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AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS can cause or contribute to depression.‛ I make sure my patients see a competent primary care physician who can rule out the obvious physical causes of depression--reactions to medication, and conditions like cancer, diabetes, heart disease, multiple sclerosis, etc. If there are no obvious physical causes, I encourage my depressed patient to find a physician, dietitian or nutritionist who can look for and treat a variety of conditions less commonly diagnosed, which may be implicated in depression, anxiety and chronic fatigue. These include nutrient deficiencies, food sensitivities, subclinical hypothyroidism, heavy metal toxicity, and small intestinal bacterial overgrowth. I sometimes test for these myself. More often, I refer to other physicians who practice ‚integrative‛ or ‚functional‛ medicine. Unless you are a physician, dietitian, or trained nutritionist, you shouldn’t ‚prescribe‛ complex dietary changes. Nonetheless, you can certainly suggest basic guidelines for healthier eating. I always encourage patients to eat whole foods (preferably organic), little or no processed food, less sugar, protein primarily from vegetarian or fish sources and poultry rather than red meat, and increased doses of fiber (we consume about one tenth as much as our Paleolithic ancestors and our indigenous brothers and sisters). Because our food supply is so depleted, and given the ordinary stress of living in modern society, virtually anyone can benefit from a high dose multivitamin/multimineral supplement (without iron, unless anemia is present). People suffering from depression or bipolar disorder will also benefit from supplementation with Omega 3 fish oil (2-6 grams a day). Those with gastrointestinal, as well as emotional upset, may well find relief from both kinds of symptoms by taking supplements with ‚probiotic‛ bacteria (bifidus and lactobacilis) that normally live in a healthy gut. Exercise is also critical for mood regulation. In fact, next to speaking with an experienced, reliable, and compassionate listener – a good therapist - exercise is probably the single most effective of all the antidepressants. As a therapist 110 you can provide information about the benefits of exercise from a wealth of studies in peer reviewed journals and also help your patients develop individualized exercise programs. The effectiveness of jogging is well-researched, but if your patient hates doing it, it won’t happen. Walking, running, dancing and yoga have also been demonstrated to be enormously helpful. Theresa was already doing yoga, and I encouraged her to continue. Later I suggested that each morning she put on fast music and dance for 15 minutes. From the first session on, I give my patients detailed instruction in guided imagery, focusing most often on two images: the creation of a ‚safe place‛ where they can find calming sanctuary in difficult, stressful times; and consultation with an ‚inner‛ or ‚wise‛ guide-an emblem of their intuition and imagination on which they can call for advice and counsel. I also often teach ‚Dialogue with a Symptom, Problem, or Issue (SPI)" -a Gestalt-like exercise in which a rapid, written dialogue between my patient and her physical, emotional, spiritual, social or interpersonal SPI often reveals both its origins and possible solutions. I work too with journaling, drawing and movement to express and reveal feelings and release them. The message to my patients is clear and consistent: You can mobilize your own mind and body to help and heal yourself; I am here to help, to equip you to do it, and to support you as you do. There may come times, especially when working with very seriously depressed people, when the increased hopefulness and good feelings you have helped stimulate seem to dissolve. Often I find that this is a good time to ask my patient to consult her ‚wise guide‛ or to use the dialogue with the SPI to mobilize her capacity for healing. Sometimes I use expressive techniques - fast deep breathing, pounding pillows, and holding yoga postures at length - to bring up suppressed feelings, facilitate emotional release and break up physical rigidity, and mobilize energy. Occasionally, someone’s distress is so great that she insists on what one of my patients called ‚a 2012
AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS physiological boost‛ – something beyond the holistic approaches already tried. At this point, I may well use the natural ‚precursor‛ supplements that directly increase the levels of the neurotransmitters serotonin, and norepinephrine, including S-adenosylmethionine (SAMe) and tryptophan and the herb St. John’s Wort. While these can also produce side effects similar to those of drugs, they are usually far less severe. I do not regard the use of these precursors as signs of treatment failure, but as necessary, quite often temporary, therapeutic aides. Clearly these are supplements that dietitians and nutritionists can effectively use. Only when these supplements, together with the rest of my approach, do not work, or if my patient explicitly requests it, do I refer her for pharmacological therapy. And, I continue to work with her while she sees a psychopharmacologist. Except in cases where people have dehabilitating chronic illnesses that may well become terminal, the time people in my practice spend on drugs is almost always relatively brief. A spiritual perspective informs my work from my first moments with each person. Not an explicit religious orientation, this perspective encompasses an appreciation for the yet unrevealed potential of each person, a sense of sacred connection within each of us to something larger than ourselves, and moments of inexplicable grace that can transform each person’s work with me and on their own. Not long ago on a phone call, Theresa reminded me of this dimension of her life and of our work together. She had moved through her depression in two months of weekly sessions with me, without neurotransmitter precursors or drugs. She had continued to see me once every month or two for ‚refresher sessions‛ for another three years. Then, two years ago, she moved away to take a position at a law school. I had watched her grow over the years into a peacefulness which she had never before known -meditating regularly, doing yoga, taking time for herself. Now we were catching up and she was looking back on our work together. ‚My depression and the sad 111 state of my spiritual life were two sides of the same coin,‛ Theresa reflected. First, I needed to look at myself psychologically to see that I was depressed, that mine were ordinary human problems. I wasn’t this bad, immoral woman, sleeping with guys who didn’t love me, drinking too much and smoking pot. I just needed to see how what I did and the sad confused way I felt connected to my childhood—to that lonely little girl with her desperate desire to please. And I needed to get my life on a track that worked for me. But, she continued, ‚I also needed to feel my spiritual side. And by that I mean the heart, or the soul, or the divine in me." Through her work with me, as well as meditation, yoga, and dance, Theresa said, she began to develop ‚some emotional radar…to sense what I was feeling—whether anxious, sad, angry—to know if something was off-kilter. I learned that I didn’t need to fight it, that it was okay just to let myself feel the pain—it was just passing feelings, and not something fundamentally wrong with me. I no longer,‛ Theresa goes on, ‚have the feeling that I won’t get what I want. I have what I want.‛ Here she emphasizes that wonderful, present tense word, so different from all the past-tense terms of loss and longing that marked her depression, ‚I feel whole and happy as I am. If I find a ‘significant other’… that would just add to it. I thank Theresa out loud, and silently, too, for sharing with me what is possible. Freud wrote about replacing neurotic with ordinary unhappiness. Psychopharmacologists praise the restoration of the ‚pre-morbid personality.‛ Theresa is showing me, telling us, what it means to move from being terribly, chronically, depressed to feeling blessed every day. Excerpts from this article are taken from the following book: Gordon, James S. (2008) Unstuck: Your Guide to the Seven-Stage Journey Out of Depression. New York: Penguin Press. James S. Gordon, a Harvard educated psychiatrist, is a world-renowned expert in using mind-body 2012
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