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Depression

• Signs and Symptoms
• Causes
• Risk Factors
• Diagnosis
• Preventive Care
• Treatment Approach
• Other Considerations
• Supporting Research

Depression is a mood disorder in which feelings of loss, anger, sadness, or frustration interfere with everyday life. Depression affects about 17 million Americans each year. It can be mild, moderate, or severe and occur as a single episode, recurring episodes, or chronic depression (lasting more than 2 years).

The primary types of depression include:

• Major depression -- five or more symptoms must be present. An episode must last at least 2 weeks, but tends to continue for 20 weeks. (A mood disorder is classified as minor depression if less than five depressive symptoms are present for at least 2 weeks.)
• Dysthymia-- a chronic, generally milder form of depression. Symptoms are similar to major depression but more mild in degree.
• Atypical depression-- depression accompanied by unusual symptoms, such as hallucinations, delusions, and physical rigidity

Other common forms of depression include:

• Postpartum depression-- experienced by 8 - 20% of women following delivery
• Premenstrual dysphoric disorder (PDD)-- experienced by 3 - 8% of women. Depressive symptoms occur 1 week prior to menstruation and disappear following menstruation.
• Seasonal affective disorder (SAD)-- experienced by 5% of adults, the majority of whom are women. It occurs during the fall-winter season and disappears during the spring-summer season.

Depression may also occur with mania (known as manic-depression or bipolar disorder). In this condition, moods cycle between mania and depression.

Signs and Symptoms

While it is normal for most people to feel "down in the dumps" on occasion, someone with major depression feels significantly depressed for a prolonged period of time, has difficulty enjoying acts that were once pleasurable, and experiences at least five of the following symptoms for 2 weeks or more:

• Sleep disturbances -- at least 90% of people with depression have either insomnia (sleeplessness) or hypersomnia (excessive sleeping).
• Significant change in appetite (often resulting in either weight loss or weight gain)
• Fatigue and loss of energy
• Feelings of worthlessness, self-hate, and inappropriate guilt
• Extreme difficulty concentrating
• Either agitation, restlessness, and irritability or inactivity and withdrawal
• Recurring thoughts of death or suicide
• Feelings of hopelessness

Although not generally considered to be defining characteristics of depression, many people with the condition report a lack of sex drive and sudden bursts of anger.

Causes

The causes of depression are complex and involve a combination of biologic, genetic, and environmental factors. People with depression may have abnormal levels of certain brain chemicals, including serotonin, acetylcholine, and catecholamines (such as dopamine). The following may alter the levels of these brain chemicals and contribute to development of depression:

• Heredity -- a recently identified gene called SERT that regulates the brain chemical serotonin has been linked to depression.
• Chronic stress (such as from loss, abuse, or deprivation in early childhood)
• Amount of exposure to light
• Sleep disturbances
• Social isolation
• Nutritional deficiencies
• Serious medical conditions, such as heart attack or cancer
• Certain medications, including those for high blood pressure, high cholesterol, or irregular heartbeat

Risk Factors

Although depression is a condition that can affect anyone, regardless of age, race, or gender, the following factors may increase your risk for an initial or recurrent episode of depression:

• Prior episodes of depression
• Family history of depression
• Suicide attempt -- a previous attempt of suicide during a major depressive episode increases the likelihood of another episode of depression.
• Female gender -- the incidence of depression appears to be greater in women than in men. Some researchers speculate, however, that women may simply report their symptoms more frequently than men, and that men may be more apt to mask their depressive symptoms with alcohol. Therefore, it is still unclear whether women truly have a greater risk for depression.
• Young adulthood or middle age -- the highest occurrence of depression is between the ages of 25 - 44. The elderly are also at particular risk due to death of loved ones, physical illness, and loss of independence.
• Stressful life events (such as the death of a loved one), particularly if the event occurs at a young age
• Postpartum period
• Chronic medical or psychological conditions, including autoimmune diseases (such as lupus), cancer, heart disease, chronic headaches, chronic pain, anxiety, obsessive-compulsive disorder, and borderline personality disorder. Medical conditions that cause shifts in hormones, such as thyroid disorders or menopause, may also contribute to depression.
• History of abuse (such as mental, physical, or sexual)
• Lack of social support system (such as a network of close friends or family)
• Current or past alcohol or drug abuse -- 25% of people with addictions have depression.

Diagnosis

If feelings of depression or any of the related symptoms are present, it is important to address them with a doctor or someone who can help direct care appropriately. Unfortunately, many people with depression tend to refrain from disclosing any or all of their symptoms in this setting. Occasionally, even when the symptoms are discussed during an appointment, a doctor may try to treat them individually, rather than recognizing the complete picture of depression. Working together with a primary care doctor is extremely important because they are often the health care providers who make a referral to a psychiatrist who, in turn, makes a definite diagnosis of depression. Proper diagnosis of depression is the first step toward proper treatment.

Only psychiatrists can prescribe medication, but psychologists and social workers, as well as psychiatrists, use psychotherapy as an important mode of treatment. These specialists will often administer a screening test, such as the Beck Depression Inventory or the Hamilton Rating Scale, which consists of about 20 questions that assess an individual's risk for depression. Even before these psychological screening tests, however, several blood tests will be performed to determine whether nutrient deficiencies or underlying medical conditions (such as a thyroid disorder) may be causing or contributing to depression.

Although the vast majority of people with depression are treated as outpatients, hospitalization is necessary for people who intend to, or do, attempt suicide, and may be necessary under other circumstances as well.

Preventive Care

The following steps can help prevent depression or decrease the chances of relapse:

• Adequate sleep, regular exercise, and a balanced, healthy diet may help prevent depression and diminish symptoms of this mood disorder.
• Mind-body techniques, such as biofeedback, meditation, and tai chi, are effective ways to prevent or reduce symptoms associated with depression.
• Psychotherapy directed at coping skills generally helps prevent relapse.
• Family therapy may prevent children or teens of depressed parents from becoming depressed later in life.
• Compliance with the prescribed treatment regimen decreases the chance of relapse.

Treatment Approach

People with depression have several options for treatment, but a combination of psychotherapy and antidepressant medications is the regimen of choice, particularly for people with major depression. Cognitive-behavioral therapy appears to be the most effective type of psychotherapy, particularly for adolescents and people with atypical or postpartum depression. As many as 90% of people with depression improve from a combination of psychotherapy and antidepressants. However, adverse side effects from certain medications make it difficult for many to take their medications. Some complementary and alternative therapies may be helpful in reducing the side effects from such medications, while other complementary and alternative therapies may actually diminish the symptoms of depression.

Lifestyle

Exercise

Studies have consistently shown that regular exercise (either aerobic or strength and flexibility training) significantly reduces depressive symptoms in people with mild to moderate depression and improves the mood of people with major depression. Some even suggest that exercise may be as effective as psychotherapy for people with mild-to-moderate depression, although additional research is needed. In the meantime, exercise can be used safely in conjunction with medication for those with depression.

Medications

Antidepressant medications are very effective; reports indicate that they are 90% successful in treating depression. In general, medications are taken for at least 4 - 6 months to assure complete and effective treatment. However, antidepressants often cause adverse side effects, making it difficult for some people to comply with taking their medications. Medications must not be stopped before first talking with a physician. Most antidepressants cause withdrawal symptoms if they are not discontinued slowly over time with guidance from a physician.

There are several classes of antidepressant medications, including:

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs increase the activity of a chemical in the brain called serotonin. Most health care providers will prescribe SSRIs before any other antidepressant medication for depression, in part because the side effects associated with SSRIs are generally fewer than for other classes of antidepressants. Typical side effects caused by SSRIs include stomach upset, weight gain or loss, drowsiness, sexual dysfunction (such as impotence, decreased libido, and diminished orgasm), headache, jaw grinding, and apathy. Very unusual side effects from this class of prescription drugs include extreme agitation, impulsivity, tremors, and insomnia. People who discontinue taking SSRIs due to side effects usually attribute their discontent to sexual dysfunction.

Drugs classified as SSRIs include:

• Fluoxetine
• Sertraline
• Paroxetine -- most likely in this class to cause sexual dysfunction
• Fluvoxamine
• Citalopram -- least likely in this class to cause sexual dysfunction

Another group of antidepressant medications (which are similar to SSRIs, but target other brain chemicals in addition to serotonin) may cause fewer negative sexual side effects. These include:

• Bupropion -- should not be used if there is history of or risk for seizure
• Nefazodone -- no sexual dysfunction reported. It begins to work very quickly and may cause a decrease in blood pressure when going from lying or sitting to standing.
• Venlafaxine -- may impair sexual function and is not recommended in the elderly. It may improve quality of life more effectively than other antidepressants, but can cause irregular heart rhythm. Withdrawal from the medication is difficult.
• Mirtazapine -- may be particularly effective if feelings of anxiety are also present. It helps with insomnia but may cause drowsiness, blurred vision, weight gain, and damage to production of cells in the bone marrow (very rare).
• Maprotiline -- may cause dry mouth, drowsiness, sensitivity to the sun, and seizures

Tricyclic Antidepressants

Tricyclics increase the activity of the brain chemicals serotonin and norepinephrine. They are as effective as SSRIs, but are usually prescribed only to those who do not respond well to SSRIs because side effects are quite common and are usually less tolerable. Tricyclic antidepressants include:

• Amitriptyline
• Amoxapine -- increases risk of seizure in those who are prone to have a seizure
• Clomipramine -- used for obsessive-compulsive disorder
• Desipramine
• Doxepin -- may help with insomnia
• Imipramine -- may cause a rare lung disorder called idiopathic pulmonary fibrosis
• Nortriptyline -- less risk of irregular heart rhythm than others in this class
• Protriptyline -- less drowsiness than others in this class and may even cause weight loss and sun sensitivity
• Trimipramine -- high risk for irregular heart rhythm

Side effects of tricyclics may include:

• Dry mouth
• Blurred vision
• Constipation
• Sexual dysfunction
• Weight gain
• Dizziness
• Drowsiness
• Urinary urgency (a sense that one has to urinate even when the bladder is empty)
• Drop in blood pressure when going from lying or sitting to standing (causes dizziness and lightheadedness)
• Irregular heart rhythm

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs boost levels of norepinephrine, dopamine, and serotonin in the brain. MAOIs are generally prescribed only when other antidepressants have not been effective, which may occur in people with atypical depression. People who take MAOIs may experience a sharp increase in blood pressure after consuming food or drink containing the amino acid tyramine (found in such foods as aged cheeses and red wine). MAOIs also negatively interact with other medications, including Ritalin (used for attention deficit hyperactivity disorder) and pseudoephedrine (decongestant in many over-the-counter and prescription medications), and should not be taken with other classes of antidepressants.

MAOIs include:

• Phenelzine -- should be avoided by people with a history of seizures or bipolar disorder (manic-depression)
• Isocarboxazid -- side effects include drowsiness, sexual dysfunction, weakness, trembling, and blurred vision.
• Tranylcypromine -- should not be used if there is any history of kidney disease or bipolar disorder

Surgery and Other Procedures

• Electroconvulsive Therapy (ECT) for depression is usually reserved for when all other therapies have been unsuccessful. In this procedure, a small electrical current induces a seizure lasting approximately 40 seconds. A muscle relaxant and mild sedative are administered prior to the procedure. ECT is generally repeated every 2 - 5 days for a total of six treatments. It may cause temporary confusion, memory impairment, headache, muscle aches, irregular heart rhythm, or nausea.
• Magnetic Resonance Imaging (MRI)-Guided Cingulotomy involves the application of an electrical current to a specific part of the brain. The MRI is used as a guide for an exact placement. Long-term improvement has been reported using this technique in over 50% of people with depression who have not responded to other treatment methods.

Nutrition and Dietary Supplements

A comprehensive treatment plan for depression may include a range of complementary and alternative therapies. Preliminary studies suggest that nutritional supplements may reduce the symptoms of some depression. Ask your team of health care providers about the best ways to incorporate these therapies into your overall treatment plan. Always tell your health care provider about the herbs and supplements you are using or considering using.

Following these nutritional tips may help reduce symptoms:

• Try to eliminate potential food allergens, including dairy, wheat (gluten), corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
• Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
• Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables such as kelp and dulce.
• Avoid refined foods, such as white breads, pastas, and especially sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
• Use healthy oils for cooking, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

You my address nutritional deficiencies with the following supplements:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids, such as fish oil, one to two capsules or one tablespoonful oil one to three times daily, to help decrease inflammation and help with mental balance.
• Vitamin C, 500 - 1000 mg one to three times daily, as an antioxidant and for immune support.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
• 5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization. Ask your health care provider about potential prescription interactions.
• Probiotic supplement (containing Lactobacillus acidophilus and other species), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. You should refrigerate your probiotic supplements for best results.
• SAMe (s-adenosyl-L-methionine), 100 - 200 mg before breakfast daily, for mood improvement.
• Dihydroepiandosterone (DHEA), start at 5 mg three times a day and work up to 100 mg per day for 7 - 12 months. It is recommended to use DHEA under the supervision of a qualified health care provider. If adverse effects develop, discontinue use.
• L-theanine, 200 mg one to three times daily, for nervous system support.
• Melatonin, 2 - 5 mg one hour before bedtime, for sleep and immune protection. Ask your health care provider about potential prescription interactions.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

• St. John's wort ( Hypericum perforatum ) standardized extract, 300 mg two to three times per day, for depression. Check with your health care provider if you are taking prescription medications.
• Kava kava ( Piper methysticum ) standardized extract, 100 - 250 mg one to three times daily, as needed for symptoms of stress and anxiety. Talk with your health care provider before taking kava kava if you have an unhealthy liver.
• Ginkgo ( Ginkgo biloba ) standardized extract, 40 - 80 mg three times daily, for blood flow and depression.
• Green tea ( Camellia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant and general health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Rhodiola ( Rhodiola rosea ) standardized extract, 100 - 600 mg daily, for antioxidant and anti-stress activity.

Acupuncture

Two randomized, controlled, clinical trials suggest that electroacupuncture may reduce symptoms of depression as effectively as amitriptyline, a tricyclic antidepressant medication. Electroacupuncture involves the application of a small electrical current through acupuncture needles. Other studies suggest that acupuncture may be effective for people with mild depression and for those with depression related to a chronic medical illness. Further research is warranted in this area.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies to alleviate the symptoms of depression based on their knowledge and experience.

Before prescribing a remedy, homeopaths take into account a person’s constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual. A few homeopathic remedies that may work for depression include:

• Ignatia -- for a sudden sense of grief or disappointment following the death of a loved one, the end of a romantic relationship, or an unexpected loss of one's job
• Natrum muriaticum -- for grief following the death of a loved one or sadness from the end of a romantic relationship

Massage and Physical Therapy

Studies of formerly depressed adolescent mothers, children hospitalized for depression, and women with eating disorders, suggest that massage decreases stress hormone levels, feelings of anxiety, and symptoms of depression. Giving massage may also be beneficial for people who are depressed. Elderly volunteers with depression showed notable improvement in their symptoms when they massaged infants.

Aromatherapy, or the use of essential oils in massage therapy, may also be of value as a supplemental treatment for depression. Theoretically, the smells of the oils elicit positive emotions through the limbic system (the area of the brain responsible for memories and emotions). However, the benefits of aromatherapy appear to be related to the relaxation effects of the treatment as well as to the recipient's belief that the treatment will be beneficial. Essential oils used during massage for depression are quite varied and include:

• Lavender ( Lavandula officinalis)
• Basil ( Ocimum basilicum )
• Orange ( Citrus aurantium )
• Sandalwood ( Santalum album )
• Lemon ( Citrus limonis )
• Jasmine ( Jasminum spp . )
• Sage ( Salvia officinalis )
• Chamomile ( Chamaemelum nobile )
• Peppermint ( Mentha piperita )
• Rosemary ( Rosmarinus officinalis )

Mind-Body Medicine

Mind-body therapies and techniques that may be useful as a part of an overall treatment regimen for depression include:

Psychotherapy

Cognitive-behavioral therapy is a type of psychotherapy in which individuals learn to identify and change distorted perceptions about themselves and adapt new behaviors to better cope with the world around them. This therapy is frequently considered the treatment of choice for people with mild-to-moderate depression, but it may not be recommended for those with severe depression. Studies of people with depression indicate that cognitive-behavioral therapy is at least as effective as tricyclic antidepressants. Compared to those treated with antidepressants, people treated with cognitive-behavioral therapy demonstrated similar, or better, results and lower relapse rates.

Other therapeutic approaches that may be applied by a psychiatrist, psychologist, or social worker include:

• Psychodynamic psychotherapy -- based on Freud's theories about unresolved conflicts in childhood and depression as a grief process
• Interpersonal therapy -- acknowledges childhood roots of depression, but focuses on current problems contributing to depression and is considered very effective treatment for depression
• Supportive psychotherapy -- nonjudgmental advice, attention, and sympathy, and this approach may improve compliance with taking medication

Relaxation

One study suggests that relaxation techniques, such as yoga and tai chi, may improve symptoms of depression in people with mild depression.

Meditation

Some researchers believe that mindfulness meditation may prevent depression from recurring in people who once had the condition.

Other Considerations

Pregnancy

• Postpartum depression is experienced by 8 - 20% of women following delivery.
• The safety of SSRIs and tricyclic antidepressant medications during pregnancy remains uncertain. The physician will provide guidance regarding use or avoidance of antidepressants during pregnancy. The risks and benefits to the mother and the fetus must be weighed in each individual case in order to determine the most appropriate regimen during pregnancy. MAOIs cause birth defects and should be avoided during pregnancy.
• Many of the dietary supplements and herbs mentioned here have not been tested for safety during pregnancy. Talk with your doctor or pharmacist.

Warnings and Precautions

• People with Parkinson's disease should avoid SSRIs.
• People with coronary artery disease should avoid tricyclic antidepressants.
• Several herbal remedies and supplements should not be combined with antidepressant medications. Be sure to inform your health care provider of all herbs and supplements you take to avoid adverse interactions.

Prognosis and Complications

Depression is a serious condition that can have a devastating effect on people's lives. It can directly and indirectly contribute to chronic medical conditions, such as heart disease and stroke, because depressed people with these conditions are less likely to engage in healthy behaviors (such as exercise) and more likely to engage in unhealthy behaviors (such as smoking). Suicide is a significant factor in depression. About 15 % of people with a major depressive disorder commit suicide. Depression also significantly shortens the lifespan of the elderly and is associated with the development of memory impairment and dementia.

When left untreated, depression can last up to 2 years. Rates of recurrence are variable: 50% of people who have had one depressive episode will have a second major depressive disorder, 70% will have a third, and 90% will have a fourth. Symptoms of depression usually disappear after menopause in women with premenstrual dysphoric disorder or seasonal affective disorder. Fortunately, there are several treatment options available for people with depression, and the prognosis improves tremendously for those who seek treatment and comply with their regimen.

Supporting Research

Alpert JE, Fava M. Nutrition and depression: the role of folate. Nutrition Rev . 1997;5(5):145-149.

Alpert JE, Mischoulon D, Nierenberg AA, Fava M. Nutrition and depression: focus on folate. Nutrition . 2000;16:544-581.

Anonymous. SAMe for depression. Med Lett Drugs Ther . 1999;41(1065):107-108.

Babyak M, Blumenthal JA, Herman S, et al. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med . 2000;62(5):633-638.

Beniamini Y, Rubenstein JJ, Zaichkowsky LD, Crim MC. Effects of high-intensity strength training on quality-of-life parameters in cardiac rehabilitation patients. Am J Cardiol . 1997;80(7):841-846.

Benjamin J, Agam G, Levine J, Bersudsky Y, Kofman O, Belmaker RH. Inositol treatment in psychiatry. Psychopharmacol Bull . 1995;31(1):167-175.

Benton D, Cook R. The impact of selenium supplementation on mood . Biol Psychiatry . 1991;29(11):1092-1098.

Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Altern Med Rev . 1998;3(4):271-280.

Bottiglieri T. Folate, vitamin B12, and neuropsychiatric disorders. Nutrition Rev . 1996;54(12):382-390.

Bottiglieri T, Laundy M, Crellin R, Toone BK, Carney MW, Reynolds EH. Homocysteine, folate, methylation, and monoamine metabolism in depression. J Neurol Neurosurg Psychiatry . 2000;69(2):228-232.

Bottiglieri T, Hyland K, Reynolds EH. The clinical potential of ademetionine (S-adenosylmethionine) in neurological disorders. Drugs . 1994;48(2):137-152.

Brenner R, Azbel V, Madhusoodanan S, Pawlowska M. Comparison of an extract of hypericum (LI 160) and sertraline in the treatment of depression: a double-blind, randomized pilot study. Clin Ther. 2000;22(4):411-419.

Briggs CJ, Briggs GL. Herbal products in depression therapy. CPJ/RPC . November 1998;40-44.

Bruinsma KA, Taren DL. Dieting, essential fatty acid intake, and depression. Nutrition Rev . 2000;58(4):98-108.

Cauffield JS, Forbes HJ. Dietary supplements used in the treatment of depression, anxiety, and sleep disorders. Lippincotts Prim Care Pract. 1999;3(3):290-304.

Eich H, Agelink MW, Lehmann E, Lemmer W, Klieser E. Acupuncture in patients with minor depressive episodes and generalized anxiety. Results of an experimental study. Fortschr Neurol Psychiatr . 2000;68(3):137-144.

Einat H, Karbovski H, Korik J, Tsalah D, Belmaker RH. Inositol reduces depressive-like behaviors in two different animal models of depression. Psychopharmacology . 1999;144:158-162.

Ernst E, Rand JI, Stevinson C. Complementary therapies for depression. Arch Gen Psychiatry . 1998;55:1026-1032.

Field TM. Massage therapy effects. Am Psychol . 1998;53(12):1270-1281.

Field T, Grizzle N, Scafidi F, Schanberg S. Massage and relaxation therapies' effects on depressed adolescent mothers. Adolescence . 1996;31(124):903-911.

Fugh-Berman A, Cott JM. Dietary supplements and natural products as psychotherapeutic agents. Psychosom Med . 1999;61:712-728.

Gaster B, Holroyd J. St. John's wort for depression. Arch Intern Med . 2000;160:152-156.

Gelenberg AJ, Wojcik JD, Falk WE, et al. Tyrosine for depression: a double-blind trial. J Affect Disord. 1990;19:125-132.

Hibbeln JR, Salem N. Dietary polyunsaturated fatty acids and depression: when cholesterol does not satisfy. Am J Clin . 1995;62:1-9.

Horrocks LA, Yeo YK. Health benefits of docosahexaenoic acid (DHA). Pharmacol Res . 1999;40(3):211-225.

Johnson MA. Nutrition and aging--practical advice for healthy eating. J Am Med Womens Assoc . 2004;59(4):262-9.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 247-248.

Kim HL, Streltzer J, GoebertD. St. John's wort for depression: a meta-analysis of well-defined clinical trials. J Nerv Ment Dis . 1999;187:532-539.

Lewy AJ, Bauer VK, Cutler NL, Sack RL. Melatonin treatment of winter depression: a pilot study. Psych Res. 1998;77(1):57-61.

Linde K, Mulrow CD. St. John's wort for depression (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

Maes M, DeVos N, Pioli R, et al. Lower serum vitamin E concentrations in major depression another marker of lowered antioxidant defenses in that illness. J Affect Disord . 2000;58:241-246.

Markus R, Panhuysen G, Tuiten A, Koppeschaar H. Effects of food on cortisol and mood in vulnerable subjects under controllable and uncontrollable stress. Physiol Behav . 2000;70(3-4):333-342.

McGinn LK. Cognitive behavioral therapy of depression: theory, treatment, and empirical status. Am J Psychother . 2000;54(2):257-262.

Meyers S. Use of neurotransmitter precursors for treatment of depression. Altern Med Rev . 2000;5(1):64-71.

Morelli V, Zoorob RJ. Alternative therapies: Part 1. Depression, diabetes, obesity. Am Fam Phys . 2000;62(5):1051-1060.

Obach RS. Inhibition of human cytochrome P450 enzymes by constituents of St. John's wort, and herbal preparation used in the treatment of depression. J Pharmacol Exp Ther . 2000;294(1):88-95.

Paluska SA, Schwenk TL. Physical activity and mental health. Sports Med . 2000;29(3):167-180.

Pizzorno JE and Murray MT. Textbook of Natural Medicine, Vols 1 & 2. New York, NY: Churchill Livingstone; 1999:1049-1059.

Reus VI. Psychiatric disorders. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine . 14th ed. New York, NY: McGraw-Hill; 1998:2490-2496.

Roschke J, Wolf CH, Muller MJ, et al. The benefit from whole body acupuncture in major depression. J Affect Disord . 2000;57:73-81.

Rush AJ, George MS, Sackeim HA, et al. Vagus nerve stimulation (VNS) for treatment of resistant depressions: a multicenter study. Biol Psychiatry . 2000;47:276-286.

Shaw, K., Turner, J., and Del Mar, C. Tryptophan and 5-hydroxytryptophan for depression. Cochrane Database Syst Rev. 2002;(1):CD003198.

Tao DJ. Research on the reduction of anxiety and depression with acupunture. Am J Acupunct . 1993;21(4):327-329.

Teasdale JD, Segal Z, Williams MG. How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behav Res Ther . 1995;33(1):25-39.

Wolkowitz OM, Reus VI, Keebler A, Nelson N, Friedland M, Brizendine L, Roberts E. Double-blind treatment of major depression with dehydroepiandrosterone. Am J Psychiatry . 1999;156:646-649.

Wurtman RJ, Wurtman JJ. Brain serotonin, carbohydrate-craving, obesity and depression. Obes Res . 1995;3(suppl4):477S-480S.

Young SN. The use of diet and dietary components in the study of factors controlling affect in humans: a review. J Psychiatr Neurosci . 1993;18(5):235-244.

• Review Date: 11/6/2006
• Reviewed By: Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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