It should come as no surprise that physical and emotional health are intertwined and impossible to tease apart. From the perspective of integrative medicine, mind and body are two aspects of an underlying unity, so that changes in one always correlate with changes in the other. Of course, conventional biology-explains-all medicine has long recognized anxiety, depression, and other disturbances of mood as symptoms of physical disease, but it has been slow to accept the possibility that imbalances in the mental/emotional realm can cause physical symptoms. I am happy to see that change as new research illuminates the complex interactions of mind and body. The findings also suggest powerful strategies for improving emotional well-being through physical interventions.
Textbooks I used in medical school included mood disturbances among symptoms of endocrine disorders, which are conditions that involve hormone-secreting glands such as the thyroid, adrenals, and pituitary. A classic example is the association of depression with hypothyroidism. Up to 20 percent of people suffering from depression are deficient in thyroid hormones; many of them have received long-term treatment with antidepressant drugs before physicians thought to check their thyroid function. That should be assessed in every depressed patient and, if low, corrected. Thyroid hormones regulate metabolism; just how they affect our emotions is not known. They may have direct effects on brain centers or may influence the production and recycling of neurotransmitters. Dysfunction of the pituitary and adrenal glands also commonly affects emotional health, as do the drugs used to treat it. In Addison’s disease, for example, the immune system damages the adrenal cortex and its ability to produce cortisol and other vitally important hormones; irritability and depression are common symptoms, along with many physical changes. The corticosteroid drugs required to keep patients with Addison’s disease alive and healthy can cause both mania and depression.*
It is well known that sex hormones affect mood in both men and women. Emotional changes associated with the female menstrual cycle and with menopause are often striking. Depression in some older men can be relieved by boosting low testosterone levels. Presumably, sex hormones have direct effects on the brain and on neurotransmitters involved with our emotions. More curious is the influence of insulin, the hormone secreted by the pancreas that controls blood sugar (glucose) and the production and distribution of energy in the body. People with diabetes are more likely to be depressed than people without it. Some studies link depression to insulin resistance, the underlying problem in the more common type-2 variety of diabetes, but we don’t know what is cause and what is effect. Insulin receptors occur throughout the brain. Might this hormone directly affect mood? A recent study in animals with type-1 diabetes demonstrated a previously unknown effect of insulin on dopamine signaling in key brain centers. Or is it that the disturbed glucose metabolism of diabetes alters brain function? (Brain cells rely on glucose as their sole source of energy and must have a constant supply of it.) Or is the source of diabetics’ depression the fact that they have a serious chronic disease that can undermine quality of life?
We might also ask that about the occurrence of depression in conjunction with other serious chronic diseases that are not rooted in hormonal imbalances. One in three heart attack survivors experiences depression, as does one in four people who have strokes and one in three patients with HIV. Certainly, such patients have reason to be depressed, but how much of their depression might be a symptom of their disease rather than a psychological reaction to it?
We have no evidence that HIV directly affects emotions, but cardiovascular disease, even before it progresses to heart attacks and strokes, often impairs blood flow to the brain, and this might disturb the function of centers that control emotions. An even higher percentage—50 percent—of people with Parkinson’s disease suffer from depression. Here, altered brain biochemistry is the likely explanation, because this progressive condition causes degeneration of neurons that use dopamine to signal other neurons in the midbrain, specifically in centers controlling movement but also in other parts of the brain, including the frontal lobes. It may damage serotonin pathways as well. One research neurologist who has studied the correlation of depression and Parkinson’s, Irene Richards, MD, of the University of Rochester (New York) Medical Center, says unequivocally, “The depression is part of the illness, not simply a reaction to the disease.”
The obvious takeaway message from this is to make sure that a physical problem is not responsible for suboptimal emotional wellness, especially an easily treatable one like hypothyroidism. So, one of my first recommendations in the list at the end of this chapter is to get a complete medical checkup, including necessary blood tests, if you have not had one recently. A more subtle conclusion I draw is that inquiry into the mechanisms linking disease and emotions can provide valuable information that we all would do well to make use of in adjusting our ways of living. I base that conclusion on my reading of the scientific literature on the common association of depression with another serious chronic disease that we are all familiar with: cancer.
As many as 25 percent of persons with cancer experience depression. With some kinds of cancer—notably pancreatic—the percentage is much higher. In some cases depression precedes the diagnosis of cancer; in others it comes afterward. Medical scientists speculate endlessly about possible explanations for the association of these conditions. Some think that depression might be an early symptom of a pancreatic tumor, especially in men. Others think the relationship is more likely to be indirect. Maybe smoking is the hidden link: cigarette smoking is a known risk factor for pancreatic cancer, and tobacco addiction is more common in people prone to emotional problems. Or chemotherapy might be to blame for the depression. Often, it has profound mental and emotional side effects: irritability and impairment of memory and concentration as well as mood. (Chemo brain is the common term for these symptoms; fortunately, they usually dissipate sometime after treatment ends.)
Recently another hypothesis—and, to my mind, a very compelling one—has attracted attention. Based on animal research models, it proposes a mechanism that links the brain and the immune system to explain cancer-related symptoms, including emotional changes. I believe it offers new possibilities for preventing and treating depression and enhancing emotional well-being. The mechanism centers on cytokines, potent regulatory proteins made by immune cells that govern responses to foreign antigens and germs. People with cancer often have abnormal immunity due to abnormal production and function of cytokines.
Cytokines have diverse effects. One type—the interleukins—controls inflammation and produces fever. Another type governs the maturation of red and white blood cells in the bone marrow. Yet another—the interferons—helps us defend against bacteria, parasites, viruses, and malignant cells; they are named for their ability to interfere with viral replication. A group of cytokines called tumor necrosis factors got their name because they can kill some cancer cells in test tubes; they regulate programmed cell suicide and general inflammation and are a significant part of the body’s defensive reaction to the presence of malignant growth.
Some cytokines have proved useful as medical treatments despite significant toxicity. In 1980, scientists succeeded in inserting a gene for human interferon into bacteria, allowing mass production and purification. Since then, synthetic injectable forms of interferon have been in wide use as treatments for a number of kinds of cancer (skin cancers, some leukemias), chronic viral hepatitis, and multiple sclerosis. A commonly reported side effect of interferon therapy is severe depression; some patients have even killed themselves. One form of interleukin is used to treat metastatic kidney cancer and advanced melanoma. In addition to severe physical side effects, it can cause paranoia and hallucinations.
Long-term activation of the immune system, as in autoimmune disease, seems to go along with depression, and depression seems to involve changes in various aspects of immunity, particularly those having to do with cytokines. People with rheumatoid arthritis, scleroderma, systemic lupus erythematosus (SLE), and other forms of autoimmunity are often depressed. And when proinflammatory cytokines are administered to animals, they elicit “sickness behavior,” a distinctive pattern of behavioral changes. The animals become listless, lose interest in eating, grooming, socializing, and sex, and show increased sensitivity to pain.
Farmers have long recognized this pattern in sick animals and attributed it to physical weakness, but in the 1960s, research revealed a blood-borne factor to be responsible. (Injections of blood from sick animals caused sickness behavior in healthy ones.) Believed to act on the brain, it was named factor X until the 1980s, when it was identified as proinflammatory cytokines made by activated white blood cells in response to bacterial antigens. Sickness behavior is an adaptive response of the organism that conserves energy and favors healing. It is also strikingly similar to the changes in behavior accompanying major depression—so similar, in fact, that researchers in the field of psychoneuroimmunology have developed a cytokine hypothesis of depression, which argues that proinflammatory cytokines are the key factor controlling the behavioral, hormonal, and neurochemical alterations characteristic of depressive disorders, including much of the depression that occurs with cancer.
Loss of interest in food and a lack of pleasure in eating make sense as short-term responses to infection—they free up energy used for digestion and make it available for immune defense. Once the immune system gains the upper hand, it can turn down the cytokines, allowing brain centers that control appetite and taste to resume normal activity. Malignant tumors, however, even when they are relatively small, often stimulate prolonged cytokine responses that do more harm than good. For example, they are responsible for the permanent suppression of appetite and aversion to food that result in the extreme wasting (cachexia) that all too many cancer patients suffer. Given that dramatic effect on the brain and body, consider the impact of prolonged cytokine responses on parts of the brain associated with thoughts and emotions.
The reason I find the cytokine hypothesis of depression so compelling is that it fits right in with my belief that doing everything we can to contain unnecessary inflammation—by adhering to an anti-inflammatory diet, for example—is the best overall strategy for attaining optimum health and experiencing healthy aging. Let me briefly summarize this view.
Inflammation is the cornerstone of the body’s healing response. It is the process by which the immune system delivers more nourishment and more defensive activity to an area that is injured or under attack. But inflammation is so powerful and so potentially destructive that it must stay where it is supposed to be and end when it is supposed to end; otherwise it damages the body and causes disease. We all know inflammation when it occurs on the surface of the body as local redness, heat, swelling, and pain; we are less aware of it when it affects us internally, particularly if it is chronic, diffuse, and low level. But chronic, diffuse, low-level inflammation inside the body—in the lining of arteries, in the brain, and in various other tissues and organs—is the root cause of the most common and serious diseases of aging, including cardiovascular disease, Alzheimer’s (and other degenerative diseases of the central nervous system), and cancer. The link with cancer may seem less obvious, but it is quite real, because anything that promotes inflammation also promotes cell proliferation, increasing risks of malignant transformation. Cytokines are the principal chemical mediators of the inflammatory response. Anything you can do to keep them within their proper bounds will reduce your risks of chronic disease and also, it now appears, help protect you from depression.
Dietary choices are of great importance. In chapter 2 I pointed to modern industrial food as a possible cause of epidemic depression. We all know that fast food and junk food and the highly processed stuff that fills the shelves of supermarkets and convenience stores are not good for us. Now there is a powerful evidence-based argument for not eating this way: these new kinds of manufactured food promote inflammation. They are a principal reason why so many North Americans and people in other developed countries go through life in proinflammatory states with their cytokine systems in high gear. Industrial food fails to provide our bodies with protective nutrients (vitamins, minerals, and the phytonutrients—plant-derived compounds—most abundant in vegetables and fruits). At the same time, it gives us too many proinflammatory fats and carbohydrates.
The natural pigments that color vegetables and fruits; antioxidants in olive oil, tea, and chocolate; novel compounds in ginger, turmeric, and other spices and herbs; and the special fats in oily fish, all protect our tissues and organs from inappropriate inflammation; some are potent natural anti-inflammatory agents. Today’s mainstream diet is glaringly deficient in these protective elements.
At the same time, it is overloaded with fats that promote inflammation: polyunsaturated vegetable oils (especially refined soybean oil, cheap and ubiquitous in industrial food products); margarine and other partially hydrogenated and trans fats; and fats in the meat of cows and chickens raised on unnatural grain-rich diets. All of these increase the production and activity of proinflammatory cytokines. And it gives us carbohydrates mostly in the form of products made from quick-digesting flour and sugar: bread, pastry, cookies, crackers, chips, sugary drinks, etc. These are classified as high-glycemic-load foods because they raise blood sugar quickly,* stimulate insulin resistance in the many of us who are genetically at risk for it, and increase inflammation, perhaps in several ways. Insulin resistance is associated with inflammation (and, as mentioned above, with depression). Also, the spikes of blood sugar that follow high-glycemic-load meals cause abnormal reactions between sugar and proteins throughout the body that produce proinflammatory compounds.* In the past, people ate mostly low-glycemic-load carbohydrate foods that digested slowly and did not cause blood sugar to spike, foods such as whole or cracked (as opposed to pulverized) grains, starchy roots and tubers, beans, and winter squashes.
I have designed an anti-inflammatory diet using the Mediterranean diet as a template. It is the way I eat and the way I recommend others eat to maintain optimum health. Based on my reading of the scientific literature on the relationship between inflammation and depression, I now recommend it to you as an effective strategy for attaining optimum emotional well-being, and I have included details of it in the program at the end of this book. I assure you that it is not hard to eat this way and that doing so does not in any way diminish the pleasure of eating. The most important rule is simply to avoid refined, processed, and manufactured foods. By taking that one step toward better nutrition, you can significantly reduce the proinflammatory pressures of modern living.
Keep in mind, however, that while diet may be the keystone of an anti-inflammatory lifestyle, it is not the only component. Many common environmental toxins and irritants trigger inflammation, among them tobacco smoke and other pollutants in air, water, and food, as well as chemicals in household products. It is a good idea to take sensible measures to limit exposure to them as well as increase your body’s resistance to their effects—by using dietary supplements appropriately, for example. Exercise is also an important factor. People who are fit and who exercise regularly have less inflammation than others. That may be one reason physical activity has such a dramatic and beneficial effect on emotional well-being. (Many other mechanisms are also probably involved; I will review them in a moment.) The quantity and quality of your sleep also influence inflammation, as does stress. Crafting an effective anti-inflammatory lifestyle means attending to all of these factors.
Here are two case examples of dramatic mood improvement brought about by changing dietary habits.* Cham from Baltimore, Maryland, reports:
Years ago every morning I would cry for about three hours. I couldn’t even get out of bed. This had about 70 percent to do with the choices I was being pressured to make and 30 percent to do with the way I was handling my food intake. Counseling helped with the bad personal choices and removing the negative people in my life, but it took me years to identify the nutrition challenge. I found that a generous helping of lean protein foods in the morning and avoidance of simple carbohydrates like sugar and refined wheat products had a dramatic effect on my mood. My breakfast now looks more like dinner, it may have lean meat, egg whites, tofu, beans, whole grains, yogurt, and always several vegetables. This works for me and would probably work for others as well. I’m no doctor, but I have been adjusting this nutrition plan for years, and I am confident that eating the right foods in the morning can help deter a morning plunge into depression.
Cham’s story conforms to my personal experience. Typical American breakfast foods may be the worst possible choices for starting the day. Cereal, waffles, pancakes, muffins, toast with jam, cinnamon rolls, orange juice, and similar blood-sugar spikers virtually guarantee a crash in mood and energy by midmorning. When I first had a traditional Japanese breakfast of fish, vegetables, miso soup, and a modest portion of steamed rice, it was an utter revelation. I now always eat protein—especially fish or whole soy—with breakfast and try to avoid high-glycemic-load carbohydrates.
Carol, from Finleyville, Pennsylvania, also has learned the importance of a dietary makeover to create a new mind and mood:
In 2003, I was overweight. I was a confirmed “bakery-o-holic,” “Dorito- and Pepsi-o-holic,” and was living on ibuprofen and quite a few other prescription drugs…. I made up my mind it was all the crap that I was eating that was making me horribly depressed and overweight. Not only did I need knee replacements, I had fibromyalgia—I was a physical and mental mess.
So between 2003 and 2005, I taught myself a whole new lifestyle…. I would like to take the opportunity to THANK YOU from the bottom of my heart, because you were the one that taught me to eat right, take the right supplements. To this day I only take an occasional ibuprofen, if all else fails.
Here I am at almost age sixty-four, and happy as can be with my fifty-pound weight loss over the course of seven years, and LOVING exercise and eating and cooking. I just can’t believe the difference in my mental well-being now compared to how I felt in 2003. I cook vegetarian, and eat WILD seafood only. I try to eat organic when I can….
My observation is that my mental well-being is linked to the right food and the right supplements, and exercise!
Many studies link specific nutrient deficiencies to suboptimal brain function and mental/emotional health. The most important by far is lack of omega-3 fatty acids. These special fats are critically important for both physical and mental health. The body needs regular daily intake of adequate amounts of both EPA and DHA, two long-chain omega-3 fats that are abundant in oily fish from cold northern waters but otherwise are hard to come by. Most of us do not get enough, making this the most serious dietary deficiency in our population. A great deal of scientific data links low tissue levels of EPA and DHA to a host of mental/emotional disorders, including depression, violent behavior, suicide, and learning disabilities. Dietary supplementation with these fats, usually in the form of fish oil, has proved to be an effective, natural, and nontoxic therapy for bipolar disorder, attention deficit hyperactivity disorder, postpartum depression, seasonal affective disorder, and more. It also helps prevent depression and improve overall emotional well-being. Very high doses of fish oil—20 grams a day or more—have been used as treatments without any ill effects. In fact, there is no downside to adding fish oil to your diet (except for the sustainability of ocean resources, a significant concern).
Human beings are literally fatheads—fat accounts for about 60 percent of the dry weight of our brains. Omega-3 fatty acids optimize brain health in several ways. DHA is the main structural component of nerve cell membranes; if it is deficient in the diet, especially during embryonic development, infancy, and early childhood, brain “architecture” will be weak, leaving the central nervous system more vulnerable to harmful effects of stress and environmental toxins and impairing its function. Both EPA and DHA reduce inflammation, and both protect neurons from injury and improve communication between them. They also contribute to the health of the cardiovascular system and its ability to meet the brain’s need for uninterrupted supplies of oxygen and glucose.
The human need for abundant omega-3s is explained by our evolutionary history. Many anthropologists now believe that humans broke away from the primate pack and developed large, complex brains when they figured out how to secure animal foods rich in omega-3 fatty acids, especially fish. A gorilla, eating mostly leaves and other raw vegetable matter that is very low in fats, has a brain that is about 0.2 percent of overall body weight, while a human’s brain is 3 percent of body weight; in relative terms, that’s 15 times larger.
The anti-inflammatory diet emphasizes omega-3-rich fish as a main source of animal protein, especially sockeye salmon, black cod, sardines, and herring, all “good” species with regard to both sustainability and toxic contamination (with mercury, PCBs, etc.). I eat these fish often and also take 3 grams of supplemental fish oil a day. Because an omega-3 deficiency is so common, and raising tissue levels of omega-3s has so many health benefits in general, I recommend that everyone take 2 to 4 grams of a good fish oil product every day. (I give product specifications on here.) I cannot overemphasize the importance of this simple measure to improve emotional well-being. Not only does it offer real protection against depression, but I believe it can help move your emotional set point away from sadness and toward contentment. Of all the body-oriented interventions I discuss in this chapter, the two that I prescribe most frequently are regular physical activity (see here) and supplemental fish oil.
Margo, forty-nine, an engineer and wellness consultant from Pottstown, Pennsylvania, uses fish oil to reduce her dependence on pharmaceuticals:
There is a long history of depression and alcoholism on both sides of my family, including my immediate family. After finally admitting that I, too, had a problem with depression, I went on antidepressants. For years I was fine. Then, slowly, I weaned myself off one of the two drugs and within six months I reached a new depth of despair, which was then relieved by going back on the second medication. I now am doing very well on minimal dosage of each since I added omega-3 to my daily diet. I am taking the most potent supplement available. I feel better than I remember feeling for a long time and plan to stay on omega-3 for life and get off drugs, if I can.
Pregnant women are particularly vulnerable to depleted omega-3 fatty acid stores. If dietary sources are inadequate, the fetus will rob the mother’s tissues of the omega-3s it needs for brain and nervous system development, leaving her at high risk for pre- and postpartum depression. Kari, thirty, a clinical social worker from Antioch, California, tells this story:
When I was in my seventh month of my first pregnancy, my hormones left me feeling so overwhelmed. Anything could trigger my heart pounding and teary eyes to well. I had taken my usual vitamin regimen, but adding fish oil helped keep my negative emotions at bay. I felt normal again and noticed that if I missed a day, my anxiety and tearfulness would creep back in.
Carol, sixty, a finance-industry manager from Lake Dallas, Texas, says she suffered from depression and posttraumatic stress disorder for “most of my adult life” but attributes a turnaround principally to two sources of omega-3 fats—fish oil and walnuts:
After about three weeks of daily use I find that my flat mood and malaise have been replaced by a lighter and more upbeat feeling. The change is subtle but real. I highly recommend this as a trial for anyone who prefers to not use antidepressants (the serotonin reuptake inhibitors always made me sleepy—way too sleepy—like all day long). Actually I tried Prozac and Paxil in the 1980s and couldn’t tell a benefit at all, so I would say that for my particular chemistry and issues, fish oil and walnuts trumped drugs.
Walnuts and other vegetarian sources of omega-3s, such as chia seeds and the seeds and oils of flax and hemp, do not provide EPA and DHA. They provide only a short-chain precursor (ALA) that the body must convert to the long-chain compounds it needs. That conversion is inefficient at best and is further inhibited in the presence of the fats that predominate in processed food. Flax and hemp seeds and walnuts are good additions to the diet, but they are not substitutes for fish and fish oil.
I am conflicted about telling people to eat more fish and take fish oil, because overfishing has so depleted the world’s oceans. I am involved with ongoing efforts to develop a sustainable source of omega-3s from algae. Salmon and other oily fish do not make their own EPA and DHA; no animal can do that. Instead, they get them by eating the algae that do make their own. A commercial algae-derived DHA product is now available, but it is hard to find one containing both EPA and DHA. Soon, I hope, I will be able to use and advise others to use an algae-derived omega-3 supplement that is equivalent to fish oil, one suitable for vegetarians and for all of us who care about the state of our oceans.
The second most common and serious nutritional deficiency in our population is lack of vitamin D, actually a hormone made in the skin on exposure to ultraviolet light from the sun. For various reasons, many people do not get adequate sun exposure to meet their needs for vitamin D, and it is almost impossible to get enough of it from diet alone. Supplementation, however, is effective and inexpensive. A recent explosion of research on vitamin D has made both doctors and laypeople aware of its myriad benefits, not just for bone health but for protection against many kinds of cancer, multiple sclerosis, influenza, and other diseases. As a result, more doctors now routinely check blood levels of vitamin D in their patients and are documenting a deficiency in many of them.
Less well known are the connections between vitamin D, brain health, and emotional well-being. Receptors for vitamin D occur throughout the brain, and it appears to play an important role in the development and function of that organ, including the activity of neurotransmitters that affect mood. High vitamin D levels may protect against age-related cognitive decline. Low levels are associated with impaired cognitive function (especially in the elderly), seasonal affective disorder, depression, and even psychosis. (The last correlation is posed as a possible explanation for the surprisingly high incidence of schizophrenia in dark-skinned immigrants who move to northern European countries; dark-skinned people already have difficulty making enough vitamin D.)
As with omega-3 fatty acids, the benefits of vitamin D on both physical and mental health are so numerous and the deficiency so common that it is wise to supplement the diet with it. I take at least 2,000 IU a day and tell others to do that as well. Unlike with omega-3s, excessive intake of vitamin D can cause problems (too much calcium in the blood and tissues and possible kidney damage), but that happens only if doses far in excess of 2,000 IU a day are taken over time. There is no risk of vitamin D overdose from sun exposure, which has direct benefits on mood independent of its role in vitamin D synthesis. I will explain those benefits later in this chapter and tell you how to get them safely, without increasing the risk of skin cancer.
Below is a personal story of the power this micronutrient can exert over mood, from Christine, who lives in Beaverton, Oregon. While her intake is above my recommendation, research has found no adverse effects with supplemental vitamin D below 10,000 IU daily, so she is probably safe at this level. Indeed, in this cloudy, rainy, relatively northerly part of the country, she might be right on target:
I have found that taking a liquid vitamin D supplement has drastically improved my mood. While pregnant with my first child in 2007, I started taking 4,000 IU of vitamin D daily. After his birth, I increased it to 6,000 IU. I am currently pregnant again and am down to 4,000 IU, but, as someone who has struggled with mild to moderate depression her whole life, I have noticed that this has really been the one thing that has had a positive impact on my mood.
And here’s a report from Christina, another northerner, who lives in Springfield, Massachusetts:
I am amazed at how much vitamin D has changed my life. I am taking a daily supplement now after a blood test showed me to be deficient. My nurse practitioner put me on a vitamin D regimen, and I soon felt so much calmer and more energetic. And I sleep better. If I forget to take it for a couple of days, I notice the depression seeping back in again.
Deficiencies of other vitamins and trace minerals have been reported in people with mood disorders. Correcting the deficiencies with dietary supplements sometimes helps. Most frequently cited is the B-complex of vitamins, a group of water-soluble compounds that the body cannot store and needs constantly for optimum metabolism. Its need for them is increased by stress, erratic diets, use of drugs and alcohol, smoking, illness, shift work, and demanding travel. Vitamins B-6, B-12, and folate are commonly included in over-the-counter formulas for depression; data are best for the first two, less solid for folate. There is no reason not to take the whole complex of B-vitamins in supplement form, but also no reason to take them separately from a daily multivitamin/multimineral supplement.
Micronutrient deficiencies are common in our population. Industrial food often provides suboptimal amounts, and many poor people cannot afford the fruits and vegetables that are the best sources. I have argued that giving all school kids a free multivitamin/multimineral supplement would be a cost-effective public health measure, one that I believe would improve performance and behavior in classrooms as well as the health of our young people. I am also on record as saying that dietary supplements are not substitutes for good diets. At best, they are partial representations of the full spectrum of protective elements in whole foods. But they are good insurance against gaps in the diet and may, as in the case of vitamin D, offer specific therapeutic and preventive benefits that cannot be obtained from diet alone. I grow a lot of my own food, prepare it myself, and am thoughtful about what I eat. I also take a good daily multivitamin/multimineral supplement and advise you to do so, too, because I consider it another safe and effective measure to optimize emotional well-being. The program in this book tells you how to identify the best products.
A national news story from June 2010 described an “unorthodox treatment for anxiety and mood disorders, including depression” that was “free and has no side effects.” The treatment was “nothing more than exercise.”
Human bodies are designed for regular physical activity; the inactivity characteristic of so many people today undermines both general health and brain health and probably plays a significant role in the epidemic incidence of depression today. It is one of the most significant differences between the lifestyles of “advanced” societies and those of primitive ones, like the hunter-gatherers I mentioned in chapter 2, who enjoy much greater contentment than we do and among whom major depression is virtually unknown. More than two thousand years ago, the classical Greek philosopher Plato wrote: “In order for man to succeed in life, god provided him with two means, education and physical activity. Not separately, one for the soul and the other for the body, but for the two together. With these two means, men can attain perfection.”
Many studies show that depressed patients who stick to a regimen of aerobic exercise improve as much as those treated with medication and are less likely to relapse. The data also suggest that exercise prevents depression and boosts mood in healthy people. More research is needed to reveal how exercise does this and to determine just how much and what kind works best, but given what we now know, I consider it inexcusable to omit exercise from an integrative treatment plan for emotional well-being. If the mainstream mental health professions do not yet endorse this prescription, it can only be explained by how little emphasis is placed on exercise in professional training and how little attention it gets in professional media. That and the fact that medical scientists say that research to date is methodologically weak.
The problem is that most of the studies on exercise and mood are cross-sectional in nature, meaning that they look at groups of people in one moment of time and observe correlations, such as better moods with regular physical activity. Studies of that kind are relatively easy to do and cost relatively little, but they do not allow us to draw solid cause-and-effect conclusions. Maybe people who are more physically active are more likely to behave in other ways that make them happier, or maybe genetic traits that make people more active also influence brain activity in ways that favor positive moods. If so, prescribing exercise to improve emotional well-being might not be effective as a general measure. What we need more of are longitudinal or prospective studies that follow groups of people over time and assess their moods as they stick to exercise regimens. Results of the few such studies that have been done generally support the effectiveness of regular exercise to maintain and enhance emotional wellness.
Many possible mechanisms are proposed for this effect, both neurobiological and psychological. There is no consensus, and my guess is that no one mechanism is responsible. We don’t need to know how exercise works to improve our moods, but we do want to know how best to take advantage of it. Most prospective studies have used walking or jogging programs, but some research finds nonaerobic exercise such as strength and flexibility training as well as yoga to be effective, too. In Yoga for Emotional Balance, clinical psychologist and yoga therapist Bo Forbes explains:
Posture and movement can be insidious in building anxiety and depression. Without realizing it, we repeat physical patterns hundreds of times daily, sharpening them on the whetstone of our experience…. Depression can imprint not only your movement patterns, but your posture as well. Your body may have what I call “Closed Heart Syndrome,” a postural pattern that illustrates the helplessness, hopelessness, and self-protective withdrawal of depression. In Closed Heart Syndrome, the chest sinks and the heart area collapses. This makes the breath shallow and slow. The upper spine and shoulders round, as though to protect the heart from further disappointment. This also protects us from intimacy, which people with depression may see as merely another chance to be hurt…. We use head and neck alignment, heart-opening restorative postures, and deep breathing to lift and balance depression. People who have physical symptoms of depression often benefit from lengthening and opening the upper thoracic spine and chest areas.
Typical therapeutic exercise programs last for eight to fourteen weeks with three to four sessions a week of at least twenty to thirty minutes. For treatment of depression and anxiety disorders, activities of moderate intensity, like brisk walking, are more successful than vigorous activity. The most important conclusions of research to date are that regular physical activity:
| • | is as effective a treatment for mild to moderate depression as antidepressant medication |
| • | is an effective treatment for anxiety disorders |
| • | in healthy people helps prevent both depression and anxiety |
Increasing my own physical activity is one of the main measures that have helped me keep my dysthymia in check, but the kinds of activity I have used over the years have changed. In my thirties and early forties, I ran three miles or so most days of the week, until I began to notice that my knees did not like it. I phased out running and spent more time hiking and cycling. Later, I came to rely on exercise machines—stationary bikes, stair climbers, and elliptical trainers—as well as workouts with weights, both on my own and under the direction of a personal trainer. I also did some yoga for stretching and better balance. By the time I turned sixty, I came to regard such workouts as drudgery, too boring to keep me motivated. I started swimming regularly. My older body likes swimming very much, and I find that concentrating on my breathing as I swim is both meditative and relaxing. I try to swim most days. I also go on walks with my dogs and with friends and work in my garden. My colleague Victoria Maizes, MD, executive director of the Arizona Center for Integrative Medicine, tells her patients that they need exercise only on days that they eat. I agree that the goal is to get some physical activity every day.
More and more, I have come to believe that integrative exercise offers more health benefits, both physical and emotional, than other sorts. Integrative exercise means exercise necessary to accomplish some task. It is what our bodies are designed for—the activities of daily living. It is what people in premodern societies do. They walk, often uphill and downhill and over uneven ground, climb, lift, carry loads, chop wood, and so forth. The healthy and happy old people I’ve met in Okinawa and other parts of the world are regularly active in these ways; none of them use exercise machines, attend aerobics classes, or work with personal trainers. Research suggests that integrative exercise conditions our bodies most effectively, and that people are more inclined to stick with this kind of exercise. I believe that a major reason people abandon workout regimes based on treadmills, weight lifting, and other gym-based exercise is that, deep in our primitive psyches, we feel that such activity wastes energy. That feeling may be in our genes, a legacy from times when calories were harder to come by, when “pointless” caloric expenditures in food-scarce environments could prove deadly. I think that’s why I love the physical activity of gardening so much. Knowing that my labors will bring fresh, healthy food to the table adds immeasurably to my motivation. I can easily get lost in hours of physical labor among the rows, something that never happens to me on a StairMaster or stationary bike. (Of course, using machines is better than being sedentary and may be the best option for city-bound folk.)
Incorporating a goal—one that at least feels useful—into workouts can make them far more enjoyable. For example, at my home in British Columbia, I make a point of swimming most days to an island in the middle of a lake. The whole swim is not much longer than my standard pool workout, but reaching that island gives me a sense of accomplishment that’s often lacking as I log laps at my home in Tucson.
The best thing about integrative exercise is that it’s easy to get by doing housework and yard work and, especially, by walking. Walking outdoors with friends is great for emotional well-being. Not only does it give you the mood-boosting effect of physical activity, but it also puts you in touch with nature and provides the added benefit of social interaction.
I know many people who report that regular exercise is the single most effective strategy they have discovered to improve their moods. For example, Kelli, an adoption coach from Redwood City, California, writes:
I have struggled with dysthymia for as long as I can remember—chronic low-level depression with periodic dips to major depressive episodes. Last year after being rear-ended by a very drunk driver, I had to go through my fourth knee surgery and months of recovery. Though the surgery was successful from the standpoint of “fixing” the parts that were injured, I was left with chronic pain. After being frustrated over all that I could not do, I finally shifted to a place where I wanted to focus on what I COULD still do. I found myself drawn to the water, the local YMCA pool to be exact, and started doing lap swimming. I had swum over my life but only as a lark on vacation. Since this was likely now going to be my main cardio activity, I started working to do it properly and for long enough to get health benefits from it. Little did I know this first dip in the pool would lead to a year of now swimming one mile (thirty-seven round-trip laps) four to five nights a week. Not only have I not had a major depressive episode since, but I have dropped twenty-five pounds to boot.
Others sing the praises of running. Depending on your body type, running can either be painful and hard on joints or a fast track to physical and mental transformation. Kim, from Boston, found it to be the perfect way to exit a depressive spiral triggered by divorce:
People said, take depression medication, etc., but I knew what would work for me. I began to run regularly. I never felt so good. Divorce is life-altering. I used exercise to keep my spirits high and my attitude very positive. I ran almost daily, just to push myself and stay positive about my future. I started at five miles, then worked my way up to run the seven-mile Falmouth Road Race in Falmouth, Massachusetts, in 2009. I then continued and ran the Boston half-marathon two months later and finished with training for the Boston Marathon. All the months of this running was such a release of life’s troubles. I took aerobics classes, strength-training classes, and ran a lot! I was the happiest I had ever been.
People who are contented and serene sleep well. They fall asleep easily, stay asleep, and wake refreshed. Conversely, people who are anxious, stressed, or depressed do not sleep well, and chronic insomnia is strongly associated with mood disorders. These are clear correlations, but what is cause and what is effect is not clear. Most experts agree that sleep and mood are closely related, that healthy sleep can enhance emotional well-being, while insufficient quantity or quality of sleep can adversely affect it.
Studies report that about 90 percent of patients with major depression have difficulty initiating and maintaining sleep. Sometimes the insomnia accompanying depression is so profound that the problem is misdiagnosed as a sleep disorder. And chronic insomnia—on and off for the better part of a year—is a strong clinical predictor of depression (as well as all types of anxiety disorders). Five to 10 percent of the adult population in Western industrialized countries suffer from chronic insomnia, making it another likely contributor to the depression epidemic.
When I am depressed, I do not get good sleep. If I’m stuck in mental rumination, I can’t fall asleep, because I can’t turn off my thinking mind. And I’m likely to wake early with my thoughts racing. Stress and anxiety interfere with my sleep as well. When I’m in good emotional health, I look forward to a sound night’s sleep, fall asleep very quickly, have an active and enjoyable dream life, and wake feeling clearheaded and ready to start my day. Typically, I get eight hours of sleep a night. If I get much less than that or if my sleep is disturbed by nonemotional factors, such as international travel, noise, or too much caffeine too late in the day, I do not feel my best on waking, and if that happens several nights in a row, I am irritable and not able to work or concentrate well.
Surprisingly, there is little experimental research on the connection between sleep and emotions. Most of it involves sleep deprivation: human subjects are observed in laboratories over days or weeks when they are allowed to sleep less than normal amounts (up to 50 percent less, for example). Sleep restriction generally makes healthy people less optimistic and less sociable and more sensitive to bodily pain. One study at the University of Pennsylvania found that subjects limited to four to five hours of sleep per night for one week reported feeling more stressed, angry, sad, and mentally exhausted. Their moods improved dramatically when they resumed normal sleep.
Another study, by investigators at Harvard Medical School and the University of California, Berkeley, used functional MRI to assess changes in brain function with sleep deprivation, in particular the interaction between the medial prefrontal cortex (MPFC) and the amygdala. I’ve told you that the amygdala is an evolutionarily old brain center that mediates emotional responses to unpleasant stimuli, producing fear and defensive reactions; its activity is heightened in depression. The newer MPFC modulates and inhibits amygdala function to shape more socially appropriate emotional responses; a main finding of the neuroscientific studies of trained meditators is that they have enhanced activity of the MPFC. Sleep-deprived human subjects react more negatively to stimuli, and functional MRI scans of their brains show disconnection of the MPFC-amygdala pathway. This neurological change is one likely mechanism for the effect of sleep on mood. Another might involve cytokines, because sleep deprivation also increases inflammation in the body.
Mood disorders are also strongly linked to abnormal patterns of dreaming and alterations in REM (rapid eye movement) sleep, the phase in which most dreaming occurs. Rosalind Cartwright, PhD, a leading sleep and dream researcher at Chicago’s Rush University Medical Center and author of The Twenty-four Hour Mind: The Role of Sleep and Dreaming in Our Emotional Lives, has shown that individuals who dream and remember their dreams heal more quickly from depressive moods associated with divorce. Rubin Naiman, PhD, a sleep and dream expert on the clinical faculty of the Arizona Center for Integrative Medicine believes that “REM/dream loss is the most critical overlooked socio-cultural force in the etiology of depression.”
Of significance is the fact that most medications used to help people sleep suppress REM sleep and dreaming and also fail to reproduce other aspects of natural sleep. They are some of the most widely used drugs in our society. Many antidepressant drugs suppress dreaming as well. (Those that are stimulants can interfere with sleep in general.)
Research suggests that the emotional content of many dreams is negative. If this is your experience and you find it disturbing, consider Dr. Naiman’s view that dreaming is “a kind of psychological yoga,” that contributes to emotional wellness. He says that “REM/dreams in the first part of the night appear to process and diffuse residual negative emotion from the waking day; dreams later in the night then integrate this material into one’s sense of self.” Just knowing that dreams have value can be helpful. Brad, a friend who lives in Phoenix, told me:
Realizing that dreaming, rather than sleep per se, is vitally important has led me to a perceptual shift that’s been very valuable. After hearing a talk by Dr. Naiman about the importance of dreaming, I stopped tormenting myself with thoughts of “I need to sleep,” which paradoxically kept me awake with anxiety. Instead, I tell myself, “I need to dream,” and surrender easily to the sleeping/dreaming state. I used to fear the negativity of my dreams—it just seemed like useless torment, and staying awake was my subconscious attempt to avoid it. Now that I know that even negative dreams provide a useful release, I embrace them, and I am finally sleeping better. My dreams are getting better, too.
I’m happy to report that my dreams are overwhelmingly pleasant. Often I’m traveling in exotic lands, having great adventures with friends and interesting strangers. My parents, both deceased, are frequently in my dreams, always appearing young, healthy, and in good spirits. Recalling my dreams when I wake can put me in a good mood at the start of a day. I think I owe some of my active and entertaining dream life to melatonin. I take it most nights both for its effect on sleep and dreaming and for its useful influence on immunity. Fortunately, one does not develop tolerance to melatonin as with other sleep aids, and it rarely has negative side effects. (In part 3 of this book, I’ll tell you how to use it as part of a program to optimize your emotional well-being.)
The message I want you to take away from these pages is that you must assess your sleep if you want to experience better moods. If you have difficulty sleeping or are not getting enough sleep or sleep of good quality, you need to learn the basics of sleep hygiene, make appropriate changes, and possibly consult a sleep expert. I give specific suggestions on here.
The most widely used mood-altering drugs in our society are alcohol and caffeine, the former a “downer,” the latter an “upper.” (That’s depressant and stimulant in medical language.) Both strongly affect mood and behavior and with regular use can lead to dependence and addiction. If you use either and want to attend to your emotional well-being, it is important to look at your relationship with the substance and learn how it might be affecting your moods.
It may seem odd that depressed individuals would be drawn to a depressant drug, but that is the case. Alcohol first affects the inhibitory centers of the brain, causing alertness; confidence; feelings of energy, warmth, and excitement; good mood; and dissipation of anxiety—a welcome, if temporary, respite from stress and sadness. The disinhibition it causes accounts for its perennial popularity as a social lubricant at cocktail and dinner parties and romantic encounters. It is worth deconstructing the term happy hour for an alcohol-centered get-together at the end of the day, especially with coworkers in a restaurant or bar that offers drinks at discounted prices during certain hours. Not only does it equate happiness with the effect of a mood-altering drug, but it restricts the experience of it to a particular situation and implies that happiness is not to be had in all the hours of the day without alcohol.
In larger doses, alcohol dulls pain, both physical and emotional, but when it wears off, the pain returns, now accompanied by the physical and mental symptoms of alcohol’s toxicity. It is tempting to try to find relief by consuming more. People suffering from depression can easily slide into frequent and excessive drinking to avoid emotional pain, only to become addicted to alcohol and suffer all of the physical, emotional, social, and behavioral consequences of that addiction.
If you use alcohol regularly and are prone to depression or simply want to experience greater emotional resilience and well-being, I would ask you to examine your relationship with it. Ask yourself these questions:
| • | Do you use alcohol to mask anxiety, sadness, or other negative feelings? |
| • | Do you look forward to the time of day when you drink as the time when you’ll feel best? |
| • | Do you depend on alcohol to help you through social situations or periods of increased stress? |
| • | Are you able to experience contentment, comfort, and serenity when you are not using alcohol? |
| • | Do you regularly use any other depressant drugs, such as anti-anxiety or sleeping medications? If so, be aware that their effects and risks are similar to those of alcohol and additive when taken together. |
Alcohol can be a benign and useful social/recreational drug that may benefit overall health by reducing stress and the risk of cardiovascular disease. Moderation and awareness are the keys to using it successfully and protecting yourself from harm and the risk of dependence.
Caffeine, especially in the form of coffee, is so much a part of our culture that most users are completely unaware of how powerful a drug it is and how much influence it has on both emotional and physical health. Sensitivity to caffeine varies greatly from person to person. Some people who drink one cup of coffee a day are physically addicted to it, will experience a withdrawal reaction if they cut it out, and have any number of physical and emotional symptoms caused by it (that they probably do not connect to their coffee use). Others can drink many cups a day without any of that.
People like caffeine because it gives them temporary feelings of increased energy, alertness, and focus; many cannot start the day without it. Few understand that the energy provided by coffee, tea, cola, yerba maté, etc., is not some gift from “out there.” It is your own energy, stored chemically in your cells, that caffeine prods your body into releasing. When the drug wears off, you are left with a depletion of stored energy and are likely to feel fatigued and mentally dull. As with other stimulants, if you take more caffeine at this point, you can stave off the downside of the drug’s effect for a bit, but you run the risk of becoming dependent on it. When people are addicted to coffee or other forms of caffeine, their energy is usually bunched up early in the day and depleted later.
Caffeine makes many people anxious and jittery. Again, in sensitive people, this can occur with small doses. I advise anyone suffering from anxiety, nervousness, and mental restlessness to eliminate all forms of caffeine in order to determine how much it is contributing to those problems or obstructing their efforts to control them. The drug also commonly affects sleep for the worse. I have seen cases of chronic insomnia resolve when patients cut out one morning cup of coffee. Of course, these were very caffeine-sensitive individuals; none of them imagined that an ordinary cup of coffee at breakfast could interfere with falling asleep or staying asleep at night.
Even more interesting to me are the case reports I have collected of people who experienced improvement in mood when they stopped using caffeine. Here, for example, is a letter I received from a friend, Bill, a filmmaker and facilitator from Victoria, British Columbia:
As far as I can remember, I’ve experienced some form of depression most of my adult life, although I only became really aware of it through the daily mirroring of a twenty-year marriage. The defining part of my experience was this “ledge” I would all too easily slip over, sending me into an almost immobilized state.
I never bought into prescription antidepressants. Tales of their side effects kept me away. So, I started with alternatives like St. John’s wort, which worked reasonably well but never completely tackled the problem. For the longest time, coffee—three large cups every morning—seemed to help. The caffeine appeared to keep me “up,” but what went up also went down: the price was a huge dip in my energy in the afternoon. After a few years passed, I was back to the usual tendencies.
Recently, I slipped into a deeper depression than I had experienced for a long time. In the midst of it, I just happened to see a post on Facebook about alternative mood cures and clicked on the link. The first thing I read was that coffee was more a contributor than cure. I immediately went cold turkey off of it. What followed were three or four mentally foggy days and some headaches. Ibuprofen nipped most of them in the bud. On another recommendation, I started taking daily doses of two supplements, 5-HTP and L-tyrosine, to balance my serotonin levels. Almost immediately, the “ledge” seemed to disappear.
Now, over a month later, while still in the midst of life’s trials and inconsistencies, I find myself down at times, but it feels more like a natural state and passes quickly. I have dropped the supplements and satisfy my caffeine yearnings with occasional high-quality black tea. I have more energy, healthier sleep, and a better interface with friends, associates, and daily challenges.
My friend’s experience is typical and revealing. Many people consider coffee to be a mild antidepressant, because it can boost mood when used occasionally or when used regularly by those who are less caffeine-sensitive and resistant to its addictive properties. In people dependent on their stimulant effects, coffee and other caffeinated beverages may well be more contributory to depression than counteractive. The only way to know how caffeine may be affecting your moods is to stop it completely. Note whether you have a withdrawal reaction: fatigue and throbbing headache are the most common symptoms, but digestive upsets and other reactions may occur; these usually appear by thirty-six hours after the last dose of the drug, persist for two to three days, and are instantly relieved if you put caffeine into your system. If you have such a reaction, this is proof that you have been addicted to caffeine and an indication that it has probably affected your energy level, sleep, and moods. See how you feel without it.
Be aware that you may be getting more caffeine than you think, because it is in many products, not only the familiar beverages and chocolate but also decaf (!), energy formulas (drinks, shots, powders, and pills), non-cola sodas, herbal products, diet pills, and over-the-counter cold, headache, and pain remedies. To do the experiment properly, you will need to eliminate all caffeine from your life.
Most drugs that people use to alter their moods, perceptions, and thoughts are either depressants or stimulants. Barbiturates (Seconal, Nembutal, “reds”), Quaaludes, and opiates all depress brain function, while cocaine, methamphetamine, and ephedrine stimulate it. Frequent or regular use of any depressant or stimulant drug can lead to dependence and addiction and undermine emotional health and stability. If you are in the habit of using substances of this sort and want to improve your emotional well-being, I advise you to learn about their effects, see how your moods change if you discontinue them, and seek professional help if you have difficulty separating yourself from them.
Cannabis (marijuana) is neither a depressant nor a stimulant but can also have significant cognitive and emotional effects. There is a great deal of individual variation in responses to cannabis. Some people find that it relaxes them, makes them more sociable and less angry, increases sensory pleasure, and helps them concentrate. It works well for some as a natural remedy for pain, muscle spasm, and other medical problems. Others become anxious or paranoid when they use it. It helps some people sleep and keeps others from sleeping. It does not cause the kinds of dependence and addiction associated with stimulants and depressants, but heavy users may consume it every day throughout the day. Although the medical safety of cannabis is great, habitual use can be a factor in suboptimal emotional well-being. If you use it more than occasionally and are going to follow the program in this book, I suggest abstaining from it for a while to find out whether it makes it easier or harder for you to maintain serenity, resilience, contentment, and comfort.
Commonly prescribed medical drugs can affect mood, often for the worse. Too frequently, neither the doctor who prescribes them nor the patient who takes them is aware of that potential. For example, antihistamines make many people depressed. (Recall that Thorazine and other major tranquilizers that are used to manage psychotic patients were developed from antihistamines.) Growing up, I had a bad seasonal allergy to ragweed, for which I was given various drugs of this sort. It was a no-win situation for me: either I would be subject to the dismal mood caused by the antihistamines or I would suffer from the allergic sneezing and itching. The drugs made me feel as if a gray curtain had descended over my brain. Although I’ve lost my allergies as a result of changing my diet and lifestyle and have not needed to take antihistamines in years, I have tried newer versions that are not supposed to get into the brain or cause sedation. I’m sorry to report that they still dampen my mood.
Other big offenders are sleeping and anti-anxiety medications, particularly the benzodiazepines (Valium, Halcion, Klonopin, Xanax, Ambien, Ativan, etc.). These drugs are addictive, interfere with memory, and commonly cause mental clouding and depression. Some experts call them alcohol in a pill. Opiates such as codeine, Demerol, and Oxycontin, which are prescribed as cough suppressants and treatments for chronic pain, are strong depressants. I mentioned the risks of hormones and corticosteroid drugs like prednisone at the beginning of this chapter. With long-term use, steroids cause emotional instability, mania, and, most often, depression. Bronchodilators—used to manage asthma and chronic obstructive pulmonary disease—are strong stimulants that make many people anxious, jittery, and sleepless. Some medications used to control high blood pressure also have negative effects on mood. In fact, so many different kinds of pharmaceutical drugs can influence your emotional life that you should pay attention to any changes you notice when starting on a prescribed medication. I also suggest that you search the Internet for full information on possible psychological effects of any medications you take regularly. Good sites are WebMD.com, drugs.com/sfx, and drugwatch.com.
The same goes for OTC (over-the-counter) products, especially sleeping aids; cough, cold, and allergy remedies; diet pills; and analgesics (pain relievers).
Herbs that affect mood include depressants like kava and valerian and stimulants like ephedra, guaraná, and yerba maté. Occasional use is not a concern, but if you take any of these regularly, pay attention to their effects on your emotions. Other natural products sold online, in health food stores, groceries, and pharmacies may contain psychoactive substances: read labels carefully.
In summary: many commonly used beverages; prescribed, OTC, and recreational drugs; as well as herbal and natural remedies affect mood. Frequent or regular use of them can make it harder to attain optimum emotional well-being and get maximum benefit from the program I have developed.
In 1974 I moved from Tucson, Arizona, to Eugene, Oregon, where I thought I wanted to live. I had a community of friends there and loved exploring the majestic forests of the nearby Cascade Mountains. I made the move in June, when the Arizona desert was unbearably hot and summer in western Oregon was delightful. With the coming of fall, the reality of living in a rain forest hit me. Not only was it the wettest place I had ever lived, it was the most sun-deprived. Yes, I found beauty in the pearlescent light that filtered through the low clouds and mist most days, but I began to long for the bright sun and blue skies of southern Arizona. As the days got shorter, my energy dropped, and with it my mood. I don’t consider myself particularly weather-sensitive. I welcome cloudy days and storms in the desert because rain is so welcome there, but I came to learn that I cannot go too long without sun.
One friend of mine gets depressed if she experiences more than two sunless days in a row. People like that are not hard to find, and it’s been known since ancient times that many people get the blues in winter, particularly in the Nordic countries, where “winter depression” is common. (Interestingly, Iceland is an exception, probably because its inhabitants have unusually high tissue levels of omega-3 fatty acids from a diet rich in oily fish, as well as high dietary intake of vitamin D, also from fish.) In 1970, Herbert Kern, an American research engineer who suffered from winter depression, wondered if lack of light was the cause and if treatment with light might help him. He got the interest of scientists at the National Institute of Mental Health, who came up with a light box designed to approximate bright daylight. Within a few days of treating himself, Kern found that his depression lifted.
In 1984, Norman E. Rosenthal, MD, and colleagues at the National Institute of Mental Health described a form of depression that recurred seasonally, usually in winter, was more common at higher latitudes and in women, and was accompanied by distinctive symptoms such as increased appetite for and intake of carbohydrate foods and weight gain. They called it seasonal affective disorder (SAD) and documented it in a controlled study using light-box therapy. Initially met with skepticism, Rosenthal’s ideas are now validated; his 1993 book, Winter Blues, is the classic treatise on the subject. The DSM-IV recognizes SAD as a subtype of major depressive episodes. An estimated 6.1 percent of the US population suffers from SAD, and more than twice as many people are prone to a milder form called subsyndromal seasonal affective disorder, or SSAD.
Although many mechanisms have been proposed to explain seasonal slumps in mood—including changes in hormones and neurotransmitters—most experts consider light to be the critical factor. Evolutionary psychologists argue that SAD is an adaptive response akin to hibernation, a way to conserve energy by reducing activity in the most food-scarce seasons in generally food-scarce environments; in women it might have played a role in regulating reproduction.
Whatever its cause, treatment with full-spectrum light—not the same as ordinary indoor light—works to relieve SAD as effectively as antidepressant drugs and faster. It has been so successful that some people have also tried it for nonseasonal depression and other mood disorders. There are not many well-designed studies of light therapy, but analysis of data so far suggests that it can be effective for treating nonseasonal depression, again working as well as medication.
I do not have SAD or SSAD, but I find that daily exposure to bright light contributes to my emotional well-being. I concur with experts who say that to get the best possible sleep, our bedrooms should be completely dark and we should get some exposure to bright light during the day. Natural sunlight is best. I wear UV-protective sunglasses when I’m outside to reduce my risks of cataract formation and macular degeneration. (These do not have to be dark or even tinted. You can get clear protective lenses that block both UV and retina-damaging blue wavelengths.) I also wear a hat and put sunscreen on my face and bald head, but I expose the rest of my body to the sun when I swim. I pay attention to the angle of the sun in the sky and stay out of it when its harmful rays are most intense.*
Light affects our moods, and I urge you to get outdoors frequently. I have never used a light box or other light-therapy device. Several different designs are on the market, some portable, at a wide range of prices. If you live at a high latitude, you might consider adding light-box therapy to the other recommendations I give you, but I must also give you one caution. Many devices include wavelengths of blue light that are hazardous to the eye, increasing the risk of age-related macular degeneration (AMD); that condition is the most common cause of blindness in older people. People who find light-box therapy beneficial may be harming their retinas. (Herbert Kern, the engineer who first tried it, reported in an article in Science in 2007 that the treatment became less and less effective for him as his eyesight deteriorated from AMD. “Now I can hardly see,” he wrote, “and all hell has broken loose…. I have had periods of depression lasting over a year.”) Blue light with wavelengths in the 460- to 465-nanometer range is most dangerous and does not appear to be necessary for light therapy to be effective. Newer products claim to deliver light that is free of harmful wavelengths. Shop carefully.
If you suffer from major depression, you may have to take prescribed antidepressant medication. Let me caution you again that the approaches described in this section and in the overall program in this book are not substitutes for antidepressant drugs in the management of severe forms of depression. Used together with medication, they may enable you to get by with lower doses of the drugs, shorten the duration of treatment with them, and make it easier to transition off them.
The reason to exercise caution with antidepressant pharmaceuticals is simple: their actions in any one person are impossible to predict. For Nancy, fifty-five, a lawyer, they proved quite valuable:
Going through a divorce, I tried my typical coping strategies, such as talking with trusted friends, reading self-help books, prayer, listening to music, drinking alcohol, eating chocolate, and regular, vigorous exercise. I could not feel anything but overwhelming sadness. I sought the help of a therapist, who suggested I try antidepressants in addition to talk therapy and occasional tranquilizers. She also taught me self-hypnosis, meditation, talking to “the empty chair,” writing letters never to be sent, journaling, and deep breathing. I was on antidepressants for about a year. I was afraid of them at the beginning. I worried that, assuming they worked, I would never be able to stop taking them, that if I stopped, I would get depressed again.
At first, I did not like how I felt on the drugs. Everything was slightly removed, like I was living life through a filter. I was afraid to be on them, and afraid to get off. But once my emotional juices started flowing again, there was no stopping them. I felt everything—even things I had never felt before. I think the antidepressants really helped me. I don’t understand the chemistry, but as time passed, it was like they woke me back up. I climbed out of that black pit, and at some point I started feeling joy again. The therapeutic activities in combination with the medication worked for me. After about a year I was weaned off the antidepressants (with a little trepidation). Thankfully, I can report that everything stayed OK. This was twenty-five years ago.
On the other hand, some people find taking antidepressants an almost entirely negative, even nightmarish, experience. Jacqueline, forty-five, a teacher from Westlake Village, California, writes:
I have tried many medications for my depression/mood disorder and have found that I am extremely sensitive to them, and react most severely to antidepressants. After two extremely bad reactions (anxiety, deep depression, suicidal ideation) in two months, I was hospitalized. Soon after, I began to look for alternative therapies. I began to see a doctor (MD) who also specializes in natural remedies. With his help, I have improved greatly. Some examples of the vitamins and supplements I take are vitamin D, B-50, fish oil, L-lutein and SAMe.*
Given this variability in individual response and potential for adverse reactions, I asked Dr. Ulka Agarwal, a California psychiatrist who is studying to be an integrative mental health practitioner, how she uses these drugs to ensure that the benefit will outweigh the risk. This is her reply:
I consider prescribing antidepressants to anyone whose functioning is impaired either socially, occupationally, or academically—are they having trouble getting out of bed and to class or work on time? Can they focus and concentrate? Are they motivated to get through their daily activities? What is self-care like? Are they withdrawing socially or from previously enjoyed hobbies/activities? Does anything bring them joy anymore? Is their sleep disturbed? Are they having suicidal thoughts? If they are impaired in several of these areas or suicidal, I will recommend an antidepressant. In addition to the medication, I recommend weekly therapy, daily exercise, and stress management (yoga, meditation, sports, contact with animals, etc.). I also ask them to eliminate or reduce alcohol and drug use (I work at a university health center, so many of my patients smoke marijuana regularly) and discuss sleep hygiene. I have not yet incorporated nutrition, supplements, or herbal treatments into my practice but hope to soon.
I usually start with an SSRI, especially if there is some associated anxiety, anger, irritability, or bulimia, but my medication choice depends on the specific symptoms and the side effects of the medication. For someone with decreased appetite and/or poor sleep, I might try mirtazapine (Remeron, a tetracyclic), which induces appetite and is sedating. My first choice for SSRIs is usually Prozac, since it is the least likely in its class to cause weight gain, is not sedating for most people, and is easy to taper off due to its long half-life.
For an isolated or first episode of depression, I recommend treatment for at least six months. If the person has had previous episodes of depression or has done poorly off antidepressants in the past, I recommend nine to twelve months of treatment.
I always taper patients off medications, even Prozac, never stop them suddenly. I usually write out a week-by-week taper schedule.
These are sensible guidelines. If you are taking antidepressants or considering taking them, please keep these points in mind:
| • | You may not need to be on medication for the long term, particularly if you are working to improve your overall emotional well-being. Ask your physician about when and how to try discontinuing a prescribed drug. |
| • | Long-term use of antidepressant drugs may actually prolong depression, a very concerning problem recently termed “tardive dysphoria” (lingering bad mood). When exposed to drugs that increase serotonin levels at neural junctions in the brain, the body responds by making less serotonin and dropping serotonin receptors, changes that do not quickly reverse when the drugs are discontinued. |
| • | Never stop taking antidepressants without discussing it with your physician, and never stop them abruptly. Taper off them gradually, following a recommended schedule. |
| • | Different types of antidepressants have different actions and different side-effect profiles. Pay attention to both positive and negative effects of these drugs and report them to your physician. If you do not get significant benefit within eight weeks or you can’t tolerate the side effects, it may be worthwhile to consult a clinical psychopharmacologist to select the medication that is best for you. |
| • | Recent research suggests that antidepressant medications may increase the risk of heart attack and stroke in men and breast and ovarian cancer in women. These are tentative findings; pay attention to this line of research if you use the drugs. |
| • | Remember that for mild to moderate depression, many treatment options exist other than prescription antidepressants. |
I have a low opinion of all the drugs prescribed for anxiety. They interfere with memory and cognition, can worsen mood, and are addictive; withdrawing from them can be very difficult. Furthermore, they do not get at the root of anxiety; they merely suppress it. They may be okay for occasional use to manage acute anxiety, but I strongly advise against taking them frequently or regularly or relying on them to deal with chronic anxiety.
The most powerful and effective anti-anxiety measure I know is the quick and simple breathing technique that I explain in the next chapter (see here). I have seen it work for the most extreme forms of panic disorder, when the strongest medications failed. It is perfectly safe, requires no equipment, and costs nothing. And, unlike suppressive drugs, it undoes anxiety at its root.
I address anxiety in patients also by suggesting lifestyle adjustments, particularly with regard to intake of caffeine (and other stimulants), physical activity, stress management, and sleep. For some, I recommend cognitive therapy and meditation practice (discussed in the following chapter) and often suggest trials of valerian and kava (see below) as alternatives to prescribed drugs.
Do an Internet search for natural depression remedies and you’ll find a lot of stuff for sale: vitamins, minerals, herbs, amino acids, and more, singly and in combination formulas. I’m sorry to tell you that few of these products have been studied systematically and even fewer in well-designed human studies. There is little hard evidence to support the claims made for most of them by manufacturers, practitioners, and patients. I’ve told you that there is very good evidence for the efficacy of fish oil and vitamin D to boost and maintain emotional wellness, and weaker evidence for a few of the B-vitamins. The natural remedies below are treatments for depression and anxiety rather than preventives, and I do not recommend them for everyone, as I do with fish oil and vitamin D. I think they are worth trying for specific emotional problems as alternatives to pharmaceutical drugs. They can be taken singly or in combination. Some can be used along with antidepressant drugs, others not or with caution. If you get benefit from them, I suggest that you try to taper them off gradually over several months to see if you can maintain improvement in mood without them.
This European plant (Hypericum perforatum) has a long history of medicinal use, including as an herbal mood booster. It is by far the most studied alternative treatment for depression, and most experimental results with mild to moderate depression have been positive, with St. John’s wort performing better than a placebo, often doing as well as prescription antidepressants, and sometimes proving more effective than the drugs. There is no good evidence that it works for severe depression. I would never recommend St. John’s wort as a stand-alone treatment to anyone with a diagnosis of major depression.
We still don’t know just how this herbal remedy works. Two active compounds have been identified, hypericin and hyperforin, which may affect the serotonin system in the brain. St. John’s wort is generally safe but may increase sensitivity to sunlight, may have an additive effect with SSRI antidepressants, and may change the metabolism of other drugs. The last possibility is of special concern to people on birth control pills, immunosuppressants, some cancer and HIV medications, and blood thinners. If you are on any prescribed drugs and want to try a course of St. John’s wort for mild to moderate depression, discuss possible interactions with your physician or pharmacist.
Peter, fifty-five, a teacher from Strafford, Missouri, found that after taking St. John’s wort for the first time, the effects were rapid and positive:
It’s supposed to take three weeks or so to “kick in” and be fully effective. I took one in the evening and then forgot about it. Next morning I came downstairs and found my depression had disappeared. I forgot all about the herb I had tried and asked my wife what I might be doing different today that was helping me. She looked at me and we both said “St. John’s wort!” at the same time!
I thought this must be a placebo effect, but I’ve taken it off and on several times since, and whenever I get back on the herb, I find almost immediate results in the lifting of depression. Now I stay on it all the time and find the results very good. Instead of one pill three times a day, I take two pills twice a day because this seems easiest for me.
I love that it has no side effects. As a former stockholder of the company that makes Prozac, I am most impressed with the safety of this herb!
However, for most, the onset of benefits comes more slowly. Jean, sixty-eight, a retired registered nurse from Borlange, Sweden, writes:
I am an American woman, married to a Swedish man, and living in Sweden for the past ten years. Five years ago, my forty-one-year-old autistic son died quite suddenly from status epilepticus. His death left me feeling very broken and alone. After a return to the States for his funeral and time to grieve with the rest of the family, I returned to Sweden.
I expected to feel normal grief and sadness for some time, but when it continued, and indeed deepened after about six months, I decided that I needed some help in recovering. I was taking several medications for hypertension at the time, and was reluctant to add yet another pharmaceutical to the mix.
I decided to try St. John’s wort, which is a well-accepted therapy for depression here in northern Europe. I took 300 milligrams of the remedy in capsule form, three times a day, and began to feel better within four to six weeks. I continued this therapy for about three years and felt that it was a helpful treatment. It eased the depression, without any noticeable side effects. After that period of time, I discontinued taking it, and felt that there was absolutely no withdrawal.
Look for tablets or capsules standardized to 0.3 percent hypericin that also list content of hyperforin. The usual dose is 300 milligrams three times a day. You may have to wait two months to get the full benefit of this treatment. If it doesn’t do much for you after four months, it is probably not worth continuing.
A naturally occurring molecule found throughout the body with high concentrations in the adrenal glands, liver, and brain, SAMe has been extensively studied as an antidepressant and treatment for the pain of osteoarthritis. Although the study populations have been small, results have generally been positive, showing SAMe to be more effective than a placebo. In recent research (reported in August 2010 in the American Journal of Psychiatry), investigators from Harvard Medical School and Massachusetts General Hospital gave SAMe or a placebo to seventy-three depressed adults who had not responded to prescribed antidepressant drugs; all continued to take the drugs. After six weeks of treatment, 36 percent of the subjects taking SAMe showed improvement, compared with just 18 percent of the placebo group. Moreover, 26 percent of those in the SAMe group had complete remission of symptoms, compared with just 12 percent in the placebo group.
Carol, sixty-one, of Tucson, Arizona, works for a church. For both her and her husband, the mood lift provided by SAMe was an unexpected side benefit:
I went through an initial and follow-up visit to your Integrative Medicine Clinic in February 2007, looking for help with osteoarthritis that seemed to be progressing and a number of other challenges. One of the recommendations I received was to take 200 milligrams of SAMe three times a day…. I tried it, and my husband joined me. We began with the recommended dose, and within one day of taking it, we both noticed a huge feeling of well-being. While I can’t remember if physically we hurt less, we most definitely saw a difference in our attitudes and felt a feeling of… well, being able to do more.
Janette, forty-eight, from Paradise, California, abused alcohol from her teenage years onward to cope with depression she had felt for “almost my entire life.” The prescription antidepressant Trazodone had not worked for her; neither had St. John’s wort:
Through further research, including Dr. Weil’s books, I learned about SAMe. I started taking it about five years ago and it has really helped me tremendously. When I first started taking it, I used about 800 milligrams a day and now I use 400. I take it when I feel I need it but can go months without it. I like how it only takes a few days to work. It stabilizes my mood, and I don’t feel the severe lows I used to feel. That being said, I also continue to work on myself and grow, and that process coupled with the SAMe has really helped me. In fact, I no longer drink any alcohol because I don’t need it anymore, and my drinking was ultimately very self-destructive. I have been sober for two and a half years.
We don’t know how SAMe works; it may affect levels of neurotransmitters or their brain receptors. An advantage of SAMe over prescription antidepressants and St. John’s wort is that it works quickly, often lifting mood within days rather than weeks. It is also quite safe, although, because it has been reported to worsen manic symptoms, those with bipolar disorder should avoid it. The only side effect, which is uncommon, is gastrointestinal upset. If you want to try SAMe, look for products that provide the butanedisulfonate form in enteric-coated tablets. The usual dosage is 400 to 1,600 milligrams a day, taken on an empty stomach. Take lower doses (under 800 milligrams) once a day, a half hour before the morning meal; split higher doses, taking the second dose a half hour before lunch. You can use SAMe with prescribed antidepressants (and other medications). It may be especially useful for people who suffer from pain as well as depression.
Rhodiola rosea, a relative of sedum and jade plant native to high latitudes of the Northern Hemisphere, is the source of arctic root, an herb with a long history of traditional use in Scandinavia, Siberia, Mongolia, and China. It has been valued for antifatigue, antistress, and sexually stimulating effects and has been extensively studied by scientists in Russia and Sweden. Rhodiola root contains rosavins, compounds that appear to enhance activity of neurotransmitters in the brain and may be responsible for the herb’s beneficial effects on mood and memory. In a 2007 double-blind, placebo-controlled human study from Sweden, researchers concluded that treatment with a standardized extract of rhodiola showed a “clear and significant antidepressant activity in patients suffering from mild to moderate depression,” with no adverse effects.
If you experience mental fog and fatigue along with mild to moderate depression, you might consider a trial of rhodiola. Look for 100 milligram tablets or capsules containing extracts standardized to 3 percent rosavins and 1 percent salidroside. The dosage is one or two tablets or capsules a day, one in the morning or one in the morning and another in early afternoon. This can be increased to 200 milligrams up to three times a day if needed. High doses can cause insomnia, especially if taken late in the day. Interactions with antidepressant drugs, anti-anxiety drugs, and other prescribed medications are not well documented. Pay attention to any undesired effects, such as increased stimulation or anxiety, if you use rhodiola together with pharmaceutical drugs.
Valerian comes from the root of a European plant (Valeriana officinalis) used safely for centuries to promote relaxation and sleep. Because the root has a strong odor that many find disagreeable, this herb is best taken in tablet or capsule form rather than as a tea or tincture. Unlike modern drugs used to reduce anxiety and promote sleep, valerian is not habit forming and does not have additive effect with alcohol. The chemistry of this herb is complex, and its mechanisms of action are not known. It is nontoxic.
Use extracts of valerian standardized to 0.8 percent valeric acid. For relief of anxiety, try 250 milligrams (one capsule or tablet) with meals, up to three times a day as needed. This herbal remedy can be used safely with antidepressants.
Kava is another root with a sedative effect, this one from a tropical plant (Piper methysticum) related to black pepper and native to islands of the South Pacific, where it has a long history of use as a social and recreational drug. Kava is an excellent anti-anxiety remedy, shown in controlled human trials to be as effective as benzodiazepine drugs. It also is a muscle relaxant.
Because of rare reports of liver toxicity associated with certain types of kava products, no one with a history of liver disease should use this herb. It may have additive effect with alcohol and other depressant drugs; otherwise it is generally safe. You can purchase powdered whole kava root to make into tea or other drinks, but I usually recommend extracts standardized to 30 percent kavalactones. Dosage is 100 to 200 milligrams two or three times a day as needed. Kava works quickly to relieve anxiety, often with one or two doses. Do not use it continually over long periods of time (more than a few months).
Ayurveda is a centuries-old traditional system of medicine that originated in northern India. It promotes health through attention to diet and lifestyle and makes use of a large repertory of medicinal plants, most of them unknown in the Western world until recently. Contemporary research is proving many of them to be safe and effective, some with unique and useful benefits. I consider the two described here to be worth experimenting with.
Ashwagandha, sometimes called Indian ginseng, comes from the root of Withania somnifera, a plant in the nightshade family esteemed in India for its tonic and stress-protective effects. The species name somnifera means “sleep-bearing,” indicating a calming action. Animal research shows ashwagandha to be equivalent to true Panax ginseng in stress protection, without ginseng’s stimulating effect. Human studies in India demonstrate ashwagandha’s anti-anxiety and mood-elevating properties and confirm its lack of toxicity. If you experience agitation with depression, high stress, and poor sleep, experiment with a six to eight week trial of ashwagandha.
Tieraona Low Dog, MD, one of the world’s foremost experts on botanical medicine and a prominent faculty member of the Arizona Center for Integrative Medicine, likes to make a pleasant tonic tea with this herb. She simmers 1 to 2 teaspoons of powdered ashwagandha with 2 cups of milk (dairy or soy) on low heat for fifteen minutes, then adds 2 tablespoons of honey or agave nectar and ⅛ teaspoon of ground cardamom, stirs the mixture well, and turns off the heat. Dr. Low Dog recommends drinking 1 cup of this tea once or twice a day. She also says this:
Studies in animals show that ashwagandha counters many of the unwanted biological effects of extreme stress, such as prolonged elevation of cortisol and insulin and suppression of the immune system. It also inhibits many of the biochemical mediators that cause inflammation in the body. This makes ashwagandha one of our best plant allies for those who are under chronic stress, not sleeping well, feel tired, and have muscle aches and pains. This describes a considerable number of people that I see in my practice—people who do not meet the criteria for major depressive disorder or generalized anxiety disorder but describe themselves as feeling overwhelmed, exhausted, and tense. They also typically show signs of early arthritis and insulin resistance, and they catch colds frequently. Ashwagandha is perfect for these individuals. It relaxes without sedating, so it can be taken during the day, and is not associated with any known serious side effects. Because quality can vary considerably in herbal products, it is probably best to purchase an extract that has been standardized to contain 2.5 to 5 percent withanolides (key compounds in the root). The dose I recommend is 300 to 500 milligrams taken two to three times per day.
Ashwagandha can be used safely with antidepressants.
Holy basil, or tulsi (Ocimum sanctum), is a sacred plant in India, always planted around temples of the Hindu deity Vishnu and often around homes. It is a relative of our culinary basil with a stronger, clovelike aroma and taste. Indians do not use it in cooking but do use it as medicine, mostly in the form of tea. Modern research in both animals and humans demonstrates a lack of toxicity and a variety of benefits. For example, it reduces inflammation and protects the body and brain from the harmful effects of stress. And it has a positive influence on mood (and is safe to use with antidepressants).
I was first introduced to holy basil more than ten years ago, during my fellowship training at the University of Arizona’s Center for Integrative Medicine. I read about its antioxidant and anti-inflammatory properties, but what fascinated me more was its use by mystics and meditators in India as a rasayana—an herb to foster personal growth and enlightenment.
Holy basil has been shown to lower elevated levels of cortisol, the long-acting stress hormone produced by the adrenal glands. High levels of cortisol can damage the cardiovascular system, retard immunity, create imbalances of other hormones, kill memory cells in the brain, worsen bone loss, increase carbohydrate cravings, raise blood pressure, cholesterol, and glucose, and accelerate the aging process.
Most of my clients have stress-related conditions that I am always trying to help them manage. Holy basil is now at the top of my list of plant-based strategies to target such issues. My personal experience with it is that it lengthens my emotional “fuse”; my reactive fight-or-flight response to stress is much less intense when I take it. I find it gives me greater patience and more opportunity to be mindful. I have been recommending holy basil for the past seven years, and most of my clients swear by it. It is one of the few remedies I’d take with me if I were going to a desert island.
I like holy basil for individuals whose stress levels are causing health problems, and I use it as an alternative to prescription drugs for mild to moderate disorders of mood.
I typically recommend extracts standardized to 2 percent ursolic acid in 400 milligram capsules at a dosage of two capsules one to two times daily with food.
Turmeric, the yellow spice that colors curry and American yellow mustard, is a potent natural anti-inflammatory agent. Its active constituent, curcumin, has shown promise as an antidepressant in animal models; it also enhances nerve growth in the frontal cortex and hippocampal areas of the brain. Indian researchers suggest doing clinical trials to explore its efficacy as a novel antidepressant. Because turmeric and curcumin offer myriad health benefits, including reduced risk of cancer and Alzheimer’s disease, I often recommend them as dietary supplements. They are poorly absorbed from the GI tract, but a recent finding is that absorption is greatly increased by the presence of piperine, a compound in black pepper. Indians—who eat turmeric at almost every meal—get its anti-inflammatory and other benefits because they usually add it to foods along with black pepper. If you want to try turmeric or curcumin supplements as part of this program, look for products that also contain piperine or black pepper extract and follow dosage instructions on labels. You can take turmeric or curcumin indefinitely and combine them with antidepressant drugs or with any of the other herbs and natural remedies I have listed.
A few studies suggest that acupuncture can be a useful treatment for mild to moderate depression. For example, in a controlled trial from China in 1994, depressed patients treated six times a week with acupuncture for six weeks improved as much as those treated with amitriptylene (Elavil). Study numbers were small, however, and expectations of the benefits of acupuncture among Chinese patients might have produced a significant placebo effect. It is difficult to rule this out because there is no good sham treatment for acupuncture that is equivalent to giving a sugar pill instead of an active drug.
In traditional Chinese medicine (TCM), placement of acupuncture needles is determined by an individual patient’s pattern of symptoms and by pulse diagnosis. Different practitioners have different styles. Some studies use electroacupuncture, a nontraditional technique in which pulsating electric current is delivered through the needles. We have no data to suggest a mechanism for how acupuncture might relieve depression, and there is no agreement as to how frequently or for how long it should be done.
I would not recommend acupuncture for severe depression or as a sole therapy for any form of depression. It might be useful as adjunctive treatment, and if you want to try it, look for a practitioner experienced in using it for mood disorders.
Touch can be a powerful contributor to emotional well-being. We know that animal and human infants deprived of physical contact do not develop normally; some actually sicken and die. Now we are learning that touch builds trust between people, allays fear, and helps elicit generosity and compassion. We never outgrow our need to be touched, but, unfortunately, we live in a touch-deprived society. I believe that the lack of touch adds to the social isolation that goes hand in hand with epidemic depression.
Some new, intriguing studies are documenting the biochemical benefits of touch. As reported in a study published in the October 18, 2010, issue of the Journal of Complementary and Alternative Medicine, researchers at Cedars-Sinai Medical Center in Los Angeles recruited fifty-three healthy adults; twenty-nine were randomly assigned to a forty-five-minute session of deep-tissue Swedish massage, and the other twenty-four to a session of light massage. All participants had intravenous catheters so that blood samples could be drawn before the massage and for up to an hour afterward.
The researchers found that a single session of massage caused positive biological changes. Those who received deep-tissue massage showed significant drops in levels of cortisol in their blood and saliva as well as drops in arginine vasopressin, a hormone that can boost cortisol. They also generated more white blood cells, evidence of increased health of the immune system. The light massage yielded advantages, too. Volunteers who received it showed bigger decreases in ACTH (adrenocorticotropic hormone, secreted by the pituitary), which stimulates the adrenal glands to release cortisol, and they had greater increases in oxytocin, another pituitary hormone associated with contentment, than did those who received the deep-tissue massage.
For years, oxytocin was thought of only as the hormone that stimulates dilation of the uterine cervix and uterine contractions at the onset of childbirth as well as the production of breast milk soon after. Like all endocrine hormones, however, oxytocin has a broad spectrum of action, including effects on the brain and emotions. It is now commonly referred to as the hormone of love, trust, and pair bonding. Touch promotes the release of oxytocin, which in turn causes the release of dopamine in the brain’s reward center. This mechanism may underlie the formation of social bonds and the building of trust between people. The process can start with a simple handshake and go on to activate the same brain systems involved in the emotions of friendship and love.
Paul J. Zak, PhD, a founder of the contemporary field of neuroeconomics, who is both an economist and brain scientist, considers oxytocin to be the “social glue” that helps us maintain closeness with friends as well as an “economic lubricant” that makes people more empathetic and generous. In one experiment in his lab at the Center for Neuroeconomics Studies at Claremont Graduate University in Claremont, California, half of a group of subjects received a fifteen-minute massage while the other half rested, and then they all played an economic game using real money. In the game, subjects were entrusted with money by strangers in the hope that they would reciprocate. The brains of those who got massage released more oxytocin than the brains of those who rested. And the massaged subjects returned 243 percent more money to the strangers who showed them trust.
I believe that in the realm of touch, variety is key. Just as we need to eat diverse nutrients and engage in a range of physical activities, human beings need a variety of touch experiences on a regular basis. These might include friendly handshakes, hugs, physical contact with companion animals, massage sessions, and passionate sex. As long as both participants engage willingly, there are few experiences that offer human beings a more profound opportunity for improving and maintaining emotional well-being.
I have loved gardening and growing indoor plants since I was a child. For many years now I have raised most of the vegetables I eat in home gardens and also gotten much pleasure from growing flowers and other ornamentals. The mental and spiritual rewards of gardening are many. Here I want you to know about a possible benefit of exposing your hands and nose to dirt, one that might account for some of those rewards through a physical mechanism.
An article with the provocative title “Is Dirt the New Prozac?” in the July 2007 issue of Discover magazine reported the results of a study published online in the journal Neuroscience in March of that year with a much less catchy title: “Identification of an Immune-Responsive Mesolimbocortical Serotonergic System: Potential Role in Regulation of Emotional Behavior.” The lead author, Christopher Lowry, a neuroscientist at the University of Bristol in the UK, became interested in the “hygiene hypothesis,” the recently popular idea that living in environments that are too clean accounts for the sharp rise in the incidence of asthma and allergies in developed countries over the past century. Proponents of the hygiene hypothesis argue that excessive cleanliness deprives young people’s developing immune systems of routine exposure to harmless microorganisms in the environment, such as soil bacteria. Without this exposure, our immune systems might not learn to ignore such molecules as those in pollen or pet dander. Pursuing this line of reasoning, some researchers have tried treating people with a common and benign soil bacterium called Mycobacterium vaccae. Preliminary results indicate that injections of a killed vaccine made from it can alleviate skin allergies. The vaccine has also been found to reduce nausea and pain in some lung cancer patients and, surprisingly, improve their general quality of life and mood.
To determine the mechanism for these effects, Dr. Lowry injected mice with the M. vaccae vaccine and also blew killed, pulverized bacteria into their windpipes. He then looked for changes in their brain centers that regulate mood. What he found is that treatment with the bacteria affected cytokine production in the animals and activated serotonin-producing neurons in key brain centers. He concluded that the bacteria “had the same effect as antidepressant drugs.” A coauthor of the Neuroscience paper, Graham Rock, an immunologist at University College, London, thinks exposure to M. vaccae stimulates growth of immune cells that curb the inflammatory reactions underlying allergies. Because depression may be, at least in part, an inflammatory disorder associated with abnormal cytokine activity, exposure to M. vaccae might be a novel way to boost mood.
It’s a long way from experiments with a few mice to practical recommendations for people who want to be happier, but it can’t hurt to kick up some dirt and not be afraid to inhale a little dust when you’re digging in the garden. You can also expose yourself to beneficial mycobacteria by eating vegetables fresh from the garden—if you don’t scrub off every speck of dirt.
| • | Before you start on the program in this book, make sure that you are in good physical health and have no conditions that might be undermining your emotional wellness. |
| • | I’ve told you that the best evidence we have of the effectiveness of physical interventions to optimize emotional well-being is for supplemental fish oil and exercise. The former is so easy and has so many preventive and therapeutic benefits that I give it high priority. Regular exercise requires motivation and commitment but also is such a key component of a healthy lifestyle that I put it too at the top of the list. Keep in mind that the goal is to get some physical activity every day, that integrative exercise is good for both mind and body, and that getting regular exercise both prevents and relieves mood problems. |
| • | It is easy to take vitamin D and B-vitamins as supplements, harder to change your eating habits. The most important dietary advice I can give you is to stop eating refined, processed, and manufactured foods. Read over the principles of my Anti-Inflammatory Diet in Appendix A and start to incorporate them into your life. Informed food choices can help you reduce overall risks of disease, maintain good health as you age, and help you feel better, both physically and emotionally. |
| • | If you are prone to depression or anxiety or just want to be happier more of the time, I urge you to look at all mood-altering drugs you may use, from caffeine and alcohol to medications and all the other classes of substances discussed in this chapter. They may be affecting your emotional life more than you realize. Experiment with the natural remedies I’ve listed. |
| • | Pay attention to your sleep and dreams and learn what you need to do to improve them. Sleep in complete darkness and try to be out in bright light during the day. And find ways to satisfy the need for physical touch to promote contentment and comfort. |