1.1 Description and Sub-Categories
Depression is a mental condition that inflicts great suffering and usually the sufferer can see no reason for their condition. The causes of it are multi-factorial and only partly known. However, some aspects of known brain chemistry help us to see what brain biochemicals may be out of balance and why.
Some textbooks of medicine address depression and mania (or manic depression) as two separate conditions, while others speak of just one continuum called ‘manic-depressive disorder’ in which the patient’s condition may be anywhere between overt depression on the one hand and obvious mania on the other.
Here, since so many patients show signs of depression without any hint of mania, we are dealing with the two states in sequence.
Depression is a state which all of us experience from time to time, usually as a result of some distressing circumstance. There are however many patients who attend their doctors seeking relief for a large number of symptoms loosely grouped under the term ‘depression’. Some may complain of feeling unduly depressed following some unhappy experience, while others are clearly neurotics of long-standing. Yet others, although looking a picture of misery, do not complain of being depressed, but seem anxious only to impress the doctor with their own wickedness and unworthiness.
From the many patients suffering from ‘depression’ it is important to separate a group who have certain features in common – important because these patients are often fairly rapidly responsive to some form of treatment and because, if left untreated, they are the most likely to commit suicide. The clinical features shown by this group, in addition to a mood varying from mild depression to black despair are:
- Insomnia of a type characterised by early waking after two to three hours sleep
- Diurnal variation of mood in which the depression often lifts considerably towards evening
- Slowness of thought and inability to make decisions
- Ideas of guilt, unworthiness and self-blame which are often delusional in intensity, i.e. they are impervious to reasoned argument or demonstration of their falsity
- Various somatic manifestations such as loss of appetite, loss of weight, occipital pressure headache, backache, constipation, retardation of physical activity (more rarely aimless over-activity or agitation), and delusions about illness that are distinctly hypochondriac.
Such a patient may sit bowed and immobile on the edge of a chair obviously in the depths of misery, weeping silently, wringing his hands and answering questions in slow monosyllables; but in the earlier stages the physical appearance is less striking. In that case the diagnosis depends on the practitioner’s ability to elicit the symptoms described above.
Such patients are suffering from ‘endogenous depression’, known in earlier times as melancholia or ‘the spleen’. They are often people who have been subject previously to mood changes or people who have over-scrupulous, rigid personalities following too strict upbringing and who develop depression particularly in later middle age (‘involutional melancholia’). Endogenous depression may be precipitated by physical diseases such as influenza, pyelonephritis and infective hepatitis, and may sometimes be the first symptom of cerebral disease, such as general paralysis of the insane (associated with syphilis) or cerebral atherosclerosis, but more often, as its name suggests, it arises without detectable signs of other pathology.
Looking at the symptoms in rather more detail, the patient experiences lowered animation and an inability to cope with his or her affairs in the usual ways. This leads to loss of confidence, indecisiveness and restriction of both mental and physical activity. The capacity for enjoyment is lost or much reduced, whilst the impact of tragic or painful events weighs heavily. There is loss of or reduction in libido (motive power for sex), at least during the worst times. Patients may describe the condition as ‘being unable to get away from themselves’, while their worries and preoccupations magnify and they can find no escape. There is profound pessimism. The tendency is to live in the past, with the failures and unhappiness of the past being relived strongly, while the future, it seems, cannot possibly hold any hope. There is often guilt over some trivial misdemeanour with a sense of impending retribution. Money worries are greatly magnified leading to delusions of poverty and the patient readily comes to believe that relatives are starving, sick or dead. Persistence of this state and the apparent hopelessness of escape from it often lead on to suicidal talk or suicide attempts.
Endogenous depression is seen particularly in patients of middle age or older. Other forms of depression, sometimes called ‘reactive depression’, may be seen in younger or middle-aged people, many of whom show concomitant symptoms of anxiety neurosis rather than the symptoms described above. When there is insomnia it usually takes the form of inability to get to sleep without the early waking characteristic of endogenous depression, and such patients often feel better in company in contrast to the sufferer from endogenous depression.
Note that we have identified the following forms of the illness:
- Endogenous depression
- Manic depression – (manic depressive psychosis).
- Involutional melancholia
- Reactive depression
Most of what we have said above relates to endogenous depression.
1.2 Orthodox Treatment of Endogenous depression
Endogenous depression used to be treated by electro-convulsive therapy but today drug treatment is a principal orthodox approach, generally employing some form of nervous system stimulant. In the earliest stages dextroamphetamine sulphate, 5 to 10 mg. morning and midday with a sedative at night may avert depression. In more severe or chronic cases two main groups of drugs are used. These are:
- The monoamine oxidase inhibitors, eg tranylcypromine (Parnate), phenelzine (Nardil), isocarboxazid (Marplan) and moclobemide.
- The iminodibenzyl derivatives, such as imipramine (Tofranil), clomipramine (Anafranil), amitriptyline (Tryptizol, Lentizol) and nortriptyline (Allegron).
These drugs are certainly subject to producing side effects. The monoamine oxidase inhibitor drugs may have serious toxic effects. Some of the drugs in this group are hydrazines, which may cause jaundice, agranulocytosis and hypotension. Others such as tranylcypromine may give rise to paroxysmal hypertension simulating or even sometimes actually producing subarachnoid haemorrhage. The iminodibenzyl group of drugs is less toxic but may cause minor side effects, especially drowsiness, dryness of the mouth, and other symptoms and signs of blockage of parasympathetic activity.
Other forms of treatment include psychotherapy and, if the health carers involved have the time and the insight, seeking to make arrangements to improve the circumstances of the patient where they are such as to promote depression.
Depressive illnesses are usually self-limiting, although it is impossible to predict the duration of the symptoms. This tendency to spontaneous recovery makes it difficult to evaluate the effects of various forms of treatment. However the results published in 1965 of a clinical trial undertaken for the Medical Research Council have shown that imipramine increases the frequency of recovery over the spontaneous rate. Imipramine appears to be more effective in men than in women. In this trial the monoamine oxidase inhibitor (phenelzine) showed no advantage over a placebo. Reactive depression may respond favourably to imipramine. Often however this type of depression is best treated by supportive psychotherapy.
The danger of suicide is ever present with depressed patients, and should never be taken lightly. The old adage that ‘those who speak of suicide never commit it’ is entirely wrong; patients with endogenous depression frequently contemplate suicide and may attempt it at any time, usually when least expected. They may even feel compelled to take their nearest and dearest with them. In the more severe cases this danger may necessitate admission to hospital.
Having described depression and/or the depressive phase of manic depression we next describe the manic condition.
1.3 Manic Depression
The classical form of this illness is characterised by the patient developing at different times contrasting moods that include both depressive and manic phases. This illness involves much more than just ordinary mood swings but the whole personality is disturbed in a profound and sustained way. Some of the patients pass at once from one phase to the other while others may experience a period of normality in between the phases.
Still others may make gradual transitions between the phases. The manic phase is characterised by becoming increasingly talkative. The patient may talk of topics that he or she only talks about during the manic phase and adopt gestures, postures or expressions that are characteristic, for that person, of the manic phase. There is also an increase in self-assertiveness and in activity. Early on this may render the patient quite efficient still at work, though people may notice a lack of restraint. Being too free and easy about what they say may prove awkward in the working environment, since tact and diplomacy have already gone. The patients are likely to be unduly familiar with both strangers and acquaintances, generating a sense of excess bonhomie. He or she may be excessive in buying drinks and may spend out of control. The patient lacks insight. Those around the patient may find it difficult to handle the situation, since the patients are by no means certifiable and yet may behave in socially unacceptable ways and may spend beyond their means. Relatives feel concerned but are powerless to act. The patient’s approach at this point may be described as ‘expansive’. This is still the early stage and, being relatively mild is described as ‘hypomanic’.
If the condition passes beyond this stage then the activity level becomes completely out of hand. One account from some medical school teaching material in psychiatric medicine records:
The patient gets up early, rouses the household with noisy bustle, clears out limber rooms, plans unnecessary expeditions, make unnecessary telephone calls, sends unnecessary telegrams. He writes unnecessary letters, untidy with many afterthoughts and postscripts, which show the writer under a characteristic pressure. His conversation may similarly become incessant. One thought may so rapidly suggest another as to cause innumerable digressions without return to the main theme. The same distractability characterises his actions, so that one task after another is taken up but none completed. The mood is usually said to be ‘elated’ and the patient often described as showing an ‘infectious gaiety’.
An exalted patient may write cheques for a million, claim and confer titles, and in general be grandiose. The patient who is more irritable than elated may be paranoid.
The impression of gaiety may not be an accurate reflection of how the patient feels and ‘excitement’ conveys the condition better. The excitement appears unnatural and the patient seems driven by it rather than being in the driving seat him or herself. It is not uncommon for patients to experience a degree of depression simultaneously. Being ruthlessly driven from within, the patients become intolerant and frustrated and consequently may be irritable and aggressive.
In full mania the patient may shout, sing and dance or may be consumed with laughter and become violent if attempts are made to bring him or her under control. The talk becomes incoherent and purposeless because one intention succeeds another too rapidly to allow the conversation to make sense. Hallucinations do not usually occur and if they happen suggest some admixture in the case with schizophrenia.
These patients are usually bright eyed and ruddy faced. They lose weight through neglecting to eat much and being so active. Sleep is disturbed and they wake often. Sexual excitability is usually increased and this, coupled with lack of restraint may lead to immodest and shameless behaviour.
1.4 Orthodox Treatment of Manic Depression
Sedation with drugs is the usual orthodox approach with these cases. The drugs commonly used in manic depression are chlorpromazine, haloperidol and pimozide, just as in schizophrenia. Lithium, in the form of the carbonate, is also used but takes some 10 days to take effect. The lithium may produce as side effects gastrointestinal symptoms, fine tremor, polyuria and polydipsia and weight gain. Patients prescribed lithium and seeking to become free from it often attend our clinics.
1.5 Other Forms of Depression
The term ‘involutional melancholia’ is reserved for depressive illness coming on for the first time in the involutional stage of life, i.e. as the ageing process accelerates. It is often characterised by severe anxiety with hypochondriac fears and delusions. It is not now thought of as a separated disease identity and management is identical with that of depressive illness in general.
The term ‘reactive depression’, also called ‘exogenous depression’, is ascribed to depression of mood that may be more variable than in endogenous depression. Rather than routine diurnal swings, the condition is more related to the flow of the patient’s thoughts and what is going on around the patient. The extreme loss of energy and interest is not present and it is a great deal easier to distract the patient temporarily into forgetting the symptoms. Indeed, the patients are apt to be irritable, oversensitive and alert. Unless there is sexual or marital conflict libido is not lost. These patients are far more likely to respond favourably to being removed from whatever life circumstances that have been connected with the onset of the condition.
Murray & Pizzorno pp 378-380 set out some theories about the causes of depression. The same authors’ contribution on the therapy of depression, pp 380-399 is also excellent.
1.6 Nutritional Treatment of Depressive Illness
The depressive patient usually has a degree of whole body chronicity that is affecting the performance of the brain. Thoroughgoing naturopathic treatment is therefore entirely appropriate to such patients. If the brain tissue, with all its delicate mechanisms is working under a chronic load, then one expects to be able to improve the position by activating the brain tissue and detoxifying it. That represents treatment at a higher ‘level’ than the disease-orientated level.
1.6.1 Diet and Lifestyle
As we bring ourselves down to the disease-orientated level we note that diet and lifestyle factors needed for avoiding or securing release from depression include maintaining adequate general nutrition. A good balanced wholefood diet is needed, free from the use of tobacco, medical drugs and environmental toxins, especially toxic metals, solvents, pesticides and herbicides. Exercise is to be very much encouraged, since it tends to lift mood.
Looking at the diet in rather more detail, it is possible to provide general guidelines. The dietary design needs to be one that will support the improvement from a hypoglycaemic position. Hypoglycaemia is considered to be an important factor in many cases of depression and, of course, it tends to drag downward the vitality of the brain tissue. The body must be expected to take some time to correct the various tissue and blood levels, and so, as in the case of hypoglycaemia, one has to help the adjustments in the first place more or less mechanically, by the way one eats. The diet is the same exactly as the low blood sugar diet, but one must be absolutely sure to observe rigorously, the bans on wheat and stimulant beverages.
There will be an emphasis on fish rather more than meat (with any meat consumed avoiding beef and pork), with the total animal produce levels being strictly controlled. There will be a special emphasis on pulses, and on the combination rice/vegetables/pulses, being careful to define vegetables. The pulses are of special value here because the frequent intake of protein helps blood sugar control in quite a major way. However unconventional it may sound, there is a case for using a rice/vegetables/ pulses combination at breakfast, and to take breakfast fairly early, to provide the means of lifting the blood sugar early in the day. Abstinence from stimulants (caffeine), alcohol, sweets and sugar should be rigorous and absolute. Indeed, it is quite a good idea to use the rice/vegetables/pulses combination three times per day, subject only to replacing pulses with fish on a small number of occasions per week.
The practitioner needs to maintain awareness that many depressions are linked to allergies. Where that is the case, little recovery can be expected until the patient is relieved of the constant stress of allergen exposure.
1.6.2 Essential Nutrients
When we look at the needs for supplements of the essential nutrients we find that there is a marked convergence between those that would be needed based upon naturopathic considerations and those indicated from research studies. Depression is known to respond to:
- Vitamin B6
- Folic Acid
- Vitamin B12
- Vitamin C
- Omega-3-fatty acids
There are some indications that the whole Vitamin B-50 complex may be superior to just the three B vitamins cited. The exact position of calcium is unclear, since it appears that either hypercalcaemia or hypocalcaemia may promote depression. Generally, due to the calming influence of calcium one would expect it to be more useful in manic cases.
Many of the above supplements can be regarded as stimulants to brain cell metabolism. They can be expected to yield benefits when the patient’s brain has been hitherto under-supplied with them.
Next we look as more specialised nutrients and herbs that can benefit the depressive patient in a more specific and therefore more disease-directed way.
Treating diseases that involve effects upon brain function, gives us the opportunity to use our knowledge of neurotransmitters and the relationships that these bear to their precursors. This is a field that places great importance upon the amino acids. For example, the amino acid tryptophan was a very useful supplement until the authorities banned it for reasons unconnected with its intrinsic safety. Its value was in providing a precursor of the neurotransmitter serotonin, increasing serotonin level and therefore benefiting depressed patients. These days 5-Hydroxytryptophan may be used in its place (eg. 100mg three times daily), thereby avoiding the use of antidepressant drugs, with their side effects.
1.6.4 Phenylalanine and Tyrosine
Phenylalanine and tyrosine act as precursors to the neurotransmitters, the catecholamines adrenaline and noradrenaline and also dopamine. The provision of extra supplies of these amino acids may therefore increase the supply of the corresponding neurotransmitters and this may be the route for the relief of depression. Phenylalanine also has the ability to yield the amine phenylethylamine that may bestow benefits on its own account. Murray & Pizzorno quote much of the literature evidence for the validity of this treatment approach, using intakes from 75 up to 400mg/day.
1.6.6 St. John’s Wort
Herbal adjuncts to our therapy can play a major role in treating depression. It is valuable, but its action is somewhat drug-like, so its use may have to be long continued unless the depression is relieved by other life factors or by other treatment. It is best seen then, as being like a drug yet with the advantage of freedom from the side effects of the tricyclic antidepressants and monoamine oxidase inhibitors.
1.6.7 Ginkgo biloba
Ginkgo is useful in depression as explained by Murray & Pizzorno pp 398-399. It is inevitable that one consequence of a mild degree of cerebral ischaemia is the reduction of mental activity, contributing towards depression. To alleviate the causes of the ischaemia is likely to result in relief of the depression. This is an instance where a palliative remedy given for one type of pathology (restriction of cerebral blood supply) has a naturopathic-type end result (extra oxygen for the cerebral tissues). The effect is naturopathic in nature because the metabolic capacity and competence of the brain is uplifted. However, that is clearly not the only mechanism and we recommend to your attention the section by Murray & Pizzorno p 398 explaining how Ginkgo can offset an undesirable reduction of serotonin receptor sites in brain tissue.
1.6.8 Kava kava
This herb is listed by Murray & Pizzorno pp 397-398 as possible treatment for depression. Note that its use is best recommended in cases of depression that are accompanied by anxiety.
1.6.9 Cases where the Depression is Manic
An excess of vanadium seems likely to lead towards depression (Werbach, 1991, p139). Some of the evidence has associated manic depression with vanadium rather more closely than depression without mania. In order to reduce the level of vanadium in manic depressive patients it has been suggested to employ a diet without potatoes (which are said to be high in vanadium) and to give a Vitamin C supplement, since this may be effective in releasing body vanadium for excretion. We have little or nothing else available in the way of disease-directed therapy for manic depression. It may be unavoidable that the patients must use drugs at first and then be relieved of them as naturopathic therapy takes effect.
2 ANXIETY STATES
Anxiety is a state of anticipation of something unpleasant about to happen, accompanied by a feeling of inner tension, and somatic manifestations such as tense muscles, sweating, tremor and tachycardia. Although anxiety is a symptom of many psychological disorders, there is a state in which it dominates the picture, and other symptoms are but minor features of the total illness. This is known as anxiety neurosis or anxiety state, and is the most common form of psychoneurosis.
Unsatisfactory hereditary factors are prominent in the genesis of an anxiety neurosis, manifestations of anxiety being frequently found in the parents. This means that the early environment of the patient must also have been inimical to healthy psychological development. The combination of heredity and early environment results in a personality characterised by an anxious, worrying disposition, the person becoming keyed up and tense with the slightest provocation.
The psychological factors that may precipitate the illness are innumerable; they may be acute events such as bereavement, financial reverses or an unhappy love affair, or more chronic troubles such as progressive failure at work or domestic strife. Often, however, no precipitating cause is apparent or it seems so trivial as to be inadequate to account for the reaction of the patient; in a person with an unsatisfactory psychological background even trifling setbacks may give rise to a serious breakdown.
The illness may take many forms. It may be an acute anxiety state, often severe in intensity, appearing against a relatively normal background, or a chronic anxiety state, present since adolescence in mild degree, but subject to periodic exacerbation according to the tide of life’s fortunes.
The outstanding feature of the illness is the anxiety, with its accompanying feeling of inner tension and unpleasant anticipation. Sometimes the anxiety is referred to a potential happening, but often it is a diffuse feeling unrelated to any particular event. It may be aggravated by a specific form of activity such as travelling in a bus or train, and so much may this be dreaded, that the patient is eventually unable to travel at all. The anxiety fluctuates in intensity, being sometimes a mild feeling of tension or nervousness, but at other times a state of panic, in which the patient may rush about in terror to escape from he knows not what.
This state of anxiety gives rise to other symptoms. The ability to concentrate is impaired, and constant fears make decisions difficult. There may be a continuous state of restlessness and excitement of varying degree or extreme irritability. Fear of insanity or of committing suicide commonly afflicts these patients though, in fact, both are extremely rare. The continued stress exhausts them so that they lack energy and perseverance, and feel that they can no longer carry on with their work.
Somatic symptoms are also prominent. There is a general tenseness of the musculature, with hyperactivity, especially of the fingers and hands, shown in such movements as screwing up a handkerchief or constantly intertwining the fingers. A fine tremor of the fingers is present, and profuse perspiration, especially of the palms, is common. The pulse rate is raised, the blood pressure labile and over activity of smooth involuntary muscle is commonly manifest by frequency of micturition or of calls to stool. Breathing is often rapid and feelings of nausea and flatulence occur. Headache of tension type, dizziness and unsteadiness are frequently mentioned. The patient sleeps badly, finding it difficult to get off to sleep, and being easily disturbed. Appetite is poor, and loss of weight may be a pronounced feature. Disturbances of menstruation are common.
The chief diagnostic problem is to distinguish an anxiety state from an organic disorder such as hyperthyroidism, especially when the patient complains mainly of somatic symptoms. Thus in the past, anxiety neurosis with cardiac symptoms was often labelled ‘disorderly action of the heart’ and believed to be of physical origin. Diagnosis is based on eliciting a history of the patient’s previous personality and present psychological symptoms indicative of an anxiety state, and the exclusion of physical disease by means of a thorough physical examination, and appropriate ancillary investigations where indicated.
Differentiation from other forms of psychological illness is less difficult. Though hysterical, obsessive or depressive symptoms may be present in an anxiety state, the diagnosis can usually be made on the totality of the picture, anxiety and its accompanying manifestations dominating the scene. Care must be taken not to overlook a case of depressive psychosis with severe agitation in which the degree of agitation and anxiety may be so marked as to lead to a mistaken diagnosis of anxiety state. A carefully taken history will reveal the underlying severe depression, with feelings of unworthiness, guilt and failure, and frequently delusions.
2.2 Nutritional Treatment of Anxiety States
There is once again very good presentation of this topic in Murray & Pizzorno’s book, pp 252- 259 and also in Werbach (1991). There is wide agreement that the diet and lifestyle calls for an approach that will be effective in minimising lactate formation. Avoidance of alcohol, caffeine beverages, sugar and food allergens are central to that aim. Moreover the patient needs to be protected against any possible deficiency of calcium or magnesium or of the B vitamins nicotinic acid, B6 or thiamine, usually by using supplements. Provision of an ample supply of Omega 3 fatty acids (often supplied as flaxseed oil) is also important. Inositol (without choline) is sometimes used to provide a calming effect. Control of anxiety is also a major area for the application of kava kava and Murray & Pizzorno’s presentation contains a very full account of this herb. Note, as stated above that kava kava, at the time of writing is under suspicion of causing liver damage and most suppliers have withdrawn it.
3.1 General Sources of stress can be emotional, mental or physical. It can, indeed, occur as combinations of these. We are, perhaps most familiar with it as work stress and relationship or family stress – each of which can often come from a combination of these three levels. From getting lost on an Arctic expedition to suffering a divorce or an unwanted pregnancy, stresses are an inevitable part of life. A stress-free life is unimaginable, but the problem becomes major, and therefore pathological when it threatens to overwhelm the individual.
Continuous experience of negative emotions works through the nervous system to overstimulate the adrenal glands. The result is an emergency ‘fight or flight’ response, with pulse rate and blood pressure raised. Driving through competitive traffic, for example, is well known to stimulate the adrenals, without allowing one to complete the process with concomitant physical activity, and this is thought to be internally destructive. The result of such stresses may well be other pathologies listed in this folder, which are stress-related, such as insomnia, fatigue, atherosclerosis, ulcers and asthma.
3.2 Diet and Lifestyle Factors
Murray & Pizzorno’s book once again offers a good presentation on stress management (pp 175-187). Among other things they analyse quite closely the causes of stress. To cope, it is necessary for patients to make life changes to reduce the stresses, or else adapt to the things that they cannot change to make them acceptable. There is ultimately no other way. Exercise and a varied, well-balanced whole food diet are supportive in unavoidable stressful situations. Watch out for negative emotions spoiling the appetite. Note the dietary recommendations offered by Murray & Pizzorno, ie avoidance of caffeine and alcohol, elimination of refined carbohydrate, increase of potassium intake relative to sodium, taking regular planned meals and avoidance of food allergens. These may seem like rather basic, non-specific recommendations but there is little doubt that they all relate to actions that can avoid unsettling one’s psyche. It is also necessary to avoid exposure to cigarette smoke and pollutants generally.
3.3 Indicated Supplements
The following supplements have been implicated in helping with stress management:-
- Trace element formula, especially for Zinc
- Vitamin B complex, especially B6 and pantothenic acid
- Vitamin C
- Panax ginseng
- Herbal formulae containing valerian (calming)
- Eleutherococcus senticosus
- Murray & Pizzorno, ‘Encyclopaedia of Natural Medicine’, Prima Publishing (1998)
- Werbach, M.R., ‘Nutritional Influences on Mental Illness’, Third Line Press, California (1991)