Alternative Approaches to the Treatment of Manic-Depression
NOTE: Following is some general information about alternative approaches to the treatment of manic-depression, in response to a number of inquiries about the topic. This information will be periodically updated, and so all comments, additions, corrections and stories of personal experiences are highly welcomed!
Most doctors who treat patients suffering from bipolar depression, as well as the patients themselves, would probably agree that it is a condition that is challenging to treat in a fully effective manner. Although an increasing number of pharmaceutical compounds to address depressions and to stabilize moods are becoming available, these are not always fully satisfactory for many patients. Many bipolars, for example, find that medications that are available can lead to significant side effects, and therefore find themselves having to choose between living with these unpleasant effects or discontinuing medications (or decreasing dosages) and somehow learning to manage despite severe mood swings. Others find that despite an exhaustive trial-and-error process involving different combinations of drugs, their mood swings continue to present major problems for them. Finally, many bipolar women who want to have children face the option of either undergoing extremely difficult mood swings while pregnant or taking a risk that their children will suffer birth defects, since all of the available mood stabilizers are known or suspected to be harmful to developing fetuses in human populations.
This summary of information about alternative medicine is designed to help to address these problems by giving bipolars an additional tool they can use to control their illness. In some cases, such alternative methods may work in a complementary way to the use of conventional medications, helping them to work better or, in some cases, to lower necessary dosages. In other cases, alternative treatments may be effective on their own, allowing some people to gradually taper off of their existing medications or (in cases where current mood stabilizers are deemed unacceptable by the patient and doctor because of health complications) may help to lessen mood swings to the point where patients can lead more normal and satisfying lives.
Alternative methods to the management of bipolar disorder tend to work in one or more of three different ways. First, some therapies seem to work in a similar fashion to pharmaceuticals, but with fewer side effects, in the direct management of moods. For example, acupuncture seems to be fairly effective at controlling mania for many people over the short-term, while the herb St. Johns Wort seems to have activity as an anti-depressant.
Second, some alternative methods look for alternate explanations for what psychiatrists may have labeled as manic-depression. For example, food allergies may cause severe mood swings in some people, and untreated endocrine problems of all sorts are widely recognized as causing mood difficulties.
Third, some treatments attempt to improve the overall health of the individual, under the theory that this will allow the body to more effectively fight off mood problems (especially depressions). Such theories suggest that when an individual's health becomes taxed, the "weakest link" is the one that is likely to snap. For some people, this means that high blood pressure of heart problems will occur; for others, that cancer will form; and for still others, that mood problems will result. It is generally recognized that periods of emotional or physical stress tend to worsen mood disorders (especially depressions) in many manic-depressives, for example, and that learning to deal better with stress (perhaps through psychotherapy) and proper nutritional and exercise habits may to some extent help to keep the disease under control. Many alternative practitioners recommend going a step farther, however, and suggest that some other kinds of more active methods (such as those described below) may provide additional help.
With a few exceptions, most of the alternative methods described below tend to address depressions or the short-term mood fluctuations suffered by "rapid-cyclers" (and generally treated by most knowledgeable doctors with anticonvulsants) rather than the more "classic," longer-term highs and lows that are usually treated with lithium. Many alternative practitioners, in fact, state that despite their best efforts, lithium is still a necessity for some patients, although they may tend to attempt to minimize the necessary dosage through a variety of other means. Most alternative practitioners, however, seem to believe that the need for the long-term use of antidepressants by bipolar or unipolar depressives can usually be eliminated through the use of alternative treatments, although it may take a substantial amount of work before this can be accomplished. The use of anti-convulsants such as Depakote and Tegretol seems to fall somewhere in the middle of the two extremes: although the use of alternative methods may help many patients to taper off of these medications, some need to continue to use at least small dosages in order to remain stable. (It should be noted that since most antidepressants increase rapid-cycling in many patients, the elimination of the antidepressants may make these drugs less necessary.) In many cases, however, decreasing the dosage of anti-manic agents is almost as desirable as eliminating the need for medications entirely, since side effects tend to be substantially less at smaller dosages for most patients.
Most of the therapies listed below tend to be relatively safe and have few side effects for most people. Nevertheless, a few points should be kept in mind. First, the patient's doctor should be kept aware of the types of alternative treatments that are being used, and should closely monitor any positive or negative effects that might occur as well as any attempts to decrease the dosages of any medications that are being used. Manic-depression is a serious illness that may have fatal consequences if inadequately treated, and psychiatric medications may have severe side effects if they are discontinued too abruptly or not kept in balance with one another. In general, most psychiatrists (especially ones that specialize in medications, who are preferable for bipolars since their medications are often difficult to manage) are not very well-versed in alternative methods of treating bipolar disorder and may put up some resistance or need to be supplied with relevant information before they will render an opinion. In general, if a practitioner strongly objects to a particular treatment for a particular reason, then it may make sense to look into other methods instead. On the other hand, if a doctor objects to all non-drug approaches, then the patient may have to take a stand that he or she wants to try some of these approaches anyway, or may need to find another doctor, if alternative methods are to be pursued.
Let me reiterate that I am not a medical practitioner myself; however, I have done extensive reading on the topic and have attempted to summarize the information on a variety of alternative treatments that is widely available or that has been published in medical journals. However, I strongly encourage you to use this information only as a starting point, and to read more about the methods that you are interested in pursuing and/or to seek out appropriate specialists.
In general, although alternative therapies can be helpful, they do seem to require a substantial commitment on the part of the individual---they are not nearly as convenient as simply taking a few pills every day. In addition, using alternative techniques can be quite expensive, since most insurance companies do not cover such treatments as acupuncture, nutritional supplements or even food allergy testing. Still, for people who find conventional medications to be insufficient or unacceptable for one reason or another, the availability of alternative medications can be potentially useful and therefore worth pursuing.
Following are some books that discuss a variety of natural approaches to treating mood disorders. References of more specific books dealing with particular types of treatments are listed under the appropriate sections.
- Optimal Wellness, Ralph Golan, M.D., Ballantine Books, New York, 1995. A wonderful book that discusses a variety of conditions (including most of those discussed below) that can lead to suboptimal health. For those who want just one book on the topic of alternative approaches to health (including mental health), this would be a good choice.
- The Good News About Depression, Mark S. Gold, M.D., Bantam Books, New York, 1993. Not a "holistic medicine" book per se, but discusses a variety of alternative diagnoses to depression and manic-depression (including hormonal problems, nutritional deficiencies and environmental toxicity) that the author believes should be ruled out before proceeding with pharmaceutical treatment.
The next four books deal specifically with issues related to alternative treatments of depression and manic-depression, and provide roughly the same kinds of information. Any of them would be a good choice.
- Beyond Prozac, Michael J. Norden, M.D., HarperCollins, New York, 1995.
- Dealing with Depression Naturally, Syd Baumel, Keats Publishing, New Canaan, CT, 1995.
- Depression and Natural Medicine, Rita Elkins, Woodland Publishing, Pleasant Grove, Utah, 1995.
- Natural Alternatives to Prozac, Michael T. Murray, N. D., William Morrow and Company, New York, 1996.
In addition, readers may be interested in looking at some books dealing with the topic of chronic fatigue, since bipolar disorder often has many of the same symptoms and responds well to the same kinds of approaches as chronic fatigue:
- "The Canary and Chronic Fatigue," by Majid Ali, M.D., Life Span Press, Denville, NJ, 1994. Although written in a somewhat haphazard manner, this is a substantive book dealing with the topic in a relatively innovative manner by a respected physician and associate professor of pathology at Columbia University.
- "From Fatigued to Fantastic," by Jacob Teitelbaum, M.D., Avery Publishing Group, Garden City Park, N. Y., 1996. Although the title sounds like a bit of an overstatement, this book cover the common alternative treatments for Chronic Fatigue Syndrome in a readable and common-sense manner. Includes references and protocols to share for the benefit of physicians treating the problem.
- "The Downhill Syndrome," by Pavel Yutsis, M. D. and Morton Walker, M. D., Avery Publishing, Garden City Park, N. Y., 1997. Another fairly good book on the topic of Chronic Fatigue Syndrome.
- "Chronic Fatigue Syndrome: The Hidden Epidemic," Jesse A. Stoff, M. D. and Charles R Pellegrino, Ph.D., Harper Perennial, 1992.
- "Chronic Fatigue Syndrome and the Yeast Connection," William G. Crook, M.D., Professional Books, Jackson, Tennessee, 1992.
A wide variety of vitamins, minerals and amino acids are related to the maintenance of a normal mood; deficiencies of any of these can present problems. Advocates of nutritional approaches to the treatment of mood disorders give several reasons why supplementation may be appropriate. First, most Americans do not eat ideal diets (for instance, they tend to consume substantial quantities of processed foods and empty calories such as sugar, white flour and alcohol, and often neglect to eat certain important food groups entirely), meaning that they may be deficient in even the Recommended Daily Allowances (RDAs) for many nutritional compounds. In addition, many people believe that the RDAs for many substances are designed only to protect the individual from life-threatening disease (e.g. scurvy, beri-beri, etc.), and that more subtle physical dysfunction (such as mood problems) may occur as a result of deficiencies even when the RDAs are achieved. Finally, some evidence suggests that certain people, such as those inclined toward mood disorders, require greater-than-normal amounts of some nutritional substances for optimal functioning, either because they do not easily absorb certain compounds, or because their abnormal metabolisms make higher amounts necessary.
Nutritional substances such as herbs may be useful not because they are inherently required by the body, but because they exhibit pharmacological actions that can suppress the symptoms of depression and/or help the body to repair itself. The action of such substances should be considered similar to that of prescription medications used to treat mood disorders; however, natural substances of this sort usually cause far fewer side effects than do most prescribed drugs.
Those interested in exploring a nutritionally based approach to the management of mood disorders should be aware that most physicians (including psychiatrists) tend to be relatively ignorant and skeptical about the efficacy of this course of action. This is probably the case because most physicians tend to receive little training in nutrition (most medical schools devote, at most, only an hour or two of lecture time in a broader class to the topic), and because less controlled research has been done on the efficacy and safety of nutritional substances than on pharmaceuticals (primarily because drug companies have no incentive to research such substances since they cannot be patented, advocates of a nutritionally based approach argue). Nevertheless, an increasing number of books, many written by well-credentialed physicians, covering this topic are available, as listed below.
Following is a summary of some various nutritional substances that have been shown or reputed to be useful in the management of mood disorders such as depression or manic-depression:
Relatively few substances are said to have the ability to control mood swings directly in the manner that prescription mood-stabilizers do. In addition, it may be the case that those substances that have been identified may be more useful in controlling rapid-cycling (which tends to be addressed with anticonvulsants by psychopharmacologists) than in the longer, more "traditional" swings that are often successfully addressed through the use of lithium. For this reason, lithium (itself a natural substance and probably required by the body in trace quantities) is often recommended by those people favoring a nutritional approach to mood disorders; however, alternative practitioners seem to be more likely to recommend the lowest possible dosage of this substance (often substantially lower than those prescribed by many psychiatrists), supplemented with other measures.
Other than lithium, substances that may have mood-stabilizing effects include the following:
1. Phosphatidyl Choline (Lecithin)
A fairly convincing number of studies suggest that this substance has significant effects on the manic-depressive, with some claiming that it stabilizes moods while others suggesting that it serves as a mood depressant. It is probable that it actually has both actions (as does the prescription drug Depakote). For that reason, although lecithin may be useful in helping to stabilize moods, it should probably be used cautiously, with the patient starting at a fairly low dosage (perhaps 2 capsules of a 35% concentration of the substance per day) and then increasing gradually until moods are stabilized or mild depression is encountered. The recommended amount of this substance for this use seems to vary widely---some people suggest that relatively small amounts (perhaps 3-12 capsules per day) can be quite effective, while others suggest that only much greater amounts tend to be fully effective. (More concentrated forms of this substance are available but not usually stocked in health food stores.) Even if lecithin is only partially successful in reducing mood swings, however, this may still be helpful for those who want to reduce their dosages of prescription medications (for instance, because of side effects at higher amounts) or for those who suffer less severe mood swings. Most writers seem to recommend splitting up the dosages of lecithin over the course of the day (2-3 times per day), or taking the full dosage at night, although there do not seem to be any studies addressing this issue.
Taurine is an amino acid that has been shown to have anti-convulsant qualities, and appears to be potentially helpful for both epileptics and those suffering from manic-depression (especially the rapid-cycling form). The usual recommended dosage seems to be 500-1000 mg, 1-3 times per day, although there seems to be no experimental or anecdotal evidence that larger dosages can cause any unwanted side effects. As with all amino acids, pharmaceutical quality product in capsules is preferable, despite the higher cost----capsules tend to be absorbed more easily, and lesser-quality forms may have the potential of being subject to contamination (such as that which occurred with tryptophan several years ago). Divided dosages are probably preferable.
GABA is usually classified as amino acid, although it actually serves as a neurotransmitter (there are more GABA sites in the brain than for any of the other neurotransmitters such as dopamine or serotonin). GABA basically serves as an inhibitory transmitter, keeping the brain and body from going into "overdrive." Currently, for instance, pharmaceutical companies are working on a GABA Reuptake Inhibitor that would artificially keep more GABA in the synapses of the brain (similar to what Prozac and related drugs do for serotonin) as a treatment for anxiety). Supplementation of GABA seems to be quite effective for anxiety disorders as well as insomnia (especially the type of insomnia where racing thoughts keep the individual from falling asleep). In addition, although there has been little if any research reported on this, there is also reason to believe that GABA may be effective in the treatment of manic-depression, since many of the substances that are currently used for this purpose (including Depakote and, obviously, gaba-pentin) affect GABA usage. Those who want to experiment with the usage of GABA for anxiety or manic-depression should start at a low dosage (perhaps 250 mg at bedtime or when anxiety occurs) and observe their reactions before taking a larger amount. This may be especially important for those people taking mood stabilizers that may affect GABA usage, since the interaction between the two may cause an undesirable overreaction to occur (just as those who are taking serotonin-based drugs such as Prozac should be careful about taking serotonin's precursor, tryptophan). Undesirable effects of too much GABA may include tingling or numbness in extremities or trunk of the body and shortness of breath; if this occurs, take a smaller amount in the future.
Other Nutrients Related to Mood
1. B Complex
The B vitamins are important factors in determining mood; deficiencies of any or all of these vitamins can produce significant symptoms relating to depression, anxiety, irritability, lethargy and fatigue. Many bipolars state that supplementation of B vitamins is extremely important to helping them to feel better. In general, B vitamins tend to work best together as a group; taking too much of any of them may result in deficiencies of others and, therefore, unwanted symptoms. B complex tends to be sold in B50 (50 mg of most of these vitamins, 50 mcg of a few, and 400 or 800 mcg of folic acid) or B100 (100 mg/mcg) dosages; bipolars may find relief with as little as 1 B50 or as many as 6 B100s per day. As with many other supplements, capsule form may be preferable although it is more expensive (some people say manic-depressives do not absorb this vitamin complex easily), and divided dosages also may be preferred. Although other factors (such as some medications) may interfere, a dark yellow-orange urine color may suggest that the individual is taking a sufficient quantity of this vitamin complex.
2. B1 (Thiamin)
Although B vitamins are usually best taken as a group, there are certain circumstances when larger amounts of a particular vitamin may be useful. Thiamin deficiencies tend to produce the following clusterof symptoms, frequently reported by the manic-depressive: chronic fatigue, irritability, memory loss, personality changes (such as aggression), insomnia, anxiety, restlessness, night terrors, appetite loss, sensitivity to noise, numbness and tingling in hands and feet, and circulation problems. Supplementation is usually 100 to 500 mg of this vitamin per day, in addition to the B complex.
3. B6 (Pyridoxine/Pyridoxal-5-Phosphate)
Deficiency of this vitamin can cause irritability, which is expressed by many manic-depressives. Those women who suffer from PMS, birth-control-pill-induced irritability, and post-partum depression often have deficiencies of this vitamin. In addition to the irritability quotient, there are several ways to detect deficiencies for this substance. a) Try the following test: Extend your hand, palm up, then try to bend the two joints in your fingers (not the knuckles of your hand), until your fingertips reach your palm. (This is not a fist, only two joints are bent.) Do this with both hands. If it is difficult, if finger joints don't allow tips to reach your palms, a pyridoxine deficiency is likely. b) Have yourself tested for pyroluria. This is a condition where an above-average amount of a substance called "kryptopyroles" circulate in the body. The substance is harmless in itself; however, it tends to attach itself to both B6 and zinc and to pull these substances out of the body through the urine, causing deficiencies of both. Most doctors are unaware of this test, but if you insist they will be able to order it from Norsom Medical Laboratories, 7243 West Wilson Avenue, Harwood Heights, IL, 60656, (708) 867-9709 . c) Deficiency of B6 causes motion sickness; if you tend toward this malady, you may be more confident that you have a deficiency of this vitamin. Supplementation of B6 is a bit tricky, since high dosages over long periods of time may result in numbness of fingers and (especially) toes and (if extremely high dosages of several thousand milligrams per day are used for an extended period of time) permanent nerve damage. Precautions include: a) Don't take B6 by itself; include an at least somewhat proportional amount of B complex. Some people think that it is not the excess B6 itself that causes problems, but rather the deficiency of the other vitamins that excess amounts leads to. b) Use the more bioavailable pyridoxal-5-phosphate form. c) Don't take amounts in excess of what is necessary to control symptoms. d) If symptoms of tingling or numbness in the toes or fingers results, reduce the dosage immediately. Recommended amounts of pyridoxal-5-phosphate (in addition to that obtained from a B complex) range from as little as 10 mg per day to as much as 250 mg; 50 mg is probably sufficient for most people. (If regular B6 is used, the amounts used are generally 50-500 mg, with 100 mg as an acceptable amount for many people.)
B12 is a vitamin necessary for energy production; a deficiency of it can cause fatigue, anemia and lack of coordination. B12 is a vitamin that is difficult to absorb through the digestive system; in particular, older people (whose digestive systems are less efficient than younger ones) are often deficient in this vitamins. In addition, since this vitamin is present mostly in meats, vegetarians are often deficient. In general, the sublingual or nasal forms of this vitamin are preferred (B12 shots are also available through physicians); between 500 to 2000 mcg per day is generally thought to be an appropriate amount for supplementation. In extreme circumstances, doctors can also give shots of several thousand mcg. (No adverse side effects to even very large amounts seem to have been reported.)
5. Folic Acid
Folic acid is a vitamin that has recently received significant attention in the media for its importance in preventing spinal malformations in fetuses. Manic-depressives, however, need to be careful about taking high dosages (probably in excess of 3000 mcg per day), since anecdotal evidence has suggested that this maylead to manic behavior. Large dosages of folic acid also reduces the efficiency of anticonvulsants such as Depakote for epileptics and (probably) manic-depressives. Finally, as most people are aware, the use of drugs such as Depakote can lead to spinal malformations in fetuses. All of this suggests that folic acid seems to act in a way that is opposite from Depakote or other anticonvulsants, and therefore should usually be avoided except in the amounts present in foods or B complex. (Vitamin pills are allowed, by decree of the FDA, to include no more than 800 mcg of folic acid, so unless a substantial number of these are taken per day, this probably shouldn't be a problem.) An exception is when the patient has a demonstrated deficiency of folic acid (observable through blood tests), either spontaneous or caused through the use of anticonvulsants or other drugs; in this case, supplementation to bring the vitamin to the normal blood level may be used.
6. Magnesium and Calcium
A majority of Americans do not consume the RDA of magnesium. This is problematic since magnesium deficiency may lead to various problems such as anxiety, insomnia (especially that which consists of waking up in the middle of the night and being unable to go back to sleep), fatigue (as experienced in chronic fatigue syndrome), fibromyalgia, high blood pressure or PMS. Supplementation of this mineral is therefore desired for most people, especially those with mood problems. Magnesium is usually supplemented concurrently with calcium, since the two work together and since absorption tends to be greater when they are taken together. (Calcium may also act to relax the individual.) The usual recommendation is 2 parts calcium to 1 part magnesium---for example, 1000 mg of calcium and 500 mg of magnesium---taken at bedtime; however, a higher ratio of magnesium may be used to control PMS or similar conditions. Calcium carbonate is the most easily obtained form of calcium but is the lest digestible; many people (especially older individuals) will obtain better results through the use of other forms such as amino acid chelates, calcium citrate or hydroxapatite.
Manganese is a trace mineral that, in deficiency, can produce fatigue, irritability, memory problems and (most specific for diagnosis) ear noises such as ringing.
An deficiency in zinc can contribute to mental problems, and is especially common among people who suffer from pyroluria (see the section on B6 above). Deficiencies of this mineral are common, since it's hard to get enough zinc from the typical American diet (unless oysters are regularly consumed). Recent studies suggest that zinc supplementation is especially important during pregnancy. Generally, supplementation of no more than 30 mg is recommended unless a diagnosis of pyroluria has been made through lab tests.
L-tyrosine is an amino acid that serves as a precursor to the neurotransmitters norepinephrine and dopamine, which have been shown to be deficient in many manic-depressives during their depressed cycles. The supplementation of this amino acid may help the body to form more of these substances during these difficult times; in addition, it may be helpful in cases when clinical or subclinical thyroid disease is present. General recommendations are usually 500-5,000 mg per day, on an empty stomach in the morning or early afternoon (start at a low level and then work up gradually). As with all amino acids, try to get pharmaceutical grade product in capsules.
10. L-Phenylalynine and DL-Phenylalynine
Phenylalynine is a precursor to tyrosine, and so exhibits many of the same effects. In addition, the supplementation of phenylalynine can help the body to produce a substance called "phenylethylamine," which has been shown to be deficient in many manic-depressives. (Phenylethylamine is also present in chocolate and marijuana, and is created by the body in greater amounts when the individual is "in love"; conversely, a deficiency such as that suffered by many manic-depressives may lead to an unhappy feeling similar to that which "normal" people feel when they are heartbroken.) Phenylethylamine is supposedly present to a greater degree in the DL form of phenylalynine than the L form; however, the DL form may be more likely to increase blood pressure. (The issue of blood pressure increases is often cited as a problem for both the DL and L forms. This increase should be no more than 10 points for an hour or two after the substance is consumed; however, those people who are inclined toward high blood pressure should monitor theirs carefully and decrease or discontinue their use of this substance if a problem is observed.) The usual recommendation for the COMBINATION of tyrosine and phenylalynine (DL or L) is 500 to 5,000 mg per day, on an empty stomach in the morning or early afternoon. It is generally recommended that users start with a low dose and work up gradually.
Methionine is an amino acid that has been shown to be helpful for some individuals suffering from depression. (Its metabolite, SAM, has also been used to treat depression in some countries, but is not currently available in the United States.) A reasonable dosage seems to be 500-2000 mg per day.
12. L-Tryptophan and 5-Hydroxy-Tryptophan
L-tryptophan is an amino acid that serves as a precursor to the neurotransmitter serotonin (the one that is affected by SSRI drugs such as Prozac, Zoloft and the like). L-tryptophan was quite popular in treating depression and insomnia during the 1980s; however, in 1990 the substance was deemed responsible for a number of deaths and pulled from the market in the United States. Although the deaths were later attributed to a contamination of the product (non-pharmaceutical grade) made by one particular manufacturer, L-Tryptophan is currently available primarily by prescription in the United States, although this may change in the near future. (Some retailers have been known to sell veterinary versions of the amino acid for human use, however; one problem with this is that animal-grade amino acids may not be of the highest quality.) One phamacy that sells l-Tryptophan by prescription is Belmar, 1-800-525-943. It is also available over-the-counter in some European countries such as Holland.
However, another related product, 5-hydroxy-tryptophan, is currently available over the counter. 5-HTP is a metabolite of tryptophan (that is made in the body) that may work even better than tryptophan, so it may be worth a try for people who suffer from depression, irritability or other symptoms
This information is not a substitute for consultation with a licensed professional.
Modified Decenber 26, 2002