Hani hamed dessoki, alternative ttt of depression

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  • 1. By: Dr. Hani Hamed Dessoki, M.D. Psychiatry Associate Prof. Psychiatry Acting Head, Psychiatry Department Beni Suef University Supervisor of Psychiatry Department El- Fayuom University 2013

2. Agenda Introduction What is CAM? Essential nutrients for optimal brain function Herbal remedies and supplements Mind body connections 3. 22 1432 202011 13645608 450 . 140, 200.. 130 .. 200. 4. Introduction Therearemorethan70differenttypesofalternative therapy. Somearesowellknownthattheyarealmostmainstream medicines,whileothersseemsobizarreasstilltobeon theveryfringesoffringemedicine. Acupuncture,herbalmedicine,Homoeopathy,and Aromatherapyarealreadypractisedinseveralcountries. 5. History of Alternative Medicine 6. What is CAM? Complementary modalities (therapies): used in conjunction with conventional medical practice. (Wilkinson, p. 1019) Alternative Modalities(therapies): used instead of traditional care. (Wilkinson, p.1019) 7. Important Points 1.Be non-judgmental despite personal opinions 2. Build rapport by showing client respect if not, he may be afraid to tell about CAM use 3. Understand that C.A.M. can be beneficial, when used correctly 4. Be aware that C.A.M. can be dangerous if it interacts or interferes with conventional treatment 8. Important Points 5. Be willing to teach the public about the positive and negative information regarding C.A.M. 6. Be aware that use of C.A.M. is popular and increasing and must be included in the history & physical exam. 7. Know that Herbals, in particular, can have significant effect on prescription drugs and body function. 9. 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! 10. Integrative Approach Lifestyle Environment, Exercise/Sleep, Nutrition, Mind-Body Supplements Massage Acupuncture 11. 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 12. 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 13. Light therapy Proven effective for SAD (Terman M Evid Based Ment Health, 2006). Benefits onset within 2 days; effective in institutionalized elderly and community; effective in summer and winter Side effects: hypomania, autonomic hyperactivation (Terman M, 2005) 14. Turn off Depressing TVDepressing 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). Ahern, Psychiatry, 2002 McLeish. Depress Anx, 2008 15. Nutrition essential nutrients for optimal brain function Omega-3 fatty acids Amino acids (SAM-E) Vitamins (B vitamins, Vitamin D) Minerals (Iron, Calcium, Magnesium, Zinc) 16. Omega-3 fatty acids Eating a diet rich in omega-3s or taking omega-3 supplements may help ease depression, especially when used in addition to standard depression treatments. These healthy fats are found in cold-water fish, flaxseed, flax oil, and walnuts. 17. Omega-6 Fatty Acids Omega-3 Fatty Acids Linoleic Acid (18:2n-6) a-Linolenic Acid (18:3n-3) (GLA) -Linolenic Acid (18:3n-6) (DHGLA) Dihomo--Linolenic Acid (20:3n-6) (AA)Arachidonic Acid (20:4n-6) Eicosanoids Leukotriene 4-series Prostaglandins E2 Thromboxanes A2 Eicosanoids Stearidonic Acid (18:4n-3) Eicosatetraenoic Acid (20:4n-3) (EPA) Eicosapentaenoic Acid (20:5n-3) 24:5n-3 24:6n-3 (DHA) Docosahexaenoic Acid (22:6n-3) Eicosanoids Leukotriene 5-series Prostaglandins E3 Thromboxanes A3 -6 Desaturase Elongase -5 Desaturase Elongase -6 Desaturase -Oxidation 18. Omega 3 EFAs: mechanism Neuronal membrane structure and function Brain development Second messenger inside cells 19. Mood and Omega-3s 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) 20. S-adenosylmethionine Pronounced "sammy," this is a synthetic form of a chemical that occurs naturally in the body. It's not approved by the FDA to treat depression in the United States. Rather, it's classified as a dietary supplement. Side effects are usually minimal, but SAMe can trigger mania in people with bipolar disorder. 21. 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 ) 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). 22. Folate Low levels of folate, a B vitamin, may cause a slowed response to some antidepressants. Taking folate supplements (folic acid) may be helpful when used in addition to antidepressants. 23. L- Methylfolate Deplin (in US) 15mg Folate supplement Adjunct therapy in depression Other indication as adjunct in schizophrenia for negative and cognitive symptoms 24. Vitamin B6 - pyridoxine Low levels of pyridoxal phosphate (PLP) are associated with depressive symptoms (Hvas AM 2004) Dose: 100 200 mg daily benefits PMS- depression (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 25. Vitamin D and depression Vitamin D receptors in brain Low level of serum 25-hydroxyvitamin D and high PTH are significantly associated with depression (Jorde, 2005) 25-hydroxyvitamin D3 and 1,25- dihydroxvitamin D3 levels are significantly lower in psychiatric patients than in normal controls (Schneider, 2000) RCT of 44 Australian patients ( 400 IU versus 800 IU vitamin D) vitamin D3 significantly enhanced mood (Landsdowne, 1998) 26. 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 27. 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 28. Non-dairy sources of calcium Soy beans, tofu Calcium fortified OJ Green leafy vegetables (broccoli) 29. Chocolate and mood Insulin inhibits theInsulin inhibits the reuptake ofreuptake of norepinephrinenorepinephrine and enhances the blood-enhances the blood- brain transport ofbrain transport of tryptophan, atryptophan, a precursor ofprecursor of serotoninserotonin. 30. Herbal remedies and supplements St. John's wort.KnownscientificallyasHypericum perforatum,thisisanherbthat'sbeenusedfor centuriestotreatavarietyofills,includingdepression. It'snotapprovedbytheFDAtotreatdepressioninthe UnitedStates. Rather, it's classified as a dietary supplement. However, it's a popular treatment in Europe for mild or moderate depression. But,itcaninterferewithotherdepressionmedicines,as wellassomedrugsusedtotreatpeoplewithheart disease,seizures,cancerandorgantransplant. 31. Saint Johns wort Comparable to sertraline in German RCT of 241 depressed adults (Gastpar. Pharmacopsychiatry, 2005) 2 open label trials in teens showed improvement within 2 weeks in 25/33 and 9/11 patients (Findling, 2003; Simeon, 2005); Improvement in 2 weeks predicts long-term response; if no benefit in 2 weeks, stop. 32. Herb- drug interactions: SJW Speeds elimination of many drugs: digitalis, theophylline, clarithromycin, erythromycin, protease inhibitors Other side effects - photosensitivity, serotonergic syndrome 33. Lifestyle: Stress management Stress is common Stress commonly triggers mood problems Managing stress: exercise, sleep, nutrition, mind/emotion/body/spirit Meditation Biofeedback 34. Stress, Emotion, and Physiological Activation High Arousal/High Energy SYMPATHETIC PARASYMPATHETIC Low Arousal/Low Energy 35. Stress, Emotion, and Physiological Activation High Arousal/High Energy SYMPATHETIC PARASYMPATHETIC Low Arousal/Low Energy Negative Emotion Positive Emotion Fight-or-Flight 36. Stress, Emotion, and Physiological Activation High Arousal/High Energy SYMPATHETIC PARASYMPATHETIC Low Arousal/Low Energy Negative Emotion Positive Emotion Fight-or-Flight Frustration, Anger, Hostility, Fear, Worry Anxiety Judgment, Resentment, Feeling Overwhelmed, Anguish Hopelessness, Submission, Despair, Depression Burnout, Withdrawal, Boredom, Apathy Exhilaration, Passion, Love, Care, Joy, Happiness Kindness, Appreciation Compassion, Tolerance, Acceptance, Forgiveness Serenity, Inner Balance, Reflection, Contentment 37. Mind-body connections The connection between mind and body has been studied for centuries. Complementary and alternative medicine practitioners believe the mind and body must be in harmony for you to stay healthy. Mind-body techniques that may be tried to ease depression symptoms include: - Acupuncture - Yoga - Meditation - Guided imagery 38. Mind-Body Meditation Stress relief/ reduce anxiety Relaxation Reduced levels of lactic acid Decreased oxygen consumption Slowed heart rate Decreased blood pressure Improved function of immune system Reduce pain Relieve symptoms of psoriasis Improve health (References: Ignativicius; Wilkinson) 39. Relaxation Relaxation techniques To reduce anxiety, tension & emotional tension which can exacerbate pain Progressive muscle relaxation (PMR) Promoting sleep Can be taught in home setting 40. Guided Imagery Distraction when confronting pain, discomfort or fear Making decisions and altering behavior Caution: not recommended for emotionally unstable or cognitively impaired client Helps reduce pain. Reduction of nausea & vomiting. Decreasing anxiety Promoting comfort during cancer treatment 41. Spiritual Life force beliefs found in most cultures. (Wilkinson, p 1020) Faith healing (Wilkinson page 260) 42. 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 43. Other Movement Therapies Dance Therapy 44. Take Home Message Keep in mind that nutritional and dietary products aren't monitored by the FDA the same way medications are. You can't always be certain of what you're getting and if it's safe. Also, be aware that some herbal and dietary supplements can interfere with prescription medications or cause dangerous interactions. 45. ThoughtsComments