Healthy Lifestyles to Promote Mental Health

Kathi J. Kemper, MD, FAAP

Caryl J Guth Chair for Complementary and Integrative Medicine

Wake Forest University School of Medicine

“The part cannot be well unless the whole is well.”

Plato

Faculty Disclosure

In the past 12 months, I have had no relevant financial relationships with the

manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity. I do not

intend to discuss an unapproved or investigative use of a commercial product

or device in my presentation.

Objectives (by the end of this session, you will be able to…):

1. Compare and contrast mental, physical and spiritual health

2. Describe the role of a healthy lifestyle in promoting mental health

3. Advise patients to make healthy lifestyle changes using effective communication skills

Objective 4: Resources

http://www1.wfubmc.edu/phim/MHN.htm

1. Are Mental Health Problems Really a Problem?

2. What is Mental Health?        3.  Exercise  4.  Sleep  5.  Nutrition  6.  Dietary Supplements Overview  7.  Vitamins  8.  Minerals9.  Essential Fatty Acids10. Amino Acids11. Hormones12. Probiotics

 

  13. Environment: Promoting Positive Aspects

  14. Environment: Protecting Against Negative Aspects

        Stress Management Overview  15.

Stress Management: Emotional Practices

  16. Managing Stress: Mental Practices

  17. Managing Stress: Spiritual Practices

        Intro to Communication Skills & Community Building

  18. Communication Skills: Talking with Yourself

  19. Communication Skills: Talking with Others

  20. Building Community to Promote Mental Health

More to follow……

Depression Case

A 16 year old girl who is sad, has had a drop in grades and been irritable with her family; recently broke up with her boyfriend; less interested in tennis, has stopped taking her SSRI after hearing about black box warnings.

How can her lifestyle choices support her mental health?

Definitions: Mental Health

• Most medical literature on mental health focuses on mental illness, eg. Depression, anxiety, Bipolar, schizophrenia, ADHD, cognition/memory problems, adjustment disorders, personality disorders, etc.

• Mental health "First say to yourself what you would be; and then do what

you have to do." Epitectus

“You got to be careful if you don't know where you're going, because you might not get there.”

Yogi Berra

Optimal Physical health: Example

• Strength• Flexibility• Stamina/Endurance• Focus• Coordination• Resilience, and• Effective teamwork

Optimal Spiritual Health

• Faith• Forgiveness• Hope• Love• Kindness• Charity/generosity, and• Transcendence – connection

with something greater than our individual self

Mental Health: elements

• Confidence and courage• Adaptability• Cheerfulness• Attention / Concentration• Harmony• Hardiness in face of stress• Social Network/

communication skills/ connection to community

Mental Health - strategies

• Healthy lifestyle – as for promoting heart health, reproductive health, immune function, etc.

• #1 Lifestyle: Exercise/Rest, Nutrition, Environment(+/-), Stress management practices (EMS), Communication and community

• #2: Supplements/Meds, Professionals (psychologists, massage, acupuncture, etc)

Content: Conventional

• Psychotherapy• Medications

Cognitive Behavioral Therapy“From an evidence-based

perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders.”

Compton SN. JAm Acad Child Adolesc

Psychiatry. 2004

SSRI Side effects 1

• GI upset• Headache; sleep

disorders• Sexual side effects

Dizziness, Fatigue, Sweating

• Neonatal withdrawal syndrome

• Drug interactions

SSRI Side effects 2• Serotonergic syndrome (HTN,

tachycardia, mania)• Agitation and hostility• Suicidal ideation, esp in those with

agitation/hostility

• Drug co. assertion: our way or deprive patients of treatment. FALSE!Mosholder AD. J Child Adolesc Psychopharmacol. 2006

Natural: used commonly • Depression is one of the top 10

diagnoses for which patients seek natural therapies

• Commonly used by women• Fewer than 30% of patients tell

docs they are using natural therapies or strategies

• Clinicians need to ask!• Clinicians need to emphasize

the importance of healthy lifestyles for overall physical and mental health

Lifestyle - overview• Environment: More Sunshine and music,

Less TV and toxins• Exercise/Sleep (more of both)• Nutrition (Essential nutrients for optimal

brain function, EFA, amino acids, vitamins, minerals)

• Manage stress – emotional, mental, spiritual practices

• Communication/Community

Sunshine, circadian rhythms and sleep

Desynchronization of internal rhythms plays an important role in the pathophysiology of depression.

Resetting normal circadian rhythms can have antidepressant effects.

“Winter depression was first modeled on regulation of animal behavior by seasonal changes in day length, and led to application of light as the first successful chronobiological treatment in psychiatry.”

Fuchs E. Int Clin Psychopharmacol, 2006

Wirz-Justice A. Int Clin Psychopharmacol. 2006

Bright light exposure therapy

• Cochrane systematic review—all published studies on bright light exposure for non-seasonal depression found “modest though promising anti-depressive efficacy, especially when administered during the first week of treatment, in the morning, and as an adjunctive treatment to sleep deprivation responders (Tuuainen et al., 2004).”

Light Therapy for Depression

Plus 3 studies not included in this review, comparing dim light to bright light. Golden R. Am J Psychiatry. 2005

Light therapy

• Proven effective for SAD (Terman M Evid Based Ment Health, 2006)

• Meta-analysis of studies from 1987-2001: (effect size=0.53, 95% CI=0.18 to 0.89, similar to medications) for non-SAD

• RCT of 29 women with non-seasonal depression; light therapy for 28 days significantly better than control, (McEnany GW, 2005)

Light Therapy 2

• Benefits onset within 2 days; effective in institutionalized elderly and community; effective in summer and winter

• Side effects: hypomania, autonomic hyperactivation

(Terman M, 2005)

Vitamin D and depression

• Vitamin D receptors in brain• Low level of serum 25-hydroxyvitamin

D and high PTH are significantly associated with depression (Jorde, 2005)

• 25-hydroxyvitamin D3 and 1,25-dihydroxvitamin D3 levels are significantly lower in psychiatric patients than in normal controls (Schneider, 2000)

• RCT of 44 Australian patients (none, 400 IU versus 800 IU vitamin D) vitamin D3 significantly enhanced mood (Landsdowne, 1998)

More positive environment

• Music (avoid ear damage from loud noises)

• Nature (Last Child in the Woods)• Aromas (mint, citrus, lavender, vanilla)• More organization; less clutter• Implications for clinic/hospital design;

school design; workplace design

Turn off Depressing TV

• 9/11. Respondents who repeatedly saw "people falling or jumping from the towers of the World Trade Center" had higher prevalence of PTSD (17.4%) and depression (14.7%) than those who did not (6.2% and 5.3%, respectively).

• Depressive symptoms after the hurricane were predicted by watching television coverage of the looting that occurred in New Orleans

• People who watch more TV socialize less

Ahern, Psychiatry, 2002McLeish. Depress Anx, 2008

Other Environmental Toxins to Minimize

• Environmental Tobacco Smoke• Pesticides (neurotoxins)• BPA (behavioral as well as endocrine

effects)• Lead, mercury, etc. • Perc (dry cleaning)• Air pollution

Exercise

• Depressed mood / fatigue are common in those deprived of usual exercise.

• Mood changes noted in patients with injuries and mono.

• Exercise benefits depression *• Common sense precautions

Berlin AA. Psychosomatic Med, 2006

Exercise as Therapy – Yes

Lawlor DA. BMJ 2001

Yoga for depression

• Five RCTs --each used different forms of yoga.

• All trials reported positive findings

• No adverse effects except fatigue and breathlessness

Pilkington K. J Affective Disord, 2005

Sleep

• Poor sleep is barometer of depression

• Reduced sleep equals impaired focus and labile mood (ADHD, Learning problems)

• Sleep quality is a good screen for good mental health

• We sleep 20% less than we did 100 yrs ago

Sleep Hygiene

• Regular time; Routine• Hot bath; cool room; dark room• Massage before bed• Lavender, chamomile, melatonin?• No caffeine within 8 hours of bedtime• Music, calm, orderly, quiet• NO TV IN BEDROOM• NO vigorous exercise right before bed• GET MORE versus intentional sleep

reduction/deprivation

Nutrition – essential nutrients for optimal brain function

• Omega-3 fatty acids• Amino acids (SAM-E,

Trp, 5-HTP)• Vitamins (B vitamins,

Vitamin D)• Minerals (Iron,

Calcium, Magnesium, Zinc)

Top Foods (scores > 90/100)

Broccoli Green cabbageOranges TomatoGreen Beans ClementinePineapple WatermelonRadish MangoSummer Squash NF MilkApple FigsGrapes Bananas

Yale’s Griffin Prevention Research Center, 2008

Omega-6 Fatty Acids Omega-3 Fatty Acids

Linoleic Acid (18:2n-6) a-Linolenic Acid (18:3n-3)

(GLA)γ -Linolenic Acid (18:3n-6)

(DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6)

(AA)Arachidonic Acid (20:4n-6)

EicosanoidsLeukotriene 4-series

Prostaglandins E2

Thromboxanes A2

Eicosanoids

Stearidonic Acid (18:4n-3)

Eicosatetraenoic Acid (20:4n-3)

(EPA) Eicosapentaenoic Acid (20:5n-3)

24:5n-3

24:6n-3

(DHA) Docosahexaenoic Acid (22:6n-3)

EicosanoidsLeukotriene 5-seriesProstaglandins E3

Thromboxanes A3

∆-6 Desaturase

Elongase

∆-5 Desaturase

Elongase

∆-6 Desaturase

β-Oxidation

Omega 3 EFA’s: mechanism

• Neuronal membrane structure and function

• Brain development• Second messenger inside cells

Mood and Omega-3’s• Inverse correlation between fish intake

and depression (Hibbeln: Lancet 1998; 351:1213; Crowe: Am J Clin Nutr, 2007)

• Effective for bipolar patients (Stoll: Arch. of Gen. Psych. 1999; 56: 407-12)

• Effective for major depression (Nemets: Am. J. Psych. 2002: 159 (3) 477-9)

• Effective for depression in children (Am J Psychiatry 2006;163:1098-0)

Fish Oil –Doses, Safety, Brands• Dose: 1 gram daily of EPA probably

enough.(Peet M, 2002); Frangou S. Br J Psychiatry, 2006)

• Safety: fish allergies, taste, belching; very high doses, increased risk of bleeding, nosebleeds? Little risk of mercury, dioxin, PCB’s;

• Brands: Compare brands at www.consumerlabs.com

• My family takes Coromega, Carlson’s or Nordic Natural

• Read labels: Omega 3 does NOT necessarily all equal EPA/DHA

Amino Acids: real protein

• SAM-E Produced from ATP and methionine • Meta-analysis: SAMe significantly improves depression,

comparable to antidepressant medications (http://www.ahrq.gov/clinic/epcsums/samesum.htm)

• Acute tryp depletion leads to depression• Dietary L-tryp -> 5-HTP -> serotonin • Meta-analysis: 5-HTP and L-trp better than placebo for

depression (Shaw K, Cochrane. 2002)

• Food sources – dairy, eggs, poultry, meat, soy, tofu, nuts; WHEY protein

Vitamin B6 - pyridoxine

• Low levels of pyridoxal phosphate (PLP) are associated with depressive symptoms (Hvas AM 2004)

• Dose: 100 – 200 mg daily benefits PMS- depression; Odds ratio ~2.(Wyatt KM. BMJ, 1999)

• Side effects: nausea, vomiting, abd. pain, anorexia, headache, somnolence, lower B12 levels, sensory neuropathy (typically with doses over 1000 mg daily, can occur lower)

• Food: Beans, nuts, legumes, fish, meat

Folate• Folate (Essential co-factor for synthesis of S-adenosyl-methionine).

– Lower levels of folate in depressed persons– Low folate associated with poorer response to antidepressant meds

• Methylfolate in depressed pts (elderly, EtOH dependent, dementia) show significant improvement (Guaraldi et al., 1993; Di Palma et al., 1994; Glória et al., 1997; Passeri et al., 1993)

• RPCT: folate as adjunctive Rx in folate deficient MDD pts showed signif improvement over placebo (Godfrey et al., 1990)

• RPCT MDD pts randomized to fluoxetine + folate (0.5mg) improved more than fluox. + placebo; differences esp striking in WOMEN (Coppen & Bailey 2000)

• Studies on supplements in non-folate deficient MDD pts on SSRIs found significant reduction in sx severity and 19% remission (Alpert et al., 2002)

• Folate augmentation may enhance response to lithium in folate deficient bipolar and unipolar depression (Coppen and Chaudhry, 1986)

Bottom line on Amino acids and B vitamins

• Healthy diet rich in green vegetables and nutritious protein sources

• Consider B-complex supplement

• Consider whey powder (high in tryptophan), SAM-E, Tryp/5-HTP

Mood and Minerals: Iron

• Iron deficiency associated with depression

• Iron deficiency common in women

• Correcting iron deficiency helps with mood and attention

Beard JL. J Nutr, 2005

LE Murray-Kolb. Am J Clin Nutr, 2007

Mood and Minerals: Calcium

• Lower levels of calcium in depressed persons

• Higher PTH in depressed persons

• Estrogen regulates calcium and PTH metabolism; sometimes dysregulates? (Thys-Jacobs S. J Am Coll Nutr, 2000)

• Supplementation may benefit women with PMS-related depression (Dickerson LM. Am Fam Physician, 2003)

• 1000 – 1200 mg daily

Non-dairy sources of calcium

• Soy beans, tofu

• Calcium fortified OJ

• Green leafy vegetables (broccoli)

Magnesium

• Needed to convert tryp to serotonin• Regulates NMDA (N-methyl-D-aspartic acid)

receptors• Alters activity of glutamate, an amino acid

involved in learning and memory• Deficiency symptoms incl: constipation,

irritability, fatigue, mental confusion, insomnia, anxiety and easily feeling stressed.

• 2 + trials on Mg suppls for PMS- related anxiety• 3+ studies on Mg for bipolar/mania – stabilizes• Spinach, beans, seeds, nuts, whole grains

Iodine

• Needed to convert T4 to T3• Can be deficient if little iodized salt or

fish intake• World Health Organization (WHO)

statistics indicate that iodine deficiency disorders affect 740 million people throughout the world, and nearly 50 million people suffer from some degree of iodine-deficiency related brain damage (cretinism/MR/low IQ), plus increased risk of anxiety and depression

Nutrition Summary

• Healthy fat (omega 3, eg fish, nuts, flax); not fried foods, saturated fats

• Healthy protein (essential amino acids)• Foods rich in minerals and vitamins (organic,

locally grown vegetables, beans, grains)• Iodized salt• Multivitamin-mineral supplement (extra D)• Fish oil supplement• Consider B vitamins, Calcium, Mg, Iron if

deficient

Lifestyle: Stress management

• Stress is common• Stress commonly triggers mood problems• Managing stress: exercise, sleep, nutrition,

mind/emotion/body/spirit– Meditation– Biofeedback

Meditation

• Meditation training ↑ left-sided anterior activation, a pattern associated with positive affect, in meditators compared with the nonmeditators

• Positive effects on anxiety and improves concentration/clarity

• Few side effects; can combine mindfulness with CBT

Davidson RJ Psychosom Med, 2003

Stress, Emotion, and Physiological Activation

High Arousal/High Energy

SYMPATHETIC

PARASYMPATHETIC

Low Arousal/Low Energy

Institute of HeartMath

Stress, Emotion, and Physiological Activation

High Arousal/High Energy

SYMPATHETIC

PARASYMPATHETIC

Low Arousal/Low Energy

Negative

Emotion

Positive

Emotion

“Fight-or-Flight”

Stress, Emotion, and Physiological Activation

High Arousal/High Energy

SYMPATHETIC

PARASYMPATHETICLow Arousal/Low Energy

Negative

Emotion

Positive

Emotion

“Fight-or-Flight”Frustration, Anger, Hostility,

Fear, Worry Anxiety

Judgment, Resentment,

Feeling Overwhelmed, Anguish

Hopelessness, Submission,

Despair, Depression

Burnout, Withdrawal,

Boredom, Apathy

Exhilaration, Passion,

Love, Care,

Joy, Happiness

Kindness, Appreciation

Compassion, Tolerance,

Acceptance, Forgiveness

Serenity, Inner Balance,

Reflection, Contentment

The Heart Brain Relationship

The heart has its own complex nervous system -the “Heart Brain”

The heart sends far more information to the brain than the brain sends to the heart

The heart signals especially affect the brain centers involved in decision making, creativity and emotional experience

Stress management: biofeedback

• HRV biofeedback appears to be a useful adjunctive treatment for the treatment of MDD

• Significant improvements in – Hamilton Depression Scale (HAM-D) – Beck Depression Inventory (BDI-II) by week 4,

Karavidas, et al. Appl Psychophysiol Biofeedback. 2007

Nolan RP. Am Heart J, 2005

Promote Social Support

• Religiosity (participation) helps protect against depression

• Participation in organized athletics, civic groups, etc. is protective

• Ongoing volunteer work is protective

• Connected people are happier people

SUMMARY: LIFESTYLE

• Sunshine, sleep, exercise, nutrition (supplement when necessary), stress management and social support (fellowship/ community)

How: Behavioral Medicine

• Identify the goal• Consider various strategies• Pick a strategy• Identify a small, achievable step that the patient

and family can support• Explore pros and cons of change• Anticipate barriers; identify resources• Plan rewards/celebrations!• Re-evaluate; take the next step

Goal-setting

• Pick a POSITIVE goal– E.g., healthier lifestyle

– NOT stop eating junk food– DEPRIVATION IS

UNATTRACTIVE

Example: Healthier lifestyle

To promote Better moodBetter focus or concentrationGreater calm More resilienceMore cheerfulness Greater adaptabilityMore confidence More creativeMore clarityBetter memoryMore harmonious relationshipsHigher self esteemMore consistent with personal valuesother?

Pick a specific strategy

• More exercise• Better nutrition• Judicious use of supplements• Better sleep• Healthier environment• Stress management; biofeedback; journal;

meditation• Use medication• Massage, psychotherapy, acupuncture or other

professional help

Identify a small, achievable step

• Rome was not built in a day; habits are not changed overnight: BABY STEPS.

• For exercise, go from sedentary, to 5 minute walks with the dog 5 days a week.

• Be specific (with or without an MP3 player; with or without a friend; regardless of weather?; distance vs. time)

How important is this to you?

0 1 2 3 4 5 6 7 8 9 10Not Very

Why did you pick that number and not a lower number? (e.g. a 7 instead of a 5)

Asking this question helps the patient/family provide their own rationale for why this is important. They talk themselves into it!

How confident are you that you can do this for one month?

0 1 2 3 4 5 6 7 8 9 10Not Very

If they pick an 8 or higher (pretty confident), proceed with next step of making a chart and planning rewards and

follow-up.

If they pick a number less than 8, “What would it take for you to go from the number you

picked to a higher number?” Begin to explore their ambivalence…. It’s OK to be ambivalent about change!

Identify Pros and Cons

  PRO CON

Change More cheerful Change routine

 More fit and cool Brother might tease

 Clothes fit better Yucky dog clean up

  Better sleep  

 Better self-esteem  

No Change Easy Continued mood probs

 Mom does yucky job Get fat

   Feel ugly

    Sleep badly

   Unhappy with myself

Identify Barriers and Resources

• In addition to (cons listed above), what other barriers or challenges might you anticipate as you try to make this change? Need new tennis shoes; need leash; need pooper-scooper

• What resources do you have/need to help you make this change? Will Mom commit to getting new shoes, leash, etc. ? Will the child want/need a reminder? Is it helpful for Dad to do that? Do they need a chore chart? A calendar?

Plan celebrations/rewards

• Pick a tangible reward and timing (will it be offered after week 1, 2, 3, 4?)

• Samples: new walking shoes; Support the patient’s choices.

• Emphasize the importance of the reward/celebration. If the patient says they expect “good” behavior, suggest they consider celebrating it (instead of rewarding it).

Sample behavior diary (OK to copy)

Goal                

Sample: M T W Th Fri Sa Su Total

Walk dog 5 minutes 5 days a week √   √ √ √ √   5

Week 1                

Week 2                

Week 3                

Week 4                

Re-evaluate.Celebrate.Next steps?

Follow Up

• Follow- up in 4-6 weeks.• Ask patient to bring chart and say you

plan to be proud of them (build expectation of success) and will ask them what they’d like to do for next step (involve them in problem solving).

• Do it!

Behavioral Medicine

• Identify the goal• Consider various strategies• Pick a strategy• Identify a small, achievable step that the patient

can embrace• Explore pros and cons of change• Anticipate barriers; identify resources• Plan rewards/celebrations!• Re-evaluate; take the next step

Resources

• Kemper KJ, Shannon S. Complementary and alternative medicine therapies to promote healthy moods.Pediatr Clin North Am. 2007 Dec;54(6):901-26

• Natural Medicines Comprehensive Database• Natural Standards

• http://www.besthealth.com/Integrated+Medicine/

• http://www1.wfubmc.edu/phim/MHN.htm