I believe, we can all feel sad, moody or low, at various times. Yet, for some people, the experience of these feelings is intense, often occurring for long periods of time, perhaps days, months or years. Depression is beyond "low mood", it is a serious condition that can affect both physical and mental health. I know for me, that my past depression could influence my desire to socialise, I would withdraw from those around me, and would live with feelings of overwhelm, guilt, frustration and disappointment. I would find it difficult to make decisions, and ruminate on the mantra "I am worthless", Its my fault" and "I have failed". Physically, I would present with headaches, a heavy fatigue and begin a cycle of poor eating habits, and weight gain. While some of these patterns seldom emerge, it is helpful to know that I have developed what I feel is effective resources to support my mental health. I am a big advocate for psychology and counsel, and believe that it plays a significant role in supporting long-term mental health. Access to Counsel and Support Groups can also provide a positive effect. In addition, Medication should not be dismissed. Although, it may not be necessary, for some who experience depression, medication could provide the support needed as the person develops the techniques and strategies imperative to managing their own mental health.
I am constantly searching research evidence to identify what may support a patients experience of depression. Over the last month, I have been creating a template designed to help patients identify whether there is a benefit in utilising a complementary approach to manage their depression (Click on Link Interventions). My search began by looking for research evidence using the key words "Natural Supplements for Mental Health", with the use of Subject Headings including "Alternative Medicine", "Depression" and "Dietary Supplements". The Content Providers included European Journal of Clinical Nutrition and Harvard Mental Health. The search included full articles published between July 2008 to July 9th 2018. 15 results returned as postive.
As you can see from the template created (Click on Link Interventions), Professor Jerome Sarris is a leading expert in the field of Mental Health. Most recently, Sarris (2017) detailed the adjunctive nutraceuticals (nutritional supplements) for use in patients diagnosed with either Unipolar depression (Major Depression, Clinical Depression) or Bipolar Depression. What adjunctive means here, is the use of supplements that could be used in conjunction with antidepressant therapy.
Omega 3 Fatty Acids:
According to Sarris (2017), the use of omega 3 fatty acids delivers a modest effect when used on its own (Monotherapy). Utilised as an adjunctive treatment, it is said to benefit individuals with Major Depression and Bipolar Depression. The key however is the high dose of EPA found in Fish Oil. It is understood that an EPA intake of 1 to 2 grams, used as an adjuvant to antidepressant therapy, may further assist in reducing depression. I would like to point out that in 2003 Marangell et al. made the same recommendation, noting that 1-2 grams of EPA as an ajuvant therapy may have a positive effect on reducing depression scores in patients diagnosed with Unipolar and/or Bipolar Depression. Marangell et al. (2003), also made the recommendation to consume foods rich in EPA such as salmon, sardines, anchovies and cold water fish. How delicious are sardines on sourdough bread with avocado and mayonaisse!
You will also note that the component of Fish Oil known as DHA is not effective as a monotherapy either. However, Smith et al. (2017) did point out that patients with Unipolar and Bipolar Depression do present with lower levels of DHA in red blood cells. Did you know you can actually test for this! The test is called a Red Cell Essential Fatty Acid Profile. The test costs $120.00 through Australian Clinical Labs, and unfortunately, at this time, is not covered by Medicare. As you can see from the study undertaken by Smith et al. (2017), lower dosages of DHA (260 milligrams) used as an adjuvant therapy may influence a positive reduction in depression. However, it is important to note that this could be affected by dependancy on current medication, stage of illness, illness severity, type of depression, age and physical health status. It is also important to point out that if you are to follow this path, get your essential fatty acid red blood cell profile prior to starting supplementation. One more thing, if you smoke, it actually modifies how you metabolise omega 3 fatty acids, meaning the dosage would change. Otherwise, quit smoking! If only that was so easy right!
As you can see, there has been two randomised control trials (RCTs) on N-Acetyl Cysteine (NAC) for Bipolar Depression. One RCT showed a positive effective for Bipolar Depression, however, a second RCT did not prove effective. According to Sarris (2017), there is no current findings to support the use of N-Acetyl Cysteine for Major Depression. Yet in saying this, Deepmala et al. (2015) makes the comment that NAC may still increase the feeling of well-being for patients diagnosed with Major Depression, with well-being defined as an improvement to vitality and reduction in fatigue. Sarris (2017) makes the comment that a dosage of 1 to 1.5 grams is recommended as an adjuvant. Carvalho et al. (2013) points out that two patients diagnosed with Bipolar Disorder, identified as treatment-resistant (one was resistant to the effect of medication another resistant to psychotherapy), showed a benefit in HDRS Depression Scores and CGI-I Scores on administration of 2 grams of NAC, twice daily, after 8 weeks use.
It is understood that S-Adenosyl Methionine (SAMe) helps to metabolise and synthesis, the neurochemicals serotonin, noradrenaline and dopamine. In a earlier analysis undertaken by Alpert et al. (2004) which reviewed 16 studies on the use of SAMe for depression, 6 of 8 studies found the use of SAMe more effective than placebo, when used as a stand alone therapy (monotherapy). However, on assessment of the other 8 studies Alpert et al. (2004) concluded that SAMe was comparable to Antidepressant medications e.g. Tricyclic Antidepressants. Alpert et al. (2004) does point out that SAMe may improve response in some patients who do not benefit from SSRI's or Effexor.
SAMe is capable of reducing the hormone prolactin. There is evidence presented by Gomes et al. (2015) that elevated levels of prolactin in women may exacerbate and heighten anxiety, stress and depression. For this reason, if you are considering SAMe with your health provider and general practitioner assessment for prolactin is key! SAMe is also capable of increasing conversion of phosphatidylcholine. It is understood that an association has been found between low levels of plasma phosphatidylcholine and increased risk for depression.
Oral augmentation, i.e. administration, is considered most safe, with use of SAMe alongside Antidepressant therapy showing increased positive response and remision rates in Antidepressant non-responders (Treatment-Resistant). This means, use of SAMe as an adjuvant therapy was necessary to trigger a positive response from the Antidepressant being administered. Sarris is currently finalising an 800,000AU study on SAMe, which is funded by the National Health and Medical Research Council (NHMRC) to confirm the effect of SAMe as an adjuvant therapy to Antidepressant. Please note that SAMe is to be cautioned in Bipolar Depression due to the potential for increased switching, i.e. moving from a state of hypomania to mania. Speak with your health provider and general practitioner regarding use.
Lifestyle and Depression:
The template outlines a series of lifestyle practices which can benefit or hinder outcomes for Depression. For instance, if you are a daily smoker, you actually increase your risk for developing affective disorders and anxiety disorders. Coupled with changes in how you metabolism healthy fats for brain health, it may be necessary to begin questioning whether you can reduce your intake of nicotine. However, as I said before, easier said then done!
Sarris et al. (2014) also points out that yoga rocks when it comes to Depression as it can quell the ruminating thoughts one will often experience when in Depression. Nevertheless, what I find most interesting is that there is actually only a small clinical effect in favour of exercise i.e. running, walking. Despite this, mindful meditation and breathing techniques do prove effective in reducing some symptoms of depression, and this being said, many a patient has made the comment to me that running and/or walking is their form of meditation!
In short, Sarris and his team suggest that being less busy is healthy for the mind. Find time to relax (reduces self-reported depression), enjoy increased leisure time, even consume a quality coffee daily - unless it affects your sleep! Stop eating unhealthy fats and refined sugars, you know they are not serving you! Again, all this is easier said then done (http://www.markhincheynaturopathy.com/new-evidence/anxiety-and-diet/)
Are There Other Items?
There are, however, the evidence is mixed.
Folic Acid does not work as a monotherapy, however, it may boost a patients response to Antidepressants (20 milligrams of Fluoxetine) (Taylor et al., 2003). Folate works gradually, and culmulatively to relieve depression.
Tryptophan and/or 5HTP:
Tryptophan may be effective as an adjunct therapy, however, no difference was found over placebo in some studies using certain Tricyclic Antidepressants (Sarris, 2017). It is also important to point out that the dosage required to generate an effect is likely to exceed the allowable prescribed dosage in Australia (http://www.markhincheynaturopathy.com/new-evidence/can-tryptophan-manage-your-anxiety/).
Preventative studies using very large doses of Vitamin D have shown no effect (Sarris, 2017).
May work as an adjuvant therapy for Major Depression. Further studies necessary to qualify outcome (Sarris, 2017).
Creatine and DHEA:
Very limited evidence to support use (Sarris, 2017; Schmidt et al., 2005). Cautioned! Assessment for blood levels of DHEA recommended prior to discussion with general practitioner regarding benefit.
I believe addressing depression takes a multifactorial approach, meaning that the combination of lifestyle, conventional medicine, complementary medicine and psychology and counsel is likely to bring about the most effective result. Some people may only require one intervention, others many. The most important thing to consider is what is safe and what works for you!
I really enjoy writing. If this has helped you, or improved your current knowledge, please write a comment. If the article is prompting you to look further into what may best support you in managing Depression please feel free to make an appointment.
Mark Hinchey Naturopathy, MacDonald Jones Stadium, Admin Building, 294 Turton Road, Broadmeadow. Appointments can be made by contacting Mark on 0432234822.