UNSTUCK: An Integrative Approach to Depression

1
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

2
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 ones life.
• The beginning of a journey. A wake up call to
  the need for change, not the end of a disease
  process.

3

Soft Belly

• Begin with Relaxation antidote to the fight or
  flight response and to stress which is so
  intimately connected to depression.

• Lee, AL, WO Ogle, RM Sapolsky. Stress and
  depression possible links to neuron death in the
  hippocampus. Bipolar Disord 20024(2)117-28
• Sapolsky, RM. Why stress is bad for your brain.
  Science 1996273(5276)749-50.

4
The Seven Stages
of the Journey Out of Depression

• 1. The Call
• The awareness that we are depressed, and that
  some kind of change, of journey, is necessary
• 2. Meeting Guides on the Path
• Meeting and choosing the men and women who can
  help, and developing our own inner guidance and
  wisdom
• 3. Surrender to Change
• Allowing and encouraging ourselves to let go of
  what constrains and freezes us, and to move into
  the current of life

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The Seven Stages

• 4. Dealing with Demons
• Meeting the challengesself-doubt, loneliness,
  procrastination, pride, resentment, apprehension,
  perfectionism, fear with all its faces, guilt,
  shame, self-pity, and all the othersand finding
  in them the unique daimon, the genius, of our own
  meaning, purpose and direction
• 5. The Dark Night of the Soul
• Allowing, and inviting, as we move through the
  despair that may come to any of us, the deepest,
  life-giving freedom to emerge

6
The Seven Stages

• 6. Spirituality The Blessing
• Experiencing 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

7

Awareness of

• The limitations of the disease theory of
  depression

• Valenstein E. Blaming the brain the truth about
  drugs and mental health. New York Free Press.
  1998.
• Sadock BJ, VA Sadock, HI Kaplan. Kaplan
  Sadocks 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 20052(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
  2002113(1-2)193-206.

8

Awareness of

• 2) The dangers of antidepressants

• 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 199723(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 200317(4)451-52.
• Black K, et al. Selective serotonin reuptake
  inhibitor discontinuation syndrome proposed
  diagnostic criteria. J Psychiatry Neurosci
  200025(3)255-61.

9

Awareness of

• 3) The limited effectiveness of drugs

• 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
  emperors 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/pre
  0050023a.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 2008358(3)252-60

10

Hope

• Hope for the possibility of change is central to
  the Unstuck approach.

• Beecher, HK. The powerful placebo. JAMA
  1955159(17)375-91.
• Roberts, A, et al. The power of nonspecific
  effects in healing implications for psychosocial
  and biological treatments. Clin Psychol Rev
  199313375-91.
• Walsh, BT, et al. Placebo response in studies of
  major depression variable, substantial, and
  growing. JAMA 2002287(14)1840-47.

11

Hope
Placebo Response

• 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.

• Beecher, HK. The powerful placebo. JAMA
  1955159(17)375-91.
• Roberts, A, et al. The power of nonspecific
  effects in healing implications for psychosocial
  and biological treatments. Clin Psychol Rev
  199313375-91.
• Walsh, BT, et al. Placebo response in studies of
  major depression variable, substantial, and
  growing. JAMA 2002287(14)1840-47.

12

Neuroplasticity

• Our brains, contrary to long term teaching, have
  the capacity to grow and change anatomically as
  well as physiologically.

• Eriksson, PS, et al. Neurogenesis in the adult
  human hippocampus. Nat Med 19984(11)1313-17.
• Kandel, E. A new intellectual framework for
  psychiatry. Am J Psychiatry 1998155457-69.

13

Neuroplasticity

• Natural, non-pharmacological techniques including
  psychotherapy, meditation, and exercise can
  produce these positive changes.

• Martin, SD, et al. Brain blood flow changes in
  depressed patients treated with interpersonal
  psychotherapy or venlafaxine hydrochloride
  preliminary findings. Arch Gen Psychiatry
  200154(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 200461(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.

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The Call
The First Note

• 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 youre thinking
  and feeling. Its a mirror, and it clarifies the
  first note of the Call.
• If youre unsure of an answer, dont linger too
  long. Just circle what seems most correct and
  move on. The scoring scale follows the test, but
  dont look at it until youre finished.
• If you score in the range of clinical concern,
  pay attention. Even if you dont 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. Its
  for your use. It provides useful hints and a
  starting place. It is not an endpoint.

• Radloff, L. The CES-D scale a self-report
  depression scale for research in the general
  population. Appl Psych Meas 19971(3)385-401.

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The First Note
CES- Depression Scale

• 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)

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.
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The First Note
CES- Depression Scale

• 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 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 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."
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The First Note
CES- Depression Scale

• 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 youre feeling right
  now. They are not set in concrete, and they
  definitely dont mean you have a disease.
• You may want to use the CES-D every few months,
  to see how your worldview and the way youre
  feeling changes. Keep the results if youd like.
  They can help you see how youve changed and show
  you some of the challenges you still have to
  meet.

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The Call
The Second Note
Its time to act. Taking the steps to prepare for
change.

• Answer the following questions
• Whats going on right now?
• Where do I want to be headed? What changes are
  necessary?
• What are my first steps for getting where Im
  going?

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A Journal for Your Journey

• Self-expression decreases stress.
• Your journal is your friend and companion.
• Write every day.

• Pennebaker JW, JK Kiecolt-Glaser, R Glaser.
  Disclosure of traumas and immune function health
  implications for psychotherapy. J Consult Clin
  Psychol, 198856(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
  200329(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 1999281(14)1304-9.

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Physical Causes of Depression

• 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.

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Physical Causes of Depression
Prescription Drugs

• Prescription Drugs that May Cause or Contribute
  to Depression

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Physical Causes of Depression
Medical Conditions

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

23

Physical Causes of Depression
Medical Conditions

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

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Physical Causes of Depression
More Subtle, Often Missed

• Subclinical Hypothyroidism
• Sometimes with normal thyroid levels and only
  slightly elevated or normal TSH.
• Rx Thyroid supplementation.

• Cooper, DS. Clinical practice. Subclinical
  hypothyroidism. N Engl J Med. 2001345(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
  1993150(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
  199371(5)367-71.

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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

• 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
  20726(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
  199951(6)535-38.

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More Subtle, Often Missed

• 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 197631(3)359-75.
• Lizko, NN. Stress and intestinal microflora.
  Nahrung 198731(5-6)443-47.
• Moore, WE, EP Cato, LV Holdeman. Some current
  concepts in intestinal bacteriology. Am J Clin
  Nutr 197831 suppl.S33-42.
• Gruenwald, J, HJ Graubaum, A Harde. Effect of a
  probiotic multivitamin compound on stress and
  exhaustion. Adv Ther 200219(3)141-50.
• Pimentel ME, J Chow, HC Lin. Eradication of
  small intestinal bacterial overgrowth reduces
  symptoms of irritable bowel syndrome. Am J
  Gastroenterol 200095(12)3503-506.

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More Subtle, Often Missed

• SAD Seasonal Affective Disorder
• Fairly common
• Rx 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
  199121(2)141-47.
• Terman, JS, et al. Efficacy of brief, intense
  light exposure for treatment of winter
  depression. Psychopharmacol Bull 199026(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 199855(10)875-82.

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More Subtle, Often Missed

• Non-Seasonal Light-Related Depression
• Consider this possibility
• No 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
  200223(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 2005111(6)453-59.
• Yamada, N, et al. Clinical and chronobiological
  effects of light therapy on nonseasonal affective
  disorders. Biol Psychiatry 199537(12)866-73.

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Healthier Body, Happier Mind
Guide to Mood Healthy Eating

• Eat whole foods, organic if possible, raw often

• 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.

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Guide to Mood Healthy Eating
Carbohydrates

• 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.

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Guide to Mood Healthy Eating
Fats

• 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
  198310(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. 1989146(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
  198823(4)326-34.

32

Guide to Mood Healthy Eating
Protein

• Protein should come mostly from plants, but also
  from deep water fish (salmon, halibut, mackerel)

33

Guide to Mood Healthy Eating
Fiber

• 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.

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Guide to Mood Healthy Eating
Soluble 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.

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Guide to Mood Healthy Eating
Insoluble 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.

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Guide to Mood Healthy Eating
Water

• 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.

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Food Sensitivity

• 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.

• Isolauri, E, S Rautava, M Kalliomaki. Food
  allergy in irritable bowel syndrome new facts
  and old fallacies. Gut 200453(10)1391-93.
• Sampson, HA. Food allergy. J Allergy Clin Immunol
  2003111(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 200453(10)1459-64.

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Elimination Diet
Creating Your Own Elimination Diet

• 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
  youll likely feel much better.

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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? Whats 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 youve 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.

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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.

41

Supplementation

• Most Americans are deficient in one or more
  essential nutrients. Many nutrient deficiencies
  may cause or contribute to depression including

• http//www.health.gov/dietaryguidelines/dga2005/re
  port/.
• http//www.who.int/nutrition/databases/micronutrie
  nts/en/index.html

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Supplementation

• Thiamine
• Folic Acid
• Pyridoxine (B6)

• Brozek, J. Psychological effects of thiamine
  restriction and deprivation in normal young men.
  Am. J. Clin. Nutr 1957 510918.

• 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 200761(7)631-7.
• Young SN. Folate and depressiona neglected
  problem. J Psychiatry Neurosci 20073280-2.
• 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
  200746604-8.

• Hvas, AM, et al., Vitamin B6 level is associated
  with symptoms of depression. Psychother Psychosom
  200473(6)340-3.

43

Supplementation

• B12
• Vitamin C
• Magnesium

• 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
  200746604-8.

• Kinsman, RA, J Hood. Some behavioral effects of
  ascorbic acid deficiency. Am J Clin Nutr,
  197124(4)455-64.

• Rasmussen, HH, PB Mortensen, IW Jensen.
  Depression and magnesium deficiency. Int J
  Psychiatry Med 198919(1)57-63.
• Eby, GA, KL Eby. Rapid recovery from major
  depression using magnesium treatment. Med
  Hypotheses 200667(2)362-70.

44

Supplementation

• Zinc
• Selenium
• Chromium

• Maes, M, et al., Lower serum zinc in major
  depression in relation to changes in serum acute
  phase proteins. J Affect Disord
  199956(2-3)189-94.
• Maes, M, et al., Hypozincemia in depression. J
  Affect Disord 199431(2)135-40.

• Benton, D. Selenium intake, mood and other
  aspects of psychological functioning. Nutr
  Neurosci 20025(6)363-74.
• Benton, D, R Cook. The impact of selenium
  supplementation on mood. Biol Psychiatry
  199129(11)1092-8.

• McLeod, MN, RN Golden. Chromium treatment of
  depression. Int J Neuropsychopharmacol
  20003(4)311-314.
• Davidson, JR, et al., Effectiveness of chromium
  in atypical depression a placebo-controlled
  trial. Biol Psychiatry 200353(3)261-4.
• http//www.health.gov/dietaryguidelines/dga2005/re
  port/.
• http//www.who.int/nutrition/databases/micronutrie
  nts/en/index.html

45

Supplementation

• Omega-3 Fatty Acids deficiencies are correlated
  with depression in epidemiological studies.

• 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 200152(4)529-31.

46

Supplementation

• Supplementation with Omega-3s improves mood in
  both major depression and bipolar disorder.

• 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.

47

Supplementation
Mood Healthy Daily Doses

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

48

Supplementation
Mood Healthy Daily Doses

• Vitamins
• Niacinamide 10-30 mg
• Vitamin B6 (pyridoxine) 50-100 mg
• Biotin 100-300 mcg
• Pantothenic acid 200-500 mg
• Folic acid 400-1200 mcg
• Vitamin B12 200-800 mcg
• Choline 150-500 mg
• Inositol 150-500 mg

49

Supplementation
Mood Healthy Daily Doses

• Minerals
• Boron 1-2 mg
• Calcium 500-1,500 mg
• Chromium 200-400 mcg
• Copper 1-3 mg
• Iodine 50-150 mcg

Magnesium 250-750 mg Manganese 5-10
mg Molybdenum 10-25 mcg Potassium 200-500
mg Selenium 100-200 mcg Zinc 15-30 mg
Omega-3 Fatty Acids (at least one half as EPA and
DHA) 3000 mg
50
Guides on the Journey
The power of human help Unconditional Positive
Regard Finding a Guide Discovering our own Inner
Guide
51
Stuckness
Stuck This is how people so often say they
feel Thats why I call this approach and my
book about it, Unstuck

• 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.

52
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.

53
Our Goal Is To Become Unstuck

• Shaking and Dancing
• A practical way to shake things up,
• to surrender to life

54
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 200616(2)179-84.
• Blumenthal, JA, et al. Effects of exercise
  training on older patients with major depression.
  Arch Intern Med 1999159(19)2349-56.
• Babyak M, et al. Exercise treatment for major
  depression maintenance of therapeutic benefit at
  10 months. Psychosom Med 200062(5)633-38.

55
Exercise and Depression

• 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

56
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.

57

Dealing with Depressions Demons
Demon and Daimon

• The Demon what disturbs and desolates us and
  keeps us stuck conceals our daimon.
• Our Daimon is the guiding principle and fulfiller
  of our lifes purpose

58

Dealing with Depressions Demons
Meditation As Your Basic Method

• 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.

59

Dark Night of the Soul

• 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.

60

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.

• 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

61

Spirituality The Blessing

• 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.

62

Spirituality
Spirituality and Breath

• Connected in many languages

• Sanskrit
• Hebrew
• Chinese
• Greek

• Prana
• Rvach
• Chi
• Pneuma

63

Spirituality
Breath

• 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.

64
Spirituality

• Religion and Spirituality
• Prayer
• Love

65

The Return

• Living Each Moment
• Being Aware
• With every Person
• In every Situation
• Celebrating each moment, Letting it go

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Available at www.cmbm.org/unstuck