Depression/SAD

Why is it depression is more common in women than men? Why is it that twice as many women are prescribed antidepressants and tranquillisers than men? Perhaps it is the extra stress of life as a woman coping with family, work, husbands and with the added social problems of divorce, poor job prospects and general frustration of life at home. This is the feminists point of view, but it does not really explain why life should be more stressful or depressing for a woman than it may be for a man. However, there is a belief that at times of anxiety and stress, women complain and men misbehave. That means that women go to their doctors and are prescribed antidepressants and men go out drinking and worse.

It is clear that this excess of depression in women starts at puberty and is no longer present in the 6th and 7th decade. The peaks of depression occur at times of hormonal fluctuation in 1) the premenstrual phase, 2) the postpartum phase and 3) the climacteric perimenopausal phase, particularly in the one or two years before the periods cease. This triad of hormone responsive mood disorders, (HRMD) often occur in the same vulnerable woman.

Postnatal depression is another example of depression being caused by fluctuations of sex hormones and having the potential to be effectively treated by hormones. It is a common condition which affects 10-15% of women following childbirth and may persist for over one year in 40% of those affected. There does seem to be a lack of any overall influence of psychosocial background factors in determining vulnerability to this postpartum disorder although it can be recurrent.

Postnatal depression is severe and more prolonged in women who are lactating and lower oestradiol levels are found in depressed women following delivery than with controls. It is probable that the low oestradiol levels with breast feeding and the higher incidence of depression are related in a causative way.

PREMENSTRUAL SYNDROME

This condition is mentioned in the fourth century BC by Hippocratic but became a medical epidemic in the nineteenth century. “The monthly activity of the ovaries which marks the advent of puberty in women has a notable effect upon the mind and body; wherefore it may become an important cause of mental and physical derangement…" This and other female maladies were recognised, rightly or wrongly, to be due to the ovaries.

Severe premenstrual syndrome (PMS) is a poorly understood collection of cyclical symptoms, which cause considerable psychological and physical distress. The psychological symptoms of depression, loss of energy, irritability, loss of libido and abnormal behaviour as well as the physical symptoms of headaches, breast discomfort and abdominal bloating may occur for up to 14 days each month. There may also be associated menstrual problems, pelvic pain, menstrual headaches and the woman may only enjoy as few as 7 good days per month. It is obvious that the symptoms mentioned can have a significant impact on the day-to-day functioning of women. It is estimated that up to 95% of women have some form of PMS but in about 5% of women of reproductive age they will be affected severely with disruption of their daily activities. Considering these figures it is disturbing that many of the consultations at our specialist PMS clinics start with women saying that for many years they have been told that there are no treatments available and that they should simply "live with it".

The exact cause is uncertain but fundamentally it is due to the hormonal or biochemical changes, (whatever they are with ovulation), and the resulting complex interaction between ovarian steroids and neuro-endocrine factors that occur with ovulation. This combination produces these varied symptoms in women who are somehow vulnerable to changes in their normal hormone levels. These cyclical chemical changes, probably due to progesterone or one of its metabolites, produce the cyclical symptoms of PMS.

MENOPAUSAL DEPRESSION

Like many aspects of depression in women, the diagnosis of climacteric depression and its treatment remains controversial. Whereas gynaecologists who deal with the menopause have no difficulty in accepting the role of oestrogens in the causation and the treatment of this common disorder, psychiatrists seem to be implacably opposed to it. This may be because there is no real evidence of an excess of depression occurring after the menopause, nor any evidence that oestrogens help postmenopausal depression or what used to be called "involutional melancholia". This is quite true and indeed many women with longstanding depression improve considerably when the periods stop. This is because the depression created by premenstrual syndrome, heavy painful periods, menstrual headaches and the exhaustion that attend excess blood loss disappears. Therefore, the longitudinal studies of depression carried out by many psychologists, particularly those as notable as Hunter(28), have shown no peak of depression in a large population of menopausal women. The depression that occurs in women around the time of the menopause is at its worst in the two or three years before the periods stop. This, of course, is perimenopausal depression and is no doubt, related to premenstrual depression as it becomes worse with age and with falling oestrogen levels.

Of the 30 or so neurotransmitters that have been identified, researchers have discovered associations between clinical depression and the function of three primary ones: serotonin, norepinephrine, and dopamine. These three neurotransmitters function within structures of the brain that regulate emotions, reactions to stress, and the physical drives of sleep, appetite, and sexuality. Structures that have received a great deal of attention from depression researchers include the limbic system and hypothalamus.

MELATONIN & DEPRESSION

Melatonin is an important nighttime hormone associated with sleep and regeneration. However, excessive levels or daytime melatonin can cause depressive disorders. Medical research confirms the relationship between melatonin and mood disorders. The following paragraphs explain how melatonin works and why it causes depression.

DARKNESS & MELATONIN

Melatonin is normally released by the pineal gland in the evening as sunlight is diminishing. Melatonin causes us to feel tired and withdraw. This helps us to sleep, but if we have to be awake when melatonin is in our system, we become lethargic, disoriented, irritable and moody. This explains why shift work and jet lag can be so debilitating, and why depression rates are highest in darker climates. Almost everyone with a mood disorder suffers worse in the winter because of excess melatonin in his or her system.

DAYTIME MELATONIN

Just as with jet lag, other factors can cause our bodies to produce melatonin into the day. Some causes such as trauma, stress, injury, age or lack of light will shift your body’s timing or release of melatonin. This shift can create excessive levels during the day and not enough melatonin at night.
If you experience any of the following symptoms, you may have a melatonin imbalance:

• Tiredness or lethargy during the day
• Social or physical withdrawal
• Irritability
• Excessive sleepiness or insomnia

SPECIALISED LIGHT SUPRESSES MELATONIN The release of melatonin is triggered by photoreceptors in the eye, called melanopsin. This is how darkness signals the brain to produce melatonin and stop the production of active, daytime hormones such as serotonin. However, when stimulated by special light, these same photoreceptors also tell the brain to stop the production of melatonin.

USE OF T3 THYROID HORMONE TO TREAT DEPRESSION

If you are tired much of the time, your doctor will order blood tests for the two thyroid hormones called T3 and T4 and for the brain hormones called TSH and prolactin. If your TSH is high and your prolactin is normal, you are probably hypothyroid and need to take thyroid hormone to give you more energy and prevent heart and blood vessel damage. Doctors treat people with low thyroid function with thyroid pills called T4 (Levothroid, one brand name is Synthroid). Many doctors think that a person needs only T4 because the thyroid gland makes T4 and then it is converted to T3 in other tissues. However, some people become depressed when they take just T4 and their depression can be cured when they take both thyroid hormones, T3 and T4. Homoeopathic hormones with herbal formulae to influence the conversion of T4 to T3 is a more naturopathic approach.

The B-Complex Vitamins

The B-complex vitamins are essential to mental and emotional well-being. They cannot be stored in our bodies, so we depend entirely on our daily diet to supply them. B vitamins are destroyed by alcohol, refined sugars, nicotine, and caffeine so it is no surprise that many people may be deficient in these.
Here's a rundown of recent finding about the relationship of B-complex vitamins to depression:

• Vitamin B1 (thiamine): The brain uses this vitamin to help convert glucose, or blood sugar, into fuel, and without it the brain rapidly runs out of energy. This can lead to fatigue, depression, irritability, anxiety, and even thoughts of suicide. Deficiencies can also cause memory problems, loss of appetite, insomnia, and gastrointestinal disorders. The consumption of refined carbohydrates, such as simple sugars, drains the body's B1 supply.
  
  
• Vitamin B3 (niacin): Pellagra-which produces psychosis and dementia, among other symptoms-was eventually found to be caused by niacin deficiency. Many commercial food products now contain niacin, and pellagra has virtually disappeared. However, subclinical deficiencies of vitamin B3 can produce agitation and anxiety, as well as mental and physical slowness.
  
  
• Vitamin B5 (pantothenic acid): Symptoms of deficiency are fatigue, chronic stress, and depression. Vitamin B5 is needed for hormone formation and the uptake of amino acids and the brain chemical acetylcholine, which combine to prevent certain types of depression.
  
  
• Vitamin B6 (pyridoxine): This vitamin aids in the processing of amino acids, which are the building blocks of all proteins and some hormones. It is needed in the manufacture of serotonin, melatonin and dopamine. Vitamin B6 deficiencies, although very rare, cause impaired immunity, skin lesions, and mental confusion. A marginal deficiency sometimes occurs in alcoholics, patients with kidney failure, and women using oral contraceptives. MAOIs, ironically, may also lead to a shortage of this vitamin. Many nutritionally oriented doctors believe that most diets do not provide optimal amounts of this vitamin.
  
  
• Vitamin B12: Because vitamin B12 is important to red blood cell formation, deficiency leads to an oxygen-transport problem known as pernicious anaemia. This disorder can cause mood swings, paranoia, irritability, confusion, dementia, hallucinations, or mania, eventually followed by appetite loss, dizziness, weakness, shortage of breath, heart palpitations, diarrhoea, and tingling sensations in the extremities. Deficiencies take a long time to develop, since the body stores a three- to five-year supply in the liver. When shortages do occur, they are often due to a lack of intrinsic factor, an enzyme that allows vitamin B12 to be absorbed in the intestinal tract. Since intrinsic factor diminishes with age, older people are more prone to B12 deficiencies.

Folic acid: This B vitamin is needed for DNA synthesis. It is also necessary for the production of SAM (S-adenosyl methionine). Poor dietary habits contribute to folic acid deficiencies, as do illness, alcoholism, and various drugs, including aspirin, birth control pills, barbiturates, and anticonvulsants. It is usually administered along with vitamin B12, since a B12 deficiency can mask a folic acid deficiency. Pregnant women are often advised to take this vitamin to prevent neural tube defects in the developing foetus

DEPRESSION - THE NUTRITION CONNECTION

Objectively evaluate  a person with abnormal biochemistry that would predispose them to depression and then change the body’s biochemistry by giving a personalised nutrition programme. "If there’s a drug that can alter the brain’s biochemistry, there’s usually a combination of nutrients that can achieve the same thing without side-effects" said Pfeiffer, who had spent most of his life researching biochemical aspects of mental health, funded by the US government. Now, after thirty years of positive research and good clinical results I believe the time has come for another option, nutrition counselling, to be made available to those with mental health problems.

Depression - not all in the mind

Depression isn’t a disease with a one cause, nor one treatment. For some the problem may be purely psychological, for others purely biochemical. Common biochemical imbalances that can induce depression include:

• Deficiencies of nutrients (vitamin B3, B6, folate, B12, C, zinc, magnesium, essential fatty acids)
  
  
• Neurotransmitter imbalances (serotonin, dopamine, adrenalin, histamine)
  
  
• Blood sugar imbalances (often associated with excessive sugar and stimulants)
  
  
• Allergies and sensitivities
  The presence of one or more of these factors may worsen a person’s ability to cope with stress and thus be an underlying contributor to what might otherwise be considered depression of a psychological origin. Conversely, many depressed people fail to adequately nourish themselves. It’s a chicken or egg situation. What is known is that nutritional deficiency is more common in those with mental illness, especially in the elderly population. For example, research at Kings College Hospital found that 33 per cent of those with psychiatric disorders were deficient in folate (1), while a survey of 93 elderly patients found 73 were deficient in iron or B vitamins, especially folic acid (2). There is suggestion that those with mental health problems may need more, or absorb fewer nutrients. It has been demonstrated, for example, that schizophrenia patients require more vitamin C to attain normal blood levels than controls (3) and more niacin to induce the normal vasodilation response than controls (4).

The Great British vitamin scandal

The most promising nutrients to date are vitamins B3, B12 and folic acid, then vitamin B6, zinc and magnesium and essential fatty acids (EFAs). The first three are involved in the vital biochemical process known as methylation, which is critical for balancing the neurotransmitters dopamine and adrenalin.
Research on folic acid have shown improvement in both depression and schizophrenia. Giving those with borderline or low folate status 15mg a day alongside standard psychotropic treatment significantly improved clinical and social recovery in patients with depression and schizophrenia in a double-blind controlled trial at Kings College Hospital and the Department of Psychiatry(1).
Vitamin B6 and zinc work together. In fact vitamin B6 (pyridoxine) does nothing in the body until it is converted into pyridoxal phosphate, this conversion depending on adequate zinc levels. About one third of the psychiatric population show the excessive excretion of ‘kryptopyrroles’ in the urine, the formation of which robs the body of B6 and zinc. Giving more of these nutrients corrects this

NEUROANALYSIS OR PSYCHOANALYSIS?

The major anti-depressants are thought to work by affecting the balance and function of certain neurotransmitters. These include serotonin re-uptake inhibitors
such as Prozac, Lustral, Seroxat which are designed to keep serotonin in circulation; adrenalin reuptake inhibitors such as Edronax, designed to keep adrenalin in circulation; monoamine oxidase inhibitors, which again help maintain adrenalin and dopamine levels and the tricyclic anti-depressants such as amitriptyline which also prevent adrenalin breakdown. Notice that most of these drugs block biochemical pathways. That is, they interfere with the body’s normal chemistry. The consequence is frequent side-effects and a need to get the dose just right to balance positive effects and the side effects. For example, Prozac, considered to be among the safest anti-depressants, has 45 known side-effects. The most common are nausea, nervousness, insomnia, headache, tremors, anxiety, drowsiness, dry mouth, excessive sweating and diarrhoea. According to a survey by US psychiatrist David Richman 10 to 25 per cent of people on Prozac experience all of these.
An alternative approach to give the nutrients our bodies have evolved to use to make more of these neurotransmitters. Figure 1 shows the symptoms associated with excess and deficiency of neurotransmitters and the co-factor nutrients involved (7).

Serotonin, for example, is made from the protein constituent tryptophan, in the presence of sufficient vitamin B3, B6 and zinc.
Tryptophan was shown to be an effective anti-depressant for some patients and tryptophan depletion can induce depression in recovered depressed patients. This has been well demonstrated by research at Oxford University’s Department of Psychiatry, in which 15 women with a history of depression were given a diet excluding or including tryptophan under double-blind conditions (8). Ten out of fifteen experienced clinically significant symptoms of depression on the tryptophan-free diet, while none experienced mood changes on the diet including tryptophan. Tryptophan itself is no longer available as a supplement, but one of its metabolites, 5-hydroxytryptophan (5-HTP) is. Tryptophan-rich foods include fish, turkey, chicken, cottage cheese, avocados, bananas and wheat germ.

Another neurotransmitter deficiency associated with depression is adrenalin. An up and coming class of anti-depressant drugs are adrenalin reuptake inhibitors, such as Edronax. Adrenalin (and dopamine) is made from the amino acid tyrosine and controlled by niacin, folic acid and B12. Associate Clinical Professor of Psychiatry, Dr Priscilla Slagle, from the University of Southern California cured her own depression with such a combination of nutrients, taking tyrosine in the morning (which is more stimulating) and Tryptophan in the evening (which is more calming) plus other nutrients. She found this combination to be helpful for many of her patients and wrote it up in a book, The Way Up from Down, published by Random House. 

HOW TO EAT YOURSELF OUT OF DEPRESSION

• Reduce stimulants - tea, coffee, sugar, chocolate
• Increase nutrient-rich foods - fruit, vegetables, wholefoods, seeds, nuts and wheatgerm
• Have a serving of fish, chicken, turkey or tofu (from soy beans) a day
• Supplement a high-strength B Complex formula
• Supplement the amino acid l-tyrosine 2,000mg in the morning, available from health food shops
• Supplement 5-HTP, 100mg twice a day
  
  For more information on this subject and for references, read Mental Health & Illness