HOLISTICSOLUTIONSFORANXIETY&DEPRESSIONINTHERAPY

CombiningNaturalRemedieswithConventionalCare

PETERB.BONGIORNO

W.W.NORTON&COMPANYNewYorkLondon

ANortonProfessionalBook

Thisbookisdedicatedfirstlytothepatientswhoteachmesomethingvaluableeveryday.Theircourageismyinspiration.IwanttoalsodedicatethisbooktothementalhealthpractitionersthatIhavethehonortoworkwithinordertocreateatrueteamcare

approach.Together,wehavelearnedthatworkinginanintegrativefashiontrulycreatesthebestresults.Finally,thisbookisco-dedicatedtothetirelesslaboratoryandclinicalresearchersrunningtrialsandpouringoverstatisticstolearnhowlifestyleandnaturalmedicineswork.Withoutthathardandoftenunrewardedwork,theinformationforthis

bookwouldnotbeavailable.

ContentsAcknowledgments

Introduction:WhyHolisticCareforAnxietyandDepression?

ONE

AREHOLISTICAPPROACHESRIGHTFORYOURCLIENT?

TWO

ASSESSINGCONTRIBUTINGLIFESTYLEFACTORS

THREE

ASSESSINGCONTRIBUTINGINTERNALFACTORS

FOUR

EFFECTIVESUPPLEMENTSFORANXIETYANDDEPRESSION

FIVE

MIND-BODYMEDICINE

SIX

WORKINGINTEGRATIVELYWITHMEDICATIONS

SEVEN

MAKINGRECOMMENDATIONSANDDESIGNINGTREATMENTPLANS

APPENDIXONE

TopSevenCAMRecommendationsYouCanOfferYourClients

APPENDIXTWO

BloodTestRecommendations

APPENDIXTHREE

CAMReferralsandResources

APPENDIXFOUR

SupplementsforAnxietyandDepression

APPENDIXFIVE

HomeopathicsCommonlyUsedforDepressionandAnxiety

APPENDIXSIX

ExampleDietandLifestyleDiary

References

Index

IntroductionWhyHolisticCareforAnxietyandDepression?

Insanity:doingthesamethingoverandoveragainandexpectingdifferentresults.

Aboutayearbeforewritingthisbook,Iworkedwitha42-year-oldfatheroftwo;letscallhimJason.Jasoncameinforhissixthmonthlyfollow-upvisit.Hehadbeendealingwithdepressionformostofhisadultlife.Anavidathleteinhisyouth,bythetimehewastwenty-fourhebegantoexperiencelowmoodandlow-gradedepression.Thiswasaroundthetimehestartedhavingseveredifficultiesinhisfamilylife,specificallydiscussingdifficultieswithhisdrug-addictedbrotherandagingalcoholicparents.Hesuddenlybegantohaveaveryhardtimeplayingsoccer,agameheloved.Foralmosttwodecadesheavoidedathleticeventsandfoughtthedarkcloud,asheputit,thatkepthimfromenjoyingsports,goingoutdancing,orevenjustbeingsocialwithfriends.Whilefunctionalathisjobasanengineer,hewaslabeleddysthymicbyhispsychiatristsandbouncedfrommedicationtomedication,withequivocalresults.Atthetimewebegantoworktogether,hewasalsoworkingwithapsychotherapist,aswellasapsychopharmacologist,andbelievedhewouldalwaysbesomewhatdepressed,forthatwashisnature.

JasonsmostrecenttherapistdecidedtoreferhimtomeforamoreholisticviewandtoseeiftherewereanyphysicalreasonsthatmightbecontributingJasonsmoodchallenges.Aftertakinghisfullhistoryandcompletingaroundofbloodtests,welearnedthatJasonsvitaminDandferritin(ironstorage)levelswereabysmallylow.Wealsofoundoutthroughthebloodteststhathehadalow-gradereactiontogluten(aproteinfromwheat)thatwaslikelycontributingtotheslightlyhighinflammationinhisbody.Ireferredhimtoahematologistandgastrointestinaldoctortocheckonthelowiron.Onceitwasclearthatnogastrointestinalorhematologicproblemswerethecauseoflowiron,Iencouragedhimtoeatmoreiron-containingfoodsandgavehimlowdosesofaneasy-to-absorbironsupplementwithherbsthathelpabsorption.IalsorecommendedvitaminD3andhadhimavoidallglutenandwheatproducts.Wealsoadjustedhissleepscheduleandaddedmorevegetablesandanti-inflammatoryfoods(e.g.,fishandoliveoil)tohisdiet.Afterworkingwiththeserecommendationsforabout4months,hismoodgraduallylifted.Heevenwentbacktoworkingout,andnowheisexcitedlyconsideringgettingbackonalocalmenssoccerteamthiscomingsummer.Isuspecthewillbeabletoweanoffhiscurrentmedicationswithinthenextfewmonths.

Jasonhaddifficultyabsorbingiron.HisvitaminDwaslowbecauseheavoidedthesunafterhismedicaldoctortoldhimsunlightwouldcauseskincancer,eventhoughhehadnoknownincreasedriskforskincancer.Becausehedidnothavedigestiveissues,laboratorytestsforglutensensitivitywereneverperformed.After

weaddedagentlebutabsorbableiron,hisredbloodcellsabilitytocarryoxygenimproved,whichhelpedbothJasonsmoodandenergy.GivinghimvitaminDlikelybalancedinflammationinhisbodyandsupportedhismood.HavingJasoneliminateglutenfoodsandaddinganti-inflammatoryfoodsalsoloweredinflammationinthebody.Inflammationinthebodytranslatestomorebraininflammationacontributortopoormoodinsusceptibleindividuals.

Atourlastvisit,Jasonaskedmeaveryreasonablequestion:fteralmost20yearsofgoingfromdoctortodoctor,whydidntanyonethinktocheckanddothesethings?Myanswerwassimple:Becauseconventionalcarerarelylooksatthebodyasawhole.Often,whenwelookatthebodyholistically,wecanelicitmuchmoreinformationtohelpsupportthebodyshealingability.

JasonsstoryisanexampleofatypeofpatientItypicallyworkwith:someonewithalong-termmooddisorderwhohastriedmanyformsofmedicationandhashadlimitedsuccess.Iamlucky,forinmyNewYorkpracticeIworkalongsidelike-mindedtherapists,socialworkers,psychologists,andpsychiatristswholooktometoassess,fromamoreholisticperspective,thephysicalreasonsforapersonsmoodissues.Inateamcarespirit,Irelyonthemfortheirexpertisetomonitorpatientssafety,workonimprovingtheirpsychologicalwell-being,andconsiderpharmaceuticaloptionswhenabsolutelynecessary.Together,wecreateafullcomplementaryandalternativemedicine(CAM)perspectivethatallowspatientsfullopportunitytohealandprovidesasmallcommunityinwhichpatientsfeelsafetoshareconcerns,changepatterns,andheal.

MosttherapistsIhavethehonortoworkwithinthisteamcareapproachtellmethatmostoftheirclienteleareeitherinterestedinorarealreadyusingsometypeofnaturalremedyorholisticmodality.However,Ihavealsoheardthat,whetheritbethelatestdietcraze,acupuncture,fishoil,vitaminD,St.Johnswort,orsomenewmiraclemoodcure,oftenthetherapistdoesnotfeelfamiliarenoughwiththeseremediestogiveanopinion,andsomehaveconfidedinmetheirconcernfordrug-nutrient-herbinteractions.Evenmoreoverarchingisthesafetyconcernthattheirclientsmayinappropriatelyusetheseremediesinlieuofmorepotentandnecessaryconventionalcare.ThisbookwillhelporientyouregardingtheseconcernsandgiveyouaholisticframeworktohelpseewheresafeandeffectiveuseofCAMcanfitwithyourclientsconcerns.

Asaclinician,youprobablyhavenoticedthatanxietyanddepressionrankasthetopreasonsthatpeoplearesickandgotothedoctor.AnxietydisordersarethemostcommonofthepsychiatricillnessesintheUnitedStates,withapproximately30%ofthepopulationexperiencinganxiety-relatedsymptomsintheirlifetime(Kessleretal.,2005).EighteenpercentoftheU.S.populationhavebeendiagnosedwithanxietydisorder.

AccordingtotheU.S.CentersforDiseaseControlandPrevention(2010),9.1%ofthepopulationmeetthecriteriaforcurrentdepression,including4.1%whomeetthecriteriaformajordepression.AreportfromtheWorldHealthOrganizationtellsusthatdepressionhasbecomethesecondmostburdensomediseaseintheworlditcausesmorelosttimeandmoneythananyotherconditionexceptheartdisease(Ferrarietal.,2013).

Anxietyanddepressionaregenerallyinextricabledisorderseachoftenoccurring

withtheother.About58%ofpatientswithlifetimemajordepressivedisorderhaveanxietydisorder,while48%ofpatientswithgeneralizedanxietydisorderalsoexperiencecomorbiddepression(Lieberman,2009).Patientswhosufferfrombothseemtohavemoresevere,chronictypesofanxiety.Thesepatientsalsohavemoresocialandworkchallenges,aswellasgreaterratesofalcoholismandsubstanceabuse.Mostunfortunate,patientswithbotharelesslikelytobenefitfromconventionalcare(Lydiard2004).WhiletheDiagnosticandStatisticalManualofMentalDisorders,version5(AmericanPsychiatricAssociation,2013)doesnotacknowledgenxiousdepressionasadistinctdiagnosis,itisaverycommonpresentationofmooddisorder.Inholisticcircles,manypractitionersconsideranxietyanddepressionacontinuum,wherecertainstressors,aswellassleep,environmental,andlifestylefactors,willhelpdecidewhetheraparticulardegreeofanxiety,depression,orbothmaymanifest.

Despitedecadesofdrugdominance,manypatientsarenowrealizingthattheyprefersomethingelsepossiblytoavoidtoxicityofthesedrugs,ormaybebecausetheyrealizetheirmedicationisnotfixingtheproblem.In2007,over38%ofadultssoughtoutsomekindofnaturalorCAMsupportintheUnitedStates(Barnes,Bloom,&Nahin,2008),asignificantincreasefromthepreviousdecade.Inmanycases,thisCAMsupportmayinvolveananxiouspersongoingtothehealthfoodstoretofindamineral,suchasmagnesium,tohelpwithsleep.Orpossiblyapersonwithdepressionmighttryasupplementliketryptophantoliftmood.Otherpeoplemaystartregularacupuncturetreatmentsoryogatherapy.Ortheymayvisitanaturopathicdoctorlikemyself,whomayindividualizelifestylechanges,recommendspecificsupplementation,andorganizeaholisticplan.

YouhaveprobablynoticedthisinterestinCAMwithyourownclientsmoreandmoreareaskingaboutthisvitaminorthatdiet.Thus,abasicworkingknowledgeofavailableCAMmodalitiesandtheirefficacyisbecominganessentialpartofhealthcareeducation.Ageneralnaturalmedicineknowledgebaseisbecomingessentialforanyhealthcarepractitionerwhowantstocommunicateandparticipateeffectivelyinahealthcarestrategywithhisorherclient.

DEFININGALTERNATIVEANDCAMMEDICINEBeforeexploringhowtoassessyourclientsforvariouslifestyleandinternalfactorsthatmaybecontributingtotheiranxietyanddepression,andtheholisticapproachesyoucanrecommend,letsfirstgetclearonsomebasicterms.

AlternativeMedicineThetermalternativemedicinereferstovariousmedicalandhealthcaresystems,modalities,andrecommendationsthatarenotpresentlyconsideredtobepartofthetypicalconventionalmedicalmodel.Theseremediesarecalledlternativebecausetheyareusedinplaceofconventionalmedicalcare.Whendefiningalternativecare,thekeyhereisunderstandingthat,bydefinition,lternativemedicinereplacesmainstreammedicalprotocol.

ComplementaryandAlternativeMedicine

Instead,Iprefertoemploythetermcomplementaryandalternativemedicine(CAM).CAMisasystemthatemploysalternativemodalitiesalongsideconventionalcare.Itdoesnotnecessarilyreplaceconventionalcarebut,rather,keepsallmethodsofcareinmindwhencreatingaplanofactionforaparticularpatient(NationalCenterforComplementaryandAlternativeMedicine,2013a).Inmyexperience,neitherconventionalnoralternativemethodsaresuperior.IpreferCAMbecauseitisnotmutuallyexclusiveandallowstheopportunitytousewhichevertreatmentmightbebestforapatientatagiventime.Usingbothconventionalandalternativemedicinestogetheristermedintegrativemedicine.

CAMpractitionersmaybephysiciansofconventionalmedicine(e.g.,medicaldoctorsandosteopathicphysicians)orphysiciansofnaturopathicmedicinelikemyself.AlsoconsideredpartoftheCAMworldarenutritionists,herbalists,Chinesemedicineandacupuncturepractitioners,chiropractors,energetichealers,andsoforth.TherapistswhoworkwithstandardpsychotherapyalongothermodalitiessuchasyogawouldalsobeundertheCAMumbrella.

CAMtherapiesmayincorporatenutrienttherapies,botanicalmedicines,NativeAmericanhealing,dietarychanges,Ayurvedicmedicine(ancientmedicinefromIndia),energyhealing,hypnosis,acupuncture,spinalmanipulation,animal-assistedtherapy,physicalmedicines,andmanyothertypesoftherapies.

HolisticMedicineCAMandintegrativemedicineare,attheirbest,atypeofholisticcare.Holisticmedicineisasystemofmedicinethatfullyappreciatesthemultiplefactorsthataffectapersonshealth.Itconsiderseachpersontobeaunifiedwhole.Thiscontraststhebiomedicalapproachoffragmentingthebodyintopartsandspecialtiessuchasanervoussystem,digestivesystem,hormonalsystem,andsoforth.Forexample,whenyouhaveastomachproblem,youseeagastroenterologist.Ifyouhaveskinissues,youseeadermatologist.Incontrast,aholisticpractitionermayrecommendfocusingonsupportingthedigestivetracttohelptheskinissues.

Biomedicinetoooftendoesnotconsiderhowtweakingonebodysystemmayaffectthewholeperson.Letstakethecommonexampleofreflux,aconditionaffecting60millionAmericanseverymonth.CommonconventionaltreatmentincludesaprotonpumpinhibitordrugsuchasNexium,whichmayhelpdecreasesymptomsandavoiddiscomfort.However,inthelongterm,suchtreatmentscancausepoornutrientabsorption,whichleadstobodydeficienciesandriskofosteoporoticfracture(Fraseretal.,2013).ACAMandintegrativeapproachmayconsideradruglikethisintheshorttermonlyifreallyneededforsymptomreductionortohealadangerousulcer.Inthemeantime,aCAMapproachwillworkontheunderlyingfactors,suchasbalancingapatientsstressresponse,changingdiet,modifyingmealtiming,improvingsleepinghabits,andusingherbsandnutrientstohealthedigestivetractliningtreatmentsIfindworkextremelywellinpracticallyallcases.

Asthewordrefluxdoesnottelluswhyapersonishavingdigestivediscomfort;sotoo,thewordsanxietyanddepressiondonotreallytellusmuchabouttheunderlyingcausesof

apersonsmoodissues.Whenwehearofpeoplewithanxietyand/ordepression,weknowtheyareinvolvedinanexperiencewheretheydonotfeellikeattheirbestandarelikelychallengedtofunctionoptimallyintheirlife.Butwedontknowwhy.Holisticmedicineseeksthereasonwhyandtohelpadjustvariousfactors,suchassleep,movement,digestion,psychology,andspirit,aswellasnutrientandsupplementintake,tohelpthebodybalanceitself.

YourQuickGuidetoCAMInthefollowingchapters,Idetailtheholisticapproachtoanxietyanddepression.Alongtheway,Iattempttoprovideclinicalstoriesalongwiththemostup-to-dateresearchandrecommendationsforpractice.Thisbookisdesignedforthebusymentalhealthprofessionallookingforago-toprimeraboutnaturalhealthcareforanxietyanddepression.Asabusyclinician,youprobablydonothavethetimetocullandsynthesizethereamsofresearchavailableonnaturalmedicinesefficacyandsafetyfordepressionandanxiety.

Thisbookwilldotheworkforyou,streamliningtheinformationintoaneasilyaccessibleread.Theappendicesincludesummarizingchartsandeasystepsthatyou,asthementalhealthprofessional,canquicklyrefertoagainandagainforhelpinguidingpatientsthroughthenewholisticmedicineworld.InsteadofofferingthewholekitchensinkwhenitcomestoCAMrecommendations,thisbookusesmydecadeofclinicalexperienceandalmost20yearsofresearchtohelpdistillthemostsalientunderlyingfactorsandtreatmentoptions.

AstheinterestinCAMandnaturalmedicinegrows,atherapistwhocanspeakknowledgeablyaboutintegrativecarewillbeofmorevaluetotheanxiousordepressedclient.Whetheryouarelookingtointegrateyourselforyourpracticeoraresimplysearchingforthemostcurrentevidence-basedrecommendationsontheprinciplesandpracticeofnaturalandintegrativemedicinecareforanxietyanddepression,thisbookprovidesthefoundationnecessarytonavigatethisexcitingapproachtotreatment.Thisbookalsoprovidesthebestavailableresourcestofurtherexploreholisticcare.Forup-to-dateresearchonnaturalmedicines,pleasevisitmywebsiteatwww.drpeterbongiorno.comandjoinmeonFacebookandTwitter(@drbongiorno).Also,pleasefeelfreetosubscribetomyclinicnewsletteratwww.InnerSourceHealth.com.

SAFETYFIRSTGrouchoMarxoncesaid,Beopenmindedbutnotsoopen-mindedthatyourbrainsfallout.Pleaserememberthatwhilewefocusonnaturalmedicineandholisticremedies,patientsafetyisalwaysparamount.Thecomplementaryaspectofthisapproachremindsusthatsometimesdrugscanalsobeafriendtothepatient,andusingnaturaltherapiesinsteadofneededurgentcarecancauseharm.Anygoodclinicianconsidersriskandbenefitswithanytreatmentoptionandshouldchoosesafetyfirst.

Incaseswherepatientsareseverelyimpaired(e.g.,patientswithseveredepression,suicidalideation,orcompletelydebilitatinganxiety),first-linetherapymayneedtoincludemedicationandsometimeshospitalizationformonitoring.Inthesecases,I

recommendusingpharmaceuticalsupporttohelpapatientstabilize.

Oncethepatientisstable,thenconsiderationofholisticoptionstoworkontheunderlyingfactorscanbegin.WhileItypicallyprefertohavepatientsusenaturalcare,ifapatientcantevenmustertheumphtogetoutofbed,itisdoubtfulheorshewill,say,gotothelocalhealthfoodstoretobuysalmonandkaleandcookitup.Norisitlikelythepatientwillstartexercising.Holisticoptionscanbeconsideredadjunctiveinseverecases,butnotnecessarilyasafirst-linetherapyinplaceofpossiblyquicker-actingdrugsforurgentcareneeds.Wemustberealisticandkeeppatientsafetyinmindatalltimes.

THEHEALINGPOWEROFNATUREIamthrilledthatyouarereadingthisbook.Together,Ibelieveweareadvancingthefuturevisionofmentalhealthcare.Mysincerehopeisthatthisworkwillimpartinsightandgreaterrecognitionintowhatnaturopathicdoctorsrefertoasthevismedicatrixnaturae(Latinforhealingpowerofnature),aswellasbringawarenessthatthebodytrulyhastheinnatewisdomtoheal.Itismysinceresthopethatthisguidebringsgreatvaluetoyoupersonallyandtoyourpractice.Evenmore,Ihopeitinspiresyourclientsnaturalhealingprocessestomoveforward.

HolisticSolutionsforAnxiety&Depression

inTherapy

ONE

AreHolisticApproachesRightforYourClient?Afriendisonetowhomonemaypouroutthecontentsofonesheart,chaffandgraintogether,knowingthatgentlehandswilltakeandsiftit,keepwhatisworthkeeping,andwithabreathofkindness,blowtherestaway.

GeorgeElliot

Beforedivingheadfirstintoexploringcomplementaryandalternativemedicine(CAM),wefirstneedtodecideifholisticcareistherightchoicerightnow.Goodpractitionersusetheirknowledgeandexperiencetohelpguidetheirclientstodecidewhichpathisworthtakingandwhichdonotmakesenseatthattime.Thischaptershouldhelpyouanswerthatquestioninregardstoholisticcare.Itgivessomestatisticsaboutanxietyanddepressionanddescribeshowtobroachtheideaofcomplementarycare.Itpresentssomebasicclinicalquestionsyoumaywanttoaskyourclientinordertodeterminewhethernaturalandintegrativemedicinesareappropriate.Itwillalsohelptoidentifysafetyissuesthatmaysuggesttheneedformedication,orcontraindicationsthatwouldsuggestthat,atthemoment,itmaybebesttoavoidholisticormoreintegrativecareinordertofocusonconventionalbiomedicine.

ISTHERERESEARCHTOSUPPORTCAMFORMOOD?Asasystem,holisticcareresearchisinitsinfancy.Cooleyetal.(2009)lookedforthefirsttimeatnaturopathiccareforsubjectswithmoderatetosevereanxiety.Eighty-onepatients,randomizedbyageandgender,receivedeithernaturopathiccareorstandardizedpsychotherapyover12weeks.Thenaturopathiccaregroupreceivedaholisticplanofdietarycounseling,deepbreathingrelaxationtechniques,astandardmultivitamin,andthebotanicalashwagandha(Withaniasomnifera;300mgtwiceaday).Thepsychotherapygroupreceivedpsychotherapy,matcheddeepbreathingrelaxationtechniques,andaplacebo.TheprimaryoutcomemeasurewastheBeckAnxietyInventory;secondaryoutcomemeasuresincludedtheShortForm36,FatigueSymptomInventory,andMeasureYourselfMedicalOutcomesProfiletomeasureanxiety,mentalhealth,andqualityofliferespectively.FinalBeckscoresdecreasedby56.5percentinthenaturopathicmedicinegroupand30.5percentinthepsychotherapygroup,withsignificantdifferencesbenefitingthenaturopathicgroupregardingmentalhealth,concentration,fatigue,socialfunctioning,vitality,andoverallqualityoflife.Noseriousadversereactionswereobservedineithergroup.

BothgroupsintheCooleyetal.(2009)studysawsignificantadvantagesinmoderateandseverecasesofdepression.IhighlightthisstudytosupportthenotionthatholisticandCAMmodelslikenaturopathicmedicineshouldbeconsideredinvirtuallyeverycaseofmooddisordercare.Inthetreatmentofmooddisordersthereisestablishedsignificantsuperiorityincombiningpsychotherapyandpharmacologicinterventionoverusingeitheralone(Furukawa,Watanabe,&Churchill,2007).ByaddingaholisticmedicinesystemsuchasnaturopathiccareorCAMtoateamcareapproach,whichincludesthetherapist

andpsychiatrist,Ibelievewecangreatlyincreasetheefficacyoftreatment.

Manystudieslookatsingleaspectsofholisticcare,suchasanherb,adietarychange,anexerciseregimen,andsoon.Manyofthesearereviewedinthefollowingchapters.FewstudieslikethatofCooleyetal.(2009)lookatmultiplechangesinholisticcareasaparadigm.Whilemorestudiesareneeded,my10yearsofclinicalexperienceworkingasanaturopathicphysicianalongsidefellowtherapists,psychologists,andpsychiatriststellsmethatateamcareapproachutilizingthebestamongthesemedicinesismorepowerfulthananysingleonealone.Thisisthefuturemodelofmentalhealthcare.

WHYUSECAM?Thereareamultitudeofpharmaceuticaltreatmentsinconventionalcareforanxietyanddepression.Dependingonthepatient,theefficacyofthesedrugsforreducingsymptomswillvaryfromveryeffectivetomakingconditionsworse.Inanysituation,however,thesedrugtreatmentsdonotreallyaddressthemultipleunderlyingcausesoftheseconditions.

Theresanoldsayinginnaturalmedicinecircles:Ifyouaredrivinginyourcar,andthecheckenginelightcomeson,youcaneithercoveritupwithelectrictapesoyoudontseethelight,oryoucanstopthecar,checkunderthehood,andfixtheproblem.Well,ifyouareinadangerousdrivingsituationwhereyoucannotstop,andthelightisglaringinyoureyes,notallowingyoutosafelyseetheroad,sometimesyouneedthatelectricaltapeasanurgentcaremeasure.Inthisurgentcaresituation,coveringupthesymptomcanbealifesaveruntilyougettoaplaceyoucanstop.Thenwhenyouareinsaferandcalmerplace(andideallyaplaceyouknowagoodmechanic),youcanstop,checkunderthehood,andtrytofigureouttheproblemmaybeitsacrackintheengineblock,maybeyousimplyforgottoaddoilforthelast8years.However,ifyouarenotinthatacutelydangeroussituation,itisbestnottousetheelectrictapetocoveruptheproblem.Instead,itmakesthemostsensetofixtheunderlyingcauseoftheredlightsymptom.

Figure.1.1.Ignorethelightorcheckyourengine?

AntidepressantSafetyConcernsTheanalogyaboveisthatconventionalbiomedicinetypicallycoversuptheredlightsymptomandrarelyaddressestheunderlyingproblemunderthehood.Meta-analysishasshownthat,incasesofdepression,drugsdonotworkanybetterthanplaceboinmildtomoderatecases(Fournieretal.,2010)themajorreasonthesemillionsofprescriptionsarewritten.Evenmorestartling,thesedrugscarrywiththemanincreaseinall-causemortality,anincreasedlikelihoodmanyotherproblems,andsideeffectsthatimpairqualityoflife.Forexample,antidepressantsshowa32percentincreasedriskforall-causemortality,includinga45percentincreasedriskforstroke(Smolleretal.,2009)inpostmenopausalwomen.AcomprehensivereviewofalltheavailablepublishedandunpublishedcontrolledclinicaltrialsofantidepressantsinchildrenandadolescentsledtheFDAtoissueapublicwarning(U.S.FoodandDrugAdministration2004)aboutanincreasedriskofsuicidalthoughtsorattemptsinchildrenandadolescentstreatedwithSSRI(selectiveserotoninreuptakeinhibitor)antidepressants.

AntianxietyMedicationSafetyConcernsEfficacyforantianxietymedicationsismuchhigherthanforantidepressants,withclearbenefitintheshortterm,butthesemedications,likeantidepressants,arefraughtwithsideeffects.AccordingtoBelleville(2010),peoplewhouseantianxietymedicationhavea36percentincreasedmortalityrisk.Evenmore,wehaveknownfordecadesthatlong-term

efficacyofantianxietymedicationhasnotbeenshown(CommitteeontheReviewofMedicines,1980).Addictiontoantianxietymedicationsisalsoanotherproblem,asdrug-inducedchangesinbrainfunctionleadtoneedforhigherdosage,withdrawalsymptoms,andgreaterdisability(Mugathanetal.,2011).Tosumup,antianxietymedicationscanhelpintheshorttermbutposecleardangersofaddiction,likelihoodofwithdrawalproblems,andincreasedriskofdeath.

MedicationWithdrawalTheexperienceofdiscontinuationsyndrome(themedicaltermforwhatreallyiswithdrawal)isamajorchallengeforbothantidepressantandantianxietymedications.Symptomsincludedepression,anxiety,confusion,irritability,dizziness,lackofcoordination,sleepingproblems,cryingspells,andblurryvision.Andthesesymptomsheraldalargerconcern,forresearchshowsthatwithdrawalitselfevokesamajorbehavioralstressresponse(Harvey,McEwen,&Stein,2003)andcancausesignificantneurologicdamagethroughpathwaysthatcreatenervoussystemoverexcitement.Thus,thesystemwearetryingtohelpcanendupmoredamagedandunabletoworkinthelongterm.

Asclinicians,wehaveallwitnessedpatientswhohave,unfortunately,stoppedtheirownmedicationscoldturkey,orcouldnotgetaholdofarefillintimetheyarenothappypeople.JeanPaulSartresfamousexistentialplayNoExitfeaturesthreecharacterswithafearoftheunknown.Theyhaveagroupdynamicofperpetualanxiety,whichleavesthemwithnoabilitytofleetheirsituation.Inmanyways,anxiousanddepressedpatientsgiventhesemedicationstoooftenhaveasenseofnotbeingabletoeverstopmedicationandflee,withoutseriouswithdrawaleffects.Thistakestheirpoweraway,leavingthemfeelingtrapped.Holisticcarecanhelpbringasenseofpowerandcontrolbackintotheirlives.

PsychotherapyBenefitsWhileIamlikelypreachingtothechoironthisone,Idowanttonotethatpsychotherapyhasclearlybeenshowntobeatleastasbeneficialasdrugsinmostcases(Cuijpersetal.,2013).Insteadofsuppressingsymptoms,psychotherapyhelpstheunderlyingcause,byaddressingthefundamentalthinkingthatcontributestoanxietyanddepression.Thesethoughtsandnegativemessagingprompttheprimitivecenterofthebrainknownasthehypothalamustooverexcitethehypothalamic-pituitary-adrenal(HPA)axis.Short-termupregulation(increasedactivity)oftheHPAaxiscanreadythebodyandhelpfleedanger,anditishoped,intheprocess,learntoprotectagainstfuturedanger.However,sufferersofanxietyanddepressionoftenhavelong-termupregulation,whichleadstochronicsymptomsofanxietyanddepressionandevenincreasesrisksformanydiseases,suchascardiovascularillness,autoimmunedisease,andboneloss.Inthecaseofdepression,researchclearlyshowsthatrelapserateswithpsychotherapyaremuchlowerthanwithantidepressants(31percentvs.76percent,respectively)(Hollonetal.,2005).Chapter3discussesdysregulationoftheHPAaxis.

TOPFIVEPRINCIPLESOFHOLISTICCARE

Asdiscussedintheintroduction,holisticmedicinestrivestolookattheindividualasawhole,notjustseparatebodysystems.Theoverarchingtenetsholisticcarekeepsinmindareasfollows:

1.Thebodyhastheinnatecapacitytohealitselfwhengiventheopportunitytodoso.

2.Thebodyisanintegratedwhole,whereanimbalanceinonesystemwillaffecttherestofthebody.

3.Symptoms(e.g.anxiety,depression,orpain)arecallstoworkonthebasicsofhealth:diet,sleep,exercise,psychologyandspirit,digestion,andnutrientstatus.

4.Thecliniciansjobistoidentifythefactorsthatareinhibitingthebodyshealingcapacityandtoformulatetreatmenttoremovethese.

5.Medicationand/orsurgeryshouldbeemployedonlyintimesofurgentneed.Otherwise,aclinicianshouldstrivetousetreatmentsthataremorenaturaltothebodyandhelpithealitself.

HOWTODECIDEWHENHOLISTICCAREISAPPROPRIATEFORYOURCLIENT

Astouchedonintheintroductionofthisbook,thefirstorderofbusinesswhenworkingwithsomeonewithahealthconditionissafety.Asanaturopathicdoctor,Idobelievemodernbiomedicineiswildlyoverusedandinmostcasesdoesnotaddresstheunderlyingissues.Havingsaidthis,modernmedicineisexceptionalinurgentcaresituationsandshouldbeconsideredfirst-linetherapyincaseswhereaclientcannotreasonablyworkontheunderlyingcausethroughmorenaturalmodalities.

Asananalogy,nomatterhowskilledatherapistyouare,ifapatientistoodepressedtogetoutofbedtovisityourofficeforpsychotherapywork,yourcarecantpossiblyhelp.Ifmedicationcanhelpgetapatientoutofbedtocometoseeyou,thenitmakescommonsensetoworkwiththemedication.Whileantidepressantsarenotveryeffectiveinmildtomoderatedepression,theydoshowefficacyinseverecases(Fournieretal.,2010),andshouldstillbeconsidered-firstlinetherapyintheseinstances,forthesafetyoftheclient.

Naturalmedicinescanbeveryeffectiveandpowerful,buttheydotaketimetowork,andoftenmultiplechangesindietandlifestyleareneededtocreateanoveralleffect.Asamatterofclientsafetyandpracticality,clientsshouldbeassessedfortheneedforpharmaceuticalmedicationsasfirst-linetherapy:

1.Isthereimmediateandacuteconcernofpatientharmtoselforothers,suchassuicidalideationorplanning,historyofharmingselfandothers,orthreatstodoso?Itisakeyforanyfirstandsubsequentintakethatthepractitioneraskaboutsuicidalideation:

Haveyoueverconsidered,orareyouconsidering,suicide,orhaveyouthoughtthatitwouldbebetterifyouwerentaround?Ifyes:Haveyoueverdevisedaplanordoyouhaveaplantodothis?

Haveyoueverconsidered,orareyouconsidering,doingharmtosomeoneelse?If

yes:Haveyoueverdevisedaplanordoyouhaveaplantodothis?

2.Istheanxiousordepressedclientnotabletofunctioninacapacitynecessarytoperformbasicfunctions(e.g.,goingtoandbeingeffectiveatwork)andisthusunabletofeedorhousehimselforherselfordependents?Anexampleofthismaybeasingleparentwhoseresponsibilityistotakecareofhischildrenbuthecannotleavehisbedand,asaresult,isplacingthechildreninjeopardy.

Ifthreatofimmediateharmissuspectedineitheroftheseconsiderations,thenmedicationandsupervisionofthepatientmaybeneededandshouldbeconsideredtofirsttostabilizeyourclient.Twopossibleexceptionsarecasesofpregnancyandbreast-feeding,whichshouldbetreatedonacase-by-casebasis.

Ifnothreatofimmediateharmissuspected,thenthefollowingquestionswillhelpassesswhetherholisticcareshouldbefirst-linetherapy:

1.Doesyourmoodstopyoufromtakingcareofyourselfwhereyoudonotbatheoreatregularly?

2.Doesyourmoodstopyoufromgoingtoworkanddoingthebasicthingsyouneedtodoforyourself?

3.Ifyouhavechildrenorpeoplewhodependonyou,doesyourmoodstopyoufromtakingpropercareofthem?

4.Wouldyouprefertryingnaturalmethodstohelpbalanceyouremotions?

Ifyourclientanswersyestoanyofquestions13,thenconventionalmedicationshouldbefirst-linetherapy,withnaturalmedicineasanadjunctwhenpossible.Iftheanswertoquestion4isno,thenitismuchlesslikelythatholistictherapieswillbeofvaluetothisparticularclient,andyoumaywanttofocusonconventionalcare,forpatientpreferenceisanimportantpredictorofeffectivecare.

Ifmedicationsareneededhelpstabilizethepatient,naturalmedicinetherapiesthataddresslifestyleandpsychology/spirit,aswellasnutrientandsupplementaltherapies,canthenbeconsideredforthelongerterm.Chapter7reviewshowtomakerecommendationsanddesigntreatmentplanstosupportapatientusingmedication.

Whenusingpharmaceuticalmedications,teammanagementbythepatientsprescribingdoctor,therapist,andCAMprovider(naturopathicdoctororotherholisticpractitioner)asacoreteamwillaffordthebestoverallcareandallowthecomanagementneededtoconsiderfuturediscontinuationofmedicationswhenappropriate.Thispossibilitywillbemoreappropriatelyrealizedonceotherlifestyle,psychological,physiologic,andnutrientfactorsaresuccessfullyaddressed.

Asdescribedintheintroduction,theteam-careapproachofaprescribingdoctor(psychiatristorpsychopharmacologist),therapist,andholisticpractitioneristhebestofallworldsregardingoptimalpatientcare.Onceadecisionismadethatthepatientdoesnotmeetthecriteriaoutlinedabovethatnecessitatesfirst-linepharmaceuticalintervention,inteam-carefashion,holisticallymindedrecommendationsshouldbegin,whileremainingvigilanttochangesintheclientsconditionthatcouldleadhimorhertofulfillingthe

abovecriteriaatalatertime,necessitatingpharmaceuticalsupport.

AccordingtoDavidMischoulon,aHarvardpsychiatristwellknownforresearchingnutrienttherapiesforemotionalillness,thebestcandidatesfornaturalremediesarethosewhoaremildlysymptomatic,thosewhohavefailedmultipletrialsorarehighlyintolerantofsideeffects,andforthosepatientsalreadyonnumerousmedications,wherethedrugreactionsduetopolypharmacymaybesignificant(Mischoulon&Rosenbaum,2002).

Whileefficacyratesforantianxietymedicationsarehigh,theintroductiondiscussedhowtherisk-to-benefitratioisoftentoohigh,andhealingtheunderlyingcausesisnotaddressed.Thevastmajorityofpatientstreatedfordepressionareactuallyseeninoutpatientgeneralpracticesettings,andmostofthesepatientsdonotmeetthediagnosticcriteriaforseveremajordepression.Mostdepressedpatientswhovisitprimarycarephysicianshavemilderformsoftheillness(Milddepression,2003).Forclientswiththesemilderformsofdepression,watchfulwaitingwithoutactivepharmacologictreatmentmayrepresentthemostappropriateoptionbecauseminordepressionrespondstobothnonspecificsupportandactivetreatment(Oxman&Sengupta,2002).

Thistimeofwatchfulwaitingisalsoaclearcueforemployingholisticassessmentandintervention.Underthedirectionofmanyconventionalpractitioners,thesepatientsareneedlesslytreatedwithdrugs.Fromanaturopathicperspective,itisregretfulthatsomanyofthesepatientsaretreatedwithmedicationsasafirst-linetherapeuticoptioninlieuofpsychotherapyandholisticcare.Inthesescenarios,holisticcarewouldprobablydothemostgoodbyinterveningwithmorenaturaloptions,whilekeepingcommonsenseinmind:medicationscanbeimplementedasalastresortifthepatientsconditiondoesbecomesevere.

NOTEABOUTPATIENTPREFERENCESAllpractitionersworkingwithanxietyanddepressionshouldnotethat,overall,patientsgenerallydotheirbestwiththetreatmenttheychooseandbelievein,whateveritmaybe.Thepractitionershouldalwayskeepinmindtheimportanceofworkingwithmodalitiespreferredbythepatientforbestresultsandmostrapidimprovement.Inonestudy,315patientswithmooddisorderwhoweretreatmentnaveandinterestedinreceivingcarewereaskedwhethertheypreferredmedications,psychotherapy,orboth.Amongthesepeople,15percentpreferredmedicationalone,24percentpreferredsolelypsychotherapy,and60percentpreferredboththerapies(holisticcarewasnotachoiceinthisstudy).Thenthesesubjectswentontoreceivecarethatwasrandomlychosenforthem.Thosewhoreceivedtheirpreferredtreatmentclearlyexperiencedthequickestresultsnomatterwhatthetreatmentwas(Linetal.,2005).Itislikelythatpatientswhovisitaholisticpractitioneraregoingtopreferthenaturalapproachandwillfindbenefitfromworkingwiththeirtherapyofchoicealone.Ascaregivers,weshouldrememberthis.

Asaholisticpractitioner,Ihaveastrongpassionfornaturalmedicine.Itismybiasandtendencytodesirenaturalmedicinecareforallmypatients.Butintruth,ifthisisnottheirwishorinterest,itmaynotbetotheirbenefitanyway,andIhavelearnedtocheck

egoatthedoorandhelpthepatientfindwhatheorsheislookingfor,evenifitdoesntincludemyhelp.

WHENTOAVOIDHOLISTICCAREWhenproperlyprescribed,holisticmedicineshaveminimalriskandtoxicity,andpotentiallypowerfulresults.Holisticcareiscontraindicatedonlyifconventionalurgentcareisneeded,oriftheclientdoesnotpreferit.However,therearesomecontraindicationstospecificvitaminsandherbs,whicharealsodiscussedinthisbook.

TWO

AssessingContributingLifestyleFactorsLikeanoldgold-panningprospector,youmustresignyourselftodiggingupalotofsandfromwhichyouwilllaterpatientlywashoutafewminuteparticlesofgoldore.

DorothyBryant

OK,great.Nowwearemovingintothereasonsyouarereadingthisbook:toidentifytheunderlyingcausesofanxietyanddepression.Understandingtheunderlyingcauseshelpstheholisticpractitionerpairtreatmentsthatarewellresearched,effective,andsafe,aswellasindividualizedtoyourclient.Asanaturopathicphysician,Iammostexcitedaboutunderstandingtheunderlyingcauses,forthisunderstandingisthekeytocreatingthebestplan.Inthealternativemedicineworld,therearesomanytreatmentsolutions:dietstofollow,herbs,vitamins,detoxificationsthelistisendless.Itisseeminglyimpossiblechooseamongthemall.Asaresult,holisticcarecanbecomeaguessinggametothetuneofthisherbdidntwork,nowletstrythisvitamin.Thisshot-in-the-darkapproachendsupfrustratingboththepatientandthepractitioner.

Gettingthelayofthelandandunderstandingindepththedetailsofaclientslifewillhelptoultimatelyferretoutunderlyingissuesandmakesenseofitall,inordertomakethebestchoices.

Anxietyanddepressionaretypicallynotcausedbyonefactor.Iftherewereonlyonecause,modernmedicinewouldalreadyhaveadrugorproceduretofixit.Asyouareprobablyalreadyaware,anxietyanddepressionstemfrommultiplefactors.Thischapterdiscussesthemostimportantlifestylefactors,tohelpyouorganizetheminyourmindandferretoutwhicharethemostsalientforyourclientsneeds.

CaseStudy:GarrettsRefluxandAnxietyAfewyearsago,IhadapatientnamedGarrettwhowasreferredbyaclinicalsocialworkercolleague.Garrettwasa33-year-oldjournalistandabusyguy.Hetaughtinarespectedschoolforjournalismandworkedonhisownfreelanceassignments.Aboutthreeyearsagohestartedhavingincredibleanxiety.HewasplacedonadailydoseofLexaprotokeepitundercontrol,whilealsousingXanaxasneeded(usuallyonceortwiceaweek)whenthingsbecameoverwhelming.Hestartedtherapyworkabout6monthsprior.Duringourfirstvisit,IlearnedthatGarrettalsohadstomachrefluxandmildintermittentpainforthepast5yearsthatwascontrolledwithNexium.WhenIaskedGarrettabouthisday,Ilearnedhesleptabout5hoursanight,claimingIamgoodwiththat,Idontneedmore.Healsotoldmehehadtostopexercisingwhenhetookhisteachingpositionduetotimeconstraints.

Atthefirstvisit,wedecidedtohoneinonsleep.Overthefollowingmonthswewereabletoadjusthisscheduletoincreasehissleeptime.Hefoundthatwiththeincreasedsleep,hefeltmoremotivatedtoexercise.Interestingly,healsowasable

tostophisNexium,withouthavingareturnofrefluxsymptoms.Thisislikelybecausetheincreasedsleepgavehisdigestivetractmoretimetoheal.Withintwomonthsonthenewplan,hestoppedusinghisXanax.Within6months,heweanedofftheLexapro.Ibelievethat,combinedwiththepsychotherapyhewasdoing,theadjustmenttosleephelpedhisdigestion.Betterdigestionhelpedhisneurotransmittersbalance.Andtheexercisehelpedburnexcessstresshormones.Allthesehelpedhimcreatemoodbalance.

SLEEPAllanimals(includinghumananimals)requiresleep.Studiesonhumansleepdeprivationshowhowinadequatesleepfunctionincreasesriskofviralillness,weightgain,problemswithbloodsugarimbalance,slowedcognition,andincreasedbraininflammationconsistentwithproblematicmood.Forinstance,Cohenetal.(2009)showedhavingthatlessthan7hoursofsleepeachnightraisestheriskofcontractingrespiratoryviralillnessby300percentcomparedwiththosewhohad8ormorehoursofsleep.

Despitetheimportanceofsleep,mostofusarenotgettingenough.Peoplearesleeping,onaverage,20percentlessthanwedid100yearsago.Forpeoplepredisposedtoanxietyanddepression,sleepingproblemswillmakemoodworse.Sleepchallengestypicallyprecedeandoccurconcomitantlywithmoodchallenges.Insomniaisawell-knownsymptomofdepression(Ringdahl,Pereira,&Delzell,2004)andoftenheraldsitsonsetorrecurrence(Ford&Kamerow,1989;Buysseetal.,1997).Sleepdisturbancesarehighlyprevalentinanxietydisorders(Staner,2003);anestimated90percentofdepressedpatientshaveinsomnia,andabouthalfthepopulationislosingsleepduetoanxietyandstress.

Theunderlyingcauseofsleepdisorderisdifferentforeachperson.Typically,thereisnooneunderlyingcause.Instead,afewunbalancingfactorsaretypicallyatplayatthesametime.Unlessapersonhasanexceedinglyrareconditioncalledfatalfamilialinsomnia,peoplewithinsomniacanusuallyfixtheirsleeppatternswithindividualizedholisticcare.Wewillgooversomeofthesecareoptions.

IAmaNightOwlandICantGettoSleepDoyouhaveclientswithanxietyordepressionwhotellyoutheyareexhaustedduringthedayandthenwakeupatnightandthatsoftenwhentheyfeeltheirbest?Somewilloftensay,Ihavealwaysbeenanightowl.

Inappropriateexposuretobrightlightandexcessivestresscancreatedisruptionsinsleeppatternsandcancauseaconditioncalleddelayedsleepphasesyndrome(DSPS).Whilenotwellknown,thisisactuallyafairlycommoncauseofinsomnia.Inthebrain,thehormonemelatoninissecretedbythepinealglandasthedarknessofnightapproaches.Melatoninisapowerfulantioxidantknowntohelpourbodydetoxifyandstrengthentheimmunesystem.Melatonintellsthebodytoprepareforsleepbyloweringbodytemperatureandinducingdrowsiness.

Theabilitymelatonintobereleasedattherighttimeisakeyforoptimalmood.When

itisnot,yourclientmayendupwithacircadianrhythmdisorder.Characteristicsymptomsofthisoftenundiagnosedproblemincludesleeponsetinsomnia(Icantgetsleepatnight)andwakingupmultipletimesthroughoutthenight,orwakingtooearlyinthemorning.GenerallypeoplewithDSPSfeelmorealertatnightthaninthemorningthesearetheself-proclaimednightowls.Manysufferthenfrominabilitytowakeupearlyenoughtogettheirdaygoingthesepeoplewanttokeepsleeping,andthenoncetheyareup,theyexperienceimmeasurableandsometimesdebilitatingfatigueduringtheday.Bythetimenightrollsaround,theygetasecondwindthatkeepsthebadsleepcyclegoing.TheprevalenceofdepressionandpersonalitydisordersinpeoplewithDSPSisveryhigh(Smits&Pandi-Perumal,2005).Upto10percentofhighschoolstudentshaveDSPSandsufferchronicsleepdeprivationbecausetheirscheduledictatestheygotosleepearlier.

ICantStayAsleeporIWakeUpWayTooEarlyManypatientswithanxietyanddepressionwillcomplainthattheycannotstayasleep,eveniftheyfallasleepwell.Somewillalsocomplainaboutwakingupearly(around3a.m.to5a.m.)andfeelingwideawake.Theywillgetupandfeelfineforafewhoursandthenslipintogreatfatiguefortherestoftheday.

REM(rapideyemovement)sleepisacomponentofthelaststageofsleepthatoccursinbothanimalsandpeople.Knownasdreamsleep,thispartofsleeptendstobeaverylightandactive.PeoplewithanxietyanddepressiontendtohavemuchmoreREMsleepandlessdeepsleepthannormal.Newbornsspendabout80percentoftheirsleepinREM,butadultsnormallyshouldnotexperiencemorethan25percentsleepasREM.InREMsleep,thebrainisprocessing.Becausebrainprocessingactivityissimilartothetypeexperiencedinwakingmoments,themoreREMsleepapersonexperiences,thelessrefreshingthesleepwillbe.

SleepstudiesofpatientswithanxietyanddepressionhaveshownthatpatientstendtoenterREMsleepunusuallyearlyandhaveanextendedfirstREMphasealongwithalossoflaterdeeperphasesofsleep.Thesearethepatientswhoreportthattheycannotstayasleepandcomplainofearlymorningawakenings.ConsistentimbalancedREMsleepispredictiveofdevelopingsymptomsofanxietydisorders.ResearcherslookingatthesleeppatternsofdepressedpatientsfoundthattheyindeedhaveincreasedREMsleepinproportiontoslow-wavenon-REMsleep(Bergeretal.,1983),anddepressedpatientswhowerepurposefullydeprivedofREMstagesleepshowedimprovedmood(Vogeletal.,1980).

ISnoreaLotSomepatients(or,moreoften,theirsleepingpartners)willcomplainaboutsnoring.Whileonlyabout6percentofthegeneralpopulationstrugglewithatypeofdisturbedsleepknownassleepapneawherethereareirregularbreathingcessationsofbreathingthroughoutthenight,20percentofpeoplewithdepressionhavesleepapnea.So,especiallyforyourclientswithdepression,youmaywanttokeepthisinthebackofyourmind.Itisbesttospeakwithasleepspecialistorpulmonologisttoproperlydiagnosethis

condition.Naturalmethodstotreatthisincludemelatonin(seep.20),avoidingfoodsensitivities(discussedinChapter3),andweightloss.Ifthesearenoteffective,itisworthconsideringacontinuouspositiveairpressure(CPAP)machineorpossiblysurgicalprocedurestohelpopentheairway.PatientswhohavehypertensionorarefallingasleepduringthedaymayneedtoconsidertheCPAPorsurgerysoonerforsafetyreasons(Milleron,etal.,2004).

QuestionstoAskaboutSleep:Howmanyhoursofsleepdoyougeteachnight?

Whattimedoyougotobed,andwhattimedoyouwakeup?

Areyouanightowl?

Doyouhavetroublefallingasleep?

Doyouwakeupmanytimesatnight?

Doyouwakeuptooearlyinthemorning?

Doyouwakeuprefreshed?

Doyouoryourspousethinkyousnorealot?

StepstoImproveSleepNowyouhaveaskedtherightquestions,andassessedthesymptomsofsleep.Soletstalkaboutsomeideastoreintroducehealthfulsleepingpatterns.Forpatientswithanxietyanddepressionwithsleepchallenges,Irecommendworkingonsleepfirst,beforeaddressinganythingelse.Assuringhealthfulsleepisprobablythebestfirststeptowardlong-termhealingofanxietyanddepression.Irecommendthefollowingeightstepstohelpgetsleepbackontrack.

1.Gettobedbeforemidnight(andideallynolaterthan10:30p.m.)TheresanoldChinesemedicineproverbthatsaysonehourbeforemidnightisworthtwohoursaftermidnight.WhiletheancientChinesedidnotknowaboutendocrinology(thestudyofhormones),thissuggestionmakesphysiologicsenseforitencouragespeopletobeinastill,darkplaceatatimewhenonsetofmelatoninreleaseallowsforoptimalsleepandcircadianregulation.Melatoninisthemasterhormonethattellsyourbodyitistimetogotosleep.

Melatoninreleaseintheadultbeginsatabout10p.m.(Smits&Pandi-Perumal,2005).Therightbedtimeoptimizesitsrelease.Laterbedtimeswillsuppressmelatoninandencouragestresshormoneactivity.Unlessnocturnal,theonlyanimalsthatstayuppastdarkareindangerorneedfood.Humanswhostayuplatealsoexperienceastressresponsethatwillencouragepoorsleep,DSPS,andexcessREMsleep.

Ifyourclientgenerallygoestobedlaterthanmidnightandwantstomakeapositivechange,Irecommendbackingupbedtimeby15minuteseveryweek,possiblytosettleinata10:30to11:00p.m.bedtimeatthelatest.Supplementalmelatonincanbeusedif

neededtohelp(seemoreaboutmelatoninwithstep7belowandinChapter4).

2.CreateaneveningritualIrecommendmypatientsstartdimmingthelightsby9:00to9:30p.m.andshutdowntheTVandcomputer.Mycomputerhasanapplicationcalledf.luxwhichisafreedownloadableprogramthatchangesthescreenlighttoalessmelatonin-suppressingamberhueintheearlyevening,whichwillhelpcurbmelatoninsuppressionwhilestillusingthecomputerintheearlyevening.Sippingacalmingteasuchaschamomileorlavenderisalsosmartchoiceatthistime.Itisbesttomakeasmallcupandsipslowly.Thiswaythebladderdoesnotfillandcausewakefulnessduringthenight.Aspeoplecreatetheirownhealthysleeprituals,theywillfindcomfortinconsistency,andtheirbodywilllearntocalminpreparationforsleep.

3.Lowerthelights30minutesbeforebedAvoidusinganybrightlightsatthistime.Thisincludesshuttinganycomputerande-mailwork,texting,tabletcomputers,andsoforth.Brightlightsuggeststothebodythatitisdaylight,whichsuppressesthereleaseofmelatonin.Readingcalmingliteratureusingalampwithanorangelightbulbisalsohelpfultoavoidmelatoninsuppression.

4.KeeptheroomdarkandcoolMelatonin,humangrowthhormone,andotherhormonesareneededforrepairanddetoxification.Thesearesuppressedwhentheroomistoobrightandtoowarm.Ifyourclientcanseetheirhandwhenheldonefootinfrontoftheface,thentheroomhastoomuchlight.Considercoveringalllightsources(likecableboxes,clocks)andkeepthecellphonecharginginanotherroom.Ialsorecommendusingcompletelyocclusiveblinds.Someofmypatientsinstallautomaticopenersthatopentheblindsgraduallyattherighttimeinthemorningtoassureaslowintroductionoflight.Keepingthetemperaturearound68Fassuresoptimalmelatoninsecretion.

5.AskaboutfoodandbloodsugarOccasionally,eatingtoolateandhavingtoomuchfoodinthestomachcaninhibitthenaturalabilitytofallasleep.Ihavenoticedcertainpatientsarealsoquitesensitivetoindividualfoods(commononesarewine,spicyfoods,anddairyproducts),whichcankeepthemup.

Alternately,whenpeoplehavelowbloodsugarbeforebed,itcanbeequallyhardtofallasleep.Whenbloodsugarislow,thissignalsouranimalbraintogohuntforfoodandtriggerthereleaseofstresshormones.Ifthisissuspected,eatingasmallamountofproteinandcarbohydratetogether(e.g.,alittleturkeywithanappleslice,ornutbutterwitharicecracker)rightbeforebedcanbehelpful.

6.JournalbeforebedManyofusleadveryhecticlivesandoftendonothaveonequietmomentduringthedayuntilthemomentwedecidetogotobed.Atthistime,thebraingetsusaloneandsays,OK,Ivegotyou.Letsgooversomethings,andwantstostartprocessinglotsofthings,overandover.Thisisthemomentallthethoughtsfloodinatonetime:familyproblems,

relationshipissues,jobstress,financialworries,worriesaboutnuclearwar,andsoon.Thesecomeatusatonceandbecomeoverwhelming.Placedinstressmode,thebrainandbodycannotshutoff.

Inthesecases,itisavaluablepracticetopauseforaminuterightbeforebedandjotdownato-dolistforthenextday,and/orwritedownthetopissuesthatareofconcern,andthenfoldoverthepaperandputittotheside,toletgoofthemuntilthenextday.Asaclinician,youmayfinditvaluabletoreviewthiswrittenlistwithyourclient,toseewhatcomesupduringthosenighttimehours.WaltWhitmansaid:IdonotthinkuntilIreadwhatIwrite.Althoughjottingthemdownmaynotfixtheissuesofconcern,itcanhelpcreatesomebalancebyprocessingthembeforegoingtosleep.

7.NaturalRemediesforSleep,IfNeededIencouragepatientstotrytheabovestepsfortwoweeksandseeifsleepingimproves.Ifitdoesnotbalanceoutcompletely,thennaturalmedicinescanbeamazingtofinishthejob.HerearethetopnaturalremediesIwilltypicallyuse.

MagnesiumMagnesiumdeficiencyiscommonandisassociatedwithchronicinflammatorystress(Nielsen,Johnson,&Zeng,2010).Deficiencywillincreasedysfunctioninthebrainsbiologicalclockareasofthesuprachiasmaticnucleiandpinealgland(Durlach,2002)anddisorganizesleeppatterns(Murck,2013).Thisnontoxicmineralhasbeenshownhelpfulinclinicaltrialsforsleepefficiency,sleepduration,sleeponsetlatency,andearlymorningawakening(Abbasietal.,2012).

Dosingisusuallyintherangeof400500mg/day.Manypatientswilltake250mgtwiceaday,withthelastdoserightbeforebed.Ioftenrecommendthemagnesiumglycinateform,forglycineisanaminoacidknownforitsowncalmingeffect.Whilethereisnoknowntoxicityassociatedwithmagnesium,somesensitiveindividualscanhaveloosebowelmovementswithextramagnesiumintake.Inthiscase,thedoseneedstobescaledback.

MelatoninStudiesfromthe1980shaveshownthatlowordelayedmelatoninlevelscancontributetodepression(Beck-Friisetal.,1984)andanxiety(Toffoletal.,2014).Apowerfulantioxidant,itprotectsbrainandnervoustissue(Garciaetal.,1997).Asasupplement,itwasoriginallyknowntofixjetlagandisnowknowntohelpfightcancer(Al-Omary,2013)andmayevenincreaseefficacyofchemotherapy(Lissoni,2007).

Melatoninsupplementsaresoldindosagesfrom0.5mgupto20mg.Regular(non-time-released)melatoninisbesttohelpcalmthebodyandletitknowwhenitistimetofallasleep.Time-released(alsoknownassustainedreleased)melatonincanbeusedfortroublefallingasleepthatoccurswithdifficultystayingasleep.Melatoninisquitesafeandnonaddictiveandisevenusedwithchildren.Atypicaladultdoseis13mgahalfhourbeforethedesiredbedtime.StudieswithDSPShaveusedverylowmelatonindosesof0.125mginthelateafternoonandevening,eachdose4hoursapart(e.g.,at4p.m.and

againat8p.m.).Ifyourclientfindsusingasinglebefore-bedtimedoseisnotworking,thentrythelowdosesgivenat4and8p.m.AdolescentswithDSPShavebeengivendosesof0.35mg(Alldredgeetal.,2012)tohelpretrainnormalsleepingpatterns.Ifaclientishavingtroublestayingasleep,butnotfallingasleep,time-releasedmelatoninindosesof36mgmayhelptokeepapersonfromwakingduringthenight.

Whilemelatoninhasnotoxicityinthedosesdescribedabove,itisbesttoscaleitbackifthepatientfeelsgroggyinthemorningafteruse.Someresearchsuggeststhatelevatedmelatoninlevelsareassociatedwithexacerbationsinnocturnalasthma,somelatoninshouldbeavoidedinsomeonewhohasnighttimeasthmaticsymptoms(Sutherlandetal.,2003).

MelatoninversussleepmedicationsStudiescomparinghypnoticmedicationwithmelatoninfoundthatmelatonincausednoposturalinstabilityinseniors,whereaszolpidem(Ambien)impairedstabilityandcausedbodysway,astrongriskfactorforfalling(Otmanietal.,2012).TwostudiescomparingmelatoninwithAmbienfoundthatmelatoninhadsleepbenefitswithoutthenext-daycognitive,attention,psychomotor,ordrivingimpairmentsreportedwiththezolpidem(Wesenstenetal.,2005;Otmanietal.,2008).Inmypractice,itiscommontousebothmelatonin,andsleepmedicationslikezolpidem,especiallywhenthesleepdrugsstopworking.Whilemostresearchcombiningmelatoninandzolpidemshownonegativeinteractions,someresearchwithextended-releasezolpidem(AmbienCR)showedincreasedpsychomotorimpairments(Otmanietal.,2008).Asaprecaution,itisbesttostartonlowdosesofmelatonin(around1mg)andincreaseasneededuntildesiredeffectisachieved,whilemonitoringfordaytimesleepinessandanyimpairment.

NaturalfoodsourcesofmelatoninOats(Avenasativa)areknowntohaveacalmingeffectonthebodyandcontainverysmallamountsmelatonin.However,togetthesameamountofmelatoninthatisfoundinasupplementpill,onewouldneedtoeatabout20bowlsofoats.Montmorencytartcherries,ginger,tomatoes,bananas,andbarleyalsocontainveryminuteamountsofmelatonin(IowaStateUniversityExtensionandOutreach,2009).Onestudyoftartcherryjuicefoundamodesteffectonsleep(Pigeonetal.,2010),anditmightworkwellformildinsomniaissues.

L-TryptophanL-Tryptophanisanaturallyderivedaminoacidthatservesasaprecursortoserotonin.Depletionoftryptophancontributestogeneralizedanxietyandpanicattacks(Klaassenetal.,1998),andL-tryptophanlevelsaresignificantlylowerindepressedsubjectsthaninnormalcontrols(Maesetal.,1997c).Lowlevelsoftryptophandonotallowthebodytomanufactureenoughserotonin.Loweredlevelsofserotonincanbeareasonforpoorsleep,especiallyforstayingasleep.

Dosageatbedtimeisusually5001,000mg,whilesomepatientsmayneedupto2,500mg.Forbestabsorptiontothebrain,itisbesttotakewithasliceofsimplecarbohydrate(likeanappleslice),becausethecarbohydratewillincreaseinsulinlevels,andinsulinwill

promotetryptophanabsorptionintothebrain.

Althoughmostconventionalpsychiatristsareafraidtomixnaturalmedicinesliketryptophanwithconventionalmedication,one8-weekrandomizedcontrolledtrialof30patientswithmajordepressionfoundthatcombining20mgfluoxetine(Prozac)with2gtryptophandailyattheoutsetoftreatmentformajordepressivedisorderappearedtobeasafeprotocolthathadbotharapidantidepressanteffectandaprotectiveeffectonslow-wavesleep(Levitanetal.,2000).

PleasenotethatseveralInternetsitesstatethatL-tryptophanisunsafeduetopasthistoryofeosinophiliamyalgiasyndrome,aconditioncontractedbyseveralpeopleinthe1980safteringestingtryptophansupplements,whichledtothedeathof30people.Thistragiceventoccurredbecausethecompanymakingthesupplementhadnoqualitycontrolsandallowedtheintroductionoffatalbacteria.Thesedeathshadnothingtodowithtryptophanitself.PleaseseemoreabouttheuseoftryptophaninChapter4.

ValerianValerianisthebest-studiedherbalmedicineforsleep.TherootwordvalerecomesfromtheLatintermforgoodhealth.PleasenotethatvalerianhasnorelationshiptoValium,exceptforthefactthatbothnamessharethesamefirstthreeletters.Valerianisespeciallyhelpfulforpeoplewhofocusstressintheirgut(nervousstomach)andwhenthereisastronganxietycomponentaccompanyinginabilitytosleep.Thisherbhasconstituentsthatacttoinhibitsympatheticnervoussystemneuronsbyenhancinglevelsofgamma-aminobutyricacid(GABA),abrain-calmingneurotransmitter.Thesympatheticnervoussystemactivatesthestressresponseinourbody,sometimescalledtheflight-or-flightresponse.

Ameta-analysisof18randomizedcontrolledclinicaltrialssuggestsbenefitusingvalerian(Fernndez-San-Martnetal.,2010).Inonerandomized,triple-blind,controlledtrialof100postmenopausalwomen,530mgofconcentratedvalerianextractgiventwiceadayfor4weeksresultedinbettersleepqualitycomparedwithplacebo.Whilemoststudiesreportpositiveeffects,onerandomizedtrialdidnotfindbenefit,althoughthisstudywasinasmallgroupof16womenandusedsuboptimaldosingof300mgonceadaybeforebed(Taibietal.,2009).Itispossiblethatusinghigherdosestypicallyrecommendedmayhaveshowedbenefit.

Valeriancanalsohelpwithstayingasleepwhentryingtoweanoffanxietymedications.Inratstudies,valerianhasbeenshowntohelpalleviatewithdrawalsyndromeresultingfromtheremovalofdiazepam(Valium)followingprolongedperiodsofadministration(Andreatini&Leite,1994),whilenotshowinganytoxiceffects(Tufiketal.,1994).AteamoutofBrazilhadasimilarnotionwhentheyprescribedvalerian(100mgthreetimesaday,with80percentdidrovaltrate,15percentvaltrate,and5percentacelvaltratefromvalerianroot)tohelppatientswithinsomniatoleratewithdrawalfrombenzodiazepines.These19patients(averaging43yearsofage)wereusingbenzodiazepineseverynightforanaverageof7yearsbutstillhadpoorsleepandwerematchedto18controlsubjects.Electroencephalogrampatternswerestudiedduringsleep

whilestillonthebenzodiazepines,andthenfor2weeksafterwhiletakingeithervalerianorplacebo.Thepatientstakingvalerianreportedsignificantlybettersubjectivesleepqualitythanthoseonplaceboafterbenzodiazepinewithdrawal,despitethepresenceofafewwithdrawalsideeffectsfromthemedications.Attheendof2weeks,therewasasignificantdecreaseinnighttimewakingtimeaftersleeponsetinvaleriansubjectscomparedwithplacebosubjects.Nonetheless,valerian-treatedpatientsdidshowincreasedalphawaves(correspondingtomoredifficultyfallingasleep)aswellaslongerblocksofsleeplatencythandidcontrolsubjects.Despitesubjectiveimprovement,sleepdatashowedthatvaleriandidnotactuallyproducefastersleeponset,whichwaslikelyduetothemedicationwithdrawalhyperarousal(astatewherethewithdrawalofthemedicationkeepsthepatientinamoreawakestate).Theauthorsconcludedthat,overall,valerianwaswelltoleratedandhadapositiveeffectonwithdrawalfrombenzodiazepineuse,withnointeractionsbetweenthetwo(Poyaresetal.,2002).

Typicaldosageofvalerianis450600mgabout2hoursbeforebedtime.Patientswithdailyanxietyorneedingmoresleepsupportmayaddanearlyafternoondose.Inmanycases,valerianworksbestwhentakenoverafewweeksratherthanacutely.Whilesafetyhasbeenshownintrialsofchildren(Francis&Dempster,2002)andintheseniorpopulation,ithasnotbeenevaluatedinpregnancy.Theactivecomponentsofvalerianmayincreasebenzodiazepineactivityandshouldbemonitoredbyaphysicianifusedwiththesemedications.

Supplementsincombination?Whileanyoftheabovesupplementscanbeofvaluealone,CAMpractitionerstypicallycombinesomeoftheseforevenbetterresults.Forexample,onedouble-blindstudyfromItalyused5mgmelatoninand225mgmagnesiumtaken1hourbeforebedtime.Resultsshowedsignificantimprovementsinsleepscores,aswellasqualitysleep,andalertnessthefollowingmorning(Rondanellietal.,2011).VeryoftenIwillstartbyrecommendingonesupplementatatimeandthenaddothersafterafewdaysiftheonesupplementdoesnotcreatethefulleffect.

FinalNote:CognitiveBehavioralTherapyandSleepAsofthiswriting,thereisanear-completedstudyof66depressedpatientsshowingthatalmost90percentofthesepatients(whetheronanantidepressantorplacebo)whoworkedwithcognitivebehaviortherapyforinsomniatwiceaweekfounddepressionresolvedin8weeksoftreatmentusingeitheranantidepressantdrugoraplacebopillalmosttwicetherateofthosewhodidnothavecognitivebehaviortherapy.Thisparticulartherapyfocusesonestablishinghealthysleeprituals,whichincludekeepingproperandconsistentsleeptimes,avoidingdaytimenapping,andnotreading,eating,orwatchingTVinbed(Carey,2013).

FOODIfyouhaveadogwithanxiousness,inflammation,digestiveissues,orvirtuallyanyproblem,whenyoubringthedogtoaveterinarian,whatisthefirstthingthevetasks?Whatareyoufeedingthisdog?Thisisbecausethevetistrainedtoknowthatwhatthe

animalingestswillaffectitshealthconsiderably.

Althoughatenetvirtuallyignoredbymodernmedicineuntilveryrecently,itstandstoreasonthatwhatyourclientingestsisgoingtoaffectthebodyinasubstantialway.Poordietwillincreasethelikelihoodofadiseasetowhichsomeonemaybepredisposed.Conversely,eatingbetterleadstobettermentalhealth.Thissectiondiscussesthebenefitsofgoodnutritionandthenidentifiessomespecificfoodchoicesparticularlyunhealthyforthosewithanxietyanddepression.

HealthyDietaryChoicesforBestMoodMoreandmorestudiesareshowingthathealthyfoodintakepreventsbothanxietyanddepressionandblockstheravagesonthebodythatoccurwithmentalillness(Antonogeorgosetal.,2012).Onelandmarkfive-yearstudyoutofSpainlookedatthelivesandeatingpatternsof10,000people.ThosepeoplewhofollowedaMediterraneandietwere50percentlesslikelytodevelopanxietyordepression.Thestudyspecificallyfoundthatintakeoffruits,nuts,beans,andoliveoilsupportedmoodbest(Snchez-Villegasetal.,2009a).

OtherstudiesregardingtheMediterraneandiethavealsoshownthattheendotheliallinings(innerliningofbloodvessels)ofthesesubjectsweremuchhealthierandpredisposedthemtolowerratesofcardiovasculardisease.Evenmore,furtherstudiesbythesamegroupfoundthatthosepeoplewhoateinthishealthywayalsohadhigherlevelsofbrain-derivedneurotrophicfactor(BDNF),aproteinsecretedbythenervoussystemthatiscriticalforgrowth,repair,andsurvivalofhealthybrainandnervoussystemcells(Snchez-Villegasetal.,2011).BDNFhasbeenshowntobelowinindividualswithdepression(Yoshimuraetal.,2010)orwithanxiety(Suliman,Hemmings,&Seedat,2013).

Dr.MiguelAngelMartinez-Gonzalez,theseniorauthorofthisseriesofstudies,offeredhisunderstandingofMediterraneandietadvantage:Themembranesofourneurons(nervecells)arecomposedoffat,sothequalityoffatthatyouareeatingdefinitelyhasaninfluenceonthequalityoftheneuronmembranes,andthebodyssynthesisofneurotransmittersisdependentonthevitaminsyoureeating(Rabin,2009).

ComponentsofaMediterraneanDiet:1.Highamountsofmonounsaturatedfatsandlowamountsofsaturatedfats

2.Highintakeoflegumes

3.Highfishintake

4.Highintakeofwhole-graincerealsandbreads

5.Highintakeoffruitsandnuts

6.Highintakeofvegetables

7.Moderatealcoholintake

8.Moderateintakeofmilkanddairyproducts

9.Lowintakeofmeatandmeatproducts

Arecentcross-sectionalstudybyDavison&Kaplan(2012)lookedcloselyatthefoodsandnutrientintakesof97peoplewithconfirmedmooddisorders,examiningintakeoffats,carbohydrates,andproteins,aswellasvitaminsandminerals.TheyevaluatedthesepatientsusingGlobalAssessmentofFunctioning(GAF)scores,aswellastheHamiltonDepressionRatingScaleandtheYoungManiaRatingScale.SignificantcorrelationswerefoundbetweenGAFscoresandenergy(kilocalories),carbohydrates,fiber,andtotalfat.Alsocorrelatedwereintakesoflinoleicacid(anomega-6fattyacid,discussedinChapter4),riboflavin,niacin,folicacid,vitaminsB6andB12,pantothenicacid,calcium,phosphorus,potassium,iron,magnesium,andzinc.Thestudyshowedhigherlevelsofmentalfunctionassociatedwithahigherintakeofnutrients.Whendietarysupplementusewasaddedtothenutrientintakesfromfood,GAFscoresremainedpositivelycorrelatedwithalldietaryminerals,suggestingthatsupplementation,alongwithhealthyfoods,canplayaroleinhelpingmooddisorder.(Chapters4and6discusssupplementationfurther.)

Often,patientsandfellowpractitionersalikewillaskmemyopiniononwhichisthebestdiet.WhileIthinkthisquestionisbestansweredbyunderstandingeachpatientcaseandpossiblefoodsensitivities,ifIdidnotknowtheindividual,orhisorherhistory,IwouldrecommendtheMediterraneandiet.Althoughnoonedietiscompletelyperfectforeveryindividualduetopossibleallergiesandsensitivities,thereisreasontobelievetheMediterraneandietmayfarsurpassthebenefitsofotherchoicesforthosewithmoodproblems.Whilenoonedietis100percenteffectiveandhealthyforeveryperson,theMediterraneandiethasoftenbeenconsideredoneofthemosthealthfulformanydifferentpeopleandconditions,andtheresearchseemstobackupthisboldstatement.

SomeSpecificallyHealthyFoodsSo,whatshouldyourclientwithdepressionoranxietybeeating?Thisnextsectionisgoingtogooversomebasicsaboutdiettohelpmakesomehealthfulandemotionallysupportivechoices.

ProteinsourcesTheCentersforDiseaseControlandPreventionsuggestsatleastone-thirdofthepopulationisobese(Ogdenetal.,2012).Despiteourovereating,manypeopleactuallyarenotgettingenoughprotein.Ourpopulationtendstoeatcopiousamountsofhigh-carbohydratefoodsbutnotenoughqualityprotein.Lowproteinintakeisaproblemespeciallyforpeopleinclinedtohavemoodissues,fortworeasons.Oneisthatproteinsbreakdowntoaminoacids,whicharethebuildingblocksofneurotransmitters,ourmoleculesofemotion.Thesecondreasonisthatitisverychallengingtoregulatebloodsugarwithinsufficientproteinandbloodsugardysregulationisanimportantfactorinbothanxietyanddepression(moreaboutbloodsugarfurtherbelow).Pregnantwomenwhoateavegetariandiettypicallylowinproteinhada25percentgreaterlikelihoodforhighlevelsofanxietysymptom(VazJdos,etal.2013),likelyduetolowproteinlevels.Excessproteincanalsobeaproblem:toomuchproteincanactuallysuppresscentralnervoussystemserotoninlevels,whichwillnegativelyaffectmood.

So,howmuchproteinshouldyourclientsbegetting?Tohelpunderstandhowmuchproteinapersongenerallyneeds,youcanusetheformula

[weight(lb)/2.2lb]0.8g=gramsofproteinyouneedperday.

Forexample,a120-poundpersonwillrequireabout44gprotein.(Notethateliteathletesshouldmultiplyby1.2ginsteadof0.8g;apersonwithkidneydiseasemayneedtodecreaseproteinintakebelowtheformulasrecommendation.)

Thehealthiestproteinsourcesarebeans,rawnutsandseeds,tofu,fishandnaturalpoultry,andgrass-fedmeats.

FishandhealthyoilsThereisampleevidenceshowingcorrelationsbetweenlowseafoodconsumptionandhigherratesofmooddisorder.Conversely,solidresearchalsotellsusthathigherintakeoffishmayhelppreventandtreatanxietyanddepression.

Seafoodintakeisshowntolowerbothanxietyanddepression.Onestudyshowedthatthelikelihoodofanxietywas43percenthigherforthosewhorarelyorneveratedarkandoilyfishcomparedwiththosethatateitonetothreetimesaweekormore(Vazetal.,2013).Athoroughreviewspanning13countriesdemonstratedthatthereisaninverserelationshipbetweenintakeoffishanddepression(Hibbeln,1998).

Therearetwomaintypesofhealthyomega-3fattyacidsinfish:eicosapentanoicacid(EPA)anddocosahexanoicacid(DHA).Itisbelievedthatthesesubstanceshelpbalanceinflammationinthebodyandbrainandlowerthelikelihoodofmooddisorder.Theseomega-3fatsareespeciallyhighinwildsalmon,stripedbass,mackerel,rainbowtrout,halibut,andsardines.WhilescienceisstilltryingtounderstandwhetherEPAorDHAismoreimportant,itisclearthatindividualswithanxietyanddepressionwhoeatlessfishshowmarkeddepletionsinomega-3fattyacidsinbloodcellfatscomparedwithpeoplewhodonothavethesemooddisorders(Jackaetal.,2013),andtheselowerlevelscorrelatewithmoreanxiousanddepressivestates.

ThestandardAmericandiet(withtheaptacronymSAD)tendstobequitelowinhealthyomega-3fishoilandhighinomega-6oils.Omega-6fattyacidsarefoundinsaturatedfatsandredmeats.Itiswellestablishedthatdietswithhighomega-6toomega-3ratiosincreasetheriskofheartdisease,aswellascontributetomoodproblems.Swedishresearcherslookedatseniorpatientsandfoundthatdepressivesymptomsandmarkersofinflammationincreasedwithhigherratiosofomega-6toomega-3fattyacids.Theyconcludedthatdietswithhighratioscanincreasetheriskofnotonlycardiovasculardiseasebutalsodepression(Kotanietal.,2006).

Becausethebrainandnervoussystemaremadeofmostlyfatsandwater,itstandstoreasonthathealthfuldietaryfatsarecrucialforthemoodofyourclients.Whilewefocusontheomega-3fats,healthyoilssuchascold-pressedextravirginoliveoil(whichconsisthealthyomega-9fatsoroleicacids)andflaxoilsarealsohighlyrecommended.Organicandnaturalfoodsandwildfishesarepreferredduetothelowerlevelsofpesticides,neurotoxins,andmetalsthatmayplayaroleinsomemoodillnesses.

BelowisalistofrecommendationsbytheNationalResourcesDefenseCouncil(2013)forhowoftendifferenttypesoffishshouldbeeaten,basedontheiraveragemercurycontent.

FishConsumptionRecommendationsBasedonMercuryContent:Lowmercury,OKtoeattwotothreetimesaweek:

Anchovies

Catfish

Flounder

Herring

Rainbowtrout

Salmon

Sardines

Scallops

Shrimp

Sole

Tilapia

Moderatemercury,eatonceortwiceamonth:

Codfish

Snapper

Highmercury,trytoavoidoreatrarely:

Halibut

Lobster

Mackerel

Seabass

Tuna

ProbioticfoodsAmazingnewresearchisemergingregardingtheroleofthemicrobiomeofthedigestivetractlining.Themicrobiomereferstothehealthfulbacteria,orgoodgerms,thatlineourdigestivetracts.AswillbediscussedinChapter3,thedigestivetractisanimportantplayerinbestmood,andgoodbacteriaisanimportantpartofhealthydigestion.Probioticsnotonlyareknowntohelpthedigestionbutalsoarekeyfactorsinobesity,hormonalbalance,healthykidneyfunction,andmuchmore.

Medicalresearchisuncoveringthemechanismofprobioticsinmood.Thesehealthy

germsboostmoodintwoimportantways:theygenerateabrain-calmingneurotransmittercalledgamma-aminobutyricacid(GABA),andtheyenhancethebrainreceptorsforGABA.GABAiscalmingaminoacid,knowntocalmareasofthebrainthatareoveractiveinanxietyandpanic.

Bravoetal.(2011),workingwithmice,showedthosemicethatingestedprobioticswere,ingeneral,morechilledoutthanthecontrolmice.Theprobiotics-fedmicehadlowerlevelsofcorticosteroneinresponsetostresscorticosteroneisthemouseversionofthehumanstresshormonecortisol.Highlevelsofcortisolarecommoninbothanxietyanddepression.ThesemicewerefedabrotheitherwiththeprobioticstrainLactobacillusrhamnosusorwithoutthesebacteria.Thelactobacillus-fedanimalsshowedsignificantlyfewerstress,anxietyanddepression-relatedbehaviorsthanthosefedwithjustbroth.

Humanstudieshavealsocorroboratedthesemousefindings.Messaoudietal.(2011),inadouble-blind,placebo-controlled,randomizedparallelgroupstudy,learnedthatgivinghumansspecificstrainsofLactobacillusandBifidobacteriumfor30daysyieldedbeneficialpsychologicaleffects,includinglowereddepression,lessanger,hostility,andanxiety,andbetterproblemsolving,comparedwiththeplacebogroup.

Whileahealthymicrobiomewillcontributetogoodmood,anunhealthyonefullofCandidaalbicans(yeast),andallthetoxinsassociatedwithit,mayalsocontributetomooddisorder.Presenceofyeastwillaltertheabilitytoabsorbnutrientsandpushhypersensitivityreactionstotoxinby-products,whichtranslatestoinflammationinthebody.Inflammationwillgreatlycontributetodepression,anxiety,andpoormentalfunction(Rucklidge,2013).

Unhealthymicrobiomeyeastbuilduptoxicby-productshypersensitivityreactionsinflammationmoodproblems(anxietyanddepression)

WhileMessaoudietal.(2011)gaveasupplement,therearealsomanywonderfulnaturalfoodsfullofprobiotics.Theseincludenatto(atraditionalJapanesefermentedfood),kimchi(Korean-stylefermentedvegetables),yogurt,kefir,tempeh,fermentedmilk(e.g.,buttermilk),miso,andnonbakedcheeses(e.g.,agedcheese).Sauerkrautisalsoagoodprobioticsource,however,store-boughtsauerkrauthaslessofthehealthyprobioticsduetopasteurizationandpreservativecontent,soobtainingfreshlymadeversionsmaybebest.

CrunchyvegetablesNoticehowmostpeoplegetpleasurefromcrunchyfoodstheideathatsomeonecanteatjustone?Theresascientificreasonwhywegoforthese.Itsbecausecrunchingmakespeoplefeelhappier(whentheyaredoingthecrunchingthemselvesnotsomuchwhensomeonerightnexttoyouisthecruncher).Hochetal.(2013)usedenhancedMRItechnologywithratsgiveneitherregularchoworcrunchysnackstofigureoutthereasonsbehindhedonichyperphagia(whichmeanseatingtoexcessforpleasure).Hefoundthatcrunchysnacksactivatemanymorebrainrewardcentersthanthenoncrunchychow.Otherresearchsuggeststhatthecrunchingsoundallowspleasurecenterstoreleasemoreendorphins.Becausecrunchyfoodcalms,thiscanbeusedtohelpanxiety.

Thatsaid,whenpeopleeattoomanycaloriesfromjunky-crunchyfoods,theytendtofeelevenworse.So,insteadofunhealthychipsandcookies,wewillwanttorecommendhealthfulcrunchfoods,suchacarrots,celery,andpeppers.Also,anumberofhealthylow-temperature-bakedsnacks,suchasflaxmealcrackersandhigh-bran-fibercrackers,canalsodothejob.Nutsaregreat,too,butshouldberaw(seebelowforwhy).

IdeasforHealthyCrunchFoods:Babycarrots

Driedcrunchyvegetables:peas,carrots,peppers,etc.

Celerywithrawalmondbutterornaturalpeanutbutter

Rawnutsandseeds:almonds,walnuts,cashews,pumpkinseeds,sunflowerseeds,etc.

Bakedcrackersmadeoutofflax

Bran-andwhole-grain-fibercrackers

Rawfoodcrunchsnacks:driedkaleorveggiechips,etc.

RawnutsRawnutshavebeeneatenbyhealth-consciouspeopleformillennia.Besidestheircrunchiness,whichcanhelpcalmthebrain,nutsarechockfullofhealthyfattyacidsandoils,aswellasproteinandminerals.Nutshavebeenstudiedfortheirabilitytolowerinflammationinthebodyaswell.Salas-Salvadetal.(2008)lookedatlevelsofinflammatorymarkersinpeoplewhoatenutsregularly.ThesepeoplehadlowerlevelsofC-reactiveprotein(CRP),whichisaproteinfoundinthebloodwheninflammationishigh.Thismarkerisstronglycorrelatedwithcardiovasculardiseaseandislikelyabetterpredictorofheartandbloodvesselproblemsthancholesterol.Otherinflammationmarkers,suchastheimmunesystemcomponentinterleukin-6(IL-6)andvascularadhesionfactors(whichmakebloodvesselwallssticky)werealsolower.CRPandIL-6aretypicallyquitehighinpeoplewhohaveanxiety(Vogelzangsetal.,2013)anddepression(Howren,Lamkin,&Suls,2009).Salas-Salvadetal.(2008)believedthebenefitinnutsisprobablyduetoboththehealthyfattyacidsandhighmagnesiumlevels.

Healthyrawnutsincludealmonds,Brazilnuts,chestnuts,andcashews.Heatingthenutscandamagetheoils,makingthemgorancidandrenderingthemunhealthfulforthebrainandbody.Ifyoupreferthetasteofroastednuts,youcantrymixingtwoorthreepartsrawtoonepartroasted,tokeepthemajorityofyourintakeasintactuncookedfat.

SaltintakeWhilemanyofustakeintoomuchsaltthroughprocessedfoods,anumberofpeoplewhoeathealthymayactuallyrestricttheirsaltintaketoomuch.Clinicalandexperimentalobservationsinanimalandhumanstudiessuggestthatlowsodiumintakecaninducebehavioralcharacteristicsthatarequitesimilartopsychologicaldepression,aswellasmodifybrainregionsformotivationandrewardspecificallygearedtosaltintakeoverotherpleasures(Morris,Na,&Johnson,2008).Saltintakeshouldbeinmoderation,unless

apersonisasalt-sensitivehypertensive,inwhichcaseitshouldbeavoided.

FoodstoAvoidAshealthyfoodscanhelpsupportahealthnervoussystemandgoodmood,poor-qualityfoodswillworkagainstthebesthealthofyourclient.Thisdiscussionaboutfoodstartedwithfoodsthatarehealthy,forthisisthebestplacetostart.Withmostpatients,oftenitisnoteffectivetobeginbyfocusingonwhattheyshouldnoteat.Ihavelearnedthatifwestartwithfoodstoavoid,patientswillfeeldeprivedandsometimesangry,andtheymayhavetheoppositereaction,eatingevenmoreoftheunhealthyfoodsasawaytogainasenseofcontrolorasatypeofbacklashreaction.

Assuch,itisbesttostartbyhavingyourclientaddfoodsthatarehealthful.Forexample,ifaclienteatsfastfoodsthreetimesaday,amovementittherightdirectionmightbetosuggestheorsheeataribofcelerybetweenbreakfastandlunchandanapplebetweenlunchanddinner.Asthepatientaccomplishesthesesmalltasks,thenyoucanaddothers(e.g.,acupofgreenswithdinnerandaglassofwaterinthemorning).Inmyexperience,aspatientsfeelhealthierandmoreempowered,eventuallytheunhealthyfoodsstarttodecreasewithoutthesenseofbeingdeprived.

Also,itisimportanttocheckpatienttastepreferences.Researchshowsthatthebrainreactssimilarlytobothsomethingmorallyviolatingandatastethatisunpleasant,soamongthehealthyfoods,pickonesthatthepatientfindspalatableunpleasanttastesmayexacerbatenegativemood.

HighglycemicfoodsSugaryfoods(juices,cakes,cookies,candy)andsimplecarbohydratefoods(breads,pasta,rice)areknownashighglycemicfoods.Thesefoodscontainhigherlevelsofeasilyabsorbedsugar,whichtriggersanydiseasetowhichsomeonemaybepredisposed,andcontributesinthelongtermtodiabetes,dementia,heartdisease,andcancer.

Specifictomooddisorder,highconsumptionofsugarsandcarbohydratescausesdepletionofimportantminerals,suchasmagnesium(Barbagallo&Resnick,1994;Pennington,2000).Mineralsareimportantcofactorsfortheproductionofneurotransmittersandhelpminimizetheeffectoftoxicburden(seemoreaboutmineralsinChapter4).

High-glycemicfoodsalsotriggerreleaseofexcessinsulin.Insulindrivesinflammation.Braininflammationcontributestomoodproblems.Higherinsulinlevelsalsowilldropbloodsugarbelownormalvalues,makingsomeonehungry.Hungerandhypoglycemia(lowbloodsugar)areprimitivesignalsknowntosetoffthestressresponseinaperson.Inpeoplewhoarepredisposed,anxietyanddepressioncanbecommonseguestothisstressresponse.

UnhealthyfatsWhichfoodsaremostdamagingtomood?Incontrasttothebenefitofhealthyfats,hydrogenatedoils,highlyheatedvegetableoil,friedfoods,andnon-grass-fedanimal-basedsaturatedfatsarebestavoided.Whilethehealthyfatskeepnervoussystem

membranesfluidandcalminflammatorypathwaysinthebody,unhealthyfatswillreplacethegoodfatsincellmembranesandmakethemrigid,notallowingtoxinstoclearornutrientstogetin.Immunesystemcellmembranesthatlackfluidityalsocontributetoinflammation.

FoodsadditivesFoodadditivessuchasartificialcolors,glutamate,andartificialsweetenershaveallbeenlinkedtomoodproblems.WhiletherearestrictFDAguidelinesforfoodadditives,thesafetyofthesenotbeenrigorouslyproven,withmoststudiesbeingconductedbythecompaniesthatproducethem.

Artificialcolors.Coloradditiveshavebeenlinkedtoconductandmooddisorders(Schab&Trinh,2004)andattentionissuesinchildren.AstudybyKamelandEl-lethey(2011)inanimalsshowedthatthosetakinginbothlowandhighdosesoftartrazine(asFD&CYellowno.5)exhibitedincreasedhyperactivity,withsignificantpromotionofanxietyresponses.Depressionresponseswerealsogreatlyheightenedcomparedwithanimalsnotexposedtotartrazine.Theauthorsconcludedthatthestudypointstothehazardousimpactoftartrazineonpublichealth.Humanstudieshavealsolinkedanxietytothesechemicals(Rowe&Rowe,1994).Tartrazineisusedincoloredfoods,candies,andevenmedicationsusedformood.

Glutamate.Glutamateisanexcitatoryneurotransmitterourbrainproducesinsmallphysiologicamountsasaby-productofeverydaycellmetabolism.Monosodiumglutamate(MSG)isthesaltformofglutamate.Whilethiscompounddoesoccurnaturallyinsomefoods(includinghydrolyzedvegetableprotein,yeasts,soyextracts,proteinisolates,cheese,andtomatoes),theadditiveMSGisusedinhighamountsprimarilytoenhancetaste.WhiletheFDAconsiderstheadditiveMSGastobegenerallyrecognizedassafe(GRAS),itcanbetoxictothebrainandmood.Infact,excessglutamateismorecytotoxictoneuronsthaniscyanide(Marketal.,2001),andstudiesshowthatlevelsofglutamateinpatientswithdepressionaresignificantlyhigherthaninhealthypeople(Kimetal.,1982).ManypeoplereacttoChinesefood,whichoftenhasalargeamountofaddedMSGthesepeopleprobablyhavealargerstoresofglutamatealreadyand/orarenotabletodetoxifyit.Whilethebrainusesaverysophisticatedsystemtoremoveglutamate,inflammationandheavymetalburdencandecreaseitsabilitytoremoveit.Peoplewithanxietyanddepressionshouldavoidtakingitinaltogether.

Artificialsweeteners.Artificialsweeteners(e.g.,saccharin,aspartame,sucralose,acesulfamepotassium)arealsoknowntopossesstoxiceffectsonthenervoussystemandmaydirectlyassaulttheneurotransmittersofmood.AstudybyYokogoshietal.(1984)revealedthataspartamemaycontributetoabnormalbalanceintheneurotransmitterserotonin.Anxietyreliefhasbeenreportedinnumerouscasesbyremovingingestionofaspartame,withrecurrenceuponreexposure(Roberts,1988).Onelargestudy(Butchkoetal.,2002)didfindaspartameassafewithnounresolvedquestionsregardingitssafety;itshouldbenotedthisstudywasfundedbytheNutraSweetCompany.

CoffeeandGreenTea

Asthemost-usedpsychoactivedrugofalltime,coffeeisaninterestingcase.Studiesshowsomewonderfulpositivehealtheffectsforcoffee.Itcandecreaseaprediabeticsriskfordevelopingdiabetes,lowerincidenceofbiletractandlivercancer,andevenhelppreventheartattacksafterameal.Infact,areviewoflargerepidemiologicstudies(Bhattietal.,2013)showsregularcoffeeconsumptiontoreducemortality,bothforall-causeandforcardiovasculardeaths.CoffeeisassociatedwithlowerriskofdementiaandAlzheimersDisease,withthelowestrisk(a65%decrease)wasfoundinpeoplewhodrank3to5cupsperdayfrommid-lifeonward(Eskelinenetal.,2009).Inaddition,coffeeintakeisassociatedwithlowerratesofheartfailure,stroke,diabetesmellitus,andsomecancers.

Asfarasmoodisconcerned,coffeecanbebothbeneficialandharmful.Sowhataboutyourclient?Aswithmanyquestionsinholisticmedicine,theanswerhereis,Itdependsontheindividual.

Thepositivemoodeffectsofcoffeelieincaffeinesabilitytoincreaseasenseofeuphoria,aswellasincreasesenseofenergylikelybyhelpingthebrainproducedopamineinthebrainsprefrontalcortex,anareaimportantformoodregulation.Ina10-yearcohortstudyofmorethan50,000olderwomen,investigatorsfoundthat,comparedwiththosewhodrank1cuporlessofcaffeinatedcoffeeperweek,thosewhodranktwotothreecupsperdayhada15percentdecreasedriskfordepression,andthosewhodrankfourcupsormorehada20percentdecreasedrisk(Lucasetal.,2011).Forpeoplepredisposedtodepression,dailyintakemaymakegoodsense.

However,thereisathresholdforcoffeesbenefit.Tanskanenetal.(2000)foundthat,althoughtheriskforsuicidedecreasedprogressivelyforthoseconsuminguptosevencupsofcoffeeperday,theriskstartedincreasingwhenconsumptionexceededeightcupsaday.Alsonoteworthyisthatdecaffeinatedcoffee,caffeinatedtea,andchocolatedidnothavepositiveeffects.

Whethercoffeeisbestforyourclientreallydependsonhisorherparticularsituation.Long-termcoffeeusecancontributetoburnoutinpeoplewhoarealreadydepletedanddeficient.Also,caffeineathighdosescanencouragelossofminerals,suchasmagnesium,whichisanimportantcofactorinbrainneurotransmitters.Coffeemayalsocontributetofluctuationsinbloodsugar,whichcanraiseanxietylevels.Caffeine-sensitiveindividualsmayseemoreinsomnia.Asdiscussedabove,poorsleepwillpromotebothanxietyanddepressioninpredisposedindividuals.

CoffeeandgreentearesearchoutofJapanwasalsoverypositivefordepressionsupport.Inastudyof537peoplebyPham(2014),amongthegreenteadrinkers,thosedrinkingtwotothreecupsadaywere41percentlessdepressedthanthosewhodrankonecuporless.Amongcoffeedrinkers,thosewhodrankmorethanonecupperdayhada26percentlowerchanceofbecomingdepressed,andthosedrinkingmorethantwocupshada40percentdecreasedrisk.Inbothgroups,highercaffeinecorrelatedwithlowerdepressionrisk.

OriginallyusedbytheChineseover4,700yearsago,greenteasfirstwell-knownusewasbymonks,whousedittoattainastateofrelaxedwakefulnesswhilemeditating.Whilethecaffeinecontentislikelyresponsibleforthiseffect,twoothercomponentsmay

accountfortherelaxationeffect.Studiesinanimalssuggestthatthegreenteapolyphenolepigallocatechingallatecaninduceanxiolytic(anxietyrelieving)activityviainteractionwithbrainGABAreceptors(Vignesetal.,2006)receptorsthatareexploitedwithanxiety-relievingdrugslikealprazolam(Xanax).Greenteaalsohastheanine,anaturallyoccurringaminoacidthathasanxiety-improvingandblood-pressure-loweringeffects,eveninpeoplewhohadhighbloodpressureincreasesinresponsetostress(Yotoetal.,2012b).

Itseemsthatcoffeeisbeneficialforthosesusceptibletolowmood,lowmotivation,anddepression,butitcanoftenbedisruptiveforpeoplewithanxietyandshouldprobablybeavoidedinanyonewhoisosteoporoticorhasatendencyforinsomnia.Greenteacanbehelpfulforbothanxietyanddepression,butIwouldcautionitsuseinpeoplewithanxietywhoareespeciallycaffeinesensitive.

HealthfulFoodstoIncrease:Mediterraneandiet

Fish

Rawnutsandseeds

Probioticfoods

Crunchyvegetables

FoodstoAvoid:Highglycemicfoods(sugaryfoodsandsimplecarbohydrates).

Unhealthysaturatedfats

Foodsadditives:MSG,dyes,FDAcolors,artificialsweeteners

Coffee:bestfordepressivemood,avoidwithanxietyandinsomnia

Greentea:OKfordepressionandinanxietypatientswhoarenotcaffeinesensitive

EXERCISEKnownsincethetimesofHippocratesasamoodbalancer,exerciseprotectsthebrainareasneededforstablemood.Expertsbelieveitmaybethemosteffectivetreatmentforbothanxietyanddepression.Exercisehasbeenshowntoreduceanxietyanddepressionandtoslashnegativemood,whilesimultaneouslyimprovingself-esteemandevenmemory(Callaghan,2004;Coventryetal.,2013).

HowDoesExerciseHelpAnxietyandDepression?Thereseemtobeafewphysiologiceffectsatplayregardingthemoodbenefitsofregularexercise.Amongthem,exerciseincreasestheproductionofbrain-derivedneurotrophicfactor(BDNF),animportantcentralnervoussystemmolecule.BDNFplaysastrongroleinbuildingnervecells(calledneurogenesis),aswellashelpingthenervoussystemrepairdamageandcommunicate.Theserolesarecriticalformood(Cotman&Berchtold,2002).

Exercisehasalsobeenshowntomaintainthebrainshippocampus,anareavitaltomood,spatialrelationships,andmemory.Astudyof120olderadultswithdementiabyEricksonetal.(2011)showedtheafter1year,subjectswhoperformedmoderate-intensityaerobicexercise3daysaweekincreasedhippocampalvolumeby2percentandeffectivelyreversedanyage-relatedlossinbrainvolume.Expectedbrainlosswasseeninthegroupwhodidnotexerciseaerobically,butinsteaddidonlystretchingandtoningwork.

EvidenceforExerciseinAnxietyandDepressionExercisehasbeenstudiedheadtoheadagainstleadingantidepressantandantianxietymedicationsandhasshowntobequiteeffective.Onerandomizedcontrolledtrialof156adultscomparedexercisewiththeantidepressantsertraline(Zoloft).Exercisetookalittlelongertohelpbutworkedjustaswellasthedruginthelongrunandhadsignificantlylowerrelapserates(8percentvs.31percent)thansubjectsinthemedicationgroup(Babyak,2000).Asecondrandomizedcontrolledtriallookedatpatientsatleast50yearsofagewithdepression.Thesevolunteerswererecommendedeitherexerciseorantidepressantmedications.Again,therewasquickerimprovementinthedruggroup,butafter16weeks,exerciseprovidedequalbenefits(Blumenthaletal.,1999).

Exerciseseemstohaveclearbenefitsforanxietystatesaswell.Becauseofthefloodofthestresshormonecortisol(discussedfurtherinrelationtothehypothalamic-pituitary-adrenalaxisinChapter3),thebrainshippocampusshrinksinpeoplewhoarechronicallyanxious(Sapolsky,2001).Animalstudieshaveshownushowexercisecanactuallyreversethisshrinkage(vanPraag,Kempermann,&Gage,1999).Asdiscussedabove,humanstudiesalsoshowthesamebenefit.Exercisehelpscreatenewbraincellsbutcanalsohelpcalmthemwhentheyareoverexcited.MousestudiesbySchoenfieldetal.(2013)suggestthatregularexercisenotonlygrowsnewneuronsbutalsocreatesmorecellsthatreleasegamma-aminobutyricacid(GABA),abrain-calmingneurotransmitter.GABAisdiscussedinthesupplementsectionofChapter4.

Asasidenote,thebenefitsofexercisedonotseemtoholdifananimalissleepdeprived(Zielinskietal.,2013)soitmaybeimportanttocreateastrongsleepschedulefirstandnotdipintoneededsleeptimeinordertoexercise.

HowtoGetStartedwithExerciseForclientsthatarenewtoexercise,Igenerallyrecommendtheystartslowinordertoavoidinjuryandincreaseenjoyment.Anexcellentwaytogetmovingwouldincludebeingoutsideinnatureifpossible,ingreenareasamongthetrees,andinthesunlight.Jogging,walking,andtaichiareallwonderful.Ifyourclienthasjointorweight-bearinglimitations,swimmingoranellipticaltrainermightbegentler.Afewofmypatientswhocantwalkormovetheirlegsuseatabletoparmpedalexerciser.

Foranyonewhowouldliketoreplicatethehippocampus-buildingstudybySantarellietal.(2003),itisdescribedbelow.

HippocampalGrowthExercise(fouroutofsevendayseachweek):1.Low-intensitywarm-uponatreadmillorstationarybicyclefor5minutes

2.Stretchingfor5minutes

3.Aerobictrainingfor40minutes:chooseamongstationarybike,treadmillrunning,Stairmasterclimbing,ortrainingwithanelliptical

4.Cooldownandstretchingfor10minutes

SUNLIGHTHippocrates,thefatherofmedicine,alsorecognizedthatpeoplewithmoodchallengesneededplentyofsunlight.Threewayshealthfulexposuretosunlightcanhelpmoodisbykeepinghealthfullevelsofserotonin,balancingcircadianrhythm,andbuildingupvitaminDstores.JohnDenversangSunlightonmyshouldersmakesmehappy.WhileIamnotsureheranaclinicaltrialonthis,hedidseemtohaveaclearunderstandingofsunlightsbenefitonmood.

TheYinandYangofLightWhentheeyeisexposedtosunlight,thebrainscenterareacalledthehypothalamusisactivated.Thehypothalamushousesourbodyclockandisalsothenexusforournervoussystem,immunesystem,andendocrinesystem.Balancedexposurestolightanddarknessarekeytocreatingcircadianrhythmsconsistentwithahealthybodyandgoodmood.TraditionalChinesemedicine(TCM)isbasedonthenotionofbalancingouryinandyang.Yinrepresentsdarknessandnighttime,whileyangrepresentslightanddaytime.InTCM,onecannothavehealthunlessyouhavebalancebetweenyinandyang.Thediscussionaboveonsleepmentionedtheessentialroledarknessplaysforourcircadianhealth.Thissectiondiscussesthebenefitsoflight.

Figure2.1.

TheConnectionbetweenSerotoninandLightSerotoninlevelsareknowntoincreasewithbrighterlight,andnotsurprisingly,researchsamplingthejugularveinbloodof101mensuggeststhatserotoninlevelsareattheirlowestinthewinter.Evenmore,therateofserotoninproductiondependedonhowlongapersonwasexposedtolight,aswellasthelightintensity(Lambertetal.,2002).Other

studieshavealsoshownhowserotonintransporters,whichwillbindupandinactivateserotonin,aremoreplentifulinthebrainduringdarkperiods(Praschak-Riederetal.,2008).Darknesssendsasignaltoourbodiestostaylow.

SunlightandCircadianRhythmOurmodernworldisfullofwaystoblockthesun.Duringthedayweworkindoors,wewearclothes,andwetravelinvehiclesthatblockthesun.Airpollutionhasparticlesthatblockhealthfulsunexposure.Evenmore,modernmedicinehasallbutscaredusintoblockingthelastbitofsunlightwemightaccidentallyreceivebytellingustousesunblock.Itispossiblethatincreasedratesofanxietyanddepressionmaycorrelatewiththelackofoutdooractivityandsunexposureofmodernsociety.

Limitedaccesstosunlight,especiallyinthemorninghours,doeslittletosupportourcircadianrhythm.Healthfulnormalcircadianrhythmsrevealhighmorningcortisol(anadrenalstresshormone),whichgenerallydecreasesasthedaygoeson.Lowestlevelsareintheevening,whenmelatoninissecretedintooursystemtohelpussleep(seefigure2.2a).Patientswithdepressionandanxietyareknowntohavestrongdysregulationofthissystemandoftenwillhavelowlevelsofcortisolinthemorningandhigherlevelsatnight(seefigure2.2b).Unusualcortisolpatterningpointstoadysregulationofthehypothalamic-pituitary-adrenal(HPA)axis,whichplaysacentralroleinthepathophysiologyofanxietyanddepressivedisorders.Thisisdiscussedfurtherinchap-ter3.

Mooddisorderhasbeenclearlyassociatedwithdelayedreleasesofmelatoninmuchlaterthannormal,whichcanhappenwhencortisolistoohighatnightand/orwegotobedtoolate.Conversely,peoplewhoaremorningtypesoftenexperienceearliereveningsleeponsetandearlierwaking.And,thosewhowakeearlieraremorelikelytogetoutandhavemorningbrightlightexposure,decreasedmorningmelatoninsecretionduration,morehealthfulcircadianrhythms,andbettermood.

Figure2.2a.Normalcircadianrhythm.

Figure2.2b.Dysregulatedcircadianrhythm.

SunlightandVitaminDLowvitaminDlevelshavestrongassociationswithincreasesinriskofdeathfromcancer,heartdiseaseandrespiratorydisease(Schttkeretal.,2013).Whilethegoalistoreduceskincancerdeaths,fearofthesunmayactuallybecausingmoredeathsfromallotherdisease,aswellascontributingtomoodproblems.

Thecomponentsofsunlightarevisiblelight,ultravioletradiation,andinfraredradiation.ThetwoultravioletwavelengthsareultravioletA(UVA;320400nm)andultravioletB(UVB;290320nm).Besidessunlightsabilitytosuppressofdaytimemelatonin,whichcreatesahealthfulcircadianrhythmofthishormone(asdiscussedabove),anotherlikelymechanismtowardhealthfulmoodissunlightsproductionofvitaminDthroughexposuretoUVBrays.Ultravioletlighthelpstheskintransformachemicalcalledcutaneous7-dehydrocholesterolintovitaminD3.

Feldmanetal.(2004)investigatedtherelationofexposureofskintoultravioletlightandmood.Overaperiodof6weeks,frequenttannersusedtwodifferenttanningbedsthatwereidenticalexceptthatonehadultravioletlightfilteredout.Eventhoughtheycouldnottellwhichonehadtheultravioletlight,participantsreportedtheyweremorerelaxedandlessanxiousafterexposuretothebedwithultravioletlight.Whenallowedtofreelychoosewhichbedtouse,11of12participantschosetheonewithultravioletlight.

Astudyof198multiplesclerosispatientsover2.3yearperiodfoundthatsunlightexposure,andnotvitaminDlevels,wasbestcorrelatedwithmoodandfatiguesymptoms(Knippenbergetal.,2014),suggestingthatoveralltimeinthesunisprobablymoreimportantthantakingasupplementtogetlevelsup.(Chapter4discussesvitaminDsupplementation.)

WhiletheabilityofUVBtomakevitaminDmaybeimportant,sunlightsinfraredwavelengthsmayplayaseparateanddistinctroleinmood.Animalresearchshowsthattheamountoftimebeforeananimalwillgiveupandbecomedepressedafter

continuousstressisincreasedsignificantlyafter4weeksofexposuretoinfraredirradiation,suggestingthatapplicationofinfraredirradiationhasantidepressanteffect(Tsai,Hsiao,&Wang,2007).Inmyoffice,IoftencombineacupuncturetreatmentswiththeuseofaninfrareddevicecalledaTedingDianciboPu(TDP)lamp,heatingbodypartssuchastheabdomenorlowerbackwithfar-infraredheat.PatientstellmethatthisTDPapplicationhelpsthemfeelverycalm,secure,andnourished,aswellaswarmer,duringtheiracupuncturesession.

SPENDINGTIMEINNATUREThepremiseofnaturopathicmedicineincludestheprinciplethatnatureheals.InChinesemedicine,healingoccursbyrebalancingyourbodysenergywiththeenergyaroundyou.Onewaywecanhelpencourageourclientshealingandbalanceforbothphysicalandmentalhealthisbyrecommendingtimeinnature.

Figure2.3.

OnefascinatingmedicaloutcomestudybyUlrich,Lundn,andEltinge(1993)comparedtherecoveryfromgallbl