American Psychiatric Association Task Force on supplements for major depression

The American Psychiatric Association recently commissioned a task force to study the state of “alternative and complementary” therapies for major depression. This follows widespread interest from the scientific community and a considerable accumulation of research to date. The Task Force reported in a 2010 article that focused special attention on these supplements: omega-3 fatty acids (commonly taken as fish oil supplements), St John’s Wort (the botanical Hypericum), Folic acid (a synthetic form of folate, a B vitamin found in leafy green vegetables, citrus fruits, beans, and fortified breads and cereals), and S-adenosyl-L-methionine (SAMe).

We welcome this acknowledgment by the mainstream US medical establishment that supplements have a role to play in treating a disabling condition that affects millions of people per year, and is not always easily treatable. (Only one-third of adult patients newly diagnosed with major depression achieve complete symptom relief when taking one antidepressant, so there is often an extended search for the right combination of drug and other treatment needed for remission.)

Below is a brief recap of some of the latest thinking on these key supplements for depression. Of course NYBC recommends that you use these supplements in consultation with your healthcare provider. More information on these supplements can be found by following the links to the NYBC website.

Omega-3 Fatty Acids (fish oil) recommended as a stand-alone treatment for people concerned about side effects, such as those with multiple medical conditions. It has also been combined with other antidepressants as an adjunct therapy. Fish oil’s blood-thinning property makes it problematic for doses above 3g/day. Added benefit: fish oil supports cardiovascular health.

St. John’s Wort is an herb widely studied and used, especially in Europe, for mild to moderate depression, though it hasn’t proved effective for major depression. Those taking protease inhibitors or certain other drugs should avoid St. John’s Wort because it interferes with their action.

SAMe (S-adenosyl-l-methionine). Supplementing with SAMe increases concentrations of neurotransmitters that influence mood, and multiple studies have confirmed its antidepressant effect. A dose of 400-800mg/day has been studied for mild-to-moderate depression, and 800-1600mg/day for moderate-to-severe. Studied as a stand-alone treatment, or as an adjunct treatment. Added benefit: SAMe supports joint health and liver function.

When combined with an antidepressant, folic acid supplements can improve symptoms, particularly in women. However, folic acid supplements are not a stand-alone treatment for depression. The safe upper limit is 1,000 mcg per day.

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Follow-up on folate and cancer risk

We’ve had a recent comment on our own post regarding the importance of B12 and folate supplementation for people with HIV. The comment expressed concern about some reports that folate may be associated with increased cancer risk. Here’s a reply to that comment:

We recommend this web page for a recent study of folate and REDUCED colorectal cancer risk:

http://www.michaelmooney.net/FolateReducesCancerWillet.html

The 2011 article cited, by a well-known nutrition scientist, finds folate from diet and folate from supplements both associated with reduced colorectal cancer incidence–when taken over a long period (we’re talking about 15-20-30 years). This fits with what is generally understood about the value of vegetables in reducing cancer risk. Not surprising to us is the other finding of the study: that short-term folate intake, around the time of the development of pre-cancers, is not going to help reduce cancer incidence! Indeed, many supplements do not necessarily produce pronounced short-term effects, but rather show health benefits over the long term.

B vitamins for eye health

A heart disease study sponsored by the NIH has also yielded some interesting information about the relationship between B vitamins and eye health. The research study, from Brigham and Women’s Hospital in Boston, found that taking a mixture of B vitamins, including B-6, folic acid and B-12, lowered the chance of middle-aged women developing macular degeneration (a common form of vision loss in older adults) by one-third. The study, which tracked more than 5000 women age 40 and older, was published in the Archives of Internal Medicine, Feb. 23, 2009.

Note that NYBC stocks this B vitamin supplement:

B-right (Jarrow)

B-right includes folic acid, B-6 and B-12; one of the rationales for its formulation is to prevent buildup of the chemical homocysteine, which in studies has been associated with heart attacks.

Folate (Folic acid) supplementation: a recommendation for acute, continuation and maintenance treatment of depression

Here is a dosage recommendation for supplementation with Folate/Folic acid during the treatment of depression. It’s the conclusion offered by Simon N. Young, Dept. of Psychiatry, McGill University in a 2004 review article:

What about the recommendation that 2 mg of folate be given during the acute, continuation and maintenance treatment of depression? The actual dosage may be debatable; 1 mg may suffice, particularly in countries where there is voluntary or compulsory fortification of food with folate, and the addition of a vitamin B12 supplement may be prudent, but the general principle is reasonable. With our current knowledge, the potential benefits seem to far outweigh any disadvantages.

Reference: Simon N. Young, “Folate and depression—a neglected problem” in J Psychiatry Neurosci. 2007 March; 32(2): 80–82.

For further discussion, see the NYBC entries:

Folate

B-Right (B vitamin complex)

B-12

Book Review: “Supplement Your Prescription — What Your Doctor Doesn’t Know About Nutrition,” by Hyla Cass, M.D.

This is an excellent guide to managing the side effects of prescription drugs through better nutrition and nutritional supplements. Published in 2007 by Basic Health Publications, it synthesizes much recent research on how the most frequently prescribed drugs for Type 2 diabetes, cardiovascular disease, osteoarthritis, and depression often cause nutrient deficiencies that can lead to additional health problems. Dr. Cass, who is a practicing physician and a specialist in integrative medicine, provides clear analyses of these damaging side effects and offers recommendations on how to address them.

The first condition discussed by the book is Type 2 Diabetes/insulin resistance/metabolic syndrome. For those who are taking the most commonly prescribed drug for Type 2 Diabetes, metformin, Dr. Cass stresses the importance of supplementing with Vitamin B12 (200-1000mg/day) folic acid (400-800mg/day) and CoQ 10 (30-200mg/day) to make up for the nutrient-depleting effects of the medication. Vitamin B12 and folic acid, together with Vitamin B6, are crucial for keeping levels of an amino acid called homocysteine in check in the body. Since elevated levels of homocysteine are associated with heart disease, stroke, hypertension, neuropathy, and Alzheimer’s, it’s a top priority to keep the body supplied with the B vitamins that can control it.

Dr. Cass also provides a “Diabetes Supplement Program” especially directed to pre-diabetics who may be able to address their condition with diet, exercise, and supplements (the B vitamins and CoQ 10 mentioned above, plus alpha lipoic acid, antioxidants, and the trace minerals chromium and vanadium, which are needed in blood sugar processing).

Much more to discuss in this very useful book, so we will come back to it again!

Depression and B vitamins – University of Maryland Medical Center’s Complementary Medicine Website

Here’s more on the role of the B Vitamins in depression, together with some common supplementation strategies.

Source: University of Maryland Medical Center’s Complementary Medicine web resource

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Depression
Studies suggest that vitamin B9 (folate) may be associated with depression more than any other nutrient. Between 15% and 38% of people with depression have low folate levels in their bodies and those with very low levels tend to be the most depressed. Many healthcare providers start by recommending a multivitamin (MVI) that contains folate, and then monitoring the homocysteine levels in the blood to ensure the adequacy of therapy. Elevated homocysteine levels indicate a deficiency of folate even if the levels of folate in the blood are normal. If the MVI alone is not enough to lower homocysteine and improve folate function, the provider may suggest additional folate along with vitamins B6 and B12 to try to bring the homocysteine levels down, thereby eliminating the functional folate deficiency and, hopefully, helping to improve feelings of depression.

Note: NYBC stocks Douglas Lab’s Added Protection Without Iron, a highly bioavailable multivitamin that includes a comprehensive B complex. The no-iron formula is recommended especially if you have elevated liver enzymes or hepatitis.

You can also consider Added Protection With Iron if you want to include iron in your supplements.

Another choice for focusing on the B Vitamins is Jarrow’s B-right, which is especially formulated to provide optimal amounts of folate/folic acid (B-9), B-6 and B-12 for lowering homocysteine levels.

Why Vitamin B12 and Folic Acid (Folate) are important to people with HIV

We’ve adapted this piece from the NYBC Info Sheet on Vitamin B12.

NYBC members often supplement with B-right B complex or with Methylcobalamin, a form of B12 that is better absorbed by the body than other forms of B12.


B-12 may play a very critical role in preventing HIV disease progression: a large Johns Hopkins University study found that people with HIV who are deficient in B-12 have a two-fold increased risk of progression to AIDS. In this study, those who were B-12 deficient progressed to AIDS four years faster than those who were not. The exact mechanism by which adequate B-12 in the body may slow progression is not known, but the finding is not surprising, given all the roles B-12 is known to play in healthy human function.

B12 and another B vitamin, folic acid, are critical to prevent or eliminate the often-overwhelming fatigue that so often accompanies HIV disease, as well as to help prevent some forms of neuropathy and brain and spinal cord changes. Maintaining adequate B12 levels also supports the bone marrow’s production of blood cells (crucial to prevent white and red blood cell decreases), and helps protect the heart.

There are countless anecdotal reports from people with HIV that using B-12 supplementation has dramatically improved their lives by its ability to reverse fatigue, often restoring normal energy to people who had previously been so exhausted that their daily functioning had been greatly affected. Many people have also reported significant improvements in memory and mental functioning, improvements that have made a huge difference in daily life. The possibility that B-12 supplementation might also help prevent or reverse the spinal cord changes that can have such devastating effects on some people is also very encouraging.

B-12 and folic acid should always be given together. Doses of B-12 (1000 mcg given daily via pills, or one to several times weekly via prescribable nasal gel or injections) and folic acid (800 mcg daily via pills) may be useful for restoring energy, treating neuropathy, protecting the heart, increasing overall feelings of well being, and boosting mental function (especially when combined with thiamin, niacin, and folic acid, since all four of these B vitamins are needed for normal neurological function) even when tests don’t indicate obvious deficiencies.

Deficiencies of B-12 can result in deterioration of mental function and neurologic damage that will yield such symptoms as memory loss, decreased reflexes, weakness, fatigue, disorientation, impaired pain perception, tinnitus (chronic ringing in the ears), neuropathy, burning tongue, and various psychiatric disorders. B-12 deficiency can also cause canker sores in the mouth, impaired bone marrow function, loss of appetite, and loss of weight, as well as impaired antibody responses to vaccines.

Folic acid deficiency can also cause fatigue and weakness, along with irritability, cramps, anemia, nausea, loss of appetite, diarrhea, hair loss, mouth and tongue pain, and neurological problems. In addition, folic acid deficiency is believed to play a role in the development of numerous and varied types of human cancers.

A combination of B-12 and folic acid deficiency can allow increases in blood levels of homocysteine, a chemical that can damage artery walls and contribute to heart disease.

One of the known causes of B12 deficiency is chronic viral illness with resulting poor gastrointestinal absorption. AZT use may contribute to deficiencies of both B-12 and folic acid. Many other drugs may worsen folate status in the body including TMP/SMX (Bactrim, Septra), pyrimethamine, and methotrexate (all three of which are folate antagonists), as well as phenytoin (Dilantin), various barbiturates, and alcohol (all of which block folate absorption). B-12 deficiency can also worsen folate levels in the body because B-12 is required to change folate into its active form.