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Beating the Blues, Naturally

Beating the Blues, Naturally. Kathi J Kemper, MD, MPH Wake Forest University. Disclaimer. I have the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity:

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Beating the Blues, Naturally

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  1. Beating the Blues, Naturally Kathi J Kemper, MD, MPH Wake Forest University

  2. Disclaimer • I have the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity:         American Academy of Pediatrics, “Mental Health, Naturally “ Author. Royalties anticipated. • The presentation will include no description of any proprietary items for screening, diagnosis, or treatments. • I do not intend to discuss an unapproved or investigative use of a commercial product in my presentation.

  3. Objectives • By the end of this session, participants will be able to • Describe the role of healthy habits and a healthy habitat in preventing and treating depression • Evaluate the evidence for the safety and effectiveness of vitamins, minerals, amino acids, omega-3 fatty acids, and herbs in promoting optimal moods • Use evidence based resources about natural therapies to promote positive moods

  4. Definitions: Mental Health • Most of medicine focuses on mental illness, eg. Depression, (Triage, Test, Diagnose, Dispense care) • Mental health – identify goals, then strategies; barriers and resources; pros and cons; BE SMART (specific, measurable, achievable, relevant, time-specific) behaviors, “You got to be careful if you don't know where you're going, because you might not get there.” Yogi Berra

  5. Is mental health more than absence of depression? Parallels between physical, mental, and spiritual health

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

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

  8. Mental Health: ideals • Confidence and courage • Adaptability • Cheerfulness • Attention / Focus • Harmony • Hardiness in face of stress • Social Network/ communication skills/ connection to community • Clarity, insight, discernment

  9. Physical: Stamina Spiritual: Hope Mental:Cheerfulness Parallels

  10. What are five fundamentals of a healthy lifestyle that promotes cheerfulness?

  11. Fundamentals – 4H; 5F Relationships Food Fitness Manage Stress Environment

  12. What does good mental health have to do with basketball andsymphonies? • Practice, practice, practice the fundamentals daily; don’t wait for the big game or concert (crisis) • Warm-up/prepare for stress • Seek a good role model and coach/guide/teacher

  13. Mental health coach: CBT; DBT “From an evidence-based perspective, cognitive-behavioral therapy is the treatment of choice for anxiety and depressive disorders.” Compton SN. JAm Acad Child Adolesc Psychiatry. 2004

  14. 5. Healthy Habitat (Fields) • More:Light, music, nature (Richard Louv, Last Child in the Woods – Nature Deficit Disorder); organization • Less: TV, toxins, tobacco, violence, discrimination

  15. Light and music therapies • Proven effective for SAD (Terman M Evid Based Ment Health, 2006) • Meta-analysis of studies: (effect sizesimilar to medications) for depression (Golden RN. Am J Psychiatry, 2005) • Music therapy is effective even for severe mental disorders – dose effect response (Gold C. Clin Psychol Rev, 2009)

  16. Vitamin D and depression • Vitamin D receptors in brain • Low level of serum 25-OH D significantly associated with depression (Jorde, 2005) • Vitamin D significantly lower in psychiatric patients than controls (Schneider, 2000) • RdbCT of 20-40,000 IU weekly of vitamin D significantly improved depression (Jorde R. J Gen Intern Med, 2008)

  17. 4. Friendship with Others • Social support promotes mental health, e.g. religious participation protects adolescent mental health • Rx: spend time with friends • Join clubs, leagues, scouts • Volunteer – those who help others feel better about themselves; mentor, tutor, coach, babysit • WRITE PRESCRIPTIONS FOR MORE SOCIALIZING

  18. 3. Friendship with self:Manage Stress • Stress is common • Physical: higher cortisol, lower DHEA; higher epinephrine/NE, BP; shorter telomeres (aging); poor sleep, more pain, GI upset. • Mental/Emotional: irritability, anxiety, depression; angry, impatient; STRESS MAKES MOODS WORSE • More in later talk

  19. Stress Management • Mental (meditation – sitting or moving,guided imagery, biofeedback, autogenic training, journaling, CBT, etc.) • Emotional (intentionally generate positive emotions) • Spiritual (not necessarily religious; forgiveness; extending compassion)

  20. Stress management: Meditation • Meditation training ↑ brain patterns associated with happiness • Can combine mindfulness with CBT • Caution for patients with thought disorders (schizophrenia) • Review of Pediatric Meditation studies to be published in upcoming Pediatrics in Review Davidson RJ Psychosom Med, 2003

  21. 2.Fitness Rx Depression Lawlor DA. BMJ 2001

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

  23. How much Exercise? • 30-60 minutes at least 5X/week • Intensity: Sweat and/or difficulty talking at the same time as exercising • Type: what you enjoy! • Track it! • Anticipate barriers; use resources; plan rewards

  24. 2. Food: The SAD Story • SAD=Standard American Diet • USDA—75% eat less than 2/3 of RDA for one or more nutrient. • < 1% teens meet RDAs • Sugar and fat > 65% of American’s calories. • Falling micronutrient content of foods—most minerals at 60-40% of 1930’s levels. Depleted farmland = depleted food quality.

  25. Nutrition – essential nutrients for optimal brain function • Vitamins (B vitamins, Vitamin D) – needed to make neurotransmitters • Amino acids (SAM-E, Trp, 5-HTP) – neurotransmitters • Omega-3 fatty acids – needed for membrane stability • Minerals (Iron, Calcium, Magnesium, Zinc) – mood and anxiety

  26. Amino Acids: SAM-E • Meta-analysis: SAMe significantly improves depression, comparable to antidepressant medications (http://www.ahrq.gov/clinic/epcsums/samesum.htm) • All tested products approved by ConsumerLab; buy on sale!

  27. SAM-E Doses, duration, products • Dose: 800 – 1600 mg daily (adult) • Benefits appear within 2-4 weeks of starting daily use • Problems –poorly absorbed (need enteric coating); mania in bipolar patients; interactions with SSRI meds; see: http://www.consumerlabs.com/results/same.asp • http://www.umm.edu/altmed/ConsSupplements/SAdenosylmethionineSAMecs.html

  28. AA: 5-HTP and L-tryp • 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

  29. L-tryp doses and side effects • Doses - start at 50 mg TID; max dose 1200 mg daily • Side effects – EMS related to contaminated lot from one manufacturer; nausea, drowsiness; May potentiate SSRI medications; decreased carbohydrate intake and weight loss?

  30. Folate • Folate (Essential co-factor for synthesis of SAMe). • 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)

  31. Omega-3’s • Eat less fish, higher depression rates (Crowe. Am J Clin Nutr, 2007) • Effective for bipolar patients (Montgomery P. Cochrane Database Syst Rev. 2008) • Effective for major depression (Freeman MP. J Clin Psychiatry. 2009) • Effective for depression and bipolar disorder in children and adolescents (Am J Psychiatry 2006; Clayton. Eur J Clin Nutr. 2009 ) • Anxiety (Ross BM. Prostaglandins Leukot Essent Fatty Acids, 2009 )

  32. Fish Oil –Doses, Safety, Brands • Dose: 1-2 grams daily of EPA+DHA probably enough.(Peet M, 2002; Frangou S. Br J Psychiatry, 2006) • Safety: fish allergies, taste, belching; Little risk of mercury, dioxin, PCB’s; • Brands: Compare brands at www.consumerlabs.com; see handout at our website: www.wfubmc.edu/cim • Read labels: Omega 3 does NOT necessarily all equal EPA/DHA • OR EAT SARDINES/ SALMON 2 - 5 times weekly

  33. 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

  34. Other: Massage, Acupuncture • Massage: • positive results for teaching teen moms to provide massage for infants; benefits for mom and infant (Oswalt KL. Pediatr Nurs, 2009; Field T. Adolescence, 2000; Field T. Adolescence, 1996); • helpful for teen psych inpatients (Garner B. Aust N Z J Psychiatry. 2008); • helpful for bulimic teens (Field T, Adolescence, 1998) • Acupuncture: effective, with relapse rates comparable to conventional treatments (Gallagher SM. Complement Ther Med. 2001; Quah-Smith JI. Acupunct Med. 2005)

  35. Suggested Practice Changes • For the next week, give prescriptions for one or more: exercise, earlier bedtime with sleep hygiene, light, music, and volunteering • For the next week, assess at least 1 patient a day for deficiencies of essential nutrients for healthy mood • Consider making or using a handout(s) for patients on essential nutrients and supplements • Find an acupuncturist and massage therapist in your community that you feel comfortable and get a treatment if you haven’t already. • Join the AAP SOCIM (tsalus@aap.org or www.aap.org/sections/chim/

  36. Resources Kaplan, B et al “Vitamins, Minerals and Mood” Psych Bull 2007, 133 (5): 747-60 Kemper, K and Shannon, S “Complementary and Alternative Therapies to Promote Healthy Moods”, Ped Clinics of NA, Dec 2007, 54 (6): 901-26 Kemper KJ. Mental Health Naturally, 2010 AAP Lake, J Textbook of Integrative Mental Health Care Thieme Publishing: NY 2007. Natural Medicines Comprehensive Database Natural Standard ConsumerLab

  37. Extra slides

  38. Saint Johns wort • Comparable to sertraline in German RCT of 241 depressed adults (Gastpar. Pharmacopsychiatry, 2005) • 2 open label trials in teens showed improvement within 2 weeks in 25/33 and 9/11 patients (Findling, 2003; Simeon, 2005); Improvement in 2 weeks predicts long-term response; if no benefit in 2 weeks, stop • “Current evidence regarding hypericum extracts is inconsistent and confusing”; different products used in different trials, different kinds of patients; in some studies St. Johns wort is as effective as standard medications, and only slightly more effective than placebo. (2005 Cochrane review)

  39. Herb- drug interactions: SJW Speeds elimination of many drugs: digitalis, theophylline, clarithromycin, erythromycin, protease inhibitors and OCPs

  40. SJW safety • Other side effects - photosensitivity, serotonergic syndrome • Product variability; see www.consumerlabs.com: Gaia, Kira, Sundown, Nature’s Bounty • Products used in POSITIVE TRIALS: Laif 900 (German STW3-VI); LI160 (Kira), WS5572; WS5570 (Perika by Nature’s Way) • St. Johns wort patient handouts are available from: University of Maryland Medical Center Wake Forest University Baptist Medical Center’s Best Health internet site (www.besthealth.com)

  41. Melatonin • Natural hormone • Good product reliability (ConsumerLabs 2008 review) • May help with sleep in children with ADHD, seizures, dev delay, jet lag; procedural sedation • Dose 0.3 – 5 mg 1-2 hours before bed Gupta M, Epilepsy Behav. 2004 Gupta M, J Child Neurol. 2005 Schmidt CM, Neuropediatrics. 2007 Van der Heijden KB, J Am Acad Child Adolesc Psychiatry. 2007 McArthur. Dev Med Child Neurol, 1998

  42. 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

  43. Magnesium Status • Magnesium deficiency is widespread • Over the last 70 years we have witnessed a dramatic decline in magnesium intake • Stress and chronic sleep deprivation deplete total body stores • Fruits and vegetables now have only (65-89%) of the magnesium content they did in the 1930’s Meyer, A Historical changes in Mineral Content of Fruits and VegetablesBritish Food Journal 1997 99:207-211

  44. 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

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