Transcript Natural Therapies for Adolescent Depression

Natural Therapies for Adolescent
Depression:
Do they work? Are they safe?
Kathi J. Kemper, MD,
FAAP
Caryl J Guth Chair for Holistic
and Integrative Medicine
Author, The Holistic
Pediatrician
Wake Forest University School
of Medicine
Faculty Disclosure
In the past 12 months, I have had no
relevant financial relationships with the
manufacturers of any commercial products
and/or providers of commercial services
discussed in this CME activity. I do not
intend to discuss an unapproved or
investigative use of a commercial product
or device in my presentation.
Objectives (by the end of this
session, you will be able to…):
1.
2.
3.
Define the role of patient-centered
communication for adolescent
depression visits
Describe the importance of a
healthy lifestyle and the safety and
effectiveness of dietary
supplements in promoting healthy
moods.
Refer patients to evidence-based
resources for additional information
about lifestyle and complementary
therapies to promote mental health
Depression Case
A 17 year old girl who is sad, has had
a drop in grades, recently broke up
with her abusive boyfriend; less
interested in participating in band,
has stopped taking her SSRI after
hearing about black box warnings.
Her only medications are oral
contraceptives.
Will St. Johns wort help (the news
reports are very confusing)?
How do you advise her?
Management Issues
• Process (communication skills)
• Content (focus on healthy lifestyle; if it’s
good for the heart, it’s probably good for
mood)
• Speed (baby steps)
• Resources
Process:
Communication Skills
• Standard approach
• Patient-centered care
• Health promotion focus
Standard approach
• Diagnose
• Provide diagnosis-specific treatment
• Challenges
• Making a diagnosis; what if they don’t meet
criteria?
• Mastering medications
Wissow and Gadomski, 2008
Parental expectations
• Don’t believe they are effective change
agents
• Have prior beliefs about what will help
• Want help but afraid of what you might say
• Want empathy but expect child is the
agenda
Wissow and Gadomski, 2008
Adolescent Expectations
• Here to be “fixed” or punished
• Not used to having a substantive role in
visit
• Uncertain about confidentiality
• Different agenda than parent
• Incomplete and stigmatizing views of
“mental health”
Wissow and Gadomski, 2008
Physician Expectations
• Will be presented with insoluble problems
• “Double drowning” – everyone will leave
more hopeless and/or angry than they
started
• Will lose control of time
Wissow and Gadomski, 2008
Evidence-based skills
Agenda setting
• Engaging both child and parent
• Prioritizing specific concerns; goals; define success
Problem formulation and solving
• Finding reasons to hope and first steps to solutions
• Framework: health promotion and stress management
Time management
• Managing rambling and interruptions
Promoting hope and confidence
Diagnosing and Advice giving
• Avoiding and managing resistance
Pediatrics 2008 Feb;121:266-75.
Finding a common agenda
• Commitment to eliciting it from both parent
and child/youth
• Setting up and “enforcing” turn-taking
– Respecting confidentiality
– Encouraging and
modeling the ability
to talk in front of each other
Crude 6-month change in child clinical measures as a
function of change in provider’s patient-centeredness
Change in SDQ symptom score
p<.0001 adjusted for baseline symptoms
Change in SDQ impact score
p=.015 adjusted for baseline function
Content: Conventional
• Psychotherapy
• Medications
Cognitive Behavioral Therapy
“From an evidence-based
perspective, cognitivebehavioral therapy is currently
the treatment of choice for
anxiety and depressive
disorders in children and
adolescents.”
Compton SN. JAm Acad Child Adolesc Psychiatry. 2004
Conventional Treatment: Rx
– TCAs - no evidence of efficacy in prepubertal children
– SSRIs - no overall evidence of efficacy in
pre-pubertal children
– SSRIs marginally better than placebo in
teens with MDD; Prozac OK for teens by
FDA
– SSRIs are HELPFUL in OCD and anxiety
disorders, even in pre-pubertal children
Safer DJ. Pediatrics, 2006; 118 (3): 1248
SSRI Side effects 1
• GI upset
• Headache; sleep
disorders
• Sexual side effects
Dizziness, Fatigue,
Sweating
• Neonatal withdrawal
syndrome
• Drug interactions
SSRI Side effects 2
• Serotonergic syndrome (HTN,
tachycardia, mania)
• Agitation and hostility
• Suicidal ideation, esp in those with
agitation/hostility
– Review of 22 RCT pediatric with 9
antidepressant drugs.
– 2298 patients with active drug; 1952 with
placebo
– Serious suicidal adverse events:
78/2298 versus 54/1952
Incidence rate ratio 1.89 (95% CI, 1.183.04)
Mosholder AD. J Child Adolesc Psychopharmacol. 2006
Psychiatric Meds in kids
• Little science of long term safety
• 1.6 million kids on 2 or more meds: ?
science
• Neurological and hormonal impact
mostly unknown
Content: natural therapies
• Depression is one of the top 10
diagnoses for which patients
seek natural therapies
• Commonly used among
depressed adolescents
• Fewer than 30% of depressed
teens tell docs they are using
natural therapies
• Clinicians need to ask!
Integrative Approach
• Lifestyle – Environment,
Exercise/Sleep,
Nutrition, Mind-Body
• Supplements
• Massage
• Acupuncture
Lifestyle - overview
• Environment: More Sunshine, Less
TV
• Exercise/Sleep (more of both)
• Nutrition (Essential nutrients for
optimal brain function, EFA, amino
acids, vitamins, minerals)
• Mind-Body Therapies – manage
stress
– Meditation
– Biofeedback
Sunshine, circadian
rhythms and sleep
Desynchronization of internal rhythms plays an
important role in the pathophysiology of
depression.
Resetting normal circadian rhythms can have
antidepressant effects.
“Winter depression was first modeled on regulation
of animal behavior by seasonal changes in day
length, and led to application of light as the first
successful chronobiological treatment in
psychiatry.”
Fuchs E. Int Clin Psychopharmacol, 2006
Wirz-Justice A. Int Clin Psychopharmacol. 2006
Light Therapy for Depression
Plus 3 studies not included in this review, comparing dim light to bright
light. Golden R. Am J Psychiatry. 2005
Light therapy
• Proven effective for SAD (Terman M
Evid Based Ment Health, 2006)
• Meta-analysis of studies from
1987-2001: (effect size=0.53, 95%
CI=0.18 to 0.89, similar to
medications) for non-SAD
• RCT of 29 women with nonseasonal depression; light therapy
for 28 days significantly better than
control, (McEnany GW, 2005)
Light Therapy 2
• Benefits onset within 2 days;
effective in institutionalized
elderly and community;
effective in summer and winter
• Side effects: hypomania,
autonomic hyperactivation
(Terman
M, 2005)
Turn off Depressing TV
• Respondents who repeatedly saw "people
falling or jumping from the towers of the
World Trade Center" had higher prevalence
of PTSD (17.4%) and depression (14.7%)
than those who did not (6.2% and 5.3%,
respectively).
• Depressive symptoms after the hurricane
were predicted by watching television
coverage of the looting that occurred in New
Orleans
Ahern, Psychiatry, 2002
McLeish. Depress Anx, 2008
Lifestyle 2: Exercise
• Depressed mood / fatigue are
common in those deprived of
usual exercise.
• Mood changes noted in
patients with injuries and
mono.
• Changes over time in kids’
exercise/gym/playground time
• Exercise benefits depression *
• Common sense precautions
Berlin AA. Psychosomatic Med, 2006
Exercise as Therapy – Yes
Lawlor DA. BMJ 2001
Yoga for depression
• Five RCTs --each
used different forms of
yoga.
• All trials reported
positive findings
• No adverse effects
except fatigue and
breathlessness
Pilkington K. J Affective Disord, 2005
Lifestyle 3: Sleep
• Poor sleep is barometer of depression
• Reduced sleep equals impaired focus and
labile mood (ADHD, Learning problems)
• Sleep quality is a good screen for good
mental health in pediatric population
• We sleep 20% less than we did 100 yrs
ago
• Promote healthy sleep!
Lifestyle 3: Sleep Hygiene
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•
•
•
•
•
•
•
Regular time; Routine
Hot bath; cool room; dark room
Massage before bed
Lavender, chamomile, melatonin?
No caffeine within 8 hours of bedtime
Music, calm, orderly, quiet
NO TV IN BEDROOM
NO vigorous exercise right before bed
GET MORE versus intentional sleep
reduction/deprivation (in those with
excessive sleep)
4: Nutrition – essential nutrients for
optimal brain function
• Omega-3 fatty acids
• Amino acids (SAM-E,
Trp, 5-HTP)
• Vitamins (B vitamins,
Vitamin D)
• Minerals (Iron,
Calcium, Magnesium,
Zinc)
Omega-6 Fatty Acids
Omega-3 Fatty Acids
Linoleic Acid (18:2n-6)
a-Linolenic Acid (18:3n-3)
∆-6 Desaturase
(GLA)γ -Linolenic Acid (18:3n-6)
Stearidonic Acid (18:4n-3)
Elongase
(DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6)
Eicosanoids
Eicosatetraenoic Acid (20:4n-3)
∆-5 Desaturase
(AA)Arachidonic Acid (20:4n-6)
(EPA) Eicosapentaenoic Acid (20:5n-3)
Elongase
24:5n-3
Eicosanoids
Leukotriene 4-series
Prostaglandins E2
Thromboxanes A2
∆-6 Desaturase
β-Oxidation
24:6n-3
Eicosanoids
Leukotriene 5-series
Prostaglandins E3
Thromboxanes A3
(DHA) Docosahexaenoic Acid (22:6n-3)
Omega 3 EFA’s: mechanism
• Neuronal membrane structure
and function
• Brain development
• Second messenger inside cells
Mood and Omega-3’s
• Inverse correlation between fish intake
and depression (Hibbeln: Lancet
1998; 351:1213; Crowe: Am J Clin Nutr,
2007)
• Effective for bipolar patients (Stoll: Arch.
of Gen. Psych. 1999; 56: 407-12)
• Effective for major depression
(Nemets: Am. J. Psych. 2002: 159 (3)
477-9)
• Effective for depression in Children (
Am J Psychiatry 2006;163:1098-0)
Fish Oil –Doses, Safety, Brands
• Dose: 1 gram daily of EPA probably
enough.(Peet M, 2002); Frangou S. Br J
Psychiatry, 2006)
• Safety: fish allergies, taste, belching; very
high doses, increased risk of bleeding,
nosebleeds? Little risk of mercury, dioxin,
PCB’s;
• Brands: Compare brands at
www.consumerlabs.com
• My family takes Coromega, Carlson’s or
Nordic Natural
• Read labels: Omega 3 does NOT
necessarily all equal EPA/DHA
Amino Acids: SAM-E
• Produced from ATP and methionine
• Low folate can lead to low levels
• Meta-analysis: SAMe significantly improves
depression, comparable to antidepressant
medications
(http://www.ahrq.gov/clinic/epcsums/samesu
m.htm)
• In an open trial of 30 adults with MDD for
whom antidepressant meds ineffective,
SAM-E led to significant improvements in
50% and remission in 43% (Alpert, 2004)
• All tested products approved by
ConsumerLab; buy on sale!
SAM-E Doses, duration, products
• Dose: 800 – 1600 mg daily (adult)
• Benefits appear within 2-4 weeks of
starting daily use
• Problems –poorly absorbed (need
enteric coating); mania in bipolar
patients; interactions with SSRI
meds; see:
http://www.consumerlabs.com/results
/same.asp
• http://www.umm.edu/altmed/ConsSu
pplements/SAdenosylmethionineSA
Mecs.html
Amino Acids: 5-HTP and L-tryp
• Acute tryp depletion leads to
depression
• Dietary L-tryp -> 5-HTP ->
serotonin
• Meta-analysis: 5-HTP and Ltrp 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
• 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?
Vitamin B6 - pyridoxine
• Low levels of pyridoxal phosphate (PLP)
are associated with depressive symptoms
(Hvas AM 2004)
• Dose: 100 – 200 mg daily benefits PMSdepression; Odds ratio ~2.(Wyatt KM. BMJ, 1999)
• Side effects: nausea, vomiting, abd. pain,
anorexia, headache, somnolence, lower
B12 levels, sensory neuropathy (typically
with doses over 1000 mg daily, can occur
lower)
• Food: Beans, nuts, legumes, fish, meat
Folate and B12
• Folate
– Lower levels of folate in depressed persons
– Low folate associated with poorer response to
antidepressant meds
– Supplemental folate can improve response to
meds
• B12
– Lower levels in depressed persons
Bottom line on Amino acids
andB vitamins
• Healthy diet rich in green
vegetables and nutritious
protein sources
• Consider B-complex
supplement
Vitamin D and depression
• Vitamin D receptors in brain
• Low level of serum 25-hydroxyvitamin
D and high PTH are significantly
associated with depression (Jorde, 2005)
• 25-hydroxyvitamin D3 and 1,25dihydroxvitamin D3 levels are
significantly lower in psychiatric
patients than in normal controls
(Schneider, 2000)
• RCT of 44 Australian patients (none,
400 IU versus 800 IU vitamin D)
vitamin D3 significantly enhanced
mood (Landsdowne, 1998)
Mood and Minerals: Iron
• Iron deficiency associated
with depression
• Correcting iron deficiency
helps with mood and
attention
Beard JL. J Nutr, 2005
LE Murray-Kolb. Am J Clin Nutr, 2007
Mood and Minerals: Calcium
• Lower levels of calcium in
depressed persons
• Higher PTH in depressed
persons
• Estrogen regulates calcium and
PTH metabolism; sometimes
dysregulates? (Thys-Jacobs S. J Am Coll Nutr,
2000)
• Supplementation may benefit
women with PMS-related
depression (Dickerson LM. Am Fam
Physician, 2003)
• 1000 – 1200 mg daily
Non-dairy sources of calcium
• Soy beans, tofu
• Calcium fortified OJ
• Green leafy vegetables
(broccoli)
Nutrition Summary
• Healthy fat (omega 3); not fried foods, saturated
fats
• Healthy protein (essential amino acids)
• Foods rich in minerals and vitamins (vegetables,
beans, grains)
• Multivitamin-mineral supplement
• Fish oil supplement
• Consider SAM-E, B vitamins, Calcium
• Iron if deficient
Lifestyle: Stress management
• Stress is common
• Stress commonly triggers mood problems
• Managing stress: exercise, sleep, nutrition,
mind/emotion/body/spirit
– Meditation
– Biofeedback
Meditation
• Meditation training ↑ left-sided
anterior activation, a pattern
associated with positive affect, in
meditators compared with the
nonmeditators
• No RCTs specifically on
depression, though positive
effects on anxiety
• Few side effects; can combine
mindfulness with CBT
Davidson RJ Psychosom Med, 2003
Stress, Emotion, and Physiological Activation
High Arousal/High Energy
SYMPATHETIC
Low Arousal/Low Energy
PARASYMPATHETIC
Stress, Emotion, and Physiological Activation
High Arousal/High Energy
SYMPATHETIC
“Fight-or-Flight”
Negative
Positive
Emotion
Emotion
Low Arousal/Low Energy
PARASYMPATHETIC
Stress, Emotion, and Physiological Activation
High Arousal/High Energy
SYMPATHETIC
“Fight-or-Flight”
Frustration, Anger, Hostility,
Exhilaration, Passion,
Joy, Happiness
Fear, Worry Anxiety
Judgment, Resentment,
Feeling Overwhelmed, Anguish
Love, Care,
Kindness, Appreciation
Negative
Positive
Emotion
Emotion
Hopelessness, Submission,
Despair, Depression
Compassion, Tolerance,
Acceptance, Forgiveness
Burnout, Withdrawal,
Serenity, Inner Balance,
Boredom, Apathy
Reflection, Contentment
Low Arousal/Low Energy
PARASYMPATHETIC
Stress management: biofeedback
• HRV biofeedback appears to be a useful
adjunctive treatment for the treatment of MDD
• Significant improvements in
– Hamilton Depression Scale (HAM-D)
– Beck Depression Inventory (BDI-II) by week 4,
Karavidas, et al. Appl Psychophysiol Biofeedback. 2007
Nolan RP. Am Heart J, 2005
Promote Social Support
• Religiosity (participation) helps
protect against depression
• Participation in extracurricular
clubs helps protect teens against
depression
• Participation in organized
athletics is protective
• Ongoing volunteer work is
protective
• Connected people are happier
people
After lifestyle and stress
management, what?
• St. Johns’ wort
• Massage
• Acupuncture
Saint Johns wort
• Most commonly used CAM therapy for depression
• 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, but no 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)
Massage
• Increased blood flow and lymphatic drainage; Muscle
relaxation; Stress reduction
• Balances R & L prefrontal cortex activity in those with
right dominance (Jones N Adolescence. 1999)
• Decreased levels of cortisol and increased levels of
serotonin and dopamine in depressed adults (Field T. Int J
Neurosci. 2005)
•
In depressed pregnant women, massage, compared
with progressive relaxation, led to higher dopamine and
serotonin levels and lower levels of cortisol and
norepinephrine (Field T. J Psychosom Obstet Gynaecol. 2004 )
• Who volunteers?
Acupuncture
• RCT of 30 patients: BDI scores fell
from baseline by 16.1 points in the
intervention group versus 6.8 points
in the sham controls (P<0.001)
(Acupunct Med. 2005)
• Meta-analysis: the effect of
electroacupuncture similar to
antidepressant medication(Mukaino Y
Acupuncture Med, 2005).
• Good safety profile. Rare infections,
broken needles, forgotten needles,
bleeding, bruising
Depression SUMMARY 1
• Listen to patients and
families
• Negotiate clear goals and
agreements
• Support healthy lifestyle,
including sunshine, sleep,
exercise, nutrition
(supplement when
necessary), and stress
management
Depression SUMMARY 2
• Correct deficiencies of B vitamins
and minerals
• Consider supplements of fish oil,
SAM-E, 5-HTP
• Consider safe therapies, including
massage and acupuncture
• Beware of potential interactions, e.g.,
Saint Johns wort
• Be PRACTICAL – How?
How: Behavioral Pediatrics
•
•
•
•
•
•
•
•
Identify the goal
Consider various strategies
Pick a strategy
Identify a small, achievable step that the patient
and family can support
Explore pros and cons of change
Anticipate barriers; identify resources
Plan rewards/celebrations!
Re-evaluate; take the next step
Goal-setting
• Pick a POSITIVE goal
– E.g., healthier lifestyle.
Example: Healthier lifestyle
To promote
Better mood
Better focus or concentration
Greater calm
More resilience
More cheerfulness
Greater adaptability
More confidence More creative
More clarity
Better memory
More harmonious relationships
Higher self esteem
More consistent with personal values
other?
Pick a specific strategy
•
•
•
•
•
•
More exercise
Better nutrition
Judicious use of supplements
Better sleep
Healthier environment
Stress management; biofeedback; journal;
meditation
• Use medication
• Massage, psychotherapy, acupuncture or other
professional help
Identify a small, achievable step
• Rome was not built in a day; habits are not
changed overnight: BABY STEPS.
• For exercise, go from sedentary, to 5
minute walks with the dog 5 days a week.
• Be specific (with or without an MP3 player;
with or without a parent; regardless of
weather?; distance vs. time)
How important is this to you?
0 1 2 3 4 5 6 7 8 9 10
Not
Very
Why did you pick that number and not a lower
number? (e.g. a 7 instead of a 5)
Asking this question helps the patient/family provide
their own rationale for why this is important. They
talk themselves into it!
How confident are you that you
can do this for one month?
0 1 2 3 4 5 6 7 8 9 10
Not
Very
If they pick an 8 or higher (pretty confident), proceed with
next step of making a chart and planning rewards and
follow-up.
If they pick a number less than 8,
“What would it take for you to go from the number you
picked to a higher number?” Begin to explore their
ambivalence…. It’s OK to be ambivalent about change!
Identify Pros and Cons
Change
PRO
CON
More cheerful
Change routine
More fit and cool
Brother might tease
Clothes fit better
Yucky dog clean up
Better sleep
Better self-esteem
No Change
Easy
Continued mood probs
Mom does yucky job
Get fat
Feel ugly
Sleep badly
Unhappy with myself
Identify Barriers and Resources
• In addition to (cons listed above), what other
barriers or challenges might you anticipate as
you try to make this change? Need new tennis
shoes; need leash; need pooper-scooper
• What resources do you have/need to help you
make this change? Will Mom commit to getting
new shoes, leash, etc. ? Will the child want/need
a reminder? Is it helpful for Dad to do that? Do
they need a chore chart? A calendar?
Plan celebrations/rewards
• Pick a tangible reward and timing (will it be offered after
week 1, 2, 3, 4?)
• Samples: extra time with mom or dad; extra phone
minutes; new walking shoes; get to pick vegetable for
dinner!; get to pick family movie; stickers for younger
kids; money for older kids – controversial in some
families. Support the family and child choices.
• Emphasize the importance of the reward/celebration. If
the family says they expect “good” behavior, suggest
they consider celebrating it (instead of rewarding it).
Sample behavior diary (OK to copy)
Goal
Sample:
M
Walk dog 5 minutes 5
days a week
√
Week 1
Week 2
Week 3
Week 4
Re-evaluate.
Celebrate.
Next steps?
T
W
Th
√
√
Fri Sa
√
√
Su
Total
5
Follow Up
• Follow- up in 4-6 weeks.
• Ask family/child to bring chart and say you
plan to be proud of them (build expectation
of success) and will ask them what they’d
like to do for next step (involve them in
problem solving).
• Do it!
Behavioral Pediatrics
•
•
•
•
•
•
•
•
Identify the goal
Consider various strategies
Pick a strategy
Identify a small, achievable step that the patient
and family can support
Explore pros and cons of change
Anticipate barriers; identify resources
Plan rewards/celebrations!
Re-evaluate; take the next step
Resources
• Kemper KJ, Shannon S. Complementary and
alternative medicine therapies to promote
healthy moods.Pediatr Clin North Am. 2007
Dec;54(6):901-26
• Motivational Interviewing: Preparing People to
Change by Miller and Roznik
• Natural Medicines Comprehensive Database
• Natural Standards
• http://www.besthealth.com/Integrated
+Medicine/