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Natural Therapies for Adolescent Depression: Do they work Are they safe

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Title: Natural Therapies for Adolescent Depression: Do they work Are they safe


1
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

2
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.

3
Objectives (by the end of this session, you will
be able to…)
  • 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

4
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?

5
Management Issues
  • Process (communication skills)
  • Content (focus on healthy lifestyle if its good
    for the heart, its probably good for mood)
  • Speed (baby steps)
  • Resources

6
Process Communication Skills
  • Standard approach
  • Patient-centered care
  • Health promotion focus

7
Standard approach
  • Diagnose
  • Provide diagnosis-specific treatment
  • Challenges
  • Making a diagnosis what if they dont meet
    criteria?
  • Mastering medications

Wissow and Gadomski, 2008
8
Parental expectations
  • Dont 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
9
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
10
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
11
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 Feb121266-75.
12
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

13
Crude 6-month change in child clinical measures
as a function of change in providers
patient-centeredness
Change in SDQ symptom score
Change in SDQ impact score
p
p.015 adjusted for baseline function
14
Content Conventional
  • Psychotherapy
  • Medications

15
Cognitive Behavioral Therapy
  • From an evidence-based perspective,
    cognitive-behavioral therapy is currently the
    treatment of choice for anxiety and depressive
    disorders in children and adolescents.
  • Compton SN. JAm Acad Child Adolesc Psychiatry.
    2004

16
Conventional Treatment Rx
  • TCAs - no evidence of efficacy in pre-pubertal
    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

17
SSRI Side effects 1
  • GI upset
  • Headache sleep disorders
  • Sexual side effects Dizziness, Fatigue, Sweating
  • Neonatal withdrawal syndrome
  • Drug interactions

18
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,
    1.18-3.04)
  • Mosholder AD. J Child Adolesc Psychopharmacol.
    2006

19
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

20
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!

21
Integrative Approach
  • Lifestyle Environment, Exercise/Sleep,
    Nutrition, Mind-Body
  • Supplements
  • Massage
  • Acupuncture

22
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

23
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

24
Light Therapy for Depression
  • Plus 3 studies not included in this review,
    comparing dim light to bright light. Golden R. Am
    J Psychiatry. 2005

25
Light therapy
  • Proven effective for SAD (Terman M Evid Based
    Ment Health, 2006)
  • Meta-analysis of studies from 1987-2001 (effect
    size0.53, 95 CI0.18 to 0.89, similar to
    medications) for non-SAD
  • RCT of 29 women with non-seasonal depression
    light therapy for 28 days significantly better
    than control, (McEnany GW, 2005)

26
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)

27
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

28
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
29
Exercise as Therapy Yes
Lawlor DA. BMJ 2001
30
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

31
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!

32
Lifestyle 3 Sleep Hygiene
  • 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)

33
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)

34
Omega-6 Fatty Acids
Omega-3 Fatty Acids
Linoleic Acid (182n-6)
a-Linolenic Acid (183n-3)
?-6 Desaturase
(GLA)? -Linolenic Acid (183n-6)
Stearidonic Acid (184n-3)
Elongase
(DHGLA) Dihomo-?-Linolenic Acid (203n-6)
Eicosatetraenoic Acid (204n-3)
?-5 Desaturase
Eicosanoids
(AA)Arachidonic Acid (204n-6)
(EPA) Eicosapentaenoic Acid (205n-3)
Elongase
245n-3
Eicosanoids Leukotriene 5-series Prostaglandins
E3 Thromboxanes A3
?-6 Desaturase
Eicosanoids Leukotriene 4-series Prostaglandins
E2 Thromboxanes A2
246n-3
ß-Oxidation
(DHA) Docosahexaenoic Acid (226n-3)
35
Omega 3 EFAs mechanism
  • Neuronal membrane structure and function
  • Brain development
  • Second messenger inside cells

36
Mood and Omega-3s
  • Inverse correlation between fish intake and
    depression (Hibbeln Lancet 1998 3511213
    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 20061631098-0)

37
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,
    PCBs
  • Brands Compare brands at www.consumerlabs.com
  • My family takes Coromega, Carlsons or Nordic
    Natural
  • Read labels Omega 3 does NOT necessarily all
    equal EPA/DHA

38
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/sa
    mesum.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!

39
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/sam
    e.asp
  • http//www.umm.edu/altmed/ConsSupplements/SAdenosy
    lmethionineSAMecs.html

40
Amino Acids 5-HTP and L-tryp
  • Acute tryp depletion leads to depression
  • Dietary L-tryp - 5-HTP - serotonin
  • Meta-analysis 5-HTP and L-trp better than
    placebo for depression (Shaw K, Cochrane. 2002)
  • Food sources dairy, eggs, poultry, meat, soy,
    tofu, nuts WHEY protein

41
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?

42
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 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

43
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

44
Bottom line on Amino acids andB vitamins
  • Healthy diet rich in green vegetables and
    nutritious protein sources
  • Consider B-complex supplement

45
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 (none, 400 IU
    versus 800 IU vitamin D) vitamin D3 significantly
    enhanced mood (Landsdowne, 1998)

46
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

47
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

48
Non-dairy sources of calcium
  • Soy beans, tofu
  • Calcium fortified OJ
  • Green leafy vegetables (broccoli)

49
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

50
Lifestyle Stress management
  • Stress is common
  • Stress commonly triggers mood problems
  • Managing stress exercise, sleep, nutrition,
    mind/emotion/body/spirit
  • Meditation
  • Biofeedback

51
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

52
Stress, Emotion, and Physiological Activation
High Arousal/High Energy SYMPATHETIC
Low Arousal/Low Energy
PARASYMPATHETIC
53
Stress, Emotion, and Physiological Activation
High Arousal/High Energy SYMPATHETIC
Fight-or-Flight
LOW PERFORMANCE
HIGH PERFORMANCE
Negative Emotion
Positive Emotion
Low Arousal/Low Energy
PARASYMPATHETIC
54
Stress, Emotion, and Physiological Activation
High Arousal/High Energy SYMPATHETIC
Fight-or-Flight
Frustration, Anger, Hostility,
Exhilaration, Passion,
Fear, Worry Anxiety
Joy, Happiness
Judgment, Resentment,
Love, Care,
LOW PERFORMANCE
HIGH PERFORMANCE
Feeling Overwhelmed, Anguish
Kindness, Appreciation
Negative Emotion
Positive Emotion
Hopelessness, Submission,
Compassion, Tolerance,
Despair, Depression
Acceptance, Forgiveness
Burnout, Withdrawal, Boredom, Apathy
Serenity, Inner Balance, Reflection, Contentment
Low Arousal/Low Energy
PARASYMPATHETIC
55
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

56
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

57
After lifestyle and stress management, what?
  • St. Johns wort
  • Massage
  • Acupuncture

58
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 long-term 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)

59
Herb- drug interactions SJW
  • Speeds elimination of many drugs digitalis,
    theophylline, clarithromycin, erythromycin,
    protease inhibitors and OCPs

60
SJW safety
  • Other side effects - photosensitivity,
    serotonergic syndrome
  • Product variability see www.consumerlabs.com
    Gaia, Kira, Sundown, Natures Bounty
  • Products used in POSITIVE TRIALS Laif 900
    (German STW3-VI) LI160 (Kira), WS5572 WS5570
    (Perika by Natures Way)
  • St. Johns wort patient handouts are available
    from
  • University of Maryland Medical Center
  • Wake Forest University Baptist Medical Centers
    Best Health internet site (www.besthealth.com)

61
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?

62
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(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

63
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

64
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?

65
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

66
Goal-setting
  • Pick a POSITIVE goal
  • E.g., healthier lifestyle.

67
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?

68
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

69
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)

70
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!

71
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…. Its OK to be ambivalent
    about change!

72
Identify Pros and Cons
73
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?

74
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).

75
Sample behavior diary (OK to copy)
76
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 theyd like to do
    for next step (involve them in problem solving).
  • Do it!

77
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

78
Resources
  • Kemper KJ, Shannon S. Complementary and
    alternative medicine therapies to promote healthy
    moods.Pediatr Clin North Am. 2007
    Dec54(6)901-26
  • Motivational Interviewing Preparing People to
    Change by Miller and Roznik
  • Natural Medicines Comprehensive Database
  • Natural Standards
  • http//www.besthealth.com/IntegratedMedicine/
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