INTEGRATIVE MEDICINE APPROACH TO DEPRESSION & ANXIETY

GREGSHUMER,M.D.,M.H.S.A

CLINICALASSISTANTPROFESSOR

DEPARTMENTOFFAMILYMEDICINE

OCTOBER5TH,2018

DISCLOSURES

•  Nofinancialorotherdisclosurestomake

OUTLINE

•  CasePresentaLons

•  Background

•  ReviewofStandardTreatments

•  Herbs&Supplements

•  OtherModaliLes

•  BacktotheCases

CASE 1: SL

•  HPI:41yohealthyfemalepresenLngforconsultaLonregardinganxiety,panicaXacks,PTSD,andfaLgue

•  Historyofphysicalabusefrombrother(8-11yo)andsexual/emoLonalabusefromex-boyfriend(25-35yo)

•  DevelopedsymptomsofweeklypanicaXacks,PTSD,andanxietyin2013

•  Treatments:•  CBT&Mindfulness-basedyogaprogramin2014

•  StartedonZolo_50mgandithelped,buthassincedisconLnued

•  Xanaxasneeded,usesrarely

•  Currentlyseesatherapistweekly

•  NowinanewrelaLonshipandsymptomsworsening,wouldliketoknowotheropLons

•  Alsowithworseningtension/achesandpainsinshouldersandneck,wouldlikerecommendaLons

•  PHQ-910,GAD-712

CASE 2: JN

•  46yofemalew/historyofmigraines,insomnia,anddepressionpreviouslyonCelexa(disconLnued1yearago)presentsforworseningdepression&anxiety

•  Reportsbaseline“anxiety&irritability.”Celexahelped,butfeltsluggish&worseinsomeways–flataffect,lessproducLveatwork

•  Symptomsgraduallyworseningsinced/cCelexa

•  Snappingatkidsandhusbandforsmallthings,likewrappingpresentstooslowly

•  TriedCBT,didnotlikeit/nothelpful

•  Nocurrentexercise.DietisOK

•  ROS:•  Frequentnighlmeawakenings;cannotfallbackto

sleep

•  HotflashesintermiXentlyandworsening

•  PHQ9:4

•  GAD7:18

CASE 3: MR

•  23yomalewithworseningdepression,lackofenergy,over-sleeping

•  Lowself-esteem,hasdifficultyleavinghome.SLllfuncLoningOKatwork;reportsgoodsocialsupport.Livesathomewithparents.

•  Otherwisehealthy.NotonanymedicaLons.DoesnotwanttostartSSRIduetoconcernforsexualsideeffects

•  Notintherapy;hasnottriedothertherapies

•  ROS:OtherwisenegaLve

•  PHQ9:20

•  GAD7:6

CASE 4: DS

•  DSisa43yomalepresenLngforanger/irritabilityissues

•  Upsetbecauseheissnappingathiswifefor“sillythings”likedishesorcluXeraroundthehome.Alsowithstressatwork,strugglingwithinsomnia

•  Hasneverbeenseenfordepressionoranxietybefore,butwouldliketreatment

•  Lifestyle:Healthydiet,exercisesmostdaysduringweekbutlesslately.Liveswithwifeandchildren

•  ROSotherwisenegaLve.

•  PMHx:HTNandgout.OnLisinoprilandallopurinol

•  PHQ9:12

•  GAD7:15

CASE 5: JT

•  JTisa76yofemalepresenLngforseveralvagueconcernsandisrequesLnglabstofindcause:

•  Changeinbowelhabits–someincreasedurgencyandhastogoa_ermeals

•  DecreasedappeLteinthemorning

•  Coldintolerance

•  EnergycrashandfaLgueina_ernoons

•  Significanthistoryoflossandgrief.

•  Herhusbandpassedawayfiveyearsagoandtheanniversaryisnextweek(alwaysahardLmeofyear).

•  HerbrotherpassedawayinDecember2017,andalsotwootherrecentdeathsofpeoplesheknewwell(aclosefriend,andapreviousclient)

•  PMHx:EssenLalHTNandBPPV.

•  SocialHistory:ReLred,livesalone.Previouslyworkedaspsychotherapistandasanurse.HasgoodfriendswhoshespendsLmewithweekly

BACKGROUND: DEPRESSION

DSM5Criteria:Atleast5of9symptomspresentmostdaysover2weeksperiod1)Depressedmoodmostoftheday

2)DiminishedinterestorpleasureinacLviLes

3)DecreaseorincreaseinappeLte

4)Insomniaorover-sleeping

5)PsychomotoragitaLonorslowmovements

6)FaLgueorlossofenergy

7)Feelingsofworthlessnessorinappropriateguilt

8)DifficultyconcentraLng,orindecisiveness

9)Recurrentthoughtsofdeath/SI

DSM5–MajorDepressiveDisorder

BACKGROUND: ANXIETY

DSM5forGeneralizedAnxietyDisorder(GAD),3ormoreof6symptomsformostdaysover6monthperiod

1)  Restlessness,feeling“onedge”

2)  EasilyfaLgued

3)  DifficultyconcentraLng

4)  Irritability

5)  Muscletension

6)  Sleepdisturbance

DSM5–GeneralizedAnxietyDisorder

BACKGROUND: DEPRESSION & ANXIETY

•  Depression&Anxietyareo_encomorbidandexisttogetheralongaspectrum

•  Verycommon•  AdultU.S.Prevalence:10%fordepression,18.1%foranxietydisorders

•  Over100millionprescripLonsannuallyforanLdepressants

•  CommoncondiLonforwhichintegraLveandalternaLvetherapiesdesired

•  Subtypesarecommon•  Depression:Dysthymia(persistentmilddepression),SeasonalAffecLveDisorder

•  Anxiety:GAD,OCD,PanicDisorder,Phobias,PTSD

•  Individualswithdepression&anxietyseekprimarycareservicesathigherratesthanothers

•  PsychosomaLcsymptomsarecommon(GI,headaches,palpitaLons)

CDC:PrevalenceofDepressionAmongAdultsAged20andOver:UnitedStates,2013–2016.

INTEGRATIVE MODEL

Sleep/Rest/RejuvinaLon

NutriLon

PhysicalacLvity

PhysicalpainMedicalcondiLons

Stress/anxiety

Guilt/shame

PsychcondiLons

Self-worth

Community

Spirituality

Love

Substanceuse

INTEGRATIVE MODEL

Sleep/Rest/RejuvinaLon

NutriLon

PhysicalacLvity

PhysicalpainMedicalcondiLons

Stress/anxiety

Guilt/shame

PsychcondiLons

Self-worth

Community

Spirituality

Love

Medications

Movement therapies & physical activity

Herbs & supplements

Nutrition

Sleep hygiene

Counseling / Therapy

SubstanceuseMindfulness practice Body work

Yoga / mindful movement

Acupuncture

Journaling

Gratitude & Self-compassion

Biofeedback

Encourage maintaining healthy relationships

Motivational interviewing

Prayer

LIFESTYLE: EXERCISE

•  SeveralstudiesdemonstratethatexerciseisaseffecLveasanLdepressantsorpsychotherapy,andsuperiorinprevenLngrecurrenceofdepression(1,2)

•  Exercise+medicaLonsaremoreeffecLvethaneitheralone

•  TotalenergyexpendituremoreimportantthanLmesperweek.Benefitforaerobicandanaerobicexercise

•  Highintensitywork-outssuperiortolow-intensity(3)

•  BOTTOMLINE:WriteanexerciseprescripLonforallpaLents;tailorthetypeofexercisetosomethingthepaLentenjoys.Besttodiversifyexerciseswithaerobic,anaerobic,andstretching.

1.BlumenthalJAetal.Exerciseandpharmacotherapyinthetreatmentofmajordepressivedisorder.2.Rimer,K.Dwan,D.A.Lawlor,C.A.Greig,M.McMurdo,W.Morley,G.E.Mead:Exercisefordepression.CochraneDatabaseSystRev.20127.3.RakelD:IntegraLveMedicine,4thediLon.2017

LIFESTYLE: NUTRITION

1)  Limitsimplesugars&alcohol

•  IncreasedconsumpLonofsimplesugarsandprocessedfoodsindepressed&anxiousindividuals(1)

•  Alcoholproblemsmorecommonindepression&anxiety,andreducLonimprovessymptoms

2)Mediterranean-stylediet>Westerndiet

3)Improveomega3:omega6raLothroughdietand/orsupplementaLon.

•  Supplement:>60%EPA,aimforatleast1000mgcombinesEPA+DHAdaily.ConsumpLonof2-3servingsofcold-waterfish(herring,mackerel,salmon,sardines)weeklyiscomparable

1.WestoverAN,MarangellLB.Across-naLonalrelaLonshipbetweensugarconsumpLonandmajordepression.2.Peet,D.F.Horrobin:Adose-rangingstudyoftheeffectsofethyl-eicosapentaenoateinpaLentswithongoingdepressiondespiteapparentlyadequatetreatmentwithstandarddrugs.

MEDICATIONS

•  SSRIMedicaLons

1)  FluoxeLne(Prozac)20-80mg/day

2)  Sertraline(Zolo_)50-100mg/day

3)  Citalopram(Celexa)20-60mg/day

4)  Escitalopram(Lexapro)5-20mg/day

5)  ParoxeLne(Paxil)20-60mg/day

•  First-linefortreatmentofdepressionandanxiety

•  Commonsideeffects:

•  GIsideeffectswhenfirststarLngmedicaLon,usuallyimproveswithLme

•  Sexualsideeffects

•  Drowsiness,insomnia,worseningagitaLon

MEDICATIONS

•  SerotoninNorepinephrineReuptakeInhibitors(SNRI)

1)  Venlafaxine(Effexor)75-375mg/day

•  SimilarsideeffectsasSSRI,lesssexualsideeffects

•  Bestfor:failedSSRI,comorbidmenopausalsymptoms(hotflashes),orcomorbidanxiety

2)  DuloxeLne(Cymbalta)20-60mg/day

•  Bestfor:failedSSRIorcomorbidchronicpain

•  DopamineNorepinephrineReuptakeInhibitors

1)  Bupropion(Wellbutrin)150-450mg/day

•  MostacLvaLng;goodforlow-energy,apatheLcpaLent

•  CancombinewithSSRI

•  Serotonin&alpha-2receptorblocker

1)  Mirtazapine(Remeron)

•  PromotessleepandincreasesappeLte/weightgain

PSYCHOTHERAPY

•  Usefulasmonotherapy,andmorebeneficialthanmedicaLonalonefordepressionandanxiety

•  Meta-analysisevaluatedfordifferencesbetweensevendifferenttypesofpsychotherapyformild-moderatedepressionandfoundallwerehelpfulwithnostaLsLcallysignificantdifferences:•  CogniLve-behaviortherapy

•  NondirecLvesupporLvetreatment

•  BehavioralacLvaLontreatment

•  Psychodynamictreatment

•  Problem-solvingtherapy

•  Interpersonalpsychotherapy

•  Socialskillstraining

Cuijpers,P.,vanStraten,A.,Andersson,G.,&vanOppen,P.(2008).Psychotherapyfordepressioninadults:Ameta-analysisofcomparaLveoutcomestudies.JournalofConsul7ngandClinicalPsychology.

SUPPLEMENTS & BOTANICALS: ST. JOHN’S WORT

•  Floweringplantthatgrowsintemperateregionsworldwide.Usedforcenturiestotreatdepression

•  MechanismofacLon:

•  Affectsserotonin,dopamine,norepinephrine,andGABAreuptakeinhibitors

•  InhibitsIL-6andincreasescorLsolproducLon

•  Invitro:affectsmonoamineoxidaseandL-glutamate

•  ClinicaleffectislikelysummaLveofmulLpleweakmechanisms

RakelD:IntegraLveMedicine,4thediLon.2017

SUPPLEMENTS & BOTANICALS: ST. JOHN’S WORT •  Safety:Generallysafe.MainprecauLoniswithCYP3A4

inducLon.PrecauLonwithseveraldrugs:macrolideanLbioLcs,HIVdrugs,benzodiazepines,CCBs,staLns,contracepLves,warfarin

•  Sideeffects:MuchlessthanSSRIs.GIandheadachesmostcommon

•  CochraneReview2008:SuperiortoplaceboandaseffecLveasstandardanLdepressants(SSRI)formajordepression,withfewersideeffects

•  Dosing:

•  Generaldosingrange900-1200mgdaily

•  Start300mgor450mgdaily&increaseevery3-5daystogoaldoseof300mgTIDor450mgBID

•  Avoida_er6pm,canbeacLvaLng

•  Standardizedto0.2%-0.3%hypericin,or3-5%hyperforin

K.Linde,M.M.Berner,L.Kriston:St.John’sWortformajordepression.[updateofCochraneDatabaseSystRev.2005;(2):CD000448]CochraneDatabaseSystRev.

SUPPLEMENTS: RHODIOLA ROSEA

•  TradiLonalmedicinecultureshaveusedRhodiolaroseaasanherbtopromoteworkendurance,resistanceagainstfaLgue,depression,andothercondiLons

•  Mayenhancemoodviaeffectsoncentralbiogenicaminesandendorphins

•  MaysLmulatenorepinephrine,serotonin,dopamine,andacetylcholinereceptorsinbrain

•  Goodsafetyprofile

MaoJJetal.Rhodiolaroseaversussertralineformajordepressivedisorder:Arandomizedplacebo-controlledtrial

SUPPLEMENTS: RHODIOLA ROSEA

•  High-qualityRCTcomparedRhodiolaversussertraline50mgformild-moderatedepressionandfoundbothbeXerthanplacebo,andequallyeffecLve

•  Rhodiolawithfewersideeffectsandsmallerdrop-outrate

•  Dosing:200-400mg1-2Lmesdaily

•  Sideeffects:anxiety/jiXeriness

MaoJJetal.Rhodiolaroseaversussertralineformajordepressivedisorder:Arandomizedplacebo-controlledtrial

SUPPLEMENTS: S-ADENOSYLMETHIONINE (SAM-E)

•  SAMe:Methyl-donorinvolvedinproducLonofnorepinephrine,dopamine,andserotonin

•  Evidence:SmallstudiesdemonstrateeffecLveness.Someshownobenefitoverplacebo(1-2)

•  Safety:Extremelysafe;thoughcauLonusewithSSRIsduetosimilarmechanism

•  Sideeffects:minor;cancausenausea/diarrhea

•  Dosing:Goaldoseof800mgtwicedaily.Start200mgtwicedailyandincreaseover2weeks

1.R.DelleChiaieetal:EfficacyandtolerabilityoforalandintramuscularS-adenosyl-l-methionine1,4-butanedisulfonate(SAMe)inthetreatmentofmajordepression:comparisonwithimipraminein2mulLcenterstudies.2.Mischoulon,L.H.Price,L.L.Carpenter,etal.:Adouble-blind,randomized,placebo-controlledclinicaltrialofS-adenosyl-L-methionine(SAMe)versusescitalopraminmajordepressivedisorder.

SUPPLEMENTS: HYDROXYTRYPTOPHAN (5-HTP)

•  5-HTPisaprecursortoserotonin,andlikelyworkssimilarlytoSSRIswithfewersideeffects

•  Evidence:Cochranereviewfoundonly2of108trialsofsufficientquality,butbothshowed5-HTPsuperiortoplacebo(1)

•  Generallysafe;cauLonwithSSRIs

•  Casereportsofeosinophilia-myalgiasyndromeinpaLentstaking5-HTP,whichiswhatcausedL-tryptophantocomeoff-marketin1989.Believedtobeduetocontaminants(2)

•  Sideeffects:GIsideeffectsmostcommon

•  Dosing:50-300mgTID.Startat50-100mgandgoupfromthere

1.K.Shaw,J.Turner,C.DelMar:Tryptophanand5-hydroxytryptophanfordepression.[updateofCochraneDatabaseSystRev.2001;(3):CD003198]CochraneDatabaseSystRev.2002.2.RakelD:IntegraLveMedicine,4thediLon.2017

SUPPLEMENTS: L-THEANINE

•  L-Theanine

•  Aminoacidfoundingreentea

•  Antagonisttoglutamate,anexcitatoryneurotransmiXer

•  Increasealpha-waves,creaLngstateof“relaxedalertness”

•  Increasedopaminelevelsandreducenorepinephrinelevelsinbrain

•  Nohigh-qualitystudiesaboutL-Theanineforanxietydisorders

EschenauerG,SweetB.PharmacologyandtherapeuLcusesoftheanine.

SUPPLEMENTS: VALERIAN ROOT

•  BotanicalthathasbeenuLlizedinEuropeforanxietyforhundredsofyears

•  Anecdotallyusefulforacuteanxietyandinsomnia

•  Maytakeseveralweekstoseefullbenefit

•  Nohigh-qualitystudiesshowingbenefit

•  Dosing:300-450mgatnightordividedBID

RakelD:IntegraLveMedicine,4thediLon.2017

SUPPLEMENTS: KAVA (PIPER METHYSTICUM)

•  BotanicalopLontotreatGAD

•  Derivedfrompulverizedrootsofsubspeciesofpepperplant

•  RecognizedbyhealthauthoriLesinEuropeasrelaLvelysaferemedyforanxiety

•  Meta-analysis:6RCTsfoundkavatobesuperiortoplaceboinsymptomaLctreatmentofGAD

•  MechanismofacLon:Unclear.LikelycombinaLonofGABAreceptorsandlimbicsystem(amygdala,hippocampus)

•  Dosing:50-70mgpurifiedextractTIDPRN

RakelD:IntegraLveMedicine,4thediLon.2017

SUMMARY OF SUPPLEMENT RECOMMENDATIONS Supplement SpecificIndica8on Dosing

St.John’sWort Depressionand/orAnxiety Start:300mgor450mgdailyandincreaseover3-5daysto300mgTIDor450mgBID

SAM-E Depressionand/orAnxiety Goaldose800mgtwicedailyStart200mgtwicedailyandincreaseover2weeks

5-HTP Depressionand/orAnxiety 50-300mgthreeLmesdaily

Rhodiolarosea Depression,lowenergy,faLgue 200-400mg1-2LmesdailyStartwithoncedailydosing,andavoida_er6pm

L-Theanine Anxiety 250-500mguptoTID

ValerianRoot Anxiety,insomnia 300-450mgatnightordividedBID

Kava Anxiety 50-70mgpurifiedextractTIDPRN

SUPPLEMENTS: OTHER

•  Magnesium(200-800mgdaily):•  Helpfulforanxietywithcomorbidheadaches,

faLgue,fibromyalgia,consLpaLon

•  Nohigh-qualitystudiesfordepression/anxiety

•  B-Vitamins&Folate(400-1000mcgdaily)•  MethyldonorsforbrainneurotransmiXersand

synthesisofSAMeandserotonin

•  Large-scalestudiesarelacking

•  VitaminD(1000-2000IUdaily)•  Deficiencyassociatedwith8-14%increasein

depression

•  Meta-analysisconcludedthatvitaminDsupplementaLonimproveddepressionsymptoms

1.RakelD:IntegraLveMedicine,4thediLon.2017.2.S.Spedding:vitaminDanddepression:asystemaLcreviewandmeta-analysiscomparingstudieswithandwithoutbiologicalflaws.Nutrients.2014Apr

OTHER THERAPIES - YOGA

•  2013systemaLcreviewandmeta-analysis(12RCTs,619subjects)onyogafordepression(1)•  Shorttermimprovementsindepressioncomparedto

usualcare,relaxaLon,oraerobicexercise

•  MeditaLveyogasubgrouphadmostsignificanteffectvsexerciseorcomplexyogagroups

•  2015reviewonyogaforprenataldepression•  Yogasuperiortostandardprenatalcare,antenatal

exercisegroups,andsocialsupportfordepressionscoresindepressedandnon-depressedpregnantwomen

•  Integratedyoga(withmeditaLon)superiortoexercise-basedyoga

1.Cramer,H.,etal.YogaforDepression:ASystemaLcReviewandMeta-analysisinDepressionandAnxiety30(11):1068-10832013.2.Gong,H.,etal.(2015).Yogaforprenataldepression:asystemaLcreviewandmeta-analysis.inBMCPsychiatry15:14.2015

OTHER THERAPIES

•  MindfulnessMeditaLon&Mind-BodyMedicine

•  AcLveparLcipaLonofindividualtolearnfromtheirsymptomscomparedtopassiveprocessoftakingmedicaLonorsupplement

•  MBSR&MBCT

•  8-weekcourses(2hoursweekly)thatfocusonallowingdistressingemoLons,thoughts,andsensaLonstocomeandgowithoutgraspingontotheneedtosuppress,fight,orescapethem

•  MBCTisspecificallydesignedfordepression

•  Usefulfortreatmentandtopreventrecurrences

S.H.Ma,J.D.Teasdale:Mindfulness-basedcogniLvetherapyfordepression:replicaLonandexploraLonofdifferenLalrelapseprevenLoneffects.JConsultClinPsychol.72:31-402004

OTHER THERAPIES

•  Biofeedback•  Atypeoftherapythatteachesapersontochangeandcontrol

physiologicalprocessesthroughpracLcewithimmediatefeedback

•  Heart-ratevariability,EMG,neurofeedback

•  UsefulforsituaLonalstress,panicaXacks,specificphobias,depressionandGAD(1)

•  Acupuncture•  UNWHO:Safemonotherapyfordepression

•  CochraneReview:InsufficientevidencetomakerecommendaLon(2)

•  Phototherapy

•  30-60minutesofbright,whitelight(10,000Lux)

•  Superiortoplacebo,andeffecLveasadjuncLvetherapy(3)

•  Safeandlow-costopLon

1.GlickRM,GrecoCM.BiofeedbackandPrimaryCare.2.C.A.Smith,P.P.Hay,H.Macpherson:Acupuncturefordepression.CochraneDatabaseSystRev.(1):2010.3.RakelD:IntegraLveMedicine,4thediLon.2017

CASE 1 SL: TREATMENT PLAN

•  HPI:41yohealthyfemalepresenLngforconsultaLonregardinganxiety,panicaXacks,PTSD,andfaLgue

•  Lifestyle:

•  ConLnueregularexercisemostdaysperweekfor30minutesormore

•  MaintainandfosterhealthyrelaLonships

•  ConLnuemindfulnesspracLces(yoga,meditaLon)

•  Heartmath.org,biofeedbackresource

•  NutriLon:

•  Mediterranean-stylediet;ConLnuetoavoidtriggers

•  Supplements:

•  TheanineSerenebySourceNaturals(Theanine200mg,GABA500mg,Magnesium300mg,Taurine,HolyBasilLeaf).1-2capsules2Lmesdailyasneededforanxiety(insteadofXanax)

•  Turmeric400-500mgasneededforjointpain

•  PharmaceuLcals:

•  RestartSertraline50mgdaily.Start25mgfor1weekthenincreaseto50mgdaily

CASE 1 SL: UPDATE 6 MONTHS LATER

•  Doingwell.Theaninewashelpfulandnolongerusingbenzodiazepines

•  SLllseeingtherapistweekly

•  SLllmaintainingmindfulnesstechniques

•  Engagedandconsideringpregnancy.HadmessagedthroughtheportalandIsuggestedstoppingsupplementsduetolackofdatainpregnancy

•  PaLentbeganslowweanoffZolo_aswell,nowtaking¼tabletdaily.Symptomsreturningabit

CASE 1 SL: UPDATE 6 MONTHS LATER

•  Supplements&AnL-DepressantsinPregnancy:

•  Mostsupplementsfordepressionrecommendedagainstduetolackofdata

•  SSRIsareCategoryC,butriskconsideredlow

•  Risksofuntreateddepression/anxietyinpregnancyincludelowbirthweight,pretermdelivery,poornutriLon,reducedadherencetoprenatalcare,andsuicide

•  IdeallyshouldbediscussedbeforeconcepLon

ACOG:hXps://www.acog.org/About-ACOG/News-Room/Statements/2015/ACOG-Statement-on-Depression-Screening

CASE 2: JN TREATMENT PLAN

•  46yofemalew/historyofmigraines,insomnia,anddepressionpreviouslyonCelexa(disconLnued1yearago)presentsforworseningdepression&anxiety

•  Alsowithhotflashesintheevening

•  CheckedTSH-normal

•  Effexor:Startat37.5mgandgoupby37.5mgweeklytogoalof150mgdaily

•  TheanineSerenetwicedaily

•  ConLnueregularexercise,healthydiet

•  InformaLongivenonmindfulnessappsandbookresources

•  Discussedsleephygiene

CASE 2: JN TREATMENT PLAN

•  6-monthupdate

•  IniLallydoinggreatwiththisplan

•  2ndfollow-up:Felt“toochill.”NowGAD-7of0,butPHQ-9of8,withlowmoLvaLon

•  Updatedplan:StoptheanineandreduceEffexorto75mgdaily

•  3rdfollow-up:Doinggreat,PHQ9&GAD7of0

•  CheckedTSH-normal

•  Effexor:Startat37.5mgandgoupby37.5mgweeklytogoalof150mgdaily

•  TheanineSerenetwicedaily

•  ConLnueregularexercise,healthydiet

•  InformaLongivenonmindfulnessappsandbookresources

•  Discussedsleephygiene

CASE 3: MR TREATMENT PLAN

•  23yomalewithworseningdepression,lackofenergy,over-sleeping

•  WantstoavoidSSRIduetosideeffects

•  Lifestyle:Needtopursuesomethingintermsofhobbiesandexercise.Encouragedleavingthehouseforwalksoutdoors–mostdaysperweek.DiscussedlightboxforSAD.Healthydiet.

•  MedicaLons/Supplements:

•  St.John’sWort

•  300mgfor5days,then300mgBID,then600mginmorningand300mginevening.Increaseto600mgtwicedailyandfollow-up

•  MeetwithSWforpsychotherapy

CASE 4: DS TREATMENT PLAN

•  DSisa43yomalepresenLngforanger/irritabilityissueswithsymptomsofmilddepression,significantanxiety/irritability,andinsomnia

•  MedicaLons:Lexapro,start5mgdailyandincreaseto10mga_er6days

•  Melatoninforsleep:3-10mgatnight

•  Lifestyle:Increaseexercisetomoredaysduringtheweekatgym.Discussedsleephygiene

•  Therapy:MeetwithSWforpsychotherapy

CASE 5: JT TREATMENT PLAN

•  JTisa76yofemalepresenLngforseveralvagueconcernsandisrequesLnglabstofindcause:•  Changeinbowelhabits–someincreasedurgency

andhastogoa_ermeals

•  DecreasedappeLteinthemorning

•  Coldintolerance

•  EnergycrashandfaLgueina_ernoons

•  Reviewofmentalhealthandstressors:•  Significanthistoryoflossandgrief.Herhusband

passedawayfiveyearsagoandtheanniversaryisnextweek(alwaysahardLmeofyear).HerbrotherpassedawayinDecember2017,andalsotwootherrecentdeathsofpeoplesheknewwell(aclosefriend,andapreviousclient).

•  Work-up:TSH,CBC,CMP,ironstudies:allnormal•  DiscussedwithpaLentthatvaguesymptomsof

faLgue,decreasedappeLte,changeinbowelpaXernsmayberelatedtomilddepressionandgrief.PaLentrecepLvetothisidea

•  DiscussedopLonsandpaLentelectedforpsychotherapy

•  RecommendedstayingsocialandacLve,avoidingisolaLon

•  Recommendedbookonspirituality:“TheWisdomofSundays”compiledbyOprahWinfrey

RESOURCES

•  ExcerptsfrominspiraLonalconversaLonswiththoughtleadersfromvariousfields

•  CHAPTERS•  Awakening

•  IntenLon

•  Mindfulness

•  SpiritualGPS

•  Ego

•  Forgiveness

•  BrokenOpen

•  Grace&GraLtude

•  Fulfillment

•  Love&ConnecLon

RESOURCES

•  GuidancebypsychiatristJamesGordononaseven-stageprogramfordepressionsymptoms-throughfoodandnutriLonalsupplements;Chinesemedicine;movement,exercise,anddance;psychotherapy,meditaLon,andguidedimagery;andspiritualpracLce.

RESOURCES

•  WriXenbyGoogleEngineerwhopioneeredmindfulnessprogramatGoogle

•  ProvidesmethodstoenhanceemoLonalintelligenceandmindfulnessatworkandathome

•  SeveralguidedmeditaLonprompts

RESOURCES

•  SMARTPHONEAPPS:

•  Headspace

•  InsightTimer(freeguidedmeditaLons)

•  DownwardDog(freeguidedyogasessions)

•  JonKabat-Zinnseries(JKZ1,JKZ2,JKZ3)

•  10%Happier(alsoabookbyDanHarris)

TAKE-HOME POINTS

•  Managementofdepressionandanxietydisorderstakesacomprehensive,mind-body-lifestyleapproach

•  Treatmentisuniquetoeachindividual,withtonsofopLons.Doctor-paLentrelaLonshipandpaLentbuy-inandparLcipaLonareimportant

•  Startlowandup-LtrateonmedicaLonsorsupplements.LesslikelihoodofsideeffectsanddisconLnuaLonwithslowapproach

•  Ifnothavingsuccesswithonetypeoftreatment,trychangingitup

•  Frequentfollow-upisimportantwhenchangingdosesorstarLngnewmedicaLon

REFERENCES •  CDC:PrevalenceofDepressionAmongAdultsAged20andOver:UnitedStates,2013–2016.hXps://www.cdc.gov/nchs/products/databriefs/db303.htm

•  DSM5:MajorDepressiveDisorder:hXps://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosLcCriteria_MajorDepressiveDisorder.pdf

•  DSM5:GeneralizedAnxietyDisorder:hXps://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosLcCriteria_GeneralizedAnxietyDisorder.pdf

•  RakelD:IntegraLveMedicine,4thediLon.2017

•  BlumenthalJAetal.Exerciseandpharmacotherapyinthetreatmentofmajordepressivedisorder.InPsychsomMed,69:587-596.2007

•  Rimer,K.Dwan,D.A.Lawlor,C.A.Greig,M.McMurdo,W.Morley,G.E.Mead:Exercisefordepression.CochraneDatabaseSystRev.2012

•  WestoverAN,MarangellLB.Across-naLonalrelaLonshipbetweensugarconsumpLonandmajordepression?InDepressAnxiety,16:118-120.2002

•  Peet,D.F.Horrobin:Adose-rangingstudyoftheeffectsofethyl-eicosapentaenoateinpaLentswithongoingdepressiondespiteapparentlyadequatetreatmentwithstandarddrugs.

•  Cuijpers,P.,vanStraten,A.,Andersson,G.,&vanOppen,P.(2008).Psychotherapyfordepressioninadults:Ameta-analysisofcomparaLveoutcomestudies.JournalofConsul7ngandClinicalPsychology,76(6),909-922.

•  K.Linde,M.M.Berner,L.Kriston:St.John’sWortformajordepression.[updateofCochraneDatabaseSystRev.2005;(2):CD000448]CochraneDatabaseSystRev.(4):CD0004482008

•  R.DelleChiaie,P.Pancheri,P.Scapicchio:EfficacyandtolerabilityoforalandintramuscularS-adenosyl-l-methionine1,4-butanedisulfonate(SAMe)inthetreatmentofmajordepression:comparisonwithimipraminein2mulLcenterstudies.AmJClinNutr.76.2002

•  Mischoulon,L.H.Price,L.L.Carpenter,etal.:Adouble-blind,randomized,placebo-controlledclinicaltrialofS-adenosyl-L-methionine(SAMe)versusescitalopraminmajordepressivedisorder.JClinPsychiatry.75(4):370-3762014

REFERENCES

•  K.Shaw,J.Turner,C.DelMar:Tryptophanand5-hydroxytryptophanfordepression.[updateofCochraneDatabaseSystRev.2001;(3):CD003198]CochraneDatabaseSystRev.2002

•  EschenauerG,SweetB.PharmacologyandtherapeuLcusesoftheanine.InAmericanJournalofHealth-SystemPharmacyJanuary2006,63(1)26-30

•  GlickRM,GrecoCM.BiofeedbackandPrimaryCare.InPrimaryCareClinicalOfficePrac7ce37(2010)91-103

•  MaoJJetal.Rhodiolaroseaversussertralineformajordepressivedisorder:Arandomizedplacebo-controlledtrial.InPhytomedicine.2015March.

•  S.Spedding:vitaminDanddepression:asystemaLcreviewandmeta-analysiscomparingstudieswithandwithoutbiologicalflaws.Nutrients.6(4):1501-15182014Apr

•  Cramer,H.,etal.YogaforDepression:ASystemaLcReviewandMeta-analysisinDepressionandAnxiety30(11):1068-1083

•  Gong,H.,etal.(2015)."Yogaforprenataldepression:asystemaLcreviewandmeta-analysis."inBMCPsychiatry15:14.2015

•  S.H.Ma,J.D.Teasdale:Mindfulness-basedcogniLvetherapyfordepression:replicaLonandexploraLonofdifferenLalrelapseprevenLoneffects.JConsultClinPsychol.72:31-402004

•  C.A.Smith,P.P.Hay,H.Macpherson:Acupuncturefordepression.CochraneDatabaseSystRev.(1):2010

•  ACOG:hXps://www.acog.org/About-ACOG/News-Room/Statements/2015/ACOG-Statement-on-Depression-Screening

QUESTIONS?