Beating the Blues, Naturally

Kathi J Kemper, MD, MPHWake Forest University

Disclaimer I have the following financial relationships

with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity:

        American Academy of Pediatrics, “Mental Health, Naturally “ Author. Royalties

anticipated. The presentation will include no description of any

proprietary items for screening, diagnosis, or treatments.

I do not intend to discuss an unapproved or investigative use of a commercial product in my presentation.

Objectives

By the end of this session, participants will be able to – Describe the role of healthy habits and a healthy

habitat in preventing and treating depression– Evaluate the evidence for the safety and

effectiveness of vitamins, minerals, amino acids, omega-3 fatty acids, and herbs in promoting optimal moods

– Use evidence based resources about natural therapies to promote positive moods

Definitions: Mental Health Most of medicine focuses on mental illness, eg.

Depression, (Triage, Test, Diagnose, Dispense care)

Mental health – identify goals, then strategies; barriers and resources; pros and cons; BE SMART (specific, measurable, achievable, relevant, time-specific) behaviors,

“You got to be careful if you don't know where you're going, because you might not get there.”

Yogi Berra

Is mental health more than absence

of depression?

Parallels between physical, mental, and spiritual health

Optimal Physical health: Example

Strength Flexibility Stamina/Endurance Focus Coordination Resilience, and Effective teamwork Specific skills

Optimal Spiritual Health Faith Forgiveness Hope Love Kindness Charity/generosity, and Transcendence – connection

with something greater than our individual self

Wisdom

Mental Health: ideals Confidence and courage Adaptability Cheerfulness Attention / Focus Harmony Hardiness in face of stress Social Network/

communication skills/ connection to community

Clarity, insight, discernment

Parallels

Physical: Stamina

Spiritual: HopeMental: Cheerfulness

What are five fundamentals of a healthy lifestyle that promotes

cheerfulness?

Fundamentals – 4H; 5F

Food

FitnessManage Stress

Relationships

Environment

What does good mental health have to do with

basketball and symphonies?

Practice, practice, practice the fundamentals daily; don’t wait for the big game or concert (crisis)

Warm-up/prepare for stress

Seek a good role model and coach/guide/teacher

Mental health coach: CBT; DBT

“From an evidence-based perspective, cognitive-behavioral therapy is the treatment of choice for anxiety and depressive disorders.”

Compton SN. JAm Acad Child Adolesc Psychiatry. 2004

5. Healthy Habitat (Fields) More: Light, music, nature

(Richard Louv, Last Child in the Woods – Nature Deficit Disorder); organization

Less: TV, toxins, tobacco, violence, discrimination

Light and music therapies Proven effective for SAD

(Terman M Evid Based Ment Health, 2006)

Meta-analysis of studies: (effect size similar to medications) for depression (Golden RN. Am J Psychiatry, 2005)

Music therapy is effective even for severe mental disorders – dose effect response (Gold C. Clin Psychol Rev, 2009)

Vitamin D and depression Vitamin D receptors in brain Low level of serum 25-OH D

significantly associated with depression (Jorde, 2005)

Vitamin D significantly lower in psychiatric patients than controls (Schneider, 2000)

RdbCT of 20-40,000 IU weekly of vitamin D significantly improved depression (Jorde R. J Gen Intern Med, 2008)

4. Friendship with Others Social support promotes

mental health, e.g. religious participation protects adolescent mental health

Rx: spend time with friends Join clubs, leagues, scouts Volunteer – those who help

others feel better about themselves; mentor, tutor, coach, babysit

WRITE PRESCRIPTIONS FOR MORE SOCIALIZING

3. Friendship with self: Manage Stress Stress is common Physical: higher cortisol, lower

DHEA; higher epinephrine/NE, BP; shorter telomeres (aging); poor sleep, more pain, GI upset.

Mental/Emotional: irritability, anxiety, depression; angry, impatient; STRESS MAKES MOODS WORSE

More in later talk

Stress Management

Mental (meditation – sitting or moving, guided imagery, biofeedback, autogenic training, journaling, CBT, etc.)

Emotional (intentionally generate positive emotions)

Spiritual (not necessarily religious; forgiveness; extending compassion)

Stress management: Meditation

Meditation training ↑ brain patterns associated with happiness

Can combine mindfulness with CBT

Caution for patients with thought disorders (schizophrenia)

Review of Pediatric Meditation studies to be published in upcoming Pediatrics in Review

Davidson RJ Psychosom Med, 2003

2.Fitness Rx Depression

Lawlor DA. BMJ 2001

Yoga for depression

Five RCTs --each used different forms of yoga.

All had positive findings

No adverse effects except fatigue and breathlessness

Pilkington K. J Affective Disord, 2005

How much Exercise? 30-60 minutes at least

5X/week Intensity: Sweat and/or

difficulty talking at the same time as exercising

Type: what you enjoy! Track it! Anticipate barriers; use

resources; plan rewards

2. Food: The SAD Story SAD=Standard American Diet USDA—75% eat less than 2/3 of

RDA for one or more nutrient. < 1% teens meet RDAs Sugar and fat > 65% of American’s

calories. Falling micronutrient content of

foods—most minerals at 60-40% of 1930’s levels. Depleted farmland = depleted food quality.

Nutrition – essential nutrients for optimal brain

function Vitamins (B vitamins, Vitamin

D) – needed to make neurotransmitters

Amino acids (SAM-E, Trp, 5-HTP) – neurotransmitters

Omega-3 fatty acids – needed for membrane stability

Minerals (Iron, Calcium, Magnesium, Zinc) – mood and anxiety

Amino Acids: SAM-E

Meta-analysis: SAMe significantly improves depression, comparable to antidepressant medications (http://www.ahrq.gov/clinic/epcsums/samesum.htm)

All tested products approved by ConsumerLab; buy on sale!

SAM-E Doses, duration, products Dose: 800 – 1600 mg daily

(adult) Benefits appear within 2-4

weeks of starting daily use Problems –poorly absorbed

(need enteric coating); mania in bipolar patients; interactions with SSRI meds; see: http://www.consumerlabs.com/results/same.asp

http://www.umm.edu/altmed/ConsSupplements/SAdenosylmethionineSAMecs.html

AA: 5-HTP and L-tryp Acute tryp depletion leads to

depression Dietary L-tryp -> 5-HTP ->

serotonin Meta-analysis: 5-HTP and L-trp

better than placebo for depression (Shaw K, Cochrane. 2002)

Food sources – dairy, eggs, poultry, meat, soy, tofu, nuts; WHEY protein

L-tryp doses and side effects

Doses - start at 50 mg TID; max dose 1200 mg daily

Side effects – EMS related to contaminated lot from one manufacturer; nausea, drowsiness; May potentiate SSRI medications; decreased carbohydrate intake and weight loss?

Folate Folate (Essential co-factor for synthesis of SAMe).Essential co-factor for synthesis of SAMe).

– Lower levels of folate in depressed persons– Low folate associated with poorer response to antidepressant meds

Methylfolate in depressed pts (elderly, EtOH dependent, dementia) Methylfolate in depressed pts (elderly, EtOH dependent, dementia) show significant improvement (show significant improvement (Guaraldi et al., 1993; Di Palma et al., 1994; Glória et al., 1997; Passeri et al., 1993)

RPCT: folate as adjunctive Rx in folate deficient MDD pts showed RPCT: folate as adjunctive Rx in folate deficient MDD pts showed signif improvement over placebo (signif improvement over placebo (Godfrey et al., 1990)

RPCT MDD pts randomized to fluoxetine + folate (0.5mg) improved more RPCT MDD pts randomized to fluoxetine + folate (0.5mg) improved more than fluox. + placebo; differences esp striking in WOMEN (than fluox. + placebo; differences esp striking in WOMEN (Coppen & Bailey 2000)

Studies on supplements in non-folate deficient MDD pts on SSRIs Studies on supplements in non-folate deficient MDD pts on SSRIs found significant reduction in sx severity and 19% remission found significant reduction in sx severity and 19% remission (Alpert et al., 2002)

Folate augmentation may enhance response to lithium in folate Folate augmentation may enhance response to lithium in folate deficient bipolar and unipolar depression (deficient bipolar and unipolar depression (Coppen and Chaudhry, 1986)

Omega-3’s

Eat less fish, higher depression rates (Crowe. Am J Clin Nutr, 2007)

Effective for bipolar patients (Montgomery P. Cochrane Database Syst Rev. 2008)

Effective for major depression (Freeman MP. J Clin Psychiatry. 2009)

Effective for depression and bipolar disorder in children and adolescents (Am J Psychiatry 2006; Clayton. Eur J Clin Nutr. 2009 )

Anxiety (Ross BM. Prostaglandins Leukot Essent Fatty Acids, 2009 )

Fish Oil –Doses, Safety, Brands Dose: 1-2 grams daily of EPA+DHA

probably enough.(Peet M, 2002; Frangou S. Br J Psychiatry, 2006)

Safety: fish allergies, taste, belching; Little risk of mercury, dioxin, PCB’s;

Brands: Compare brands at www.consumerlabs.com; see handout at our website: www.wfubmc.edu/cim

Read labels: Omega 3 does NOT necessarily all equal EPA/DHA

OR EAT SARDINES/ SALMON 2 - 5 times weekly

Mood and Minerals: Iron

Iron deficiency associated with depression

Iron deficiency common in women

Correcting iron deficiency helps with mood and attention

Beard JL. J Nutr, 2005LE Murray-Kolb. Am J Clin Nutr, 2007

Other: Massage, Acupuncture

Massage: – positive results for teaching teen moms to

provide massage for infants; benefits for mom and infant (Oswalt KL. Pediatr Nurs, 2009; Field T. Adolescence,

2000; Field T. Adolescence, 1996); – helpful for teen psych inpatients (Garner B. Aust N Z J

Psychiatry. 2008); – helpful for bulimic teens (Field T, Adolescence, 1998)

Acupuncture: effective, with relapse rates comparable to conventional treatments (Gallagher SM. Complement Ther Med. 2001; Quah-Smith JI. Acupunct Med. 2005)

Suggested Practice Changes

For the next week, give prescriptions for one or more: exercise, earlier bedtime with sleep hygiene, light, music, and volunteering

For the next week, assess at least 1 patient a day for deficiencies of essential nutrients for healthy mood

Consider making or using a handout(s) for patients on essential nutrients and supplements

Find an acupuncturist and massage therapist in your community that you feel comfortable and get a treatment if you haven’t already.

Join the AAP SOCIM (tsalus@aap.org or www.aap.org/sections/chim/

ResourcesKaplan, B et al “Vitamins, Minerals and

Mood” Psych Bull 2007, 133 (5): 747-60Kemper, K and Shannon, S “Complementary

and Alternative Therapies to Promote Healthy Moods”, Ped Clinics of NA, Dec 2007, 54 (6): 901-26

Kemper KJ. Mental Health Naturally, 2010 AAP

Lake, J Textbook of Integrative Mental Health Care Thieme Publishing: NY 2007.

Natural Medicines Comprehensive DatabaseNatural StandardConsumerLab

Extra slides

Saint Johns wort

Comparable to sertraline in German RCT of 241 depressed adults (Gastpar. Pharmacopsychiatry, 2005)

2 open label trials in teens showed improvement within 2 weeks in 25/33 and 9/11 patients (Findling, 2003; Simeon, 2005); Improvement in 2 weeks predicts long-term response; if no benefit in 2 weeks, stop

“Current evidence regarding hypericum extracts is inconsistent and confusing”; different products used in different trials, different kinds of patients; in some studies St. Johns wort is as effective as standard medications, and only slightly more effective than placebo. (2005 Cochrane review)

Herb- drug interactions: SJW

Speeds elimination of many drugs: digitalis,

theophylline, clarithromycin,

erythromycin, protease inhibitors and OCPs

SJW safety Other side effects - photosensitivity, serotonergic

syndrome Product variability; see www.consumerlabs.com:

Gaia, Kira, Sundown, Nature’s Bounty Products used in POSITIVE TRIALS: Laif 900

(German STW3-VI); LI160 (Kira), WS5572; WS5570 (Perika by Nature’s Way)

St. Johns wort patient handouts are available from:University of Maryland Medical CenterWake Forest University Baptist Medical Center’s Best Health internet site (www.besthealth.com)

Melatonin Natural hormone Good product reliability (ConsumerLabs

2008 review) May help with sleep in children with ADHD,

seizures, dev delay, jet lag; procedural sedation

Dose 0.3 – 5 mg 1-2 hours before bed

Gupta M, Epilepsy Behav. 2004Gupta M, J Child Neurol. 2005

Schmidt CM, Neuropediatrics. 2007

Van der Heijden KB, J Am Acad Child Adolesc Psychiatry. 2007 McArthur. Dev Med Child Neurol, 1998

Magnesium Needed to convert tryp to serotonin Regulates NMDA (N-methyl-D-aspartic acid)

receptors Alters activity of glutamate, an amino acid involved

in learning and memory Deficiency symptoms incl: constipation, irritability,

fatigue, mental confusion, insomnia, anxiety and easily feeling stressed.

2 + trials on Mg suppls for PMS- related anxiety 3+ studies on Mg for bipolar/mania – stabilizes Spinach, beans, seeds, nuts, whole grains

Magnesium Status

Magnesium deficiency is widespread Over the last 70 years we have witnessed a

dramatic decline in magnesium intake Stress and chronic sleep deprivation deplete total

body stores Fruits and vegetables now have only (65-89%) of

the magnesium content they did in the 1930’s

Meyer, A Historical changes in Mineral Content of Fruits and

Vegetables British Food Journal 1997 99:207-211

Iodine Needed to convert T4 to T3 Can be deficient if little iodized salt or

fish intake World Health Organization (WHO)

statistics indicate that iodine deficiency disorders affect 740 million people throughout the world, and nearly 50 million people suffer from some degree of iodine-deficiency related brain damage (cretinism/MR/low IQ), plus increased risk of anxiety and depression