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

2. Agenda
 Introduction
 What is CAM?
 Essential nutrients for optimal brain function
 Herbal remedies and supplements
 Mind body connections

3. ،‫الهرام‬ ‫جريدة‬‫الخميس‬22‫القعدة‬ ‫ذى‬ ‫من‬1432 ‫هـ‬20‫اكتوبر‬2011
‫السنة‬136‫العدد‬45608
‫يصيب‬ ‫أصبح‬ ‫الذي‬ ‫والعصبي‬ ‫النفسي‬ ‫المرض‬450
.‫الرض‬ ‫سطح‬ ‫فوق‬ ‫إنسان‬ ‫مليون‬
‫الي‬ ‫وصل‬ ‫وحده‬ ‫الكتئاب‬ ‫وان‬140,‫انسان‬ ‫مليون‬
‫العالم‬ ‫في‬ ‫وصلت‬ ‫فقد‬ ‫والخوف‬ ‫القلق‬ ‫حالت‬ ‫أما‬
‫الي‬200..‫وقلق‬ ‫خائف‬ ‫انسان‬ ‫مليون‬
‫الي‬ ‫أيضا‬ ‫العالم‬ ‫في‬ ‫الدمان‬ ‫ووصل‬130‫مليون‬
..‫مدمن‬ ‫إنسان‬
‫مليون‬ ‫وجود‬ ‫تؤكد‬ ‫فإنها‬ ‫مصر‬ ‫في‬ ‫الرقام‬ ‫أما‬
‫و‬200.‫الكتئاب‬ ‫عذاب‬ ‫يعاني‬ ‫مصري‬ ‫إنسان‬ ‫ألف‬

5. Introduction
 There are more than 70 different types of alternative
therapy.
 Some are so well known that they are almost mainstream
medicines, while others seem so bizarre as still to be on
the very fringes of fringe medicine.
 Acupuncture, herbal medicine, Homoeopathy, and
Aromatherapy are already practised in several countries.

6. History of Alternative Medicine

7. What is CAM?
Complementary modalities
(therapies): used in conjunction
with conventional medical
practice. (Wilkinson, p. 1019)
Alternative Modalities(therapies):
used instead of traditional care.
(Wilkinson, p.1019)

8. Important Points
1.Be non-judgmental despite personal opinions
2. Build rapport by showing client respect – if not, he
may be afraid to tell about CAM use
3. Understand that C.A.M. can be beneficial, when
used correctly
4. Be aware that C.A.M. can be dangerous if it
interacts or interferes with conventional treatment

9. Important Points
5. Be willing to teach the public about the positive
and negative information regarding C.A.M.
6. Be aware that use of C.A.M. is popular and
increasing and must be included in the history &
physical exam.
7. Know that Herbals, in particular, can have
significant effect on prescription drugs and body
function.

10. 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!

11. Integrative Approach
 Lifestyle –
Environment,
Exercise/Sleep,
Nutrition, Mind-Body
 Supplements
 Massage
 Acupuncture

12. 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

13. 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

14. Light therapy
 Proven effective for SAD (Terman
M Evid Based Ment Health, 2006).
 Benefits onset within 2 days; effective in
institutionalized elderly and community;
effective in summer and winter
 Side effects: hypomania, autonomic
hyperactivation
(Terman M, 2005)

15. Turn off Depressing TVDepressing TV
 Respondents who
repeatedly saw "people
falling or jumping from the
towers of the World Trade
Center" had higher
prevalence of PTSD (17.4%)
and depression (14.7%) than
those who did not (6.2% and
5.3%, respectively).
Ahern, Psychiatry, 2002
McLeish. Depress Anx, 2008

16. Nutrition – essential nutrients for
optimal brain function
 Omega-3 fatty acids
 Amino acids (SAM-E)
 Vitamins (B vitamins,
Vitamin D)
 Minerals (Iron,
Calcium, Magnesium,
Zinc)

17. Omega-3 fatty acids
Eating a diet rich in omega-3s or taking omega-3
supplements may help ease depression,
especially when used in addition to standard
depression treatments.
These healthy fats are found in cold-water fish,
flaxseed, flax oil, and walnuts.

18. Omega-6 Fatty Acids Omega-3 Fatty Acids
Linoleic Acid (18:2n-6) a-Linolenic Acid (18:3n-3)
(GLA)γ -Linolenic Acid (18:3n-6)
(DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6)
(AA)Arachidonic Acid (20:4n-6)
Eicosanoids
Leukotriene 4-series
Prostaglandins E2
Thromboxanes A2
Eicosanoids
Stearidonic Acid (18:4n-3)
Eicosatetraenoic Acid (20:4n-3)
(EPA) Eicosapentaenoic Acid (20:5n-3)
24:5n-3
24:6n-3
(DHA) Docosahexaenoic Acid (22:6n-3)
Eicosanoids
Leukotriene 5-series
Prostaglandins E3
Thromboxanes A3
∆-6 Desaturase
Elongase
∆-5 Desaturase
Elongase
∆-6 Desaturase
β-Oxidation

19. Omega 3 EFA’s: mechanism
 Neuronal membrane structure
and function
 Brain development
 Second messenger inside
cells

20. Mood and Omega-3’s
 Inverse correlation between fish intake
and depression (Hibbeln: Lancet 1998;
351:1213; Crowe: Am J Clin Nutr, 2007)
 Effective for bipolar patients (Stoll: Arch.
of Gen. Psych. 1999; 56: 407-12)
 Effective for major depression (Nemets:
Am. J. Psych. 2002: 159 (3) 477-9)
 Effective for depression in Children ( Am J
Psychiatry 2006;163:1098-0)

21. S-adenosylmethionine
 Pronounced "sammy," this is a synthetic form of a
chemical that occurs naturally in the body.
 It's not approved by the FDA to treat
depression in the United States.
 Rather, it's classified as a dietary supplement.
 Side effects are usually minimal, but SAMe can
trigger mania in people with bipolar disorder.

22. Amino Acids: SAM-E
 Produced from ATP and methionine
 Low folate can lead to low levels
 Meta-analysis: SAMe significantly
improves depression, comparable to
antidepressant medications (
http://www.ahrq.gov/clinic/epcsums/samesu
)
 In an open trial of 30 adults with MDD
for whom antidepressant meds
ineffective, SAM-E led to significant
improvements in 50% and remission in
43% (Alpert, 2004).

23. Folate
 Low levels of folate, a B vitamin, may cause a
slowed response to some antidepressants.
 Taking folate supplements (folic acid) may be
helpful when used in addition to antidepressants.

24. L- Methylfolate
 Deplin (in US)
 15mg
 Folate supplement
 Adjunct therapy in depression
 Other indication as adjunct in schizophrenia
for negative and cognitive symptoms

25. Vitamin B6 - pyridoxine
 Low levels of pyridoxal phosphate
(PLP) are associated with depressive
symptoms (Hvas AM 2004)
 Dose: 100 – 200 mg daily benefits
PMS- depression (Wyatt KM. BMJ, 1999)
 Side effects: nausea, vomiting, abd.
pain, anorexia, headache, somnolence,
lower B12 levels, sensory neuropathy
(typically with doses over 1000 mg
daily, can occur lower)
 Food: Beans, nuts, legumes, fish, meat

26. Vitamin D and depression
 Vitamin D receptors in brain
 Low level of serum 25-hydroxyvitamin D
and high PTH are significantly
associated with depression (Jorde, 2005)
 25-hydroxyvitamin D3 and 1,25-
dihydroxvitamin D3 levels are
significantly lower in psychiatric patients
than in normal controls (Schneider,
2000)
 RCT of 44 Australian patients ( 400 IU
versus 800 IU vitamin D) vitamin D3
significantly enhanced mood
(Landsdowne, 1998)

27. 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

28. 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

29. Non-dairy sources of calcium
 Soy beans, tofu
 Calcium fortified OJ
 Green leafy vegetables
(broccoli)

30. Chocolate and mood
Insulin inhibits theInsulin inhibits the
reuptake ofreuptake of
norepinephrinenorepinephrine and
enhances the blood-enhances the blood-
brain transport ofbrain transport of
tryptophan, atryptophan, a
precursor ofprecursor of
serotoninserotonin.

31. Herbal remedies and supplements
 St. John's wort. Known scientifically as Hypericum
perforatum, this is an herb that's been used for
centuries to treat a variety of ills, including depression.
 It's not approved by the FDA to treat depression in the
United States.
 Rather, it's classified as a dietary supplement.
However, it's a popular treatment in Europe for mild
or moderate depression.
 But, it can interfere with other depression medicines, as
well as some drugs used to treat people with heart
disease, seizures, cancer and organ transplant.

32. Saint Johns wort
 Comparable to sertraline in German RCT of 241
depressed adults (Gastpar. Pharmacopsychiatry,
2005)
 2 open label trials in teens showed improvement
within 2 weeks in 25/33 and 9/11 patients
(Findling, 2003; Simeon, 2005); Improvement in 2
weeks predicts long-term response; if no benefit
in 2 weeks, stop.

33. Herb- drug interactions: SJW
Speeds elimination
of many drugs:
digitalis,
theophylline,
clarithromycin,
erythromycin,
protease
inhibitors
 Other side effects - photosensitivity,
serotonergic syndrome

34. Lifestyle: Stress management
 Stress is common
 Stress commonly triggers mood problems
 Managing stress: exercise, sleep, nutrition,
mind/emotion/body/spirit
– Meditation
– Biofeedback

35. Stress, Emotion, and Physiological Activation
High Arousal/High Energy
SYMPATHETIC
PARASYMPATHETIC
Low Arousal/Low Energy

36. Stress, Emotion, and Physiological Activation
High Arousal/High Energy
SYMPATHETIC
PARASYMPATHETIC
Low Arousal/Low Energy
Negative
Emotion
Positive
Emotion
“Fight-or-Flight”

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

38. Mind-body connections
 The connection between mind and body has
been studied for centuries.
 Complementary and alternative medicine
practitioners believe the mind and body must be
in harmony for you to stay healthy.
 Mind-body techniques that may be tried to ease
depression symptoms include:
- Acupuncture - Yoga
- Meditation - Guided
imagery

39. Mind-Body
 Meditation
– Stress relief/ reduce anxiety
– Relaxation
– Reduced levels of lactic acid
– Decreased oxygen consumption
– Slowed heart rate
– Decreased blood pressure
– Improved function of immune system
– Reduce pain
– Relieve symptoms of psoriasis
– Improve health
(References: Ignativicius; Wilkinson)

40. Relaxation
Relaxation techniques
– To reduce anxiety, tension & emotional tension
which can exacerbate pain
Progressive muscle relaxation
(PMR)
Promoting sleep
Can be taught in home setting

41. Guided Imagery
– Distraction when confronting pain, discomfort
or fear
– Making decisions and altering behavior
– Caution: not recommended for emotionally
unstable or cognitively impaired client
– Helps reduce pain.
– Reduction of nausea & vomiting.
– Decreasing anxiety
– Promoting comfort during cancer treatment

42. Spiritual
 Life force beliefs found in most cultures.
(Wilkinson, p 1020)
 Faith healing (Wilkinson page 260)

43. 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

44. Other Movement Therapies
 Dance Therapy

45. Take Home Message
 Keep in mind that nutritional and dietary
products aren't monitored by the FDA the
same way medications are.
 You can't always be certain of what you're
getting and if it's safe.
 Also, be aware that some herbal and dietary
supplements can interfere with prescription
medications or cause dangerous
interactions.

46. Thoughts…Comments