Healthy Lifestyles to Promote Mental Health

1. Healthy Lifestyles to Promote Mental Health Kathi J. Kemper, MD, FAAP Caryl J Guth Chair for Complementary and Integrative Medicine Wake Forest University School of Medicine

2. “The part cannot be well unless the whole is well.” Plato

3. Faculty Disclosure In the past 12 months, I have had no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity. I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation.

4. Objectives (by the end of this session, you will be able to…): • Compare and contrast mental, physical and spiritual health • Describe the role of a healthy lifestyle in promoting mental health • Advise patients to make healthy lifestyle changes using effective communication skills

5. http://www1.wfubmc.edu/phim/MHN.htm 1. Are Mental Health Problems Really a Problem? 2. What is Mental Health?  3.  Exercise   4.  Sleep   5.  Nutrition   6.  Dietary Supplements Overview   7.  Vitamins   8.  Minerals 9.  Essential Fatty Acids 10. Amino Acids 11. Hormones 12. Probiotics   13. Environment: Promoting Positive Aspects   14. Environment: Protecting Against Negative Aspects Stress Management Overview   15. Stress Management: Emotional Practices   16. Managing Stress: Mental Practices   17. Managing Stress: Spiritual Practices Intro to Communication Skills & Community Building   18. Communication Skills: Talking with Yourself   19. Communication Skills: Talking with Others   20. Building Community to Promote Mental Health More to follow…… Objective 4: Resources

6. Depression Case A 16 year old girl who is sad, has had a drop in grades and been irritable with her family; recently broke up with her boyfriend; less interested in tennis, has stopped taking her SSRI after hearing about black box warnings. How can her lifestyle choices support her mental health?

7. Definitions: Mental Health • Most medical literature on mental health focuses on mental illness, eg. Depression, anxiety, Bipolar, schizophrenia, ADHD, cognition/memory problems, adjustment disorders, personality disorders, etc. • Mental health "First say to yourself what you would be; and then do what you have to do." Epitectus “You got to be careful if you don't know where you're going, because you might not get there.” Yogi Berra

8. Optimal Physical health: Example • Strength • Flexibility • Stamina/Endurance • Focus • Coordination • Resilience, and • Effective teamwork

9. Optimal Spiritual Health • Faith • Forgiveness • Hope • Love • Kindness • Charity/generosity, and • Transcendence – connection with something greater than our individual self

10. Mental Health: elements • Confidence and courage • Adaptability • Cheerfulness • Attention / Concentration • Harmony • Hardiness in face of stress • Social Network/ communication skills/ connection to community

11. Mental Health - strategies • Healthy lifestyle – as for promoting heart health, reproductive health, immune function, etc. • #1 Lifestyle: Exercise/Rest, Nutrition, Environment(+/-), Stress management practices (EMS), Communication and community • #2: Supplements/Meds, Professionals (psychologists, massage, acupuncture, etc)

12. Content: Conventional • Psychotherapy • Medications

13. Cognitive Behavioral Therapy “From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders.” Compton SN. JAm Acad Child Adolesc Psychiatry. 2004

14. SSRI Side effects 1 • GI upset • Headache; sleep disorders • Sexual side effects Dizziness, Fatigue, Sweating • Neonatal withdrawal syndrome • Drug interactions

15. SSRI Side effects 2 • Serotonergic syndrome (HTN, tachycardia, mania) • Agitation and hostility • Suicidal ideation, esp in those with agitation/hostility • Drug co. assertion: our way or deprive patients of treatment. FALSE! Mosholder AD. J Child Adolesc Psychopharmacol. 2006

16. Natural: used commonly • Depression is one of the top 10 diagnoses for which patients seek natural therapies • Commonly used by women • Fewer than 30% of patients tell docs they are using natural therapies or strategies • Clinicians need to ask! • Clinicians need to emphasize the importance of healthy lifestyles for overall physical and mental health

17. Lifestyle - overview • Environment: More Sunshine and music, Less TV and toxins • Exercise/Sleep (more of both) • Nutrition (Essential nutrients for optimal brain function, EFA, amino acids, vitamins, minerals) • Manage stress – emotional, mental, spiritual practices • Communication/Community

18. 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

19. Bright light exposure therapy Cochrane systematic review—all published studies on bright light exposure for non-seasonal depression found “modest though promising anti-depressive efficacy, especially when administered during the first week of treatment, in the morning, and as an adjunctive treatment to sleep deprivation responders (Tuuainen et al., 2004).”

20. Light Therapy for Depression Plus 3 studies not included in this review, comparing dim light to bright light. Golden R. Am J Psychiatry. 2005

21. Light therapy • Proven effective for SAD (Terman M Evid Based Ment Health, 2006) • Meta-analysis of studies from 1987-2001: (effect size=0.53, 95% CI=0.18 to 0.89, similar to medications) for non-SAD • RCT of 29 women with non-seasonal depression; light therapy for 28 days significantly better than control, (McEnany GW, 2005)

22. Light Therapy 2 • Benefits onset within 2 days; effective in institutionalized elderly and community; effective in summer and winter • Side effects: hypomania, autonomic hyperactivation (Terman M, 2005)

23. 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 (none, 400 IU versus 800 IU vitamin D) vitamin D3 significantly enhanced mood (Landsdowne, 1998)

24. More positive environment • Music (avoid ear damage from loud noises) • Nature (Last Child in the Woods) • Aromas (mint, citrus, lavender, vanilla) • More organization; less clutter • Implications for clinic/hospital design; school design; workplace design

25. Turn off Depressing TV • 9/11. 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). • Depressive symptoms after the hurricane were predicted by watching television coverage of the looting that occurred in New Orleans • People who watch more TV socialize less Ahern, Psychiatry, 2002 McLeish. Depress Anx, 2008

26. Other Environmental Toxins to Minimize • Environmental Tobacco Smoke • Pesticides (neurotoxins) • BPA (behavioral as well as endocrine effects) • Lead, mercury, etc. • Perc (dry cleaning) • Air pollution

27. Exercise • Depressed mood / fatigue are common in those deprived of usual exercise. • Mood changes noted in patients with injuries and mono. • Exercise benefits depression * • Common sense precautions Berlin AA. Psychosomatic Med, 2006

28. Exercise as Therapy – Yes Lawlor DA. BMJ 2001

29. Yoga for depression • Five RCTs --each used different forms of yoga. • All trials reported positive findings • No adverse effects except fatigue and breathlessness Pilkington K. J Affective Disord, 2005

30. Sleep • Poor sleep is barometer of depression • Reduced sleep equals impaired focus and labile mood (ADHD, Learning problems) • Sleep quality is a good screen for good mental health • We sleep 20% less than we did 100 yrs ago

31. Sleep Hygiene • Regular time; Routine • Hot bath; cool room; dark room • Massage before bed • Lavender, chamomile, melatonin? • No caffeine within 8 hours of bedtime • Music, calm, orderly, quiet • NO TV IN BEDROOM • NO vigorous exercise right before bed • GET MORE versus intentional sleep reduction/deprivation

32. Nutrition – essential nutrients for optimal brain function • Omega-3 fatty acids • Amino acids (SAM-E, Trp, 5-HTP) • Vitamins (B vitamins, Vitamin D) • Minerals (Iron, Calcium, Magnesium, Zinc)

33. Top Foods (scores > 90/100) Broccoli Green cabbage Oranges Tomato Green Beans Clementine Pineapple Watermelon Radish Mango Summer Squash NF Milk Apple Figs Grapes Bananas Yale’s Griffin Prevention Research Center, 2008

34. Omega-6 Fatty Acids Omega-3 Fatty Acids Linoleic Acid (18:2n-6) a-Linolenic Acid (18:3n-3) ∆-6 Desaturase (GLA)γ -Linolenic Acid (18:3n-6) Stearidonic Acid (18:4n-3) Elongase (DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6) Eicosatetraenoic Acid (20:4n-3) ∆-5 Desaturase Eicosanoids (AA)Arachidonic Acid (20:4n-6) (EPA) Eicosapentaenoic Acid (20:5n-3) Elongase 24:5n-3 Eicosanoids Leukotriene 5-series Prostaglandins E3 Thromboxanes A3 ∆-6 Desaturase Eicosanoids Leukotriene 4-series Prostaglandins E2 Thromboxanes A2 24:6n-3 β-Oxidation (DHA) Docosahexaenoic Acid (22:6n-3)

35. Omega 3 EFA’s: mechanism • Neuronal membrane structure and function • Brain development • Second messenger inside cells

36. 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)

37. Fish Oil –Doses, Safety, Brands • Dose: 1 gram daily of EPA probably enough.(Peet M, 2002); Frangou S. Br J Psychiatry, 2006) • Safety: fish allergies, taste, belching; very high doses, increased risk of bleeding, nosebleeds? Little risk of mercury, dioxin, PCB’s; • Brands: Compare brands at www.consumerlabs.com • My family takes Coromega, Carlson’s or Nordic Natural • Read labels: Omega 3 does NOT necessarily all equal EPA/DHA

38. Amino Acids: real protein • SAM-E Produced from ATP and methionine • Meta-analysis: SAMe significantly improves depression, comparable to antidepressant medications (http://www.ahrq.gov/clinic/epcsums/samesum.htm) • Acute tryp depletion leads to depression • Dietary L-tryp -> 5-HTP -> serotonin • Meta-analysis: 5-HTP and L-trp better than placebo for depression (Shaw K, Cochrane. 2002) • Food sources – dairy, eggs, poultry, meat, soy, tofu, nuts; WHEY protein

39. 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; Odds ratio ~2.(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

40. Folate • Folate (Essential co-factor for synthesis of S-adenosyl-methionine). • Lower levels of folate in depressed persons • Low folate associated with poorer response to antidepressant meds • Methylfolate in depressed pts (elderly, EtOH dependent, dementia) show significant improvement (Guaraldi et al., 1993; Di Palma et al., 1994; Glória et al., 1997; Passeri et al., 1993) • RPCT: folate as adjunctive Rx in folate deficient MDD pts showed signif improvement over placebo (Godfrey et al., 1990) • RPCT MDD pts randomized to fluoxetine + folate (0.5mg) improved more than fluox. + placebo; differences esp striking in WOMEN (Coppen & Bailey 2000) • Studies on supplements in non-folate deficient MDD pts on SSRIs found significant reduction in sx severity and 19% remission (Alpert et al., 2002) • Folate augmentation may enhance response to lithium in folate deficient bipolar and unipolar depression (Coppen and Chaudhry, 1986)

41. Bottom line on Amino acids and B vitamins • Healthy diet rich in green vegetables and nutritious protein sources • Consider B-complex supplement • Consider whey powder (high in tryptophan), SAM-E, Tryp/5-HTP

42. Mood and Minerals: Iron • Iron deficiency associated with depression • Iron deficiency common in women • Correcting iron deficiency helps with mood and attention Beard JL. J Nutr, 2005 LE Murray-Kolb. Am J Clin Nutr, 2007

43. 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

44. Non-dairy sources of calcium • Soy beans, tofu • Calcium fortified OJ • Green leafy vegetables (broccoli)

45. Magnesium • Needed to convert tryp to serotonin • Regulates NMDA (N-methyl-D-aspartic acid) receptors • Alters activity of glutamate, an amino acid involved in learning and memory • Deficiency symptoms incl: constipation, irritability, fatigue, mental confusion, insomnia, anxiety and easily feeling stressed. • 2 + trials on Mg suppls for PMS- related anxiety • 3+ studies on Mg for bipolar/mania – stabilizes • Spinach, beans, seeds, nuts, whole grains

46. Iodine • Needed to convert T4 to T3 • Can be deficient if little iodized salt or fish intake • World Health Organization (WHO) statistics indicate that iodine deficiency disorders affect 740 million people throughout the world, and nearly 50 million people suffer from some degree of iodine-deficiency related brain damage (cretinism/MR/low IQ), plus increased risk of anxiety and depression

47. Nutrition Summary • Healthy fat (omega 3, eg fish, nuts, flax); not fried foods, saturated fats • Healthy protein (essential amino acids) • Foods rich in minerals and vitamins (organic, locally grown vegetables, beans, grains) • Iodized salt • Multivitamin-mineral supplement (extra D) • Fish oil supplement • Consider B vitamins, Calcium, Mg, Iron if deficient

48. Lifestyle: Stress management • Stress is common • Stress commonly triggers mood problems • Managing stress: exercise, sleep, nutrition, mind/emotion/body/spirit • Meditation • Biofeedback

49. Meditation • Meditation training ↑ left-sided anterior activation, a pattern associated with positive affect, in meditators compared with the nonmeditators • Positive effects on anxiety and improves concentration/clarity • Few side effects; can combine mindfulness with CBT Davidson RJ Psychosom Med, 2003

50. Stress, Emotion, and Physiological Activation High Arousal/High Energy SYMPATHETIC Low Arousal/Low Energy PARASYMPATHETIC Institute of HeartMath