Lifestyle Changes

St. John's Wort and Other Herbal Remedies

St. John's wort (Hypericum perforatum ) is an herbal remedy that may help some patients with mild-to-moderate depression. It does not appear to help patients with moderate or severe depression.

Yoga is a mind-body exercise which combines stretching and controlled breathing to achieve relaxation and a stabilized mood.

This herbal substance is not regulated, and there is no guarantee of quality in any brands currently available. In fact, in a 2003 study, only 2 of 54 St. John's products bought in Canada and the U.S. contained concentrations of the active ingredients that fell within 10% of the claims on the labels.

The following guidelines are recommended:

• People with mild depression should not use St. John's wort without consulting a doctor. Children and pregnant or nursing women should not take this substance.
• People should purchase brands only from well-established manufacturers.
• Although no dose levels have been established, trials indicate that 300 milligrams taken 3 times a day may be effective. (Patients should check with a knowledgeable doctor.)
• It takes between 2 - 3 weeks for the herb to have an effect.
• St. John's wort should not be combined with other antidepressants. This herb may also interact with other types of medications and increase or decrease their potency.

Side Effects. Side effects are uncommon but may include nausea, dry mouth, allergic reactions, and fatigue. This herb may increase sensitivity to light (photosensitivity). Some people have reported temporary nerve damage after sun exposure, specifically pain and tingling on sun-exposed areas.

Herbs and Supplements

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

The following are special concerns for people taking natural remedies for depression:

• St. John's wort. St. John's wort can increase the risk for bleeding when used with blood-thinning drugs. It can also reduce the strength of certain drugs including cancer and HIV treatments. St. John's wort can increase sensitivity to sunlight.
• Valerian. Valerian has sedative qualities. This herb is listed on the FDA's list of generally safe products. However, its effects could be dangerously increased if it is used with standard sedatives. Other interactions and long-term side effects are unknown. Side effects include vivid dreams. High doses of valerian can cause blurred vision, excitability, and changes in heart rhythm.
• Kava. Kava is used for its calming effect for people with anxiety and depression. There have been reports of liver failure and death from this herb. Those at highest risk have existing impaired liver function. Other side effects include itchy, scaly skin, muscle weakness, and problems with coordination. Kava also interacts dangerously with certain medications, including alprazolam, an anti-anxiety drug. It increases the potency of certain drugs, including sleep medications, alcohol, and antidepressants.

Dietary Factors

Carbohydrates and Tryptophan. Some people report relief from depression by eating foods or diet supplements that boost levels of tryptophan, an amino acid involved in the production of serotonin. There are high-carbohydrate drinks available over the counter that increase tryptophan levels and may alleviate depression associated with premenstrual syndrome for about 3 hours. Simply eating a high amount of carbohydrates, however, is not a solution for depression. In fact, a 2002 study found a correlation between high sugar consumption and higher rates of depression, although there is no evidence to suggest a causal association.

Impurities found in diet supplements containing L-tryptophan itself have caused cases of eosinophilia-myalgia syndrome, a condition that elevates certain white blood cells and can be fatal. Supplements containing L-tryptophan are currently banned in the U.S. by the FDA. Fish Oil. Some evidence suggests that an imbalance in the ratio of specific fatty acids (omega-6 to omega-3) may increase the risk for depression. Both are polyunsaturated fats, but omega-6 fatty acids are mostly found in corn, safflower, soybean, and sunflower oil whereas omega-3 fatty acids are found in fish oil, canola oil, soybeans, flaxseed, and certain nuts and seeds. One study reported more depression in patients who had higher ratios of foods rich in omega 6 compared to those containing omega 3 fatty acids. (This imbalance has also been associated with heart disease.)

The bottom line may be to increase intake of omega-3 rich foods, such as fish, nuts, and canola oil, and reduce consumption of foods containing omega-6 fatty acids, such as corn and sunflower oils. Such a dietary approach is healthy in any case. Researchers are studying whether eating fish or taking fish oil supplements can reduce depression. Small preliminary studies suggest that these dietary approaches may be helpful for some patients. Scientists are also investigating which type of fish oil compound -- eicosapentaenoic acid (EPA) or docosahexaenoic acid (DHA) -- provides the greatest benefit.

Caffeine. Studies have found an association between moderate consumption of caffeinated beverages and a lower incidence of suicide, indicating that coffee or tea might help reduce depression. One study supported the findings for a lower risk for suicide with moderate coffee intake but reported a higher risk for suicide with high coffee consumption. In such cases, coffee may not be the cause of the higher risk; women who drink such large amounts of coffee may be self medicating their depression. Heavy coffee use may also coincide with a higher risk for abuse of other substances, such as alcohol or cigarettes, which may increase the risk for suicide.

Vitamins and Other Supplements. Certain B vitamins have been associated with some protection against depression.

• Vitamin B-3 (niacin) is important in the production of tryptophan and is produced from processing vitamin B3 (niacin). Dietary sources of niacin include oily fish (such as salmon or mackerel), pork, chicken, dried peas and beans, whole grains, seeds, and dried fortified cereals.
• Vitamin B-12 and calcium supplements may help reduce depression that occurs before menstruation. A 2001 study also suggested that calcium might help prevent postpartum depression.
• Folate, a B vitamin, may enhance the effectiveness of SSRIs and other antidepressants.

Exercise

Increasingly studies are reporting major benefits from exercise for people with depression. The following are some examples:

• A 2002 study reported that 55% of older women with depression that did not respond to medication improved with 10 weeks of exercise. (Only a third of women who did not exercise improved during that time.)
• A 2000 study reported that 30 minutes of brisk exercise three times a week may be just as effective as medication in relieving the symptoms of mild to moderate depression and reduces the risk of relapse.
• A 1999 study on exercise in the elderly reported that after 26 weeks, exercise was as effective as antidepressants. (Antidepressants relieved depression earlier, however.)
• One study found that teenagers who were active in sports have a greater sense of well-being than their sedentary peers; the more vigorously they exercised, the better their emotional health.

Aerobics. Either brief periods of intense training or prolonged aerobic workouts can raise chemicals in the brain, such as endorphins, adrenaline, serotonin, and dopamine that produce the so-called runner's high. And, of course, weight loss and increased muscle tone can boost self-esteem.

Yoga. Yoga practice, which involves rhythmic stretching movements and breathing, has been found to positively affect mood and may have clinical potential as a technique for improving and stabilizing mood. One study, in fact, suggested that men actually may have better results with yoga than with aerobic exercise. In the study men experienced significantly lower levels of tension, fatigue, and anger after yoga than after swimming. (Yoga and swimming tended to produce equal benefits in women.)

Social Support

A strong network of social support is important for both prevention and recovery from depression. Support from family and friends must be healthy and positive. One study of depressed women showed, however, that overprotective as well as very distant parenting was associated with a slow recovery from depression. Studies indicate that people with strong spiritual faiths have a lower risk for depression. Such faith does not require an organized religion. People with depression might find solace from less structured sources, such as those that teach meditation or other methods for obtaining spiritual self-fulfillment.