Adjuvant use of nutritional and herbal medicines with antidepressants, mood stabilizers and benzodiazepines

Herb-drug interactions: A short review on central and peripheral nervous system drugs

Herbal medicines are widely perceived as natural and safe remedies. However, their concomitant use with prescribed drugs is a common practice, often undertaken without full awareness of the potential risks and frequently without medical supervision. This practice introduces a tangible risk of herb-drug interactions, which can manifest as a spectrum of consequences, ranging from acute, self-limited reactions to unpredictable and potentially lethal scenarios. This review offers a comprehensive overview of herb-drug interactions, with a specific focus on medications targeting the Central and Peripheral Nervous Systems. Our work draws upon a broad range of evidence, encompassing preclinical data, animal studies, and clinical case reports. We delve into the intricate pharmacodynamics and pharmacokinetics underpinning each interaction, elucidating the mechanisms through which these interactions occur. One pressing issue that emerges from this analysis is the need for updated guidelines and sustained pharmacovigilance efforts. The topic of herb-drug interactions often escapes the attention of both consumers and healthcare professionals. To ensure patient safety and informed decision-making, it is imperative that we address this knowledge gap and establish a framework for continued monitoring and education. In conclusion, the use of herbal remedies alongside conventional medications is a practice replete with potential hazards. This review not only underscores the real and significant risks associated with herb-drug interactions but also underscores the necessity for greater awareness, research, and vigilant oversight in this often-overlooked domain of healthcare.

Psychological aspects of rehabilitation nutrition: A position paper by the Japanese Association of Rehabilitation Nutrition (secondary publication)

Psychological aspects of rehabilitation nutrition affect physical, cognitive, and social rehabilitation nutrition. When depression is recognized, not only pharmacotherapy and psychotherapy, but also non-pharmacological therapies such as exercise, nutrition, psychosocial, and other interventions can be expected to improve depression. Therefore, accurate diagnosis and intervention without overlooking depression is important. Psychological aspects of preventive rehabilitation nutrition is also important because depression can be partially prevented by appropriate exercise and nutritional management. Even in the absence of psychological negatives, increasing more psychological positives from a positive psychology perspective can be useful for both patients and healthcare professionals. Positive rehabilitation nutrition interventions can increase more psychological positives, such as well-being, through cognitive-behavioral therapy and mindfulness on their own, as well as through interventions on environmental factors. Consequently, physical, cognitive, and social positives are also expected to be enhanced.

Antidepressant-like effect of Campomanesia xanthocarpa seeds in mice: Involvement of the monoaminergic system

Background and aim

Campomanesia xanthocarpa Berg. (Myrtaceae) present several pharmacological actions, but there are no reports on its antidepressant-like potential. This study investigated the antidepressant-like effect and mechanism of action of Campomanesia xanthocarpa seeds extract obtained from supercritical CO₂ (40 °C, 250 bar).

Experimental procedure

Mice were orally treated with the extract 1 h before the TST. To investigate the involvement of the monoaminergic system in the antidepressant-like activity of the extract, pharmacological antagonists were administered prior to the acute oral administration of the extract (60 mg/kg). Also, the interaction of the extract with antidepressants was assessed in the tail suspension test (TST). The in vitro inhibitory potential of C. xanthocarpa seeds extract towards MAO A and MAO B enzymes was tested in vitro.

Results and conclusion

Animals treated with Campomanesia xanthocarpa seeds extract showed a significant reduction in the immobility time in the TST. Mice pretreatment with SCH23390, sulpiride, prazosin, yohimbine, and p-chlorophenylalanine prevented the anti-immobility effect of the extract in the TST. The combined administration of sub-effective doses of the extract with imipramine, bupropion and fluoxetine significantly reduced mice immobility time in the TST. The extract showed MAO A inhibitory activity (IC₅₀ = 151.10 ± 5.75 μg/mL), which was greater than that toward MAO B (IC₅₀ > 400 μg/mL).

The extract of Campomanesia xanthocarpa seeds obtained by supercritical CO₂ shows antidepressant-like activity, which relies on the activation of the monoaminergic neurotransmission (serotoninergic, dopaminergic and noradrenergic), suggesting that this species might represent a resource for developing new antidepressants.

•

C. xanthocarpa show antidepressant-like effect in mice tail suspension test.

•

C. xanthocarpa potentiates the effect of antidepressants in tail suspension test.

•

C. xanthocarpa mode of action involves the monoaminergic system.

A double-blind, randomized pilot study for comparison of Melissa officinalis L. and Lavandula angustifolia Mill. with Fluoxetine for the treatment of depression

Background

Depression has rapidly progressed worldwide, and the need for an efficient treatment with low side effect has risen. Melissa officinalis L and Lavandula angustifolia Mill have been traditionally used in Asia for the treatment of depression. Many textbooks of traditional Persian medicine refer to these herbs for the treatment of depression while there are no adequate clinical trials to support this claim.

The present study aimed to evaluate the efficacy of M. officinalis and L. angustifolia compared to fluoxetine for the treatment of mild to moderate depression in an 8-week randomized, double-blind clinical trial.

Methods

Forty-five adult outpatients who met the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) for major depression, were randomly assigned to 3 groups to daily receive either M. officinalis (2 g) or L. angustifolia (2 g) or fluoxetine (20 mg) and were assessed in weeks 0, 2, 4 and 8 by the Hamilton Rating Scale for Depression (HAM-D) including 17 items.

Results

Our study showed that M. officinalis and L. angustifolia effect similar to fluoxetine in mild to moderate depression. (F = 0.131, df = 2,42, p = 0.877).

Conclusion

Due to some restrictions in this study including absence of placebo group, large-scale trials are needed to investigate the anti-depressant effect of these two herbs with more details.

Trial registration

IRCT2014061718126N1. Registration date: 2015-06-04-“Retrospectively registered”.

Polyunsaturated Fatty Acids: What is Their Role in Treatment of Psychiatric Disorders?

In the central nervous system omega-3 fatty acids modulate cell signaling and affect dopaminergic and serotonergic pathways. On this basis, a new application for omega-3 fatty acids has been proposed, concerning the treatment of several psychiatric disorders. The present article is an update of a previous systematic review and is aimed to provide a complete report of data published in the period between 1980 and 2019 on efficacy and tolerability of omega-3 fatty acids in psychiatric disorders. In July 2019, an electronic search on PUBMED, Medline and PsychINFO of all RCTs, systematic reviews and meta-analyses on omega-3 fatty acids and psychiatric disorders without any filter or MESH restriction was performed. After eligibility processes, the final number of records included in this review was 126. One hundred and two of these studies were RCTs, while 24 were reviews and meta-analyses. The role of omega-3 fatty acids was studied in schizophrenia, major depression, bipolar disorder, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, eating disorders, substance use disorder and borderline personality disorder. The main evidence of the efficacy of omega-3 fatty acids has been obtained in treating depressive symptoms in patients with major depression and, to a lesser degree, bipolar depression. Some efficacy was also found in early phases of schizophrenia in addition to antipsychotic treatment, but not in the chronic phases of psychosis. Small beneficial effects of omega-3 fatty acids were observed in ADHD and positive results were reported in a few trials on core symptoms of borderline personality disorder. For other psychiatric disorders results are inconsistent.

Nutrient and genetic biomarkers of nutraceutical treatment response in mood and psychotic disorders: a systematic review

Objective: Nutrient and genetic biomarkers in nutraceutical trials may allow for the personalisation of nutraceutical treatment and assist in predicting treatment response. We aimed to synthesise the findings of trials which have included these biomarkers to determine which may be most useful for predicting nutraceutical response in mood and psychotic disorders.Methods: A systematic review was conducted assessing available literature concerning nutraceutical clinical trials in mood and psychotic disorders (major depression, bipolar disorder, schizophrenia) with baseline and endpoint blood nutrient markers or genetic data available.Results: We identified 35 eligible studies (total n = 3836 participants) examining baseline and endpoint nutrient biomarkers and/or genetic polymorphisms. The key result, as reported in 10 out of 11 omega-3 studies, was a strong association between polyunsaturated fatty acid concentrations (mostly EPA and DHA) and psychiatric outcomes, although the exact nature of the association varied between studies and diagnoses. There was no consistent evidence for levels of other nutrients (including Vitamin D, SAM/SAH ratios, carnitine, folate and vitamin B12) relating to treatment response. The evidence for associations between one-carbon cycle genotypes (e.g. MTHFR C677 T, MTR and FOLH1) and treatment response was also inconsistent.Discussion: The available data tentatively supports omega-3 indices as biomarkers of response to omega-3 treatments in mood disorders. Further research with larger samples examining combinations of polymorphisms is required to determine if any genetic factors influence nutraceutical response in mood and psychotic disorders.

L-theanine in the adjunctive treatment of generalized anxiety disorder: A double-blind, randomised, placebo-controlled trial

Partial or non-response to antidepressants in Generalized Anxiety Disorder (GAD) is common in clinical settings, and adjunctive biological interventions may be required. Adjunctive herbal and nutraceutical treatments are a novel and promising treatment option. L-theanine is a non-protein amino acid derived most-commonly from tea (Camellia sinensis) leaves, which may be beneficial in the treatment of anxiety and sleep disturbance as suggested by preliminary evidence. We conducted a 10-week study (consisting of an 8-week double-blind placebo-controlled period, and 1-week pre-study and 2-week post-study single-blinded observational periods) involving 46 participants with a DSM-5 diagnosis of GAD. Participants received adjunctive L-theanine (450-900 mg) or matching placebo with their current stable antidepressant treatment, and were assessed on anxiety, sleep quality, and cognition outcomes. Results revealed that adjunctive L-theanine did not outperform placebo for anxiety reduction on the HAMA (p = 0.73) nor insomnia severity on the Insomnia Severity Index (ISI; p = 0.35). However, LT treated participants reported greater self-reported sleep satisfaction than placebo (ISI item 4; p = 0.015). Further, a separation in favour of L-theanine was noted on the ISI in those with non-clinical levels of insomnia symptoms (ISI ≤ 14; p = 0.007). No significant cognitive effects (trail making time and the modified emotional Stroop) were revealed. While this preliminary study did not support the efficacy of L-theanine in the treatment of anxiety symptoms in GAD, further studies to explore the application of L-theanine in sleep disturbance are warranted.

The Use of Larval Zebrafish (Danio rerio) Model for Identifying New Anxiolytic Drugs from Herbal Medicine

Anxiety is a widespread psychiatric disorder. The search for a cure is still continuing since many of the synthetic drugs were inefficient in completely treating anxiety, yet caused some dangerous side effects until many of the drugs were withdrawn from the market. One promising source of new anxiolytics could be herbal medicines. The challenge is to screen plant extracts. Rodent models can be used for this purpose but are expensive. Moreover, rodent tests are costly and consume relatively large quantities of sample. For this reason, alternative animal models may be useful. Zebrafish larvae have many advantages for screening natural products. The main advantage is that they can be produced cheaply and in large numbers. Several studies have shown that the zebrafish is a good model for studying drugs that affect anxiety. This review focuses on the use of animal models, including zebrafish larvae, for studying anxiety and screening for herbal medicines that modulate anxiety. Finally, future prospects of the zebrafish larva as an alternative model in this field are also discussed.

Complementary Therapies for Mental Health Disorders

Approximately 18% of the US adult population has a mental illness, yet only 13% with mental illness receive any treatment. Although pharmacotherapy and psychotherapy are the mainstays of treatment, treatment discontinuation and failure are common. Skepticism toward such treatments has fueled interest in and use of complementary therapies, such as acupuncture, meditation, and natural products. Many medical providers are unaware of the use of these therapies by their patients, and knowledge of the evidence base for these therapies is often lacking. This article presents current evidence-based recommendations for complementary therapies in the treatment of depression, anxiety, and posttraumatic stress disorder.

Emulsified omega-3 fatty-acids modulate the symptoms of depressive disorder in children and adolescents: a pilot study

BACKGROUND

The prevalence of mood disorders in children is a growing global concern. Omega-3 fatty acids (FA) are emerging as a promising adjuvant therapy for depressive disorder (DD) in paediatric patients. The primary objective of this pilot, single-centre, randomized, double-blind controlled study was to compare the efficacy of an Omega-3 FA fish oil emulsion with a control oil emulsion alongside standard treatment for depressive symptoms in children and adolescents suffering from depressive disorder (DD) and mixed anxiety depressive disorder (MADD).

METHODS

38 children (12 patients were treated and diagnosed for at least 1 month before enrolment, 26 patients were first-time diagnosed as DD) aged 11-17 years were randomised 1:1 to the intervention (Omega-3 FA, 19 patients) or active comparator (Omega-6 FA, 19 patients) groups. Children's depression inventory (CDI) ratings were performed at baseline, every 2 weeks for a 12-week intervention period and at 4-week post-intervention. 35 patients (17 in Omega-3 and 18 in Omega-6 groups) who completed the whole intervention period were evaluated. Patients from Omega-3 group were stratified according to diagnosis into two subgroups (DD-10/17 and mixed anxiety depressive disorder (MADD)-7/17 patients) and in the Omega-6 group into DD-10/18 and MADD-8/18 patients. Groups were evaluated separately. Differences between-groups were tested with the Student´s t test or non-parametric Mann-Whitney U test. Two-way ANOVA with repeated measures and Friedman test were used to analyse the Treatment effect for response in CDI score. p < 0.05 was considered significant in all statistical analyses.

RESULTS

Significant reductions in CDI scores in 35 analysed patients who completed 12 weeks intervention were observed after 12 weeks of intervention only in the Omega-3 group (p = 0.034). After stratification to depressive disorder and mixed anxiety depressive disorder subgroups, the DD subgroup receiving the Omega-3 FA fish oil showed statistically greater improvement (score reduction after 8 week treatment of -9.1 CDI, p = 0.0001) when compared to the MADD subgroup (score reduction after 8 week treatment -4.24 CDI, p = 0.271).

CONCLUSIONS

CDI scores were reduced in the Omega-3 group and the depression subgroup had greater improvement than the mixed depressive/anxiety group. An Omega-3 fatty acid rich fish oil emulsion may be an effective adjuvant supplement during the treatment of depressive disorders in children. Trial registration ISRCTN81655012.

Herbal Medicines: challenges in the modern world. Part 5. status and current directions of complementary and alternative herbal medicine worldwide

INTRODUCTION

Herbal medicine (HM) use is growing worldwide. Single herb preparations, ethnic and modern HM formulations are widely used as adjunct therapies or to improve consumer wellbeing. Areas covered: This final part in the publication series summarizes common tendencies in HM use as adjunct or alternative medicine, education of healthcare professionals and consumers, current and proposed guidelines regulating of production. We discuss potential HM-HM and HM-drug interactions that could lead to severe adverse events in situations where HMs are taken without proper medical professional oversight. Expert commentary: A number of serious problems have arisen with the steady global increase in HM use. HM interaction with conventional drugs (CD) may result in inadequate dosing of CD or adverse reactions; HM-HM interaction within herbal supplements could lead to toxicity of formulations. Inadequate education of clinicians and patients regarding medicinal properties of HMs must be addressed regionally and globally to ensure consumer safety.

S-adenosyl methionine (SAMe) for depression in adults

BACKGROUND

Depression is a recurrent illness with high rates of chronicity, treatment-resistance and significant economic impact. There is evidence in the literature that S-adenosyl methionine (SAMe), a naturally occurring compound in the human body, has antidepressant efficacy. This product may be an important addition to the armamentarium of antidepressant agents.

OBJECTIVES

To assess the effects of SAMe in comparison with placebo or antidepressants for the treatment of depression in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR Studies and Reference Register), MEDLINE, EMBASE, PsycINFO, international trial registers ClinicalTrials.gov and the World Health Organization trials portal (ICTRP). We checked reference lists, performed handsearching and contacted experts in the field. The CCMDCTR literature search was last updated on 5 February 2016.

SELECTION CRITERIA

Randomised controlled trials comparing SAMe with placebo or antidepressants in adults with a diagnosis of major depression.

DATA COLLECTION AND ANALYSIS

Two authors independently performed extraction of data and assessment of risk of bias. We contacted trialists of included studies for additional information.

MAIN RESULTS

This systematic review included eight trials comparing SAMe with either placebo, imipramine, desipramine or escitalopram. We accepted trials that used SAMe as monotherapy or as add-on therapy to selective serotonin reuptake inhibitors (SSRIs), and we accepted both oral and parenteral administration. The review involved 934 adults, of both sexes, from inpatient and outpatient settings.The trials were at low risk of reporting bias. We judged the risk of selection, performance, detection and attrition bias as unclear or low, and one study was at high risk of attrition bias.There was no strong evidence of a difference in terms of change in depressive symptoms from baseline to end of treatment between SAMe and placebo as monotherapy (standardised mean difference (SMD) -0.54, 95% confidence interval (CI) -1.54 to 0.46; P = 0.29; 142 participants; 2 studies; very low quality evidence). There was also no strong evidence of a difference in terms of drop-out rates due to any reason between SAMe and placebo, when used as monotherapy (risk ratio (RR) 0.88, 95% CI 0.61 to 1.29; P = 0.52; 142 participants; 2 studies; low quality evidence).Low quality evidence showed that the change in depressive symptoms from baseline to end of treatment was similar between SAMe and imipramine, both as monotherapy (SMD -0.04, 95% CI -0.34 to 0.27; P = 0.82; 619 participants; 4 studies). There was also no strong evidence of a difference between SAMe and a tricyclic antidepressant in terms of drop-outs due to any reason (RR 0.61, 95% CI 0.28 to 1.31; P = 0.2; 78 participants; 3 studies; very low quality evidence).There was little evidence of a difference in terms of change in depressive symptoms from baseline to end of treatment between SAMe and escitalopram, both as monotherapy (MD 0.12, 95% CI -2.75 to 2.99; P = 0.93; 129 participants; 1 study; low quality evidence). There was no strong evidence of a difference between SAMe and escitalopram in terms of drop-outs due to any reason (RR 0.81, 95% CI 0.57 to 1.16; P = 0.26; 129 participants; 1 study; low quality evidence).There was low quality evidence that SAMe is superior to placebo as add-on to SSRIs in terms of change in depressive symptoms from baseline to end of treatment (MD -3.90, 95% CI -6.93 to -0.87; P = 0.01; 73 participants; 1 study). There was no strong evidence of a difference between SAMe and placebo as adjunctive therapy to an SSRI in terms of drop-outs due to any reason (RR 0.70, 95% CI 0.31 to 1.56; P = 0.38; 73 participants; 1 study; very low quality evidence).For all comparisons, secondary outcome measures of response and remission rates were consistent with these primary outcome measures.With regard to all extractable measures of the acceptability of SAMe, the quality of the evidence was low to very low. SAMe was not different from placebo and established antidepressants. The exception was that compared to imipramine, fewer participants experienced troublesome adverse effects when treated with parenteral SAMe.The specific adverse effects were not detailed in most of the included studies. There were two reports of mania/hypomania recorded for 441 participants in the SAMe arm.

AUTHORS' CONCLUSIONS

Given the absence of high quality evidence and the inability to draw firm conclusions based on that evidence, the use of SAMe for the treatment of depression in adults should be investigated further. Future trials should be in the form of large randomised controlled clinical trials of high methodological quality, with particular attention given to randomisation, allocation concealment, blinding and the handling of missing data. Comparator antidepressants from all classes should be used. Adverse events should be detailed for each participant, bearing in mind that induction of mania is of particular interest.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 5. Complementary and Alternative Medicine Treatments

BACKGROUND

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals.

METHODS

Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Complementary and Alternative Medicine Treatments" is the fifth of six sections of the 2016 guidelines.

RESULTS

Evidence-informed responses were developed for 12 questions for 2 broad categories of complementary and alternative medicine (CAM) interventions: 1) physical and meditative treatments (light therapy, sleep deprivation, exercise, yoga, and acupuncture) and 2) natural health products (St. John's wort, omega-3 fatty acids; S-adenosyl-L-methionine [SAM-e], dehydroepiandrosterone, folate, Crocus sativus, and others). Recommendations were based on available data on efficacy, tolerability, and safety.

CONCLUSIONS

For MDD of mild to moderate severity, exercise, light therapy, St. John's wort, omega-3 fatty acids, SAM-e, and yoga are recommended as first- or second-line treatments. Adjunctive exercise and adjunctive St. John's wort are second-line recommendations for moderate to severe MDD. Other physical treatments and natural health products have less evidence but may be considered as third-line treatments. CAM treatments are generally well tolerated. Caveats include methodological limitations of studies and paucity of data on long-term outcomes and drug interactions.

Synergistic interaction between diene valepotriates from V aleriana glechomifolia Meyer (Valerianaceae) and classical antidepressants: an isobolographic analysis

Objectives

Combinations of different classes of antidepressants (including herbal adjuvants) have been used as an alternative means of achieving better results in the treatment of depressed patients. However, studies characterizing the interactions between herbal adjuvants and antidepressants are lacking. This study is the first to investigate the interaction between diene valepotriates (VAL) from Valeriana glechomifolia, a species with antidepressant-like effects, and imipramine (IMI), desipramine (DESI) and bupropion (BUP). The interactions were assessed via isobolographic analyses, which represent a tool for evaluating interactions between drugs.

Methods

The interaction between VAL and each antidepressant was evaluated in mice given concurrent oral administration of each drug with fixed ED50 ratios and subjected to a forced swimming test (FST). Spontaneous locomotion was measured in the open field test.

Key findings

The drug combinations produced a dose-dependent anti-immobility effect in the FST without altering mouse locomotor activity. Isobolographic analysis revealed that VAL resulted in synergistic interactions in combination with each of the antidepressants tested.

Conclusion

The synergistic interactions between VAL and IMI, DESI and BUP highlight the potential for VAL to serve as adjuvants to antidepressant drugs and suggest that VAL does not directly target the same sites on neuronal transporters as the antidepressants.

Efficacy of Jollab in the Treatment of Depression in Dyspeptic Patients

The current study aimed to evaluate the efficacy of jollab, a well-known beverage from traditional Persian medicine in the treatment of depression among patients suffering from functional dyspepsia. In a randomized, double-blind, placebo-controlled trial, a pair of 80 patients were enrolled in 2 parallel groups as Jollab and placebo. The Beck Depression Inventory–II questionnaire was used for the assessment. At all, 133 patients enrolling in the treatment and placebo groups ended the protocol. According to the outcomes, changes in scores between the 2 groups were statistically significant at the end of trial ( P ≤ .001). Taken as a whole, treatment group was significantly more effective than the placebo. Focusing on nutritional and pharmaceutical properties, jollab may be introduced not only as a medication for depression and allied ailment but also a pleasant daily drink.

Behavioural screening of zebrafish using neuroactive traditional Chinese medicine prescriptions and biological targets

The mechanism of the therapeutic action of antidepressants remains uncertain in traditional Chinese medicine (TCM). In this study, we selected 7 classical TCM prescriptions and utilised an automatic video-tracking system to monitor the rest/wake behaviour of larval zebrafish at 4 days post-fertilisation (dpf) for 48 hours. We found that the curative effects of the prescriptions were dose-dependent. K-means clustering was performed according to the shared behavioural phenotypes of the zebrafish. The results revealed that the rest/wake behavioural profiles induced by the same class of prescriptions were similar. A correlation analysis was conducted between the TCM prescriptions and the known compounds. The results showed that the TCM prescriptions correlated well with some well-known compounds. Therefore, we predicted that they may share a similar mechanism of action. This paper describes the first study to combine TCM research with zebrafish rest/wake behaviour in vivo and presents a powerful approach for the discovery of the mechanism of action of TCM prescriptions.

A randomized double-blind comparison of fluoxetine augmentation by high and low dosage folic acid in patients with depressive episodes

BACKGROUND

Though encouraging evidence exists for the use of folic acid as an augmenting agent to antidepressants, evidence regarding its optimal dosage is lacking.

METHODS

Forty-two female out-patients with moderate (with or without somatic syndrome) or severe depressive episodes (without psychotic symptoms) diagnosed as per ICD-10 criteria, were randomized in a double-blind fashion to receive either 20 mg fluoxetine and a relatively low dose folic acid (1.5 mg/day; n=23; Group I) or 20 mg fluoxetine and high dose folic acid (5 mg/day; n=19; Group II). Primary outcome measures were weekly changes of scores on Hamilton Depression Rating Scale (HDRS) and Beck Depression Inventory (BDI) for 6 weeks.

RESULTS

Group II patients showed greater improvement in both HDRS [Mean (SD) baseline HDRS score=21 (2.3) for group I and 20.0 (1.4) for group-II; time X group interaction effect: p=0.01] and BDI [Mean (SD) baseline BDI score=25.1 (5.2) for group-1 and 23.1 (2.7) for group-II; time X group interaction effect: p=0.01]. With regard to HDRS, 7 (36.8%) group II patients remitted compared to 2 (8.7%) group I patients (p=0.03); 9 (47.4%) patients of group II responded when compared to 6 (26.1%) from group I (p=0.15). When BDI was considered, 5 (26.3%) group II patients remitted when compared to 2 (8.7%) from group I (p=0.13); 10 patients (52.6%) from group II responded when compared to 5 (21.7%) from group I (p=0.04). No adverse effects were noted in either group.

LIMITATIONS

Lack of a placebo arm and small sample size.

CONCLUSION

Compared to folic acid 1.5 mg/day, augmentation with 5 mg/day may be more beneficial in female patients with depressive episodes taking fluoxetine 20 mg/day.

Nutrient- and non-nutrient-based natural health product (NHP) use in adults with mood disorders: prevalence, characteristics and potential for exposure to adverse events

BACKGROUND

To address knowledge gaps regarding natural health product (NHP) usage in mental health populations, we examined their use in adults with mood disorders, and explored the potential for adverse events.

METHODS

Food and NHP intake was obtained from 97 adults with mood disorders. NHP data was used to compare prevalence with population norms (British Columbia Nutrition Survey; BCNS). Bivariate and regression analyses examined factors associated with NHP use. Assessment of potential adverse effects of NHP use was based on comparing nutrient intakes from food plus supplements with the Dietary Reference Intakes and by reviewing databases for reported adverse health effects.

RESULTS

Two-thirds (66%; 95% CI 56 to 75) were taking at least one NHP; 58% (95% CI 47 to 68) were taking NHPs in combination with psychiatric medications. The proportion of each type of NHP used was generally higher than the BCNS (range of p's < 0.05 to 0.0001). When intakes from food and NHP sources were combined, a small proportion exceeded any Lowest-Observed-Adverse-Effect-Levels: only for niacin (n = 17) and magnesium (n = 6), two nutrients for which the potential for adverse effects is minimal. Conversely, about 38% (95% CI 28 to 49) of the sample were taking a non-nutrient based NHP for which previous adverse events had been documented.

CONCLUSIONS

The prevalent use of NHPs in this population suggests that health care providers need to be knowledgeable about their characteristics. The efficacy and safety of NHPs in relation to mental health warrants further investigation.

Mood disorders and complementary and alternative medicine: a literature review

Mood disorders are a major public health problem and are associated with considerable burden of disease, suicides, physical comorbidities, high economic costs, and poor quality of life. Approximately 30%-40% of patients with major depression have only a partial response to available pharmacological and psychotherapeutic interventions. Complementary and alternative medicine (CAM) has been used either alone or in combination with conventional therapies in patients with mood disorders. This review of the literature examines evidence-based data on the use of CAM in mood disorders. A search of the PubMed, Medline, Google Scholar, and Quertile databases using keywords was conducted, and relevant articles published in the English language in the peer-reviewed journals over the past two decades were retrieved. Evidence-based data suggest that light therapy, St John's wort, Rhodiola rosea, omega-3 fatty acids, yoga, acupuncture, mindfulness therapies, exercise, sleep deprivation, and S-adenosylmethionine are effective in the treatment of mood disorders. Clinical trials of vitamin B complex, vitamin D, and methylfolate found that, while these were useful in physical illness, results were equivocal in patients with mood disorders. Studies support the adjunctive role of omega-3 fatty acids, eicosapentaenoic acid, and docosahexaenoic acid in unipolar and bipolar depression, although manic symptoms are not affected and higher doses are required in patients with resistant bipolar depression and rapid cycling. Omega-3 fatty acids are useful in pregnant women with major depression, and have no adverse effects on the fetus. Choline, inositol, 5-hydroxy-L-tryptophan, and N-acetylcysteine are effective adjuncts in bipolar patients. Dehydroepiandrosterone is effective both in bipolar depression and depression in the setting of comorbid physical disease, although doses should be titrated to avoid adverse effects. Ayurvedic and homeopathic therapies have the potential to improve symptoms of depression, although larger controlled trials are needed. Mind-body-spirit and integrative medicine approaches can be used effectively in mild to moderate depression and in treatment-resistant depression. Currently, although CAM therapies are not the primary treatment of mood disorders, level 1 evidence could emerge in the future showing that such treatments are effective.

Vitamin and mineral intakes in adults with mood disorders: comparisons to nutrition standards and associations with sociodemographic and clinical variables

OBJECTIVE

The purpose of this study was to investigate the nutrient intakes of people with mood disorders.

METHOD

A cross-sectional survey using 3-day food records was carried out in 97 adults with bipolar or major depressive disorder to compare nutrient intakes with Dietary Reference Intakes and British Columbia Nutrition Survey (BCNS) data. Blood levels of selected nutrients were compared to reference ranges. Bivariate and multivariate analyses examined the effects of sociodemographic and clinical variables on nutrient intakes.

RESULTS

The average age of respondents was 46 (±13) years; most were women (n = 69) who had less than a university degree (n = 60) and whose incomes were in the government-defined lower range (n = 39). Compared with the BCNS, a larger proportion of the sample was below the estimated average requirement for thiamin (26% vs 8%), riboflavin (21% vs 4%), folate (64% vs 27%), phosphorous (12% vs 1%), and zinc (39% vs 15%; all P < 0.0001), as well as vitamin B(6) (25% vs 16%) and vitamin B(12) (27% vs 8%; both P < 0.05). Combined intakes of food and supplements helped reduce the prevalence of inadequacy; however, with supplementation, the proportion of participants exceeding the tolerable upper intake levels for niacin, vitamin B(6), folate, vitamin C, calcium, magnesium, iron, and zinc ranged from 1%-8%. Income, relationship status, age, gender, and caloric intake were associated with intakes of many nutrients. Types of medications were associated with nutrient intakes, as lower intakes of thiamin and phosphorous (P < 0.05) were found with antidepressant use, higher calcium and iron intakes (P < 0.05) were associated with antianxiety medication use, and magnesium intakes were increased with mood stabilizers (regression coefficient = 52.61, P < 0.05, 95% confidence interval = 0.74 to 104.48).

CONCLUSIONS

Adults with mood disorders are at risk for many nutrient inadequacies, as well as occasional excesses; social, demographic, and clinical factors may affect their nutrient intakes.

Integrative Mental Health (IMH): paradigm, research, and clinical practice

This paper provides an overview of the rapidly evolving paradigm of "Integrative Mental Health (IMH)." The paradigm of contemporary biomedical psychiatry and its contrast to non-allopathic systems of medicine is initially reviewed, followed by an exploration of the emerging paradigm of IMH, which aims to reconcile the bio-psycho-socio-spiritual model with evidence-based methods from traditional healing practices. IMH is rapidly transforming conventional understandings of mental illness and has significant positive implications for the day-to-day practice of mental health care. IMH incorporates mainstream interventions such as pharmacologic treatments, psychotherapy, and psychosocial interventions, as well as alternative therapies such as acupuncture, herbal and nutritional medicine, dietary modification, meditation, etc. Two recent international conferences in Europe and the United States show that interest in integrative mental health care is growing rapidly. In response, the International Network of Integrative Mental Health (INIMH: www.INIMH.org) was established in 2010 with the objective of creating an international network of clinicians, researchers, and public health advocates to advance a global agenda for research, education, and clinical practice of evidence-based integrative mental health care. The paper concludes with a discussion of emerging opportunities for research in IMH, and an exploration of potential clinical applications of integrative mental health care.

Complementary medicine, self-help, and lifestyle interventions for obsessive compulsive disorder (OCD) and the OCD spectrum: a systematic review

BACKGROUND

In Obsessive Compulsive Disorder (OCD) current standard pharmacotherapies may be of limited efficacy. Non-conventional interventions such as Complementary and Alternative Medicine (CAM), self-help techniques, and lifestyle interventions are commonly used by sufferers of OCD, however to date no systematic review of this specific area exists.

METHODS

We conducted a systematic review of studies using CAM, self-help, and lifestyle interventions for treatment of OCD and trichotillomania (TTM). PubMed, PsycINFO, China Academic Journals Full-text Database, The Cochrane Library and CINAHL were searched (up to Jan 11th 2011), for controlled clinical trials using non-conventional interventions for OCD. A quality analysis using a purpose-designed scale and an estimation of effect sizes (Cohen's d) where data was available, were also calculated.

RESULTS

The literature search revealed 14 studies that met inclusion criteria. Methodological quality of nutraceutical studies (nutrients and herbal medicines) were rated as high (mean 8.6/10), whereas mind-body or self-help studies were poorer (mean 6.1/10). In OCD, tentative evidentiary support from methodologically weak studies was found for mindfulness meditation (d=0.63), electroacupuncture (d=1.16), and kundalini yoga (d=1.61). Better designed studies using the nutrient glycine (d=1.10), and traditional herbal medicines milk thistle (insufficient data for calculating d) and borage (d=1.67) also revealed positive results. A rigorous study showed that N-acetylcysteine (d=1.31) was effective in TTM, while self-help technique "movement decoupling" also demonstrated efficacy (d=0.94). Mixed evidence was found for myo-inositol (mean d=0.98). Controlled studies suggest that St John's wort, EPA, and meridian-tapping are ineffective in treating OCD.

CONCLUSIONS

While several studies were positive, these were un-replicated and commonly used small samples. This precludes firm confidence in the strength of clinical effect. Preliminary evidence however is encouraging, and more rigorous research of some of the more hypothesis-based interventions in the treatment of OCD and TTM may be indicated.

Nutrient intakes are correlated with overall psychiatric functioning in adults with mood disorders

OBJECTIVE

To evaluate the relation between nutrient intake and psychiatric functioning in adults with confirmed mood disorders.

METHOD

A cross-sectional study was conducted of the intake of major (that is, carbohydrates, fat, and protein) and minor (that is, vitamins and minerals) nutrients (from 3-day food records and a Food Frequency Questionnaire), Global Assessment of Functioning (GAF) scores, and symptoms of depression and mania (the Hamilton Depression Rating Scale and the Young Mania Rating Scale) in 97 community-based adults with mood disorders whose diagnoses were confirmed with structured interviews.

RESULTS

Significant correlations were found between GAF scores and energy (kilocalories), carbohydrates, fibre, total fat, linoleic acid, riboflavin, niacin, folate, vitamin B6, vitamin B12, pantothenic acid, calcium, phosphorus, potassium, and iron (all P values < 0.05), as well as magnesium (r = 0.41, P < 0.001) and zinc (r = 0.35, P < 0.001). Though modest in magnitude, the pattern of correlations was consistent, indicating higher levels of mental function associated with a higher intake of nutrients. Depression and mania scores, which were generally mild or moderate, did not individually show consistent patterns. When dietary supplement use was added to nutrient intakes from food, GAF scores remained positively correlated (P < 0.05) with all dietary minerals.

CONCLUSION

This detailed analysis in a clinically diagnosed sample was consistent with prior epidemiologic surveys, revealing an association between higher levels of nutrient intakes and better mental health. Nutrient intakes warrant further consideration in the treatment of people with mood disorders.

Antidepressant-like effect of Valeriana glechomifolia Meyer (Valerianaceae) in mice

The antidepressant-like effect of a supercritical CO2 (SCCO2) Valeriana glechomifolia extract enriched in valepotriates was investigated in a mice tail suspension test (TST) and forced swimming test (FST). The SCCO2 extract decreased mice immobility in the FST (0.5-20 mg/kg p.o.) and elicited a biphasic dose-response relationship in the TST (1-20 mg/kg p.o.) with no alterations in locomotor activity and motor coordination (assessed in the open-field and rota-rod tests, respectively). The anti-immobility effect of the SCCO2 extract (5 mg/kg, p.o.) was prevented by mice pre-treatment with yohimbine (1 mg/kg, i.p., an α2 adrenoceptor antagonist), SCH 23390 (15 μg/kg, s.c., D1 dopamine receptor antagonist) and sulpiride (50 mg/kg, i.p., D2 dopamine receptor antagonist). However, mice pre-treatments with prazosin (1 mg/kg, i.p., α1 adrenoceptor antagonist) and p-chlorophenilalanine methyl ester (4×100 mg/kg/day, i.p., a serotonin synthesis inhibitor) were not able to block the anti-immobility effect of the SCCO2 extract. Administration (p.o.) of the SCCO2 extract (0.25 mg/kg) and imipramine (10 mg/kg), desipramine (5 mg/kg) and bupropion (3 mg/kg) at sub-effective doses significantly reduced mice immobility time in the FST. These data provide the first evidence of the antidepressant-like activity of V. glechomifolia valepotriates, which is due to an interaction with dopaminergic and noradrenergic neurotransmission.

Herbal medicine for depression, anxiety and insomnia: a review of psychopharmacology and clinical evidence

Research in the area of herbal psychopharmacology has increased markedly over the past decades. To date however, a comprehensive review of herbal antidepressant, anxiolytic and hypnotic psychopharmacology and applications in depression, anxiety and insomnia has been absent. A search of MEDLINE (PubMed), CINAHL, PsycINFO, and the Cochrane Library databases was conducted (up to February 21st 2011) on commonly used psychotropic herbal medicines. A review of the literature was conducted to ascertain mechanisms of action of these botanicals, in addition to a systematic review of controlled clinical trials for treatment of mood, anxiety and sleep disorders, which are common comorbid psychiatric disorders. Specific emphasis was given to emerging phytomedicines. Analysis of evidence levels was conducted, as were effect sizes (Cohen's d) where data were available. Results provided evidence of a range of neurochemical, endocrinological, and epigenetic effects for 21 individual phytomedicines, which are detailed in this paper. Sixty six controlled studies were located involving eleven phytomedicines. Several of these provide a high level of evidence, such as Hypericum perforatum for major depression, and Piper methysticum for anxiety disorders. Several human clinical trials provide preliminary positive evidence of antidepressant effects (Echium amoenum, Crocus sativus, and Rhodiola rosea) and anxiolytic activity (Matricaria recutita, Ginkgo biloba, Passiflora incanata, E. amoenum, and Scutellaria lateriflora). Caution should however be taken when interpreting the results as many studies have not been replicated. Several herbal medicines with in vitro and in vivo evidence are currently unexplored in human studies, and along with use of emerging genetic technologies "herbomics", are areas of potential future research.

Nutraceuticals in the treatment of obsessive compulsive disorder (OCD): a review of mechanistic and clinical evidence

Obsessive-compulsive disorder (OCD) is a debilitating mental illness which has a significant impact on quality of life. First-line SSRI treatments for OCD typically are of limited benefit to only 40-60% of patients, and are associated with a range of adverse side effects. Current preclinical research investigating nutraceuticals (natural products) for OCD, reveals encouraging novel activity in modulating key pathways suggested to be involved in the pathogenesis of OCD (glutamatergic and serotonergic pathway dysregulation). Emerging clinical evidence also appears to tentatively support certain nutrients and plant-based interventions with known active constituents which modulate these pathways: N-acetlycysteine, myo-inositol, glycine, and milk thistle (Silybum marianum). The serotonin precursor tryptophan is unlikely to be of use in treating OCD while 5-HTP may possibly be a more effective precursor strategy. However, there is currently no clinical evidence to test the efficacy of either of these substances. Currently the balance of clinical evidence does not support the use of St. John's wort (Hypericum perforatum) in OCD. While clinical research in this area is in its infancy, further research into nutraceuticals is warranted in light of the promising preclinical data regarding their mechanisms of action and their favourable side effect profiles in comparison to current SSRI treatments. It is recommended that future clinical trials of nutraceutical treatments for OCD utilize randomized placebo-controlled study designs and considerably larger sample sizes in order to properly test for efficacy.

Systematic review of safety and tolerability of a complex micronutrient formula used in mental health

BACKGROUND

Theoretically, consumption of complex, multinutrient formulations of vitamins and minerals should be safe, as most preparations contain primarily the nutrients that have been in the human diet for millennia, and at safe levels as defined by the Dietary Reference Intakes. However, the safety profile of commercial formulae may differ from foods because of the amounts and combinations of nutrients they contain. As these complex formulae are being studied and used clinically with increasing frequency, there is a need for direct evaluation of safety and tolerability.

METHODS

All known safety and tolerability data collected on one complex nutrient formula was compiled and evaluated.

RESULTS

Data were assembled from all the known published and unpublished studies for the complex formula with the largest amount of published research in mental health. Biological safety data from 144 children and adults were available from six sources: there were no occurrences of clinically meaningful negative outcomes/effects or abnormal blood tests that could be attributed to toxicity. Adverse event (AE) information from 157 children and adults was available from six studies employing the current version of this formula, and only minor, transitory reports of headache and nausea emerged. Only one of the studies permitted a direct comparison between micronutrient treatment and medication: none of the 88 pediatric and adult participants had any clinically meaningful abnormal laboratory values, but tolerability data in the group treated with micronutrients revealed significantly fewer AEs and less weight gain.

CONCLUSIONS

This compilation of safety and tolerability data is reassuring with respect to the broad spectrum approach that employs complex nutrient formulae as a primary treatment.

Potential of St John's Wort for the treatment of depression: the economic perspective

The burden of rising health care expenditures has created a demand for information regarding the clinical and economic outcomes associated with complementary and alternative medicines. Meta-analyses of randomized controlled trials have found Hypericum perforatum preparations to be superior to placebo and similarly effective as standard antidepressants in the acute treatment of mild to moderate depression. A clear advantage over antidepressants has been demonstrated in terms of the reduced frequency of adverse effects and lower treatment withdrawal rates, low rates of side effects and good compliance, key variables affecting the cost-effectiveness of a given form of therapy. The most important risk associated with use is potential interactions with other drugs, but this may be mitigated by using extracts with low hyperforin content. As the indirect costs of depression are greater than five times direct treatment costs, given the rising cost of pharmaceutical antidepressants, the comparatively low cost of Hypericum perforatum extract makes it worthy of consideration in the economic evaluation of mild to moderate depression treatments.