Should I Treat my Depression or Anxiety with Nutraceuticals and Herbs?

Should I Treat my Depression or Anxiety with Nutraceuticals and Herbs?

David Mischoulon, MD, PhD

David Mischoulon, MD, PhD

Dr. Mischoulon is the Joyce Root Tedlow Professor of Psychiatry at Harvard Medical School, and Director of the Depression Clinical and Research Program (DCRP) at MGH. He graduated in 1994 from the MD-PhD program at Boston University School of Medicine, and completed his residency in adult psychiatry at MGH in 1998, serving as Chief Resident in Pscyhopharmacology.

Dr. Mischoulon's research has focused on various areas of depression, including psychopharmacology and complementary and alternative medicine. His research on omega-3 fatty acids has been funded my NARSAD, MCCAM/NCCIH, and the NIH. He mentors researchers from all over the world. He has published more than 300 articles, a textbook on natural medications, and a guide to treatments of depression. He has been an invited speaker at various sites around the country and internationally, and is a Distinguished Fellow of the American Psychiatric Association.

In addition to his research activities, Dr. Mischoulon teaches and supervises MGH/McLean psychiatry residents and Harvard medical students, and also lectures in various MGH/Harvard continuing medical education programs. He serves as Director of Training in the MGH Clinical Trials Network and Institute (CTNI), where he educates research clinicians on the proper administrative of diagnostic instruments in clinical trials. He also cares for patients through the DCRP clinical practice, and is regularly sought out for consultation regarding management of treatment-resistant depression and use of complementary therapies for psychiatric disorders.

Should I Treat my Depression or Anxiety with Nutraceuticals and Herbs?

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David Mischoulon, MD, PhD Should I treat my depression or anxiety with nutraceuticals and herbs?

Nutraceuticals and herbal remedies are very popular in the United States and worldwide.  Reasons for their popularity include access without a prescription, and generally fewer side effects compared to prescription drugs.  However, the safety and efficacy products are less well studied and understood compared to FDA approved drugs. With growing use, we have seen more cases of serious side effects, toxic reactions, and interactions with other drugs.  Shopping for nutraceuticals can also be tricky because different commercial preparations may vary in purity and strength.  Finally, these treatments are not generally covered by medical insurance, so the consumer must pay out of pocket.

Potential Natural Remedies for Depression

St. John's wort appears to be comparable in efficacy to SSRIs and tricyclic antidepressants.  Side effects tend to be mild, though some are particularly serious, including extreme sensitivity to sunlight.  If combined with SSRIs or other drugs that increase serotonin levels, St. John's wort may cause potentially fatal reaction, serotonin syndrome.  It may also have adverse interactions with various drugs. For these reasons, it should be used with caution.

S-adenosyl methionine or SAMe is much safer than St. John's wort.  Taking SAMe supplements may help stimulate synthesis of some of the key neurotransmitters that can promote better mood.  SAMe appears as effective as tricyclic antidepressants, but there are fewer studies comparing it against SSRIs.  It can, however, be safely combined with most antidepressants, often resulting in a greater improvement.  Side effects tend to be mild, including nausea, loss of appetite, and constipation.  SAMe is relatively expensive, which may limit accessibility.

Omega-3 fatty acids, such as EPA and DHA, are obtained from fish oil or marine algae.  They can be used alone or in conjunction with standard antidepressants.  Research generally supports EPA as the more effective omega-3.  The omega-3's are safe and well tolerated.  Stomach upset and a fishy taste have been reported, although newer preparations are more highly purified and better tolerated.

Folic acid in different forms may also have benefits in mood, usually as an adjunct to standard antidepressants.  Deplin is a prescription form of L-methylfolate which may be particularly effective for depression. It is very safe and has few side effects.

Potential Natural Remedies for Anxiety and Insomnia

Kava is a popular herbal remedy that originated in the Polynesian Islands.   It seems to work for generalized anxiety, but evidence is mixed.  There have been reports about skin disorders and liver problems developing with kava.  It is therefore generally advisable to use it for short periods of time and under medical supervision.

Valerian is a popular herbal remedy used primarily for insomnia.  Results from research studies have been mixed.  It may work for some as well as benzodiazepines, but with less risk of tolerance and side effects.  It appears safe to use in children and an older people.  Common side effects include headaches and stomach upset, but toxic reactions are rare.  It does not seem to interact with other drugs.

The hormone melatonin is made in the pineal gland of the brain, and helps control our sleep wake cycle.  It appears effective for improving sleep, particularly in people whose insomnia is due to disturbances in their sleep-wake cycle--for example, shift workers and people who travel across time zones. It also appears safe and effective in children and the elderly.  Although well tolerated, it may cause some sedation during the day, so it is best to begin at low doses and increase gradually.

Recommendations

In my practice, the patients most likely to be candidates for these therapies include people with mild symptoms who have a strong interest in natural remedies and does not mind the out-of-pocket cost.  At the other end of the spectrum, individuals who tried many approved drugs without benefit and/or  had many side effects may also want to try these remedies. There are limited data on safety in pregnancy with these natural products.  The fish oils and SAMe as well as folic acid appear to be safe in pregnancy thus far, but we do not know what the safest dose ranges may be.  In general, I advise caution in pregnant or breast-feeding women.  Finally, I recommend that individuals who think they may have depression or anxiety obtain a professional evaluation first.  If they are interested in trying complementary therapies, their use should ideally be supervised by a physician or nurse practitioner.


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David Mischoulon, MD, PhD

David Mischoulon, MD, PhD

Dr. Mischoulon is the Joyce Root Tedlow Professor of Psychiatry at Harvard Medical School, and Director of the Depression Clinical and Research Program (DCRP) at MGH. He graduated in 1994 from the MD-PhD program at Boston University School of Medicine, and completed his residency in adult psychiatry at MGH in 1998, serving as Chief Resident in Pscyhopharmacology.

Dr. Mischoulon's research has focused on various areas of depression, including psychopharmacology and complementary and alternative medicine. His research on omega-3 fatty acids has been funded my NARSAD, MCCAM/NCCIH, and the NIH. He mentors researchers from all over the world. He has published more than 300 articles, a textbook on natural medications, and a guide to treatments of depression. He has been an invited speaker at various sites around the country and internationally, and is a Distinguished Fellow of the American Psychiatric Association.

In addition to his research activities, Dr. Mischoulon teaches and supervises MGH/McLean psychiatry residents and Harvard medical students, and also lectures in various MGH/Harvard continuing medical education programs. He serves as Director of Training in the MGH Clinical Trials Network and Institute (CTNI), where he educates research clinicians on the proper administrative of diagnostic instruments in clinical trials. He also cares for patients through the DCRP clinical practice, and is regularly sought out for consultation regarding management of treatment-resistant depression and use of complementary therapies for psychiatric disorders.

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