Healing Depression and Integrative Depression Care Peter B. Bongiorno ND, LAc New York

www.drpeterbongiorno.com www.InnerSourceHealth.com www.InnerSourceHealth.com

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I - INTAKE II – DRUGS?

the plan

III - LABS IV - RECOMMENDATIONS — Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy — Detoxification — Supplements

I - INTAKE II – DRUGS? III - LABS IV - RECOMMENDATIONS — Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy — Detoxification — Supplements

From: Bongiorno P. Put Anxiety Behind You

intake

The first duty of love is to listen.” - Paul Tillich

Elements of a first visit 1 – Greet the patient in the waiting area 2 – Ask How the Patient Found You 3 – Introduction to yourself and what you do 4 – Magic Wand Question 5 – 7 attributes for each CC / Suicide? 6 – Bowel Function, Sleep, Exercise 7 – Food and Water Intake 8 – Childhood, Schooling, Current Work, Family Life and Religion 9 – Spirit: Stressors, Goals, Passions and Calming Rituals 10 – Daily Schedule 11 – Review of Systems and Physical Exam 12 – “Anything Else We Missed?” 13 – Recommendation Plan and Follow Up 14 –Hug / Touch Your Patient

I - INTAKE II – DRUGS? III - LABS IV - RECOMMENDATIONS — Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy — Detoxification — Supplements

— NMDA: NRX 1074, partial agonist of glycine site — Multimodal (s, da, ne) : Vortioxetine (Brintellix™)

drugs

— Melotinergic: Agomelatine (Valdoxan, Melitor)— SSRIs (s):citalopram (celexa), escitalopram (lexapro), paroxetine (paxil), fluoxetine (prozac), sertraline (zoloft), fluvoxamine (luvox)

— SNRIs (s, ne): duloxetine (cymbalta), venlafaxine (effexor), desvenlafaxine (pristiq)

— SSRI (s) and 5HT partial agonist: Vilazodone (Viibryd) — TCAs (s, ne, anticholinergic): amyptriptyline (elavil), imipramime (tofranil), nortriptyline (pamelor), chlomipramine (anafranil),

— MAOi’s (s, ne, mel, d): Tranylcypromine (Parnate), Phenelzine (Nardil))à Selegiline (Emsam)

— Wellbutrin (da): buproprion (wellbutrin) — Anxiolytic (benzos): busparone (buspar) — Sedative: SARI (serotonin antagonist and reuptake inhibitor): trazadone (Oleptro), nefazadone, mirtazepine (remeron),

—

add-ons: antipsychotics: quetiapine (Seroquel), aripiprazole (abilify) (5HT (c) www.InnerSourceHealth.com 3/14/2016 D2 agonist), lamotrigine (lamictal)

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— STAR*D trial Trivedi (c) www.InnerSourceHealth.com

et al. Am J Psychiatry. 2006 Jan;163(1):28-40. 3/14/2016

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other conventional care: — ECT - 1 week for effect — Transmagnetic stimulation — Vagus nerve stimulation — Deep brain stimulation — Psychosurgery — Ketamine

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Conventional or integrative? 1) If risk of hurting self or others à use conventional therapies first and natural as an adjunct

2) If patient cannot take care of self or family à use conventional therapies first and natural as an adjunct

3) If the above criteria is not met and patient is willing à use natural therapies first

4) Pregnancy and breast feeding à needs case by case evaluation

5) If patient is on medications à start by working

with natural therapies and begin to slowly taper medications after natural treatments begin to take an effect

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I - INTAKE II – DRUGS? III - LABS IV - RECOMMENDATIONS — Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy — Detoxification — Supplements

helpful lab tests — Fasting glucose — CBC — Chem Panel — Lipid Panel — Homocysteine — Histamine — TSH, T3, T4 — DHEA/DHEAs — Free & total T — Progesterone (c) www.InnerSourceHealth.com

— 25(OH) vitamin D/Zn/ Copper

— B12/folic acid — MTHFR — Carnitine — Serum mercury — Celiac — Urine kryptopyrroles — Environmental: \metals, u/ provocation, hair

— SIBO / Leaky3/14/2016 Gut Test

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Saliva testing

George – 28 – depression, CFS

Elina – 39 – depression, some anxiety

Roz – 58 – depression, insomnia

The first duty of love is to listen.” - Paul Tillich

labs? listen to clinical Sxs — Serotonin: worried, anxious, often negative attitude, carb cravings, obsessive worrying

— Dopamine / norepinephrine: low motivation and movement forward

— GABA: can’t turn the mind off, can’t relax — Melatonin: tough to fall or stay asleep

I - INTAKE II – DRUGS? III - LABS IV - RECOMMENDATIONS — Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy — Detoxification — Supplements

recommendations — Sleep — Stress Support — Thought Work — Mind / Body Work — Food / Digestion / Blood Sugar / Inflammation — Exercise — Hydrotherapy — Detoxification — Supplements

sleep — Depression is often characterized by sleep disturbances and often precede the onset or recurrence of depression

— 70% of sleep apnea patients have depression sxs J. of Sleep Clin Med Setp . 2015

— 30% of pts with insomnia are depressed Rakecki S, Arch Fam Med 1993;2:1129–34

— Depression is often characterized by sleep disturbances and often precede the onset or recurrence of depression

Sleep Rx? — Bedtime rituals — Eat before bed? — Melatonin — Melatonin Prolonged Release — Tryptophan: 2 g hs — Valerian — Casein decapeptide — Magnesium glycinate/threonate — Phosphatidylserine

“You call it sleep, I call it keeping reality at bay.”

Phosphatidylserine and golf — healthy young golfers with handicaps of 15–40. — 200 mg per day PS (n = 10) or placebo (n = 10) — significantly improves (p < 0.05) the number of good ball flights during tee-off which might result in improved golf scores, and trend towards improved stress levels versus placebo

recommendations — Sleep

— Stress Support —Thought Work —Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy — Detoxification — Supplements

Bongiorno P. Healing Depression page 76

Bongiorno. Holistic Soultions for Anxiety and Depression. p 102.

“Glucocorticoid Resistance”

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How to work on the HPA? — Relationships — Passion for life/spirit - “Follow your bliss” - Fun is the Raison d'être

Mental illness? “Pathologizing one’s non-conformity.” - gary greenberg

- Rx: Laughing, MP3 player, sky diving, new clothes and haircut, creative work, volunteering

— Rx: Self-Esteem work — Rx: psychotherapy, acupuncture, meditation, herbs (c) www.InnerSourceHealth.com

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acupuncture

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recommendations — Sleep — Stress Support — Thought Work — Mind / Body Work

— Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy — Supplements

Food: What to Eat? — Water - needed for trp brain absorption — Cold water fish a few times a week — Low glycemic load foods — High protein: beans, fish, raw nuts — Oatmeal (avena sattiva) — Mediterranean Diet — almonds, pomegranate — Food allergies / sensitivities

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digestion — 95% of body serotonin is in the gi system EC cells — Celiac disease: reduces CSF trp (reversed after gluten free diet x 1 yr)

— Trp stores are especially vulnerable to intestinal malabsorption

— Food allergies create “exorphins” which ↓’s endorphins

— 20% of patients with functional bowel disorders also have psychiatric comorbidities Agazzi A. et al. Dig Liver Dis. 2003; 35(8):590-5

the microbiome

— Natto, kim chi, yogurt, miso, tempeh, sauerkraut

blood sugar control

— Small frequent meals — Low glycemic load foods — Protein / healthy fat / healthy carb — Chromium

inflammation — Lower stress — Anti-inflammatory diet — Saffron: 30mg qd. serotonergic, antioxidant, anti-inflammatory, neuro-endocrine and neuroprotective effects. meta-analyis of 6 studies: Hum Psychopharmacol. 2014 Nov;29(6):517-27.

— Curcumin: 500 mg capsule qd 50.

— Leaky gut test à Gut healing

Eur Neuropsychopharmacol. 2015 Jan;25(1):38-

Shakespeare break

It seems his sleeps were hinder’d by thy railing, And therefore comes it that his head is light. Unquiet meals make ill digestions. Thereof the raging fire of fever bred, And what’s a fever but a fit of madness? Thou sayest his sports were hinderd by thy brawls. Sweet recreation barred, what doth ensue But moody and dull melancholy, Kinsman to grim and comfortless despair…The consequence is, then, thy jealous fits Have scared thy husband from the use of wits. (c) www.InnerSourceHealth.com

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Shakespeare, Comedy of Errors, Act V, scene I - The abess talking with Adriana about husband Antipholous

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Bongiorno. Holistic Solutions for Anxiety and Depression. p 102.

Bongiorno. Holistic Solutions for Anxiety and Depression. p 102.

— Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation

— Exercise — Hydrotherapy — Supplements

exercise — Study comparison with conventional Rx: RCT of 156 adults compared exercise with sertraline (zoloft). After 10 months, subjects in the exercise group had significantly lower relapse rates (p = 0.01) than subjects in the medication group. — Babyak M Psychosom Med. 2000 ;62(5):633-8. (c) www.InnerSourceHealth.com

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Exercise - not so scientific study Totals: n = 58 ‘Escalators’: 47 1: 9-3

4:11-3

‘Step people’: 11

18% of people choose the stairs (82% did not)

2:12-2 5:8-3)

3:7-0 (c) www.InnerSourceHealth.com

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— Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation

— Exercise

—Hydrotherapy / Nature — Supplements

hydrotherapy — Water: “allays lassitude”

nature

(hippocrates)

— Physiolgic stressors important for brain

— lower cortisol, blood pressure, heart rate, and inflammation, while enhancing parasympathetic activity

— Moderate cold stressors: lower brain inflammation, activates epinephrine and b-endorphins

— But, extreme cold: can impair fxn

— phytoncides

— Rx: start warm shower

— “forest bathing” (Shirin yoku)

with 5 minute cooling down to a sustain 2 -3 minute period of 68F. Qd to bid (Shevchuk. Adapted Cold Shower for

— Sunshine – vitamin D —

Mao J Cardiol. 2012 Dec;60(6):495502 2012

Depression. Med Hypoth2008 (70)5:995-1001).

— Constitutional hydrotherapy (c) www.InnerSourceHealth.com

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Multi-modal mood study — 2001 - University of Washington, — 112 women with mild or moderate depression. — walk outside during daylight hours for 20 minutes 5/7 days — also: multiple vitamin — control group: who did not do any walking, and they received a placebo vitamin.

— 85% of tx group: less depression, better mood all around, with greater self-esteem and well-being

— Brown, M.A., Goldstein-Shirley, J., Robinson, J., et al. The effects of multi-modal intervention trial on light , exercise, and vitamins on women’s mood. Women & Health 2001; 34:93-112.

Heavy metals:

detoxification

- toxic to the brain, mitochondria, and nervous system

- Increases inflammation - inhibits glutamate removal - Depression: Pb, Hg, Cd, Ar - CV/DM: BPA - Mitochondrial deficits Treatments: food and detox,chelators:suppository, oral, i.v (c) www.InnerSourceHealth.com

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— Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy — Environmental

—Supplements

Supplemental plan 1 – “lab test repletion” 2 - treatment resistance support 3 - “3 U Need”: Multiple, Fish Oil, Probiotic 4 - Mood Systems Physiology Support 5 - Neurotransmitter Support

Blood Work:

“lab test” supplements

— Vitamin D: Shaffer Psychosom Med. 2014 Apr;76(3):190-6. , vitamin B12 Hanna, Prim Care Companion J Clin Psychiatry. 2009; 11(5): 269–270.

— Iron / ferritin:

Yi, Psychiatry Res. 2011 Oct 30;189(3):368-72.

— Hormonal: thyroid, progesterone, estrogens, testosterone, DHEA — B vitamins, methylators, MTHF — ALC: Wang. J Psychiatr Res. 2014 Jun;53:30-7. Carnitine: Rexaee, et al. Curr HIV Res. 2013 Apr;11(3):226-30.

Adrenal:

— Licorice: inhibitory effects of one of its active components glycyrrhetinic acid on 11β-hydroxysteroid dehydrogenase Al-Dujaali, et al. Mol Cell Endocrinol. 2011 Apr 10;336(1-2):102-9.

— Ashwaganda: 300mg twice a day of root extract lowered stress levels and cortisol / adrenal hyperplasia. Chandrasekhar K Indian J Psychol Med. 2012 Jul;34(3):255-62, Kalani et al. BMJ Case Rep. 2012 Sep 17;2012

— Phosphatidylserine and omega 3’s: lower perceived stress and studies in high stress men. Raised cortisol in low responders and lowered cort in high responders Hellhammer et al. Nutr Res. 2012 Apr;32(4):241-50.

Treatment resistance? — Folic acid (MTHF) – 15mg. (75 pt. study) Fava et al. 49th annual meeting of the American College of Neuropsychopharmacology; December 5–9, 2010

— Testosterone / estrogen / thryoid if applicable — Zinc – 30mg. Takes 6 weeks to work. Small study. Pol J Pharmacol. 2003 Nov-Dec;55(6):1143-7.

— Vitamin B12: a full response to anti-depressant medications when B12 levels were higher (439.1 pmol/L) versus non-responders (347.2pmol/L) and partial responders (396.0pmol/L) . BMC Psychiatry. 2003;3:17.

— Creatine: women study of 5 grams creatine plus lexapro had positive results by week 2. J Psychiatry. 2012 Sep 1;169(9):937-45.

— Fatty acids: “Augmenting a standardised antidepressant treatment with omega-3 fatty acids resulted in a marked improvement in depression symptoms measured on the Hamilton scale in the majority of patients with treatment-resistant depression.”

3 u need — Mutliple vitamin: significant reduction in the overall score on a depression anxiety and stress scale

Harrris Human

Psychopharmacol.. 2011;26(8):560-7.

— Fish oil: 2 g/day in total, looking for 1,000 mg/day of EPA and ~800 mg DHA

Hegarty. Curr Opin Psychiatry. 2013 Jan;26(1):33-40.

— Probiotics: lactobacillus / bifidus: two probiotic compounds given for 30 days, yield beneficial psychological effects: lowered depression, anger-hostility, anxiety, and better problem solving, compared with the placebo group. British Journal of Nutrition (2011), 105 : pp 755-764

Supplements for physiology Supplements for neurotransmitters

some favorites: support for physiology Chromium: - Insulin utilization

- depressed mood - binge eating - insulin resistant

- Availability of trp - Norepinephrine, dopamine, serotonin support — 8 pt monotherapy 200mcg BID: Int J Neuropsychopharmacol. 2000 Dec;3(4):311-314.

— Studies with co-morbid depression and binge eating. Brownely et al. Med Hypotheses. 2015 Jul;85(1):45-8.

some favorites: support for physiology

Rhodiola — 340 mg (rosavin 3.07%/rhodioloside 1.95%) qd Phytomedicine. 2015 Mar 15;22(3):394-9

— history of chronic stress and and high AM cortisol that increase the patient’s awakening response. Olsson et al. Planta Med. 2009;75(2):105112.

some favorites: support for physiology Berberine — inhibit monoamine oxidase-A (stops breakdown of Se and Norepi) and (murine research: Kulkami et al. Eur J Pharmacol. 2008 Jul 28;589(1-3):163-72.

— Sigma-1 receptor à neurogenesis and neuroplasticity — serotonergic, noradrenergic, and dopaminergic effect — No clinical trials in depression

some favorites: support for physiology

Curcumin: — 60 pts with MDD, given either fluoxetine, curcumin, or both — Responders of HAM-d: combination group (77.8%) than in the fluoxetine (64.7%) and the curcumin (62.5%)

— 500 mg capsule qd Eur Neuropsychopharmacol. 2015 Jan;25(1):38-50.

some favorites: support for physiology

Saffron — serotonergic, antioxidant, anti-inflammatory, neuroendocrine and neuroprotective effects.

— Australian meta-analysis of 6 studies “large treatment effects, similar antidepressant efficacy”

— 15 to 30mg qd.

saffron for sexual healing

Men: - 2012 randomized, double-blind trial - 36 married men w/ MDD successfully on Prozac w/ sex dysfxn - 15 milligrams of saffron or a placebo - 4 weeks saffron group had experienced significantly greater improvement in erectile function and intercourse satisfaction - “tolerable and efficacious treatment” Moddabernia et al. Psychopharmacology (Berl). 2012;223(4):381-8.

Women: - 38 women - 30 milligrams daily of saffron extract and the rest were assigned a placebo - significant improvement in total sexual function (FSFI), arousal, lubrication, and pain Kashani et al. Hum Psychopharmacol. 2013 Jan;28(1):54-60.

favorites: support for neurotransmitters Tyrosine: — precursor of the catecholamine — RCT of MDD pts of tyrosine vx. Imipramine showed no effect by itself

— Gelenberg et al. J. Affect Disord. 1990 Jun;19(2):125-32

some more favorites: support for neurotransmitters Macuna: — Seed contains: L-dopa, alkaloids and a minor amount of 5hydroxytryptamine. Neuroprotective

— hyperprolactinemia and Parkinson’s — Forced swimming test immobility time decreased — Rana. Ayu. 2014 Jan;35(1):90-7.

some more favorites: support for neurotransmitters SAMe: — remission rates were 34% for SAMe, 23% for escitalopram (lexapro) , and 6% for placebo (1600-3200mg/daily in this study).

— 200 -1600mg of SAM-e twice a day (min). J Affect Disord. 2014 Aug;164:76-81. — Greater therapeutic effect in males? Sarris et al. 5):141-4.

Pharmacopsychiatry. 2015 Jul;48(4-

some more favorites: support for neurotransmitters

5-HTP: — 60 pts x 8 weeks, 5-HTP or fluoxetine — “has definitely got antidepressant effect in patients of depression.” Antidepressant effect (73 vs 80%) was seen within 2 weeks of treatment and was apparent in all degrees of depression.“

— and: “better than placebo” according to Cochrane Database Syst Rev. 2001;(3):CD003198.

one more new fav Apocynum venetum (Rafuma leaf extract), a shrub of the dogbane family — Chinese medicine: clears damp. SXs: neurasthenia, palpitation, insomnia, edema with frequent urination, hypertension, and nephritic edema

— Flavonoids (kaempferol) . No hypericin or hyperiform — significant antidepressant-like effects, which likely attribute to increased NE and DA, and serotonin

— Anti-anxiety effects (with GABA). Yoto. Jap J Phys. Anthro. 2009:14;3

— case reports of women treated for premenstrual syndrome (PMS) and depression

— 50mg – 150mg qd. Yang J. of Nut. Food. 2009: 12;1-9 — Safe.

Xie, W J Ethnopharmacol (May 7)141(1): 1–8.

endnote: patient preferences

n

15% preferred medication alone. 24% preferred just psychotherapy; 60% who preferred both (n=315) n those who received a preferred treatment experienced more rapid improvements Lin P et al. Ann Behav Med. 2005 Oct;30(2):164-73. (c) www.InnerSourceHealth.com

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Hippocrates recommendations (fifth century BC): — Vegetable diet — Physical movement

— Water therapy — St. john’s wort (c) www.InnerSourceHealth.com

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— INTAKE — DRUGS?

summary

— LABS — RECOMMENDATIONS

— Sleep — Stress Support — Thought Work — Mind / Body Work — Food/Digestion / Blood Sugar /Inflammation — Exercise — Hydrotherapy - Nature — Environmental - Mitochondria — Supplements

thank you / namaste peter bongiorno nd, lac www.drpeterbongiorno.com www.InnerSourceHealth.com

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