Transcript Beating the Blues - American Academy of Pediatrics

Beating the Blues,
Naturally
Kathi J Kemper, MD, MPH
Wake Forest University
Disclaimer
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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.
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Objectives
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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
Definitions: Mental Health
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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
Is mental health
more than absence of
depression?
Parallels between physical,
mental, and spiritual health
Optimal Physical health:
Example
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Strength
Flexibility
Stamina/Endurance
Focus
Coordination
Resilience, and
Effective teamwork
Specific skills
Optimal Spiritual Health
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Faith
Forgiveness
Hope
Love
Kindness
Charity/generosity, and
Transcendence – connection
with something greater than
our individual self
Wisdom
Mental Health: ideals
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Confidence and courage
Adaptability
Cheerfulness
Attention / Focus
Harmony
Hardiness in face of stress
Social Network/
communication skills/
connection to community
Clarity, insight,
discernment
Parallels
Physical: Stamina
Spiritual: Hope
Mental: Cheerfulness
What are five fundamentals of a
healthy lifestyle that promotes
cheerfulness?
Fundamentals – 4H; 5F
Relationships
Manage
Stress
Food
Fitness
Environment
What does good mental health
have to do with
basketball and symphonies?
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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
Mental health coach: CBT; DBT
“From an evidence-based
perspective, cognitivebehavioral therapy is the
treatment of choice for
anxiety and depressive
disorders.”
Compton SN. JAm Acad Child Adolesc
Psychiatry. 2004
5. Healthy Habitat (Fields)
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More: Light, music, nature
(Richard Louv, Last Child
in the Woods – Nature
Deficit Disorder);
organization
Less: TV, toxins, tobacco,
violence, discrimination
Light and music therapies
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Proven effective for SAD
(Terman M Evid Based Ment Health,
2006)
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Meta-analysis of studies:
(effect size similar to
medications) for depression
(Golden RN. Am J Psychiatry, 2005)
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Music therapy is effective even
for severe mental disorders –
dose effect response (Gold C. Clin
Psychol Rev, 2009)
Vitamin D and depression
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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)
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RdbCT of 20-40,000 IU weekly of
vitamin D significantly improved
depression (Jorde R. J Gen Intern Med, 2008)
4. Friendship with Others
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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
3. Friendship with self:
Manage Stress
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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
Stress Management
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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)
Stress management: Meditation
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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
2.Fitness Rx Depression
Lawlor DA. BMJ 2001
Yoga for depression
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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
How much Exercise?
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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
2. Food: The SAD Story
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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.
Nutrition – essential nutrients
for optimal brain function
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Vitamins (B vitamins, Vitamin
D) – needed to make
neurotransmitters
Amino acids (SAM-E, Trp, 5HTP) – neurotransmitters
Omega-3 fatty acids –
needed for membrane
stability
Minerals (Iron, Calcium,
Magnesium, Zinc) – mood
and anxiety
Amino Acids: SAM-E
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Meta-analysis: SAMe
significantly improves
depression, comparable to
antidepressant medications
(http://www.ahrq.gov/clinic/epcsu
ms/samesum.htm)
All tested products approved by
ConsumerLab; buy on sale!
SAM-E Doses, duration, products
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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/C
onsSupplements/SAdenosylm
ethionineSAMecs.html
AA: 5-HTP and L-tryp
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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
L-tryp doses and side effects
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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?
Folate
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Folate (Essential co-factor for synthesis of SAMe).
– Lower levels of folate in depressed persons
– Low folate associated with poorer response to antidepressant meds
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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)
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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)
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Studies on supplements in non-folate deficient MDD pts on SSRIs
found significant reduction in sx severity and 19% remission (Alpert
et al., 2002)
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Folate augmentation may enhance response to lithium in folate
deficient bipolar and unipolar depression (Coppen and Chaudhry,
1986)
Omega-3’s
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Eat less fish, higher depression rates
(Crowe. Am J Clin Nutr, 2007)
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Effective for bipolar patients (Montgomery P.
Cochrane Database Syst Rev. 2008)
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Effective for major depression (Freeman MP.
J Clin Psychiatry. 2009)
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Effective for depression and bipolar
disorder in children and adolescents (Am J
Psychiatry 2006; Clayton. Eur J Clin Nutr. 2009 )
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Anxiety (Ross BM. Prostaglandins Leukot
Essent Fatty Acids, 2009 )
Fish Oil –Doses, Safety, Brands
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Dose: 1-2 grams daily of EPA+DHA
probably enough.(Peet M, 2002; Frangou S. Br
J Psychiatry, 2006)
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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
Mood and Minerals: Iron
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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
Other: Massage, Acupuncture
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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)
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Acupuncture: effective, with relapse rates
comparable to conventional treatments
(Gallagher SM. Complement Ther Med. 2001; Quah-Smith JI.
Acupunct Med. 2005)
Suggested Practice Changes
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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 ([email protected] or
www.aap.org/sections/chim/
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
Extra slides
Saint Johns wort
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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 longterm 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)
Herb- drug interactions: SJW
Speeds elimination of many
drugs: digitalis,
theophylline,
clarithromycin,
erythromycin, protease
inhibitors and OCPs
SJW safety
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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)
Melatonin
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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
Magnesium
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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
Magnesium Status
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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
Vegetables British Food Journal
1997 99:207-211
Iodine
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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