Day # 41: Nutraceuticals / Complimentary and Alternative Medicine (CAM)

Today is our last day of our current theme of depressive disorders. Today we are going to be discussing neutraceuticals and complimentary and alternative medicine (CAM) within psychiatry. This is an enormous topic and a short Bullet Psych post obviously can't completely do this justice. However we are going to provide an introduction and preview of some of the more commonly used agents including 5-HTP, Omega-3 fatty acids, SAMe, St. John's Wort, kava kava, valerian, and more.

Today's content level: All levels (Beginner, Intermediate, Advanced)

INTRODUCTION

•Nutraceuticals = Nutritional supplements that are "pharmaceutical grade"

•The FDA does monitor safety but does not monitor efficacy (treated similar to a dietary supplement).

•Because dietary supplements are not regulated by the FDA, the contents and quality on store shelves can vary dramatically and different preparations by different companies may vary in regards to dosing and potency.

•Despite this the use of neutricuticals is common, and we should do our part to understand some of the more commonly used options. Below we will briefly discuss a handful of neutricuticals, but for a more thorough and comprehensive review please see Chapters 24 and 29 of Kaplan and Sadock's.

St. John's Wort (Hypericum perforatum)

• Mechanism under investigation. May act as an MAOI and/or SSRI.

• Also interacts with HPA axis to reduce cytokine and cortisol production.

• Effective in mild-moderate depression with similar effects of SSRI's. 1

• Do not combine with SSRIs or other serotonergic agents due to risk of serotonin syndrome.

• Some reports of manic reaction when combined with SSRI.

• Headaches, photosensitivity, and constipation are common.

• Induces CYP-3A4. Will decrease effectiveness of oral contraceptives and warfarin.

S-Adenosyl-L-methionine (SAMe)

• Intermediate product in the metabolism of B12 and Folate. Natural molecule made from the a amino acid methionine and ATP.

• Serves as a methyl group donor of catecholamines, increased serotonin turnover, reuptake inhibition of norepinephrine, and enhanced dopamine activity.

• Anti-inflammatory properties and used for arthritis and fibromyalgia.

• May be effective as an augmentation strategy for SSRI in depression.

5-Hydroxytryptophan (5-HTP)

• Immediate precursor of serotonin 5HT (derivative of tryptophan).

• Shown to be superior to placebo for depression.

• 5-HTP + carbidopa used in Europe to treat depression.

• Also has been used in obesity, insomnia, fibromyalgia, and headaches.

Phenylalanine

• This is an essential amino acid found in vegetables, juices, yogurt, and miso.

• Investigated uses include treatment of depression, analgesia, and vitiligo.

• Contraindicated in patients with PKU.

Kava kava (Piper methysticum)

• Extract from a crop native to the pacific islands.

• Blocks voltage-gated sodium and calcium channels which leads to inhibition of excitatory neurotransmitters (glutamate). Also enhances GABA-A receptor activity.

• This overall leads to a sedative and hypnotic effect.

• Can cause hepatotoxicity.

Valerian (Valeriana officinalis)

• Flowering plant native to Europe and Asia.

• Activates GABA receptors to produce sedative and mild hypnotic effects.

• Investigated uses include treatment of anxiety and insomnia.

• Some studies suggest equivalence to benzodiazepines. 2

Ginkgo Biloba

• Extract made from the leaves/tree native to China.

• Mechanism not fully understood but believed to have antioxidant/anti-inflammatory properties.

• Purported for the symptomatic relief of delirium/dementia and improves concentration and memory deficits.

• Possible treatment for SSRI-induced sexual dysfunction.

Vitamin D

• Fat-soluble vitamin that increases the expression of genes encoding for the precursor of dopamine and norepinephrine (tyrosine hydroxylase).

• Receptors found in brain areas related to depression (prefrontal cortex, hypothalamus, and substantiated nigra).

• Vitamin D deficiency is noted to be a medical contributor to depression and decreased energy.

Omega-3 Fatty Acids

• Fatty acid that comes in three forms (EPA, DHA, and LNA). DHA formula may not be effective in psychiatry.

• Broad mechanism includes stabilization of neuronal membranes, anti-inflammatory properties, and modulates monoamine (serotonin, norepinephrine, dopamine) reuptake and degradation.

• Used as a supplement for heart disease, high cholesterol, and high blood pressure.

• May also be helpful adjunct in treatment of depression, schizophrenia, and ADHD.

• At high doses there is an increased risk of bleeding and cycling in bipolar disorder.

Melatonin

• Natural hormone produced by the pineal gland and interacts with the suprachiasmatic nucleus to regulate the circadian rhythm.

• Given for direct mild sedative effect in insomnia as well as for circadian rhythm disorders.

CONCLUSION

I hope this was a helpful overview of some of the common nutraceuticals used within psychiatry. There are so many more that are in use, but impossible to cover them all in this one article. I recommend asking all of your patients what they are ingesting from a medication and nutraceutical perspective and reading up on them as needed.

Also, this is the last day of the depressive disorders theme. Next lesson we will start our next theme which is bipolar disorder.

Resources for this post include Kaplan and Sadock's Synopsis of Psychiatry and Pocket Psychiatry.

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