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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*.

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the ecology of mental health

The Ecology of Mental Health

scott shannon, md abihm

agenda
Agenda
  • Philosophy
  • Concerns with psychiatry
  • Assessment-Treatment format
  • Depression
  • Anxiety
  • Addictions
what is integrative psychiatry
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
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
Ecological in scope
  • Person as ecosystem
  • Interconnected and interdependent
  • The myth of narrow treatments
  • Precautionary principle
  • Homeostasis and stability
intuitive in style
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
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
Humanistic in approach
  • Caring
  • Respectful
  • Supportive
  • Inspiration and motivation
  • Empowerment as crucial concept
developmental in 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
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
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
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 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
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
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
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 anti psychotics
CATIE Study of Anti-Psychotics
  • 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
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
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
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 medications-increased 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
Anti-Depressants and Depression Severity
  • Meta-analysis of RCTs from 1980 to 2009
  • Effect size for mild to moderate depression : non-significant
  • 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 JAMA2010 303 (1): 47-53

Kirsch, I et al PLoS Med 2008 5(2): 45

publication bias in psychiatry
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
Questions Long-Term Efficacy

Robert Whitaker-Anatomy of an Epidemic 2010

safety efficacy and the patient
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):84-91

depression as a model
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
Depression—Overview
  • What is it? What heals it?
  • Mood disorder spectrum
  • Current treatment trends
  • Vulnerability and resilience
the six realms
The Six Realms
  • Environmental
  • Physical
  • Mental
  • Emotional
  • Social
  • Spiritual
depression holistic assessment
Depression—Holistic Assessment
  • History (also collateral)
  • Physical
  • Mental/Emotional
  • Spiritual
depression history
Depression—History
  • First onset—age, situation
  • Chronicity/severity
  • Response to treatment
  • History of trauma
  • Relational history
  • Specific quality of experience
assessment environmental
Assessment: Environmental
  • Time outside and sunlight
  • Chaotic settings
  • Commute
  • Heavy metals
  • Pesticides
  • Air quality
assessment physical
Assessment: Physical
  • Exercise
  • Energy/vitality/sexuality
  • Appetite/diet/food allergy
  • Weight
  • Sleep (also rule out sleep apnea)
  • Physical illness/symptoms
assessment lab
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
Assessment: Emotional
  • Emotional regulation
  • Affective expression
  • History of trauma
  • Family of origin
assessment mental
Assessment: Mental
  • Recreational/relaxation
  • Work
  • Hobbies
  • Addictions/patterns
  • Creative outlet
assessment social
Assessment: Social
  • Primary relationships
  • Family time/play
  • Family relationships/dynamics
  • Friends-type and variety
  • Community connection
  • Neighbors
assessment spiritual
Assessment: Spiritual
  • Worship/path
  • Prayer
  • Centering
  • Love
depression treatments physical 1 overview
Depression Treatments: Physical–1Overview
  • Exercise
  • Nutrition/oils
  • Herbs and supplements
  • Energy medicine
  • Acupuncture
  • Somatic
  • Pharmacology
  • Hormonal
depression treatments physical 2 aerobic exercise increases bdnf
Depression Treatments: Physical–2Aerobic 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
Depression Treatments: Physical–3Nutrition
  • 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
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
efa and psychosis
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
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
Depression Treatments: Physical–4Herbs 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 sam
Depression Treatments: Physical–5SAMé
  • 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
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
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

LindeK, Berner MM, Kriston L. St John's wort for major depression.Cochrane Database of Systematic Reviews 2008, 4. October

st john s wort risks
St. John’s wort: Risks

Cytochrome P450 effects-

Decreases potency of:

  • BCP
  • cyclosporine
  • digoxin
  • warfarin
  • protease inhibitors
  • Theophyline

Increases potency of:

MAOi, SSRI, Alcohol, triptans, narcotics

st john s wort1
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 sam e
S-adenosyl-l-methionine (SAM-e)

B12 B12

Folate5MTHF + Homocysteine MethionineSAM-e

Methyl DonationDA

SAM-e  5HT

NE

same in depression
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.pdf

depression treatments physical 6 energy medicine
Depression Treatments: Physical–6Energy Medicine
  • Light—10,000 lux, 18 inches, 30 minutes in the a.m. Dawn simulator also helpful
  • Cranial electrical stimulation
  • Negative ions
  • Homeopathy–Cochrane meta- analysis does not support
depression treatment physical acupuncture
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
Depression Treatments: Physical–8Hormonal 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
Depression Treatments: Physical–9Medications
  • SSRIs
  • Buproprion
  • Venlafaxine
  • Stimulants
  • Iatrogenic Cause
  • Other
depression treatments physical 10 somatic
Depression Treatments: Physical—10Somatic
  • Massage/Rolfing
  • Qi Gong
  • Cranial Manipulation (head injury, headaches)
  • Reiki
vitamin d and depression
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 1,25-dihydroxvitamin 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
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
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

treatment
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
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
Depression Treatments: Mental
  • Psychotherapy
  • Recreation
  • Social/Relationships
  • Work
  • Hobbies
  • Education
depression treatments mental therapies
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
Depression Treatments: Spiritual
  • Retreat
  • Spiritual Counseling
  • Dream Work
  • Service
  • Existential Exploration: meaning and life purpose
  • Prayer
  • Love, Joy, Hope
sample protocol depression
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
Anxiety
  • What is it? What heals it?
  • Anxiety Disorder Spectrum
  • Developmental Context
  • Vulnerability and Trauma
anxiety treatments body supplements and herbs
Anxiety Treatments: BodySupplements 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
Anxiety Treatments: PhysicalNutrition
  • No caffeine and low sugar
  • Consider gluten free trial
  • Complex carbohydrates
  • Food allergies
  • Watch additives/nutrasweet
anxiety treatments physical exercise
Anxiety Treatments: PhysicalExercise
  • Walking
  • Swimming
  • Yoga
  • Tai Chi
anxiety treatments physical somatic
Anxiety Treatments: PhysicalSomatic
  • Acupuncture
  • Cranial manipulation
  • Cranial Electrical Stimulation (CES)
  • Massage
  • Hot baths
  • Yoga
cranial electrical stimulation
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
Anxiety Treatments: PhysicalMedications
  • SSRIs – low dose
  • Buspirone
  • Avoid Benzo s beyond 6 wks
  • Beta-blockers
problems with 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
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 messenger-relays info to nucleus
inositol1
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 A-RCT]
inositol and panic
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
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
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
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 theanine1
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
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
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
Anxiety Treatments: Mental
  • Biofeedback
  • Relaxation Training
  • Breath Work
  • Meditation
  • Education
  • EMDR
anxiety treatments spirit
Anxiety Treatments: Spirit
  • Faith vs. Fear
  • Death
  • Ritual
  • Centering
  • Prayer
  • Spiritual Community
sample protocol anxiety
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
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
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
Addictions—Overview
  • Nutrition
  • Acupuncture
  • EEG Biofeedback
  • AA/NA
  • Exercise
addictions nutrition
Addictions: Nutrition
  • High protein
  • Avoid sugar, simple carbohydrates
  • Taper off caffeine
  • EFA = (1-2 gm of EPA/DHA/ daily)
addictions supplements detox period
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
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
Addictions: Summary
  • Coordinated, combined treatment critical
  • Bill W’s three legged stool—Body, Mind, Spirit
  • Support, inspire and confront
sample protocol addictions
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
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

Scott Shannon, MD ABIHM

Wholeness Center

2620 E Prospect Rd. #190

Fort Collins, Colorado 80525

970.221.1106 scott@wholeness.com

www.wholeness.com

micronutrient supplementation in young adult prisoners
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
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 mood1
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
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 health1
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
ReferencesDepression
  • 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
ReferencesMore 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
ReferencesSt. 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
slide118

ReferencesSAMe

  • Bressa, GM, SAMe as Antidepressant: Meta-analysis of Clinical Studies. Acta Neurologica Scand. 1994; 154: 7-14
  • Kagan, BL, et al: Oral SAMe in Depression. Am. J. Psychiatry, 1990; 147: 591-595
slide119

References5–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 Anti-depressants Efficacy and Adverse Effects, J. Clin. Psychopharmacology, 1987 (7), 127-137.
slide120

ReferencesKava–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.
slide121

ReferencesInositol

  • Levine, J., Controlled Trials of Inositol in Psychiatry, European Neuropsychopharmacology, 1997, May; 7 (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 Obsessive-Compulsive Disorder, Am. J. Psychiatry, 1996, Sept.;153(9)
resources
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

resources1
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
Scams
  • Urinary Neurotransmitter Testing
  • MLMs
  • Chelation?
urinary neurotransmitter testing
Urinary Neurotransmitter Testing
  • Aggressively promoted
  • Three major companies
  • Test: urinary metabs: Serotonin, E, NE, Dopamine, Glutamate, Glycine, Taurine, etc
recent ifm debate
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
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
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
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
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
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

summary1
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.”
scams2
Scams
  • Urinary Neurotransmitter Testing
  • MLMs
  • Chelation?