By: Dr. Hani Hamed Dessoki, M.D. Psychiatry

Associate Prof. Psychiatry

Acting Head, Psychiatry Department

Beni Suef University

Supervisor of Psychiatry Department

El- Fayuom University

2013

Agenda

Introduction

What is CAM?

Essential nutrients for optimal brain function

Herbal remedies and supplements

Mind body connections

االهرام، القعدة 22الخميس جريدة ذى 2011اكتوبر 20هـ   1432من45608 العدد 136السنة

يصيب أصبح الذي والعصبي 450المرضالنفسي . األرض فوقسطح إنسان مليون

الي وصل وحده االكتئاب , 140وان انسان مليون

العالم وصلتفي والخوففقد القلق حاالت أما.. 200الي خائفوقلق انسان مليون

الي أيضا العالم في اإلدمان مليون 130ووصل .. مدمن إنسان

و مليون وجود تؤكد فإنها مصر في األرقام 200أما. االكتئاب عذاب يعاني مصري إنسان ألف

Introduction

 There are more than 70 different types of alternative therapy.

Some are so well known that they are almost mainstream medicines, while others seem so bizarre as still to be on the very fringes of fringe medicine.

Acupuncture, herbal medicine, Homoeopathy,  and Aromatherapy are already practised in several countries.

History of Alternative Medicine

What is CAM?

Complementary modalities (therapies): used in conjunction with conventional medical practice. (Wilkinson, p. 1019)

Alternative Modalities(therapies): used instead of traditional care. (Wilkinson, p.1019)

Important Points

1.Be non-judgmental despite personal opinions

2. Build rapport by showing client respect – if not, he may be afraid to tell about CAM use

3. Understand that C.A.M. can be beneficial, when used correctly

4. Be aware that C.A.M. can be dangerous if it interacts or interferes with conventional treatment

Important Points

5. Be willing to teach the public about the positive and negative information regarding C.A.M.

6. Be aware that use of C.A.M. is popular and increasing and must be included in the history & physical exam.

7. Know that Herbals, in particular, can have significant effect on prescription drugs and body function.

Natural therapies Depression is one of the top 10

diagnoses for which patients seek natural therapies

Commonly used among depressed adolescents

Fewer than 30% of depressed teens tell docs they are using natural therapies

Clinicians need to ask!

Integrative Approach

Lifestyle – Environment, Exercise/Sleep, Nutrition, Mind-Body

Supplements

Massage

Acupuncture

Lifestyle - overview

Environment: More Sunshine, Less TV

Exercise/Sleep (more of both)

Nutrition (Essential nutrients for optimal brain function, EFA, amino acids, vitamins, minerals)

Mind-Body Therapies – manage stress

Sunshine, circadian rhythms and sleep

Desynchronization of internal rhythms plays an important role in the pathophysiology of depression.

Resetting normal circadian rhythms can have antidepressant effects.

“Winter depression was first modeled on regulation of animal behavior by seasonal changes in day length, and led to application of light as the first successful chronobiological treatment in psychiatry.”

Fuchs E. Int Clin Psychopharmacol, 2006

Wirz-Justice A. Int Clin Psychopharmacol. 2006

Light therapy

Proven effective for SAD (Terman M Evid Based Ment Health, 2006).

Benefits onset within 2 days; effective in institutionalized elderly and community; effective in summer and winter

Side effects: hypomania, autonomic hyperactivation

(Terman M, 2005)

Turn off Depressing TVDepressing TV

Respondents who repeatedly saw "people falling or jumping from the towers of the World Trade Center" had higher prevalence of PTSD (17.4%) and depression (14.7%) than those who did not (6.2% and 5.3%, respectively).

Ahern, Psychiatry, 2002

McLeish. Depress Anx, 2008

Nutrition – essential nutrients for optimal brain function

Omega-3 fatty acids

Amino acids (SAM-E)

Vitamins (B vitamins, Vitamin D)

Minerals (Iron, Calcium, Magnesium, Zinc)

Omega-3 fatty acids

Eating a diet rich in omega-3s or taking omega-3 supplements may help ease depression, especially when used in addition to standard depression treatments.

These healthy fats are found in cold-water fish, flaxseed, flax oil, and walnuts.

Omega-6 Fatty Acids Omega-3 Fatty Acids

Linoleic Acid (18:2n-6) a-Linolenic Acid (18:3n-3)

(GLA)γ -Linolenic Acid (18:3n-6)

(DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6)

(AA)Arachidonic Acid (20:4n-6)

Eicosanoids

Leukotriene 4-series

Prostaglandins E2

Thromboxanes A2

Eicosanoids

Stearidonic Acid (18:4n-3)

Eicosatetraenoic Acid (20:4n-3)

(EPA) Eicosapentaenoic Acid (20:5n-3)

24:5n-3

24:6n-3

(DHA) Docosahexaenoic Acid (22:6n-3)

Eicosanoids

Leukotriene 5-series

Prostaglandins E3

Thromboxanes A3

∆-6 Desaturase

Elongase

∆-5 Desaturase

Elongase

∆-6 Desaturase

β-Oxidation

Omega 3 EFA’s: mechanism

Neuronal membrane structure and function

Brain development

Second messenger inside cells

Mood and Omega-3’s

Inverse correlation between fish intake and depression (Hibbeln: Lancet 1998; 351:1213; Crowe: Am J Clin Nutr, 2007)

Effective for bipolar patients (Stoll: Arch. of Gen. Psych. 1999; 56: 407-12)

Effective for major depression (Nemets: Am. J. Psych. 2002: 159 (3) 477-9)

Effective for depression in Children ( Am J Psychiatry 2006;163:1098-0)

S-adenosylmethionine

Pronounced "sammy," this is a synthetic form of a chemical that occurs naturally in the body.

It's not approved by the FDA to treat depression in the United States.

Rather, it's classified as a dietary supplement.

Side effects are usually minimal, but SAMe can trigger mania in people with bipolar disorder.

Amino Acids: SAM-E

Produced from ATP and methionine

Low folate can lead to low levels

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

In an open trial of 30 adults with MDD for whom antidepressant meds ineffective, SAM-E led to significant improvements in 50% and remission in 43% (Alpert, 2004).

Folate

Low levels of folate, a B vitamin, may cause a slowed response to some antidepressants.

Taking folate supplements (folic acid) may be helpful when used in addition to antidepressants.

L- Methylfolate

Deplin (in US)

15mg

Folate supplement

Adjunct therapy in depression

Other indication as adjunct in schizophrenia for negative and cognitive symptoms

Vitamin B6 - pyridoxine

Low levels of pyridoxal phosphate (PLP) are associated with depressive symptoms (Hvas AM 2004)

Dose: 100 – 200 mg daily benefits PMS- depression (Wyatt KM. BMJ, 1999)

Side effects: nausea, vomiting, abd. pain, anorexia, headache, somnolence, lower B12 levels, sensory neuropathy (typically with doses over 1000 mg daily, can occur lower)

Food: Beans, nuts, legumes, fish, meat

Vitamin D and depression

Vitamin D receptors in brain

Low level of serum 25-hydroxyvitamin D and high PTH are significantly associated with depression (Jorde, 2005)

25-hydroxyvitamin D3 and 1,25-dihydroxvitamin D3 levels are significantly lower in psychiatric patients than in normal controls (Schneider, 2000)

RCT of 44 Australian patients ( 400 IU versus 800 IU vitamin D) vitamin D3 significantly enhanced mood (Landsdowne, 1998)

Mood and Minerals: Iron

Iron deficiency associated with depression

Correcting iron deficiency helps with mood and attention

Beard JL. J Nutr, 2005

LE Murray-Kolb. Am J Clin Nutr, 2007

Mood and Minerals: Calcium

Lower levels of calcium in depressed persons

Higher PTH in depressed persons

Estrogen regulates calcium and PTH metabolism; sometimes dysregulates? (Thys-Jacobs S. J Am Coll Nutr, 2000)

Supplementation may benefit women with PMS-related depression (Dickerson LM. Am Fam Physician, 2003)

1000 – 1200 mg daily

Non-dairy sources of calcium

Soy beans, tofu

Calcium fortified OJ

Green leafy vegetables (broccoli)

Chocolate and mood

Insulin inhibits the Insulin inhibits the reuptake of reuptake of norepinephrinenorepinephrine and enhances the blood-enhances the blood-brain transport of brain transport of tryptophan, a tryptophan, a precursor of precursor of serotoninserotonin.

Herbal remedies and supplements

St. John's wort. Known scientifically as Hypericum perforatum, this is an herb that's been used for centuries to treat a variety of ills, including depression.

It's not approved by the FDA to treat depression in the United States.

Rather, it's classified as a dietary supplement. However, it's a popular treatment in Europe for mild or moderate depression.

But, it can interfere with other depression medicines, as well as some drugs used to treat people with heart disease, seizures, cancer and organ transplant.

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.

Herb- drug interactions: SJW

Speeds elimination of many drugs:

digitalis, theophylline,

clarithromycin, erythromycin,

protease inhibitors

Other side effects - photosensitivity, serotonergic syndrome

Lifestyle: Stress management

Stress is common

Stress commonly triggers mood problems

Managing stress: exercise, sleep, nutrition, mind/emotion/body/spirit

– Meditation

– Biofeedback

Stress, Emotion, and Physiological Activation

High Arousal/High Energy

SYMPATHETIC

PARASYMPATHETIC

Low Arousal/Low Energy

Stress, Emotion, and Physiological Activation

High Arousal/High Energy

SYMPATHETIC

PARASYMPATHETIC

Low Arousal/Low Energy

Negative

Emotion

Positive

Emotion

“Fight-or-Flight”

Stress, Emotion, and Physiological Activation

High Arousal/High Energy

SYMPATHETIC

PARASYMPATHETIC

Low Arousal/Low Energy

Negative

Emotion

Positive

Emotion

“Fight-or-Flight”Frustration, Anger, Hostility,

Fear, Worry Anxiety

Judgment, Resentment,

Feeling Overwhelmed, Anguish

Hopelessness, Submission,

Despair, Depression

Burnout, Withdrawal,

Boredom, Apathy

Exhilaration, Passion,

Love, Care,

Joy, Happiness

Kindness, Appreciation

Compassion, Tolerance,Acceptance, Forgiveness

Serenity, Inner Balance,

Reflection, Contentment

Mind-body connections The connection between mind and body has been studied

for centuries.

Complementary and alternative medicine practitioners believe the mind and body must be in harmony for you to stay healthy.

Mind-body techniques that may be tried to ease depression symptoms include:

- Acupuncture - Yoga

- Meditation - Guided imagery

- Massage therapy

Mind-Body Meditation

– Stress relief/ reduce anxiety– Relaxation– Reduced levels of lactic acid– Decreased oxygen consumption– Slowed heart rate– Decreased blood pressure– Improved function of immune system– Reduce pain– Relieve symptoms of psoriasis– Improve health

(References: Ignativicius; Wilkinson)

Relaxation

Relaxation techniques

– To reduce anxiety, tension & emotional tension which can exacerbate pain

Progressive muscle relaxation (PMR)

Promoting sleep

Can be taught in home setting

Guided Imagery – Distraction when confronting pain, discomfort

or fear

– Making decisions and altering behavior

– Caution: not recommended for emotionally unstable or cognitively impaired client

– Helps reduce pain.

– Reduction of nausea & vomiting.

– Decreasing anxiety

– Promoting comfort during cancer treatment

Spiritual

Life force beliefs found in most cultures. (Wilkinson, p 1020)

Faith healing (Wilkinson page 260)

Promote Social Support

Religiosity (participation) helps protect against depression

Participation in extracurricular clubs helps protect teens against depression

Participation in organized athletics is protective

Ongoing volunteer work is protective

Connected people are happier people

Other Movement Therapies

Dance Therapy

Take Home Message

Keep in mind that nutritional and dietary products aren't monitored by the FDA the same way medications are.

You can't always be certain of what you're getting and if it's safe.

Also, be aware that some herbal and dietary supplements can interfere with prescription medications or cause dangerous interactions.

Thoughts…Comments