UNSTUCK: An Integrative

Approachto Depression

James S. Gordon, MD

Founder and Director, The Center for Mind-Body Medicine

Clinical Professor, Departments of Psychiatry and Family Medicine, Georgetown Medical School

Chair, White House Commission on Complementary and Alternative Medicine Policy

What is Depression?

•A human experience, not a disease •It is often precipitated by loss of a person, a

role, a status, and can be a catalyst for a journey toward greater health and wholeness.

•A sign of imbalance – physical, emotional, mental, social, spiritual – in one’s life.

•The beginning of a journey. A wake up call to the need for change, not the end of a disease process.

Begin with Relaxation – antidote to the

fight or flight response and to stress which is so intimately connected to depression.

Soft Belly

• Lee, AL, WO Ogle, RM Sapolsky. Stress and depression: possible links to neuron death in the hippocampus. Bipolar Disord 2002:4(2):117-28

• Sapolsky, RM. Why stress is bad for your brain. Science 1996:273(5276):749-50.

The Seven Stages

1. The CallThe awareness that we are depressed, and that some kind of change, of journey, is necessary

2. Meeting Guides on the PathMeeting and choosing the men and women who can help, and developing our own inner guidance and wisdom

3. Surrender to ChangeAllowing and encouraging ourselves to let go of what constrains and freezes us, and to move into the current of life

of the Journey Out of Depression

The Seven Stages

4. Dealing with Demons Meeting the challenges—self-doubt, loneliness, procrastination, pride, resentment, apprehension, perfectionism, fear with all its faces, guilt, shame, self-pity, and all the others—and finding in them the unique daimon, the genius, of our own meaning, purpose and direction

5. The Dark Night of the SoulAllowing, and inviting, as we move through the despair that may come to any of us, the deepest, life-giving freedom to emerge

The Seven Stages

6. Spirituality: The BlessingExperiencing the unity and peace, the love and generosity, the connection to something or someone greater than ourselves, that can transform our lives

7. The Return Learning to live every day joyously, deeply, consciously, with ourselves and others, in the light of what we have experienced and are always learning

1) The limitations of the disease theory of

depression

Awareness of…

• Valenstein E. Blaming the brain: the truth about drugs and mental health. New York: Free Press. 1998.

• Sadock BJ, VA Sadock, HI Kaplan. Kaplan & Sadock’s comprehensive textbook of psychiatry. 8th ed. Philadelphia: Lippincott Williams & Wilkins. 2005. Lacasse JR, J Leo. Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med 2005;2(12):e392.

• Roggenbach J, B Muller-Oerlinghausen, L Franke. Suicidality, impulsivity, and aggression – is there a link to 5HIAA concentration in the cerebrospinal fluid? Psychiatry Res 2002;113(1-2):193-206.

2) The dangers of antidepressants

Awareness of…

• Montejo-Gonzalez AL, et al. SSRI-induced sexual dysfunction: fluoxetine, paroxetine, srtraline, and fluvoxamine in a prospective, multicenter, and descriptive clinical study of 344 patients. J Sex Marital Ther 1997;23(3):176-94.

• Hansen L. Fluoxetine dose-increment related akathisia in depression: implications for clinical care, recognition, and management of selective serotonin reuptake inhibitor-induced akathisia. J Psychopharmacol 2003;17(4):451-52.

• Black K, et al. Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria. J Psychiatry Neurosci 2000;25(3):255-61.

3) The limited effectiveness of drugs

Awareness of…

• Moncrieff, J. and I. Kirsch, Efficacy of antidepressants in adults. BMJ, 2005. 331(7509): p. 155-7.

• Kirsch I, JT Moore, A Scoboria, SS Nicholls. The emperor’s new drugs: an analysis of antidepressant medication data submitted to the US Food and Drug Administration. Prevention and Treatment 5 (Article 23). 2002; http://www.journals.apa.org/prevention/volume5/pre0050023a.html.

• Khan, A., H.A. Warner, and W.A. Brown, Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: an analysis of the Food and Drug Administration database. Arch Gen Psychiatry, 2000. 57(4): p. 311-7.

• Turner EH, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008;358(3):252-60

Hope for the possibility of change is

central to the Unstuck approach.

Hope

• Beecher, HK. The powerful placebo. JAMA 1955:159(17):375-91.

• Roberts, A, et al. The power of nonspecific effects in healing: implications for psychosocial and biological treatments. Clin Psychol Rev 1993:13:375-91.

• Walsh, BT, et al. Placebo response in studies of major depression: variable, substantial, and growing. JAMA 2002:287(14):1840-47.

Placebo – “I shall please” in Latin, a

medical way of describing hope as well as faith. Placebo is powerful medicine. We need always to use

it.It can be 35-70% as effective as an

active, proven intervention.

Hope

• Beecher, HK. The powerful placebo. JAMA 1955:159(17):375-91.

• Roberts, A, et al. The power of nonspecific effects in healing: implications for psychosocial and biological treatments. Clin Psychol Rev 1993:13:375-91.

• Walsh, BT, et al. Placebo response in studies of major depression: variable, substantial, and growing. JAMA 2002:287(14):1840-47.

Placebo Response

Our brains, contrary to long term

teaching, have the capacity to grow and change anatomically as well as

physiologically.

Neuroplasticity

• Eriksson, PS, et al. Neurogenesis in the adult human hippocampus. Nat Med 1998:4(11):1313-17.

• Kandel, E. A new intellectual framework for psychiatry. Am J Psychiatry 1998:155:457-69.

Natural, non-pharmacological

techniques including psychotherapy, meditation, and exercise can produce

these positive changes.

Neuroplasticity

• Martin, SD, et al. Brain blood flow changes in depressed patients treated with interpersonal psychotherapy or venlafaxine hydrochloride: preliminary findings. Arch Gen Psychiatry 2001:54(7):641-48.

• Goldapple, K, et al. Modulation of cortical-limbic pathways in major depression: treatment –specific effects of cognitive behavior therapy. Arch Gen Psychiatry 2004:61(1):34-41. Rhodes, J.S., et al., Exercise increases hippocampal neurogenesis to high levels but does not improve spatial learning in mice bred for increased voluntary wheel running. Behav Neurosci, 2003. 117(5): p. 1006-16.

• van Praag, H., G. Kempermann, and F.H. Gage, Running increases cell proliferation and neurogenesis in the adult mouse dentate gyrus. Nat Neurosci, 1999. 2(3): p. 266-70.

• van Praag, H., et al., Exercise enhances learning and hippocampal neurogenesis in aged mice. J Neurosci, 2005. 25(38): p. 8680-5.

• Lazar, S.W., et al., Meditation experience is associated with increased cortical thickness. Neuroreport, 2005. 16(17): p. 1893-7.

Becoming aware of your depression and of

the need for change.Following is the CES-D scale. Use it as an aid to becoming more aware of what

you’re thinking and feeling. It’s a mirror, and it clarifies the first note of the Call.

If you’re unsure of an answer, don’t linger too long. Just circle what seems most correct and move on. The scoring scale follows the test, but don’t look at it until you’re finished.

If you score in the range of “clinical concern,” pay attention. Even if you don’t score in that range, notice your answers. What areas and issues do they suggest that you need to work on? Remember, this is just a diagnostic tool. It’s for your use. It provides useful hints and a starting place. It is not an endpoint.

The Call

• Radloff, L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psych Meas 1997:1(3):385-401.

The First Note

Begin, using the scale below, by circling the number

before each statement which best describes how you felt or behaved DURING THE PAST WEEK

0 = Rarely or none (less than 1 day) 2 = Occasionally or moderate (3-4 days) 1 = Some or a little (1-2 days) 3 = Most or all of the time (5-7 days)

The First Note

CES- Depression Scale

0 1 2 3 I was bothered by things that usually don't bother me.0 1 2 3 I did nor feel like eating; my appetite was poor.0 1 2 3 I felt that I could not shake off the blues even with help from my family/friends.0 1 2 3 I felt that I was just as good as other people (Reverse Score).0 1 2 3 I had trouble keeping my mind on what I was doing.0 1 2 3 I felt depressed.

The First Note

CES- Depression Scale

0 1 2 3 I felt that everything I did was an effort.0 1 2 3 I felt hopeful about the future (Reverse Score).0 1 2 3 I thought my life bad been a failure.0 1 2 3 I felt fearful.0 1 2 3 My sleep was restless.0 1 2 3 I was happy (Reverse Score).

0 = Rarely or none (less than 1 day) 2 = Occasionally or moderate (3-4 days) 1 = Some or a little (1-2 days) 3 = Most or all of the time (5-7 days) 0 1 2 3 I talked less than

usual.0 1 2 3 I felt lonely.0 1 2 3 People were unfriendly.0 1 2 3 I enjoyed life (Reverse Score).0 1 2 3 I had crying spells.0 1 2 3 I felt sad.0 1 2 3 I felt that people dislike me.0 1 2 3 I could not get "going."

Scoring: Add up all the circled numbers (Questions 4, 8, 12 and 16 are reverse scored, meaning that a response of 3 is scored as a 0 and a response of 0 as 3; similarly, a 1 response is scored as a 2 and a 2 response as 1).

The interpretation of your scoring varies depending on your age and culture. In general, however, if your score is between 10-15 you may be mildly depressed. A score of 16-25 suggests moderate depression and scores over 25 indicate that, at least right now, you may be significantly depressed. Remember, however, that these questions and scores are simply a way for you to take stock of how you’re feeling right now. They are not set in concrete, and they definitely don’t mean you have a disease.

You may want to use the CES-D every few months, to see how your worldview and the way you’re feeling changes. Keep the results if you’d like. They can help you see how you’ve changed and show you some of the challenges you still have to meet.

The First Note

CES- Depression Scale

Answer the following questions:

1) What’s going on right now?

2) Where do I want to be headed? What changes are necessary?

3) What are my first steps for getting where I’m going?

The Call

The Second NoteIt’s time to act. Taking the steps to prepare

for change.

Self-expression decreases stress.

Your journal is your friend and companion.

Write every day.

A Journal for Your Journey

• Pennebaker JW, JK Kiecolt-Glaser, R Glaser. Disclosure of traumas and immune function: health implications for psychotherapy. J Consult Clin Psychol, 1988;56(2):239-45.

• Hemenover SH. The good, the bad, and the healthy: impacts of emotional disclosure of trauma on resilient self-concept and psychological distress. Pers Soc Psychol Bull 2003;29(10):1236-44.

• Smyth JM, et al. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial. JAMA 1999;281(14):1304-9.

Depression is not a disease, but disease, and drugs, can cause or

contribute to depression.Rule out obvious physical illnesses and

drug effects (side effects), and then address more subtle biological

imbalances.

Physical Causes of Depression

Prescription Drugs that May Cause or Contribute to

DepressionAntianxiety medicines

Antidepressants

Antihistamines (these can, of course, be purchased over the counter in drugstores as well as be prescribed_

Antihypertensives (a variety of drugs that lower blood pressure

Anti-inflammatory agents (used for an injury, arthritis, etc.)

Antiseizure medicines (used to protect against epilepsy)

Birth control pills

Chemotherapeutic agents (used to treat a variety of cancers)

Corticosteroids (synthetic versions of the adrenal stress hormones used for a wide variety of conditions from arthritis to asthma and eczema)

Sleeping pills of all kinds

Prescription Drugs

Physical Causes of Depression

May Give Rise To, and/or Be Accompanied By,

DepressionAcquired Immune Deficiency Syndrome (AIDS)

Adrenal gland overactivity, with hypersecretion of stress hormones (Cushing’s Disease), and underactivity (Addison’s Disease)

Autoimmune Illnesses, where the body’s immune cells attack its own tissue in a variety of locations; examples include lupus erythematosus and rheumatoid arthritis

Cancer, especially cancer of the brain (where pressure on the brain may contribute to the symptoms) and cancer of the pancreas

Cerebrovascular disease, in particular, strokes, or “cerebrovascular accidents,” in which the blood supply to the brain, and therefore its adequate functioning, is compromised

Chronic Fatigue Immune Deficiency Syndrome (CFIDS): A multisystem condition, perhaps precipitated by Epstein Barr or another viral illness, characterized by extreme fatigue, and sometimes muscle and joint pain, as well as depression

Chronic pain

Diabetes, a disease in which major problems in sugar metabolism and in circulation are caused by the body’s inability to produce, or adequately use, insulin

Medical Conditions

Physical Causes of Depression

May Give Rise To, and/or Be Accompanied By,

DepressionHeart disease, including heart failure and heart-valve malfunction; these are often accompanied by shortness of breath

Infections, both bacterial and viral, including Lyme disease

Lung disease, particularly chronic obstructive pulmonary disease, which may be present in longtime smokers, coal miners, asbestos workers, etc.

Multiple sclerosis, a disorder with a variety of symptoms, including visual problems and weakness of limbs, produced by inflammation in the “white matter” that surrounds the nerve cells in the brain

Parkinson’s disease, a disease characterized by dopamine deficiency in the substancia nigra of the brain, with symptoms including trembling, especially of the hands; muscular rigidity; and difficulty moving

Thyroid disease, including both overactivity (hyperthyroidism) and underactivity (hypothyroidism)

Trauma to the head

Wilson’s disease, an inherited illness in which abnormal copper metabolism may damage the nervous system and liver

Medical Conditions

Physical Causes of Depression

• Subclinical Hypothyroidism

Sometimes with normal thyroid levels and only slightly elevated or normal TSH.

Rx: Thyroid supplementation.

Physical Causes of Depression

• Cooper, DS. Clinical practice. Subclinical hypothyroidism. N Engl J Med. 2001:345(4):260-65.

• Haggerty, JJ Jr, RA Stern, GA Mason, J Beckwith, et al. Subclinical hypothyroidism: a modifiable risk factor for depression? Am J Psychiatry 1993:150(3):508-10.

• Monzani, F, P DelGuerra, N Caraccio, CA Pruneti, E Pucci, et al. Subclinical hypothyroidism: neurobehavioral features and beneficial effect of L-thyroxine treatment. Clin Investig 1993:71(5):367-71.

More Subtle, Often Missed

• Heavy Metal Toxicity

A subject of maximum controversy. Look for it if any possibility of exposure (dental

assistance) and/or if all else in the Unstuck approach is not working.

Rx: Detoxification, Chelation

More Subtle, Often Missed

• Cordeiro, Q., Jr., M. de Araujo Medrado Faria, and R. Fraguas, Jr., Depression, insomnia, and memory loss in a patient with chronic intoxication by inorganic mercury. J Neuropsychiatry Clin Neurosci, 2003. 15(4): p. 457-8.

• Powell, T.J., Chronic neurobehavioural effects of mercury poisoning on a group of Zulu chemical workers. Brain Inj, 2000. 14(9): p. 797-814.

• Otto D, Y Xia, Y Li, K Wu, L He, J Telech, et al. Neurosensory effects of chronic human exposure to arsenic associated with body burden and environmental measures. Hum Exp Toxicol 207;26(3):169-77.

• Schlegel-Zawadzka M, A Zieba, D Dudek, J Zak-Knapik, G Nowak. Is serum copper a “trait marker” of unipolar depression? A preliminary clinical study. Pol J Pharmacol 1999;51(6):535-38.

• SIBO – Small Intestinal Bowel Overgrowth

High toxic bacteria - Low lactobacillus, bifidobacterium

Often accompanies stress.Rx: Replace lactobacillus and bifidobacterium

(2-3 billion/capsule; 1 per day).• Holdeman, LV, IJ Good, WE Moore. Human fecal flora: variation in bacterial composition within individuals and a possible

effect of emotional stress. Appl Environ Microbol 1976:31(3):359-75.

• Lizko, NN. Stress and intestinal microflora. Nahrung 1987:31(5-6):443-47.

• Moore, WE, EP Cato, LV Holdeman. Some current concepts in intestinal bacteriology. Am J Clin Nutr 1978:31 suppl.:S33-42.

• Gruenwald, J, HJ Graubaum, A Harde. Effect of a probiotic multivitamin compound on stress and exhaustion. Adv Ther 2002:19(3):141-50.

• Pimentel ME, J Chow, HC Lin. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol 2000:95(12):3503-506.

More Subtle, Often Missed

• SAD – Seasonal Affective Disorder

Fairly commonRx: May be remedied by using full spectrum light

(10,000 lux; 30 minutes in the morning)

• Magnusson, A, H Kristbjarnarson. Treatment of seasonal affective disorder with high-intensity light: a phototherapy study with an Icelandic group of patients. J Affect Disord 1991:21(2):141-47.

• Terman, JS, et al. Efficacy of brief, intense light exposure for treatment of winter depression. Psychopharmacol Bull 1990:26(1):3-11.

• Terman, M, JS Terman, DC Ross. A controlled trial of timed bright light and negative air ionization for treatment of winter depression. Arch Gen Psychiatry 1998:55(10):875-82.

More Subtle, Often Missed

• Non-Seasonal Light-Related Depression

Consider this possibilityNo harm in treatment, possible significant benefit

• Prasko, J, et al. Bright light therapy and/or imipramine for inpatients with recurrent non-seasonal depression. Neuro Endocrinol Lett 2002:23(2):109-13.

• Martiny, K, et al. Adjunctive bright light in non-seasonal major depression: results from patient-reported symptom and well-being scales. Acta Psychiatr Scand 2005:111(6):453-59.

• Yamada, N, et al. Clinical and chronobiological effects of light therapy on nonseasonal affective disorders. Biol Psychiatry 1995:37(12):866-73.

More Subtle, Often Missed

•Eat whole foods, organic if possible, raw often

Healthier Body, Happier Mind

Guide to Mood Healthy Eating

• Westover, A.N. and L.B. Marangell, A cross-national relationship between sugar consumption and major depression? Depress Anxiety, 2002. 16(3): p. 118-20.

• Lien, L., et al., Consumption of soft drinks and hyperactivity, mental distress, and conduct problems among adolescents in Oslo, Norway. Am J Public Health, 2006. 96(10): p. 1815-20.

•Decrease sugar and high glycemic index carbohydrates and focus on the complex carbohydrates – vegetables,

whole grains

• Westover, A.N. and L.B. Marangell, A cross-national relationship between sugar consumption and major depression? Depress Anxiety, 2002. 16(3): p. 118-20.

• Lien, L., et al., Consumption of soft drinks and hyperactivity, mental distress, and conduct problems among adolescents in Oslo, Norway. Am J Public Health, 2006. 96(10): p. 1815-20.

Guide to Mood Healthy Eating

Carbohydrates

•No trans fats •Less animal fat, more from plant oils

from such sources as extra virgin olive oil

•PGE 1 and PGE3 may improve mood, PGE2 in red meat may lower it• Norden M. Beyond Prozac: Brain-Toxic Lifestyles, Natural Antidotes & New Generation Antidepressants . 1995.

Harper Collins. 258p.

• Lieb J, R Karmali, D Horrobin. Elevated levels of prostaglandin E2 and thromboxane B2 in depression. Prostaglandins Leukot Med 1983;10(4):361-67.

• Nishino S, R Ueno, K Ohishi, T Sakai, O Hayaishi. Salivary prostaglandin concentrations: possible state indicators for major depression. Am J Psychiatry. 1989;146(3):365-68.

• Ohishi K, R Ueno, S Nishino, T Sakai, O Hayaishi. Increased level of salivary prostaglandins in patients with major depression. Biol Psychiatry 1988;23(4):326-34.

Guide to Mood Healthy Eating

Fats

•Protein should come mostly from

plants, but also from deep water fish (salmon, halibut, mackerel)

Guide to Mood Healthy Eating

Protein

•Constipation is a symptom of depression.

•Eat enough fiber. Increase from 15gm a day that is our average to the 100gm a day our ancestors consumed.

•We need both soluble and insoluble fiber.

Guide to Mood Healthy Eating

Fiber

•Soluble fiber (pectin) is present in oatmeal as oatbran, nuts, seeds, beans, and fruit.

•Soluble fiber slows sugar metabolism, increases growth of beneficial bacteria.

Guide to Mood Healthy Eating

Soluble Fiber

•Insoluble fiber (cellulose) is present in whole grains and bran, as well as in lentils and beans and many vegetables (carrots, zucchini, cucumbers, etc).

•Insoluble fiber promotes bowel regularity; removes cholesterol, hormones, and toxins from gut.

Guide to Mood Healthy Eating

Insoluble Fiber

•Drink more (filtered or spring).Approximately 3 quarts per day

including 2 12 ounce glasses first thing in the morning to stimulate the gastrocolic

reflex, improve bowel movement.

Guide to Mood Healthy Eating

Water

Non IgE mediated, probably by IgG

Reactions of tissues in the body to proteins that cross the intestinal wall to enter the blood

stream.Many symptoms including depression.

Food Sensitivity

• Isolauri, E, S Rautava, M Kalliomaki. Food allergy in irritable bowel syndrome: new facts and old fallacies. Gut 2004:53(10)1391-93.

• Sampson, HA. Food allergy. J Allergy Clin Immunol 2003:111(2):540-47.

• Atkinson, W, TA Sheldon, N Shaath, PJ Whorwell. Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial. Gut 2004:53(10):1459-64.

For three weeks, eliminate foods that are the main part of many modern American diets and that clinicians have found to be the most obvious and consistent causes of food sensitivity: milk, wheat, sugar, corn, soy, and citrus. Eat a diet of whole foods, preferably organic, and preferably without red meat. And drink plenty of water.During the first few days, as you “withdraw” from the food(s) to which you are sensitive, you may feel worse – and even more depressed. This is unpleasant, but it may actually be a good sign, a confirmation of a food sensitivity. In a few more days, these symptoms should subside, and you’ll likely feel much better.

Elimination Diet

Creating Your Own Elimination Diet

Keep a diary and each day record the answers to the following questions: How do you feel? What do you crave? What’s the relationship between the time you ate, what you ate, and how you feel? Are you less, or more, depressed on this elimination diet, more energetic or better able to concentrate? What about other symptoms? Does any of this change over time?Then, after three weeks, reintroduce the foods that you’ve eliminated, one at a time. See, for example, how you feel after a meal of conventional wheat pasta (with olive oil rather than cheese or butter). What is it like the next day? Is your mood unchanged or worse? Are you more fatigued? Is your digestion affected? You may want to record the answers in your journal.

Creating Your Own Elimination Diet

Then, a week or two later, experiment with another of the eliminated foods, perhaps milk (or cheese) and so on. If you are truly sensitive to a food, eliminating it should, after several weeks, improve your symptoms, and reintroducing it should reproduce some of the original symptoms.

Creating Your Own Elimination Diet

Most Americans are deficient in one or more essential nutrients. Many

nutrient deficiencies may cause or contribute to depression including:

Supplementation

• http://www.health.gov/dietaryguidelines/dga2005/report/.

• http://www.who.int/nutrition/databases/micronutrients/en/index.html

Supplementation

• Thiamine

•Folic Acid

•Pyridoxine (B6) • Hvas, AM, et al., Vitamin B6 level is associated with symptoms of depression. Psychother Psychosom

2004:73(6):340-3.

• Gilbody, S, T Lightfoot, and T Sheldon. Is low folate a risk factor for depression? A meta-analysis and exploration of heterogeneity. J Epidemiol Community Health 2007:61(7):631-7.

• Young SN. Folate and depression—a neglected problem. J Psychiatry Neurosci 2007;32:80-2.

• Tiemeier, H, et al., Vitamin B12, folate, and homocysteine in depression: the Rotterdam Study. Am J Psychiatry 2002: 159(12): 2099-101.

• Dimopoulos N, Piperi C, Salonicioti A, et al. Correlation of folate, vitamin B12 and homocysteine plasma levels with depression in an elderly Greek population. Clin Biochem 2007;46:604-8.

• Brozek, J. Psychological effects of thiamine restriction and deprivation in normal young men. Am. J. Clin. Nutr 1957: 5:109–18.

Supplementation

• B12

• Vitamin C

• Magnesium• Rasmussen, HH, PB Mortensen, IW Jensen. Depression and magnesium deficiency. Int J Psychiatry Med

1989:19(1):57-63.

• Eby, GA, KL Eby. Rapid recovery from major depression using magnesium treatment. Med Hypotheses 2006:67(2):362-70.

• Kinsman, RA, J Hood. Some behavioral effects of ascorbic acid deficiency. Am J Clin Nutr, 1971:24(4):455-64.

• Tiemeier, H, et al., Vitamin B12, folate, and homocysteine in depression: the Rotterdam Study. Am J Psychiatry 2002: 159(12): 2099-101.

• Dimopoulos N, Piperi C, Salonicioti A, et al. Correlation of folate, vitamin B12 and homocysteine plasma levels with depression in an elderly Greek population. Clin Biochem 2007;46:604-8.

Supplementation

• Zinc

• Selenium

• Chromium• McLeod, MN, RN Golden. Chromium treatment of depression. Int J Neuropsychopharmacol

2000:3(4):311-314.

• Davidson, JR, et al., Effectiveness of chromium in atypical depression: a placebo-controlled trial. Biol Psychiatry 2003:53(3):261-4.

• http://www.health.gov/dietaryguidelines/dga2005/report/.

• http://www.who.int/nutrition/databases/micronutrients/en/index.html

• Benton, D. Selenium intake, mood and other aspects of psychological functioning. Nutr Neurosci 2002:5(6):363-74.

• Benton, D, R Cook. The impact of selenium supplementation on mood. Biol Psychiatry 1991:29(11):1092-8.

• Maes, M, et al., Lower serum zinc in major depression in relation to changes in serum acute phase proteins. J Affect Disord 1999:56(2-3):189-94.

• Maes, M, et al., Hypozincemia in depression. J Affect Disord 1994:31(2):135-40.

Omega-3 Fatty Acids deficiencies are correlated with depression in

epidemiological studies.

Supplementation

• Sanchez-Villegas, A., et al., Long chain omega-3 fatty acids intake, fish consumption and mental disorders in the SUN cohort study. Eur J Nutr, 2007. 46(6): p. 337-46.

• Tanskanan A, JR Hibbeln, J Tuomilehto, A Uutela, A Haukkala, et al. Fish consumption and depressive symptoms in the general population in Finland. Pschiatr Serv 2001;52(4):529-31.

Supplementation with Omega-3s improves mood in both major

depression and bipolar disorder.

Supplementation

• Stoll, A.L., et al., Omega 3 fatty acids in bipolar disorder: a preliminary double-blind, placebo-controlled trial. Arch Gen Psychiatry, 1999. 56(5): p. 407-12.

• Lin, P.Y. and K.P. Su, A meta-analytic review of double-blind, placebo-controlled trials of antidepressant efficacy of omega-3 fatty acids. J Clin Psychiatry, 2007. 68(7): p. 1056-61.

• Logan, A.C., Omega-3 fatty acids and major depression: a primer for the mental health professional. Lipids Health Dis, 2004. 3: p. 25.

VitaminsVitamin A (retinol) 5,000 IUVitamin A (from beta-carotene) 5,000-10,000 IUVitamin D 100-300 IUVitamin E (d-alpha tocopherol) 200-400 IUVitamin K (phytonadione) 60-90 mgVitamin C (ascorbic acid) 500-2,000 mgVitamin B1 (thiamine) 15-50 mgVitamin B2 (riboflavin) 10-50 mgNiacin 20-60 mg

Supplementation

Mood Healthy Daily Doses

VitaminsNiacinamide 10-30 mgVitamin B6 (pyridoxine) 50-100 mgBiotin 100-300 mcgPantothenic acid 200-500 mgFolic acid 400-1200 mcgVitamin B12 200-800 mcgCholine 150-500 mgInositol 150-500 mg

Supplementation

Mood Healthy Daily Doses

MineralsBoron 1-2 mgCalcium 500-1,500 mgChromium 200-400 mcgCopper 1-3 mgIodine 50-150 mcg

Supplementation

Mood Healthy Daily DosesMagnesium 250-750 mgManganese 5-10 mgMolybdenum 10-25 mcgPotassium 200-500 mgSelenium 100-200 mcgZinc 15-30 mg

Omega-3 Fatty Acids (at least one half as EPA and DHA) 3000 mg

Guides on the Journey

The power of human help“Unconditional Positive Regard”

Finding a GuideDiscovering our own Inner Guide

“Stuckness”

• Depression is an impasse to be navigated, as well as an imbalance to be corrected.

• People feel stuck in a prolonged fight or flight response or frozen in immobility.

• They feel stuck in helplessness and hopelessness.

• They feel stuck in their lives, dissatisfied with where they are now, and unable to change.

• This is the end result of underlying physical, emotional, mental and spiritual blocks and imbalances that produce depression, inhibit our normal functioning and blight our relationships.

“Stuck”: This is how people so often say they feel

That’s why I call this approach and my book about it, “Unstuck”

Surrender into the Current of

Our Lives

Some people can simply do this.

Most of us need to act to breakup up the fixed psychological, emotional,

mental, and spiritual stuckness, before we can surrender.

Our Goal Is To Become Unstuck

Shaking and Dancing

A practical way to shake things up,

to surrender to life

Exercise and Depression

By itself, exercise is as effective as any known treatment for depression.

Exercise should always be a significant part of any integrative approach.

• Nabkasorn C, N Miyai, A Sootmongkol, S Junprasert, H Yamamoto, M Arita, K Miyashita. Effects of physical exercise on depression, neuroendocrine stress hormones, and physiological fitness in adolescent females with depressive symptoms. Euro J Pub Health 2006;16(2):179-84.

• Blumenthal, JA, et al. Effects of exercise training on older patients with major depression. Arch Intern Med 1999;159(19):2349-56.

• Babyak M, et al. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med 2000;62(5):633-38.

Exercise alters brain chemistry, increasing serotonin, norepinephrine,

and endorphin levels.

• Soares, J., M.G. Naffah-Mazzacoratti, and E.A. Cavalheiro, Increased serotonin levels in physically trained men. Braz J Med Biol Res, 1994. 27(7): p. 1635-8.

• Carr, D.B., et al., Physical conditioning facilitates the exercise-induced secretion of beta-endorphin and beta-lipotropin in women. N Engl J Med, 1981. 305(10): p. 560-3

Exercise and Depression

Exercise and Depression

Exercise may promote neurogenesis.

• Rhodes, J.S., et al., Exercise increases hippocampal neurogenesis to high levels but does not improve spatial learning in mice bred for increased voluntary wheel running. Behav Neurosci, 2003. 117(5): p. 1006-16.

• van Praag, H., G. Kempermann, and F.H. Gage, Running increases cell proliferation and neurogenesis in the adult mouse dentate gyrus. Nat Neurosci, 1999. 2(3): p. 266-70.

• van Praag, H., et al., Exercise enhances learning and hippocampal neurogenesis in aged mice. J Neurosci, 2005. 25(38): p. 8680-5.

The Demon – what disturbs and desolates us and keeps us stuck –

conceals our daimon. Our Daimon is the guiding principle and

fulfiller of our life’s purpose

Demon and Daimon

Dealing with Depression’s Demons

Relax with your demons using mindfulness to help you gain distance

from and perceptive on them.Use specific exercises to come to know

and learn from your demons.Dialogue with an SPI.

Dealing with Depression’s Demons

Meditation As Your Basic Method

•Suicide is more common than we

imagine, and suicidal thoughts and feelings are present in many of us.

•These times are excruciating and they can be our deepest teachers.

•We need to be able to share these thoughts and feelings.

•Most often need a Guide.

Dark Night of the Soul

Dark nights and suicidal thoughts and

actions are particularly common among adolescents.

• 3rd leading cause of death in the US population age 15-44, 2nd for college students.

• 1/5 of high school students have “considered” suicide.

• 1/10 have attempted it.

Dark Night of the Soul

• Youth Risk Behavior Surveillance: National College Health Risk Behavior Survey – United States, 1997,” Morbidity and Mortality Weekly Report, 47 (1997): No SS-3

• http://www.cdc.gov/ncipc/factsheets/children.htm

•Spirituality connects us to what is

beyond us and what is deepest within us – informs and encourages our daimon

•Spirituality is fundamental to our understanding and experience of the journey.

•Spiritual experience and understanding change the nature of the journey.

Spirituality: The Blessing

Connected in many languages:

Spirituality

Spirituality and Breath

• Sanskrit• Hebrew• Chinese• Greek

• Prana• Rvach• Chi• Pneuma

Life begins and ends with breath.

Breath connects us to that which is beyond us.

Breath allows us to experience spirituality through its calming and

energizing qualities.

Spirituality

Breath

•Religion and Spirituality

•Prayer

•Love

Spirituality

•Living Each Moment

•Being Aware

•With every Person

•In every Situation

•Celebrating each moment, Letting it go

The Return

Available at:

www.cmbm.org/unstuck