CAM is a broad category of non-conventional strategies to prevent and treat illness and promote wellness. CAM can be used in conjunction with, or alternative to, conventional medical treatment; it includes dietary supplements, herbal remedies, acupuncture, and practices such as exercise and meditation. This column will briefly summarize what we currently know about the efficacy and potential risks of a few of the CAM strategies commonly considered for depression and anxiety.
A few caveats: for most CAM approaches, the research base is weak, mainly due to challenges in conducting well-designed trials. CAM should not be used as a replacement for medical consultation for a concerning symptom or major illness, including serious depression. Any treatments, including CAM strategies, carry risks and potential side effects. Dietary supplements and herbal remedies can interact with other medications in potentially harmful ways and can also be unsafe in pregnancy, so it is best to talk with your doctor about any CAM strategies you are using or considering. “Natural” does not necessarily mean “safe.” In addition, dietary supplements are not as closely regulated as prescription and over-the-counter medications and may contain contaminants, including unlabeled prescription drugs.
Exercise
In addition to improving physical health, exercise can provide significant benefits for mood and anxiety, both in prevention and treatment. It is associated with decreased stress, improved energy, better sleep, and overall wellbeing and self-confidence. Exercise can be just as effective as medication for mild-to-moderate depression and anxiety, with fewer risks and side-effects. Some of the beneficial underlying mechanisms seem to include release of endorphins, release of neurotransmitters, anti-inflammatory effects, and neurogenesis (neuronal growth).
It is unclear if there is an optimal type or “dose” of exercise, but studies do offer some clues. Improvements in mood and wellbeing seem strongest if one engages in a form of exercise which is enjoyable and personally meaningful, and at least some of the exercise is associated with leisure activities or transportation (as opposed to housework, job-related activities etc.). Also, exercise paired with music or done outdoors and in nature seems especially powerful. Aerobic and muscle strengthening activities both seem to be beneficial for mental health. For some people, a social aspect can be an extra bonus, since isolation worsens depression. In terms of “dose,” even modest amounts of exercise have clear anti-anxiety and antidepressant effects. Current guidelines recommend about 30 minutes a day, five times a week of moderate exercise, and the 30 minutes can be divided up over the course of the day. If that is not possible due to time constraints or other factors, getting some exercise is much better than none. Even starting with 5-minute walks outside can be surprisingly efficacious.
Mindfulness Meditation
Although it is difficult to design good efficacy studies, the evidence does point to benefits of mindfulness meditation in reducing anxiety and depression. This practice involves slowing down and achieving a state of concentration. Focused breathing is a common exercise, for example. You then observe, without judgement, your thoughts, bodily sensations, and emotions. Deliberately focusing attention on one thing at a time can counteract distracting, anxiety-producing thoughts that tend to bombard us as we are going about our daily lives. Nonjudgmental observation can provide some distance and perspective, an opportunity to consider things more objectively as opposed to getting caught up in a downward spiral of negative emotions. And through mindfulness, we can learn to better tolerate difficult feelings without falling apart. Mindfulness meditation practice is most beneficial when learned through expert instruction (which can be gained through in-person groups, on-line, and through apps), and when practiced regularly. In terms of downsides, it does require motivation and a time commitment. For some vulnerable people, such as those with a trauma history or vulnerability to psychosis, there can be a risk of adverse reactions such as depersonalization (a disturbing sense of disconnection), fear/anxiety, or psychotic symptoms.
Yoga
Yoga is related to the above categories of exercise and mindfulness. While many of the studies of yoga alone are flawed, it does seem to have a beneficial effect on depression. Also, through a tamping down of the body’s stress response systems (with, for example, reductions in heart rate and blood pressure), yoga can lead to decreases in feelings of stress and anxiety. As with any exercise practice, there is a risk of injury if not practiced carefully.
St. John’s Wort
St. John’s Wort (Hypericum perforatum) is a plant-based dietary supplement used for many years, especially in Europe, to treat depression. Although there’s been some controversy as to its efficacy, with some trials showing it to be no better than placebo, a 2016 review of the literature concluded that it can be effective for mild-moderate depression, with fewer side-effects than prescription SSRI (selective serotonin reuptake inhibitor) antidepressants. St. John’s Wort does act in similar ways as SSRI’s, with comparable effects on neurotransmitters and receptors.
There are several concerns to be aware of. In the U.S., it is considered a dietary supplement, so it is not subject to the same safety and purity regulations as prescription medications. Also, St. John’s Wort can interact with other medications in potentially serious ways, including decreasing the effectiveness of cancer drugs, birth control, HIV medication, drugs used in transplant patients, and heart medications. It should not be mixed with other medications that increase serotonin, such as SSRI antidepressants, due to risk of “serotonin syndrome,” which can be life-threatening. In addition, if one has serious depression, it’s best to consult with a physician or other mental health professional for a full assessment. In someone with bipolar disorder (diagnosed or not), it can lead to mania, psychosis, or mood swings. As with any medication or supplement, it should not be taken during pregnancy without first consulting with your physician. Standard dosing is 900mg a day in divided dosing.
Folate
Folic acid (vitamin B9), which is involved in the synthesis of several neurotransmitters, shows promise as an adjunctive treatment for depression when added to SSRI antidepressants. The study results are strongest with l-methylfolate (a more bioactive form of folate) taken at higher doses (15mg a day). Responders to l-methylfolate include those with low folate levels and those with difficulty converting folate to l-methylfolate due to a fairly common gene mutation. Folate (less expensive but possibly less effective) and l-methylfolate (MethylPro) are available over-the-counter. A prescription form of l-methylfolate (Deplin) is available by prescription and can be more expensive. There seem to be few risks or side-effects.
Omega- 3 Fatty Acids (Fish Oil)
Omega-3 fatty acids are important to the proper function of brain neurons. There is epidemiological evidence showing that populations (like the Inuits) whose diets are richer in Omega-3 fatty acids, such as diets high in fish, have a lower incidence of depression and suicidality, although causality is not clear. Cardiovascular mortality is lower in these populations as well. It is not yet clear if Omega 3 fatty acids alone have a strong antidepressant effect, although several studies have suggested that dietary EPA and DHA doses between 1-3 grams/day do combat depression. (1 gram/day is the equivalent of about three salmon meals in a week). Several studies suggest benefit when added to a traditional antidepressant. In addition, omega-3 fatty acids may be useful add-ons during the depressive phase of Bipolar Disorder. There has been some worry that they could increase cycling to mania, but that is unclear. More research is needed in these areas.
Dietary sources of omega-3 fatty acids include fish, shellfish, flaxseed oil, seeds, and nuts. Commercial preparations (fish oil capsules) are available over-the counter, but may not be as effective.
Omega-3 fatty acids can reduce inflammation, which is thought to be one of the mechanisms underlying probable neuroprotective effects as well as cardiovascular benefits. And, as an added benefit, they can alter the gut microbiome in positive ways; there is increasing interest in the “gut-brain axis,” and how our diets can affect mood and cognition.
Omega-3 fatty acids are considered generally safe and also provide benefits for cardiovascular health. The main safety concerns would be uncertainly about the purity of commercial preparations, nausea or loose stools from high doses, an unpleasant fishy taste from capsules, and risk of mercury toxicity from some fish and shellfish (especially a concern during pregnancy). Also, high intake levels can potentially increase the risk of bleeding, which could be an issue if you are on blood thinners or planning to have surgery.
Vitamin D
Vitamin D has been of interest depression given that there are receptors throughout the brain and also because of its anti-inflammatory properties. (The role of inflammation in psychiatric disorders is now of major interest). Studies show a relationship between low vitamin D levels and increased rates and severity of depression. However, it is unclear if low vitamin D contributes to depression, or if depression can cause low vitamin D levels, or both. Studies treating depression with vitamin D supplementation show conflicting results. It’s possible that one issue is that it may take a longer time for normalized vitamin D levels to affect mood. In subpopulations, low vitamin D levels in pregnant women can be associated with postpartum depression, and low levels are more common in the elderly and can be associated with higher risk of developing poststroke depression. In one study of depressed adolescents with low Vitamin D levels, supplementation resulted in improvements in mood, energy and irritability. In a few studies, people with seasonal depression benefited from supplementation in the winter.
Given the current lack of clarity about the role of vitamin D in depression, the current recommendations are to consider screening for low levels and supplement if needed to reach a normal serum level. And, most importantly, for general health reasons, that people receive adequate vitamin D through sunlight exposure, diet, and exercise. It is thought that exercise itself can increase levels through various physiologic mechanisms; exercise outdoors is an added bonus. Dietary sources include dairy, fatty fish (see omega-3 fatty acids above), fortified cereals, fortified orange juice and soy milk. Over-the-counter supplements are available as well. Current recommended intake is 400 IU daily. Risk factors for vitamin D deficiency include being elderly, living at high latitudes/ insufficient sunlight, obesity, dark skin, breast feeding, and medical illness. It is important not to take mega doses of vitamin D to avoid toxicity.
Diet
This is a big and active topic. Very briefly, there is thought that diets which reduce inflammation can have antidepressant effects. Examples include a “Mediterranean” diet (lots of fruit and vegetable, whole grains, seeds/nuts, olive oil and low-fat proteins) and minimizing intake of meat and dairy, sugar, and processed foods
Kava
Kava kava (“intoxicating pepper”) is a plant-based drink used for anxiety, stress, insomnia, alcohol withdrawal and many other purposes. The plant, Piper methysticum, is native to the Pacific Islands, where Kava has been widely used for hundreds of years. However, Kava has been linked with many cases of liver damage, some fatal. Because of these safety concerns, Canada and Europe have taken it off the market. I recommend AGAINST taking it for this reason.
S-adenosylmethionine (SAM-e)
SAM-e is an amino acid metabolite involved in the synthesis of some hormones and neurotransmitters and has been used for depression. In the U.S., a synthetic form is available as a dietary supplement. The evidence for its efficacy is limited, but there have been some positive trials, as stand-alone treatment or as an adjunct to traditional antidepressants. Given these promising results, more studies are needed. While side-effects can include gastrointestinal symptoms, anxiety or insomnia, it is generally well tolerated.
Cannabinoids
Cannabinoids include CBD and THC. This is a large topic, to which I will devote a future column.
CAM therapies with possible efficacy but insufficient evidence include: Acupuncture, massage therapy, aromatherapy, biofeedback, curcumin, saffron, homeopathy, inositol, tryptophan, N-acetylcysteine, zinc, rhodiola rosea, and probiotics.
