Depression is multifactorial and can stem from genetics, stressful or traumatic life events, disease, diet, and/or hormonal fluctuations. It can affect all lifespans, genders and nationalities ^[1,2], with 17% of Australians aged 16 to 85 years having experienced anxiety and/or depression in the past 12 months ^[3]. Whether the condition continues after 12 months is unknown ^[3].

Unfortunately, antidepressant medications may not be specifically tailored to the patient, resulting in little to no improvement or unwanted side effects such as fatigue, insomnia, loss of libido, weight gain, and anxiety ^[4]. Additionally, antidepressants are only effective in moderate to severe depression (about 20 people out of 100 prescribed medications), and once on medication, there is no agreed safe way to reduce or cease antidepressants ^[4,5].

As naturopathic practitioners, our approach fits with the current scientific concept that demonstrates low mood may also be a result of ‘adrenal burnout from stress’, poor lifestyle choices, and an inflammatory diet ^[6]. As such, the clinical aim in this case was to balance the hypothalamic-pituitary-adrenal axis (HPA), reduce corticotrophin-releasing factor (CRF) and inflammatory factors in the brain and gut, using a holistic lifestyle approach ^[7].

Patient History

The 27-year-old male patient was pale and worn out, presenting with weak vitality, a worried demeanor and a nervous fidgeting tension. He had felt depressed and anxious since he was a child, which had worsened during his adolescence, when he tried to cope using alcohol. He had tried “St John’s Wort” in the past for a few weeks but stated it was not effective. Six months prior to this visit, the patient had started on Zoloft, however, he reported there was very little improvement in his mood and that the medication has made his anxiety worse. The reason for his visit was triggered by his new girlfriend, as he felt he should be happy and wanted a healthy libido but he experienced neither and felt numb.

Other relevant history:

• Refugee status, migration at age 7
• Estranged father, with mental health issues
• Previously lived with his single mother and grandmother, but now lives alone
• At age 10, underwent several exploratory surgeries for gastric pain, however, nothing abnormal was found. He states this is when his low mood started.
• Loose bowel function (Bristol Stool Score 6 to 7), daily on average
• Diet: Frozen vegetables, rice and vegetable dishes, high glycemic index carbohydrates, little to no protein, possibly some at night. He consumed commercial breakfast cereals, full-fat milk, and coffee 3 times a day (he is aware this leads to poor sleep). His diet did not include fish, nuts or seeds.
• No other known illnesses
• Low Vitamin D
• No exercise
• Finance is an issue (low income)

Initial Consultation

This patient was seeking assistance to help him ‘feel well, lift mood and reduce anxiety’.

 Presenting Symptoms

• Stress (financial) 8/10
• Gradual weight loss of 10 kg over the past 8 years
• Thin, pale and exhausted, energy 2 to 3/10
• Low mood 8/10
• Loose bowel motions (5 out of 7 days)

Prescription

Aims of the following prescription were to balance the HPA axis, reduce brain-gut inflammation, improve gut balance, diet and improve lifestyle, while remaining on anti-depressants ^[1].

• Choline and DHA supplement: Dosage: 2 capsules, twice daily with food
  • Concentrated fish omega-3 triglycerides (equivalent to docosahexaenoic acid (DHA) 450 mg and eicosapentaenoic acid (EPA) 98 mg
    • To reduce inflammatory factors in the gut and brain ^[1]
  •  Choline Bitartrate 352.4mg (equivalent Choline 143.5 mg)
    •  To reduce anxiety symptoms ^[8]
  • Colecalciferol 6.25mcg (equivalent vitamin D3 250 IU)
    • Reparative to the brain in low mood and depressive states ^[9]
• Zinc and C Powder: Dosage: 5 g, twice daily in water
  • Zinc citrate dihydrate (78 mg equivalent to elemental zinc 25 mg) and Ascorbic Acid (1.0 g), with quercetin, manganese, pyridoxal 5-phosphate (P5P), beta-carotene and selenomethionine
    •  To support the HPA axis function^[10]
• (Off-the-Shelf) Tablet: Dosage: chew 2 tablets, three to four times a day
  • Potassium Phosphate- dibasic 33mgs (PP)
    • A nerve power activator
      • For decreased nervous energy, low mood, despondency, anxiety, fatigue, weakness, and poor memory
  • Magnesium Phosphate 65mgs (MP)
    • For insomnia, confusion, weakness, lethargy, tremors, low mood, and anxiety ^[11]

Dietary recommendations:

• Encouraged to pre-prepare foods for the week to save money
• Increase intake of high B vitamin foods such as ½ an avocado, 50 g pistachios (or other unsalted nut variety), ½ an eggplant, and 2 tbsp tomato paste in cooking, at least three times per week ^[12]
• Increase protein by including 2 x 100 g serves per day of the following high protein foods: chickpeas, hormone-free (organic is possible) meat, poultry, and sardines daily ^[12]
• 80 g liver (twice per week) ^[12]
• 3 to 5 cups of brightly coloured fresh vegetables per day
• 2 serves of fruit per day
• 50 ml of extra virgin olive oil per day
• 2 tablespoons of almond or nut butter per day
• 2 slices of whole meal, wholegrain sourdough bread with butter per day
• 2 x 150 g serves of one of the following: quinoa, basmati rice, sweet potato, pumpkin, or new potatoes per day
• 1 cup of bone broth, daily, for gut repair (grandmother makes this for him)
• 60 ml homemade kefir on an empty stomach each morning, for gut repair (Grandmother also makes this for him)
• No coffee after 3 pm

Lifestyle recommendations:

• Listen to anxiety relief self-hypnosis before bed (Selfhypnosis.com)
• Walk 30 minutes a day in a peaceful park or wooded/beach area ^[13]

The patient was also referred to his general practitioner (GP) to assess his current vitamin D levels and general health, and to ascertain digestive capacity via protein and albumin levels.

4-Week Follow-Up

While the patient reported that he had gained 1 kg, he reported that he had great difficulty reaching the goal of 5 serves of vegetables a day. He also stated that he had difficulty eating so much food and felt bloated after eating protein. He stated that he was not feeling much better at this stage but that the celloid helped with his acute anxiety, which he found helpful. He was happy to continue with treatment as he did feel he was gaining some benefit from it.

Presenting symptoms

• Financial stress continues 8/10
• Gradual weight gain, 1 kg
• Thin and pale but slightly more energy 4 to 5/10
• Low mood 6 to 7/10
• Bowel motions still loose 4 out of 7 days, with wind and odour

 Blood test results

• Nothing abnormal was detected, however, total protein 63 g/L (range 64 to 83 g/L) and albumin 38 g/L (range 36 to 47 g/L) were low, which may be implicated in affective depressive states according to animal studies ^[14].

His prescription was continued, with the addition of:

• Digestive Enzyme: Dosage: one capsule with breakfast and lunch, two with his largest meal of the day (dinner).
  • Amylase 15,000 DU (100 mg), Lipase 1,200 LipU (11 mg), Tilactase 1,500 ALU (16.5 mg), Cellulase 300 CU (1.65 mg), bromelains 2 400 000 PU (53.3 mg), Taraxacum officinale (Dandelion root) 166mg, Zingiber officinale (Ginger) 42 mg.
    • To address malabsorption (low protein and albumin), improve digestive power and enzyme activity, and reduce to wind and flatulent odour.

8 Week Follow-Up

The patient reported an improvement in energy and digestion (loved the digestive enzymes!) levels, now rating energy as 4 to 5/10 and he had gained 2.5 kg. His bowel had settled, and his loose bowel motions occurred 1 out of 7 days, with little to no wind or odour. He also mentioned his mood was better (6 to 7/10) and was feeling more social and enjoying life at times, with less anxiety. His vitality showed in his upbeat demeanour and he stated his libido was better. He had not started any exercise, although he agreed he needed to. He was less reliant on the celloid for acute relief, and he mentioned he wanted to come off his medication. I referred him to his GP to discuss this.

12-Week Follow-Up

The patient’s mood continued to increase (3 to 4/10) and he rated his energy as an 8 to 9/10. His sleep was better, he was more social and starting to do some walking with his girlfriend. He was happy that he had now gained ‘healthy weight’ of 5 kg. His libido had also improved. His bowel motions remained stable with no diarrheal episodes. His GP suggested he stay on his medication for another few months to see if his change in mood was permanent and then they would discuss titrating his medication down. 

Having achieved a return to a good mood and energy, the patient remained on a lowered dose prescription.

Follow-up blood tests were not requested due to management of his symptoms.

His prescription for long-term treatment included:

• Less reliance on the celloid: Dosage: As required
• Choline and DHA supplement: Dosage: 1 capsule, twice daily with food
• Zinc and C Powder: Dosage: 5 g, once daily in water.
• Digestive enzyme: Dosage: one capsule with breakfast and lunch, one with dinner
• Continue with healthy diet and lifestyle recommendations

Clinical Thoughts:

When co-prescribing with antidepressants, it is important to cross-check and be aware of herbal and nutritional interactions or prescribing cautions. For example, Taraxicum officinale (Dandelion) induces CYP450, which may affect the metabolism of antidepressant medications, however, the dose in the digestive enzyme supplement was perceived as low risk.

Additionally, as the patient was financially challenged, multiple supplements and nutrient provisions were not possible. Other supplements that would have assisted in his recovery include a B vitamin complex, a higher dose of Vitamin D (5,000 IU/day) short-term to increase levels quickly, and a Magnesium diglycinate (600 to 800 mg/day), all of which were discussed but discarded due to the additional cost.

The main aim of the treatment was to reduce the impact of the inflammatory processes in the brain-gut axis and to reduce his anxiety symptoms to allow time for the HPA axis to repair. Diet is often overlooked in low mood cases, and when you consider you have 35 meals per week, this is always a good place to start to make a significant impact on any health condition, especially when cost is an issue.

References

1. Ljungberg T, Bondza E, Lethin C. Evidence of the Importance of Dietary Habits Regarding Depressive Symptoms and Depression. Int J Environ Res Public Health. 2020 Mar 2;17(5):1616. doi: 10.3390/ijerph17051616. PMID: 32131552; PMCID: PMC7084175.
2. National Research Council (US) and Institute of Medicine (US) Committee on Depression, Parenting Practices, and the Healthy Development of Children; England MJ, Sim LJ, editors. Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention. Washington (DC): National Academies Press (US); 2009. 3, The Etiology of Depression. Available from: https://www.ncbi.nlm.nih.gov/books/NBK215119/
3. Beyond Blue (2022) Statistics. https://www.beyondblue.org.au/media/statistics
4. Hurley S. New Cochrane review explores the latest evidence on approaches to stopping long term antidepressant. Cochrane Australia. 2021. https://australia.cochrane.org/news/new-cochrane-review-explores-latest-evidence-approaches-stopping-long-term-antidepressants
5. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Depression: How effective are antidepressants? [Updated 2020 Jun 18]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK361016/
6. Hechtman, L. Clinical Naturopathic Medicine Second Edition: The neurological System. Chpt 22, 2020, Pages 1258-1359. Elsevier Australia. Ltd.
7. Emmanuel Jesulola, Peter Micalos, Ian J. Baguley, Understanding the pathophysiology of depression: From monoamines to the neurogenesis hypothesis model - are we there yet? Behavioural Brain Research, Volume 341, 2018, Pages 79-90, https://doi.org/10.1016/j.bbr.2017.12.025.
8. Bjelland I, Tell GS, Vollset SE, Konstantinova S, Ueland PM. Choline in anxiety and depression: the Hordaland Health Study. Am J Clin Nutr. 2009 Oct;90(4):1056-60. doi: 10.3945/ajcn.2009.27493. Epub 2009 Aug 5. PMID: 19656836.
9. Menon V, Kar SK, Suthar N, Nebhinani N. Vitamin D and Depression: A Critical Appraisal of the Evidence and Future Directions. Indian J Psychol Med. 2020 Jan 6;42(1):11-21. doi: 10.4103/IJPSYM.IJPSYM_160_19. PMID: 31997861; PMCID: PMC6970300.
10. Kocot J, Luchowska-Kocot D, Kiełczykowska M, Musik I, Kurzepa J. Does Vitamin C Influence Neurodegenerative Diseases and Psychia tric Disorders? Nutrients. 2017 Jun 27;9(7):659. doi: 10.3390/nu9070659. PMID: 28654017; PMCID: PMC5537779.
11. Blackmores Mineral Therapy Quick Reference Chart (2012). Available from Blackmores Pty. Ltd.
12. Food Standards Australia and New Zealand. Australian Food Composition Database (2022). Available from: https://www.foodstandards.gov.au/science/monitoringnutrients/afcd/pages/default.aspx
13. Bernard P, Ninot G, Bernard PL, Picot MC, Jaussent A, Tallon G, Blain H. Effects of a six-month walking intervention on depression in inactive post-menopausal women: a randomized controlled trial. Aging Ment Health. 2015;19(6):485-92. doi: 10.1080/13607863.2014.948806. Epub 2014 Aug 18. PMID: 25133492.
14. Belinskaia DA, Voronina PA, Shmurak VI, Jenkins RO, Goncharov NV. Serum Albumin in Health and Disease: Esterase, Antioxidant, Transporting and Signaling Properties. Int J Mol Sci. 2021 Sep 25;22(19):10318. doi: 10.3390/ijms221910318. PMID: 34638659; PMCID: PMC8508759.

The information contained within is intended to be used as an educational tool and it is not intended to be used to diagnose, treat, cure or prevent any disease, nor should it be used for therapeutic purposes or as a substitute for your own health professional's advice.