UNSTUCK: An Integrative Approach to Depression

1. UNSTUCK: An Integrative Approachto Depression James S. Gordon, MD Founder and Director, The Center for Mind-Body Medicine Clinical Professor, Departments of Psychiatry and Family Medicine, Georgetown Medical School Chair, White House Commission on Complementary and Alternative Medicine Policy

2. What is Depression? • A human experience, not a disease • It is often precipitated by loss of a person, a role, a status, and can be a catalyst for a journey toward greater health and wholeness. • A sign of imbalance – physical, emotional, mental, social, spiritual – in one’s life. • The beginning of a journey. A wake up call to the need for change, not the end of a disease process.

3. Soft Belly Begin with Relaxation – antidote to the fight or flight response and to stress which is so intimately connected to depression. • Lee, AL, WO Ogle, RM Sapolsky. Stress and depression: possible links to neuron death in the hippocampus. Bipolar Disord 2002:4(2):117-28 • Sapolsky, RM. Why stress is bad for your brain. Science 1996:273(5276):749-50.

4. The Seven Stages 1. The Call The awareness that we are depressed, and that some kind of change, of journey, is necessary 2. Meeting Guides on the Path Meeting and choosing the men and women who can help, and developing our own inner guidance and wisdom 3. Surrender to Change Allowing and encouraging ourselves to let go of what constrains and freezes us, and to move into the current of life of the Journey Out of Depression

5. The Seven Stages 4. Dealing with Demons Meeting the challenges—self-doubt, loneliness, procrastination, pride, resentment, apprehension, perfectionism, fear with all its faces, guilt, shame, self-pity, and all the others—and finding in them the unique daimon, the genius, of our own meaning, purpose and direction 5. The Dark Night of the Soul Allowing, and inviting, as we move through the despair that may come to any of us, the deepest, life-giving freedom to emerge

6. The Seven Stages 6. Spirituality: The Blessing Experiencing the unity and peace, the love and generosity, the connection to something or someone greater than ourselves, that can transform our lives 7. The Return Learning to live every day joyously, deeply, consciously, with ourselves and others, in the light of what we have experienced and are always learning

7. Awareness of… The limitations of the disease theory of depression • Valenstein E. Blaming the brain: the truth about drugs and mental health. New York: Free Press. 1998. • Sadock BJ, VA Sadock, HI Kaplan. Kaplan & Sadock’s comprehensive textbook of psychiatry. 8th ed. Philadelphia: Lippincott Williams & Wilkins. 2005. Lacasse JR, J Leo. Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med 2005;2(12):e392. • Roggenbach J, B Muller-Oerlinghausen, L Franke. Suicidality, impulsivity, and aggression – is there a link to 5HIAA concentration in the cerebrospinal fluid? Psychiatry Res 2002;113(1-2):193-206.

8. Awareness of… 2) The dangers of antidepressants • Montejo-Gonzalez AL, et al. SSRI-induced sexual dysfunction: fluoxetine, paroxetine, srtraline, and fluvoxamine in a prospective, multicenter, and descriptive clinical study of 344 patients. J Sex Marital Ther 1997;23(3):176-94. • Hansen L. Fluoxetine dose-increment related akathisia in depression: implications for clinical care, recognition, and management of selective serotonin reuptake inhibitor-induced akathisia. J Psychopharmacol 2003;17(4):451-52. • Black K, et al. Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria. J Psychiatry Neurosci 2000;25(3):255-61.

9. Awareness of… 3) The limited effectiveness of drugs • Moncrieff, J. and I. Kirsch, Efficacy of antidepressants in adults. BMJ, 2005. 331(7509): p. 155-7. • Kirsch I, JT Moore, A Scoboria, SS Nicholls. The emperor’s new drugs: an analysis of antidepressant medication data submitted to the US Food and Drug Administration. Prevention and Treatment 5 (Article 23). 2002; http://www.journals.apa.org/prevention/volume5/pre0050023a.html. • Khan, A., H.A. Warner, and W.A. Brown, Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: an analysis of the Food and Drug Administration database. Arch Gen Psychiatry, 2000. 57(4): p. 311-7. • Turner EH, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008;358(3):252-60

10. Hope Hope for the possibility of change is central to the Unstuck approach. • Beecher, HK. The powerful placebo. JAMA 1955:159(17):375-91. • Roberts, A, et al. The power of nonspecific effects in healing: implications for psychosocial and biological treatments. Clin Psychol Rev 1993:13:375-91. • Walsh, BT, et al. Placebo response in studies of major depression: variable, substantial, and growing. JAMA 2002:287(14):1840-47.

11. Hope Placebo Response Placebo – “I shall please” in Latin, a medical way of describing hope as well as faith. Placebo is powerful medicine. We need always to use it. It can be 35-70% as effective as an active, proven intervention. • Beecher, HK. The powerful placebo. JAMA 1955:159(17):375-91. • Roberts, A, et al. The power of nonspecific effects in healing: implications for psychosocial and biological treatments. Clin Psychol Rev 1993:13:375-91. • Walsh, BT, et al. Placebo response in studies of major depression: variable, substantial, and growing. JAMA 2002:287(14):1840-47.

12. Neuroplasticity Our brains, contrary to long term teaching, have the capacity to grow and change anatomically as well as physiologically. • Eriksson, PS, et al. Neurogenesis in the adult human hippocampus. Nat Med 1998:4(11):1313-17. • Kandel, E. A new intellectual framework for psychiatry. Am J Psychiatry 1998:155:457-69.

13. Neuroplasticity Natural, non-pharmacological techniques including psychotherapy, meditation, and exercise can produce these positive changes. • Martin, SD, et al. Brain blood flow changes in depressed patients treated with interpersonal psychotherapy or venlafaxine hydrochloride: preliminary findings. Arch Gen Psychiatry 2001:54(7):641-48. • Goldapple, K, et al. Modulation of cortical-limbic pathways in major depression: treatment –specific effects of cognitive behavior therapy. Arch Gen Psychiatry 2004:61(1):34-41. Rhodes, J.S., et al., Exercise increases hippocampal neurogenesis to high levels but does not improve spatial learning in mice bred for increased voluntary wheel running. Behav Neurosci, 2003. 117(5): p. 1006-16. • van Praag, H., G. Kempermann, and F.H. Gage, Running increases cell proliferation and neurogenesis in the adult mouse dentate gyrus. Nat Neurosci, 1999. 2(3): p. 266-70. • van Praag, H., et al., Exercise enhances learning and hippocampal neurogenesis in aged mice. J Neurosci, 2005. 25(38): p. 8680-5. • Lazar, S.W., et al., Meditation experience is associated with increased cortical thickness. Neuroreport, 2005. 16(17): p. 1893-7.

14. The Call The First Note Becoming aware of your depression and of the need for change. Following is the CES-D scale. Use it as an aid to becoming more aware of what you’re thinking and feeling. It’s a mirror, and it clarifies the first note of the Call. If you’re unsure of an answer, don’t linger too long. Just circle what seems most correct and move on. The scoring scale follows the test, but don’t look at it until you’re finished. If you score in the range of “clinical concern,” pay attention. Even if you don’t score in that range, notice your answers. What areas and issues do they suggest that you need to work on? Remember, this is just a diagnostic tool. It’s for your use. It provides useful hints and a starting place. It is not an endpoint. • Radloff, L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psych Meas 1997:1(3):385-401.

15. The First Note CES- Depression Scale Begin, using the scale below, by circling the number before each statement which best describes how you felt or behaved DURING THE PAST WEEK 0 = Rarely or none (less than 1 day) 2 = Occasionally or moderate (3-4 days) 1 = Some or a little (1-2 days) 3 = Most or all of the time (5-7 days) 0 1 2 3 I was bothered by things that usually don't bother me. 0 1 2 3 I did nor feel like eating; my appetite was poor. 0 1 2 3 I felt that I could not shake off the blues even with help from my family/friends. 0 1 2 3 I felt that I was just as good as other people (Reverse Score). 0 1 2 3 I had trouble keeping my mind on what I was doing. 0 1 2 3 I felt depressed.

16. The First Note CES- Depression Scale 0 1 2 3 I felt that everything I did was an effort. 0 1 2 3 I felt hopeful about the future (Reverse Score). 0 1 2 3 I thought my life bad been a failure. 0 1 2 3 I felt fearful. 0 1 2 3 My sleep was restless. 0 1 2 3 I was happy (Reverse Score). 0 1 2 3 I talked less than usual. 0 1 2 3 I felt lonely. 0 1 2 3 People were unfriendly. 0 1 2 3 I enjoyed life (Reverse Score). 0 1 2 3 I had crying spells. 0 1 2 3 I felt sad. 0 1 2 3 I felt that people dislike me. 0 1 2 3 I could not get "going." 0 = Rarely or none (less than 1 day) 2 = Occasionally or moderate (3-4 days) 1 = Some or a little (1-2 days) 3 = Most or all of the time (5-7 days)

17. The First Note CES- Depression Scale Scoring: Add up all the circled numbers (Questions 4, 8, 12 and 16 are reverse scored, meaning that a response of 3 is scored as a 0 and a response of 0 as 3; similarly, a 1 response is scored as a 2 and a 2 response as 1). The interpretation of your scoring varies depending on your age and culture. In general, however, if your score is between 10-15 you may be mildly depressed. A score of 16-25 suggests moderate depression and scores over 25 indicate that, at least right now, you may be significantly depressed.Remember, however, that these questions and scores are simply a way for you to take stock of how you’re feeling right now. They are not set in concrete, and they definitely don’t mean you have a disease. You may want to use the CES-D every few months, to see how your worldview and the way you’re feeling changes. Keep the results if you’d like. They can help you see how you’ve changed and show you some of the challenges you still have to meet.

18. The Call The Second Note It’s time to act. Taking the steps to prepare for change. Answer the following questions: What’s going on right now? Where do I want to be headed? What changes are necessary? What are my first steps for getting where I’m going?

19. A Journal for Your Journey Self-expression decreases stress. Your journal is your friend and companion. Write every day. • Pennebaker JW, JK Kiecolt-Glaser, R Glaser. Disclosure of traumas and immune function: health implications for psychotherapy. J Consult Clin Psychol, 1988;56(2):239-45. • Hemenover SH. The good, the bad, and the healthy: impacts of emotional disclosure of trauma on resilient self-concept and psychological distress. Pers Soc Psychol Bull 2003;29(10):1236-44. • Smyth JM, et al. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial. JAMA 1999;281(14):1304-9.

20. Physical Causes of Depression Depression is not a disease, but disease, and drugs, can cause or contribute to depression. Rule out obvious physical illnesses and drug effects (side effects), and then address more subtle biological imbalances.

21. Physical Causes of Depression Prescription Drugs Prescription Drugs that May Cause or Contribute to Depression

22. Physical Causes of Depression Medical Conditions May Give Rise To, and/or Be Accompanied By, Depression

23. Physical Causes of Depression Medical Conditions May Give Rise To, and/or Be Accompanied By, Depression

24. Physical Causes of Depression More Subtle, Often Missed Subclinical Hypothyroidism Sometimes with normal thyroid levels and only slightly elevated or normal TSH. Rx: Thyroid supplementation. • Cooper, DS. Clinical practice. Subclinical hypothyroidism. N Engl J Med. 2001:345(4):260-65. • Haggerty, JJ Jr, RA Stern, GA Mason, J Beckwith, et al. Subclinical hypothyroidism: a modifiable risk factor for depression? Am J Psychiatry 1993:150(3):508-10. • Monzani, F, P DelGuerra, N Caraccio, CA Pruneti, E Pucci, et al. Subclinical hypothyroidism: neurobehavioral features and beneficial effect of L-thyroxine treatment. Clin Investig 1993:71(5):367-71.

25. More Subtle, Often Missed Heavy Metal Toxicity A subject of maximum controversy. Look for it if any possibility of exposure (dental assistance) and/or if all else in the Unstuck approach is not working. Rx: Detoxification, Chelation • Cordeiro, Q., Jr., M. de Araujo Medrado Faria, and R. Fraguas, Jr., Depression, insomnia, and memory loss in a patient with chronic intoxication by inorganic mercury. J Neuropsychiatry Clin Neurosci, 2003. 15(4): p. 457-8. • Powell, T.J., Chronic neurobehavioural effects of mercury poisoning on a group of Zulu chemical workers. Brain Inj, 2000. 14(9): p. 797-814. • Otto D, Y Xia, Y Li, K Wu, L He, J Telech, et al. Neurosensory effects of chronic human exposure to arsenic associated with body burden and environmental measures. Hum Exp Toxicol 207;26(3):169-77. • Schlegel-Zawadzka M, A Zieba, D Dudek, J Zak-Knapik, G Nowak. Is serum copper a “trait marker” of unipolar depression? A preliminary clinical study. Pol J Pharmacol 1999;51(6):535-38.

26. More Subtle, Often Missed SIBO – Small Intestinal Bowel Overgrowth High toxic bacteria - Low lactobacillus, bifidobacterium Often accompanies stress. Rx: Replace lactobacillus and bifidobacterium (2-3 billion/capsule; 1 per day). • Holdeman, LV, IJ Good, WE Moore. Human fecal flora: variation in bacterial composition within individuals and a possible effect of emotional stress. Appl Environ Microbol 1976:31(3):359-75. • Lizko, NN. Stress and intestinal microflora. Nahrung 1987:31(5-6):443-47. • Moore, WE, EP Cato, LV Holdeman. Some current concepts in intestinal bacteriology. Am J Clin Nutr 1978:31 suppl.:S33-42. • Gruenwald, J, HJ Graubaum, A Harde. Effect of a probiotic multivitamin compound on stress and exhaustion. Adv Ther 2002:19(3):141-50. • Pimentel ME, J Chow, HC Lin. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol 2000:95(12):3503-506.

27. More Subtle, Often Missed SAD – Seasonal Affective Disorder Fairly common Rx: May be remedied by using full spectrum light (10,000 lux; 30 minutes in the morning) • Magnusson, A, H Kristbjarnarson. Treatment of seasonal affective disorder with high-intensity light: a phototherapy study with an Icelandic group of patients. J Affect Disord 1991:21(2):141-47. • Terman, JS, et al. Efficacy of brief, intense light exposure for treatment of winter depression. Psychopharmacol Bull 1990:26(1):3-11. • Terman, M, JS Terman, DC Ross. A controlled trial of timed bright light and negative air ionization for treatment of winter depression. Arch Gen Psychiatry 1998:55(10):875-82.

28. More Subtle, Often Missed Non-Seasonal Light-Related Depression Consider this possibility No harm in treatment, possible significant benefit • Prasko, J, et al. Bright light therapy and/or imipramine for inpatients with recurrent non-seasonal depression. Neuro Endocrinol Lett 2002:23(2):109-13. • Martiny, K, et al. Adjunctive bright light in non-seasonal major depression: results from patient-reported symptom and well-being scales. Acta Psychiatr Scand 2005:111(6):453-59. • Yamada, N, et al. Clinical and chronobiological effects of light therapy on nonseasonal affective disorders. Biol Psychiatry 1995:37(12):866-73.

29. Healthier Body, Happier Mind Guide to Mood Healthy Eating Eat whole foods, organic if possible, raw often • Westover, A.N. and L.B. Marangell, A cross-national relationship between sugar consumption and major depression? Depress Anxiety, 2002. 16(3): p. 118-20. • Lien, L., et al., Consumption of soft drinks and hyperactivity, mental distress, and conduct problems among adolescents in Oslo, Norway. Am J Public Health, 2006. 96(10): p. 1815-20.

30. Guide to Mood Healthy Eating Carbohydrates Decrease sugar and high glycemic index carbohydrates and focus on the complex carbohydrates – vegetables, whole grains • Westover, A.N. and L.B. Marangell, A cross-national relationship between sugar consumption and major depression? Depress Anxiety, 2002. 16(3): p. 118-20. • Lien, L., et al., Consumption of soft drinks and hyperactivity, mental distress, and conduct problems among adolescents in Oslo, Norway. Am J Public Health, 2006. 96(10): p. 1815-20.

31. Guide to Mood Healthy Eating Fats No trans fats Less animal fat, more from plant oils from such sources as extra virgin olive oil PGE 1 and PGE3 may improve mood, PGE2 in red meat may lower it • Norden M. Beyond Prozac: Brain-Toxic Lifestyles, Natural Antidotes & New Generation Antidepressants. 1995. Harper Collins. 258p. • Lieb J, R Karmali, D Horrobin. Elevated levels of prostaglandin E2 and thromboxane B2 in depression. Prostaglandins Leukot Med 1983;10(4):361-67. • Nishino S, R Ueno, K Ohishi, T Sakai, O Hayaishi. Salivary prostaglandin concentrations: possible state indicators for major depression. Am J Psychiatry. 1989;146(3):365-68. • Ohishi K, R Ueno, S Nishino, T Sakai, O Hayaishi. Increased level of salivary prostaglandins in patients with major depression. Biol Psychiatry 1988;23(4):326-34.

32. Guide to Mood Healthy Eating Protein Protein should come mostly from plants, but also from deep water fish (salmon, halibut, mackerel)

33. Guide to Mood Healthy Eating Fiber Constipation is a symptom of depression. Eat enough fiber. Increase from 15gm a day that is our average to the 100gm a day our ancestors consumed. We need both soluble and insoluble fiber.

34. Guide to Mood Healthy Eating Soluble Fiber Soluble fiber (pectin) is present in oatmeal as oatbran, nuts, seeds, beans, and fruit. Soluble fiber slows sugar metabolism, increases growth of beneficial bacteria.

35. Guide to Mood Healthy Eating Insoluble Fiber Insoluble fiber (cellulose) is present in whole grains and bran, as well as in lentils and beans and many vegetables (carrots, zucchini, cucumbers, etc). Insoluble fiber promotes bowel regularity; removes cholesterol, hormones, and toxins from gut.

36. Guide to Mood Healthy Eating Water Drink more (filtered or spring). Approximately 3 quarts per day including 2 12 ounce glasses first thing in the morning to stimulate the gastrocolic reflex, improve bowel movement.

37. Food Sensitivity Non IgE mediated, probably by IgG Reactions of tissues in the body to proteins that cross the intestinal wall to enter the blood stream. Many symptoms including depression. • Isolauri, E, S Rautava, M Kalliomaki. Food allergy in irritable bowel syndrome: new facts and old fallacies. Gut 2004:53(10)1391-93. • Sampson, HA. Food allergy. J Allergy Clin Immunol 2003:111(2):540-47. • Atkinson, W, TA Sheldon, N Shaath, PJ Whorwell. Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial. Gut 2004:53(10):1459-64.

38. Elimination Diet Creating Your Own Elimination Diet For three weeks, eliminate foods that are the main part of many modern American diets and that clinicians have found to be the most obvious and consistent causes of food sensitivity: milk, wheat, sugar, corn, soy, and citrus. Eat a diet of whole foods, preferably organic, and preferably without red meat. And drink plenty of water. During the first few days, as you “withdraw” from the food(s) to which you are sensitive, you may feel worse – and even more depressed. This is unpleasant, but it may actually be a good sign, a confirmation of a food sensitivity. In a few more days, these symptoms should subside, and you’ll likely feel much better.

39. Creating Your Own Elimination Diet Keep a diary and each day record the answers to the following questions: How do you feel? What do you crave? What’s the relationship between the time you ate, what you ate, and how you feel? Are you less, or more, depressed on this elimination diet, more energetic or better able to concentrate? What about other symptoms? Does any of this change over time? Then, after three weeks, reintroduce the foods that you’ve eliminated, one at a time. See, for example, how you feel after a meal of conventional wheat pasta (with olive oil rather than cheese or butter). What is it like the next day? Is your mood unchanged or worse? Are you more fatigued? Is your digestion affected? You may want to record the answers in your journal.

40. Creating Your Own Elimination Diet Then, a week or two later, experiment with another of the eliminated foods, perhaps milk (or cheese) and so on. If you are truly sensitive to a food, eliminating it should, after several weeks, improve your symptoms, and reintroducing it should reproduce some of the original symptoms.

41. Supplementation Most Americans are deficient in one or more essential nutrients. Many nutrient deficiencies may cause or contribute to depression including: • http://www.health.gov/dietaryguidelines/dga2005/report/. • http://www.who.int/nutrition/databases/micronutrients/en/index.html

42. Supplementation • Thiamine • Folic Acid • Pyridoxine (B6) • Brozek, J. Psychological effects of thiamine restriction and deprivation in normal young men. Am. J. Clin. Nutr 1957: 5:109–18. • Gilbody, S, T Lightfoot, and T Sheldon. Is low folate a risk factor for depression? A meta-analysis and exploration of heterogeneity. J Epidemiol Community Health 2007:61(7):631-7. • Young SN. Folate and depression—a neglected problem. J Psychiatry Neurosci 2007;32:80-2. • Tiemeier, H, et al., Vitamin B12, folate, and homocysteine in depression: the Rotterdam Study. Am J Psychiatry 2002: 159(12): 2099-101. • Dimopoulos N, Piperi C, Salonicioti A, et al. Correlation of folate, vitamin B12 and homocysteine plasma levels with depression in an elderly Greek population. Clin Biochem 2007;46:604-8. • Hvas, AM, et al., Vitamin B6 level is associated with symptoms of depression. Psychother Psychosom 2004:73(6):340-3.

43. Supplementation • B12 • Vitamin C • Magnesium • Tiemeier, H, et al., Vitamin B12, folate, and homocysteine in depression: the Rotterdam Study. Am J Psychiatry 2002: 159(12): 2099-101. • Dimopoulos N, Piperi C, Salonicioti A, et al. Correlation of folate, vitamin B12 and homocysteine plasma levels with depression in an elderly Greek population. Clin Biochem 2007;46:604-8. • Kinsman, RA, J Hood. Some behavioral effects of ascorbic acid deficiency. Am J Clin Nutr, 1971:24(4):455-64. • Rasmussen, HH, PB Mortensen, IW Jensen. Depression and magnesium deficiency. Int J Psychiatry Med 1989:19(1):57-63. • Eby, GA, KL Eby. Rapid recovery from major depression using magnesium treatment. Med Hypotheses 2006:67(2):362-70.

44. Supplementation • Zinc • Selenium • Chromium • Maes, M, et al., Lower serum zinc in major depression in relation to changes in serum acute phase proteins. J Affect Disord 1999:56(2-3):189-94. • Maes, M, et al., Hypozincemia in depression. J Affect Disord 1994:31(2):135-40. • Benton, D. Selenium intake, mood and other aspects of psychological functioning. Nutr Neurosci 2002:5(6):363-74. • Benton, D, R Cook. The impact of selenium supplementation on mood. Biol Psychiatry 1991:29(11):1092-8. • McLeod, MN, RN Golden. Chromium treatment of depression. Int J Neuropsychopharmacol 2000:3(4):311-314. • Davidson, JR, et al., Effectiveness of chromium in atypical depression: a placebo-controlled trial. Biol Psychiatry 2003:53(3):261-4. • http://www.health.gov/dietaryguidelines/dga2005/report/. • http://www.who.int/nutrition/databases/micronutrients/en/index.html

45. Supplementation Omega-3 Fatty Acids deficiencies are correlated with depression in epidemiological studies. • Sanchez-Villegas, A., et al., Long chain omega-3 fatty acids intake, fish consumption and mental disorders in the SUN cohort study. Eur J Nutr, 2007. 46(6): p. 337-46. • Tanskanan A, JR Hibbeln, J Tuomilehto, A Uutela, A Haukkala, et al. Fish consumption and depressive symptoms in the general population in Finland. Pschiatr Serv 2001;52(4):529-31.

46. Supplementation Supplementation with Omega-3s improves mood in both major depression and bipolar disorder. • Stoll, A.L., et al., Omega 3 fatty acids in bipolar disorder: a preliminary double-blind, placebo-controlled trial. Arch Gen Psychiatry, 1999. 56(5): p. 407-12. • Lin, P.Y. and K.P. Su, A meta-analytic review of double-blind, placebo-controlled trials of antidepressant efficacy of omega-3 fatty acids. J Clin Psychiatry, 2007. 68(7): p. 1056-61. • Logan, A.C., Omega-3 fatty acids and major depression: a primer for the mental health professional. Lipids Health Dis, 2004. 3: p. 25.

47. Supplementation Mood Healthy Daily Doses Vitamins Vitamin A (retinol) 5,000 IU Vitamin A (from beta-carotene) 5,000-10,000 IU Vitamin D 100-300 IU Vitamin E (d-alpha tocopherol) 200-400 IU Vitamin K (phytonadione) 60-90 mg Vitamin C (ascorbic acid) 500-2,000 mg Vitamin B1 (thiamine) 15-50 mg Vitamin B2 (riboflavin) 10-50 mg Niacin 20-60 mg

48. Supplementation Mood Healthy Daily Doses Vitamins Niacinamide 10-30 mg Vitamin B6 (pyridoxine) 50-100 mg Biotin 100-300 mcg Pantothenic acid 200-500 mg Folic acid 400-1200 mcg Vitamin B12 200-800 mcg Choline 150-500 mg Inositol 150-500 mg

49. Supplementation Mood Healthy Daily Doses Magnesium 250-750 mg Manganese 5-10 mg Molybdenum 10-25 mcg Potassium 200-500 mg Selenium 100-200 mcg Zinc 15-30 mg Minerals Boron 1-2 mg Calcium 500-1,500 mg Chromium 200-400 mcg Copper 1-3 mg Iodine 50-150 mcg Omega-3 Fatty Acids (at least one half as EPA and DHA) 3000 mg

50. Guides on the Journey The power of human help “Unconditional Positive Regard” Finding a Guide Discovering our own Inner Guide