A cornerstone of mental health treatment is rapport, understanding, and supporting the goals of the client. Although health care providers strive to understand their clients, they may also negate their interest in different treatment options because they, as practitioners, are uncomfortable discussing unfamiliar treatment options. Practitioners should be able to discuss treatment options with clients from a knowledge perspective. What can be recommended based on the research behind these “complementary” treatment options for depression? How can they be integrated into practice? Understanding and discussing a client's use of dietary supplements or manipulative therapies will build client trust and confidence with the provider (Sarris, Glick, Hoenders, Duffy, & Lake, 2014).
The purpose of the current article is to review existing research and practices on selected complementary and integrative health (CIH) treatment options as adjunct treatment to conventional medical practices for depressive mood. The search strategy included published studies found in MEDLINE, PubMed, and CINAHL. Keywords included depression, complementary integrative medicine, specific dietary supplements, and complementary treatment for depressive symptoms.
Complementary medicine is a term that too often carries a derogatory implication because it seems only harmful practices make the news headlines. The term complementary and alternative medicine often conjures up negative second-class treatment options. With more valid scientific research on these therapies, it is time to move them out of alternative and into CIH. Whereas historically these treatment options were interpreted to be “instead of” traditional allopathic medicine, it is now recommended that they be considered “in conjunction with” traditional care. CIH is a model of care that aims to combine conventional medicine with evidence-based non-conventional treatments, such as mind–body medicine, acupuncture, botanical medicine, exercise instruction, and dietary and lifestyle modification (Sarris et al., 2014).
Depression is a common mental health illness affecting individuals of all races, ethnicity, and socioeconomic levels. During their lifetime, approximately 20% of all adults will require treatment for a mood disorder, and specifically, 8% of the world's population will have a major depressive episode (Kessler & Bromet, 2013). Depression can cause mental, physical, emotional, and functional distress that may go un-diagnosed unless it is identified by a health professional (National Institute of Mental Health [NIMH], 2011). The effects of depression can range from obvious mental expressions to symptoms of a physical illness, thus making diagnosis a challenge. Signs and symptoms of depression vary with each individual but can include persistent sadness, anxiety, or “empty” feelings. Symptoms can include feelings of hopelessness, guilt, negativity, poor self-esteem, helplessness, irritability, restlessness, loss of enjoyment in activities or hobbies, decreased interest in sex, fatigue, poor sleep or excessive sleep, poor focus and concentration, changes in eating behavior, thoughts of suicide, or suicide attempts (American Psychiatric Association [APA], 2013). Physical depressive symptoms may be aches or pains, headaches, abdominal cramps, or digestive problems that do not appear to be triggered by a physical source (NIMH, 2011). Depressive symptoms can be vague at first and present gradually over time.
National Center for Complementary and Integrative Health
National Center for Complementary and Integrative Health (NCCIH) replaces the name National Center for Complementary and Alternative Medicine. NCCIH is a federal government agency under the National Institutes of Health (NIH) that has the commission for scientific research on “different” medical and health systems, practices, and products not considered part of conventional medicine. NCCIH (2016a) organizes the various complementary health practices into two groups: natural products and mind–body practices. The natural products category includes herbs/botanicals, vitamins, minerals, and probiotics. Mind–body practices include yoga, chiropractic manipulation, meditation, massage therapy, acupuncture, relaxation techniques, tai chi and qigong, healing touch, hypnotherapy, and movement therapies.
Why Do Individuals Use CIH Therapies?
CIH emerges in direct response to clients' desire for a choice of treatments. Clients want to be part of the decisions concerning their health care. CIH reaffirms the importance of the practitioner and client working together to focus on the whole person to achieve optimal health. CIH therapies for mental illness may be beneficial as part of conventional treatment options. Effective communication as part of patient-centered care is defined as sharing information that supports and encourages participation from clients; it is an ongoing process that is respectful and values clients' experiences to guide health care decision making (Newell & Jordan, 2015). In a review of published literature that focused on patient satisfaction factors, Mohammed et al. (2016) identified communication and shared decision making as two of 10 major dimensions of health care quality. Communication was most often identified as a patient indicator of high health care quality, stressing the importance of providers who listened to the client and demonstrated respect and courtesy for patients' opinions (Mohammed et al., 2016).
The percentage of adults in the United States who use complementary health treatments has remained consistent over 10 years: 2012, 33.2%; 2007, 35.5%; and 2002, 32.3% (Clarke, Black, Stussman, Barnes, & Nahin, 2015). In 2012, 17.7% of adults and 4.9% of children ages 4 to 17 used dietary supplements (other than vitamins and minerals) (Clarke et al., 2015). These statistics translate into $12.8 billion out-of-pocket purchasing of supplements in 2012 and $14.7 billion for visits to complementary health practitioners (Nahin, Barnes, & Stussman, 2012). The 2012 National Health Interview Survey (NHIS) reports yoga and spinal manipulation are the second and third most used complementary health treatments (Clarke et al., 2015). Reasons given by those surveyed for the decision to use these treatments are “general wellness or disease prevention” and the belief that using these treatment modalities “make them feel better overall” (Stussman, Black, Barnes, Clarke, & Nahin, 2015, p. 5). Adults report that dietary supplements reduce stress, improve sleep, and improve emotions (Stussman et al., 2015). Spinal manipulation, as reported by adults, is used for a specific health condition as well as overall well-being (Stussman et al., 2015).
Dietary Supplement Health and Education Act: History of Dietary Supplements
Congress passed legislation called the Dietary Supplement Health and Education Act (DSHEA) of 1994, outlining that the U.S. Food and Drug Administration (FDA) will regulate dietary supplements like a food rather than like a drug. DSHEA describes dietary supplements as products intended to supplement the diet, which bear or contain dietary ingredients or a dietary substance that increases an individual's total dietary intake. DSHEA states that a dietary supplement must be a concentrate, metabolite, constituent, extract, or combination of a vitamin, mineral, amino acid, herb, or other botanical, and that the product must be intended for ingestion in the form of a capsule, powder, soft gel, or gel cap (NCCIH, 2016b).
Although dietary supplements resemble drugs, they are regulated as food and presumed safe based on historical use in humans. Therefore, the FDA has no role in the evaluation of the product, ingredient, efficacy, safety, or how it is manufactured prior to it being sold to consumers. Manufacturers of these products are not required to prove to the FDA the product is safe (or even that it does what it advertises as the intended benefit) prior to being released and sold. Once a product is on the market, it remains on the market unless there are sufficient reports of adverse responses to allow the FDA to remove it. This removal depends on adverse reports from practitioners and consumers of possible problems with the product (NCCIH, 2016b). DSHEA also establishes label requirements for dietary supplements. With very few exceptions, a dietary supplement cannot make a claim to treat, cure, mitigate, or prevent a disease. Supplements can make claims called structured-function claims. A dietary supplement ingredient cannot claim to reduce cholesterol levels, but it can say that it “maintains a healthy heart.”
Dietary Supplements for Depression
Clients may believe taking natural products will avoid the complications and problems associated with synthetic medications. It is a mistake to assume that a substance is safe and/or effective because it is naturally occurring. Another concern is an herb as a plant growing in nature is not the same as the ingredient that has been manufactured into a capsule or tablet. In addition, all manufactured brands are not the same. One cannot be assured products of the same name, but manufactured by a different company, are all of the equivalent value or that they even contain the same parts of the plants that they purport to contain (NCCIH, 2016b).
A recognized concern with studies using dietary supplements is that, although there are more controlled trials being published, the quality of the studies is at times questionable. When replicating or comparing a study, the products must be identical in every way and manufactured by the same company to have an appropriate comparison. There are significant differences in manufacturing from company to company, which can affect the results of these studies. NCCIH (2016b) points out concerns for some studies are inconsistencies in the diagnostic criteria, inadequate sample size, lack of blinding or placebo controls, and inadequate evaluations of side effects to the products.
Omega-3 Fatty Acids (Fish Oil)
Fish oil capsules are the number one natural product used by adults, according to the 2012 NHIS, with 7.8% (18.8 million) individuals using these products (Clarke et al., 2015). Omega-3 oils are most abundant in salmon, sardines, anchovies, and other cold-water fish but are also found in many nuts and seeds, such as flaxseed, walnuts, and chia seeds. Omega-3 fatty acids are receiving increased investigation as an adjunct treatment for depression (Sarris, 2017). Although various clinical investigations have mixed results for the potential usefulness of omega-3 fatty acids for major depression and bipolar depression, the risk of depression is lower in countries where fish consumption is higher than in nations where individuals eat less fish (Marangell et al., 2003).
Omega-3 fatty acids are found in the human lipid layer of cell membranes, produced in the body from linoleic acid, and are released by way of neurotransmitter stimulation (Giles, Mahoney, & Kanarek, 2013). Omega-3 fatty acids have many important cell functions, such as: (a) assist brain cells to communicate more effectively with each other by acting as a second messenger or with the G-protein receptors on glial cells; (b) inhibit the release of the stress hormone cortisol; (c) inhibit inflammation; (d) anti-apoptotic effects; (e) maintenance of cell synthesis and degradation; (f) receptor binding; and (g) neurogenesis by means of up-regulation of brain-derived neurotrophic factor (BDNF) (Amminger et al., 2010; Giles et al., 2013). Omega-3 fatty acids also maintain cell structure by allowing fluids to flow in and out of the membrane and are important for the reuptake and regulation of the neurotransmitters norepinephrine, dopamine, and serotonin (Giles et al., 2013).
A Cochrane review of 25 trials of adults (N = 1,438) with major depressive disorder compared omega-3 fatty acids as monotherapy to placebo and found that omega-3 fatty acids had a small-to-modest beneficial effect for improving mild depressive symptoms (Appleton, Sallis, Perry, Ness, & Churchill, 2015). Giles et al. (2013) reviewed studies evaluating the relationship of omega-3 fatty acids intake and major depressive disorder (MDD) in the general population. They noted six studies found beneficial effects of omega-3 fatty acids supplements when used as an adjunct to antidepressant agents compared to placebo. However, seven studies with similar participants found no effect of omega-3 fatty acids supplements when used as a monotherapy compared to placebo.
In another study discussed by Giles et al. (2013), participants between the ages of 18 and 65 were given omega-3 fatty acids daily in 1-g, 2-g, or 4-g doses three times per day in adjunct with tricyclic and serotonin reuptake anti-depressant agents for MDD. Improved depressive symptoms were reported with three doses of 1 g per day beginning Week 4, but statistical significance did not occur until the dose was increased to 2 g and 4 g three times per day. Another study reviewed by Giles et al. (2013) compared omega-3 fatty acids to placebo. After 8 weeks of 1.5 g per day, depressive scores did not improve (Giles et al., 2013). Giles et al. (2013) concluded the greatest benefit to individuals seemed to be when omega-3 fatty acids supplemented an antidepressant agent and were not used as monotherapy. Although not completely understood, emotional stress increases proinflammatory cytokine production, and this relationship may put individuals at risk for MDD. Acknowledging that the current studies are generally split between benefit and no benefit of omega-3 fatty acids for depressive symptoms, the researchers recommended future investigations focusing on the role of omega-3 fatty acids for reversing proinflammatory cytokines, which are increased as a secondary effect of depression (Giles et al., 2013).
Practitioners should caution clients who are taking >3 g of an omega-3 supplement per day that an increased risk of bleeding, including stroke, can occur. In addition, clients taking blood thinners, or who are otherwise at risk for bleeding, should be cautioned about consuming excessive doses of omega-3 (Fares, Lavie, DiNicolantonio, O'Keefe, & Milani, 2014; Harris, 2007; Marangell et al., 2003).
S-Adenosylmethionine (SAMe), discovered in 1952, is present in the body with the purpose of modulating the neurotransmitters serotonin, norepinephrine, and dopamine. Clients with depression may have low serum levels of SAMe, and supplements may help restore these levels to normal (Clouatre, 2012). Although not entirely clear, it is thought that SAMe has the ability to release a methyl carbon that increases brain levels of serotonin, dopamine, and norepinephrine. SAMe may also increase the cell membrane ability to bind these neurotransmitters to receptor cites by increasing the cell membrane fluidity (Carpenter, 2011).
A study of 51 males and 62 females compared SAMe to placebo for gender differences. Using the 17-item Hamilton Depression Rating Scale (HAMD), males treated with SAMe as monotherapy compared to placebo declined an average 8.9 points compared to women who had an average 5.4-point reduction of depressive symptoms (Sarris, Price, et al., 2015). Another study reported SAMe improved memory in clients with depression (Levkovitz, Alpert, Brintz, Mischoulon, & Papakostas, 2011). SAMe (800 mg twice daily) was augmented for 73 individuals taking a selective serotonin reuptake inhibitor (SSRI) compared to placebo in a 6-week, double-blind randomized trial (Papakostas, Mischoulon, Shyu, Alpert, & Fava, 2010). Using the HAM-D, remission rates were 36.1% for individuals taking SAMe adjunctive with a SSRI and 25.8% for individuals taking SAMe adjunctive with a placebo (Papakostas et al., 2010).
For depression, at a dosage of 800 mg per day, an improvement in symptoms may require several weeks, and some individuals may need a higher 1,600-mg daily dose. Oral forms are less effective than an injection due to first pass destruction by the liver (Clouatre, 2012). A large body of data supports the use of SAMe for depression, by intramuscular or intravenous administration, but it has not been shown that SAMe continues to be an effective treatment for extended periods of time (Clouatre, 2012; Janicak, Lipinski, Davis, Altman, & Sharma, 1989; Papakostas et al., 2010). Even with coated tablets of SAMe and taken on an empty stomach, the oral bioavailability is only approximately 1%, which is quickly excreted in urine and feces.
Although there is a long record of research dating to the 1970s, significant limitations to these studies are the lack of rigor to the methodology and small sample sizes in the majority of studies.
SAMe is contraindicated whenever bipolar disorder is confirmed or suspected as it may cause agitation or worsen mania (Clouatre, 2012). Side effects reported, especially at higher doses, include an increase of depression or anxiety, gastrointestinal symptoms, dry mouth, headache, mild insomnia, anorexia, sweating, dizziness, and nervousness. An excessive level of serotonin may result if SAMe is taken with the cough suppressant dextromethorphan, antidepressant agents, or the narcotic pain reliever, pentazoci. SAMe lessens the efficacy of levodopa for Parkinson's disease symptoms (Clouatre, 2012; Levkovitz et al., 2011; NCCIH, 2015). SAMe does not cross the blood–brain barrier (Clouatre, 2012).
As with many products offered on the health products market, 30% of all SAMe sold typically contains less active ingredient than is claimed on the label (FDA, 2008).
Folate/folic acid is one of the B-complex vitamins needed for proper neuronal function. Folate is the natural form of vitamin B9, whereas folic acid is the synthetic form. Good sources of folate are orange juice and other citrus fruits, legumes, green leafy vegetables, as well as asparagus, mushrooms, and yeast found in baked goods. Among its functions, folate/folic acid encourages proper brain functioning and production of serotonin, which affects mood. A serum deficiency of B9 is reported in patients with depression and poor responders to antidepressant medications (Lizer, Bogdan, & Kidd, 2011).
Some individuals may have a genetic deficiency in the methylenetetrahydrofolate reductase (MTHFR) gene that limits conversion of dietary folate to L-methylfolate (active folate in the central nervous system). Genomic DNA from a cheek swab can identify this mutation (Lizer et al., 2011). Folate deficiency may increase the risk of depression and adding folic acid to an antidepressant agent may improve response to the medication (Stahl, 2007).
L-methylfolate metabolized from dietary folate and folic acid is the bioactive form of folate, and is classified as a medical food. Although not a “drug,” L-methylfolate is meant to be monitored under the supervision of a primary health care provider (FDA, 2016). Authors evaluated the effect of L-methylfolate for bipolar I depression in a small study of 10 participants who received their usual treatment plus 15 mg of L-methylfolate for 6 weeks. Using the Montgomery-Asberg Depression Rating Scale (MADRS), four participants reported remission of depressive symptoms and six participants reported 50% symptom improvement (Nierenberg et al., 2017). In another study, 148 outpatients with SSRI treatment-resistant MDD participated in one of three trials: 7.5 mg L-methylfolate for 30 days followed by 15 mg per day for another 30 days; placebo for 30 days followed by L-methylfolate 7.5 mg per day for 30 days; and placebo for 60 days. All groups remained on their scheduled SSRI during the trial period. Participants taking L-methylfolate at 15 mg per day adjunctive to the SSRI reported improved depression symptoms on the HAM-D compared to the other groups (Papakostas et al., 2012).
In a randomized, double-blind placebo trial of citalopram (20 to 40 mg), vitamin B12 (0.5 mg), folic acid (2 mg), and vitamin B6 (25 mg) for 52 weeks, there was some evidence that adding folic acid (in these various forms) to the antidepressant drug slightly improved outcomes. The citalopram and vitamin group reported 78.1% (n = 58/73) remission of depressive symptoms on the MADRS. The placebo (no vitamins) and citalopram group reported 77% (n = 57/73) MDD remission (Almeida et al., 2014).
Folic acid has few side effects but can mask symptoms of pernicious anemia, a vitamin B12 deficiency. Individuals should be advised not to take B9 and B12 together (Taylor, Carney, Geddes, & Goodwin, 2003). The recommended dose is 400 μg per day. Pregnant women usually take 1 mg, but they should discuss with their obstetrician. Too much folate acid can cause bloating, muscle weakness, fatigue, and numbing or tingling in the extremities. A deficiency is frequently seen in individuals with alcohol dependence (NIMH, 2016a). The medications taken by individuals can also impact absorption of these important vitamins and supplements. Vitamin B12 deficiency has been associated with proton pump inhibitor use for ≥2 years (Lam, Schneider, Zhao, & Corley, 2013).
Zinc deficiency is linked to increased depressive symptoms, and evidence is emerging that zinc supplementation improves depressed mood, mainly as an adjunctive intervention with an antidepressant agent (Mischoulon, 2007, 2009; Yary & Aazami, 2012). Zinc is an abundant trace element that is involved in cytokine modulation and hippocampal neurogenesis via up-regulation of BDNF, and it also modifies N-methyl-D-aspartate and glutamate activity. Sources of zinc are primarily poultry and red meat but this element can also be found in beans, nuts, and whole grains. In infants, older adults, and vegetarian diets, zinc intake may not be sufficient. Recommended dose is 20 to 30 mg per day taken with food (Sarris, 2017). Zinc supplements can interact with antibiotic and diuretic agents; therefore, clients should be advised to take the antibiotic agent either 2 hours before or 4 to 6 hours after taking zinc. Thiazide diuretic agents increase urinary excretion of zinc, possibly leading to depleted zinc levels. Therefore, clinicians should monitor zinc levels of individuals taking diuretic agents (NIMH, 2016b). The absorption of zinc is reduced by medications such as cimetidine and ranitidine (Sturniolo et al., 1991).
Vitamin D is an essential nutrient for bone growth but it is also a neurosteroid, with data suggesting that it plays a role in depressive symptoms. The relationship is not fully understood, and current evidence does not show vitamin D deficiency as a risk factor for depression or that taking supplements will improve depressive symptoms (Mischoulon, 2007, 2009; Parker, Brotchie, & Graham, 2017; Sarris, 2017).
A meta-analysis of all randomized controlled studies of vitamin D supplementation for the effect on depressive symptoms narrowed 1,820 studies down to only seven that met the inclusion criteria for quality as assessed by the Cochrane Risk of Bias Tool. These seven studies (N = 3,191; participant ages 18 to 79; published between 2003 and 2013) evaluated individuals with depressive symptoms given vitamin D supplementation. The authors acknowledged the characteristics of the studies were variable with the dosage ranging from 600 to 300,00 IU of vitamin D3, the frequency of administration varying from daily to weekly to a single dose, and durations of 6 weeks to 2 years. Conclusions of the meta-analysis are that overall effect of vitamin D supplementation on depressive symptoms is small and insignificant (p = 0.16) (i.e., vitamin D supplementation did not worsen or improve depressive symptoms) (Shaffer et al., 2014).
In two studies, supplementation with vitamin D was statistically significant (p = 0.046) for participants with MDD or clinically significant depressive symptoms, However, in five studies where depressive symptoms were not clinically significant, the effects of vitamin D supplementation were not significant (p = 0.61). Conclusions from the reviewed studies of this meta-analysis imply that vitamin D supplementation improves clinically significant depressive symptoms but not minor depressive symptoms. The authors point out these mixed results of the studies and the need for additional research to investigate the impact of vitamin D supplementation on depressive symptoms (Shaffer et al., 2014).
Shaffer et al. (2014) discussed other concerns with the meta-analysis, including lack of consistency in the designs in all seven studies, and a failure to evaluate participants' pre- and post-serum levels of 25-hydroxyvitamin D. Shaffer et al. (2014) recommended additional double-blind trials to evaluate the baseline serum levels of vitamin D in clients with depression and the impact of dosing and delivery method (oral versus intravenous).
Low levels of vitamin D can be due to insufficient dietary intake or inadequate exposure to sunlight, such as what occurs during winter months. Vitamin D is being studied in connection with seasonal affective disorder (SAD). Some studies suggest an association between low vitamin D levels and SAD (Howland, 2011). SAD is characterized by depressive symptoms that occur at the darkest time of the year and it is thought that light deficiency is the cause because symptoms lessen in spring and summer months. Taking vitamin D prior to the onset of winter may help with symptoms of depression (Melrose, 2015). Taking 400 to 800 IU daily or 100,000 IU weekly for up to 1 month may improve symptoms of depression associated with SAD (Mayo Clinic, 2013).
St. John's Wort
St. John's wort (SJW) has been documented to treat depression and “nervous conditions” in early Greek and Roman history. In folk medicine, the flowers were used to treat depression, anxiety, insomnia, restlessness, irritability, and menstrual cramps. Hanging it from a window or doorway was hoped to prevent evil spirits from entering the home. The supplement is produced from making an extract of hypericin and hyperforin, two of the active ingredients contained in the plant. These two compounds are believed to impact serotonin in the brain, causing an effect on mood. Serotonin regulates mood as well as sleep and appetite (Lawvere & Mahoney, 2005). In Europe, pharmaceutical companies prepare a standard formula of the plant and it is commonly sold as an antidepressant agent available without a prescription. In Germany, it is taken by millions of individuals for depression and anxiety (Mischoulon, 2007).
A Cochrane meta-analysis of 28 research trials involving 5,489 clients with depressive symptoms sought to determine if extracts of SJW: (a) were more effective than placebo; (b) were as effective as antidepressant medications; and (c) had comparable adverse effects to antidepressant agents. Participants were adults with MDD as categorized by criteria from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders or 10th revision of the International Statistical Classification of Diseases and Related Health Problems. The severity of depression was mild to moderate in 19 trials and moderate to severe in nine trials. Eighteen trials were from German-speaking countries, four from the United States, and two from the United Kingdom, with one each from Canada, Denmark, France, and Sweden (Linde, Berner, & Kriston, 2008).
Improved depressive symptoms were based on the mean score reduction of at least 50% or a score of <10 on the HAM-D. Of the trials, 18 were placebo-control, 17 compared SJW extract with SSRIs (i.e., fluoxetine, sertraline, imipramine, citalopram, and paroxetine), and six compared placebo and older antidepressant agents (e.g., amitriptyline, maprotiline [available in Europe]). Placebo with SJW extract had an overall mean symptom reduction on HAM-D of 3.4 points and SJW extract compared to an antidepressant agent showed a mean reduction of 1.1 points (Linde et al., 2008).
The authors concluded that for individuals with mild to moderate depression, the results from the studies suggested that SJW extract: (a) was superior to placebo, (b) was as effective as prescription antidepressant agents, and (c) had fewer side effects than antidepressant agents. The authors noted that trials from German-speaking countries reported more favorable findings of SJW (compared to placebo) for major depression treatment than from other (non-German) countries, including the United States. German-speaking countries reported a mean score reduction on the HAM-D of 4.29, whereas non-German–speaking countries reported <1-point reduction on the scale (Linde et al., 2008).
Pirotta et al. (2014) asked individuals about their reason(s) for taking SJW. The top responses were: (a) the availability of SJW without a prescription; (b) in place of prescribed antidepressant agents because of experienced side effects; and (c) family, friends, or internet recommendations for SJW effectiveness.
Reported side effects of SJW are minor, including insomnia, headache, skin rash, and skin hypersensitivity to the sun. Other concerns are the interactions or weakening with other medications, such as fexofenadine, theophylline, warfarin, phenprocoumon, amitriptyline, digoxin, simvastatin, nifedipine, and oral contraceptives. SJW substantially reduces the effects of antiretroviral medications (e.g., for HIV/AIDS), including indinavir. Combining SJW with serotonergic antidepressant agents and other serotonergic agents can cause serotonin syndrome with symptoms of confusion, muscle stiffness, altered body temperature, and possibly death (FDA, 2016).
(available in the online version of this article) provides a summary of dietary supplements for depression.
Dietary Supplements for Depression
Mind–body practices include movement therapies (e.g., tai chi, qigong), relaxation techniques (e.g., breathing exercises, guided imagery, progressive muscle relaxation), healing touch, hypnotherapy, and acupuncture. The most popular mind–body practices used by adults according to the 2012 NHIS are yoga, chiropractic and osteopathic manipulation, meditation, and massage therapy.
Meditation, originally stemming from Buddhist meditation traditions, is the process of intentionally directing attention to create a state of inner stillness or awareness that may be facilitated by the use and/or focus of a mantra, word, phrase, sound, image, or breath. There are hundreds of types of meditation practices. Popular forms include transcendental meditation and mindfulness meditation. Transcendental meditation trains the individual to focus attention on a single word, sound, mantra, or object. Mindfulness meditation has the individual focus on internal and external experiences that exist at the time of meditating. The premise is that mindfulness meditation allows an individual to be fully present and aware of his/her state of mind, senses, and emotions. Thoughts, emotions, and body sensations are accepted with openness and these experiences are not evaluated but rather acknowledged and reflected on. Mindfulness meditation asks the individual to be still and become aware of the present moment as it is occurring. Mindfulness meditation strives to reduce anxiety and depression by teaching individuals to increase cognitive interpretation and decrease emotional reactions. Through practice, individuals are expected to gain insight into what they are experiencing and accept these experiences.
Numerous studies on the effects of mindfulness meditation and emotion regulation report improved positive mood and the ability to decrease the intensity and frequency of a negative mood (Edenfield & Saeed, 2012; Tang, Hölzel, & Posner, 2015). In a meta-analytic review that identified 727 articles, Hofmann, Sawyer, Witt, and Oh (2010) selected 39 studies (N = 1,140) to evaluate effect size for clients who received a mindfulness intervention for medical or psychological disorders. Results showed mindfulness meditation was moderately effective for reducing anxiety (Hedge's g = 0.63) and depressive symptoms (Hedge's g = 0.59). (Hedge's g measures effect size between groups.)
Twelve studies (N = 578) were selected for a meta-analysis for the effect of mindfulness-based interventions (MBI) on individuals with a confirmed diagnosis of MDD (four studies, N = 160) or anxiety disorder (eight studies, N = 418) and currently experiencing depressive or anxiety symptoms compared to a control group (Strauss, Cavanagh, Oliver, & Pettman, 2014). MBI was the primary intervention in each therapy session along with encouragement for participants to practice daily mindfulness. This analysis demonstrated MBI was moderately effective (Hedge's g = −0.59) and statistically significant (p = 0.01) for reducing the severity of the primary symptom being reported at post-intervention. Significant benefit was seen for an improvement in depressive symptom severity (Hedge's g = −0.73) across studies. However, MBI had a moderate effect size (Hedge's g = −0.52) for reducing the severity of the primary symptom being reported for anxiety at post-intervention. The authors caution that this effect size for anxiety was likely skewed by one study that had a low Jadad rating (which assesses the quality of published trials methods relevant to random assignment, double blinding, and description of patient withdrawal). The authors recommended using MBI as an effective adjunct treatment for individuals with depressive symptoms and encouraged additional research on MBI for treatment options for individuals with anxiety (Strauss et al., 2014).
A review of research that focused on longitudinal studies and changes in brain structure found some potential problems with evaluating experienced practitioners of meditation compared with a control group. For example, comparing at-rest brain activity of experienced mindfulness meditation practitioners with a control group may not provide valid comparisons because an experienced mindfulness meditation practitioner likely automatically enters a state of meditation when at rest. The authors suggested using imaging protocols with blood oxygen level–dependent contrast that allows observation of the most active parts of the brain. Although acknowledging these changes occur in the brains of meditation practitioners, the authors also reported their uncertainty about the implication of these changes but hypothesized the changes are related to the components of the brain responsible for attention (i.e., alertness, vigilance, orienting, and conflict monitoring) (Tang et al., 2015).
Yoga is a system of practice of various physical postures (asana) and breathing techniques to align the body's musculoskeletal structure and emotional equilibrium. All yoga stems from hatha yoga. Different schools emphasize various dimensions according to its pre-eminent teacher. Iyengar, Vinyasa, Anusara, Ashtanga, Bikram, and Bhakti yoga are the most common forms.
The number of adults practicing yoga has increased from 5% in 2002 to 6.1% in 2007 and 9.5% in 2012. Yoga practitioners report reduced stress (85%), more regular exercise (65%), and a healthier diet (40%). They also state yoga promoted “feeling better emotionally” more often than individuals who use dietary supplements or spinal manipulation (Clarke et al., 2015).
A study evaluating the effects of hatha yoga on the mental health of sedentary adults was compared to a resistance exercise group and control group. The hatha yoga group and exercise group reported improvements in depressive symptoms on the Beck Depression Inventory Scale. The yoga group also reported improved fatigue, self-esteem, and quality of life; the exercise group reported improved body image. The control group did not report any improvements (Taspinar, Aslan, Agbuga, & Taspinar, 2014).
Another review of 12 studies evaluating the effects of yoga on posttraumatic stress disorder showed that it appeared to be useful in trauma management by helping individuals regain a sense of self-control of their lives. The authors recognized that the sample size was small for the studies and the assessment tools used were not similar for reliability and validity. The authors also reviewed studies measuring gamma-aminobutyric acid (GABA) in experienced yoga practitioners. Using magnetic resonance spectroscopic imaging, GABA levels increased by 27% in yoga practitioners after one 60-minute session compared to no change in the control group who read periodicals and popular fiction (Telles, Singh, & Balkrishna, 2012).
Streeter et al. (2010) randomized healthy adults to a yoga intervention (n = 19) or a walking intervention (n = 15). Participants on a stable nonpsychoactive medication for at least 1 month were included in the study. Exclusion criteria were any yoga practice in the previous 3 months, a history of yoga practice, participation in any mind–body discipline, any neurological disorder or medical condition that would compromise participation in the study, any medication or tobacco use that might affect GABA levels, or a contraindication to magnetic resonance imaging (MRI) evaluation. Mood was assessed with the Exercise-Induced Feeling Inventory and anxiety was assessed with the Spielberger State-Trait Anxiety Inventory. MRI of thalamic GABA levels was completed at baseline and after the 12-week interventions concluded. A third scan was obtained immediately after participants engaged in either 60 minutes of walking or yoga. No difference in GABA levels was reported at baseline. At post-intervention and in the scan following 60 minutes of walking or yoga, yoga participants reported greater improvements in mood and a decrease in anxiety symptoms compared to the walking group. This result correlated to the increased thalamic GABA levels in the yoga group. The researchers concluded that a behavioral intervention, such as yoga, is associated with changes to GABA levels and improvement in mood and anxiety. They also concluded yoga practice releases more GABA in the brain because it increases parasympathetic nervous system activity (Streeter et al., 2010).
Other studies evaluated changes in the brain and the amount of gray and white matter of yoga practitioners. Six brain regions consistently showed alterations: (a) frontopolar cortex, a large area of the brain's frontal lobe that likely plays a role in complex higher order behavior; (b) sensory cortices and insula, a part of the cerebral cortex with the function to receive and interpret sensory information; (c) hippocampus, which is involved with long-term memory and storage of facts that can be purposely recalled; (d) anterior cingulate cortex, which is responsible for decision making, empathy, and social interactions; (e) superior longitudinal fasciculus, a major language pathway; and (f) corpus callosum, the bundle of white matter connecting the right and left hemispheres of the brain (Edenfield & Saeed, 2012).
Tai Chi and Qigong
Tai chi and qigong are considered mind–body interventions and also meditative movements. Both practices are suitable for individuals of any gender, age, and health status because they are low-impact, moderate-intensity aerobic exercises. Tai chi is a system of slow, flowing coordinated movements with the aim to relax the mind and restore the chi (energy force). Many styles exist (e.g., Chen, Sun, Wu, Yang), and all vary in terms of intensity and rhythm. Qigong is a system of slow, gentle, and deliberate circular movements, breath work, and meditation to improve the flow of qi (life force) and emotional stability.
Wang et al. (2009) reviewed evidence for the effect of tai chi and qigong on psychosocial well-being, concluding that both are relatively safe, nonpharmacological practices and may be used for treatment and prevention of psychosomatic disorders, depression, and anxiety. However, the authors suggested viewing current research with caution because the quality of the trials varied and conclusions were limited due to concerns about poor study designs and lack of comparison with control groups. Although tai chi seems to significantly increase psychological well-being, reduce anxiety and depression, and enhance mood in the studies reviewed, the authors recommended additional studies are needed to make informed decisions based on trials that are longer in duration and use control groups that are randomized (Wang et al., 2009).
The Japanese healing art of Reiki is another “energy therapy.” The term comes from the Japanese language, “rei,” which means universal, and “kei,” which means life energy. Mikao Usui rediscovered Reiki, a 2,500-year-old Japanese system of healing, in the early 20th century (Joyce & Herbison, 2015). Chujiro Hayashi developed the Usui system of standardized hand placements (Joyce & Herbison, 2015). The Reiki practitioner uses a light touch on or above the body to transfer vibrational or subtle energy from her/himself to the client. Traditional Usui Reiki treatment ranges from 45 to 90 minutes and usually involves placing the hands on the head and the front and back of the torso in 12 positions (Lee, Pittler, & Ernst, 2008). A Cochrane review found only three studies (N = 52 individuals with depression and/or anxiety) that were of moderate quality and concluded there is insufficient evidence that Reiki is beneficial in reducing depressive or anxiety symptoms (Joyce & Herbison, 2015).
Acupuncture is one of the key components of traditional Chinese medicine that has been practiced in China and other Asian countries for thousands of years to correct the imbalance of chi. The acupuncture technique most often studied involves penetrating the skin with thin, solid, metallic needles that are manipulated by hand or electrical stimulation (NCCIH, 2015). The purpose of insertion of fine needles into different body parts is to unblock and allow the chi flow to return to a balance in the body. After reviewing 30 trials and 2,810 participants, Smith, Hay, and Macpherson (2010) reported there is insufficient evidence to recommend acupuncture for depressive symptoms.
Another review by the American Psychiatric Association Task Force Report (Freeman et al., 2010) found evidence of beneficial effects of acupuncture in improving the clinical global score of clients with depression. However, the authors concurred there is insufficient evidence to support acupuncture as a treatment for depression. They reported the studies lacked heterogeneity of design and included small samples, thereby limiting recommendation of acupuncture as a treatment option. Rare cases of HIV, hepatitis B and C, pneumothorax, and cardiac tamponade were reported in clients treated with acupuncture due to the skill and technique of the practitioner (Freeman et al., 2010).
Evidence is increasing for the relationship between nutritional deficiencies and effect on mental health. Although the determinants of mental health are complex, diet and nutrition seem to be as important to psychiatry as they are to cardiology, endocrinology, and gastroenterology. The human brain operates at a very high metabolic rate and requires a substantial amount of an individual's total energy and nutrient intake for the functioning of intra- and intercellular communication (Sarris, Logan, et al., 2015). The importance of replacing amino acids, fats, vitamins, and minerals or trace elements with nutrient-based supplements, which address these deficiencies, can be achieved with monotherapy or augmentation to antidepressant agents for treating depressive symptoms. Although not definitive, individuals randomly assigned to a Mediterranean diet consisting of higher intakes of vegetables, fruits, seafood, whole grains, lean meat, nuts, and legumes showed a reduced risk for depression (Freeman et al., 2010). Such a diet may improve resiliency against the development of depression and also impact the immune system and antioxidant defense system (Sarris, Logan, et al., 2015). A healthy diet that matches the natural physiological needs of the body might prove even more effective than isolated nutrients alone. Clients seeking treatment for depressive symptoms should be encouraged to acknowledge that a healthy lifestyle as well as psychological, cultural, and spiritual/religious factors all work together for their general well-being as a whole person.
A study of 20 volunteers evaluated the effects of lavender oil on their emotional state and autonomic nervous system. Participants reported inhaling the aroma of lavender caused them to feel more relaxed, and it also significantly decreased autonomic arousal with lowering of blood pressure, heart rate, and skin temperature (Sayorwan et al., 2012). A randomized double-blind multicenter trial in Germany investigated whether silexan reduced scores on the Hamilton Anxiety Scale (HAM-A) over placebo and paroxetine (Kasper et al., 2014). Silexan is an oral preparation of lavender oil sold over the counter in German pharmacies. Participants (N = 539) who met criteria for generalized anxiety disorder were randomized to either 80 mg per day or 160 mg per day of silexan, paroxetine 20 mg per day, or placebo. After 10 weeks, the HAM-A score for participants taking silexan 80 mg per day decreased by 14.1 points, those taking silexan 160 mg per day decreased by 12.8 points, those taking paroxetine 20 mg per day decreased by 11.3 points, and for placebo, scores decreased by 9.5 points (Kasper et al., 2014).
Role of the Nurse Practitioner
“Talk with your health care provider” is frequently advised when it comes to dietary supplements and CIH. Unfortunately, many health care providers have limited knowledge on these topics. One hundred fifty-three nurses in Northern California were surveyed using the Nurse Complementary and Alternative Medicine Nursing Knowledge and Attitudes Survey developed by Rojas-Cooley and Grant (2009). Nurses scored 51% on the knowledge portion, suggesting poor baseline knowledge of CIH, and <33% were able to define the term complementary and alternative medicine. These results suggested nurses would be unable to accurately assess their clients' use of CIH practices and unlikely to initiate a discussion. The majority of nurses surveyed did not think that it was their role to educate their clients about CIH (Trail-Mahan, Mao, & Bawel-Brinkley, 2013).
CIH treatment and therapies impact all nursing practices and content areas. Due to the increase of CIH by individuals, it is important for health care providers to broaden their knowledge of these treatment options to understand whether CIH is supportive or contraindicated as an adjunct to conventional medicine and to offer recommendations for best practices. Although providers need to empower clients, they also need to protect them. Nurses unfamiliar with these practices cannot successfully discuss risks or benefits with clients or understand their clients' reasons for using these treatments. Nurse practitioners (NPs) can guide clients through evaluation of treatment options by encouraging them to use reputable sites for their information such as the NIH and NCCIH to evaluate effectiveness, safety, and quality concerns of treatment options being considered. Many reputable online sites are available to either educate or refer clients for information on dietary supplements and other treatment options for improving depressive symptoms (Table B, available in the online version of this article). In addition, the FDA posts a MedWatch safety alert on dietary supplements along with dietary fact sheets and various other information on CIH topics (access http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm153239.htm).
Self education sources and sources to share with patients:
Several practice ideas to consider include:
- having the nurse or medical assistant initiate the conversation when asking the reason for the visit to stimulate the client's thinking prior to the practitioner's entrance;
- providing clients with a list of dietary/botanical supplements and additional treatments such as yoga, tai chi, and massage, and ask them to check off the ones they use; and
- educating clients who are using CIH as to the credential and certification body for the therapy (Table C, available in the online version of this article).
Credentials and Certification Bodies
Proof of competence for many CIH practitioners frequently rests with the community of teachers and organizations and is largely unregulated by state agencies. Other concerns to discuss with clients are the cost of the therapy and if the therapy matches the client's culture and belief system. NPs can build client trust and strengthen client rapport by being open, empathetic, objective, nonjudgmental, flexible, and interested in the CIH health practices of the client.
Clients should be advised to be wary of supplements for sexual enhancement, weight loss, and bodybuilding. The FDA reports some of these types of supplements could contain illegal steroids or prescription drugs. The FDA also lists recalled dietary supplements (access https://www.fda.gov/Food/RecallsOutbreaksEmergencies/SafetyAlertsAdvisories/default.htm). Clients should be encouraged to lose weight through exercise and monitoring their diet, get in shape through training, and consult their medical provider if they experience sexual dysfunction. Clients should look for the “USP Verified” mark on supplements. U.S. Pharmacopeia (USP) is a nonprofit private organization that supplement manufacturers can voluntarily request to verify the quality and potency of their raw ingredients or the finished products. USP maintains a list of verified products on its website (access http://www.quality-supplements.org).
Additional questions to ask clients or include on new client forms include:
Do you take any substances or herbs not prescribed by a medical person, but by someone you trust, on a regular basis or occasion to improve your health or well-being?
Please tell me what it is, why you are using it, do you think it is helping, is it causing you any discomfort?
Does the prescribing person call him/herself Doctor or some other title?
Do you obtain the product from a store or does the person have it available and provides it to you?
Do you have a family member or friend who has special folk knowledge or the ability to provide or recommend special substances or herbs to improve health or well-being?
If available, would you try or consider acupuncture, reflexology, massage therapy, healing touch, relaxation, or any other complementary option?