Transcript The Ecology of Mental Health

The Ecology of Mental Health
scott shannon, md abihm
Agenda
Philosophy
Concerns with psychiatry
Assessment-Treatment format
Depression
Anxiety
Addictions
What is Integrative Psychiatry?
It is the ecologically sound
care of the whole person:
body, mind and spirit*.
*mental, emotional, social or spiritual issues
may predominate as presenting complaints
Integrative Psychiatry
Ecological in scope
Intuitive in cognitive style
Scientific in framework
Humanistic in approach to the patient
Developmental in concept
Collaborative in practice
Ecological in scope
Person as ecosystem
Interconnected and interdependent
The myth of narrow treatments
Precautionary principle
Homeostasis and stability
Intuitive in style
Intuition vs Logical thought
Pattern recognition
Non-linear and non-algorithmic
Looking for imbalances
Can’t be forced
Mindfullness and receptivity
Scientific in Framework
Use of evidenced based approaches
Safety vs efficacy
The limitations of RCTs
Commercial bias
Level of Risk should determine
caution
Power of placebo
Humanistic in approach
Caring
Respectful
Supportive
Inspiration and motivation
Empowerment as crucial concept
Developmental in concept
We grow from one cell, we reach an
incredible level of complexity
We are neuro-plastic and ever
changing-the cns rewires as we go
Epigenetics can make change last
Integration as frontal lobe capacity
Nutrition, environment, family
Illness? or deficit of nutrient, skill or
nurturing
Collaborative in practice
The need to listen and listen some
more
Need vs want
Decision making as real partners
Provide choices
“The Empowered Patient”
Psychiatric Disorders
Complex Pattern
Multi-faceted cause
Power of Mind and Spirit
Relational Foundation
Self-correcting Power
Mental/Emotional/Spiritual Homeostasis
Mechanistic Assumptions
in Psychiatry
Complex triggers often ignored
Narrow measures of efficacy and
success
Assumes isolation of effect
Mind has no effect on brain
Treatment is often narrowly focused
Ignores self-correcting capacity
Assumes static/non-plastic CNS
Ignores epigenetics
The Power of Epigenetics
The Human Genome Project has
disappointed
Affected 1 to 2% of psychiatric care at
most
Epigenetic changes from diet, trauma,
environment, can last years to
generations-the Agouti Mice
Swedish farmers and harvest
Challenged Assumptions
Psychiatric illnesses represent fundamental
imbalances of brain biochemistry
Our current psychiatric diagnostic system is valid or
reliable
Over the long term psychiatric medications are safe
and effective treatments
Psychiatric treatments other than
psychopharmacology represent second tier options
Low Reliability
Large meta-analysis
38 studies
16,000 patients
Low correlation between clinical
evaluations and standardized diagnostic
interviews (SDIs)
K value: 0.27 overall (poor)
Rettew, DC et al Int Methods Psych Res 2009, 18:169-184
STEP-BD
Study of Bipolar Relapse
1,469 patients with Bipolar Disorder
48.5% relapse within two years
Depression more common than mania
Lamotrigine better than antidepressants
“Recurrence common and highlights the
need for more treatment options”
Perlis, R, American Journal of Psychiatry 2006, 163:217-24
CATIE Study of AntiPsychotics
Largest and longest study of its kind
Over 1,400 patients with schizophrenia
18 months: Tolerability and Efficacy
Efficacy and Tolerability: poor
74% stopped meds for any reason
Substantial side effects: 64% to 70%
FGA fared as well as Atypicals
Stroup, T and McEvoy, J. American Journal of Psychiatry 2006, 163: 600-622.
STAR*D
Study of Major Depression
Largest US study of Major Depression.
3,671 patients over one year.
No medication better than another.
37% remission after 1 trial, 67% after 4.
Massive drop out rates= 21, 30 and 42%
More than one med= more likely to relapse
“The 67% rate is almost certainly an over
estimate of what would happen in the real
world”
Rush, J, American Journal of Psychiatry 2006, 163:1905-17
Common Themes
Research not sponsored by
pharmaceutical industry
Looks at long term results
Designed to mimic clinical practice
Offers much more pessimistic view of
meds
Humbles us in psychiatry
Is Psychiatry Evidenced
Based?
Does the current clinical practice of psychiatry
follow evidence?
The trend towards polypharmacy grows
13,079 psychiatric visits monitored:1996-2006
Visits with 2 or more psychiatric medicationsincreased from 42% to 60%
Very little evidence to support this
1.2 million children on 2 or more psych meds: even
less evidence
Mojabai, R Arch Gen Psych 2010; 67: 26-36
Anti-Depressants and Depression Severity
Meta-analysis of RCTs from
1980 to 2009
Effect size for mild to
moderate depression : nonsignificant
Separation increases as
depression severity increases
Reaches significance at
HDRS of 25 (very severe=
13% of depressed patients)
Reinforces Kirsch’s prior
articles
Fournier, JC et al JAMA
2010
303 (1): 47-53
Kirsch, I et al PLoS Med 2008
5(2): 45
Kirsch meta-analysis 2008
Publication Bias in Psychiatry
12,564 patients and 74 FDA registered studies
reviewed
31% not published
94% of published trials positive (51% positive by
FDA)
37 positive published, 1 positive not
Vast majority of unpublished: negative
Compared FDA effect size to published: increase
ranged from
11 to 69%,
average distortion
= 32%
Turner, E NEJM 2008, 17;358(3):252-60
Questions Long-Term Efficacy
Robert Whitaker-Anatomy of an Epidemic 2010
Safety, Efficacy and the
Patient
RCTs highlighted as gold standard, highly
scrutinized
Safety appears to be less severely scrutinized
Safety vs Effectiveness: a paradigmatic split---CAM vs Conventional
Patient preference should help to determine
direction
True informed consent rarely provided
Shannon, Weil, Kaplan Alternative and Complementary Therapies 2011,17 (2):8491
Depression as a Model
Ecosystem: Environmental, physical,
emotional, mental, social, or spiritual
triggers
Final common pathway
Lack of core pathophysiology
Very broad assessment needed
Depression—Overview
What is it? What heals it?
Mood disorder spectrum
Current treatment trends
Vulnerability and resilience
The Six Realms
Environmental
Physical
Mental
Emotional
Social
Spiritual
Depression—Holistic
Assessment
History (also collateral)
Physical
Mental/Emotional
Spiritual
Depression—History
First onset—age, situation
Chronicity/severity
Response to treatment
History of trauma
Relational history
Specific quality of experience
Assessment: Environmental
Time outside and sunlight
Chaotic settings
Commute
Heavy metals
Pesticides
Air quality
Assessment: Physical
Exercise
Energy/vitality/sexuality
Appetite/diet/food allergy
Weight
Sleep (also rule out sleep apnea)
Physical illness/symptoms
Assessment: Lab
Thyroid: TSH, T3, T4 (antibodies?)
Adrenal: DHEA-s, cortisol pattern
Blood: CBC/ferritin
GI/dysbiosis and elimination diet
Vitamin D level
Cholesterol
High Sens CRP
Homocysteine/MTHFR
Assessment: Emotional
Emotional regulation
Affective expression
History of trauma
Family of origin
Assessment: Mental
Recreational/relaxation
Work
Hobbies
Addictions/patterns
Creative outlet
Assessment: Social
Primary relationships
Family time/play
Family relationships/dynamics
Friends-type and variety
Community connection
Neighbors
Assessment: Spiritual
Worship/path
Prayer
Centering
Love
Depression Treatments:
Physical–1
Overview
Exercise
Nutrition/oils
Herbs and supplements
Energy medicine
Acupuncture
Somatic
Pharmacology
Hormonal
Depression Treatments:
Physical–2
Aerobic Exercise: increases BDNF
15-20 minutes
4 times per week
Lots of supportive/encouragement
needed
Prescribe it
SMILE study: 10 months later 70%
response vs. 48%. Relapse 8%v38%
Babyak, D
Psychosomatic Medicine 2000
(62): 633-38
Depression Treatments:
Physical–3
Nutrition
High protein
Food allergy concerns
Caffeine free
Low sugar
Omega 3 oils—1,000 mg of EPA/day
minimum (EPA/DHA better than flax)
Food Allergy
Colic or reflux as infant
Eczema
Chronic otitis media; lots of anti-bx
Insomnia
IBS or chronic constipation
Mood issues/irritibility
Narrow food interest
Cookbook from the1940’s
EFA and Psychosis
Randomized, placebo controlled, DB 12 wk
trial
High risk group (sub-threshold psychosis)
13-25 years old-81 patients
1.2 gm/d of omega 3 EFA for 12 weeks
Progression to psychosis monitored over
next 40 wks.
Active: 4.9% vs 27.5% placebo
Amminger, GP et al, Arch Gen Psych 2010 67(2): 146-154
EFA in Pregnancy
Randomized placebo controlled DB trial
EFAs in Pregnancy with MDD
One month washout, 8 week trial
33 subjects (all female)
3.4 grams Omega-3 EFAs
Significantly higher response rate (p=.03) and
lower HAM-D (p=.001)
Su, KP et al, J Clinical Psychiatry, 2008 69(4): 644-51
Depression Treatments:
Physical–4
Herbs and Supplements
St. John’s Wort (0.3%)—600mg a.m./300mg
p.m. (mild to moderate depression)
5-HTP—50-400 mg/day–sedating
Ginkgo Biloba—80-120 mg BID–stimulating
Tonics (Ginseng/Ginger)
B-6 and B-12- (B complex 50mg best)
Depression Treatments:
Physical–5
SAMé
S–adenosyl methionine (crucial methyl
donor)
Enhances methylation in body
Profound, effective and synergistic
antidepressant
Stimulating, works quickly (2 weeks)
Headache, insomnia, nausea
200-800 mg twice daily, start low, give on
empty stomach
Can induce mania
St. John’s wort
Common roadside
plant
Traditional use for
centuries
Few side effects
(headache, nausea,
rash)
Non-fatal in
overdose
Three to four week
onset of action
St John’s wort: Cochrane
29 studies from a variety of countries with
5,489 patients, randomized and double blind.
Major Depression only
Placebo or antidepressants
Superior to placebo in treating patients with
major depression and are "similarly effective"
as standard antidepressants
Linde K, Berner MM, Kriston L. St John's wort for major
depression.
Cochrane Database of
Systematic Reviews 2008, 4. October
St. John’s wort: Risks
Cytochrome P450 effectsDecreases potency of:
BCP
cyclosporine
digoxin
warfarin
protease inhibitors
Theophyline
Increases potency of:
MAOi, SSRI, Alcohol, triptans,
narcotics
St. John’s wort
Safe, effective treatment for
depression (mild to major)
No Black Box warning
Use quality product; 0.3%
hypericins is a general marker
Cost $8–20 per month
BID dosing best: 900mg/day total,
age 8 up
S-adenosyl-l-methionine (SAMe)
B12
B12
Folate5MTHF + Homocysteine
MethionineSAM-e
DA
Methyl Donation
SAM-e

5HT
NE
SAMe in Depression
28 acceptable studies vs either
antidepressants or placebos
Superior to placebo
Comparable or more effective than
antidepressants
Faster (1-2 weeks)
Better tolerated, fewer side effects
AHRQ Reviews:
(www.ahrq.gov/clinic/epcsums/samesum.pd
f
Depression Treatments:
Physical–6
Energy Medicine
Light—10,000 lux, 18 inches, 30
minutes in the a.m. Dawn
simulator also helpful
Cranial electrical stimulation
Negative ions
Homeopathy–Cochrane metaanalysis does not support
Depression Treatment:
Physical–Acupuncture
Electro-stimulation
Meta-analysis: 9 RCTs, 4 good quality
“Odds ratios suggests some evidence
for the utility….General trends suggests
acupuncture as effective as
antidepressants.” Sham looks similar
Leo, R et al J Affective Disorders 2007 (97): 13-22
Depression Treatments:
Physical–8
Hormonal Augmentation
Desiccated thyroid (1-2 grains in the
a.m.)
Cytomel (10-25 mg once or twice daily)
DHEA Check DHEA sulphate blood level
first
Estrogen/Testosterone
Arch Gen Psych. 2005;62:154-162
(90mg and 450 mg of DHEA for 6 weeks)
Depression Treatments:
Physical–9
Medications
SSRIs
Buproprion
Venlafaxine
Stimulants
Iatrogenic Cause
Other
Depression Treatments:
Physical—10
Somatic
Massage/Rolfing
Qi Gong
Cranial Manipulation (head injury,
headaches)
Reiki
Vitamin D and depression
Vitamin D receptors exist in the brain
Low level of serum 25-hydroxyvitamin D and
high PTH are significantly associated with a
high depression score (Jorde, 2005)
25-hydroxyvitamin D3 and 1,25dihydroxvitamin D3 levels are significantly
lower in psychiatric patients than in normal
controls (Schneider, 2000)
Lowest Vit D in fibromyalgia assc with
depression (Armstrong, 2007)
Vitamin D and Mood
RCT of 441 overweight
pts in Norway
Vit D levels less than 40
ng/ml= more depression
Vit D supp with 20k or
40k IU/wk= significant
reduction in BDI over 1
yr
Jorde R et al J Int Medicine 2008,
264(6): 599-609
Sunshine
Vitamin D deficiency is “a pandemic”
Cause: tall buildings, unbanization, obesity,
pollution, cars, sunblock, sun fear
11 million in US with SAD
Vitamin D deficiency found in many illnesses
Vitamin D improves serotonin levels
Levels drop significantly summer to winter
Holick, MF NEJM 2007 Jul 357 (3): 266-81
Veith, R Nutritional Journal 2004 Vol 13: 213-18
Zillerman, A British J Nutrition 2003 Vol 89 (5): 552-72
Light Therapy for Depression
Treatment
Get active and outside, midday best
Temper melanoma hysteria
Measure Vit D levels: 25(OH)D not D3
Target = 50-65 ng/ml not 30
Use Cholecalciferol (D3) not ergocalciferol or
calcitriol
RDA: prob insufficient, should exceed 1,000iu
If mood disorder: Measure level, if low add
3,000
to 6,000 iu/day of D3 and retest in 6 wks.
Gloth, FM J Nutr Health, 1999 3(1):5-7
Treat Depression with
Photons
Not just SAD alone: any depressed mood d/o
Effective for pediatric SAD: RCT
As effective as 20mg of fluoxetine with fewer sides
and faster onset. No blackbox warning
10,000 Lux for 30 to 60 minutes in AM-early
Dawn simulation looks to be as good or better
Avery, DH et al Biol Psych 2001 50(3):205-16
Lam, RW et al Am J Psych 2006 163(5):805-12
Swendo, SE et al JAACAP 1997 36(6): 816-21
Depression Treatments:
Mental
Psychotherapy
Recreation
Social/Relationships
Work
Hobbies
Education
Depression Treatments:
Mental–Therapies
Cognitive–Behavioral
Solution Oriented
DBT (Dialectical Behavior Therapy)
Hakomi, Somatic Experiencing (body oriented)
Meridian Therapies (Energy Psychology-EFT, etc)
Groups
Depression Treatments:
Spiritual
Retreat
Spiritual Counseling
Dream Work
Service
Existential Exploration: meaning and
life purpose
Prayer
Love, Joy, Hope
Sample Protocol-Depression
Vitamin C 1,000 mg
B complex 50 mg with Folate 1 mg
EPA 1-2 grams
SAMe or SJW or SSRI based on pt preference
Inositol 3-6 grams bid
High Protein diet
Exercise
Psychotherapy
Inner work
Sunlight, Vit D (if needed) and nature
Anxiety
What is it? What heals it?
Anxiety Disorder Spectrum
Developmental Context
Vulnerability and Trauma
Anxiety Treatments: Body
Supplements and Herbs
St. John’s Wort (0.3%)—900 mg/day
Calcium/Magnesium glycinate 200-600 mg of
Mag; 600-1,200 mg of Calcium per day
Inositol—2 to 6 grams TID
L-theanine 200-400mg BID
Valerian BID or qhs
Melatonin—0.5 mg qhs
Anxiety Treatments: Physical
Nutrition
No caffeine and low sugar
Consider gluten free trial
Complex carbohydrates
Food allergies
Watch additives/nutrasweet
Anxiety Treatments: Physical
Exercise
Walking
Swimming
Yoga
Tai Chi
Anxiety Treatments: Physical
Somatic
Acupuncture
Cranial manipulation
Cranial Electrical Stimulation (CES)
Massage
Hot baths
Yoga
Cranial Electrical Stimulation
First clinical trail in 1804
Prescription device in US
Approved by FDA and VA
Low level pulsed current between ears
(less than one milliampere)
40 clinical studies: 8 of them quality
Safe and effective for anxiety
Klawansky, S J Nervous Mental Dis, 1995 183 (7): 478-84
Anxiety Treatments: Physical
Medications
SSRIs – low dose
Buspirone
Avoid Benzo s beyond 6 wks
Beta-blockers
Benzos
Problems with Benzos
Meta-analysis: 13 studies
Cognitive decline noted on meds: ALL 12
areas of psychological evaluation
3 mos to 3 yrs AFTER withdrawal:
Significant cognitive decline noted in 5
areas: visual-spatial, attention and
concentration, problem solving, general
IQ, psychomotor speed.
Stewart, S J Clinical Psych 2005, 66: (2): 9-13
Inositol
Part of cell membranes
Found in our food
Isomer of glucose: sugar
alcohol
Needed for proper
functioning of serotonin
CSF of depressed
patients=low inositol
Key second messengerrelays info to nucleus
Inositol
Effective for depression [Evidence level
A-RCT]
Effective for panic [Evidence level A-RCT]
Effective for bulimia [Evidence level B]
Effective for OCD [Evidence level A-RCT]
Not effective for schizophrenia,
Alzheimer’s or ADHD [Evidence level ARCT]
Inositol and Panic
Compared to placebo (sugars)
RCT/cross-over; 21 completed study
6 grams twice daily after washout
Well tolerated
Significant decrease in panics and
phobias
Benjamin, J et al American J Psychiatry 1995 ; 152: 1086
Inositol and OCD
RCT of 15 patients
Placebo vs 18 grams per day
6 weeks each phase
Significant improvement on inositol
Subscale: Compulsions >> Obsessions
SSRI responders did well
Resisters resisted again
Fux, M et al American J Psychiatry 1996; 153: 1219-21
Inositol in Panic
RCT-cross over/random order of 20
pts
Fluvoxamine 150 mg vs. inositol 18
grams
Inositol superior at 4 wks; equal at 9
wks
Inositol had fewer side effects
Palatnick, A et al J Clinical Psychopharmacology 2001 ; 21:
335-39
Inositol: Use
Sweet tasting powder-mix in any
liquid
Well tolerated
Dosing: 1 to 6 grams BID or TID
Excellent sleep aid or stress
moderator
Children love it
L-theanine
L-Theanine
Natural component of tea
Analog of glutamine and glutamate
Increases GABA and dopamine
Promotes alpha waves/non-sedating
Neuroprotective and non-toxic
Dose: 100 to 800 mg/day
Evidence level: +
Haskell, R Biol Psychiatry 2008 77(2): 113-22
Clinical Actions of L-Theanine
Promotes relaxation- described as a calm alert without
sedation
(Ito 1998).
Reduces stress-induced reactions in humans (Kimura
2007).
Heart rate variability: reduced activation of the
sympathetic nervous system (Kimura 2007).
Increased EEG alpha waves, consistent with relaxation
(Ito 1998, Abdou 2006, Gomez-Ramirez 2007).
Enhances attentional functioning in humans
(Gomez-Ramirez 2007).
Improves memory and learning in humans and animal
models.
Trichotillomania
N-acetylcysteine seems to restore
glutamate conc in nucleus accumbens
12 week RCT of 50 people
NAC: 1200 to 2400 mg (vs placebo)
56% much or very much improved vs 16%
(p= .001)
9 weeks to initial improvement
Grant, JE et al Arch Gen Psych 2009; 66 (7): 756-763
Anxiety Treatments: Mental
Biofeedback
Relaxation Training
Breath Work
Meditation
Education
EMDR
Anxiety Treatments: Spirit
Faith vs. Fear
Death
Ritual
Centering
Prayer
Spiritual Community
Sample Protocol-Anxiety
Inositol- 4 to 6 grams bid or tid
5 HTP 50 to 200 mg tid
Relaxation, meditation, walking, yoga,
journaling
Psychotherapy, EMDR if trauma
L-theanine 200 to 400mg bid
No caffeine
If obsessive: NAC 600-1200mg bid
NAC in schizophrenia
RCT of 140 pts-refractory schizophrenia
Average duration of 12 years
NAC- 1,000 mg BID over 6 months
Significant benefit: negative symptoms,
global function, abnormal movements
Other effects: better insight, self-care, social
interaction and mood regulation.
Berk, M et al Biological Psychiatry 2008 ; 64: 361-368.
N-acetylcysteine (NAC)
Precursor of glutathione: most
common and powerful antioxidant in
body
Crucial in detoxification process
Modulates dopamine and glutamate
Multiple positive studies in addiction
RCT (75 pts) in bipolar: + for
depression- 1 gm bid over 6 months
Berk, M Biological Psychiatry 2008 ; 64: 468-475
Addictions—Overview
Nutrition
Acupuncture
EEG Biofeedback
AA/NA
Exercise
Addictions: Nutrition
High protein
Avoid sugar, simple carbohydrates
Taper off caffeine
EFA = (1-2 gm of EPA/DHA/ daily)
Addictions:
Supplements Detox Period
B Complex—50-100 mg of each in a.m. and
p.m.
Vitamin C (ester)—1,000 mg 2 or 3 times a
day
Zinc—20 mg twice daily
Cal/Mag (Citrate)—400/200 mg 3 times a day
Inositol—4 gm two or three times daily
Melatonin—0.5 to 2 mg qhs
Free form amino acids 4 to 6 caps AC TID
Addictions: Acupuncture
Michael Smith, MD–Lincoln Hospital, Bronx
500,000 plus treatments there
4 needles in each ear
NADA protocol, 200 plus facilities
Reduces cravings and recidivism
Hazleton and Hennepin County, MN
Bullock, ML Lancet; 1989 24:1435-1439
Addictions: Summary
Coordinated, combined treatment
critical
Bill W’s three legged stool—Body,
Mind, Spirit
Support, inspire and confront
Sample Protocol-Addictions
Acupuncture
B complex 50 mg in am, Vit C 1,000
TID, Cal/Mag 500/250 TID, 4 to 6 caps
of free form amino acids TID and
Inositol 4 to 6 grams TID
Exercise
High Protein, low sugar, low carb diet
Loose the caffeine
Summary
People are unique and multi-dimensional
Education, support and motivation are
invaluable
Avoid simple solutions and one-dimensional
thinking
Strive for balance and harmony
Embrace the complexity and potential in each
person
Love yourself and those you serve
Scott Shannon, MD ABIHM
Wholeness Center
2620 E Prospect Rd. #190
Fort Collins, Colorado 80525
970.221.1106
[email protected]
www.wholeness.com
Micronutrient Supplementation
in
Young Adult Prisoners
RCT in 231 young offenders
Broad array of minerals, vitamins,
EFA’s
Active group—26.3% fewer rule
violations
Active group—35.1% fewer violent acts
Gesch et al (Oxford), British Journal of Psychiatry, 2002,
181:22-28
Multivitamins and Mood
Placebo controlled trial of 129 adults for one year
Quarterly psychological testing
10x DRI of 9 vitamins
At 12 months hostile subscale significantly
improved
Mood status related to thiamine (B1) riboflavin
(B2) and pyridoxine (B-6)status
The delay in results suggests resolution of chronic
nutritional deficiencies is responsible
(Benton et al, Neuropsychology 32:98-105, 1995)
Multivitamins and Mood
Randomized placebo controlled trial of 80 adults
B vitamins, calcium, magnesium, zinc (12x DRI)
Within 28 days—significantly lower anxiety
Depression scores significantly improved
Perceived stress significantly lower
(Carroll et. al. Psychopharmacology 150:220-225, 2000)
Multivitamins and Mental
Health
8 week placebo controlled trial of 1081 men
Compared mood, cognitive factors: MVI vs.
placebo
Deficiency levels = increased irritability,
nervousness, fear, depression
Significant improvement only in deficient group
(Hesker et. al. Annals NY Academy of Science 669:352-357, 1992)
Multivitamins and Mental
Health
Baseline Vit C deficiency when supplemented = significantly
reduced depression, anxiety and mood lability
Baseline folate deficiency = significantly improved mood
lability, concentration, self-confidence, extroversion and
mood
Conclusion: nutritional status is correlated with
psychological functioning and that even slight deficiencies,
if chronic, can result in clinically significant impairment
(Hesker et. al. Annals NY Academy of Science 669:352-357, 1992)
References
Depression
Apparent fish consumption and the prevalence of major
depression: a cross-national perspective[letter].
Lancet 1998;351:1213.
Essential fatty acids predict metabolites of serotonin and
dopamine in cerebrospinal fluid among healthy control subjects,
and early and late onset alcoholics.
Biol Psychiatry 1998;44:235-42.
A replication study of violent and non-violent subjects: CSF
metabolites of serotonin and dopamine are predicted by plasma
essential fatty acids.
Biol Psychiatry 1998;44:243-9.
References
More on Omega-3 Fatty Acids in
Depression
Low plasma concentrations of DHA predict low CSF levels of
5-hydroxyindolacetic acid.
A marker of brain serotonin turnover
Such low concentrations are strongly associated with
depression and suicide
World Rev Nutr Diet 82:175-86, 1996
References
St. John’s Wort
Shelton, RC and Keller, MB Effectiveness of St. John’s
Wort in Major Depression, JAMA 2001; 285: 1978-86
Linde, K. et al., St. John’s Wort for Depression–Overview
and Meta-analysis, Br.Med. J. 1996; 313: 253-8
Hypericum Depression Trial Study Group: Effects of
Hypericum in Major Depressive Disorder, JAMA 2002;
287: 1807-14
References
SAMe
 Bressa, GM, SAMe as Antidepressant: Meta-analysis of
Clinical Studies. Acta Neurologica Scand. 1994; 154: 714
 Kagan, BL, et al: Oral SAMe in Depression. Am. J.
Psychiatry, 1990; 147: 591-595
References
5–HTP
 Angst, J., et al, The Treatment of Depression with
5–HTP Arch. Psychiatrica Nerv. 1977; 224: 175-186
 Turner, S., Tryptophan and 5—HTP for Depression,
Cochrane Database Syst. Review, 2002 (1):
CD003198
 Burley, WF, et al, 5—HTP: A Review of its Antidepressants Efficacy and Adverse Effects, J. Clin.
Psychopharmacology, 1987 (7), 127-137.
References
Kava–Kava
 Volz, H.P. and Kieser, M. Kava–Kava Extract in Anxiety
Disorders, Pharmacopsychiatry, 1997, Jan.; 30(1): 1-5
 Pittler, M.H. and Ernst, E., Kava Extract for Treating
Anxiety, Cochrane Database Syst. Review, 2003 (1):
CD003383.
 Boerner, R.J. et al, Kava–Kava Extract in Generalized
Anxiety Disorder, Phytomedicine, 2003; (10) 4: 38-49
 Schulze, J. et al, Toxicity of Kava Pyrones,
Phytomedicine, 2003; (10) 4: 68-73.
References
Inositol
 Levine, J., Controlled Trials of Inositol in Psychiatry,
European Neuropsychopharmacology, 1997, May; 7
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(2): 147-155
Palatnik, A. et al, Double-Blind, Controlled, Crossover
Trial of Inositol vs. Fluvoxamine for the Treatment of
Panic Disorder, J. Clinical Psychopharmacology, 2001;
21: 335-339
Gelber, D. et al, Effects of Inositol on Bulimia, Int. J.
Eating Disorders, 2001, April; 29(3): 345-8
Levine, J. et al, Double-Blind, Controlled Trial of
Inositol Treatment of Depression, Am. J. Psychiatry,
1995, May, 152(5): 792-4.
Fux, M. et al, Inositol Treatment of ObsessiveCompulsive Disorder, Am. J. Psychiatry, 1996,
Sept.;153(9)
Resources
Emmons, H., The Chemistry of Joy Simon and Schuster: NYC, 2006
Kemper, K., Mental Health, Naturally AAP: Elk Grove, Il, 2010
Lake, J and Spiegel D Complementary and Alternative Treatments in
Mental Health Care APPI: Washington DC, 2007.
Lake J Textbook of Integrative Mental Health Care Thieme Medical
Publishers: NY, 2007
Larsen, J. Seven Weeks to Sobriety Ballentine Books: NY 1997
Logan, A., The Brain Diet Cumberland House: Nashville TN, 2007
Murray, M., Encyclopedia of Nutritional Supplements, Prima Press: NY
1996
Pizzorno, J. and Murray, M., Encyclopedia of Natural Medicine, Prima
Press: NY 1997
Ratey, J., Spark: Exercise and the Brain Little, Brown: NYC, 2008
Shannon, S., Handbook of Complementary and Alternative Therapies in
Mental Health, Academic Press: San Diego, CA 2002
Zuess, J., The Wisdom of Depression, Harmony Books: NY 1998
Resources
Nordic Naturals (Pro EPA), 1-800-662-2544 ext. 102
www.nordicnaturals.com
Omega Brite (Hi EPA), 1-800-383-2030
www.omegabrite.com
Pharmax (Frutol), 1-425-467-8054
www.pharmaxllc.com
Synergy (EM Powerplus), 1-888-878-3467
www.truehope.com
Scams
Urinary Neurotransmitter Testing
MLMs
Chelation?
Scams
Urinary Neurotransmitter
Testing
Aggressively promoted
Three major companies
Test: urinary metabs: Serotonin, E,
NE, Dopamine, Glutamate, Glycine,
Taurine, etc
Recent IFM Debate
Chip Watkins, MD
FP, Chief Medical Officer, Sanesco
Jay Lombard, MD
Neurologist, Assistant Professor-Cornell
Medical School
Topic: what is the value of UNT testing
Chip Watkins’ points
It is an accurate and reliable test
We are testing a complex system
We should be testing the brain
A variety of studies show changes
with UNT and psychiatric illness
Many people improve with testing
and treatment
Jay Lombard’s Points
No relationship between serotonin in CNS
and urine
5-HIAA research not clear, quite conflicting
biomarker in psychiatry
Not clear what high or low 5-HIAA means
Dopamine extremely complex in CNS
NE has some correlation in urine, but
phenotype is so obvious testing is just not
needed
If you want to test: cortisol males more sense
Other Points
These companies provide conflicting
advice with same data
NIH research: RCT, 84 patients No
difference between depressed patients
and controls: HVA/5-HIAA
These companies sell proprietary
products linked to their testing
Mixed Effect on Excretion
Previous studies (small) gave mixed results
824 healthy individuals
Given doses of up to 2700 mg of 5-HTP
and 17 grams of Tyrosine (up to qid
dosing)
No correl with 5-HTP and urine serotonin
1671 data points: 390=inverse
relationship and 375=no change
Responsive group: 150 to 900 mg
(Cont..)
Tyrosine
Consistent suppression of dopamine with
supplementation across dose range
Majority of both neurotransmitters
synthesized in kidney or gut. (95% or
more from outside brain)
No value to test UNT prior to treatment
Trachte, GJ et al Neuropsychiatric Disease and Treatment 2009:5
227-35
Summary
Patient Response to oral loading: 1/3 up. 1/3
same. 1/3 down
“The uncoupling of NT excretion from the
ingestion of precursors is most likely caused
by the degradation of blood born NT in the
kidney. Most of the serotonin or dopamine
found in the urine is made by the kidney.”
Scams
Urinary Neurotransmitter Testing
MLMs
Chelation?