidence that fish oil may benefit people who fail to respond to standard
antidepressant medications (discussed in Chap-ter 6).
Fish oil dosage
While dosages vary in different studies, a typical dosage of fish oil is 1,000 mg/day of
EPA and about 800 mg/day of DHA. Read the fish oil label closelyif it does not break
down the numbers, then purchase another one that does.
Also of note, you should encourage your clients to look for high-quality,
pharmaceutical-grade fish oils only, for the lesser quality versions may have an increased
chance of rancidity, as well as toxins and impurities. Because of our poor environmental
stewardship of our seas, fish are at risk of high contaminant levels (mercury and other
metals, dioxins, PCBs, etc.). Encouraging your client to purchase fish oil from a highquality company is important. These companies use molecular distillation and assure their
oil is certified contaminant-free. Molecular distillation to clear fish oil of contaminants is
easily achieved by a company of integrity.
A small percentage of patients may experience reflux with fish oil, in which case they
can try dosing with or away from a meal, either of which may resolve symptoms. Also,
some patients report that capsules are better tolerated, while others think the liquid oil is
best for them. Anecdotally, some patients report capsules kept in the refrigerator or freezer
tend to minimize reflux or fishy breath. If none of the above ideas work to eliminate reflux
effectively, try enteric-coated capsules. I recommend liquid fish oil taken from the a spoon
if possible for three reasons: (1) capsules are significantly bigger to swallow and more
expensive; (2) oil directly on the tongue sends a signal to the lower digestive tract to most
adequately prepare for fat digestion; and (3) and most important, your grandmother
create this molecule is with an enzyme called delta-6-desaturase. It helps linoleic acid
convert to the omega-6 fatty acid gamma-linolenic acid (GLA). If delta-6-desaturase is
impaired for any reason, mood can declineusually more toward depression.
Besides boosting mood, PGE1 also helps the cardiovascular system by decreasing
clotting and lowering inflammation in the blood vessels. When PGE1 is low, it may also
contribute to an increased risk of heart attacks and stroke, lead to high blood pressure, and
contribute to nervous tissue degeneration.
The delta-6-desaturase enzyme can also be deficient or inhibited in people with
diabetes or obesity, in older people, and when there is too much insulin in the blood or too
much coffee, trans-fatty acids (hydrogenated oils), or alcohol is consumed. Experiments in
rats suggest that prolonged stress also inhibits activity of this enzyme (Hibbeln & Salen,
1995). In these circumstances, taking supplemental GLA can be helpful (Horrobin, 1993).
The nutrients vitamin B6, zinc, and magnesium are cofactors in this reaction.
theres a link between alcoholism and this enzyme deficiency. In people predisposed,
alcohol can temporarily stimulate production of PGE1 and help lift mood. But with
cessation of alcohol, PGE1 levels fall again and depression returns. For some individuals,
this will result in looking for alcohol as a way to get away momentarily from depression,
thus contributing to an unhealthy cycle.
Even those individuals without delta-6-desaturase enzyme deficiency can deplete
dihomo-gamma-linolenic acid with repeated drinking by preventing timely replenishment
from linoleic acid. These individuals will also find the need for more and more alcohol to
transiently increase PGE1 to lift mood (Greeley, 2000, chap. 11).
Supplemental GLA, in the form of evening primrose or borage oil, is easily converted
to PGE1. For alcoholics, this can help support better mood and discourage the need to
drink for relief. Premenstrual symptoms such as breast tenderness with feelings of
depression, as well as irritability, swelling, and bloating from fluid retention, may also be
indications for GLA supplementation (Horrobin, 1983).
Dosage and toxicity of GLA
The best indication for GLA would be for a depressed individual with alcoholic tendency,
and for those who are Celtic Irish, Scottish, Welsh, Scandinavian, or Native American
origin. Good sources of GLA include evening primrose oil, black currant seed oil, and
borage oil. Dosage of GLA ranges from 1,000 mg to 2,500 mg once a day, whereas
evening primrose oil is usually dosed between 4,000 mg and 8,000 mg/day. Doses of GLA
>3,000 mg/day should be avoided due to possible exaggerated arachidonic acid levels,
which may exacerbate inflammatory reactions (Yam, Eliraz, & Berry, 1996). GLA
supplementation should not be used in patients with epileptic history, those with prostate
cancer risk, or those who are pregnant (Hawkins & Ehrlich, 2011).
The only known food sources of GLA are black currants.
Vegan Oils
The benefits of fish oils are multiple. The question then is, can practicing vegans get the
same benefits by taking vegan oils? Vegan fatty acids have not been well studied in mood
disorder. Plant foods are relatively low in alpha-linolenic acid (ALA) and higher in
linoleic acid, an omega-6 fat. And these need to be converted to EPA and DHA in the body
to have the mood benefits. Because fish oil already has EPA and DHA, it is likely that fish
oil may be more beneficial than the plant oils. Also, some people do not do as good a job
at making the conversion, which may predispose to mood problems.
For vegan oil dosage, an ALA intake of roughly 4 g/day is optimal. This level should
provide enough to ensure that significant amounts of EPA and DHA are formed by the
body. (Conversion rates are known to be around 510 percent for EPA and 25 percent for
DHA.) However, it is also important for vegetarians to ensure that their intake of linoleic
acid is not too high compared with ALA because a higher intake of linoleic acid interferes
with the process in which the human body converts ALA into the even more beneficial
EPA and DHA. An LA-to-ALA ratio of around 41 or slightly lower is considered to be
the optimal (Vegetarian Society, 2009).
PROBIOTICS
Chapter 3 established the importance of digestive function for mood balance. One aspect
of optimal digestive health relies on its main resident: the gastrointestinal microbiome.
The microbiome includes all the microorganisms that inhabitant our digestive tractabout
100 trillion bacteria. A healthy microbiome starts with vaginal birth: as the baby
transcends the birth canal, the probiotics in the mothers vaginal fluid enter the babys
mouth and begin its healthful colonization of the digestive tract. It is possible that the high
caesarian birth rate in the United States may be contributing to anxiety and depression due
to lack of probiotic transference.
Gut bacteria, including both the healthy flora and pathogenic bacteria, can activate
neural pathways and central nervous system signaling systems (Foster & McVey Neufield,
2013). The microbiome contributes to the bidirectional communication between the
digestive tract and the brain. The autonomic nervous system, enteric (gut) nervous system,
neuroendocrine system, and immune system all meet in the digestive tract and coordinate
healthy physiologic and psychological responses. A healthy microbiome works to boost
mood by generating healthy levels of brain-derived neurotrophic factor (Bercik et al.,
2010) and gamma-aminobutyric acid (GABA) and enhancing brain receptors for GABA.
Research has also shown that hypothalamic-pituitary-adrenal (HPA) axis dysregulation
can be reversed by treatment with Lactobacillus and Bifidobacterium (Gareau et al., 2007;
OMahony et al., 2005). This research verifies the two-way communication between the
digestive tract and the brain and shows how the HPA axis is modulated by the enteric
microbiota.
Animal studies to date clearly show probiotic supplementation benefits. In one mouse
study, animals that received probiotics were, in general, more relaxed than the control
mice. The probiotic mice had lower levels of corticosteroid release in response to stress, as
well as lower anxiety and depression-related behaviors than those fed with just broth. In
this study, they also performed a vagotomy (severing of the vagus nerve that
communicates changes from the digestive tract to the brain) in some of the mice (Bravo et
al., 2011). Other studies found that switching gut bacteria from a stressed mouse to a
nonstressed one made the nonstressed one more stressed, and the reverse was also true
when nonstressed animal gut bacteria was placed in an anxious animal (Ridaura et al.,
2013; Bravo et al., 2011).
Probiotic supplementation has recently been referred to as psychobiotic, for they can
produce and deliver neurotransmitters such as gamma-aminobutyric acid and serotonin,
with some experts going as far to suggest probiotics may become a useful alternative to
pharmaceuticals due to their antidepressant and anxiolytic activity (Dinan, Stanton &
Cryan, 2013). While still relatively few, emerging clinical research corroborates the
animal studies showing supplementation can replenish a healthy microbiome in order to
gain psychological benefit. In healthy people not diagnosed with a mental disorder, strains
of the probiotic Lactobacillus and Bifidobacterium given for just 30 days lowered
psychological distress and depression, decreased anger and hostility, lessened anxiety, and
improved problem solving, compared with the placebo group (Messaoudi et al., 2011). In
another double-blind, placebo-controlled trial, Benton et al. (2007) fed healthy subjects
either a probiotic-containing milk drink or placebo for 3 weeks, with mood and cognition
assessed before treatment and after 10 and 20 days of consumption. Subjects who initially
scored in the lowest third for depressed mood showed significant improvement in
symptoms after probiotic treatment. In one pilot study, Rao et al. (2009) gave patients with
chronic fatigue Lactobacillus casei every day for 60 days. Based on the Beck Depression
and Anxiety Inventories, these patients showed far less anxiety symptoms than placebo
group.
Probiotics dosage and best application
Identified in the 1800s with Ilya Ilyich Mechnikovs groundbreaking work, probiotics
were virtually ignored until recently and thus represent a relatively new field of research.
Human studies have used various probiotic dosing and strains, so study comparisons are
not possible until dosing procedures become standardized. Studies utilized a range of 6.5
24 billion colonies of Lactobacillus casei per day, while another supplemented with only 3
billion colonies of both Lactobacillus helveticus and Bifidobacterium longum per day. In
our clinic we use a Lactobacillus acidophilus and Bifidobacterium lactis at a dose of 4 to 8
billion one to three times a day. Given that antibiotics are known to disrupt the
microbiome and create feelings of anxiety and depression (Denou et al., 2011), it is
recommended to dose probiotics during any antibiotic treatment. Probiotics are possibly
contraindicated in digestive tract issues when there is active bleeding (e.g., active
ulcerative colitis or active Crohns disease) due to concern of bacteria moving into the
bloodstream at a high volume.
Probiotic toxicity
While probiotic studies have not demonstrated toxicity, oversight for using live bacteria in
foods or food supplements is also relatively new and evolving. There have been many
controlled clinical trials on the use of probiotics that demonstrate safe use (Snydman,
2008). I recommend these are purchased from high-quality companies that provide
evidence for absence of any pathogenic germs, for these have been detected in inferiorquality products (Wassenaar & Klein, 2008).
Food sources of probiotics
Yogurt is the most familiar source of probiotics, although for people who are lactose
intolerant or have a dairy sensitivity or allergy there are other choices: natto (a traditional
Japanese fermented soy food), kimchi (traditional Korean fermented vegetables), miso,
and sauerkraut.
most pertinent for anxiety and depression. Keep in mind that some vitamins and minerals
may already be dosed in a multiple vitamin in adequate levels, while others may need to
be increased for optimal dosing. Also, while most vitamins can be ingested safely in doses
higher than the recommend daily allowance, it is best to be careful to not overdose certain
vitamins, especially the fat-soluble ones (vitamins A, D, E, and K), which can become
toxic when the levels are too high.
Table IV.2 in Appendix IV reviews the reviews the most commonly used vitamins for
anxiety and depression, which are described in detail below.
Multiple Vitamins
There is good reason to consider the shotgun approach of a high-quality multiple vitamin.
There is a demonstrated association between poor mood and deficiency in several
micronutrients. The standard American diet (with the appropriate acronym SAD) is low in
vegetables and whole foods and woefully deficient in many nutrients (e.g., folic acid, B
vitamins) necessary for metabolic processes, antioxidant protection (e.g., vitamin E and C)
needed to protect cells, and levels of protein and amino acid precursors (e.g., tryptophan)
needed to make chemical neurotransmitters.
Dietary studies also show us that even people who are trying to eat healthy are in
trouble. Misner (2006) reviewed 70 dietary analyses of 20 different diets from a cross
section of people, ranging from elite athletes (who had pristine dietary intakes) to
sedentary people who did not exercise or take good care of themselves. All diets fell short
of 100 percent of the recommended RDA micronutrient levels. Even more, the more
athletic and active the person, the greater the tendency toward deficiency.
In one randomized, double-blind, placebo-controlled trial in Australia, Harris et al.
(2011) gave a multivitamin and mineral formulation or a placebo to 50 healthy men
ranging in age from 5069 years. Compared with the placebo, the multiple vitamin led to
significant reduction in depression and stress scales, as well as better wakefulness and
higher daily function. A meta-analysis of eight studies on the effect of a multivitamin on
mild psychiatric symptoms found that the multiple vitamin reduced the levels of mild
psychiatric symptoms, perceived stress and anxiety, and fatigue and confusion but had no
benefit for depression (Long & Benton, 2013).
Multivitamin dosing
The better-quality vitamins are usually made out of capsules that have powder in them (as
opposed to hard tablets), and higher-quality vitamins are usually dosed around four to six
capsules a day. Once patients are doing well and have been replete for a few months at full
dose, I often will recommend a half dose of a high-potency multiple as maintenance.
Because vitamins vary in potency, it is recommended that the dosage on the bottle be
followed and taken with food unless otherwise indicated.
Multiple vitamin safety
A study by the U.S. Preventive Services Task Force (Fortmann et al., 2013) suggests
multiple vitamins have no reportable toxicity. The study did find two large trials of over
27,000 men that reported lower cancer incidence when taking a multivitamin for more
than 10 years, but there was no benefit for cardiovascular disease and no extra benefit for
either condition in women. Multiple vitamins have a good safety record, although it is
controversial whether there is clear benefit by itself for any specific disease.
Foods source of multiple vitamins
Generally, the best source for a wide array of healthy vitamins is in green vegetables and
fruits.
B12. Anecdotal reports suggest weekly intramuscular administration of vitamin B12 (in
the form of hydroxocobalamin) may improve unexplained anxiety patients with normal
serum vitamin B12 (Gaby, 2011). One study showed a full response to antidepressant
medications when B12 levels were higher (discussed further in Chapter 6 in the section on
vitamin B12).
Folic acid (folate)
Folic acid has been studied in the literature for its mood benefit over the last 30 years. The
word folate comes from the Latin word folium, which means leaf, emblematic of the
high levels of this vitamin in leafy greens. Populations whose diets that are rich in folate
have high serum folate concentrations and tend to have very low lifetime rates of major
depression (Coppen & Bolander-Gouaille, 2005). Depletion can be encouraged by eating
poorly, intestinal malabsorption, certain drugs (e.g., antiepileptic medications or birth
control pills), and chronic alcohol intake.
Low folate status seems to be more associated with low mood and depression and less
associated with anxiety (Bjelland et al., 2003). Folic acid status is also important for
bipolar patients who are looking to gain benefit from lithium (Coppen, Chaudhry, &
Swade, 1986). In his study of the interaction between folic acid and the opioid system,
Brocardo et al. (2009) reviews for us how folic acid has been well implicated in
depressive disorders, and folic acid deficiency has been noted among people with
depression, with some estimates suggesting up to 33 percent of depressed individuals are
folate deficient. He notes several studies that regard its role in the pathophysiology of
depression, showing that patients with depression often have a functional folate
deficiency, and the severity of such deficiency correlates with depression severity. Low
folate status makes it much less likely a drug treatment will work, for folate is required for
the synthesis of serotonin.
Besides being an important factor in serotonin synthesis, folic acid is also needed to
support dopamine, norepinephrine, and epinephrine (Stahl, 2008). Folate also helps to
reduce homocysteine levels (Slot, 2001), a cardiovascular risk factor that tends to be
elevated in depression. Homocysteine is discussed in Chapter 3.
Inositol
Inositol is an abundant carbohydrate molecule with half the sweetness of sucrose. It is
derived from component of plant seeds known for benefit in cancer care (Vucenik &
Shamsuddin, 2003). While it is not actually related to the B vitamin family, it is often
combined with B vitamins when treating mood challenges. Early animal studies on
inositol have reported efficacy in relieving symptoms of depression (Einat et al., 1999) via
serotonin receptor modulation (Brink et al., 2004) and neurotransmitter reuptake (Einat et
al., 2001).
While two studies looked at 612 g/day of supplemental inositol for depression
resulted in positive therapeutic improvements similar to common antidepressant drugs
(Levine et al., 1993, 1995), a Cochrane review of four trials with a total of 141
participants did showed mixed evidence of therapeutic benefit (Taylor et al., 2004).
Inositol may be best for patients with anxieties, especially those who exhibit traits of
obsessive-compulsivity and panic. Dosages of 18 g/day were found effective in small
patient groups with obsessive-compulsive disorder (Fux et al., 1996). A follow-up doubleblind, controlled, randomized crossover study looked at 20 patients taking 18 g/day
followed by 1 month of fluvoxamine (150 mg/day). In the first month, inositol reduced
panic attacks per week by 4.0 compared with a reduction of 2.4 with fluvoxamine.
B complex studies
One workplace study of 60 nonanxious, nondepressed participants given a B complex who
completed the 3-month, double-blind, randomized, placebo-controlled trial found the B
complex group reported significantly lower personal strain and a reduction in confusion
and depressed/dejected mood (Stough et al., 2011), suggesting that work productivity may
increase with the administration of B complex to combat the stressors many workers
experience.
A large study by Skarupski et al. (2010) looking at over 3,500 adults showed that
higher intakes of B6, folate, and B12, whether through foods or supplementation, was
associated with a decreased likelihood of incident depression for up to 12 years of followup. For each additional 10 mg vitamin B6 and additional 10 g vitamin B12, there was a 2
percent decreased risk of depressive symptoms per year. In a randomized, double-blind,
placebo-controlled trial, Lewis et al. (2013) evaluated the efficacy of a B complex
nutritional supplement that included vitamins B1 (1.7 mg), B2 (as riboflavin-5-phosphate;
1.6 mg), B5 (3.3 mg), B6 (as pyridoxal 5-phosphate; 3 mg), B12 (263 g), and folate (as
folinic acid; 1,000 g) and inositol hexanicotinate (30 mg) for improving anxiety and
depression symptoms in 60 depressed adults for 60 days. The Beck Depression and
Anxiety Inventories showed significant, moderate improvements in both depressive and
anxiety symptoms compared with placebo. Interestingly, the B complex group showed
greater improvement on the anxiety scale, while the placebo group demonstrated greater
improvement on the depression scale (25 percent vs. 22 percent, and 34 percent vs. 39
percent, respectively), suggesting that B vitamins may be more effective for symptom
relief in anxiety cases than in depression cases. The vitamin group achieved a more
continuous decrease throughout the protocol, while the placebo group had less or no
improvement from 3060 days, suggesting a subtle but longer-lasting effect. Also, there
was significant improvement on the mental health scale of the Medical Outcomes Study
Short Form 36 compared with placebo. It should be noted that this study was supported by
the company that made the vitamins, and a main contributing author received
rumuneration from this company as well.
Dosages of B vitamins, folate, and inositol
For anxiety and depression support, generally I recommend using a B complex, which
includes vitamins B2, B3, B5, B6, and B12. It typically will also include folate (400
1,000 g). Depending on the individual case, I often dose extra vitamin B12 (up to 5,000
g/day) and folate (up to total 15 mg/day), and I may also consider adding a powdered
inositol (up to 18 g/day) if there is a strong anxiety, obsessive, or panic aspect.
Certain forms of the vitamins are best utilized by the body. For vitamin B6, the
activated form of the vitamin, pyridoxine 6-phosphate, is recommended. For vitamin B12,
methylcobalamin is best, and for folate, the methyltetrahydrofolate form is best and is
most like the form that appears in natural vegetables. In fact, some studies are now
suggesting that using the common form of the supplement folic acid, which is employed in
most vitamins, pregnancy formulas, and enriched foods, may actually make the more
bioavailable L-methylfolate form less available for the body to use to protect against
cancers. Those with the a MTHFR gene mutation (see the section on the MTHFR gene test
in Chapter 3) will benefit even further from using the methtyltetrahydrate form of the this
vitamin.
In treatment-resistant cases of depression, oral doses of both folic acid (800 g/day)
and vitamin B12 (1 mg/day) should be tried (Coppen & Bailey, 2000). Folic acid intake
for treatment-resistant depression may be dosed as high at 15 mg/day (see Chapter 6).
Taking 100 mg vitamin B3 several times daily with meals may also enhance the
effectiveness of supplemental tryptophan doses, which is useful in both anxiety and
depression.
Toxicity of B vitamins, folic acid, and inositol
Prolonged high doses of vitamin B6 of 200 mg/day or more may cause a reversible
tingling or neuropathy in the hands and feet, along with fatigue (Beers & Berkow, 1999,
1526). Do not use more than 100 mg/day of B6 (or pyridoxine 6-phosphate) to be safe.
Because the drug methotrexates anticancer effect works via interference with folate
metabolism, it is best not to take any folate when treating cancer (Fugh-Berman & Cott,
1999) with methotrexate. However, folate can be used supportively for patients using
methotrexate to treat rheumatoid arthritis (RA) without blocking its general effect, because
methotrexate works by another non-folate-mediated mechanism to treat RA. A 48-week,
randomized, double-blind, placebo-controlled trial where patients supplemented with 1
mg/day folate did need slightly higher levels of the drug to be fully effective in RA, but
these patients enjoyed lower liver enzymes than the group given only the drug (van Ede et
al., 2001). Folate has also been reported to reduce the effectiveness of several
anticonvulsants, potentially leading to seizures, so clients should not take folate if they are
taking any epilepsy medications (Fugh-Berman & Cott, 1999). A 2004 Cochrane review
(Taylor, et. al, 2004) of 18 g/day of inositol showed good tolerability. In my office, I have
had two clients with obsessive-compulsive disorder complain of apparent minor gastric
distress with gram doses of inositol, with full resolution once the supplement was
discontinued.
Food sources of B vitamins, folic acid, and inositol
Sources of vitamin B3 include chicken, turkey, beef, liver, peanuts, sunflower seeds,
mushrooms, avocado, and green peas. Best vitamin B6 sources include bell peppers,
spinach, and turnip greens. Great sources of B12 are snapper and calfs liver, and very
good sources of vitamin B12 include venison, shrimp, scallops, salmon, and beef.
Vegetarian food sources have significantly lower available B12. The best vegetarian
sources are sea plants (e.g., kelp), algae (e.g., blue-green algae), brewers yeast, tempeh,
miso, and tofu. High levels of methylfolate are in spinach, asparagus, romaine lettuce,
turnip greens, mustard greens, calfs liver, collard greens, kale, cauliflower, broccoli,
parsley, lentils, and beets. Inositol sources include most vegetables, nuts, wheat germ,
brewers yeast, bananas, liver, brown rice, oat flakes, unrefined molasses, and raisins.
Minerals
Like the B vitamins, minerals are quite supportive for healthiest mood. Minerals like zinc,
magnesium, and selenium are important for neurotransmitter production, blood sugar
balance, oxygen-carrying capacity, hormonal balance, and antioxidant status. Minerals
such as calcium, magnesium, zinc, selenium, and manganese may competitively inhibit
the absorption and utilization of toxic metals like lead, mercury, and aluminum (Baumel,
2003, p.50). Thus, it is possible that dietary deficiency of minerals may increase ones
ability to absorb unwanted toxic metals.
Table IV.5 in Appendix IV reviews the minerals most commonly used to support
anxiety and depression, which are described in detail below.
Magnesium
Magnesium is one of my all-time favorite nutrients. Beneficial to the heart and
cardiovascular system, relaxing to the muscles, and calming to the mind, it may not
always be the first nutrient thought about for anxiety and depression. Nevertheless, I have
relied on magnesium for my own optimal mood and consider it a strong ally for many of
my patients.
Magnesium is an essential trace mineral that is often quite low in most American diets,
as many nutrients get stripped away with processing. For example, only 16 percent of the
magnesium found in whole wheat remains in refined flour, and magnesium has been
filtered from most drinking water supplies, setting the stage for human magnesium
deficiency (Eby & Eby, 2006). As explained in the Foods to Avoid section of Chapter 3,
low magnesium can also be caused by high carbohydrate consumption because minerals
literally flush out our system with carbohydrates (Pennington, 2000). This makes simple
carbohydrates like breads, cakes, and cookies doubly problematic, because not only do
they not provide any good-quality nutrients, but they also dysregulate blood sugar and
deplete minerals from the body. Lowered magnesium intake will also contribute to another
mood factor: inflammation. With magnesium deficiency, nervous tissue becomes damaged
easier, thus increasing inflammation throughout the body. This can increase levels of the
inflammatory marker C-reactive protein (Pakfetrat et al., 2008), another factor in mood
disorder. (See Chapter 4 for more about C-reactive protein.)
People with mood issues are even more prone to deficiency. Magnesium deficiency is
found in 80 percent of depressed individuals (Shealy et al., 1992) and may play a strong
role in anxiety by causing dysregulation of the HPA axis (Sartori et al., 2012). Suicidal
patients show low levels of magnesium in their cerebral spinal fluid (Banki et al., 1985).
One study that included 23 elderly patients with type 2 diabetes and hypomagnesemia
(low magnesium in the blood) showed that magnesium chloride treatment was as effective
to improve depressive symptoms as imipramine (Barragn-Rodrguez, Rodrguez-Morn,
& Guerrero-Romero 2008). It seems the less magnesium in the body, the more anxiety and
depression. One Norwegian study of community-dwelling men and women consisted of
5,708 individuals 4674 years of age where magnesium intake was recorded (Jacka et al.,
2009). A clear inverse correlation was found between magnesium intake with anxiety and
depression symptoms. This study adjusted for age, gender, body type, blood pressure,
level of income, and lifestyle variables. Another four case histories showed rapid recovery
(<7 days) from major depression using 125300 mg magnesium (in the forms of glycinate
or taurinate) with each meal and at bedtime (Eby & Eby, 2006). Thats pretty fast action
but not unusual, for the body responds when given what it needs to heal.
Magnesium dosage and best application. Typical dosages of magnesium range from 300
to 800 mg/day (Jee et al., 2002; Magnesium, 2002). For patients with mood issues, I
typically recommend the magnesium glycinate or magnesium taurate form over other
types. (Glycine and taurine are discussed under mino Acids, below.) Magnesium in the
form of Epsom salts can be used in a relaxing bath, with one to two cups in a standard size
bathtub.
Magnesium toxicity. Toxicity from magnesium is exceedingly rare, even at higher than
normal doses. Supplementation is not recommended for patients who have compromised
renal function or are undergoing dialysis. Supplementation can sometimes cause a looser
stool, especially in higher doses. Nonchelated forms such as magnesium sulfate (as found
in Epsom salts), oxide, hydroxide, or chloride will typically encourage diarrhea sooner
than the malate, citrate, glycinate, and taurate forms.
Magnesium food sources. Magnesium is found in mineralized hard water. In fact, many
experts believe it is the mineral water that keeps French hearts healthy, despite the
tendency to eat richer foods. Also, Swiss chard, summer squash, blackstrap molasses,
spinach, mustard greens, halibut, turnip greens, and seeds (pumpkin, sunflower, and flax)
are higher in magnesium content.
Chromium
As discussed in Chapter 3, poor blood sugar control (low blood sugar, fluctuating blood
sugar, or high blood sugar and diabetes) will contribute to mood problems. The essential
trace element chromium is a component of glucose tolerance factor, a complex molecule
in the body used balance insulin levels and blood sugar. Chromiums modus operandi may
also be its activation of brain serotonin (Attenburrow et al., 2002), as well as ability to
increase insulin sensitivity (Anderson, 1998). Like other minerals, increased carbohydrate
intake increases chromium loss.
Atypical types of major depressive disorder constitute more than 20 percent of all
cases of depression. The atypically depressed patient can experience extreme reaction to
events as well as a greatly increased sensitivity to rejection, resulting in depressed
overreaction. Atypically depressed patients can also have greater physical feelings, such as
extreme sense of physical heaviness (lead legs), weight gain or increased appetite, and
these patients can sleep too much. These symptoms are summarized as follows.
Toxicity of selenium. Large doses of selenium can be toxic. Doses larger than 400 g may
cause symptoms of dermatitis, hair loss, and brittle nails.
Food sources of selenium. Best sources of selenium include meat, fish, nuts (especially
Brazil nuts), and garlic.
Lithium orotate
Lithium is a mood stabilizer with both antidepressant and antimanic properties. However,
its mechanism of action is unclear. In the carbonate form, it is prescribed for patients with
bipolar disorder, although now newer drugs are available. Geographical areas with higher
natural lithium concentrations in the drinking water are associated with lower mortality
rates from suicide (Kapusta et al., 1987). Bipolar disorder patients who take lithium
carbonate have lower rates of Alzheimers disease, as well as less cognitive impairment,
suggesting lithium may have a neuroprotective quality as well (Lowry, 2011).
The supplemental form of lithium is lithium orotate, which is a salt of lithium and
orotic acid. Lithium orotate may be the preferred form, for the orotate ion is known to
more easily traverse the blood-brain barrier than the drug version, which uses the
carbonate ion of lithium. As a result, the orotate form can be used in much lower doses
with reasonable results and no side effects (Lakhan & Vieira, 2008). Typical lithium
orotate dosages can be as low as 5 mg/day, versus up to the 180 mg needed for the lithium
carbonate form.
While considered more natural, lithium orotate has been minimally studied. In one
evaluation, alcoholic patients prescribed 150 mg lithium orotate (approximately 57
mg/day of elemental lithium) four to five times a week along with a diet low in simple
carbohydrates that assured moderate amounts of protein and fat were studied by Sartori et
al. (1986). Of 42 patients, 10 had no alcoholic relapse for over 3 and up to 10 years, and
13 patients remained without relapse for 13 years. The remaining 12 had relapses
between 6 and 12 months.
It is suggested that lithiums beneficial effects on mood may be due to its oxytocinraising properties. In one small study by Winstock et al., 20 long-term marijuana smokers
took 500 mg lithium carbonate twice daily for seven days. Three months later, most were
getting high less, and some had quit entirely. Winstock et al. also noted that those that
stopped completely had greater levels of happiness than those who smoked less. This
corroborates previous studies on rats that showed higher levels of oxytocin with lithium
supplementation (Cui et al., 2001).
Lithium orotate dosage and best usage. Lithium orotate is commonly dosed at 520
mg/day of elemental lithium. Lithium might be best used with someone who is anxious or
depressed and has demonstrated doing well with oxytocin-building activity like receiving
a massage. More study is clearly needed to understand who will best benefit from lithium
supplementation.
Lithium orotate toxicity. While common supplemental doses show no toxicity, high doses
can cause muscle weakness, loss of appetite, mild apathy, tremors, nausea, and vomiting.
In high doses, lithium may also cause dulled personality, reduced emotions, memory loss,
tremors, or weight gain (Waring, 2006), as well as impair kidney function (Smith &
Schou, 1979). One case of an 18-year-old who ingested 18 tablets (2,160 mg total) of a
lithium-containing over-the-counter relaxation supplement had normal vital signs but
complained of nausea and vomiting and presented with tremor, which resolved after 3
hours of intravenous fluids and observation (Pauz & Brooks., 2007).
Food sources of lithium. Primary food sources are grains and vegetables.
Zinc
Known as a mineral cofactor, zinc is responsible for many aspects of health, including
wound healing, as well as immune and nervous system balance. Deficiency will contribute
to emotional instability and depression. Low zinc status may cause lower levels of GABA,
increasing anxiety symptoms. Zinc deficiency has been found to be associated with GABA
receptor impairment (Takeda et al., 2006). It has been reasoned that zinc may protect the
brain by blocking the toxic effect of glutamate (Nowak et al, 2003).
Patients with anxiety have been shown to have low zinc levels, especially in
relationship to copper levels. In these patients, zinc piccolinate daily for 8 weeks restored
that balance and improved symptoms (Russo, 2011). For depression, lower zinc correlates
with increased severity. As is the case with folic acid, low serum zinc increases the
likelihood antidepressants will not work (Maes et al., 1997a). (This is discussed further in
Chapter 6.)
Zinc dosage and toxicity. Optimal zinc dosage is 1530 mg/day. It should be taken with
food due to the possibility of gastric upset. It may be most indicated for patients with
mood problems along with acne or low immune status. If taking zinc for more than 2
months, and high copper is not a concern, it is best to take 12 mg/day copper, for extra
zinc supplementation can cause the body to lose copper.
Zinc food sources. Known to accompany animal protein, zinc is found in highest levels in
beef, lamb, turkey, chicken, pork, crabmeat, lobster, clams, and salmon. The best
vegetable source is pumpkin seed.
Amino Acids
Amino acids are the precursors to neurotransmitters. Adding supplemental amino acids
can create happy mood and help avoid the need for medications. While most vitamins and
minerals act as cofactors in the production of neurotransmitters, the amino acids are the
building blocks of the neurotransmitters and can play a central role in changing mood for
the better.
Table IV.6 in Appendix IV reviews the top supplemental amino acids used for anxiety
and depression, which are described in detail below.
Gamma-aminobutyric acid and phenibut
Gamma-aminobutyric acid (GABA) is a natural calming brain neurotransmitter that may
act like a natural benzodiazepine. People who suffer with anxiety, insomnia, epilepsy, and
other brain disorders often do not manufacture sufficient levels of GABA. Supplemental
GABA helps open chloride channels in neurons, which hyperpolarizes them so that the
positive charges remain on one side of the membrane, which inactivates the nerve cell.
This slows firing and calms the brain.
GABA dosage, best application, and toxicity. The typical dosage for GABA is 100200
mg up to three times daily away from food, although some practitioners dose higher for
better effect. Though no side effects have been reported, as a general guideline it is
recommended to take no more than 1,000 mg within a 4-hour period and no more than
3,000 mg within a 24-hour period. The best application for GABA is either as a natural
Xanax where a patient would like something relatively quick as a calmative, or for
enhancing the process of falling asleep in times when he or she cannot wind down and
move into the alpha state.
GABA toxicity. No known toxicity is associated with GABA when used in recommended
dosages. Phenibut has limited research, with one case report suggesting dependence,
tolerance, and withdrawal symptoms (Samokhvalov et al., 2013).
Food sources of GABA. The highest levels of GABA are found in green, black, and
oolong teas, which is probably why sipping these can be relaxing. Fermented foods (e.g.,
yogurt, kimchi, and sauerkraut), as well as oats, whole grains, and brown rice, also include
GABA.
Glycine
The simplest of the amino acids, glycine is a calming amino acid known to reduce
neuronal excitement, optimize GABA, and bind to the locus coeruleus to decrease the
release of norepinephrine. Glycine, like GABA, is also known to help open chloride
channels, which calms electrical activity.
Two double-blind, placebo-controlled studies in 14 and 16 healthy patients exposed to
loud sounds found that high doses of glycine (0.8 g/kg body weightabout 44 grams for a
120 pound person) calmed the brains cortex and decreased reaction to the sound by
lessening auditory evoked potentials (ONeill et al., 2007; Leung et al., 2008). Several
double-blind trials in patients with schizophrenia using 0.40.8 g/kg body weight/day for
612 weeks along with antipsychotic medication improved negative symptoms by 1530
percent, over using medication by itself. Heresco-Levy et al., 1999). One trial of 0.8 g/kg
saw no benefit in cognitive in already healthy young people (Palmer et al., 2008),
suggesting its best use may be in people could use calming.
Dosage and best application. Glycine usually comes in a powder that can be taken in a
little water. The studies described above used very high doses (0.8 mg/kg is equivalent to a
whopping 44 g/day of powder) to achieve benefit. In my experience, prescribing lower
doses (two or three teaspoons a dayabout 1015 g total), along with other lifestyle and
dietary changes and supplements, can help keep anxiety at bay. Patients experiencing or
anticipating panic attacks can take 510 g in one dose before anxiety-provoking situations.
Glycine tends to work within 30 minutes of ingestion. Often, I will have patients mix one
teaspoon of glycine powder with passionflower tincture to take three times a day for
anxiety.
Glycine toxicity. While glycine has no known toxicity, no long-term studies at very high
doses (0.8 g/kg) have been conducted. Patients with kidney or liver disease should talk to
their doctor before using high doses of amino acids.
Tryptophan and 5-HTP safety. When dosed accordingly, tryptophan appears to be quite
safe and effective. The most common and reversible adverse effects are gastrointestinal:
nausea, vomiting, and diarrhea. Much less common, patients have complained of
headache, insomnia, and palpitations.
About 20 years ago, there was a lot of misinformation about the safety of tryptophan.
In 1989 more than 1,000 people fell ill after consuming the supplement, causing concern
for eosinophilia-myalgia syndrome (EMS) in the United States. This syndrome consisted
of severe muscle and joint pain, high fever, swelling of the arms and legs, weakness, and
shortness of breath. Sadly, more than 30 deaths were attributed to EMS caused by
tryptophan supplements (Belongia et al., 1990). Although the supplement itself was
originally blamed and then banned in the United States, it was actually poor quality
control that was at fault due to contaminants in the supplementit had nothing to do with
tryptophan itself. No new cases of EMS have been reported since (Das et al., 2004).
More salient to our conversation would be discussion of serotonin syndrome. This is
a theoretical situation where combined SSRIs drugs or an SSRI drug and serotoninpromoting natural therapy (e.g., tryptophan, 5-HTP, or St. Johns wort) might increase
serotonin levels. This syndrome is characterized by severe agitation and confusion and
may include symptoms of hallucinations, fast heart beat, blood pressure changes, feeling
hot, coordination issues, hyperreflexes, and gastrointestinal tract symptoms such as
nausea, vomiting, and diarrhea. Severe cases can cause rapid fluctuation of temperature
and blood pressure, mental status changes, and even coma.
Although polypharmacy (taking several drugs at the same time) has caused this
syndrome (Gnanadesigan et al., 2005), no reports of natural substances being the cause
have been reported to date. This chapter, along with Chapter 6 presents a number of
studies showing the benefit of using tryptophan or 5-HTP together with SSRIs and
tricyclic antidepressants. For example, in 870 patients taking medications with 5-HTP,
there has not been one case of serotonin syndrome (Turner, Loftis, & Blackwell, 2006).
Nevertheless, to be safe, any integrative care practitioner should watch for signs of
serotonin syndrome until more study is done. With careful dosing of SSRI drugs along
with tryptophan or 5-HTP, supplementation may prove a side-effect-free integrative
approach. 5-HTP has also been used clinically in combination with tryptophan, with no
signs of serotonin syndrome (Quadbeck, Lehmann, & Tegeler, 1984).
Tryptophan and 5-HTP food sources. Tryptophan can be found in all protein foods in
small amounts. Relatively high amounts are present in pumpkin seeds, bananas, turkey
(which some believe contributes to the post-Thanksgiving meal sleepinessbut research
suggests this is really the effect of excess food intake), red meat, dairy, nuts, seeds, soy,
tuna, and shellfish. There are no food sources of 5-HTP.
Phenylalanine and tyrosine
Because tryptophan and 5-hydroxytryptophan are the building blocks for serotonin, Lphenylalanine and tyrosine are the precursors that convert to the two neurotransmitters
dopamine and norepinephrine (Gelenberg & Gibson, 1984). As such, people experiencing
mild to moderate depression who have low dopamine or norepinephrine may find it
subjects between 1 and 13 days of treatment. No important adverse reaction was observed.
A second study showed that L-phenylalanine supplementation elevated mood in 31 of 40
depressives with doses of 14 g/day (Sabelli et al., 1986).
Gelenberg et al. (1990) performed a randomized, prospective, double-blind
comparison of 65 outpatients with major depression given oral L-tyrosine or imipramine.
Although both treatments trended toward some improvement, imipramine showed greater
improvement, with little difference between placebo and tyrosine. The only effect noted to
achieve statistical significance was greater dry mouth with imipramine. Gelenberg et al.
concluded that the idea that a natural product with negligible side effects would turn out
to be an effective treatment for depression appeared too good to be trueand our data
suggest that it was. Thus, although there is certainly promise with phenylalanine and
tyrosine, more studies are clearly needed. I still find both tyrosine + penylalanine useful as
adjunctive to the other supports for clients, especially in the cases of low motivation and
pain.
Phenylalanine and tyrosine dosages and best application. The L form of phenylalanine
may be dosed of up to 14 g/day in divided doses. The D form of phenylalanine has been
studied in doses of 350 mg/day. As an antidepressant strategy, L-tyrosine may be used in
doses of 5001,000 mg two or three times a day, with some studies dosing up to 6,000
mg/day in total. Because tyrosine can be stimulating and possibly affect sleep, a
reasonable clinical strategy would be to prescribe tyrosine during the daytime and
supplementing at night with 10001500 mg L-tryptophan or 50100 mg 5-HTP in
patients with mild to moderate depression. No known studies have used phenylalanine and
tyrosine at the same time.
These amino acids would be useful for a depressed person but would not be
recommended for anxiety. The best choice would be an overweight client with a strong
appetite who experiences regular pain (maybe suffering migraines or arthritis) and has
many physical stressors and/or low motivation and apathy. Using tyrosine and glucose
tolerance fac-tor (a nutrient found in brewers yeast) or chromium may lessen tobacco
withdrawal symptoms and may increase the chance of success in a smoking cessation
program if your client smokes.
Phenylalanine and tyrosine toxicity. Taking too much of these amino acids may result in
increased blood pressure and emotional jitters, trouble sleeping, or headaches.
Phenylketonuria (PKU) is a disorder in which the body fails to turn phenylalanine into
tyrosine properly. Those with PKU should not supplement with phenylalanine. Tyrosine
seems to be generally safe, though reports of nausea, diarrhea, headache, vomiting, or
excessive nervousness have occurred with doses >9 g. Insomnia can be prevented by
avoiding evening supplementation. Tyrosine should not be taken by anyone who is taking
monoamine oxidase inhibitors for depression, or by patients with hypertension. The
Parkinsons drug levodopa may interfere with the absorption of tyrosine and could reduce
tyrosine levels in the blood. Tyrosine may also be contraindicated in multiple myeloma, a
cancer of bone marrow cells. Patients with Graves disease and an overactive thyroid
should use caution when supplementing with tyrosine because it can boost thyroid
enzymes (Jorissen et al., 2002; Phosphatidylserine, 2008). While more studies are
welcome, there is no evidence of toxicity for phosphatidylserine.
Food sources of phosphatidylserine. The sources with the greatest amounts of
phosphatidylserine are mackerel, herring, chicken liver, tuna, soft-shell clams, and white
beans.
N-Acetyl-cysteine
Known for years in conventional care as an emergency intravenous treatment to thwart the
effects of acute liver toxicity (e.g., eating a poison mushroom), N-acetyl-cysteine (NAC)
has found a strong place in the natural medicine armamentarium due to its glutathioneregenerating capability as well as its ability to balance levels of glutamate in the brain.
Glutathione is the bodys master antioxidant and is produced in the liver.
NACs effect on anxiety has been shown to be helpful in cases of obsessivecompulsive disorder, gambling issues, and trichotillomania (hair pulling) (Grant, Odlaug,
& Kim, 2009). NAC has also been given to children and adolescents with autism by
helping resperidone more effectively treat irritability symptoms (Ghanizadeh, & Moghimi
Sarani. 2013).
NAC has also been studied for use of depressive symptoms. One study of 17 patients
with bipolar disorder found that 8 of the 10 patients taking NAC over 24 weeks achieved a
very beneficial effect on mood (Magalhes et al., 2011). However, a larger open-label trial
of 149 patients did not confirm these results (Berk et al., 2012).
N-Acetyl-cysteine dosage and best application. Typical dosages of NAC are 500600
mg two or three times a day.
N-Acetyl-cysteine toxicity. Occasional headaches or stomach discomfort might occur, but
it is known to be quite nontoxic. One study did report considerable headaches, agitation,
social withdrawal, and severe aggression in a few young patients being studied for
pathologic nail-biting habits (Ghanizadeh, Derakhshan, & Berk, 2013). NAC may
interfere with certain cancer treatments and could be avoided with chemotherapy.
N-Acetyl-cysteine food sources. While there are no direct food sources of NAC, cysteine
is a precursor of NAC and is found any high-protein food (meats, tofu, eggs, dairy
products, etc.).
Taurine
Made from cysteine with the cofactor vitamin B6, taurine it is thought to act by supporting
levels of glycine and GABA to help relax the brain and nervous system while keeping
levels of toxic glutamate low (Mori, Ghwiler, & Gerber, 2002). It is also known as a
cardiovascular support and prevents aggregation of platelets to help decrease excess
clotting. While animal studies do suggest an anxiolytic effect (El Idrissi et al., 2009), no
clinical studies to date have evaluated the direct use of taurine in anxiety or depression.
Overall, studies are lacking to fully support the use of this nutrient.
Taurine dosage and best application. Taurine is usually dosed about 500 mg up to three
times daily and may be good for a person with anxiety, low energy, and cardiovascular
concerns who would do best to relax. Taurine can also be obtained by using the
magnesium taurate form of magnesium.
Taurine toxicity. One study using doses of 1,500 mg/day did not find significant toxicity
in patients with epilepsy. Four of 25 patients did report headaches, nausea, nosebleeding,
or temporary balance disturbance (Takahashi & Nakane, 1978). Because taurine may
lower blood pressure or cause slight drowsiness, bedtime may be a good time to take it,
and persons taking antihypertension medications should monitor their blood pressure.
Food sources of taurine. Taurine is present only in animal foods, so meats and eggs
would be top sources.
S-Adenosyl-L-methionine
S-Adenosyl-L-methionine (SAMe) is a naturally occurring molecule derived from the
amino acid methionine and adenine triphosphate (ATPthe main energy molecule in the
body). SAMe is involved in the synthesis of various neurotransmitters in the brain and is
not a newly identified substanceits chemical structure was described as early as 1952. It
has been in use for decades in Europe. While it is a prescription medication in most other
countries, it is found over-the-counter in the United States. Even the American Psychiatric
Association (2010) has acknowledged it might be considered as an alternative to
pharmaceutical medicationsthats a rave from them as far as natural substances are
concerned.
Known best as an antidepressant, SAMe serves in many biological reactions by
transferring molecules called methyl groups to DNA, proteins, fats, and amino acid
compounds. Methylation (carbon-molecule-donating) reactions supported by SAMe have
been shown to form monoamine neurotransmitters such as dopamine, serotonin, and
norepinephrine (Miller, 2008; Bottiglieri, 2002)all of which are needed for good mood.
This chapter has already discussed the importance of B vitamins and folic acid. In
depression, folate, vitamins B6 and B12, and unsaturated omega-3 fatty acid deficiencies
all affect the biochemical processes in the central nervous system, as folic acid and
vitamin B12 participate in the metabolism of SAMe. The deficiency of these vitamins
results in high homocysteine levels. Research shows that approximately 4555 percent of
patients with depression develop significantly elevated serum homocysteine. This
homocysteinemia causes a decrease in SAMe. This stops the needed methylation, which is
a process needed to make neurotransmitters and fatty myelin sheaths for nerve cells.
Electrical conduction along the nerve cells does not work well when the myelin sheaths
are not well made or if they are damaged. Hyperhomocysteinemia also leads to increased
glutamate, a brain toxin linked to mood disorder. It also affects the cardiovascular system
by causing breakdown in the linings of the vessel walls, which contributes to
inflammation and heart disease. All this promotes the development of various disorders,
including depression (Karakula et al., 2009).
No research has been done using SAMe to treat severe depression, so it is unknown
whether SAMe would have the same benefits as seen in mild to moderate depression.
SAMe is considered expensive and may be a good second-line choice if other natural
treatments are not effective or a first-line choice in older patients with other health
challenges such as cardiovascular disease, Parkinsons disease, or dementia.
A number of studies directly compared SAMe to tricyclic antidepressants, with about
eight studies showing equal benefits and lower side effect profiles. Pancheri, Scapicchio,
and Chiaie (2002) ran a multicenter study where patients with depression received 400
mg/day via an intramuscular injection, or 150 mg/day by mouth. A total of 146 patients
received SAMe, and 147 received 150mg per day of imipramine, for a period of 4 weeks.
The drug or SAMe worked equally as well in both groups, but SAMe was significantly
better tolerated. Another study by the same group compared 1,600 mg/day of SAMe by
mouth, or 400 mg/day via intramuscular injection, with the tricyclic antidepressant
Tofranil (imipramine; 150 mg/day) and found the same positive results (Delle Chiaie et
al., 2002). The conclusion drawn from these studies is that the antidepressant effect of
SAMe at 1,600 mg/day orally or 400 mg/day intramuscularly is comparable with that of
150 mg imipramine/day orally, with much better toleration of SAMe over its
pharmaceutical counterpart.
SAMe dosage, toxicity, and best application. Because oral SAMe may cause nausea in
some people, it is suggested to start a dosage of 200 mg twice daily, then increase to 400
mg twice daily on day 3, then to 400 mg three times daily on day 10, and finally to the full
dose of 400 mg four times daily on day 14. Of course, if there are any noticeable side
effects, then SAMe may need to be ramped up slower. SAMe has been used safely in
children as well and has been studied doses of 200 mg up to 1,400 mg over a 2-month
period in young teens (average age of 14 years) to help with functional abdominal pain,
with no side effects or change in liver function (Choi & Huang, 2013). For maximal
absorption, SAMe is best taken away from food.
The best application for SAMe is in a depressed patient who has low energy and little
motivation. SAMe may increase anxiety in patients who are already anxious, and is
contraindicated in bipolar disorder.
SAMe food sources. The body makes SAMe, but there are no known food sources.
BOTANICAL MEDICINES
From time immemorial, plants have been a source of nutrition and medicine for humans.
Botanical medicines (also known as herbs) may be used as a supplement in the sense of
using plant material as a source of certain vitamins or minerals. Botanicals can also be
used to create more physiologic or biological effects in the body, similar to how a drug
may work.
Herbs are typically safe because herbal medications, as natural plants, contain many
ingredients that will communicate with the body and create warning messages before
toxicity can occur. For example, we can look at the herbal plant Digitalis (foxglove) and
the medication digoxin (Digox). The Native Americans used foxglove for apparent
cardiovascular distress, as they noticed a positive effect on energy and circula-tion upon
consumption of the plant. From foxglove, modern medicine extracted the component
digoxin, which works as a positive inotrope (strengthens heart muscle contractions). The
problem with digoxin is it has a narrow therapeutic windowyou take too little and it
doesnt work, but take too much and it can cause bradycardia and quickly kill a person.
The whole plant foxglove, on the other hand, tends to make a person vomit and creates
great digestive distress well before levels of digoxin become too high. While both the drug
and the plant can be toxic, the multiple molecules in the plant will usually create nonfatal
signs of toxicity first, whereas processing has removed the drugs ability to do this. This
example underscores the reason that, in general, natural herbal substances tend to be safer,
and also that it may be best to use whole herbs, instead of extracting and studying certain
molecules and ctive ingredients only.
Table IV.7 in Appendix IV reviews the top botanical medicines for anxiety and
depression, which are described in detail below.
curcumin (Antony et al., 2008). While side effects are uncommon, curcumin
supplementation may cause mild gastritis and mild nausea, and for effectiveness is best
taken away from meals.
have that interesting smell, and traditional belief is that consumption can help its user gain
horse-like strength and vitality (Shastry, 2001).
While ancient medicines view it as a overall tonic for the body, modern research has
keyed in on its advantage for inflammatory conditions, Parkinsons disease, neurologic
disorders and as an adjunct in cancer care to support drops in white blood cell counts
(Mishra, Singh, & Dagenais, 2000). While this herb possesses numerous compounds that
help balance physiology, this plants alkaloids and lactones (known as withanolides),
acting as hormonal precursors, have been the center of much research on ashwagandha
(Withania somnifera, 2004).
In holistic care, ashwagandha is seen as adaptogenic and can bind to receptors to
increase effect when available ligands (receptor stimulators) are low but block excess
stimulation when ligand availability is high (Bhattacharya et al., 2000). While most
understanding of ashwagandha is based on its long history and animal studies, a few
studies do show benefit for anxiety.
A study by Chandrasekhar, Kapoor, and Anishetty (2012) randomized 64 people to
either placebo or 300 mg of high-concentration extract from the ashwagandha root, as one
capsule twice a day, for 60 days. During the treatment period (on days 15, 30, 45, and 60),
follow-up telephone calls were made to all subjects to check for treatment compliance and
to note any adverse reactions. The treatment group exhibited a significant reduction in
scores on all the stress-assessment scales on day 60 relative to the placebo group. Serum
cortisol levels were substantially reduced compared with the placebo group. The adverse
effects were mild and comparable in both groups. A case study (Kalani, Bahtiyar, &
Sacerdote, 2012) showed benefit in women with adrenal hyperplasia (a situation where the
adrenal glands have swollen due to chronic stress). The women found improvements in
levels of cortisol, progesterone, and pregnenolone, as well as noticeable improvement in
alopecia (hair loss). In another case study, men with stress-related fertility issues showed
higher antioxidant status and healthier sperm (Mahdi et al., 2009).
Ashwagandha dosage and best usage
Typical dosage is 300 mg once or twice a day of ashwagandha with standardized
withanolide content (considered an active component of ashwagandha) of at least 15
percent. Ashwagandhas best use is for someone with anxiety and a stressful life
accompanied by nervous depletion and sleeplessness. I have taken ashwagandha myself
and can attest to its value to help support stressful situations by making the body less
reactive.
Ashwagandha toxicity
No toxicity was noted in any studies with this botanical medicine, save one case report
that documented a woman who presented with hirsutism (body hair growth) who appeared
to have increased levels of dehydroepiandrosterone sulfate along with lowered
testosterone levels while taking ashwagandha. While not clear if the ashwagandha was the
cause, this resolved once she stopped the herb (Nguyen et al., 2013). One senior patient of
mine reported vomiting with this herb.
effectiveness in both anxiety and mild to moderate depression. As a result, SJW is now
becoming one of worlds standard treatment consideration for low mood. Like SAMe,
even the American Psychiatric Association (2010) has acknowledged it might be
considered as an alternative to pharmaceutical medicationsagain, thats pretty much
another rave from them as far as natural substances are concerned.
SJW is best known as an antidepressant, and most conventional circles consider it, at a
cursory glance, as simply another antidepressant drug with some SSRI capability. While
SJW may exhibit some SSRI mechanisms, it has numerous other effects in both the brain
and the central nervous system. In truth, despite all the study, the exact antidepressant
mechanism of action of SJW is still not fully understoodlikely because it, likely other
botanical medicines, has numerous chemical components that cause multiple gentle effects
throughout the body. Initially it was believed to work like the first drugs used for
depression, the monoamine oxidase inhibitors, which act by slowing the breakdown of
neurotransmitters (Mller et al., 1997). Other studies then suggested it stops the
breakdown of acetylcholine (Re et al., 2003) and has a serotonin-like activity (Helgason,
2007), where it can act like a weak SSRI with fewer side effects (Morelli & Zoorob,
2000). It also gently balances other neurotransmitter levels, including norepinephrine and
dopamine, as well supporting GABA (Nierenberg Lund & Mischoulon, 2008;
Hammerness, 2003). Other studies show this wonderful herb to have anti-inflammatory
and nerve protective properties (Wong et al., 2004). What we can take from all this is that
SJW has pleiotropic effectsall around the body and brainand in total they seem to
lower both depression and anxiety symptoms.
With hundreds of studies reviewing SJW for depression, the most recent meta-analysis
as of this writing is a 2008 study from Munich (Linde, Berner, & Kriston, 2008) that
reviewed only randomized and double-blind studies of patients with depression.
Compared with previous reviews, this meta-analysis included newer well-designed studies
published between 1995 and 2006. SJW for 412 weeks was compared with placebo and,
in 17 studies published between 1997 and 2006, with standard antidepressants, including
fluoxetine, sertraline (Zoloft), imipramine, citalopram (Celexa), paroxetine (Paxil), and
amitriptyline (Elavil). In all, it included 29 studies with 5,489 patients. The studies came
from many of countries, tested several different SJW extracts, and mostly included
patients suffering from mild to moderately severe symptoms. Overall, the SJW extracts
tested in these trials were superior to placebo and were at least as effective as standard
antidepressants. Furthermore, patients given SJW extracts dropped out of trials less
frequently due to adverse effects than those given older antidepressants. Further research
goes on to suggest that antidepressant side effects are between 10- and 38-fold higher than
those of SJW (Kasper et al., 2010a). Given the same benefits as the drugs, and fewer side
effects, there is no reason not try it first for mild to moderate depression.
While SJW is well studied for depression, newer studies are starting to unearth its
antianxiety power. Animal studies in diabetic rats given SJW showed clear benefits toward
lowering glucose levels, as well as minimizing anxiety and depression behaviors (Husain
et al., 2011). Another study found benefit for mood and anxiety in postmenopausal women
(Geller & Studee, 2007). However, study of 60 subjects did not see benefit for obsessive-
saffron is known for its vibrant color and flavor and also for being the worlds most
expensive spice. With a high amount of antioxidative carotenoids (which give it its burnt
orange color) and B vitamins, saffron has been traditionally used as a calmative,
antidepressant, and anti-inflammatory, with a digestive specialty of relaxing the muscles
of the digestive tract to reduce spasms and help digest food, as well being an appetite
enhancer (Yarnell, 2008).
A number of recent preclinical and clinical studies indicate that the stigma of the plant
(the top of the plant where the pollen is, which is technically called the saffron) and
petal of the Crocus sativus plant both have antidepressant effects. Animal studies show
that the compounds safranal and crocin may exert antidepressant effects by keeping
balanced levels of dopamine, norepinephrine, and serotonin (Hosseinzadeh, Karimi, &
Niapoor, 2004).
In an 8-week double-blind randomized trial, Akhondzadeh et al. (2007) randomly
assigned 40 depressed adult outpatients to receive either a 15-mg capsule of petals of the
crocus plant in the morning and evening or 10 mg Prozac, in the morning and in the
evening. At the end of trial, the crocus petal capsules were as effective as the drug, with no
significant differences in percentages of responders: fluoxetine had an 85 percent
responder rate (17 of 20 patients, an unusually high rate for this drug) and crocus petal
capsules showed a similar 75 percent responder rate. A 6-week comparison with
imipramine found significantly better Hamilton Depression Scale outcomes with the herb
(Akhondzadeh et al., 2005).
Crocus dosage and toxicity
For the above clinical studies, 15 mg of the petal or stigma (saffron) was given twice a
day. Crocus petal is reported to have the same antidepressant effect as the stigma in at
least three clinical trials (Noorbala et al., 2005; Akhondzadeh et al., 2004, 2005)the
petal costs significantly less than saffron but with the same benefit.
No toxicity has been reported at these dosages or when ingested in culinary amounts.
One study on rats with exceedingly high levels of the herb injected directly into their
abdomen showed reductions in red blood cells, as well as changed liver and kidney
function. However, these are much higher doses than used clinically, and intraperitoneal
(abdominal) injection doses are not processed through the digestive tract as oral doses
would be (Mohajeri et al., 2007). As a precaution, patients with liver and kidney problems
may not want to use this herb if other treatment choices are available. Interestingly, in rats
given the chemotherapy drug cisplatin, crocus, along with the amino acid cysteine and
vitamin E, actually protected the kidneys from toxicity (el Daly, 1998).
Mucuna has been studied for its effectiveness in helping patients with Parkinsons disease,
a condition where the area of the brain that makes dopamine does not function. Three
open label studies where patients took an average of 45 g/day of mucuna seed powder
extract (which is equivalent to about 1,500 mg L-dopamine) reported significant symptom
improvement (HP-200 in Parkinsons Disease Study Group, 1995; Vaidya et al., 1978;
Nagashayana et al., 2000). Another study suggested the mucuna might have fewer side
effects than the standard Parkinsons medication (Katzenschlager et al., 2004).
I mention this herb for depressed patients who may be benefiting from dopamineboosting medications like bupropion or aripiprazole. Patients who have found these to
help with motivation, self-esteem, and a general good mood may be able to use low doses
of this herb to help them wean off the medication while maintaining their better mood.
Some patients may be able to use this as an alternative to the medicationsplease note,
though, that this idea has not been studied clinically, although my personal experience
with patients suggests it works.
Mucuna dosage
For support with medication, I recommend starting with 200 mg of the extract and moving
up to 200 mg twice a day after 2 weeks (which supplies ~120240 mg L-dopamine). This
is a relatively low dose. Higher doses may be appropriate if patients are not on dopamineboosting medications.
Mucuna toxicity
Mucuna may cause some bloating and nausea in some people and can interfere with
anticoagulant (blood-thinning) drugs. It may boost testosterone and could aggravate
polycystic ovarian syndrome in women. There have been reported cases of severe
vomiting, palpitations, difficulty in falling asleep, delusions, or confusion. To be safe, I
recommend that a patient work with a knowledgeable practitioner when using this herb.
HOMEOPATHY
The term homeopathy is derived from the two Greek words homeo, which means
similar, and pathos, which refers to suffering. Homeopathy is one of the most interesting
and controversial modalities in the holistic armamentarium. Homeopathy can be a staple
treatment or point of contention for the integrative medicine practitioner, as well as a focus
of vitriol for those looking to discredit natural medicine.
Homeopathy is also one of the more difficult natural medicine approaches to explain
from a Western science standpoint. Despite this, it has prescribed as a part of successful
care in Europe and India for over a 100 years. The theory of homeopathy suggests that a
given remedy may play a role in changing the energetics of a persons condition to allow
the body to heal from the inside.
Developed by physician Samuel Hahnemann in the late eighteenth and early
nineteenth centuries, homeopathy is a system of therapy based on the concept that each
naturally occurring element, plant, and mineral compound will, when ingested or applied,
result in certain symptoms and physiologic change. Using this knowledge, a given disease
may be treated with minute homeopathic doses of the substance thought capable of
producing in healthy people the same symptoms of that disease. This is known as the
concept like cures like (Medicine.net, 2009).
Using this principle, Hahnemanns work found clinical value and gained acceptance.
The first homeopathic medical college was established in Allentown, Pennsylvania, in
1835 (which is todays Medical College of Pennsylvania). The American Medical
Association (AMA) was founded in 1847 and from its inception pursued policies to
discredit natural medicines and specifically homeopathy. Despite the AMAs influence, by
the latter half of the nineteenth century homeopathy continued to grow and gain
acceptance. With a reputation for efficacy, it spread throughout Europe, as well as in Asia
and North America. Today, it is well accepted in India and Germany for use along with
conventional care.
the former Office of Alternative Medicine at the National Institutes of Healthnow called
the National Center of Complementary Medicine) and his colleagues (Davidson et al.,
2011) found 25 eligible studies from an initial pool of 1,431 subjects. Efficacy was found
for the functional somatic syndromes group (fibromyalgia and chronic fatigue syndrome),
but not for anxiety or stress. For other psychiatric disorders, homeopathy produced mixed
effects. As mentioned above, there have been no placebo-controlled studies for depression.
Meaningful safety data were lacking in the reports, but the superficial findings suggested
good tolerability of homeopathy for treatment of psychiatric illness.
One recent randomized, double-blind, placebo-controlled study looked at a
combination homeopathic remedy in stressed women (Hellhammer & Schubert, 2013).
For 14 days, 40 female subjects took three tables of a homeopathic comprising respinum,
gelsemium, passionflower, coffea, and veratrum. On the 15th study day, participants took
three pills in the morning and upon arrival at the study site. Subjects were assessed for
salivary cortisol, plasma cortisol, adrenocorticotrophic hormone, epinephrine,
norepinephrine, and heart rates; well-being, anxiety, stress, and insecurity during the stress
test; and sleep and quality of life. While cortisol levels did not differ between groups,
homeopathically treated participants had better sleep quality and lower norepinephrine
levels. The authors concluded that the homeopathic helped regulate the neuroendocrine
stress response during acute stress and impaired sleep.
Combined, these studies show that when studying homeopathy using conventional
parameters, results are mixed, with some suggestion of efficacy. It is highly possible,
however, that studying homeopathy from a more systems-based paradigm (food, sleep,
work, stress reduction, nutrients, etc.), and more specific prescribing for the individual,
may show better results in the future.
Appendix V lists homeopathics commonly used for depression and anxiety. The tables
suggest mental and emotional patterns, as well as physical appearance and/or peculiar or
idiosyncratic aspects, that may be found in your client. It is likely that not all clients will
display all of these, but ideally you will see an overall pattern that may fit. Please note that
a few remedies may be appropriate for either anxiety or depression. If you are more
interested in homeopathy, you may want to purchase a homeopathic material medica,
which describes the remedies in greater detail.
Dosage of homeopathics
As is true for many forms of natural medicines, different sources recommend various
methods of dosing. One simple low-potency method is to take one dose of 30X potency
every 612 hours and look for change in about a week. Clients should stop taking the
remedy once symptoms are better. If there is no change, or if symptoms worsen after
dosing, then consider another remedy.
FIVE
Mind-Body Medicine
Clinical Case Study: Anxious Alice
Alice is a 43-year-old mother of three girls, ages three, seven, and nine. About five
years ago she started having her first panic attacks while driving over a bridge.
While she drove (albeit with great discomfort), her anxiety slowly moved into the
realm many anxious moms report: Dying and leaving my children motherless.
To make it worse, last year her husbands sister died at the age of 34, leaving two
children behind.
She continually worried that something would happen to her, either an
accident or, she felt more likely, an illness. Her focus centered on breast cancer.
Given that she is from Long Island, an area of New York known for its record-high
breast cancer rates, she found much fuel for this thought. She started seeing her
current therapist about four years ago. This helped her function better and get out
and drive, but the daily stress did not let up. Mammogram after mammogram was
negative, which gave her a few days of relief until she learned that mammograms
themselves might cause breast cancer! In her mind now, she didnt know what to
do: keep checking and increase her risk more, or let a cancer go undetected.
One year ago, she decided to visit another naturopathic doctor who put her on
a solid regimen of health food and vitamins for anxiety and cancer prevention
support. This helped as well. When she came to see me, she had her good days
when she could distract herself enough with being busy, and bad days when
nothing could stop her from thinking about death. Either way, she still went to bed
thinking in detail about the various scenarios her death would take and picturing
the milestone events in her daughters lives coming up without her.
I asked Alice if she ever had anxiety before five years ago, she first told me no.
But, as we talked, she told me she could never stay still. My mind is never quiet.
Even as a kid, I was always worried about the next thing. I thought that was
normal. I asked her if she every meditated. Her face tightened, and almost paled
as she said, That is the worst thingit makes me crazy. I wont do it. I explained
to her how the mind is like a puppy, and if we let the puppy run around
undisciplined, it will grow up very unhappy, and in a sense, her mind is a puppy
that needs some gentle but firm discipline.
Starting very, very slowly (30 seconds twice a day), she began to deeply
breathe and meditatelearning to deal with the thoughts that flooded in. In two
months, she was up to 10 minutes twice a day. She also added yoga once a week to
her regimen. Today, she still has fleeting thoughts of death but uses them as a
moment to appreciate her life and to enjoy her family. In fact, after doing more
therapy work, she now states how death is natural part of life and I cant
teach my kids to fear death. Theres an old adage that says sometimes the thing
you hate the most is what you need the most. In Alices case, this was true.
Once relegated to the world of placebo, it is quite clear that mind-body modalities are
not simply feel-good distractions but instead can be an effective part of healing anxiety
and depression. In fact, given the research, it may be argued that these therapies are the
most elegant method to create change in the hypothalamic-pituitary-adrenal (HPA) axis,
thus altering the neuroendocrine, digestive, and inflammatory pathways of the body for
the benefit of the patient. This chapter touches on some of the top mind-body methods, but
this is by no means an exhaustive list.
YOGA
At least 5,000 years old, the practice of yoga predates Hinduism. The Sanskrit word yuj
means yoke or to unite and points to creating an awareness that unites our physical,
spirit, and emotional worlds. While todays Western practices focus on movement of the
body, yoga inspires us to bring synergy to all aspects of life, mental, physical, and
emotional, by using breath and movement and changing thoughts. In our modern society,
these aspects of life are often missing and can predispose us to anxiety and depression.
Yogic controlled breathing helps to focus the mind and achieve relaxation (in contrast to
meditation, which aims to calm the mind). Like exercise, yoga is an excellent method to
deepen the breath and keep the blood flowing.
From a spiritual standpoint, yoga is a strong practice that can help modify emotional
processing. Sukha is the Sanskrit word for happiness, which literally translates to
unobstructed peace. Yoga practice is thought to clear blockages within the body, which
leads to greater sense of calm and contentment with reality as it is, often with greater sense
of happiness and connectedness with others (Weintraub, 2005).
Numerous studies point to yogas ability to modulate HPA function. Yogas ability to
lower cortisol, modulate hormones, and regulate the activity of both the parasympathetic
and sympathetic nervous systems may underlie some of the benefits it offers for both
anxiety and stress (Kerstan et al., 2007). Yoga also helps mood by balancing the
neurotransmitter serotonin and stabilizing blood sugar. Physiologically, yoga has been
shown to lower cortisol and decrease inflammatory markers such a C-reactive protein, and
may be effective at lowering blood pressure. For example, a significant decrease in
salivary cortisol was seen following a 90-minute session of Iyengar yoga, an important
physiologic finding that may help to explain yogas beneficial effects for stress and
anxiety (Michalsen et al., 2005). Yoga practitioners experienced a significant increase in
GABA levels following a 60-minute yoga session compared with a control group who
read magazines and fiction (Streeter, 2010).
A systematic review by Kirkwood et al. (2005) that included only controlled clinical
trials of patients with anxiety disorders found positive results with the use of yoga for
anxiety. Shannahoff-Khalsa et al. (1999) conducted a hospital-based randomized
controlled trial in the United States with a group of participants diagnosed with obsessivecompulsive disorder. After 3 months, an experimental group practicing Kundalini yoga
along with a number of other yoga techniques, including mantra meditation, experienced
significantly greater improvements on the Yale Brown Obsessive Compulsive Scale, as
well as other scales, than a control group that practiced a meditative control regimen.
Five randomized controlled trials have also reported positive results for patients with
reactive depression (depression due to a specific event) (Broota & Dhir, 1990),
melancholic depression (depression with strong aspects of not enjoying activities and
guilt) (Janakiramaiah et al., 2000), major depression (Rohini et al., 2000) and even severe
depression (Khumar, Kaur, & Kaur, 1993), with no side effects noted. Woolery et al.,
(2004) looked at the Iyengar style of yoga, which focuses on body alignment. The asanas
(postures) recommended are those that involve opening and lifting of the chest, inversions,
and vigorous standing poses. Patients were randomly assigned to two 1-hour yoga classes
each week for 5 weeks or control group. A total of 5 patients withdrew (3 out of 13 in the
yoga group, 2 out of 15 in the control group), without reported reasons. Of the subjects
who remained, significant reductions in depression and anxiety scales were observed in
the yoga but not in the control group who had received no intervention. The effects
emerged about 2.5 weeks into the study and were maintained at week 5.
Yoga contraindications
While yoga presents very few contraindications and practically no interaction with
Western medications, certain poses may need modification to work with pregnancy, and
there is special caution for those with glaucoma, high blood pressure, and sciatica
(National Center for Complementary and Alternative Medicine, 2013b).
Meditation is also known to boost brain activity, organize brain wave activity,
strengthen neural connections, and thicken gray matter (Cromie, 2006). Admittedly,
medical science doesnt fully understand how or why meditation benefits and rebuilds
nerve tissue. Mediation also enhances vagal nerve tone: when stimulated, the vagus nerve
can turn off inflammation and help turn on digestive function (Das, 2007). It is possible
that helping digestion might be another key of how meditation to balances the mind. More
studies are needed to learn if specific meditative techniques may be most beneficial.
Regarding anxiety and depression, studies dating back to the early 1900s have shown
that meditation training programs can effectively reduce symptoms of anxiety and panic
and will help maintain these reductions in patients with generalized anxiety disorder, panic
disorder, or panic disorder with agoraphobia (Kabat-Zinn et al., 1992). A meta-analysis by
Chiesa and Serretti (2009). found that mindfulness meditation can reduce stress in healthy
people. It has also been shown to reduce ruminative thinking and trait anxiety, both factors
contributing to stress. Compared with other relaxation techniques, mindfulness meditation
may offer a greater ability to significantly reduce cortisol levels (Tang et al., 2007).
Meditation has been shown to alleviate depressed symptoms significantly in 51 treated
versus 41 control subjects (Sephton et al., 2007).
While likely great for just about everyone, meditation may be best for those depressed
patients who have a strong anxieties. In cases of sole depressed mood without any
anxiousness, sometimes I prefer the patient get up and do some movement, in which case
qigong (which involves breathing practice with gentle movement) might be more
balancing than stationary meditative work. One study by Gaik (2003) of 39 subjects
suffering from major depression, dysthymia, or bipolar disorder were taught a qigong
technique in a one-day training session with two follow-up sessions 1 and 2 months later.
Supportive audio and videotapes were also given to the volunteers. The subjects were
directed to practice for at least 40 minutes each day and to keep a log of their practice
sessions. Gaik found that ll subjects improved over the treatment period and observed
very significant level of improvement in the majority of the subjects who were measured
at serious levels of depression.
the efficacy of MBT, Hofmann et al. (2010) analyzed the most well-constructed 39 studies
of a possible 723 studies, totaling 1,140 participants who worked with mind-body
therapies. They found anxiety and depression responded quite well and the effect size was
robust in favor of symptom improvement.
Contraindications to meditation and MBT
According to the National Center for Complementary and Alternative Medicine of the
National Institutes of Health (2014), meditation is considered quite safe, with virtually no
side effects reported. There have been some isolated and rare reports of worsening of
symptoms in persons with psychiatric illness, but this has not been well researched (Arias
et al., 2006). Patients with physical limitations (e.g., inability to sit in a certain position)
should also seek the assistance of a knowledgeable health care provider or an experienced
meditation practitioner in choosing a style that is right for them.
MASSAGE THERAPY
Massage therapy is one of the most ancient of health care practices. First recorded in
Chinese medical texts more than 4,000 years old, massage has been advocated outside of
Asia at least since the time of Hippocrates, who said The physician must be acquainted
with many things and assuredly with rubbing [massage].
Mechanistically speaking, massage therapy is shown to reduce pain perception
(Ferrell-Torry, 1993), to significantly balance electroencephalogram currents in the brain
(Jones & Field., 1999), to decrease cortisol an average of 31 percent (Field et al., 1996),
and to increase dopamine and serotonin 31 percent and 28 percent, respectively (Field et
al., 2005).
Massage helps circulation of blood, the flow of blood and lymph and can reduce
muscle tension, improve weakness, balance the nervous system, and enhance tissue
healing. Although more studies are needed, some have shown massage to be effective in
reducing both state and trait anxiety, blood pressure and heart rate, pain, and depression
(Kutner, et al., 2008).
The ability of massage to alter HPA axis dysregulation and help balance
neurotransmitters helps to explain the findings of an extensive review that showed benefits
of massage to rival even psychotherapy in depression and state anxiety (a temporary
anxious change spurred on by an outside situation). A review by Moyer, Rounds &
Hannum. (2004). looked at 37 randomized, controlled trials on massage and included 17
studies on trait anxiety and depression from 1998 through 2002. On average, the massage
therapy participants experienced a reduction in state anxiety of at least 77 percent
compared with controls, with 73 percent decreases in depressive symptomology compared
with nonmassage therapy controls. Comparatively, psychotherapy for these conditions has
been shown to have a 79 percent benefit rate over untreated patients. It is possible that
using both in tandem may give even more substantial results.
ACUPUNCTURE
Practiced for the last three to four millennia, traditional Chinese medicine (TCM) is a
medical system based on the concept of comparing the state of the human body to the
natural world and then attempting to balance the human body to be in harmony with the
laws of nature. Acupuncture is a central modality in TCM, which involves inserting fine
needles into the body in order to balance the energy of the body to create a healing effect.
TCM uses the basic concept of yin and yang, as depicted in figure 2.1. The white areas
represent yang, which is full of light, energy, daytime, and movement. Yang represents the
male energy, going outward, and heat. The darker area is the yin part, representing quiet,
female, nourishment, dark, nighttime, stillness, cool, and energy in reserve. In the body,
yang and yin work together to create harmony and move in and out of each other all the
time. When the body is experiencing disease of balance, TCM would say that yin and
yang are out of harmony, and one is taking over the other, either because one is too strong
or the other is too weak.
In the paradigm of TCM, anxiety is often an issue of excess yang, or deficient yin,
whereas depression is more typically a deficient yang or excess yin problem. When these
are out of balance, people become very anxious and agitated, depressed and withdrawn, or
both. In TCM, emotional illness is often due to accumulated anger, sorrow, and other
unprocessed emotions that lead to dysfunction and imbalances in yin and yang. Chronic
outside stress, poor food choices, lack of sleep, and inadequate movement can also
unbalance the life energy force known as qi. As a result, knotted qi accumulates, and a
disruption of the body and mind results (Jilin & Peck, 1995). As a result, anxious people
may act too yang while depressed people act much more yin.
In TCM, emotional problems often center on a particular organ. The emotional issue
can decide which organ in the body has the most problems. For example, some patients
tend toward excess fear, which can cause a kidney imbalance. Please note, this does not
suggest there is a problem with the physical organ in the Western biomedical senseit is
the Chinese sense of the kidney, which stores our life energy to keep our physical and
emotional well-being maintained. Other people will have a lot of anger, hostility, or lack
of motivation, which is a liver-centered issue. Excess amounts of sorrow or even too much
happiness will attack the heart. Grief and loss will affect the lungs.
A first responder named Mel who arrived at the scene of 911 was diagnosed
with chronic bronchitis and possible sarcoidosis about three years after this
traumatic event. I noticed, as I would ask Mel about his symptoms, that his
discussion ultimately returned to the death he saw around him, with special
memory of watching people jump out of smoked-filled windows and falling to their
deaths. Once we discussed the Chinese view of the lungs and the grief, he
lightened, suggesting that, for the first time, he believed his illness made sense. We
used herbs specific for the lungs and acupuncture twice a weekin two months he
was better. I have, numerous times, seen this varied approach centering on the
TCM aspect work amazingly well when other approaches failed. Sometimes, TCM
sees patterns and formulates a plan in a way other medicines do not.
The exact mechanism of acupuncture action is unknown. Present Western medical
interpretation of the treatment effect is that acupuncture stimulates nerves called afferent
group III nerve fibers. These fibers are like electrical wires that transmit impulses to
various parts of the central nervous system and induce the release of serotonin,
norepinephrine, dopamine, beta-endorphin, and other emotional supportive molecules
called enkephalins and dynorphins (Wang et al., 2008; Samuels, Cornelius, & Shepherd,
2008). Many of these are secreted and modulate the hypothalamus, suggesting a direct
mode of influence on mood disorder (Wang et al., 2007). Other possible modes of action
may include acupunctures ability to influence changes of the autonomic nervous system
(the part of the immune system that governs the ability to get stressed or stay calm), the
immune system, inflammation, and hormones, as well as its ability modulate the
recognition of serotonin, norepinephrine, and acetylcholine in brain and body (Gurguis et
al., 1999).
A literature review by Pilkington et al. (2007) looked at the benefits of acupuncture for
anxiety in 12 controlled trials, of which 10 were the more stringent randomized controlled
kind. The authors found positive results for generalized anxiety disorder or anxiety
neurosis (a diffuse type of anxiety) but concluded more research is needed for clear
conclu-sions to be drawn. They were also not able to find studies on obsessive-compulsive
disorder or panic attacks. Interestingly, the study found a good deal of benefit using
auricular acupuncture (acupuncture using small needles on the outer ear) for anxiety
before operations. In my experience, patients with mild to moderate anxiety do well with
calming acupuncture treatments, but sometimes those with very high anxiety may
overthink the administration of needles and find the treatments unpleasant. For some, this
can be an opportunity to work with anxiety, and messaging using mindfulness therapies
may help the patient move through these moments while in a secure setting. I personally
was introduced to acupuncture during my early twenties when I experienced great stress,
anxiety, and insomnia. When conventional medicine offered me drugs, which I didnt want
to take, I decided to try acupuncture, although I didnt believe in it. I was very impressed
how, from the first treatment, I started sleep better and how it clearly lowered my anxiety.
Research studies are somewhat conflicting regarding the benefits of acupuncture for
depression. While one randomized controlled study of 151 depressed patients showed that
12 sessions of acupuncture failed to prove more effective than sham acupuncture (Allen et
al., 2006), another positive study compared electroacupuncture and Prozac. In this
evaluation, Luo et al. (2003) gave patients a type of acupuncture with gentle electrical
stimulation placed on the needles 45 minutes in the morning for 6 weeks. In 90 subjects
divided into drug only, acupuncture only, or controls, acupuncture was found as effective
as using Prozac. Another positive study used electroacupuncture with patients already
taking Paxil. This treatment showed superior efficacy to using only the drugand those
who used both had an even quicker response rate (Zhang et al., 2007). A thorough metaanalysis by Wang et al. (2008) of eight small randomized trials with sham (fake)
acupuncture as control comparisons, with a total of 477 patients, concluded that
acupuncture could significantly reduce the severity of disease in the patients with
depression. This is an important study, for sham acupuncture uses real needling on body
points not considered real acupuncture points. This helps us realize the specific points
used make a difference, and that it is not merely a placebo effect making people feel
better.
In my own clinic, I find clear benefits using acupuncture as therapy instead of and
adjunctively to conventional medicine and other natural remedies for anxiety and
depression. Acupuncture allows the pharmaceutical medications to work quicker and
typically allow for a lower effective dose. It is also very effective to support the patient
while weaning off conventional medications when they are ready to do so.
Acupuncture safety and contraindications
One of the benefits of acupuncture is that, when used properly, there are virtually no
contraindications to treatment, and it does not adversely interact with other treatments,
such as conventional pharmaceutical therapy. It is safe with pregnancy and does not
interfere with lactation for breast-feeding women. Large-scale studies have reviewed
millions of treatments.
One systematic review of nine studies of nearly a quarter of a million acupuncture
treatments found adverse events to be exceedingly rare when acupuncture is performed by
a competent acupuncturist (Ernst & Adrian, 2001). In a large survey by Witt et al. (2009)
with 2.2 million consecutive acupuncture treatments provided for 229,230 patients, two
patients were found to have had a pneumothorax (non-life-threatening for either patient)
and one had a lower limb nerve injury that persisted for 180 days. While there are some
reports of hepatitis spread due to improper and illegal acupuncture techniques (U.S. Food
& Drug Administration, 1996), when preformed properly it is exceedingly safe.
moderately to severely depressed college students 3 weeks after having four 90-minute
EFT sessions (Church, De Asis, & Brooks, 2012).
My personal experience working with this simple technique has generally yielded mild
to significant results in approximately 70 percent of patients, using it for such conditions
as grief, pain, guilt, anxiety, posttraumatic stress disorder, stuck emotion, and functional
digestive illness. This represents a very loose and informal review of my casescertainly
not a scientific study. Nevertheless, I believe it is especially valuable for it is something
clients can try for their own self-care and does not have any known contraindications.
Please visit www.emofree.com for more information.
Table 5.1 lists several effective mind-body therapies.
Table 5.2 Most commonly Effective Mind-Body Therapies for Anxiety and Depression
Method
Yoga (30 to 90 minutes twice a week or
more)
Anxiety
Depression
*Caution with pregnancy, glaucoma, high blood pressure, and sciatica
Meditation
Anxiety
Depression
*May be best for depressed patients with strong anxiety
Qigong
Mindfulness-based therapy
Depression
Anxiety
Massage
anxiety
depression
when anxiety and depression are associated with high blood pressure
Acupuncture
Anxiety
Depression
*Excellent as adjunctive care to medications and helping to wean from
medication
Depression
Anxiety
Posttraumatic stress disorder
Pain issues
Digestive issues
SIX
Mixing ones wines may be a mistake, but old and new wisdom mix
admirably.
Bertolt Brecht
2. The medications are not helping. In this situation, patients often find themselves
switching drugs, seemingly randomly, or medications are just piled on top of each
other. Generally, this approach is hard on the body. It can also be psychologically
traumatic as different medications bounce neurotransmitters around.
3. The medications are helping but are causing unwanted sexual side effects. This is a
main complaint, especially from SSRI users. Patients are placed in a tough spot, for
they are glad to feel better but their sexuality and relationships suffer.
This chapter addresses the second and third scenarios. It reviews the emerging literature
about using natural medicines alongside conventional drugs to help foster better outcomes
and efficacy and to lessen their sexual side effects. It then broaches the often
psychiatrically taboo subject of using natural medicines with drugs to help the patient
safely get off the medications.
The conventional media and the medical establishment often warn us about the
dangers of mixing vitamins and herbs with medications, which unfortunately has
persuaded many psychiatrists and patients to think about conventional and natural
medicines as a cant have both scenario in which the very natural things that can help
the body heal the most are considered secondary, or mistaken as dangerous. My hope is
this chapter will start to debunk some of the unsubstantiated concerns, while noting safety
concerns when merited.
Exercise
Can a good walk help a medication work? Can it be better than adding another drug to a
current drug that is not working all that well? One study seems to suggest it can. Trivedi et
al. (2011) looked at 126 patients whose selective serotonin reuptake inhibitors (SSRIs)
were not working for them. Their next treatment choice is usually an add-on drug that has
a 2030 percent success rate (also known as a 7080 percent failure rate), typically with a
higher risk of side effects.
These patients had never exercised before and were allowed to choose exercise instead
of an add-on medication. One group chose a daily easy, light exercise, like strolling at two
to three miles an hour, or gentle exercise biking. A second choice was following the
American College of Sports Medicine recommendations of exercising a bit more
vigorously by walking in a brisk manner, at the rate of 4 miles an hour, every day.
For both groups, overall about 30 percent of patients felt better in 4 monthsa little
better than one would expect from a second medication. Interestingly, more people
stopped their exercise if they were in the more vigorous group; thus, more people were
able to stick to the lighter exercising. This tells us that a patient should start at his or her
own comfort level, beginning with lighter exercise (especially if new to exercise) and then
gradually increasing intensity. In truth, the exercise did not do much better than the
medicationbut my clinical experience tells me that the benefits of exercise help the
underlying causes of mood issues, and are more substantial and long lasting. (For more
about exercise, see Chapter 2.)
Thyroid Hormone
Chapter 2 discussed the multiple important actions of thyroid hormone to help the mind
and body of a person with depression. Thyroid hormone can also be an important ally to a
medication that is otherwise not working.
As early as 1969, astute researchers had shown that when patients on tricyclic
antidepressants were given tri-iodothyronine (T3), the result was an enhanced and
accelerated recovery (Prange & Loosen, 1982). About 5560 percent of patients who
previously failed to respond to tricyclic antidepressants will respond when they have
enough thyroid hormone (Barowsky & Schwartz, 2006). In one study of almost 300
patients, those treated with T3, or a more natural glandular thyroid support, were twice as
likely to respond than to placebo and almost three times more likely to respond than to
thyroxine (T4) (Joffe & Singer, 1990).
Joffes (1992) review of the literature supports the successful utilization of T3 in
patients taking SSRIs. Lack of energy was especially common in patients given Prozac,
but when the T3 was added the low energy went away, with no side effects noted.
If a patient is using a medication that is not working well, checking thyroid levels may
be in order. If these are normal but on the low-normal side, a small dose of T3 (Cytomel)
or natural glandular supplements like Armour Thyroid or Nature-Throid could be tried to
see if there is benefit, while monitoring blood tests and looking for signs of excess thyroid
hormone (fast heart rate, palpitations, sweating, greasy skin and hair, and anxiety). Since
excess levels of thyroid may contribute to anxiety feelings, it may be best to avoid in
anxious patients.
Estrogen
As mentioned in Chapter 3, estrogen levels play a role in mood. Estrogen will affect the
level of serotonin and also modify the reactivity of serotonin receptors. As some women
with imbalanced menstrual cycle may attest, estrogen fluctuations can also bounce mood
around. If a woman is predisposed to anxiety or depression, especially around the time of
menopause and postmenopause, these estrogen changes will allow the mood issues to fully
manifest. In postmenopausal women being treated for depression, estrogen replacement
therapy has improved the effects of conventional antidepressants (Schneider, Small, &
Clary, 2001). In a number of cases in my practice, administration of a little extra estrogen
in the form of a skin cream made all the difference in allowing both anxiety and
antidepressant medications work their best. (Please refer to Chapter 3 for more about
estrogen.) While I prefer women first work with sleep, lifestyle, diet, and other natural
ways to balance the body before considering hormones, natural estrogen replacement may
be a good second-line option.
Progesterone
As discussed in Chapter 3, optimal levels of progesterone are known to help calm the
brain, improve sleep, and strengthen libido. Both animal and human clinical research
suggests that progesterone and its metabolites may have a calming effect by enhancing
GABA in the brain, an action similar to that of the common benzodiazepine medications.
Balbalonis et. al (2011) looked at whether progesterone can potentiate the effects of the
benzodiazepine triazolam (Halcion). The natural bioidentical form of progesterone called
oral micronized progesterone (at 0, 100, and 200 mg doses) along with oral triazolam
(0.00, 0.12, and 0.25 mg/70 kg) was given to 11 healthy premenopausal women who had
documented low levels of sex hormones. Triazolam alone produced expected sedative-like
effect and the progesterone alone also had some, albeit weaker, sedative effects that were
shorter in duration. Most notably, progesterone increased and extended the duration of
triazolam effects, suggesting that progesterone may alter how a benzodiazepine will work
in the body. This concerned the researchers, who raised the question about whether
progesterone could increase the risk of addiction.
I have two thoughts about this study: one, it used an oral progesterone, which has a
first pass through the liver before going into the general circulation. This may increase the
effects of altering the liver metabolism of the benzodiazepine medication. Any hormone
taken orally will have to first pass through the liver, before going out to the general
circulation. This first pass will have a stronger effect on the processing of other drugs and
hormones. A better method might have been using a transdermal cream, that would go
through the skin and diffuse into the general blood circulation, creating less of a
progesterone hit in the liver. Also, we may consider the possibility that use of
progesterone might supplant the need for benzodiazepines in women who are low in
progesterone, or may lower the required dosage of the drug. More research is needed, and
progesterone might be considered for an anxious woman alongside a benzodiazepine as
long as she is well monitored for any signs of addiction to the drug.
Testosterone
Chapter 3 discussed the importance of this hormone when discussing blood tests. While
some testosterone may helpful for anyone who suffers from anxiety and depression and
has low testosterone levels, it may be even more beneficial in patients already taking
medications but not getting good results. In a randomized controlled trial of 56 men with
treatment-resistant depression, Pope et al. (2003) found that 24 of these men had morning
serum total testosterone levels of 350 ng/dl (normal range, 2701,070 ng/dl). Of these 24
men with low testosterone, 23 entered the study. One man responded quickly to a 1-week
single-blind placebo period, while the 22 others were subsequently randomly assigned to
either 10 g/day of a 1 percent testosterone gel or a placebo, while continuing their
antidepressant drugs. Ten subjects receiving testosterone and nine receiving placebo
completed the 8-week trial. Subjects receiving testosterone gel had significantly greater
improvement in scores on the Hamilton Depression Rating Scale than subjects receiving
placebo. A significant difference was also found on the Clinical Global Impression
severity scale but not the Beck Depression Inventory. One subject assigned to testosterone
reported increased difficulty with urination, suggesting an unconfirmed exacerbation of
benign prostatic hyperplasia; no other subject reported adverse events attributable to
testosterone. This study also showed that it is possible to use pharmaceutical medications
with transdermal testosterone concurrently.
In a second, smaller randomized controlled trial by Barowsky and Schwartz (2006), 19
men with difficult-to-treat depression who also had low or even normal testosterone levels
completed an 8-week, randomized, placebo-controlled study. Participants were given
either 10 g/day of transdermal testosterone gel or an equivalent amount of pla-cebo cream.
Each subject continued his existing antidepressant regimen. The testosterone-treated
patients had a significantly greater decrease in depression questionnaire scores than the
placebo-treated patients.
I have seen many cases of healthy mood adjustments using a little testosterone in both
men and women. I have also witnessed cases of patients with low testosterone not able to
successfully wean off medication until their testosterone was adjusted.
Fish Oil
As discussed in Chapter 3, fish oil is immensely supportive of the nervous tissue and the
adrenal system and as gentle but consistent anti-inflammatory support. Of all the
supplements, this is my first choice for anyone with mood issues, whether they are taking
medication or not (unless, of course, they have a fish allergy).
One study of 20 patients taking anti-depressant medications found the addition of fish
oil in a 4-week, parallel-group, double-blind evaluation found highly significant benefits
with the addition of the omega-3 fatty acid compared with placebo by the third week over
those that did not take fish oil. (Nemets et al., 2002). In a study of 70 patients with
persistent depression, despite ongoing treatment with an adequate dose of a standard
antidepressant, Peet and Horrobin (2003) found benefit from 1 g/day of ethyleicosapentaenoate (ethyl-EPA) versus placebo. Interestingly, this 1g/day dose may have
had greater benefit over the 2 and 4 g doses. Ethyl-EPA is a pure, prescription form of EPA
that is devoid of other essential fatty acids (and is discussed in Chapter 4). Strong
beneficial effects were seen while patients were monitored for depression, anxiety, sleep,
fatigue, low sex drive, and thoughts of suicide.
Folic Acid
Folic acid in the form of methyltetrahydrofolate is becoming well known in the
conventional psychiatric community as a support for antidepressants. Fava et al. (1997)
were among the first to study this, when they examined the relationships among levels of
folate, vitamin B12, and homocysteine with response to fluoxetine (Prozac) treatment in
213 outpatients with major depressive disorder. For a baseline assessment, a blood sample
was collected from each patient. Subjects with low folate levels were more likely to have
melancholic depression and were significantly less likely to respond to the Prozac. Fava et
al. concluded that there was a link between low folate levels and poorer response to
antidepressant treatment. They suggested that folate levels be considered in the evaluation
of depressed patients who do not respond to antidepressant treatment. It makes sense to
Zinc
Like B vitamins, zinc may be a valuable ally if a patient is prescribed antidepressant
medications that simply arent working. Mlyniec, Oboszewska, & Nowak (2011) looked at
the effect of zinc deprivation on the beneficial effect of antidepressant drugs. The
researchers gave some mice a zinc-deficient diet, which significantly lowered the levels of
this mineral in their body. The control mice had a normal diet. Then the animals were
subjected to a stressor (the forced swim test) to induce depression. The animals that were
zinc deprived had a minimal response to antidepressant medication support, whereas the
animals with plenty of zinc in their body responded more positively when given
medication. This suggests antidepressants could possibly work much better but that they
may not work for so many people because we are a nutrient-depleted society.
Human studies also support this hypothesis. Nowak et al. (2003) ran a placebocontrolled, double-blind pilot human trial. One group of 6 patients with depression was
given 25 mg zinc once a day with standard antidepressant drug therapy, while a control
group of 8 patients were given standard antidepressant drug therapy only. Each patients
sense of well-being was evaluated before the treatment, and also 2, 6 and 12 weeks after
the treatment started. Although the zinc treatment did not take effect until week 6, a very
strong benefit was conferred on the mood of the patients taking the zinc over those who
did not take the extra zinc. This was a small study, but given the safety of zinc and
possible benefit, it may make sense to try. For zinc supplementation more than 2 months,
it is helpful to take are taking 2 mg/day of copper, too (often found in a good multiple
vitamin), for sometimes extra zinc can decrease copper levels in the body. More about
zinc can be found in Chapter 3.
SAMe
SAMe is a methionine compound helpful in supporting the methylation pathways needed
to create optimal neurotransmitter balance. It is discussed Chapter 3, along with several
studies. In addition, a study by De Beradis et al. (2013) examined 33 patients with secondstage treatment-resistant depressive disorder, meaning the pharmaceutical medications
were not working after 8 weeks of two different antidepressants. These patients had
depression for an average of 8 years. They were then openly given SAMe at 800 mg/day
for 8 weeks in addition to their current medication. Hamilton Rating Scale for Depression
scores at 8 weeks showed significant decreases, with response achieved by 60 percent of
the patients and remission by 36 percent. Additionally, most responders demonstrated a 50
percent or greater reduction of total score within the first 5 weeks of treatment, which is
quite rapid improvement in depressive symptoms, especially over the usual effect of
antidepressant drugs when they do work (which is a minimum of 6 weeks). The most
frequently observed side effects were mild constipation and nausea with decreased
appetite. Another trial, called the STAR*D (Sequenced Treatment Alternatives to Relieve
Lavender
One a double-blind randomized control trial looking at a combination of lavender with the
antidepressant imipramine (Tofranil) found the herbal addition to be more effective than
the drug alone in the treatment of depression (Akhondzadeh et al., 2003). This studys
double treatment group took 100 mg/day of imipramine plus 60 drops/day of a lavender
tincture. The findings suggested that taking a moderate amount of lavender may help
reduce the amount of tricyclic antidepressants needed to treat depression, leading to fewer
side effects. While there are no studies specifically using lavender with antianxiety
medications, clinically I have seen benefit of adjunctive lavender, helping to decrease use
of antianxiety medications.
Acupuncture
Research using acupuncture alongside conventional medications is just starting to surface.
One double-blind study looked at acupuncture in combination with Prozac for major
depression. Zhang et al. (2009) divided 80 patients into two groups: one received
acupuncture plus 10 mg/day of Prozac and the second group received sham acupuncture
plus 2030 mg/day of Prozac. Acupuncture was administered five times a week for 6
weeks. Both groups showed similar responses (80 percent for the true acupuncture and
77.5 percent for the sham group), with the true acupuncture group showing lower
medication side effects and anxiety. The overall rate of adverse events due to acupuncture
from this study was 8.75 percent. In my clinical and research experience, this is a much
higher adverse event rate than commonly encountered.
Table 6.1 reviews the best supports for patients on pharmaceutical medications for
anxiety and depression.
Indication
Dosage
Antianxiety and antidepressant support Walking outside or more intense if preferable to the client
Progesterone
Testosterone
Fish oil
Folic acid
Vitamin B12
(methylcobalamin)
Zinc
SAMe
Rhodiola or
Patients with depression or depression
eleutherococcus and anxiety on tricyclic
antidepressants
Dosage
4080 mg three times a day, with a standardization of 24 percent gingko
flavonglycosides
*May be especially useful for women
*Should be avoided if taking diabetes medications, anticlotting medications, or
antiepileptic drugs
Yohimbe (Pausinystalia
yohimbe)
In an open trial, Cohen and Bartlik (1998) found ginkgo extract to be 84 percent
effective in treating antidepressant-induced sexual dysfunction predominately caused by
SSRIs. In this study of 96 people, women had more response to the sex-enhancing effects
of ginkgo than the men, although both saw benefit. The relative success rates for women
were 91 percent and for men were 76 percent. Ginkgo generally had a positive effect on
all four phases of the sexual response cycle: desire, excitement (including erection and
lubrication), orgasm, and resolution (the fterglow or good feeling immediately following
orgasm). A triple-blind study by Wheatley (2004) of 240 mg gingko given to eight men
and five women found some excellent individual responses in both groups, but as a whole
there were no statistically significant differences suggesting benefit overall. While these
studies are promising, more research is welcome to understand exactly who may benefit
best from ginkgo.
Ginkgo dosage and toxicity
Gingko biloba extract may be used at a dosage of 4080 mg three times a day,
standardized at 24 percent gingko flavonglycosides. Although levels the flavonglycosides
are important, remember to use a preparation that includes the whole ginkgo leaf with it,
for we do not know exactly what part or parts of the gingko are actually helping with
mood and sexual side effects.
Ginkgo biloba leaf extract is quite low in toxicity, but this supplement should be
avoided if a patient is taking diabetes medications (Kudolo, 2001), anticlotting
medications (Kim et al., 1998), or antiepileptic drugs (Granger, 2001).
yohimbine at an average dose of 16.2 mg, as needed, for an 81 percent response rate.
Pausinystalia yohimbe dosage and toxicity
A variety of sexual side effects, including low libido, have been reported to be alleviated
by yohimbine (the drug component derived from the whole plant yohimbe) in doses
ranging from 2.7 to 16.2 mg daily, usually divided into three daily doses. Typically, it has
been prescribed either as 5.4 mg up to three times a day or on an as-needed basis with
single doses up to 16.2 mg (Sanacora et al., 2004). Another choice is to use the whole
plant herb itself instead of a prescription form of yohimbine. In this case, it may be easiest
to use a liquid herbal tincture in a concentration of 1:5, taking a range of 520 drops three
times a day. The amounts of yohimbine in these liquid preparations may vary.
For my patients with sexual side effects, I recommend trying gingko first (see above).
If they do not show improvement with gingko after 2 months, herbal yohimbe may be a
reasonable second choice. If you have a client who wants to work with yohimbe, then it
important to work with a naturopathic physician, qualified herbalist, or other practitioner
experienced with this herband critical to advise the prescribing medical doctor as well.
It is best to start at low doses and titrate to therapeutic dose to avoid side effects, while
monitoring blood pressure before starting and then daily while taking the herb.
My first experience hearing about yohimbine was as a researcher at Yale in the
Department of Pharmacology. A postdoctoral fellow in whose lab I was assisting had
taken some yohimbine while participating in a trial of the drug. The poor fellow suffered a
full erection for over 24 hours and I believe needed a procedure to drain the penis. The
potency of the drug yohimbine is much higher than that of the whole herb yohimbe.
Possible side effects of yohimbe include higher blood pressures, excessive sweating,
increased anxiety, and a wound-up feeling in some patients. This is not an herb to use
lightly, so please be respectful of this one. It should not be used by anyone with high blood
pressure or glaucoma, and may be contraindicated in anxiety disorders.
Acupuncture
Acupuncture has a potential role in treating the sexual side effects of antidepressant
medications. In a pilot study by Khamba et al. (2013), 35 patients (18 men and 17 women)
experiencing antidepressant sexual side effects received a traditional Chinese medicine
(TCM) assessment, followed by an acupuncture treatment protocol for 12 consecutive
weeks. The treatment protocol used TCM theory and addressed what was called heart yin
deficiency and kidney qi deficiency, two diagnoses that relate to sexual dysfunction
and mood issues. Acupuncture points were kidney 3, governing vessel 4, bladder 23,
pericardium 6, and heart 7. Male participants reported significant improvement all areas of
sexual functioning, as well as in both anxiety and depressive symptoms, while female
participants reported a significant improvement in libido and vaginal lubrication and a
nonsignificant trend toward improvement in several other areas of function.
Limiting this study was the fact that it was an open-label, noncontrolled study.
Additionally, in TCM, chosen acupuncture points are typically individualized for the
particular patient, which was not the case here. Individualized selection of point for the
patients might have increased effectiveness. Nevertheless, this study corroborates what I
see clinically in my practice regarding the benefit of using acupuncture alongside
medications for helping with sexual side effects. With virtually no risk to the patient, it is
worth trying.
Paroxetine (Paxil,
Paxil CR, Pexeva)
Sertraline (Zoloft)
SSRI/SSNRI
Drugs:
Venlafaxine
(Effexor)
Tyrosine: 500 mg once a day for 1 week, THEN ADD 5-HTP: 50 mg/day for the second week.
Start tapering medication, while adding 500 mg of tyrosine for week 3, then adding 50 mg of 5HTP for week 4 while continuing the medication taper.
Desvenlafaxine
(Pristiq)
Duloxetine
(Cymbalta)
Milnacipran
(Savella, Ixel)
Tricyclic
Tyrosine: 500 mg once a day for one week THEN ADD 5-HTP: 50 mg/day for the second week.
Antidepressants:
Start tapering medication, while adding 500 mg of tyrosine for week three, then 50 mg of 5-HTP
Amitriptyline
(Elavil, Endep,
Vanatrip)
Amoxapine
(Asendin)
Desipramine
(Norpramin)
Doxepin (Adapin,
Silenor, Sinequan)
Imipramine
(Tofranil, TofranilPM)
Maprotiline
(Ludiomil)
Nortriptyline
(Pamelor)
Protriptyline
(Vivactil)
Trimipramine
(Surmontil)
Others
Bupropion
(Wellbutrin,
Zyban)
Mucuna: 200 mg extract once a day for 2 weeks, then start tapering medication while increasing
to 200 mg twice/day. Once the patient is off the medication completely and feeling good for 2
weeks, 200 mg once a day for 1 month, then 200 mg every other day for 1 month, then
discontinue.
Aripiprazole
(Abilify)
Mucuna: 200 mg extract once a day for 2 weeks, THEN ADD 5-HTP: 50 mg once a day for 2
weeks. Start medication taper.
Mirtazapine
(Remeron)
Tyrosine: 500 mg once a day for 1 week THEN ADD 5-HTP: 50 mg/day for the second week.
Start tapering medication, while adding 500 mg tyrosine for week 3, and adding then 50 mg of
5-HTP for week 4 while continuing the medication taper.
Benzodiazepines
(Xanax,
Klonopin,
Rivotril, Librium,
Ativan)
ready to reduce medication, three steps will help organize this process: (1) talk to the
prescribing doctor and assure monitoring, (2) follow the naturopathic path, and (3)
prescribe supplements to support the medication weaning process.
SEVEN
Figure 7.1. A decision flow chart for the integrative care of anxiety and depression.
trajectory. As a therapist, you are keenly aware the critical nature of meeting each person
where he or she is in terms of speaking tone, communication style, and vocabulary, which
will be invaluable in creating a therapeutic relationship that both is professional and feels
safe for your client. To create a holistic plan, this therapeutic relationship is key.
The first two questions I typically ask a patient are these:
I know you are here to work on having a better mood. If I could wave a magic wand, is there any particular feeling,
thought, or symptom that you would like to see go away or balance out first?
This is not a standard question, but I find this helps me understand what is really bothering
the patient. For example, I may know a patient is diagnosed with generalized anxiety
disorder, but I dont know what bothers that person mostis it the sweating in their
palms, the fear someone will touch them, the tingling in their feet? This can give a strong
clue as to what treatment modality will help the most.
When was the last time you felt well?
This question helps me ascertain if the patient remembers or can visualize what it was like
to feel well at some point. Patients who can remember this well typically get better
quickerthe others may be more challenging. Patients who respond I always felt this
way or I cannot remember the last time I felt well typically need a longer course, closer
monitoring, and possibly more rigorous treatment regimens.
Following these two questions, I will ask about the mood issue itself.
It is key to understand what life events were happening for a particular patient when it all
started. Sometimes difficult sickness can contribute to feeling depressed, and sometimes it
can clue a practitioner in to possible underlying causes.
Family History
Do mood disorders appear in your family?
Establishing family history may clue the clinician in that healing and balance may be a
longer-term and more neurotransmitter-based endeavor than someone without family
history. In my clinical experience, those patients with a strong family history often have
more neurotransmitter imbalances, and typically need a longer duration of care for
healing. Of course, there are exceptions, as thoughts and messages are learned from our
family environment the same way genetics are passed on.
Medications
What medications are you now taking?
Have any medications been helpful to you? Which ones?
Have any medications made you feel worse?
Knowing what medications a patient is taking can alert you to other conditions present, as
well as how to watch out for interactions with natural treatments. The last two questions
can help you ascertain what mechanisms are more salient, which can help you decide
which natural supplements would be more effective or possibly make a patient feel worse.
Supplements
Are you currently taking any natural supplements?
Have any supplements helped you?
Have any supplements made you feel worse?
Patients typically visit a holistic practitioner after hitting the health food store a few times
and trying things themselves outside of a comprehensive treatment plan. If any
supplement may have helped or made the patient worse, this may aide in future
supplement choices.
Pale skin may be a sign of iron deficiency or vitamin D deficiency due to little
sunlight.
Pale crevices in hands may be a sign of iron deficiency.
Purple or darkness under the eyes may be a sign of inadequate sleep or food allergies.
Nail cracks, ridges, furrows may be a sign of general nutrition deficiency.
Lower leg swelling not associated with kidney or heart problems is often a sign of
hypothyroidism or circulation challenges.
Dry skinconsider fatty acid deficiency, inadequate hydration, or low thyroid
function.
Tongue
In Chinese medicine, the tongue has a lot to offer regarding understanding the body and
digestion. Here is a quick summary of main ones features to look for:
Thick white coatslow digestion
Think yellow coatslow digestion with excess heat, that may represent anger or low
acid production
Large deep crack in middle of tonguedeep emotional issues
Red tipped tonguelow yin energy
Oversized and pale tonguespleen qi deficiency (digestive weakness) or blood
deficiency (often caused by low nutrient status)
Lateral sides darkenedliver qi stagnated (often a sign of high stress)
Lungs
In traditional Chinese medicine, lung issues are correlated with grief. Anyone with lung
issues may be asked if they have experienced unusual grief or grief that has not dissipated
with time.
Cardiovascular system
Low blood pressure can be a sign of adrenal fatigue.
Nervous system
Tingling in hands and feet? This can be a sign of blood sugar instability. In Chinese
medicine it also suggests phlegm or stuck energy in the middle of the body not
moving out to the periphery. Diabetes and neurological issues should be ruled out.
Excess sweating? This can be a sign of hyperthyroid function. In Chinese medicine it
may be a sign of yang deficiency.
Hormonal system
Problems with the thyroid (either hypo- or hyperthyroid) will affect mood.
Menstrual irregularities change both serotonin levels and receptivity in the brain to
affect mood.
Problems with the parathyroid gland will also affect mood via suppression of vitamin
D.
Digestion and bowel habits
Any digestive problems?
How often do you have a bowel movement?
Digestive issues of many kinds may be a sign of food allergies or sensitivities,
inflammation, and poor ability to balance neurotransmitters. It may also suggest an
imbalance in bowel flora.
Musculoskeletal system
Poor muscle toneconsider lack of exercise.
Back or joint painmay hinder a persons ability for mood to improve due to excess
pain, or from lack of exercise. In either case, a plan to address pain may be needed
as a first step even before fully addressing mood issues.
Any sleep deficit can cause or exacerbate mood problems. Difficulty falling asleep would
suggest melatonin may be useful. Difficulty staying asleep would point to using 5-HTP,
tryptophan, or sustained-released melatonin. If sleep apnea is present, it should be treated.
Exercise: Do you exercise? What is your routine? After you exercise, do you feel
better, or worse?
Exercise, in virtually any form, is beneficial for mood. It is also helpful to get a sense of a
patients constitution and energy reserves. Some equate inability to feel energetic after
exercise as an issue of drenal fatigue requiring support.
Food intake: What did you eat for breakfast, lunch, and dinner yesterday?
I recommend having each patient, if possible, complete a diet and lifestyle diary that
tracks what a patient eats, their activities, and their emotions for 7 days. (See appendix
VI.) Often, patients themselves will make connections between their food, activity, and
their emotions
How do you feel if you dont eat for a few hours?
Both anxiety and depression can be related to hypoglycemia and low blood sugar.
Generally, people who get symptoms when they havent eaten will benefit from bloodsugar-related work, such as eating more protein at breakfast, frequent meals, and
chromium supplementation.
Recreational drugs and smoking
Number of alcohol drinks per day? Past or current history of alcohol abuse?
Do you smoke? If yes, how much?
Is there current recreational drug use, or a history of substantial recreational drug use
or abuse?
Current use of cigarettes, alcohol, and recreational drugs may hinder the effort for healing.
Substantial past use may indicate toxicity and the need for a detoxification protocol as
well.
Stress reduction rituals. Do you have a daily stress reduction ritual?
Everyone should have some daily ritual that helps process or mitigate the effects of stress:
meditation, prayer, massage, acupuncture, journaling, and so forth. If this is not in place in
your clients schedule, this is an opportunity to learn what your client might enjoy.
Wakes up exhausted
Some energy during the end of the day into the evening
When I dont eat, I get a little crazy and I feel cold.
Worse fatigue: after exercise in the AM. I try to work out hard so I dont
disappoint my trainer, but, sometimes I cantIm just exhausted.
Doctor says Im anemic, but I stopped taking iron two years ago for it was
making me more constipated.
Other concerns:
Patient would like to lose some weight.
Review of Systems and Lifestyle Factors:
Digestion:
Bowel movement every third daybeen like this since high school. MD
says its normal for me.
Foods/Water
No time for breakfast, sandwich for lunch and healthy dinner of chicken,
some vegetable and quinoa. Tend to overeat late night.
Water intakenot great.
Coffee: Need it. Starbucks venti with milk and 3 sugars twice a day. Only
thing that keeps me up, but makes me more anxious.
No alcohol or recreational drug use.
Sleep:
In bed by 12:30 a.m. and up by 6:30 a.m.
Trouble falling asleep every night, so I like to stay up and watch late night
with Conan. He is so hilarious and it helps me stay calm until I am finally
sleepy. Once asleep, I tend to stay asleep.
Sometimes I cant fall asleep because my mind is bouncing all over the
place. The klonopin helps this by knocking me out.
Relaxation Work:
I tried to meditate, but it makes me crazy.
Medications:
Zoloft: helps the anxiety a little, but no change in the depression.
Klonopin at night when needed (once a week, usually).
Supplements:
Centrum, sometimes.
CoQ10 (friend told her would be good for energy), hasnt helped.
O//:
Patient appears well nourished and not in distressed.
Height: 5' 9
Weight: 142 lbs
Blood pressure, left arm 92/58
A//:
Depression, Anxiety
P//:
See recommendation plan below
Date: 03-21-2014
Patient: Carla Composite
DOB: 1-19-1966
Sample First Visit: Treatment Plan
1. FOLLOW-UP TESTS:
Adrenal saliva test and blood work (see attached list)this way we can see
how your stress hormones are running, and if there are any nutrient
deficiencies or hormonal issues contributing to how you are feeling.
2. THERAPY WORK:
Continue your work with your therapist, and have her contact me so we can
coordinate care.
3. EXERCISE
Please keep this gentlegentle walking in the sun every morning as it
feels good for you. For now, do not push your body with heavy duty
exercise.
4. SLEEP:
Shut any bright lights/computer/TV/cell phone by 10 p.m. and sit and read.
Sip some chamomile tea with a dropperful of Passiflora tincture in the tea
to help calm the mind.
If you enjoy Conan, then DVR it to watch earlier the next night.
Take one capsule of melatonin (1 mg per capsule) at 10:30 p.m. to be in
bed at 11 p.m. If you are not falling asleep easily, please add one capsule
(300 mg) of GABA to help the mind shut down.
Before shutting the light, write down in bullet point form any thoughts you
are having.
5. WATER:
Drink water in the morning: one big glass, room temperature. You can
squeeze half a lemon if you like.
6. FOODS:
Eat breakfast every morning, here are some ideas:
- Two hard-boiled eggs with Ezekiel toast and butter
- Ezekiel bread with natural peanut butter
- Rice protein powder with half a frozen banana and blueberries
- Turkey bacon with scrambled eggs
- Oatmeal with walnuts, butter, and cinnamon
For constipation help, add these to your daily diet:
- 5 organic prunes
- 1 cup of dark greens
- 1 tablespoon of flax mealcan add to oatmeal, a salad, or a shake
For your coffee, ask for caf for 2 weeks, then go to caf.
7. SUPPLEMENTS:
Discontinue Centrum and start a higher-potency multiple vitamin: 3
capsules a day with food.
Fish oil: one teaspoon a day, with or away from food, for overall brain
support.
Probiotic: one capsule at bedtime, to support digestion.
You can discontinue the CoQ10 for now if you feel it is not helping.
8. ACUPUNCTURE:
Once a week to support energy, relax, and help lift mood.
NOTE: Please do not change any medications without speaking to your
prescribing doctor.
Next Visit Follow-up in One Month:
Check on recommendations above.
Review saliva test blood tests: consider herbs and supplements for
adrenal/circadian support and gentle iron or other nutrients depending on
blood tests.
will be doing at our next visit and what longer term options may be considered. This
mentions that we will review the current plan, to see what was accomplished and helpful,
and look further at what wasnt accomplished and understand the challenges to these.
Also, I mention to the patient that we havent actually used any mood supplements yet
(e.g., 5-HTP or St. Johns wort) but that we may discuss using these if needed. Many
times, an executed plan like this precludes the need for direct mood supplementation.
Finally, I mention addressing the weight loss. In truth, working on diet, bowels, and
healthy exercise will probably have some positive effects on weight, but I want my patient
to know that we are keeping all the things important to her in sight.
Finally, as I walk my patient out of my office into the waiting area, I ask permission to
give her a hug, and tell her I look forward to our follow-up visit.
The namesake for my medical school, Bastyr University in Seattle, is John Bastyr,
ND, DC. He recommended to his students to lways touch your patientslet them know
you care (Grimes, 2005, p. 58). At the end of the visit, this can take the shape of a twohanded deliberate handshake, or asking the patient, Is it OK if I give you a hug? In my
10 years of practice, only one person has ever said nostating that he would not be
comfortable. A gentle hug is a powerful expression of care and will relay to your patients
your heartfelt interest in their well-being. Plus, it is very healthy for me to get a few hugs
every daya win-win for everyone involved.
Appendices
APPENDIX I
APPENDIX II
Hormonal panel:
TSH
Free and total T3, T4
PTH
DHEA
DHEAs
Testosterone: free and total
Serum estrogen (if female)
Serum progesterone (if female)
Celiac panel:
Anti-gliadin IgG antibodies
Anti-gliadin IgM antibodies
TTG
Secretory IgA
Serum carnitine
Serum folic acid
Serum B12
MTHFR gene test
Serum 25(OH)vitamin D
Serum mercury
APPENDIX III
practitioner base, they also offer resources and conferences geared towards medical
doctors interested in learning about a more integrative approach.
Journals
Journal of Alternative and Complementary Medicine:
http://www.liebertpub.com/acm
This well-respected peer-reviewed journal publishes research on a variety of CAM topics,
including acupuncture, nutrition, massage, botanical medicine, Ayurveda, yoga, and many
other modalities.
Natural Medicine Journal: http://www.naturalmedicinejournal.com/
This is the official journal of the American Association of Naturopathic Physicians. It is
an e-journal offering peer-reviewed research on integrative and naturopathic medicine.
Alternative and Complementary Therapies:
http://www.liebertpub.com/overview/alternative-and-complementary-therapies
This is an evidence-based journal that includes articles on many different CAM modalities
and integrative medicine topics, such as building a holistic practice and integrating CAM
into a clinical practice.
Evidence-Based Complementary and Alternative Medicine:
http://www.hindawi.com/journals/ecam/
This is an international, peer-reviewed journal founded in 2004 with information on CAM
and integrative medicine.
Naturopathic Doctor News and Reviews: http://www.ndnr.com
This publication provides clinical information for naturopathic physicians in North
America. It informs and educates physicians in the recent developments of the practice of
natural medicine. It includes protocols, practice management, business development,
marketing, clinical research, news, and more.
Holistic Primary Care: http://holisticprimarycare.net
Provides health professionals with a credible source for natural and holistic medicine.
Townsend Letter: http://townsendletter.com
Since 1983, providing practitioners with a wide variety of alternative medicine topics.
APPENDIX IV
Table IV.2. Most Commonly Used Vitamins for Anxiety and Depression
Supplement
Best use
Typical dose
Vitamin C
High CRP
Vitamin D
Vitamin B3 (niacinamide
form)
Vitamin B12
(methylcobalamin)
Depression
2550 mg/day
May work best when taken with magnesium
1 mg daily
Treatment-resistant depression
Panic disorder
618 g/day
High homocysteine
Betaine (trimethylglycine)
High homocysteine
Toxicity/contraindication/interactions
3,600 mg/day
Food sources
Fat-soluble vitamin can build up Small amounts in salmon, tuna, mackerel, beef,
to toxic levels
liver, egg yolk
Overdosing can raise calcium
absorption, leading to heart
abnormalities
May help antidepressants work
better
None known
No side effects
None known
No known toxicities
None known
Table IV.3. Supplementation Supportive in Specific Cases of Mood Dyregulation Due to Hormonal
Imbalance
Supplement
Armour
Thyroid or
NatureThroid
DHEA
Best use
Typical dose
Testosterone
Depends on preparation
Depression
Depends on preparation
Toxicity/contraindication/interactions
Food sources
Excess hair
None known
Excess sweating
Shakiness
Anxiety
Fast-paced thought
patterns
Irritability
Higher risk of blood clots in smokers Foods with gentle phytoestrogens: soy, kidney,
pinto, and navy beans; flaxseeds; sunflower seeds
Leg swelling
Blood clots
Increased feelings of
sadness and
weepiness
Depression
Sleepiness
Vaginal bleeding
Table IV.4. Plant-Derived Oils That Can Be Helpful for Mood
Supplement
Gamma-linolenic acid (GLA) or
primrose oil
Vegan oils
Possible side
Best use
Typical dose
Toxicity/contraindication/interactions
Food sources
effects
Occasional
reflux
None
known
None known
Black currants
Table IV.5 Minerals Most Commonly Used to Support Anxiety and Depression
Supplement
Best use
Typical dose
Chromium
Zinc
Treatment-resistant depression
15 mg twice a day
Leaky gut
Iron
Sleep issues
Anxiety
Selenium
100200 g/day
Lithium orotate
Toxicity/contraindication/interactions
Food sources
Large doses (>150 mg/ day) can cause Beef, lamb, turkey, chicken, pork, crabmeat,
vomiting and appetite loss
lobster, clams, salmon, pumpkin seeds
Contraindicated in postmenopausal
women and in men except for clear
Mineral water
green vegetables
Best use
Typical dose
Glutamine
Leaky gut
Carnitine
GABA
Glycine
Anxiety
Lysine and
arginine
L-Theanine
5002,500 mg
Take away from food, but with a high glycemic simple
carbohydrate (e.g., cracker)
5-HTP
Tyrosine
Supportive with physical stressors For tobacco withdrawal support: Add chromium, 200
and sleep deprivation
mg/three times a day
Tobacco withdrawal
Obsessive-compulsive disorder
Gambling issues
Trichotillomania
Possibly bipolar disorder
Adjunct to respiridone, for
irritability symptoms
Taurine
SAMe
Toxicity/contraindication/interactions
May prevent chemotherapyinduced side effects
Food sources
Cabbage, chicken, beef, fish
None known
May be beneficial in
schizophrenia
High doses (2030 g)
of arginine may cause
diarrhea
Arginine is contraindicated if
there is a heart attack history
Arginine may be contraindicated
Green tea
None known
Consider avoiding
night supplementation
or use with tryptophan
at night if night
wakefulness results
Same as for Tyrosine,
above
None known
Occasional headache
or stomach discomfort
None
Headaches
Nausea
Phenylketonuria
Nosebleeding
Temporary balance
disturbance
Anxiety
Mild nausea
Contraindicated in bipolar
disorder
None
Mild diarrhea
Table IV.7 Top Botanical Medicines for Anxiety and Depression
Supplement
Psyllium
(Plantago ovata)
Best use
High CRP
Typical dose
One teaspoon twice a day
Cinnamon
Curcumin
Inflammation
(from Curcuma
longa)
(Cinnamomum
cassia)
Depression
Leaky gut
Inflammation
Passionflower
Anxiety
(Passiflora
incarnata)
Spinning thoughts
Kava
(Piper methysticum)
Lavender
(Lavendula
angustfolium)
Ashwagandha
(Withania
somnifera)
Chronic anxiety
Alopecia
Postmenopausal depression
May help lower blood sugar levels in diabetics
Improves effectiveness of clopidogrel (Plavix)
Saffron (Crocus
sativus)
Macuna (Macuna
pruriens)
Toxicity/contraindication /interactions
None known
None known
None known
None known
Paradoxical increase in anxiety symptoms in May be best avoided with liver disease
small percentage of users
May cause mild lavender burp after
ingestion
None
None known
Photosensitivity
APPENDIX V
Mental/emotional symptoms
Shortness of breath
Demanding
Type A person: impatient, interrupts others, walks
and talk sat a fast pace
Has a short fuse and can be curt or rude
Enjoys company
Aurum
metallicum
Nightmares or insomnia
Short fuse
Kali
More depressed after stressors: excess work,
phosphoricum
illness, emotional stress, or excitement
Ability to concentrate is low, and as a result
becomes discouraged and loses confidence
Natrum
carbonicum
Avoids conflict
Keeps feelings to self
When feeling lonely, withdraws to rest or listen to
sad music, which can increase isolation
Natrum
muriaticum
Anhedonia
Cant concentrate
Doesnt feel as intelligent as usual
Lost motivation at work and no longer interested in
business matters
Past disappointments like lost love are hard to get
over
Pulsatilla
Depression brings tears, with desire for consolation Childlike behavior and clinging
and hugs
Childlike softness and sensitivity
Sometimes whiny, jealous, and moody
Crying, fresh air, and gentle exercise usually
improves mood
Anxiety can get worse with warmth or being in a
stuffy room
If female: experienced more depression around the
time of hormonal changes (e.g., puberty, menstrual
periods, menopause)
Sepia
Staphysagria
Mental/emotional symptoms
Aconite
napellus
Sense of palpitations
Chronic anxiety
Chronic worrier
Fear of heights
Arsenicum
album
Shortness of breath
Gelsemium
Fear of changes
Desires the open air and the outdoors, which can make client
feel better, while stuffy rooms will make symptoms worse
Agoraphobia
Ignatia
amara
Anxiety with mood swings leading to Feeling of a lump in the throat and have a heaviness in the
low mood
chest
Anxiety with menopause
Kali
Anxiety, especially about
arsenicosum
cardiovascular problems
Lycopodium
Loves sweets
audience
Bed-wetting as a child
Loves company
Highly social and likeable person
Highly imaginative person
Pulsatilla
Childlike sweetness
Clingy and teary anxiousness
Loves to be consoled
Silica
APPENDIX VI
Time
Major Activities
Acknowledgments
To my best friend, wife, and fellow naturopathic doctor Pina LoGiudice, who is the
grounding center from which I can traverse out. To the Bongiornos and LoGiudices who
love me and my family without reserve. To Andrea Costella at Norton, whose vision
conceived this project, and whose gentle guidance allowed it to take form. Also, to
Nortons Kathyrn Moyer for allowing me to feel safe and secure with transition; and Trish
Watson, who spent an amazing amount of time bringing things to a usable form. Finally, to
Joy Sanjek, LCSW, a beloved clinician whose invaluable time, insight and feedback is
greatly appreciated.
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Index
Page numbers listed correspond to the print edition of this book. You can use your devices search function to locate
particular terms in the text.
Note: Italicized page locators refer to figures; tables are noted with t.
AACE. see American Academy of Clinical Endocrinologists (AACE)
Abdou, A. M., 163
Abilify
folic acid and, 227
natural supports for weaning off, 240t
acesulfame potassium, 37
acetylcholine, 193, 213
acetyl-L-carnitine (ALC), 81
Aconite napellus, for anxiety, 300t
ACTH. see adrenocorticotropic hormone (ACTH)
action plan, printing out, 255. see also treatment plan
acupressure palpation, 215
acupuncture, xiii, xiv, xvi, 90, 92, 21015, 216t, 254, 259, 261
clinical case study, 212
Prozac used integratively with, 23031
safety of, and contraindications for, 21415
sexual side effects of antidepressant medications and role of, 23738
sham, randomized trials with, 214
traditional Chinese medicine and, 21011
acupuncture practitioners, xvi
acute stress, 1034, 106
adaptogens, 176, 190, 191, 229
addiction, to antianxiety medications, 5
Addisons disease, 105
adenine triphosphate (ATP), 179
adolescents
antidepressants, FDA warning, and, 5
melatonin for DSPS and, 21
adrenal hyperplasia, 190
adrenaline, forest bathing and, 48
adrenal tests, 257, 260, 267
adrenocorticotropic hormone (ACTH), 103, 104
advanced glycation end-products (AGEs), 67, 93
afferent group III nerve fibers, acupuncture and stimulation of, 212
AGEs. see advanced glycation end-products (AGEs)
agonists, defined, 117
agoraphobia
phosphatidylserine, 17677
S-Adenosyl-L-methionine, 17983
taurine, 17879
tyrosine, 17276
see also neurotransmitters
amitriptyline, 194
amygdala
dopamine and, 117
humorous television programming and, 54
oxytocin and, 120
stress-induced changes in, 100
amyotrophic lateral sclerosis (ALS), acetyl-L-carnitine and, 81
Anafranil, 170
Andrews, G., 56
anemia, 68, 259
animal-assisted therapy, xvi
Anishetty, S., 190
antagonists, defined, 117
anterior cingulate cortex, 74, 117
antianxiety medications, 11415
discontinuation syndrome and, 56
high risk-to-benefit ratio with, 10
optimizing use of, 219
safety concerns with, 5
stopping, 238
antibiotics, probiotics and, 147
antidepressant medications, 8, 114
all-cause mortality and, 5
discontinuation syndrome and, 56
estrogen replacement therapy and, 221
fish oil working integratively with, 224
folate and, 226, 227
optimizing use of, 219
safety concerns with, 45
SAMe working integratively with, 229
side effect profiles, efficacy, and, 115
stopping, 238
vitamin B12 and, 151, 22728
zinc treatment and, 22829
see also sexual side effects of antidepressant medications; tricyclic antidepressants
anti-inflammation diet, 59
antioxidants, toxic metal removal and, 128
D-Phenylalanine, 174
DRD4 gene, depression and anxiety and, 111
dream sleep, 15
drugs, recreational, 253, 254
DSPS. see delayed sleep phase syndrome (DSPS)
Dubois, O., 52
duloxetine, 53
dynorphins, afferent group III nerve fibers and, 212
eating, sleep and, 1819. see also diet; food
EFT. see emotional freedom technique (EFT)
eicosapentatoic acid (EPA), 29, 135, 136, 137, 138, 139, 144
Elavil, 194
electric shock therapy, 53
electronics use, 5357
brain on TV, 5455
computer blues and benefits, 5556
social media and cell phones, 5657
eleutherococcus
pharmaceutical medications for anxiety and depression and patient support with, 233t
tricyclic antidepressants working integratively with, 230
Eliot, T. S., 54
El-lethey, H. S., 36
Elliot, G., 1
Eltinge, J. L., 47
Emmanuel, A. V., 89
emotional freedom technique (EFT), 215, 216t
end-stage renal disease, 67
energy healing, xvi
enkephalins, afferent group III nerve fibers and, 212
enteramine, 122
enteric nervous system, 88, 145
eosinophilia-myalgia syndrome (EMS), 22, 171
EPA. see eicosapentatoic acid (EPA)
epigallocatechin gallate, in green tea, 38
epigenetics
behavioral, 113
defined, 111
epinephrine, 111, 125, 173
depression and, 118
folic acid and, 82, 151
lowering, suggestions for, 119
Epsom salts, 189
Erickson, K. I., 40
Erythrocyte Sedimentation Rate, 98
essential fatty acids, 119, 134, 137
estradiol, 78
estrogen, 278t279t
low, managing, 7980
estrogen (cont.)
medications working integratively with, 22122
pharmaceutical medications for anxiety and depression and patient support with, 232t
serotonin and, 7778
estrogen replacement therapy, 78
ethyl-EPA, 138, 139, 224
evening primrose oil, 143
Evidence-Based Complementary and Alternative Medicine, 271
exercise, 3942, 62, 79, 112, 131, 133, 219, 261, 265
anxiety and depression and evidence for, 4041
CRP-lowering benefit of, 67
dopamine support and, 118
getting started with, 4142
HDL cholesterol and, 64
inflammation work and, 98
lifestyle summary and, 253
medication working integratively with, 220
pharmaceutical medications for anxiety and depression and patient support with, 232t
sleep and, 41
stable mood and, 39
treatment plan and, 258
exhaustion, 105, 106
exophthalmos, excess thyroid hormone and, 7071
family history, establishing, 248
fatal familial insomnia, 14
fatigue, 95
adrenal, 105
chronic, 93, 96, 104, 105
low iron and, 68
sleep disturbances and, 15
Fatigue Symptom Inventory, 2
fats
healthy, 26, 2930
saturated, 135
unhealthy, 35
unsaturated, 136
L-Carnitine in, 82
lithium orotate in, 162
low HDL and, 64
magnesium in, 158
multiple vitamins and, 149
phenylalanine and arginine in, 118, 17576
phosphatidylserine in, 177
probiotic, 3132, 39, 147
raw nuts, 3334
SAMe in, 183
seafood, 2930
selenium in, 160
sensitivities, 16, 27
treatment plan and, 25859, 260
tryptophan and 5-HTP in, 172
tyrosine in, 118
vegan oils in, 144
vitamin D in, 86
which to avoid, 3437, 39
zinc in, 162
food allergies, 97, 249
Food and Drug Administration (FDA), 5, 36
food sensitivity (food intolerance), 9798
footbaths, warm, 51
forced swim test, nomifensine and, 117
forest bathing, in Japan, 4748
free radicals, 12728
fruits, 67
GABA. see gamma-aminobutyric acid (GABA)
Gaik, F., 208
gambling issues, N-acetyl-cysteine and, 177
gamma-aminobutyric acid (GABA), 23, 114, 145, 16365, 168, 178, 193, 260
for anxiety and depression, 284t285t
calming influence on the brain with, 163, 164
description of, and studies on, 16364
dosage, best application, toxicity, and, 165
exercise and, 41
food sources of, 165
micronized progesterone and, 79
probiotics and, 31
probiotics and f, 146
progesterone and, 222
hedonic hyperphagia, 32
hemoglobin A1C, fasting blood sugar and, 61
herbalists, xvi
herbal supports, for sexual side effects of antidepressants, 231, 23437, 234t
herbal tea, 18
herbicides, 128
herbs. see botanical medicines (herbs)
high-glycemic foods, 35, 39
high school students, delayed sleep phase syndrome and, 15
Hintikka, J., 227
hippocampal growth exercise, 4142
hippocampus, 100
DHEA and, 74
exercise and maintenance of, 40
meditation and cellular regeneration in, 207
Hippocrates, 39, 42, 51, 209
history for patient, taking, 24550
better/worse symptoms, 249
family history, 247
listening and, 246
medications, 247
mood concern onset and chronology, 24647
supplements, 24748
Hoch, T., 32
Hofmann, S. G., 209
holistic care, 6, 10
appropriateness of, for your client, 710
as first-line therapy, assessing, 9
supporting bodys healing ability with, xii
top five principles of, 7
when to avoid, 11
holistic medicine, xvixvii
Holistic Primary Care, 271
Hollander, E., 236
homeopathics
for anxiety, 300t301t
for depression, 295t299t
dosages of, 202
homeopathy, 198202
defined, 199
derivation of word, 198
studies in anxiety and depression, 199201
Massey, A. E., 74
Mattson, R. H., 50
McAllister-Williams, R. H., 74
McCarley, A., 236
Meany, M., 113
Measure Yourself Medical Outcomes Profile, 2
meats, grass-fed, 28
Mechnikov, I. I., 146
media, anxiety and depression and multiple use of, 5556
medical doctors, xvi
medical students, stress, fish oil intake, and, 137
medications
common patient scenarios around, 218
defined, 133
estrogen working integratively with, 22122
exercise working integratively with, 220
fish oil working integratively with, 224
folic acid working integratively with, 22627
lavender working integratively with, 230
patient history and, 248
patient preferences and, 11
progesterone working integratively with, 22223
rhodiola and eleutherococcus working integratively with, 22930
testosterone working integratively with, 22324
thyroid hormone working integratively with, 22021
vitamin B12 working integratively with, 22728
weaning off, natural medicines as aid to, 238, 239t240t, 24143
withdrawal from, 56
zinc working integratively with, 22829
see also antianxiety medications; antidepressant medications; pharmaceutical medications
medication withdrawal hyperarousal, 24
meditation, 75, 90, 92, 109, 120, 132, 204, 2068, 216t, 254
contraindications to, 209
dopamine support and, 118
epinephrine lowered with, 119
inflammation work and, 98
practice types, 2067
Mediterranean diet, 39, 92, 98
benefits of, 26, 27
components of, 2627
medroxyprogesterone acetate (Depo-Provera), 78, 79
melancholic depression, yoga and, 206
nervous system
evaluation of, 251
healthy foods and, 34
neuroendocrine system, digestive tract and, 145
neurogenesis, exercise and, 40
neuronal suicide, heavy metal exposure and, 124
neurosteroids, 74
neurotoxic compounds, 12930
neurotransmitters, 11315
amino acids as precursors to, 172
cholesterol depletion and, 63
defined, 11314
dopamine, 11718
epinephrine, 11819
gamma-aminobutyric acid, 119
gastrointestinal tract and, 88
glutamate, 11920
medication weaning process and, 242
minerals and production of, 35
norepinephrine, 11819
oxytocin, 12021
serotonin, 12123
newborns, REM sleep and, 15
Nexium, xvii, 13
niacin, 27
niacinamide. see vitamin B3 (niacinamide)
nicotinamide, 150
9/11 terrorist attacks
firefighter during, and experience with acupuncture, 212
parental loss in, HPA dysregulation in children and, 108
Nippon Medical School (Japan), 48
N-methyl-D-aspartate (NMDA)
glutamate and, 120
homocysteine elevation and, 66
No Exit (Sartre), 6
nomifensine, 117
norepinephrine, 53, 114, 122, 172, 173, 173, 184, 193, 196, 213
afferent group III nerve fibers and, 212
depression and, 118
folic acid and, 82, 151
Norplant, 78
Nowak, G., 228
NutraSweet Company, 37
nutrient therapies, xvi, 10
nutrition, 116
balanced HPA function and, 108, 109
epigenetics and, 111
see also diet; foods
nutritionists, xvi
nuts and seeds, raw, 28, 3334, 98
oats (Avena sativa), melatonin in, 21
obesity, 28, 31, 54, 105, 141
Oboszewska, U., 228
obsessive-compulsive disorder
N-acetyl-cysteine and, 177
sexual side effects with SSRIs, yohimbine dosing, and patients with, 236
yoga and, 2056
oils
fish oil, 13441
healthy, 30, 59
vegan, 144
Oklahoma City bombing, significant HPA dysregulation in children exposed to, 108
oleic acids, 30
olive oil, cold-pressed extra virgin, 30
omega-3 fatty acids, 29
in fish oils, 135, 136, 141
phosphatidylserine and, 176
omega-6 fatty acids, 27, 29, 135, 136
omega-9 fatty acids, 30
oolong tea, 119
oral contraceptive use, vitamin B6 deficiency and, 150
organophosphates, 129
Osler, W., 246
osteopathic physicians, xvi
osteoporosis, 87, 103
oxazepam, 185
oxytocin, 12021, 122
Pace, C., 79
Pancheri, P., 182
panic attacks, inositol and reduction in, 152
panic disorder, 100
5-HTP and, 170
homeopathic study for, 199200
meditation and, 208
vitamin D and, 84
prenatal environment, HPA axis and, 1079
presynaptic nerve terminal, 113
primrose oil, 280t281t
probiotics, 3132, 39, 14447, 254, 259, 260, 265
for anxiety or depression, 273t
benefits of, 145
dosage and best application for, 14647
food sources of, 147
inflammation lowered with, 99
as psychobiotics, 146
toxicity and, 147
professional holistic collaboration, 26971
progesterone, 78, 278t279t
low, managing, 7980
medications working integratively with, 22223
pharmaceutical medications for anxiety and depression and patient support with, 232t
progressive muscle relaxation, pregnant women and, 109
prostaglandin E1 (PGE1), 141, 142
prostate cancer
DHEA cautionary note and, 76
fish oil studies and, 140
protein, 59, 131
blood sugar control and, 61, 62
needs, formula for, 28
sources of, 28
prothrombin time, 140
proton pump inhibitor drugs, xvi
Prozac, 22, 184, 196
acupuncture working integratively with, 23031
electroacupuncture study and, 21314
folate levels and, 226
tri-iodothyronine working integratively with, 221
tryptophan used in combination with, 225
yohimbine used in combination with, 23536
psychopharmacology-CAM relationship, 11516
psychotherapy
benefits of, 6
patient preferences and, 11
psyllium (Plantago ovata), 90
for anxiety and depression, 290t291t
husk, 67
stress
epigenetics and, 111
fish oil intake and, 137
homeopathic remedy study on women and, 201
hypothalamic-pituitary-adrenal (HPA) axis and, 75
stress adaptation syndrome, resistance of, 105
stress management, 62, 254
bowel movement and, 90
meditation and, 208
thyroid health and, 72
stroke, antidepressants and, 5
Sublette, M. E., 136
substance abuse, xiv
sucralose, 37
sugary foods, 35
suicidal behavior, HDL cholesterol and, 64
suicidal ideation
first-line therapy for patients with, xviii
pharmaceutical medications and assessing patient for, 8
suicidality
antidepressants, FDA warning, and, 5
magnesium deficiency and, 157
short 5-HTT allele, stressful events, and, 110
tryptophan deficiency and, 168
sunlight, 4246, 265
circadian rhythm and, 42, 4344
components of, 45
healthful exposure to, 42
serotonin and, 42, 43
vitamin D and, 42, 4546, 85
yin and yang of, 4243
supplements, 265
for anxiety or depression, 273t
considerations related to, 13334
defined, 133
for mood dysregulation due to hormonal imbalance, 278t279t
patient history and, 24849
patient profile matched with, 25455
treatment plan and, 259
suprachiasmatic nuclei, magnesium deficiency and, 20
sweeteners, artificial, 37, 39
swimming, 41