Alternative Approaches to Treatment of Depression and Bipolar Disorder

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Book Cover: Depression and Bipolar Disorder

In a recently published book Depression and Bipolar Disorder: Your Guide to Recovery, author William R. Merchand, MD discusses the biological and psychological causes of this mental illness and enables the reader to become empowered to find the best treatment approach. The following is an excerpt from the 10th chapter of the book where the author discusses alternative and complementary treatment options to Depression and Bipolar Disorder.

This chapter describes a number of recovery strategies that may be helpful in addition to, or in some cases instead of, treatments provided by mental health or medical professionals. I strongly encourage you to consider some of these approaches to maximize your chances of getting well and staying in recovery.

What’s in this chapter? I include some approaches that might be broadly considered complementary or alternative medicine. Some are strategies that you can implement on your own, or at least without the assistance of a medical or mental health professional. So, some of what you’ll find here could be considered “self-help.” Maybe the best description is a selection of tools for your recovery toolbox. The tools I have included are those for which there is enough evidence of benefit that I recommend that you consider using them. I also discuss some options for which there is considerably less evidence for benefit. They are included because you may hear about them from other sources and perhaps my review will be helpful.

Most of what is in this chapter may be most useful to consider as an add-on or “adjunctive” treatment. By that I mean strategies that you might consider in addition to medication or traditional psychotherapy. However, some approaches may be sufficient as monotherapy for those with very mild depressive spectrum disorders. In this book, I use the term complementary for all of these strategies. Finally, as I have said elsewhere in this book, please develop a comprehensive recovery plan. A comprehensive plan includes as many strategies as are appropriate for your situation. Adding some of the approaches in this chapter to more conventional treatments is one way to make your plan comprehensive.

Acupuncture is a traditional Chinese medicine approach. Some studies have found that acupuncture is effective in treating depression. These studies are difficult to evaluate, though, because some are published in Asian languages and there is significant variation in the acupuncture techniques used. A number of studies, but not all, suggest possible benefit; however, recent reviews of the evidence have concluded that the benefit is uncertain and that there is insufficient evidence to recommend this treatment approach for depression. Nonetheless, it is possible that future rigorous studies may demonstrate a benefit.

Aerobic exercise
Some studies have shown that higher levels of physical activity are generally associated with lower levels of depression. Further, a fairly large body of literature suggests that aerobic exercise may be associated with reduced depressive symptoms. There is also some evidence for the benefits of nonaerobic exercise. Reviews of the evidence published in scientific journals generally conclude that exercise is beneficial for depression. However, further research is needed to establish the degree of effectiveness. Nonetheless, there is some indication that aerobic exercise may be similar in effectiveness to treatments with either antidepressants or psychotherapy. It has been proposed that exercise might be beneficial for bipolar disorder, but studies are lacking.

There are a number of unanswered questions in regard to the extent of the therapeutic benefit of exercise for depression; however, there is fairly convincing evidence of some benefit and exercise certainly has general health benefits. Therefore, implementing an exercise program is definitely worth trying for depression. It may be reasonable to try exercise alone for very mild depression, and exercise should be considered as an adjunctive treatment for more severe episodes of depression. Although exercise has not been studied as a treatment for bipolar disorder, given the general health benefits it seems worth trying.

As discussed in Chapter 4, the endorphin hypothesis suggests that exercise releases endorphin neurotransmitters, which results in the decrease of depressive symptoms. This hypothesis has been based on the idea that the runner’s high occurs as a result of endorphin release.

Like all interventions, exercise is not without risk. Please check with your primary health care provider before starting an exercise program. In regard to how much aerobic exercise is needed for treating depression, one recommendation is for three 30-minute sessions per week of aerobic exercise at 60%?80% of maximum heart rate for at least eight weeks. For some individuals, it may be necessary to start at a lower level and increase to that intensity. I said above that it might be reasonable to try exercise alone for treating mild depression. However, if you do start to improve quickly, then other approaches such as psychotherapy or medication must be considered. Also, if you previously had depression that required medication or psychotherapy, then trying exercise alone may not be a good strategy. I strongly recommend that you seek a professional evaluation even if you want to try exercise alone. That way you can discuss whether exercise alone is a good option for your specific situation. Also, if you find that other treatments are needed, then you will already have a relationship established with a provider.

Dietary supplements
In this section, I will discuss a group of treatment approaches that fall into the general category of dietary, food, or nutritional supplements; another definition might be “natural health products.” Some countries may define several of these supplements as drugs. For ease of discussion, I use the term supplement to encompass all of these labels. Supplements are generally substances intended to provide nutrients that may be missing or may not be consumed in sufficient quantities in an individual’s regular diet.


Folate is a B vitamin found in some vegetables and fruits. Folate is necessary for the brain to synthesize the neurotransmitters norepinephrine, serotonin, and dopamine, which are involved in mood disorders (see Chapter 4). There is evidence that folate deficiency may be associated with the occurrence of depression, poor response to antidepressants, and relapse of illness. The three commercially available folate formulations that can be taken as a supplement are folic acid, 5-methyltetrahydrofolate (5-MTHF; also known as methylfolate and L-methylfolate), and folinic acid.

Folate supplementation has been studied as an adjunctive and monotherapy treatment for unipolar depression. These studies have a number of limitations but suggest possible benefit, particularly for those with low folate levels. Therefore, folate has been recommended for consideration as an adjunctive treatment for unipolar depression. There may be some side effects of folate supplementation, however, including increasing the cancer risk, masking vitamin B12 deficiency, and worsening depressive symptoms. Thus, a decision to take folate supplements should be made only in consultation with a health care provider.

Omega-3 fatty acids
Omega-3 fatty acids are a family of unsaturated fatty acids that are essential for normal growth and health. These substances are not manufactured by the body and must be taken in as part of a person’s diet. The two omega-3 fatty acids that have been most studied are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Most of the health benefits that have been demonstrated with omega-3 fatty acids are specifically associated with these two acids. The most efficient natural dietary source of EPA and DHA is fish and shellfish. Another omega-3 fatty acid, linolenic acid, is available from plant sources but requires more enzymatic steps to be used by the body than EPA.

Studies have shown that omega-3 fatty acids have a number of medical benefits, many involving the health of the heart and circulatory system. American Heart Association (AHA) experts have concluded that omega-3 fatty acids may positively influence cardiovascular health in several ways, including decreasing the risk for irregular heartbeat, decreasing triglyceride levels, lowering blood pressure, and reducing inflammation. Thus, the AHA recommends consumption of these substances.

There is evidence that omega-3 fatty acids may have benefits for the prevention of mood disorders as well as the reduction of symptoms. In regard to prevention, studies have found that higher fish and seafood consumption is associated with lower rates of major depression, postpartum depression, and bipolar disorder. A number of studies have evaluated the possibility that omega-3 fatty acids might have treatment benefits for depressive and bipolar spectrum disorders. Most of these investigations have assessed whether these substances might contribute to symptom reduction when used as an adjunctive treatment. The results are difficult to interpret because of different methods used and different omega-3 fatty acids studied. Nonetheless, there is some evidence that omega-3 fatty acids may help treat unipolar and bipolar depression, but not all studies have demonstrated benefit. For example, one major study found no benefit for depression among patients with coronary artery disease when omega-3 fatty acids were added to treatment with the antidepressant sertraline. Perinatal depression is depression in the mother during pregnancy or after childbirth. Omega-3 treatment has also been evaluated for this condition by a number of studies, but the results are inconclusive.

In summary, there is some evidence that omega-3 fatty acid supplementation may be beneficial for unipolar depression, but the jury is still out. Further, we do not currently know which dosage levels and which specific omega-3 acids should be used. Despite the lack of conclusive evidence for benefit, a current recommendation is to CONSIDER omega-3 fatty acids as an adjunctive treatment for major depression. Specifically, adding EPA or the combination of EPA and DHA to other treatments is suggested. One reason for the recommendation is the evidence for health benefits, aside from the possibility of improving mood. Further, levels of omega-3 fatty acids tend to be low in the typical American diet. Finally, the risk of adverse effects appears low; however, at very high doses, omega-3 fatty acids may have an anticoagulant effect that might put one at risk of bleeding. Thus, a decision to add omega-3 fatty acids to your treatment should be discussed with your health care provider.

S-adenosyl methionine (SAM-e) is a naturally occurring molecule present in all living human cells that plays a key role in the synthesis of the neurotransmitters norepinephrine, serotonin, and dopamine. There is some evidence that SAM-e may have benefits for unipolar depression. However, the strongest evidence is for intravenous or intramuscular administration, which limits the usefulness of this agent. There is less evidence supporting the use of oral SAM-e. SAM-e may cause such side effects as gastrointestinal symptoms, headache, anxiety, fatigue, insomnia, tachycardia, and restlessness.

Based on the current evidence, I cannot recommend SAM-e as a treatment for depression. However, this recommendation may change if additional studies suggesting benefit are completed. See your health care provider for the latest information.

St. John’s wort
St. John’s wort (Hypericum perforatum) is a plant that has been used to treat depression. St. John’s wort contains a number of substances. Two of these substances in particular, hypericin and hyperforin, are thought to have actions similar to antidepressant medications. Multiple studies have examined the effectiveness of St. John’s wort for mild or more severe depression. Some of these, but not all, have suggested benefit. Expert reviews of these investigations conclude that there is a possibility of effectiveness for mild depression but that St. John’s wort is likely not effective for more severe cases.

In addition to limited evidence of effectiveness, there is a significant risk of interactions with a number of prescribed medications. Specifically, St. John’s wort can reduce the efficacy of medications such as antiretroviral medications, immunosuppressants, anticancer agents, anticoagulants, oral contraceptives, and hormone replacement therapy. Further, there are concerns about adverse effects of combining St. John’s wort with the SSRI class of prescribed antidepressants.

In summary, the evidence provides little support for the use of St. John’s wort, at least when compared with other approaches discussed in this and other chapters. IF YOU DO TAKE ST. JOHN’S WORT, BE SURE TO DISCUSS POSSIBLE DRUG INTERACTIONS WITH YOUR MEDICAL AND MENTAL HEALTH PRESCRIBERS.

Excerpt from Depression and Bipolar Disorder: Your Guide to Recovery
William R. Marchand, MD
Copyright - 2012 by Bull Publishing Company
ISBN 9781933503998
Bull Publishing Company

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