For more about amino acids, see chapter 2.
Julia Ross, MA, MFT, is a pioneer in nutritional psychology and has 30 years of experience directing counseling programs that address mood problems, addiction, and eating disorders. Nutritional psychology recognizes the central role that biochemistry plays in mental health and regards nutritional intervention in the form of diet and supplements as an essential treatment for restoring that health.
Having witnessed the potent effects that amino acids and other nutrients can have on psychological states, in 1988 Ross established Recovery Systems, a clinic in Mill Valley, California, devoted to treating mood disorders, addiction, and eating disorders from a nutritional-psychology orientation. Ross is director of the clinic and has detailed her approach in two books, The Diet Cure and The Mood Cure.
Amino acids (nutrients found in high-protein foods) are central to her work because they are the building blocks for neurotransmitters, those “unbelievably powerful natural mood stabilizers,” as Ross describes them. The four neurotransmitters that feature consistently in the disorders Ross treats are serotonin, dopamine/norepinephrine, GABA, and endorphins. She combines dopamine and norepinephrine because the symptoms of deficiency are the same for both, as are the amino acids required for their synthesis. By giving the body the amino acid building blocks (in simple supplement form) for “whatever mood-enhancing neurotransmitters you have in short supply, they can typically be replenished quickly, easily, and safely,” she states.178
For more about amino acids, see chapter 2.
In the case of bipolar disorder, L-tryptophan (or its converted form, 5-HTP) is the amino acid precursor most often required, says Ross, as the primary neurotransmitter deficiency involved is usually serotonin. L-tyrosine and L-phenylalanine can also be important, as they are the precursors to norepinephrine and dopamine, which are also implicated.
Ross recommends other amino acids as needed, based on the signs and symptoms the individual is manifesting, notably GABA, taurine, and glycine for calming; DL-phenylalanine for excessive emotional sensitivity; and L-glutamine to stabilize brain function by stabilizing blood sugar in the brain. If the person's diet has been chronically poor or other factors have resulted in overall amino acid depletion, a complete amino acid formula may also be indicated.179
The other components of Ross's treatment approach to bipolar disorder are omega-3 essential fatty acids in the form of fish oil, high-potency multivitamin/mineral supplements and a well-balanced diet to build a strong nutritional foundation, plus a recommendation to eliminate gluten-containing foods from the diet, which has proven beneficial for most of her bipolar clients.
The first step in designing a treatment plan is to identify the individual's amino acid deficiencies. “You can't directly test the neurotransmitter levels in the brain,” says Ross. “Testing blood levels of amino acids doesn't tell you exactly what's happening in the brain.” Fortunately, the symptoms of deficiency of the neurotransmitters in question are “very obvious” and distinct from each other.
Ross gathers information about a client's full range of physical, emotional/psychological, and behavioral symptoms in an initial psychosocial assessment of that person and his or her family. A nutritional evaluation, medical workup, and basic blood work to determine vitamin and mineral status and blood sugar levels among other parameters are also part of the preliminaries to treatment recommendations.
Both serotonin and dopamine/norepinephrine deficiencies are characterized by depression, but the depressions are of different kinds. With low serotonin, it is the agitated, restless, anxious, worried form of depression, the negative, dark cloud variety, says Ross. “It is not the can't-get-out-of-bed kind. In fact, often they wish they could get into bed because they're up pacing and worrying, having dark thoughts at night.” Suicidal thoughts and sleep problems of all kinds (inability to fall asleep, waking up in the night, inability to fall back asleep) are common, as are irritability, anger, and edginess. All forms of fear, from nervous worry to panic attacks, are also characteristic of serotonin deficiency.
While this cluster of symptoms may understandably cause people “to assume that they are seriously mentally ill, perhaps traumatized by an early childhood distress,” notes Ross, having heard this from numerous clients, “in fact, in many cases all of it can be eliminated practically overnight by taking L-tryptophan or 5-HTP, which are quickly converted to serotonin.”
In contrast to that of serotonin deficiency, the depression manifested in dopamine/norepinephrine deficiency is not an “agitated depression. This is the flat, wanting-to-stay-in-bed-all-day depression,” explains Ross. With this neurotransmitter deficiency, people “are tired, they can't concentrate, and their vitality and ambition are compromised.” L-tyrosine and L-phenylalanine are the amino acid supplements needed to reverse this deficiency. (Omega-3 fish oil is helpful with this kind of depression as well.)
A stressed-out, burned-out state is the number one symptom of GABA deficiency, says Ross. “People lacking in this neurotransmitter describe themselves as ‘overwhelmed, stressed out, burned out, and tense.’ They have that kind of wired inability to relax, but it's more physical than mental. They're stiff; their bodies tend to be erect rather than relaxed.” They are chronically in the fight-or-flight response, with its attendant adrenaline flow. “They feel as if they're ‘on’ all the time, they can't turn off, and they're exhausted from it.” GABA as an amino acid supplement is indicated in these cases. The other “relaxing aminos,” taurine and glycine, can be used as corollary calming agents.
Endorphin deficiency can also be a factor, although neither GABA nor endorphin deficiency is endemic to bipolar disorder. Deficiencies in either may be present in depression of any kind, including that found in bipolar disorder. Deficiency of endorphins, the natural painkillers, results in vulnerability to physical and emotional pain. Typical signs are being “overly sensitive to emotional injury. People hurt their feelings, and they just can't get over it,” states Ross. “They're just emotionally exposed, raw.” The amino acid building blocks for endorphins are DL-phenylalanine and D-phenylalanine.
L-glutamine is another amino acid that can be useful as general support and a source of fuel for the whole brain. Its primary role is to keep the blood sugar in the brain stable. The brain burns glutamine when it runs out of glucose in a hypoglycemic blood sugar drop, Ross explains. Supplementation with glutamine usually promotes “stable, calm, alert brain function.”185 It is typically needed when the person eats a lot of sweets and starches, has a high caffeine intake, and skips meals.
The advantages of amino acid supplementation over prescription drugs aimed at neurotransmitter function are numerous. Unlike the drugs, which can take weeks to begin to work, supplementation produces effects rapidly, often in a matter of days or even hours, says Ross.
—ROBERT, who suffered with bipolar disorder for 30 years
Also unlike drugs, amino acid supplementation addresses the underlying problems—that is, neurotransmitter deficiency and function—rather than manipulating brain chemistry in an unnatural way. And, as Dr. Walsh noted in the previous chapter, drugs may be designed to target certain neurotransmitters, but they alter the chemistry of the whole brain in the process. It is important to know that “people with bipolar tendencies can have negative as well as positive reactions to these amino acids,” Ross states. The reactions subside, however, when the person stops taking the supplement.
Tryptophan has been the amino acid most often indicated for Ross's bipolar clients. With supplementation, she has seen “dramatic improvement in mood”; a reduction in depression, irritability, and anxiety; increased energy; and the amelioration of sleep problems. For most people, tryptophan and 5-HTP have identical effects, she says. “There are a few people who do better on one or the other, but most people do equally well on both.” As noted previously, however, self-dosing with supplements is not advisable, as everyone is different, and it's important to determine exactly what your particular deficiencies and imbalances are.
Tyrosine is sometimes important. “Tyrosine feeds the thyroid as well as the brain,” says Ross. As lithium is somewhat suppressive to the thyroid gland, taking tyrosine can provide thyroid support to those people who are on the mood-regulating drug. The people on the severe end of the bipolar disorder spectrum who have come to Ross for treatment are all still on lithium, she reports. They have been able to significantly cut their dosage, however.
“Tyrosine also, at least initially, can increase serotonin,” she adds. “But it can be too energizing and stimulating for some who are on the manic end or who cycle rapidly.” Ross notes that this can also be true of omega-3 fish oil and flax oil, which can raise dopamine/norepinephrine levels too high.
People with bipolar disorder also need to be careful when it comes to taking glutamine, cautions Ross. Normally, glutamine does not produce an effect on mood, aside from the common report that it makes people “feel even,” she says. “That's because it really does burn as fuel, an alternate fuel to glucose. It keeps the blood sugar in the brain really balanced, so you get that even feeling. But it doesn't usually have an emotional tone to it.
“Glutamine can be helpful for people who are in a deep depression,” Ross observes. “If they're not, it may not be helpful.” With some bipolar people, it eliminates depression and then moves them into mania. Others are not affected in this way. In any case, it is important to be careful with glutamine, she says, noting that her bipolar clients who take it closely monitor their symptoms. “They know themselves, and they don't want to be manic.”
Glutamine can be a problem in the case of people who don't know that they have bipolar disorder. “They may come to you for hypoglycemia or diabetes, and you give them glutamine, and all of a sudden, you see that they're really buzzing,” says Ross. “They may report to you, ‘Gee, I feel high on this stuff,’ or ‘I feel really energetic.’ They may not even see it as a negative.
“It's actually a way of inadvertently diagnosing people,” Ross notes, because there is “no other condition for which glutamine produces that kind of effect.” (The mania brought on by taking glutamine subsides when the person stops taking the supplement.) In cases in which clients have been affected by glutamine in this way, there was no inkling of bipolar disorder in the initial assessment Ross did with them. When she questioned them further, asking if they had ever considered that they might be bipolar, a typical answer was: “I've wondered about that, but I've never been diagnosed with it. I never get that depressed or that manic, but I do have frequent mood swings.”
With the proper amino acids, along with a healthful diet with sufficient intake of protein and fat (the good fats, such as those found in olive oil and fish), a multivitamin/mineral formula designed to balance blood sugar, an omega-3 fish oil supplement, and other nutrients as indicated, people with bipolar disorder do well, says Ross. As mentioned, eliminating gluten from the diet can also be beneficial, as was true for Darien in the case study to follow.
“The first connection that I made between nutrition and bipolar problems,” recalls Ross, “was in the late 1970s when I read several articles about psychiatric hospitals doing experiments removing the gluten-containing grains from the diets of certain randomly selected bipolar patients, and what extraordinary success they had.” In her clinic, she has seen enough benefit from this practice in cases of bipolar disorder to recommend that clients try it and see if it makes a difference for them.
Gluten is a protein found in wheat, barley, rye, oats, and other cereal grains, and added to many commercial foods. During digestion, this large protein (consisting of long chains of amino acids) is first broken down into smaller peptides before being further reduced into its amino acid components. Peptides are similar to endorphins, substances that athletes know as the source of “runner's high.” The peptide form of gluten is called glutemorphin. It is an opioid, meaning that it has an opium-like effect on brain cells.187
Gluten is difficult to digest, and many people develop an intolerance to it, which means that the body regards it as a foreign substance and the immune system launches an immune reaction against it. In addition, researchers theorize that incomplete digestion of gluten leads to excessive absorption of glutemorphins from the intestines into the bloodstream, which leads in turn to their passage across the blood-brain barrier, where they exert their opioid effects.188
In so doing, they depress serotonin, dopamine, and norepinephrine levels in the brain.189 The opioid aspect also leads people to become addicted to gluten products, notes Ross.
While the intake of carbohydrates in general initially increases serotonin levels, chronic intake dramatically reduces serotonin levels in the brain. Typical results are depression, sleep problems, a craving for carbohydrates, and irritability.190
As discussed in chapter 2, allergies can produce mental and behavioral symptoms. This type of allergy or intolerance is termed a brain allergy or a cerebral allergy.
For more about the role of allergies in bipolar disorder, see chapter 8.
Eating foods that prompt an immune system reaction (foods to which one is sensitive or allergic) can actually interfere with neurotransmitter function. In regard to gluten, research has found that when people who are sensitive to gluten eat food containing it, their neurological function is altered. Depression is one of the manifestations of the alteration, which can occur without people being aware that gluten is a problem for them. Sometimes depression is the only symptom in evidence.191
Darien, at the age of 40, woke up one morning in the throes of a depression that was so crippling that he couldn't go to work. It was the second week of a new job, for which he had relocated. He loved the new job, but suddenly was unable to do it. Weeks passed, and, still not able to work, he lost the job. Before the depression began, he had plans to marry the woman he loved, but the depression brought those plans to a halt as well. “He was just incapacitated,” recalls Ross.
Darien had been diagnosed with bipolar disorder and had been cycling between mania and depression for the last 15 years. During the mania, which was severe, he would suddenly jump in his car and drive for thousands of miles, sometimes from one coast to the other, all the way across the country. He would also spend huge sums of money. His mania was also characterized by an extreme personality change. He would be outrageous and loud and pick fights with people—it didn't matter whether they were family, friends, acquaintances, or total strangers. “He just wanted to get into it with people,” says Ross. At one point, his behavior in public led to his arrest on charges of disturbing the peace.
Darien took antidepressants at different times and was supposed to be on lithium on a permanent basis, per his doctor's instructions. When he took the lithium, it prevented manic episodes, but he tended to be somewhat depressed all the time and said that on lithium he “just felt flat.” Sometimes the depression wasn't as bad as at other times. He finally sought an alternative solution and came to Julia Ross.
Based on his symptom picture, she and her staff nutritionist started him on 5-HTP and glutamine. Later, he took tyrosine on an as-needed basis when he felt his energy was low. As his depression lifted, he stopped taking the glutamine because it began to make him feel manic. Darien also took a multivitamin/mineral supplement and, later, omega-3 essential fatty acids in the form of fish oil. “He felt more focused and more energetic on the omega-3 fatty acids,” states Ross. “At one point, however, he took too much fish oil and had a manic reaction that required him to raise his lithium dose briefly.” She explains that since he was not depressed, he didn't need as much fish oil and needed to adjust the dosage accordingly.
Within a week of starting this program, Darien's depression began to lift. Within a few months, he could safely say he had moved out of the depressive episode. By the six-month mark, under his physician's supervision, he had cut his lithium dose down to half of what it had been previously.
In Darien's case, it took him a year to go off gluten. He didn't want to give up bread and the other foods that contain gluten, and maintained that it was not a problem for him. Finally, his wife (he had gotten married by then) started pointing out to him that he got diarrhea every time he ate wheat. He had ignored this symptom for years, as many people do. He agreed to try a gluten-free diet for two weeks. Even in that short time, he felt quite a bit better in terms of mood. Nevertheless, he went back on wheat, but the first time he ate it, he had terrible diarrhea.
He got depressed again as well. “The aminos protected him from the depression getting severe, but it was noticeable,” says Ross. “He realized it was going to have to be a forever thing. So he began to get really motivated, and he would call manufacturers to find out what was in products because he learned that even a very tiny amount would set him off.”
Ross already had him taking a high-potency multivitamin/mineral supplement, along with additional vitamin C. “Whenever somebody has clearly been gluten intolerant, especially with diarrhea, there's a lot of damage to the digestive lining, and they haven't been absorbing nutrients well. We wanted him to get lots of everything.” Darien was a good cook and ate three good meals a day, so there was no need for much in the way of dietary changes, aside from eliminating gluten.
It has now been four years since Darien started treatment with Ross. He's still taking the 5-HTP, although much less than at the beginning. “He finds that he needs that still and feels that he always will,” says Ross. “Most people get off the aminos because they no longer need them. They don't even like them after a certain period of time,” which is the body's way of telling them that it no longer has a deficiency of amino acids. This pattern applies to most of the people who come to Ross for treatment, “whether they're addicts or suffering from mood-related problems.” But someone like Darien, with a severe bipolar problem, is an exception to the rule.
In addition to the 5-HTP, Darien continues to use the other amino acids when he feels he needs them: “a little glutamine if he's feeling like he's sinking into depression,” and tyrosine if his energy feels too low. “Since his moods have leveled out, his marriage is much more relaxed and happy,” Ross reports. As for his professional life, he started a new career in business and is now working full-time for the first time in 15 years—as a CEO, no less.