Natural Ways to Heal
ANXIETY AND DEPRESSION
In this chapter I am going to continue our discussion about the common brain problems that can interfere with having a magnificent mind. I will discuss anxiety, depression, and bipolar disorder. According to the National Institutes of Health nearly seventy-five million Americans, or one in four of us, will suffer from one of these disorders at some point in our lives.
Many famous people throughout history have struggled with anxiety and depression, including Mark Twain, Ernest Hemingway, J. K. Rowling, and Princess Diana. It is no secret that Abraham Lincoln suffered from periods of severe depression, including suicidal thoughts. In 1836 he told a friend that there were times he was “so overcome with depression that he never dare carry a knife in his pocket.” It’s possible that Lincoln inherited the tendency for depression from his mother, whom he described as melancholy with “eyes as pools of sadness.” Or it may have been the result of a severe brain injury he had when he was twelve years old. Brain injuries often predispose people to mood disorders. Without effective medication or natural supplements to rely on, Lincoln used laughter as a form of self-medication. If his friends could get him to laugh with a funny story or have him tell one of his humorous anecdotes, Lincoln’s mood would begin to brighten. On the election night of 1864 Lincoln was very nervous and tense, anticipating a bad outcome. He read a book of humor to calm his nerves. When a member of his cabinet saw what Lincoln was reading, he left the White House in disgust, thinking that the president did not understand the seriousness of the evening. Apparently, Lincoln understood what modern-day doctors are now just discovering—laughter is healing.
Even now, many people think that anxiety and depression are the result of a bad attitude or a weak will. If only you tried harder, the bad feelings would go away. Yet these disorders are often the result of a brain that is out of balance, just like diabetes is a disorder of insulin. Seeing these as medical problems rather than moral problems enables people to get the help they need.
One common misconception is that anxiety and depression are separate problems. They actually run together nearly 70 percent of the time. Through our brain imaging work I have described seven different types of anxiety and depression, and knowing which type you have is critical to getting the right help. Shortly, I will tell you about all of the types, but first I want to share with you the treatments I recommend for all types.
Treatments for All Types of Anxiety and Depression
I recommend a general five-step approach for treating anxiety and depression. First, it is important to rule out a medical cause of anxiety or depression. Thyroid abnormalities, anemia, sleep apnea, brain injuries, and certain medications can all cause these problems. Getting a physical exam is one of the first, most important steps in dealing with these issues. One of my best friends from college came to see me because she was feeling overwhelmed and depressed. When I scanned her, she had severe overall low activity in her brain. Her brain looked like she was a drug addict. But I had known her for many years and knew that was not the case. Her blood work indicated a severe vitamin B12 deficiency, causing her to be very anemic. Treating her medical problem helped her mood and her brain.
Second, exercise helps all of the types. Exercise boosts blood flow and helps bring nutrients to the brain. In one head-to-head study comparing exercise with Zoloft, one of our effective antidepressants, they were equally effective after twelve weeks and exercise was actually more effective after ten months.
Third, I recommend that all of my patients take a multiple vitamin and fish oil supplement every day. Why? People who are depressed often do not eat balanced diets and vitamins can provide essential nutrients, such as vitamin D, that have been found to be low in many depressed patients. Vitamin D is made in our skin from sun exposure, but because we are exercising less outdoors and using sunscreen when we do, many people even in sunny climates have vitamin D deficiencies. Taking a supplement or walking in the sun every day for twenty minutes without sunscreen may be good for you.
Fish oil contains omega-3 fatty acids, which have been found to be low in people suffering from depression, ADD, Alzheimer’s disease, and in those who have suicidal thoughts. A search of the medical literature on omega-3 fatty acids found twelve studies that apply to mood enhancement. Of the twelve studies, ten were positive and two were negative. I think omega-3 fatty acids are an essential component to the treatment of depression. As I mentioned in the last chapter, omega-3 fatty acids have two major components: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). EPA tends to be stimulating while DHA tends to be sedating. For unfocused anxiety and depression, I recommend the EPA component of fish oil (NeuroEPA from Amen Clinics) and for the other types a combination of EPA and DHA (NeurOmega). For adults I recommend taking 2,000–4,000 milligrams a day and 1,000–2,000 milligrams for children. An easy form for children to take is Coromega.
Fourth, people with anxiety and depression are often filled with automatic negative thoughts, or ANTs. These are the thoughts that automatically come into your mind and ruin your day. For many people, learning how to correct these negative thought patterns have been found to be as effective as antidepressant medication, without any side effects. There will be more on this technique later.
Fifth, natural supplements or medication can be very helpful. My bias usually is to start with natural supplements, while others prefer to start with medication. Either way, it is critical to know the type of anxiety or depression you have so you can get the right help. If these descriptions are not clear enough, consider picking up my book Healing Anxiety and Depression or taking the Brain Systems test at www.amenclinics.com.
7 Types of Anxiety and Depression
Type 1: Pure Anxiety
Anxiety is the main issue. People with this type suffer from feeling anxious, tense, and nervous. They live with a sense that something bad is about to happen and often have physical feelings of anxiety, such as headaches, stomachaches, and heart palpitations. People with “pure anxiety” tend to avoid anything that makes them nervous, such as new places, and they are not good with conflict and tend to avoid it like the plague. I often say people with this type have way too many “fortune-telling” ANTs. They are masterful at predicting the worst and look to the future with fear.
Here’s an example: Gary had gone to his doctor for back pain. When the doctor examined him he found a tender spot over his kidneys. He told Gary he wanted to order a kidney x-ray. That is when Gary’s thoughts ran wild.
“The doctor is going to find out I have cancer,” he thought. Notice the little leap in logic! But his thoughts didn’t stop there. “I’m going to have to have chemotherapy. I’m going to vomit my guts out, lose all my hair, be in a tremendous amount of pain, and then I’m going to die!” All in about thirty seconds. Then in a panic Gary said to the doctor, “I can’t have that x-ray.”
“Why?” the doctor asked. “I need this x-ray, so I can figure out—”
Gary said, “No, you don’t understand! I can’t have the x-ray!”
That is when the doctor found my number and referred Gary to me.
As Gary told me this story, I knew that he suffered with a panic disorder. Gary was a master at predicting the worst, which was driving his panic symptoms. In treating Gary, I used deep relaxation and taught him to correct the ANTs that were feeding his anxiety. After two sessions I went with Gary to have the kidney x-ray. I hypnotized him to be calm during the procedure, and he did well until the technician came back into the room with a worried look on his face and asked Gary what side his pain was on. Gary grabbed his chest and looked at me as if to say, “I knew you were lying to me! I am going to die.” I patted him on the leg and said, “Look Gary, before you die, let me take a look at the x-ray.” Gary had a big kidney stone, which can be terribly painful, but kidney stones usually don’t kill anyone! Gary’s anxiety was ruining his life.
In treating pure anxiety, I teach my patients deep relaxation techniques and how to correct the negative thoughts that cause their suffering. In addition, certain supplements such as gamma-aminobutyric acid (GABA), vitamin B6, L-glutamine, valerian, or kava kava may be helpful. I don’t much like the typical antianxiety medications, like Xanax, because on scans the effects look very similar to those of alcohol, plus they can be addictive and affect memory.
Type 2: Pure Depression
Sadness is the main symptom. People with this type also struggle with low energy, sleep and appetite problems, and they may have little interest and get little pleasure in things that are usually fun. Their ANTs are different from the fortune-telling ANTs of Type 1 patients and tend to be more focused on feeling hopeless, helpless, worthless, and guilty. For this type I like the natural supplement S-adenosyl-methionine (SAMe), which has been found to be helpful for depression and pain, or I prescribe the antidepressant Wellbutrin.
Type 3: Mixed Anxiety and Depression
A combination of both anxiety symptoms and depressive symptoms, which is much more common than the pure types alone, calls for a combination of Types 1 and 2 treatments.
Type 4: Overfocused Anxiety and Depression
People with this type have anxiety or depression, and they get stuck on negative thoughts or behaviors. When this type is combined with anxiety, people get stuck on fearful thoughts. When it is combined with sadness, people get stuck on depressing thoughts. Obsessive-compulsive disorder occurs when people get stuck on obsessions or compulsive behaviors. With phobias, people get stuck on a fear, such as snakes. With post-traumatic stress disorder, people get stuck on something bad that happened in the past. Overfocused anxiety and depression is also associated with people who tend to worry, hold grudges, are rigid, and tend to be oppositional or argumentative. I have noticed that this type occurs more frequently in children or grandchildren of alcoholics.
In treating Type 4, it is important to boost serotonin, an important mood chemical in the brain. Supplements that do this include 5-hydroxytryptophan (5-HTP), L-tryptophan, and inositol, and there are currently six medications that do it as well: Prozac, Zoloft, Celexa, Paxil, Luvox, and Lexapro.
Type 5: Temporal Lobe Anxiety and Depression
The temporal lobes are underneath your temples and behind your eyes. They are very important to learning, memory, and emotional control. When there are problems in this part of the brain, people struggle with temper outbursts; memory problems; mood instability; and sometimes dark, evil, or frightening thoughts. People with this type tend to misinterpret comments as negative when they are not and they have trouble reading social cues. This type is common after a brain injury.
The supplements used to treat this type include GABA and fish oil. An antiseizure medication can also be helpful for this type. When there are memory issues present, I may use the supplements gingko, phosphatidylserine, or huperzine, or if they are severe I may use the medications Aricept or Namenda.
Type 6: Cyclic Anxiety and Depression
Mood cycles, sometimes mild, sometimes severe, is the typical symptom. The classic cyclic mood disorder is called bipolar disorder; people’s moods swing between two poles, from depression to mania. It affects nearly 3 percent of Americans in any given year and seems to have been increasing over the last few decades. Mania is the opposite of depression. During a manic episode, people need less sleep, often have racing thoughts, and feel pressure to keep talking. They also may be irritable and very impulsive. People with bipolar disorder can become hypersexual, hyperreligious, or spend large amounts of money they do not have. One of my first patients with this disorder spent thirty thousand dollars the family did not have and she had no idea how she would tell her husband.
Sometimes bipolar disorder is mistaken for ADD. The distinction between the two is critical, however, because if you give people with bipolar disorder stimulant medications you can make them much worse. Like ADD and other forms of anxiety and depression, there are degrees and types of bipolar disorder. Some people suffer with mild mood swings while others have trouble staying out of hospitals or jails. For severe bipolar disorder medication is usually important. I have not found natural supplements to be as effective to fully treat this illness. Having said that, I give all of my bipolar patients fish oil in addition to medication, as researchers from Harvard found it helpful to decrease mood swings and relapse.
Type 7: Unfocused Anxiety and Depression
People suffering from this type exhibit very low energy, trouble thinking, and feeling as though they are in a fog. Rather than worry, they tend to have trouble holding on to thoughts and often have memory problems. In treating Type 7, it is important to find out why the brain is so underactive, treat any problems that might be present, and then find ways to stimulate the brain. The best supplement for this type is SAMe, and Wellbutrin is the best antidepressant.
Matilda was brought to our clinic by her family after she nearly burned down her house by forgetting something on the stove. Her family was at their wits’ end. At age sixty-nine Matilda had been diagnosed with Alzheimer’s disease and had been getting worse. She had also lost her driver’s license because she had been in four minor accidents. Five of her six children thought she should be in a facility for her own safety. One of her daughters, however, had heard about me and brought her for more testing. “One more try,” she told me. “You are our last hope.” When I first met Matilda I thought she had Alzheimer’s disease too, but the results of her scan suggested otherwise. She had good activity in the areas usually affected by Alzheimer’s. Her scan was more consistent with depression. Sometimes in the elderly it can be hard to distinguish Alzheimer’s disease from depression. Based on her scan I put Matilda on the antidepressant Wellbutrin. Within three weeks Matilda came out of the fog she had been in. Her memory was better and she became more talkative. After a month she asked if I would write the DMV to help her get her driver’s license back. I told her, “Matilda, I drive on the same highways you drive. I need you to take your medicine and do the other things we discussed. If in six months you are still better and your scan is better, then I will write the DMV.”
Six months later she remained better, her scan had improved, and I wrote the DMV!
Natural Supplement Strategies for Each Type
In this section I will reexamine each type of anxiety and depression and provide more details about the supplements that I have seen to have clinical benefit. I’ll give you the rationale and dosage protocols that I suggest to my patients. Some of these I have discussed in the last chapter and will refer you there if the information is repeated. As I mentioned in chapter 6, if you decide to use these supplements instead of medication, as many people do, make sure you keep tabs on their effectiveness and inform your health care professional about what you are taking. I only want my patients to take something that is clearly beneficial to them. I also want them to take medication if the supplements are not effective. Many patients say that they want to try the natural supplements before they try medication. That’s okay, but if the supplements are not fully effective, they should pursue more effective treatments, including medication. Anxiety, depression, and bipolar disorder can be potentially very harmful when left untreated or inappropriately treated. Follow through to find out what works best for yourself or your child.
TYPE 1: PURE ANXIETY
For this type of anxiety, GABA, B6, L-glutamine, kava kava, or valerian may be helpful. I discussed GABA in the last chapter but include more information here as well.
GABA
A search of the medical literature on GABA supplementation found only two studies for anxiety and depression. Of the two studies, both were positive. In my experience, GABA can have a calming effect on anxiety and irritability, and can help with sleep.
GABA is an amino acid that also functions as a neurotransmitter in the brain. GABA is reported in the herbal literature to work in much the same way as the antianxiety drugs and the anticonvulsants. It helps stabilize nerve cells by decreasing their tendency to fire erratically or excessively. This means it may have a calming effect for people who struggle with temper, irritability, and anxiety, whether these symptoms relate to anxiety or to temporal lobe disturbance. Natural therapies that produce relaxation also act, at least in part, by enhancing GABA levels. A controlled pilot study found brain GABA levels were significantly increased after a single sixty-minute yoga session compared with a sixty-minute reading session.
The effect of orally administrated GABA on relaxation and immunity during stress has been studied in humans. One study evaluated the effect of GABA intake on the brain wave patterns of thirteen subjects. Electroencephalograms were obtained after three tests on each volunteer as follows: water as only intake, GABA, or L-theanine. After sixty minutes, GABA significantly increased alpha waves (calming brain waves) and decreased beta waves compared with water or L-theanine. These findings suggest that GABA not only induces relaxation but also reduces anxiety. In another study evaluating the effect of GABA on anxiety and immunity, eight people who were afraid of heights were divided into two groups (placebo and GABA). All acrophobics were crossing a suspended bridge as a way to induce stress. Immune response was measured by sampling immunoglobulin A (IgA) levels in their saliva while crossing the bridge. The placebo group showed marked decreases of their IgA levels, while the GABA group showed significantly higher levels. The authors of this study concluded that GABA could work effectively as a natural relaxant and its effects could be seen within one hour of its administration to induce relaxation and diminish anxiety. Moreover, GABA administration could enhance immunity under stress conditions.
GABA can be taken as a supplement in doses ranging from 250 milligrams–1,500 milligrams daily for adults and from 125 milligrams–750 milligrams daily for children. For best effect, GABA should be taken in two to three divided doses.
VITAMIN B6 AND L-GLUTAMINE
Vitamin B6 supports the action of the enzymes that convert the amino acid L-glutamine to GABA in the brain. Anxious people may not have enough L-glutamine or they may have vitamin B6 deficiencies, which render them deficient in the building blocks necessary for GABA production. GABA is one of the amino-acid-based neurotransmitters with inhibitory properties and decreases the rate of nerve cell firing. The recommended dose is 500 milligrams of L-glutamine three to four times daily between meals and 50–100 milligrams of vitamin B6 twice daily. A cautionary note: excessive doses of vitamin B6 may cause nerve damage that is usually reversible when vitamin B6 is stopped.
KAVA KAVA
A search of the medical literature on kava kava supplementation found seventeen studies for anxiety and insomnia on approximately fourteen hundred patients. Of the seventeen studies, fifteen were positive. In my experience kava kava can have a calming effect on anxiety and irritability and can also help with sleep.
Several years ago I went through a painful time of grief, where for the first time in my life I experienced panic attacks and trouble sleeping. Of all the supplements I tried, kava kava helped me the most. Kava kava is recommended by some alternative medicine practitioners to calm anxiety, promote healthy sleep, and reduce the physical and emotional effects of stress. Kava kava is thought to work by enhancing the production of GABA in the brain. It comes from the root of a South Pacific pepper tree and is commonly used as a social and ceremonial drink in the Pacific Islands. The herb is so widely used that it is thought to be, in part, responsible for the laid-back lifestyle of the islands. My patients have reported the following relief after taking kava kava: being relaxed without feeling drugged; having less muscle tension; and feeling a sense of peace and contentment, increased sociability, and initial alertness followed by a feeling of drowsiness. Do not take kava kava if you are going to drive.
Kava kava is not the type of supplement, like fish oil, that you should take every day. At most, use it for three weeks and then take a week off. Kava kava use on a daily basis may harm the liver. Kava kava has known interactions with alcohol; barbiturates; monoamine oxidase inhibitor antidepressants; benzodiazepines; other tranquilizers and sleeping pills; anticoagulants; antiplatelet agents including aspirin, antipsychotics, and drugs used for treating Parkinson’s disease; and drugs that suppress the central nervous system. Kava kava can exacerbate Parkinson’s disease and increase muscle weakness and twitching. Women who are pregnant or breast-feeding should not take kava kava.
Standardized dosage is 150–300 milligrams, one to three times daily as needed for anxiety or nervousness, standardized to contain 30–70 percent kavalactones. Most clinical trials have used the German kava kava extract WS 1490. It may take four weeks before you notice improvement. Kava kava should not be taken for more than three months without a two-week rest period.
VALERIAN
A search of the medical literature on valerian supplementation found ten studies for anxiety and insomnia. Of the ten studies, six were positive and four were negative. In my experience, valerian can be a useful sleep aid.
Many patients find valerian to be remarkably helpful as a sleeping aid. It is a well-recognized herb with antianxiety properties that is used as a mild tranquilizer, sedative, and muscle relaxant. There are about 150 species of valerian widely distributed in temperate regions of the world. The active ingredient is found in a foul-smelling oil produced in the root of the plant. The Roman physician Galen wrote about the virtues of valerian, it has been associated with the term all heal in medical literature of the Middle Ages, and it is also used in Chinese and Indian medicine. It was used in the United States prior to the development of modern pharmaceuticals. This centuries-old treatment for insomnia has also been helpful for symptoms of nervousness, stress, increased emotional reactivity, pain, and agitation, and it also appears to decrease seizure frequency for epileptic patients. Valerian seems to work by enhancing the activity of the calming neurotransmitter, GABA. Studies have shown valerian to be helpful for many types of anxiety disorders and for people with performance anxiety and those who get stressed in daily situations like traffic. Valerian is available in capsules, tablets, liquids, tinctures, extracts, and teas. Most extracts are standardized to 0.8 percent valeric acids. Unlike prescription tranquilizers, valerian has a much lower potential for addiction and has been used to help people who are trying to decrease their use of prescription tranquilizers or sleeping pills. (Anyone using prescription sleeping pills or tranquilizers should decrease or stop their use only under the supervision of a physician.) Sometimes valerian can cause nervousness or drowsiness, so make sure you know how your body reacts to it before you drive or do other activities that require sustained attention. Do not take valerian with alcohol, barbiturates, or benzodiazepines. Valerian is not recommended for use during pregnancy or breast-feeding. The recommended dose of valerian is 150–450 milligrams in capsules or teas.
TYPE 2: PURE DEPRESSION
I use SAMe, which was discussed in chapter 6 (see Chapter 6).
TYPE 3: MIXED ANXIETY AND DEPRESSION
I use a combination of the treatments in Types 1 and 2. So I may use SAMe (Chapter 6) plus GABA (see Chapter 6).
TYPE 4: OVERFOCUSED ANXIETY AND DEPRESSION
I use supplements that boost serotonin availability in the brain, such as St. John’s wort (see Chapter 6), 5-HTP (see Chapter 6), or inositol.
INOSITOL
A search of the medical literature on inositol supplementation found sixteen studies for a wide range of problems, including depression, obsessive-compulsive disorder, panic disorder, ADHD, Alzheimer’s disease, autism, binge-eating disorder, schizophrenia, and antidepressant augmentation. The results suggest that inositol has therapeutic effects in the spectrum of illness responsive to serotonin-enhancing medication, including depression, panic disorder, and obsessive-compulsive disorder and is not beneficial in schizophrenia, Alzheimer’s ADHD, or autism.
Inositol is a natural biochemical found normally in the human brain. Some scientists think it is a member of the B vitamin family. It is reported to help neurons more efficiently use the neurotransmitter serotonin. In a well-designed study of thirteen patients who suffered from obsessive-compulsive disorder, 18 grams of inositol compared with placebo significantly reduced symptoms. Spinal fluid inositol has been reported to be low in depression. Another well-designed study of 12 grams of inositol in twenty-eight depressed patients showed impressive improvement when compared with sugar pills. Since many antidepressants are effective in patients with panic disorder, twenty-one patients with this severe anxiety disorder were given 12 grams on inositol per day for four weeks. Compared with placebo, inositol was more effective with minimal side effects. Studies on inositol were not effective for all conditions. For example, it did not help schizophrenia, ADD, or Alzheimer’s disease. By its actions and the conditions it helps, inositol seems to act like mild Prozac, though with fewer of the side effects. Think of trying it if you are a worrier, have trouble letting go of negative thoughts, tend to be rigid or inflexible, or hold grudges. The dose is up to 18 grams a day.
Do not take St. John’s wort, L-tryptophan, 5-HTP, or inositol with prescribed antidepressants, unless under the close supervision of your physician.
TYPE 5: TEMPORAL LOBE ANXIETY AND DEPRESSION
The supplements used to treat this type include GABA (see Chapter 6) and fish oil, discussed in the last chapter (see this chapter). A higher protein, lower carbohydrate diet may also be helpful. Eight studies from Johns Hopkins researchers found that a ketogenic diet (very low carb) significantly reduced seizure frequencies in children with epilepsy. Many physicians believe that sugar is both pro-inflammatory and pro-epileptic. This kind of diet is worth a try for this type.
TYPE 6: CYCLIC ANXIETY AND DEPRESSION
As I said for severe bipolar disorder, I often think that medication is important. Having stated that, many of my patients do not want to take lithium, anticonvulsant medication, or antipsychotic medication. One dentist I treated had clear bipolar disorder, where he didn’t need to sleep; had racing thoughts; and became hypersexual, hyperreligious, and spent vast sums amount of money he didn’t have. He felt terrible on lithium and wanted to try natural treatments exclusively. To my surprise he responded to high-dose fish oil at 10 grams a day. I think all of my bipolar patients should take fish oil. In addition I also think some bipolar patients may benefit from a ketogenic diet, as it has antiseizure qualities and we use anticonvulsants to treat bipolar disorder.
Another type of cyclic anxiety and depression is seasonal affective disorder, or winter blues. Prozac has been found in some studies to be effective; in other studies, bright light therapy has been found to be even more effective, as has vitamin D supplementation. Vitamin D deficiencies are becoming more common across North America. It is associated with both depression and pain syndromes. Vitamin D is made in our skin from sun exposure, but because we exercise less outdoors and use sunscreen, many people even in sunny climates are deficient in vitamin D. I recommend that my patients test their 25-hydroxy vitamin D levels and, if found to be low, take a vitamin D3 supplement or walk in the sun every day for at least twenty minutes without sunscreen.
TYPE 7: UNFOCUSED ANXIETY AND DEPRESSION
The supplement for Type 7 is SAMe (see Chapter 6). This type is associated with overall low activity in the brain. Another natural treatment I may recommend if there has been an infection, brain trauma, or environmental toxic exposure is hyperbaric oxygen treatment, which has been found on SPECT scans to boost overall blood flow to the brain.
Knowing the type of anxiety and depression you have is critical to getting the best help. One treatment does not fit everyone and I have found this type-specific approach to be the most clinically effective way to think about and treat anxiety and depression.