Keeping the Blues at Bay
A Holistic Approach to Maintaining a Positive Mood in Dark Times
What is Depression? - A Spectrum Disorder
Minor Depression, Major Depression, Recurrent Brief Depression, Dysthymia, Adjustment Disorder with Depressed Mood. These are fluid distinctions, and people often move from one subtype to another in their clinical course.
Symptoms: Low mood or Loss of interest in activities that were once enjoyable,
and at least four additional symptoms:
appetite disturbance psychomotor agitation or retardation
sleep disturbance feelings of worthlessness, sinfulness or guilt
fatigue trouble with concentration
thoughts of death or suicidal ideation
Depression Without Sadness: Many patients present to health care providers with primarily physical complaints, not complaints about their mood (70% in one international study). For some people, anxiety or irritability predominate. Anhedonia (loss of pleasure in usual activities) has been the most useful clue for me.
How Common Is It? Lifetime prevalence of MD is 7% to 12% in men and 20% to 25% in women. This incidence is increasing - our lifestyles are becoming more and more unbalanced.
Suicidal Thoughts: Extremely common - about 70% of our general medical intakes have had thoughts of suicide at some time. A recent study in Colorado showed 30% of high school students commonly think of suicide and feel hopeless. Suicide is one of the top 10 causes of death in all age groups and one of the top three causes in young adults and teenagers. Generally transient - if survived. Beware impulsivity.
What is Depression? (Connie’s more existential take on it)
A final common pathway for expression of dis-ease in the Mind/Body/Spirit
A survival mechanism for animals when sick, or in the winter?
A cry of distress or a call to action when some circumstance needs to be altered (i.e. don’t just put the cover on the canary’s cage)
What Causes Depression?
Multifactorial:
• Body: Biological Factors
• Mind: Patterns of Thought
• Spirit: Loss of Connection and Purpose
• Environment: Toxic or nurturing
• Social support: Loneliness, disconnection
• Life Events: Sudden Stressful Events, Longterm Intolerable Conditions
Treatment should be focused on the level(s) most out of balance
Tacks Rule #1: If you are sitting on a tack, it takes a lot of aspirin to make it feel good.
You can substitute psychotherapy, meditation, organic foods, etc for the aspirin and the rule still holds. The proper treatment for tack-sitting is tack removal
Tacks Rule #2
If you are sitting on two tacks, removing just one does not result in a 50% improvement.
-Syd Baker, M.D.
A Corollary to the Tacks Rules
If you are sitting on a tack and you use morphine to make it feel good, this may prevent you from removing the tack
In terms of tacks, the biological medical model has probably been overemphasized.
Mind: General level of challenge and stimulation, Patterns of thought: negative, pessimistic, self-defeating, external focus of control (Learned helplessness: Dogs taught to be helpless are noted to have alterations in neurotransmitter levels, which normalize on being re-educated in control.)
Spirit: Lack of purpose/value/meaning in life, Absence of centering, praying, meditating regularly
Environment: Is workplace or school healthy, supportive, nurturing? Toxins, allergens, pollutants,
Lack of connection with earth, plants, beauty; Overcrowding, Lack of Sunlight
Social: Loss of parent, Number and quality of connections, Low level of perceived support
Body Causes:
Genetic - 10% concordance in siblings
Nutrition: B12, folate, EFA’s, protein (digestion as well as intake)
Lack of Exercise
Inflammation - IFN experience in treatment of hepatitis C
Food Allergy - elevates circulating cytokines
Chronic Infection: Lyme Disease, HIV disease, Hepatitis C
Autoimmune disease: Lupus, Rheumatoid arthritis, Inflammatory bowel disease
Hormonal:
1. Thyroid: high or low (Blood tests may not be reliable; consider am temperature testing.)
2. Sex hormones: Postpartum, PMS, Menopause - action of estrogen on 5HT 2A receptor and serotonin transporter in brain, Andropause - low testosterone in men
3. Adrenal - Depression elevates am cortisol; adrenal fatigue can mimic depression
Substances/Toxins:
1. Substance Abuse
2. Toxins - solvent exposure, etc.
3. Medications: Hormones, Blood pressure, Anticonvulsants, Steroids, Digitalis, Antiparkinsonian agents, Antineoplastic agents, Antibiotics, Pain medications, benzodiazepines, Acid blockers: cimetidine, ranitidine
Other Illnesses: Heart Disease, Lung Disease, Neurological disease, Pain Disorders
Treatment: effective in more than 90% of patients, continue 6-9 months after complete remission
Placebo response rates vary widely across patient groups, may be as high as 65 percent, even in groups with major depression. Placebos aren’t all bad, but it is best if they are cheap and safe. . . .
A systematic review of antidepressant trials submitted to the FDA for approval of 6 widely prescribed antidepressants (many of which were not published):
80% of the response to medication was duplicated in placebo control groups.
The mean difference between drug and placebo on the Hamilton Depression Scale was less than 2 points (on a 64-point scale). There is less difference in effectiveness when antidepressants are compared with placebos with side effects that mimic the effects of the antidepressants.
Treatment Options
Remove Tacks - This can be huge - depression can be a catalyst for major life change (Toxic Relationships, Unresponsive Career Path, Toxic Environment, Etc.) Caveat: Judgment can be clouded while depressed, people or other factors may be scapegoated - don’t act impulsively!
Eliminate caffeine and simple sugars Behav Ther 19:593-604, 1988, food allergens(consider gluten), and toxins, including alcohol
Address other medical conditions
Exercise - as effective as antidepressants(aerobics, weights, yoga breathing have all been studied)
Light - The Sunbox Company
Psychotherapy, including Bibliotherapy (Burns, Seligman) - When studied head-to-head with medication, generally equivalent response rates, but therapy has lower relapse rate after discontinuation. Best response to the combination.
Diet - omega 3 - ideally fish oil or vegetarian source of DHA, 3-4 grams per day, protein, digestion (consider bitters)
Supplements - omega 3 as above, B-complex, possible megadose folic acid (consider testing B12, homocysteine)
Consider vitamin D 4000 IU per day
SAMe- 800-1200 mg per day, with bromelain for absorption, watch for mania, elevated
homocysteine (also watch brand - consumerlab.com) (1600 mg/d costs $2.40 - 3.60 per day) An alternate approach is to supplement B vitamins, betaine (trimethylglycine), methionine - no studies, but I have found this to be very helpful empirically
5HTP - 5-Hydroxytryptophan (50 - 300 mg/day) is more effective than placebo and
almost as effective as pharmaceutical antidepressants; contamination issues
DLPA 200 mg per day as effective as imipramine, effective in PMS
Drugs - consider thyroid as well as antidepressants
Magnets, Electricity, etc.
Herbs
I will not address homeopathics, flower essences, etc. - very little controlled data, but
some promising anecdotes
General Herbal Approach:
Support for the whole organism, for health in general is important - the “silver bullet” is illusory
Therefore, consider treatment of inflammation, etc.
Consider Bitters
Consider Adaptogens, particularly for those with chronic stress (who does not have that?)
Definition of an Adaptogen
• must be innocuous and cause minimal disorders in the physiological functions of an organism
• must have a non-specific action (i.e. it should increase the resistance to adverse influences by a wide range of physical, chemical, and biochemical factors)
• usually has a normalizing action irrespective of the direction of the pathologic state (alterative action).
Some Examples: Siberian Ginseng, Rhodiola rosea, Panax Ginseng, Ashwagandha
Eleutherococcus senticosus (Siberian Ginseng)
In healthy human subjects:
• increases the ability of humans to withstand many adverse physical conditions (i.e. heat, noise, motion, work load increase, exercise, and decompression)
• increases mental alertness and work output
• improves athletic performance and the quality of work under stressful conditions.
Demonstrated ability to increase the sense of well-being, regardless of the psychological complaint (insomnia, hypochondriasis, anxiety, etc.).
Improved balance of the biogenic amines (serotonin, dopamine, norepinephrine, epinephrine, etc.) in rat studies
Other Adaptogens
Withania somnifera (Ashwaganda): effective in rat models of depression, not well-studied in humans, helps with sleep
Panax ginseng: proven effective for depression, may induce mania
Rhodiola Rosea - 100 - 200 mg per day, Elevates brain serotonin 30%, Stimulates opioid receptors, May elevate dopamine in the brain as well
Should not be taken with antidepressants that raise serotonin or with triptan medicines for migraines
Cordyceps
Schisandra
Nervine tonics and trophorestoratives: in addition to the above, and traditionally,
Avena officionalis (oatstraw)
Scutellaria lateriflora (skullcap)
Verbena officinalis (Vervain)
Bacopa monnieri
Specifics:
St. John’s Wort (Hypericum perforatum)
Multiple mechanisms of action:
affects serotonin, dopamine, norepinephrine, and GABA reuptake inhibition
in vitro monoamine oxidase inhibition
binds opiate receptors, as well as acetylcholine sigma receptors
Hypericum extract inhibits interleukin-6 production
More effective than placebo and as effective as conventional antidepressant medications in the treatment of mild to moderate depression:
Dose: 900 mg per day of extract (standardized to at least 0.3% hypericin or 2-5% hyperforin)
Issues of methods/solvents of extraction - methanol extracts hypericin well, but hyperforin is more in the oil extract; hypericin is poorly bioavailable without procyanidin
Side Effects : Fewer than pharmaceutical antidepressants, but can include: gastrointestinal upset, allergic reaction, fatigue, dry mouth, restlessness, constipation, photosensitivity, and I have had 3 patients with neuropathy (tingling, numbness in fingers or toes). Hypomania can be seen, as with other antidepressants.
Drug Interactions: Avoid combination with pharmaceutical antidepressants
Multiple drug interactions because it increases some of the detox enzymes:
Lowers levels of HIV medications, affects some blood pressure medications, blood thinners, possibly birth control pills
Ginkgo biloba
Improves brain perfusion/circulation, Improves memory
Adjunctive for treatment of depression in older people (>50 yo)
Standardized Extract 24% ginkgo flavone glycosides, 120-240 mg per day
Takes up to three months to see full effects
Side effects: antiplatelet effects - watch for bruising; caution with aspirin and blood thinners
Aromatherapy
The effects of aromas are evoked by both pharmacological and psychological mechanisms.
Aroma of spiced apple possesses pronounced vasodepressor and stress reduction effects, increases alpha waves on EEG
Lemon aroma and sweet orange oil caused an increase of heart rate - stimulating
Rose aroma led to a decrease of heart rate - sedative
Nutmeg-based aroma can reduce stress in humans as measured by the reduction in blood pressure and self-ratings
Ylang-ylang oil exhibited a harmonizing effect - decrease of blood pressure and an increase of subjective attention
Rosemary by inhalation produced significant increases in alertness, memory, and contentedness, but impairment in memory speed compared with controls. Lavender aroma had a significant negative effect on memory, memory speed, and contentedness compared with controls.
Aromatherapy Clinical Trials
In chronic hemodialysis patients hiba oil is an effective, non-invasive means for the treatment of depression and anxiety, lavender alleviates anxiety.: Itai Tet al. Psychiatry and Clinical Neurosciences, Volume 54, Number 4, August 2000, pp. 393-397(6)
Lavender, marjoram, eucalyptus, rosemary, and peppermint blended in proportions of 2:1:2:1:1
Significantly decreased both the pain score and the depression score of an experimental group with arthritis compared with the control group. Taehan Kanho Hakhoe Chi. 2005 Feb;35(1):186-94.
How Can I Do All This When I Can’t Get Out of Bed in the Morning?
Sometimes, depression causes so much inertia, that any treatment requiring more commitment than swallowing a pill once a day may be difficult:
Consider a stepped treatment plan, with biological approaches or drugs initially to allow enough improvement to then implement exercise, psychotherapy, etc.
Anxiety Disorders
Includes General Anxiety Disorder, PTSD, OCD, panic disorder, phobias
Affect 13.3% of the population every year
Again, often present with physical complaints: easy fatigability, difficulty concentrating, irritability, muscle tension, restlessness, sleep disturbance, sweating, headache, and trembling.
Many have comorbid depression - treating that may correct the anxiety
Many develop drug or alcohol abuse problems as well (self-medicating)
Consider medical disorders that produce anxiety (asthma, hyperthyroidism, etc.)
Aerobic exercise programs exceeding 21 minutes per day (ideally, 40 minutes) for a minimum of 10 weeks were needed to achieve significant anxiety reduction.
Eliminate caffeine, alcohol, sugar (recommend low glycemic index diet to stabilize blood sugar)
Supplement Magnesium, B complex, Fish oil
Consider taurine, GABA
Mind-body:
Relaxation techniques - abdominal breathing, body scan/PMR, imagery
EMDR for trauma
Cognitive restructuring
Are you addicted to stress-relief products? There’s nothing wrong with candles and the sound of running water, but don’t kid yourself into thinking that’s changing the problem. You might just find yourself urinating constantly, with the curtains on fire. And you’ll still have your problems. Loretta LaRoche
The herbs:
Adaptogens and trophorestorative herbs (nervine tonics) as in depression
Specifics/Nervine relaxants:
Passiflora (Passionflower) - Chrysin is a benzodiazepine partial agonist. ¼ tsp per day of tincture. No impairment of function in human trials, no effects on memory in rodents. **We have had great results with this!**
Piper methysticum (Kava) - kavalactones facilitate GABA binding, inhibit Na+/Ca2+ channels, MAOI, inhibit TXA2 synthesis, inhibit NE uptake
Effectiveness - Effective as an anxiolytic in multiple controlled trials, muscle relaxant, analgesic, improved cognitive function in some trials
Dosage 60 - 240 mg per day of kavalactones
Toxicity concerns - About 70 cases of various degrees of liver damage have been documented worldwide. About 80% of these patients took kava overdoses and/or self-medicated kava for longer than 3
months. Most patients administered comedications with known hepatotoxicity.
Acetone and alcohol extracts may be more toxic than water extraction, and there is suspicion of use of peelings of the kava stump which contain the hepatotoxic alkaloid pipermethystine not normally contained in good quality kava supplements.
A rough estimation of the incidence of liver damage yields similar results for kava and benzodiazepines. There seems to be little difference between the reported incidence of kava-induced hepatotoxicity and that of other psychoactive drugs such as valproic acid, fluoxetine, paroxetine, sertraline, fluvoxamine, impiramine, and codeine. The many adverse effects (other than hepatotoxicity) of psychoactive drugs (eg, sedation, dependence, memory impairment, accidents) should also be taken into account. E. Ernst Journal of the New Zealand Medical Association, 05-November-2004, Vol 117 No 1205
Ginger/ginkgo 2.5:1 was anxiolytic in animal models - ginger has anti-inflammatory, serotonergic end other effects
Centella asiatica (gotu kola) - also helps wound healing, venous insufficiency, 20 - 40 drops, up to 4x per day
Valerian - sesquiterpenes stimulate GABA release and inhibit breakdown, probable multiple components/mechanisms facilitating GABA action, antidepressant activity in the forced-swimming test; improvements in sleep quality
Theanine from Camellia sinensis - increases serotonin and dopamine production, increases alpha brainwave activity (relaxation), 200 mg 2-3 x per day
Melissa officinalis (Lemon balm) - sedative, analgesic, also helpful with digestive complaints, herpes, Graves’ disease and hyperthyroidism. Safe in pregnancy, lactation and in children. 3 cups of tea per day, or 2-5 mL tincture tid
Skullcap - for PMS-related anxiety. 20 - 60 drops, up to three times a day
Motherwort - for menopause-related anxiety, palpitations, 30-60 drops up to 4x per day
Chamomile - Apigenin, benzodiazepine agonist, inhibition of Ca2+ channels, MAOI, blocks NE uptake, standard infusion as needed
Catnip - terpenes resemble valepotriates from valerian, ¼ - 1 tsp, up to 4 x per day
Hops 30-90 drops, up to three times a day
Connie Basch, M.D. April 2007
