A Healthy Diet

healthy dietWe are glad to have recently added a page to our “Topics” section that discusses a healthy diet and also reviews some information about nutritional supplements.

This is a huge topic, and none of us are dietitians, but it is an important issue and so, with the caveat that we approach the topic from the standpoint of what helps people with mood disorders, not what is generally best for all aspects of our health, please look over the information.

And definitely send us comments….

MoodSurfing – It Isn’t About Reaching a Goal

goalI have had a couple of conversations this past week that reminded me of my belief that one of the big problems in this country is our preoccupation with “results.”

Elsewhere, I’ve noted how this leads to short term strategies that have bad long term consequences.

In education, this means cramming for exams instead of learning the material. In business it means not investing in long term growth if it will reduce the short term bottom line. Etcetera. 

Today I am focusing on how this preoccupation with achieving a short term goal affects people who are trying to live creatively with moods.

A middle aged woman who is facing an unprecedented series of personal and professional challenges tells me, again, how frustrated she is that “the medications aren’t working.” Later in our conversation she, once again, refuses to consider making any of the changes in her sleep and daily activities that would help stabilize and improve her moods.  And then, a few minutes after that, she brings up her sense of frustration with her inability to “just lead a normal life with normal healthy routines.”

Why is it that she can see the value of “normal health routines” but at the same time rejects any plan that would lead to developing these healthy habits?

At least part of the problem is that “developing healthy habits” is about a process, not about achieving a goal.  

If you are successful there’s nothing tangible you have accomplished or earned as a result of your success. You have taken an important step towards building a strong foundation for a healthy life, which is an essential task for everyone, but especially for someone dealing with depression.  But as with most work building foundations, it isn’t visible and it is not the kind of work that is well rewarded in our society. 

A younger woman with two children, who had been so enthusiastic about her work with me three months ago, tells me that she’s stopping her medications on her own. Later on she mentions that she is feeling increasingly physically ill, and then she tells me that she really doesn’t want to come in to see me any more.

What happened? How did I go from the “doctor who can do no wrong” to the “doctor to be avoided?”

I think the answer is similar: In the short-run, she got enthusiastic about taking care of herself and the good feelings that resulted, but then that project began to lose interest for her because it was “accomplished.”  

She stopped devoting attention to living a healthy life and managing her moods, and then, when the old depressed and irritable moods began to show up again, she decided the problem was with the treatment, rather than with the challenges she faced in trying to stay consistent with mood regulating activities and taking her medications.

Big projects and big successes are wonderful. Much of what we have accomplished as a country is based on our capacity to fulfill these kinds of goals. But success at “moodsurfing” often relies on consistency and healthy habits. It isn’t about reaching a goal and then moving on to other goals. You have to keep at it.

Zinc Might Prevent Depression

depressionIn several animal studies, zinc deficiency can cause behavior that looks like depression. In other animal studies, giving  zinc can have antidepressant-like activity if the animals are zinc-deficient.

And there is some clinical evidence that zinc might boost the effectiveness of antidepressants in humans.

Now a large meta-analysis of studies that looked at zinc blood levels in people with depression (Swardfager, et al) finds that depressed individuals have significantly lower zinc concentrations in their blood.

The authors summarized 17 studies, with a total of 1643 depressed patients and 804 controls studied, in which blood zinc concentrations were measured. In those studies, on average, zinc concentrations were 1.85 μmol/L lower (P < .00001) in depressed subjects than in controls.

The study result is strengthened because the study also found that depression severity was inversely correlated with zinc levels. In other words, the greater the deficiency the more severe the depression.

The finding that zinc levels are associated with depression does not mean that lower zinc causes depression, but there are some interesting aspects of zinc’s role in the body that make the link at least plausible.

Zinc is an anti-oxidant, it helps support the endocrine (hormone) system and the functioning of the immune system. It is involved in regulating brain circuits in the hippocampus (which controls memory) and the cortex (thinking) that use the neurotransmitter glutamate. These circuits are involved in regulating mood.
and immune function, and participates in regulation of

It is possible that normal zinc levels are necessary for normal mood functioning, and that lower zinc levels might lead to depression.

It turns out that zinc is also one of a handful of nutrients that a significant number of people are deficient in.

The Food and Nutrition Board of the Institute of Medicine and the World Health Organization (WHO) have published standard recommendations for daily zinc intake. They recommend that women get 8 mg daily and men receive 11 mg a day.

If you are looking for a supplement, and you are not sure that you are deficient, you should look for a supplement that is no more than 50 mg a day. Higher levels of zinc can actually interfere with the absorption of copper, which is also an essential mineral.

For information about zinc and other natural supplements you might want to get a subscription to Consumer Labs, which is the only source for objective and unbiased reviews of natural supplements in this country.


Swardfager W, Herrmann N, Mazereeuw G, Goldberger K, Harimoto T, Lanctôt KL. Zinc in depression: a meta-analysis. Biol Psychiatry 2013;74(12):872-878.

Yoga for Mood and Health

yogaMany of our patients with chronic mood disorders report that beginning yoga and doing it consistently has been associated with periods of remarkable stability. There are studies supporting yoga as an evidence based approach to the treatment of depression. But it is hard to figure out where to begin. At the end of this page are some additional resources.

One thing to realize is that for yoga to work requires a fair amount of consistency. Twice a week is probably a minimum dose and 3 to 4 times a week seems to be much better.

Yoga is one of the great meditative traditions. The word Yoga means union, and comes from “yuj” which means “to join,” to bring together into union the various aspects of yourself that were never divided in the first place. From that comes the direct experience of yourself that is beyond the false identities stemming from the seemingly countless colorings of attraction and aversion. Another modern adaptation of this principle is the word holistic, meaning to become whole, or to realize your underlying wholeness. Patanjali describes this in the Yoga Sutras where he defines Yoga as the mastery (nirodha) of the mind (sutra 1.2), allowing the true Self to then come shining through (sutra 1.3). Patanjali also explains that the purpose of Yoga is discrimination (viveka) among the inner processes (sutras 2.26-2.29).

In the Yoga Sutra of Patanjali there are many similar references to an active process of reaching clarity. This is from Sadhana Pada (On Practice) – Sutras 23 – 26.

23. Union (samyoga) is the cause of apprehending as [one] self-form the two powers of owner and owned.
sva-svami-saktyoh sva-rupa-upalabdhi-hetuh samyogah

24. The cause of it is ignorance.
tasya hetur avidya

25. From its absence, samyoga ceases; [this is] the escape, the isolation from the seen. tad-abhavat samyoga-abhavo hanam tad-drseh kaivalyam

26. The means of escape is unfaltering discriminative discernment.
viveka-khyatir aviplava hanopayah

This is from a wonderful site about yoga philosophy: http://www.santosha.com/philosophy/index.html .

Those who practice yoga follow one, or more, of the many paths to greater peace, and greater “enlightenment” that derive from the book Yoga Sutra written 2000 years ago by the Indian wise man Patanjali.

Most Westerners who practice yoga practice a form of yoga that is based on performing a series of “asanas” or postures. There are nine branches in total: yamas (restraints), niyamas (observances), asana (postures), pranayama (breathing), pratyahara (withdrawal of senses), dharana (concentration), dhyani (meditation), and samadhi (absorption).

Elsewhere on the Self Help page we refer to breathing exercises (pranayama), meditation (dhyani) and mindfulness (samadhi). The point is that this vast tradition encompasses almost all of the ways that people throughout the ages have found to achieve peace.

We can recommend based on patient successes two approaches that are quite different: one is Bikram Yoga (which is an intense, very physical and demanding form of yoga done in a heated room, it involves doing the same routines every day) and the other is one on one yoga training with someone who adapts yoga to your body and needs. We really like Karen Kibler for this.

Another good place to start exploring this tradition is the “Yoga Basics” page from the Yoga Journal website. Other resources are available online that may be useful.

Befriending Stress

befriending stressA colleague recommended this fantastic TED talk by Kelly McGonigal on the cardiovascular and social benefits of befriending stress (and potentially other negative emotions) as opposed to fearing these types of feelings. Kelly offers a fascinating perspective on oxytocin as a stress hormone that serves as a mechanism for resilience, helping people connect with others in times of challenge.

Kelly cites a very large study that found that, indeed, high stress was associated with a higher risk of death…. but only for those people who believed that stress was bad for them.

A study done by researchers at Harvard found that if participants were taught that the stress response can be healthy, that it is preparing them for a challenge… those people had different physical responses to stress… although their heart was racing, and they were breathing more rapidly, they did not have an increase in blood pressure, which is the part of the stress response that is responsible for many of the bad effects of stress.

Check it out.

And have a healthier response to the inevitable stressful events in your life.

Make Stress Your Friend

Exercise or Inactivity Changes Your Brain’s Structure and Its Resilience to Stress

exerciseThis past year has been a remarkable year in terms of new studies examining the effects of exercise on your brain.

Everyone knows, of course, that exercise is good for you. But these studies together provide compelling evidence that exercise (and inactivity) profoundly change the structure and function of your brain.

One set of studies has shown that exercise profoundly affects your genes.

It used to be thought that your biologic makeup was determined entirely by the genes you inherited. But a set of studies over the past decade have demonstrated that your biology is also affected by the way your body turns on or turns off your genes. The most important process that changes which genes are active involves methylation of the DNA.

DNA methylation involves the addition of a methyl group to the cytosine or adenine DNA nucleotides (these are the building blocks of DNA). DNA methylation stably alters the expression of genes in cells.

It turns out that one of the things that most profoundly affects this gene regulation is exercise.

In essence, the genes that are turned on if you exercise regularly are very different from the genes that are activated when you are inactive.

More recently, Gretchen Reynolds, in a New York Times blog post in January 2014, summarizes data showing how inactivity changes the structure of the brain and increases vulnerability to stress.

In a study recently published in The Journal of Comparative Neurology, scientists at Wayne State University School of Medicine looked at how exercise or inactivity affected the brain in rats (obviously this study couldn’t be done in humans). They focused on changes in a particular part of the brain, the rostral ventrolateral medulla, which governs your body’s unconscious responses to stress.

After three months, there were significant changes in this area of the brain in the animals who were not allowed to exercise (rats, unlike some humans, like running, and will do so if they have a chance). In those animals, there were new connections between the neurons (brain cells) and these changes appeared to correlate with a much more reactive sympathetic nervous system.

The sympathetic nervous system is the part of the brain that governs our “fight or flight” response to stressful or frightening situations.

If your sympathetic nervous system is hyperactive, you have trouble calming down when you are dealing with moderately stressful situations (you are overly sensitive to stress, and your reactions to stress last longer than they should).

As a result you have a higher risk of heart attacks, hypertension, stroke, and anxiety and depression.

This brain change could explain why exercising is so good at reducing the risk of these conditions.

A number of studies suggest that you can get a lot of benefit from a little exercise – just 30 minutes of activity that raises your heart rate per day (walking, vigorous vacuum cleaning, etcetera).

It seems like a small price to pay for a health brain and body.

Sleep Deep Cleans Your Brain

deep cleansBeep, beep, beep, beep! Snooze……Beep, beep, beep, beep!

You open your eyes, roll out of bed and start wondering why you stayed up so late to watch another episode of your favorite TV series, play another video or computer game, or catch up with your friends, etc. We have busy and full lives, which results in less and more disrupted sleep; this is especially the case for women. The National Sleep Foundation suggested that we are sleeping 20% less than we did a century ago and that 76% of Americans want to improve the quantity and quality of their sleep. Besides not wanting to feel as tired, why is sleep important?

An interesting opinion article in The New York Times discussed sleep research conducted by biologist Maiken Nedgergaard, M.D., D.M.Sc (see link to article below). Dr. Nedgergaard hoped to better understand the function of sleep since we have evolved to sleep despite it not appearing to be productive (i.e., it can’t be for nothing!). After researching the brains of mice at rest, she concluded that sleep may provide the brain with the opportunity to do a “deep clean” and rid the brain of the waste accumulated during waking hours. Dr. Nedgergaard termed this system the “glymphatic system” to reflect the similar concept of the lymphatic system, which serves as a cleansing and filtering system within the body.

Dr. Nedgregaard is planning similar research to determine if human brains have a similar process to that observed in the mice. If this is the case, a lack of sleep, and therefore a lack of thorough cleaning and “neural trash” buildup, may be further linked to neuronal degeneration and dementia.

Check out The National Sleep Foundation (NSF) website for information about physiological and psychological consequences resulting from sleep deprivation including weight gain, decreased ability to pay attention and increased risk of heart problems as well as depression.

NSF recommends adults get between 7-9 hours of sleep per night.
Here are some of their tips to get a better night sleep:

1. Stick to the same bedtime and wake up time, even on the weekends
2. Practice a relaxing bedtime ritual
3. Avoid naps, especially in the afternoon
4. Exercise daily
5. Evaluate your room
6. Sleep on a comfortable mattress and pillows
7. Use bright light to help manage your “body clock”
8. Avoid alcohol, cigarettes, and heavy meals in the evening
9. Wind down. Your body needs time to shift into sleep mode, so spend the last hour before bed doing a calming activity such as reading
10. If you can’t sleep, go into another room and do something relaxing until you feel tired.

See the NYT article to read more about the effects of short term versus long term sleep deprivation: http://www.nytimes.com/2014/01/12/opinion/sunday/goodnight-sleep-clean.html?emc=eta1&_r=0

Was James Bond a Lush?

lushAlways in search of the latest cutting edge medical knowledge, we happened across a fascinating research article in the December 2013 British Medical Journal that asks the question –

“Were James Bond’s drinks shaken because of alcohol induced tremor?”

Before going any further and looking at the research methods and conclusions, we have to warn readers that this may be tough stuff to read if you were ever a James Bond fan. In other words, it is not for the squeamish…

The authors, three eminent physicians with appropriate specialty interests in emergency medicine and liver disease, undertook to quantify the amount of alcohol that James Bond drank per week, according to his amanuensis Ian Fleming, as chronicled in the James Bond books.

Using a conservative methodology, and noting the times when he could not drink because he was incarcerated, or for other reasons,

They summarize the results –

Across 12 of the 14 books, 123.5 days were described, though Bond was unable to consume alcohol for 36 days because of external pressures (admission to hospital, incarceration, rehabilitation). During this time he was documented as consuming 1150.15 units of alcohol (table 2). Taking into account days when he was unable to drink, his average alcohol consumption was 92 units a week (1150 units over 87.5 days). Inclusion of the days incarcerated brings his consumption down to 65.2 units a week. His maximum daily consumption was 49.8 units (From Russia with Loveday 3). He had 12.5 alcohol free days out of the 87.5 days on which he was able to drink.

As if this is not bad enough, and assuming that he didn’t occasionally dispose of his drinks in nearby potted 12-20-2013 9-30-39 AMplants, it raises the question about the state of his liver. Their analysis shows a clear pattern of high use at the beginning of his career, then a decline, and finally, near the end of his career, even higher levels of intoxication. The authors note that this pattern is often seen in people with terminal alcoholic hepatitis.

They also note several incidents of high speed and reckless driving associated with excessive intake of alcohol. They note that in Casino Royale, “he drinks over 39 units before engaging in a high speed car chase, losing control, and spending 14 days in hospital. We hope that this was a salutatory lesson.”

Caveat emptor… we were a bit shocked to read this at the end of the article, raising questions about the ethics of the authors…

Ethical approval: The impact of this study on fictional British spies was thought to be minimal and therefore ethical approval was not sought for this study.No consent has been sought from the Commander Bond chronicled in the original Ian Fleming novels. The barrier to this chiefly being his fictional nature meaning he is unable to give valid consent.

For the record, this study had significant impact on this author, who read too much James Bond as a child, and it seems heartless of the authors to imagine that it didn’t have a significant impact on fictional British spies, and their fans…

Mediterranean Diet and Depression

Boost your brain power naturally! Try this simple intervention to reduce depression, stroke, heart disease and improve cognition.

Does that statement make you a bit wary?Mediterranean

A recent meta-analysis of 22 studies spanning two decades finds that the Mediterranean diet is associated with significant reductions in the risk of depression and stroke, and significant improvements in cognition.

Across the studies, in those people who were “highly adherent” with the diet there was an overall 33% reduction in risk for depression, a 40% improvement in cognitive function, and a 30% reduction in risk for stroke. To put that in context, antidepressants appear to reduce depression by about 33% more than placebo (overall reductions are about 55%), and daily aspirin, which is often recommended to women to reduce their risk of stroke, is associated with about a 17% reduction in risk.

The Mediterranean diet is characterized as high in vegetables, fruits, nuts, and seeds; moderate in fish, poultry, eggs, and olive oil; and low in red and processed meat and saturated fats.

There are many theories about why the diet helps. Among the theories are that it may be due to the anti-inflammatory or antioxidant properties of the diet, or its effect on glucose regulation (it is also associated with reductions in risk for diabetes).

For more about the Mediterranean diet you can go to this page on our site.


These books might be of interest also.


Ann Neurol. 2013 Oct;74(4):580-91. doi: 10.1002/ana.23944. Epub 2013 Sep 16. Mediterranean diet, stroke, cognitive impairment, and depression: A meta-analysis. Psaltopoulou TSergentanis TNPanagiotakos DBSergentanis INKosti RScarmeas N.

Herbal Supplements Often Not What They Claim

11-19-2013 7-26-40 AMA recent study concluded that herbal supplements are often not what they claim to be. The study was published in the journal BMC Medicine and it got front-page coverage on the New York Times website.

Using DNA analysis, researchers tested 44 products from a dozen companies. The DNA signatures were compared with samples obtained from horticultural greenhouses.

The study was summarized in the New England Journal of Medicine Journal Watch for Psychiatry. The authors write –

More than half the products contained plant species not listed on the label, and one third had a product “substitution” (the advertised ingredient was not even present). One product labeled as St. John’s wort actually contained senna — a laxative. A ginkgo product was contaminated with a tree nut — dangerous for people with nut allergies. Another contaminant, feverfew, can react with warfarin and aspirin and increase the risk for bleeding.

The study authors point out that there are currently no standards for authenticating herbal products….

(For a study documenting that some Chinese herbal supplements are associated with risk for heavy metal poisoning, which causes a variety of psychiatric symptoms, see NEJM JW Psychiatry Mar 6 2002.)

These findings are particularly relevant to readers of this blog since large surveys of users of herbal supplements show that a high proportion of patients with depression and anxiety use them.

Caveat emptor – let the buyer beware. There are no standards for quality control of herbal products and essentially no monitoring of what gets put into them.

The only reliable resource for information about the quality of supplements is Consumer Lab, which does independent quality testing. You have to subscribe to get the results (that is how they pay for the testing) but I think that this study demonstrates that you should not be spending a lot of money on supplements if you don’t subscribe to Consumer Lab’s tests. 


O’Connor A.Herbal supplements are often not what they seem. NY Times 2013 Nov 3; (http://www.nytimes.com/2013/11/05/science/herbal-supplements-are-often-not-what-they-seem.html?_r=1&)

Newmaster SG.DNA barcoding detects contamination and substitution in North American herbal products. BMC Med 2013 Oct 11; 11:222. (http://www.biomedcentral.com/content/pdf/1741-7015-11-222.pdf)

Changing Hormone Levels and Mood

hormoneI was on the phone yesterday having an urgent consultation with a woman we have worked for 15 years. She has had a pretty straight forward history of depression and anxiety that we’ve treated primarily with antidepressants
and cognitive behavioral therapy. She’s had a good response to this treatment approach. The two things about her depression that are a little unusual are that she has a strong family history of bipolar depression, although she herself has  had only depressive episodes, and after the birth of her first child, she had a very unusual period of depression and anxiety but associated with a lot of agitation and, after she had not be able to sleep for a couple of nights, even some paranoia.

This responded very well to treatment with an estrogen patch and some medication to help her sleep. But I have often wondered about the possibility that she has a very small tendency to bipolar because people with postpartum psychosis definitely have a higher likelihood of having bipolar moods.

She started to go into menopause a couple of months ago (she developed hot flashes and irregular menstrual cycles), and at almost exactly the same time, seems to have experienced her first clearly hypomanic episode. This started us thinking about what we know about menopause and mood episodes.

There is an increased incidence of depression around the time of menopause. However, many studies have tried to identify correlations between levels of female hormones and these depressive episodes, without much success. Current thinking is that it’s not so much the absolute level of estrogen as the fluctuations in estrogen that take place in the menopausal period. These fluctuations are much greater than those that take place during a normal menstrual cycle. There are times when estrogen levels are relatively normal, but these are followed by times when estrogen levels fall well below those values.

The up and down fluctuations seem to be what are associated with mood episodes. In a similar fashion, it may be the sudden and dramatic drop in estrogen hormone levels after the birth of a child that is the trigger for postpartum mood episodes. Certainly the period right after the birth of the child is a time of very high risk for women who have any kind of genetic predisposition to depression, or bipolar.

And many woman who otherwise never experience psychotic symptoms can have those symptoms right after the birth of a child.

The good new in terms of menopause is that once the change is complete and a woman is solidly in the post menopausal state, depression seems to significantly taper off.

Depression and Inflammation

inflammationRecently there has been increasing interest in the relationship between depression and chronic overactivity of the body’s biological defense system – inflammation.

When we have an infection, or an injury, or almost any other kind of illness, the body activates a series of processes designed to respond to the threat.

Unfortunately, the inflammation system, especially if it is turned on chronically, has many negative effects on the body itself.

Inflammation plays a major role in a number of chronic medical diseases, such as heart disease, rheumatoid disease, etcetera.

Now there is evidence that some people with depression may also have an over-active inflammation system. These people appear to be less likely to respond to traditional antidepressants.

Causes of Treatment Resistance

We know that a number of factors are associated with less likelihood of responding to antidepressants, these include childhood mistreatment or adversity, the presence of a chronic medical illness, obesity, and having certain 9-21-2013 7-08-19 AMadditional psychiatric disorders (anxiety, personality disorder, perhaps bipolar). It turns out that most of these factors are also associated with increased inflammation.

How might an overactive inflammation system affect response to treatment of depression?

There are a number of ways that inflammation affects systems that are essential to treatment response. These can be broken down into three categories.

Glutamate Effects

Inflammation increases activity of glutamate neurotransmission. Glutamate is one of the main stimulatory neurotransmitters – when it is released by one neuron (or brain cell) it stimulates activity in the next neuron. However, excessive activation of the glutamate system is associated with toxic effects on the brain (as happens with seizures, or after a stroke).

It was recently discovered that ketamine (an anesthetic agent that blocks some of glutamate’s effects) has remarkable short-term positive effects on depression. Some people with chronic treatment resistant depression snap out of their depression briefly after just one treatment with ketamine.

Brain Growth Effects

Many of the longer term beneficial effects of antidepressants are associated with increases in the release of factors that stimulate the growth of neurons (brain cells). For example, depression is associated with a reduction in brain levels of Brain-Derived Neurotrophic Factor (BDNF) which is a key chemical that support brain cell health. Treatment of depression with anti-depressants results in a return to normal levels of BDNF.

Inflammation causes a reduction of BDNF, and blocks the brain’s ability to create neural stem cells (cells that may be able to replace lost brain cells).

Effects on Monoamine Neurotransmitters

Monamine neurotransmitters (serotonin, norepinephrine, dopamine) are the primary first target of antidepressants. Almost all antidepressants increase the release of these neurotransmitters.

Inflammation can reduce activity of monoamine systems by interfering with the production of monoamine neurotransmitters directly and by increasing activity of the reuptake proteins in brain cells. Think of reuptake as a system that vacuums up monoamines – thus reducing their level in the brain – most antidepressants block reuptake, and inflammation increases reuptake.


At this point we don’t know for sure how much of a role inflammation plays in chronic treatment resistant depression. What we know is that many things that predict poor response to antidepressants are associated with inflammation,and inflammation itself can negatively affect many brain functions that are necessary in order to respond to treatment.

But what to do about this?

If you are a neuroscientist, you might want to consider looking at the possibility that medications that block inflammation could help in treating some people with depression (those who don’t respond adequately to an antidepressant or who have some of the marker suggesting chronic inflammation – such as a high C-Reactive Protein or CRP).

For now it doesn’t make sense to take these medications. Inflammation plays important beneficial roles as well as harmful ones in the brain.

On the other hand, there is one treatment for depression that can have dramatic beneficial effects on excessive inflammation – exercise.

It has been hard to find a big positive effect of exercise on depression, although a recent comprehensive analysis of the literature by the Cochrane Review group suggests that there is a benefit.

Perhaps the reason for this is that exercise is not essential to treatment response for everyone who is depressed. It may be only those with inflammation who respond the best to exercise.

This may help clinicians as well. For many people exercise may not be an essential intervention, but for those with chronic depression and risk factors for chronic inflammation, it may make sense to really focus on increasing aerobic exercise (perhaps adding a trainer to the treatment team?).

For More Information

A somewhat technical but very informative review of this area is in an article in Psychiatric Times by Charles Raison et al (“Inflammation and Treatment Resistance in Major Depression: The Perfect Storm”).

Hormones and Food

hormonesIn an earlier post we talked about some of the research on appetite. We reviewed some of the peptide hormones that regulate appetite and how the entire system that controls appetite is really designed to cope better with a time of scarcity than a time of plenty.

Here I want to talk more specifically about the interplay between other hormone systems and appetite and weight regulation.

This part of the overall set of articles on appetite and body composition focuses on hormone systems that are not specifically designed to control appetite, but do so because changing body composition or diet is important for other reasons. For example, having better availability of quick energy stores like glucose when facing challenges.

Broadly we will consider these hormone systems –

  • The cortisol system – your stress hormones.
  • The thyroid system – your body’s overall metabolism regulator.
  • Sex hormones and their relationship to body composition.
  • The insulin system which controls blood glucose.

The Cortisol System


Cortisol plays a large role in regulating many functions throughout the body. It is best known as the “stress” hormone, and, these days, with lives that have relatively few imminent dangers, discussion about cortisol mostly focuses on things that it does that are bad for us.

However, it plays a central role in the body’s ability to adapt to almost any stressful situations – illness, injury, external threats – and it is worth beginning this discussion by reflecting on the fact that we could literally not survive without an intact cortisol system.

As with many hormone systems, cortisol is regulated in a complicated way that starts with the brain (hypothalamus) and proceeds to a part of the body that is midway between brain and hormone gland (the anterior pituitary) and then ends up with the hormone glands themselves (the adrenal cortex).

In terms of its effects on appetite and body composition, think of cortisol as the system whose philosophy is – use it now because this struggle is a matter of life and death.

So, high cortisol levels draw down on all of the body’s long term stores of energy and shifts the overall body metabolism away from building and regenerating (things like muscles, skin, etcetera) and towards an immediate ability to use large amounts of energy to deal with a crisis.

The main sources of this kind of energy are glucose and fatty acids. So high cortisol levels tend to result in higher blood glucose and fatty acid levels (cholesterol, triglycerides).

Other effects are –

  • Cortisol stimulates the release of insulin and has a role in maintaining blood sugar levels
  • It makes you want to eat a lot
  • It causes cravings for sweets and simple carbohydrate foods that cause insulin levels to spike and then plummet quickly, which makes you hungrier
  • Tends to cause increased deposition of “stress fat”, which is concentrated in the abdominal stomach area

The Thyroid System

The thyroid system is all about overall body metabolism. Think of it as the dimmer switch for the body’s energy Thyroid_systemsystems.

High levels of thyroid stimulate increased activity and energy. Low levels of thyroid turn off energy and activity systems.

Based on that, you might not be surprised to learn that one of the main symptoms of high or low thyroid is sweating and feeling hot (hyperthyroidism) and abnormally low sweating and feeling cold (hypothyroidism).

Just as with the cortisol system. There are three steps involved in regulating thyroid hormone release: they hypothalamus, the anterior pituitary and the thyroid gland itself.

This may help to explain one of the most common misunderstandings about thyroid test results.

“Doc, why do you say my thyroid is low if my TSH (thyroid stimulating hormone) is too high?”

If the thyroid gland starts to lose its ability to put out an adequate level of thyroid hormone, then the anterior pituitary starts to crank up the levels of TSH that it sends out, hoping to get the thyroid gland to produce more thyroid hormone. So, usually, as one becomes hypothyroid TSH goes up.

In terms of effects on appetite and body composition the main effects are indirect. As your body uses less energy (low thyroid) more of what you eat gets stored as fat. As your body uses more energy (high thyroid) you tend to lose weight.

This has led, over the years, to a recurrent idea that the solution to being overweight is to crank up the thyroid.

The problems with this approach are –

  • Overshooting your body’s natural thyroid level results in other negative effects which outweigh any effects on weight – early osteoporosis, cardiac problems.
  • High thyroid tends to have only a modest effect on weight loss

Sex Hormone Systems

These systems have more profound effects on body composition than we have really been aware of up until the last few years. Testosterone (in both men and women) regulates muscle mass. And estrogen (in both men and women) regulates fat stores.

Testosterone increases muscle mass and strength. And low testosterone is associated with loss of strength and may be a major source of disability in older people.

Estrogen turns out to have an important role in fat regulation in both men and women. As estrogen levels fall (after menopause for women) fat stores tend to increase. In men the blood level of estrogen is determined by how much testosterone there is – testosterone gets converted to estrogen – so as testosterone levels fall, estrogen levels go down, and that, in turn, leads to more fat deposition. testosterone_aromatase_estrogen_gnrh

Before the recent research on the benefits of higher levels of estrogen, in men and women, in terms of reduced level of body fat, the fact that testosterone is converted to estrogen in the body (particularly, as it happens, in fat cells) had led to prescribing medicines to block that conversion. Medicines which may, inadvertently, have contributed to increased body fat.

Whereas estrogen supplementation in men is probably not a good idea, this may lead to another reason to use testosterone supplements in older men.

The Insulin System

The insulin – glucagon system serves to regulate blood sugar. Blood sugar is critically important to a number of organs that rely almost exclusively on blood sugar as a source of energy. Of these organs, the brain is probably the most important one. Low blood glucose rapidly leads to shutting down the brain, and ultimately to seizures and death. 9-12-2013 8-26-21 PM

Again, maintaining high enough levels of blood sugar had always been the most important challenge, until we changed our diet and lifestyle and high blood sugar became an epidemic.

Nowadays the main problem is “insulin resistance.”

Some people, in the presence of a diet rich with simple carbohydrates and a lifestyle with little exercise, become increasingly resistant to the effects of insulin. There appears to be a strong genetic basis to this tendency – some native american populations have incredibly high rates of diabetes in this century.

Insulin basically stimulates the body to use blood sugar. Insulin resistant cells can’t use the blood sugar, and because they can’t use blood sugar, the body develops abnormally high levels of blood sugar that are associated with damage to various organ 9-12-2013 8-40-00 PMsystems.

The metabolic syndrome is the combination of insulin resistance, elevated cholesterol (along with other lipids) and hypertension. Although the exact way that this syndrome develops are not entirely clear, it does appear that early intervention with lifestyle changes, and, often, medication like metformin that enhance insulin sensitivity may help to prevent some of the adverse consequences of this condition.

Paying attention to the literature in this evolving area is probably a good idea.


Hunger Regulation

Rechungerently several folks have asked us questions about diet, hunger, weight gain, and nutrition.

Certainly for many people with depression, gaining weight is an important issue, both as a cause and consequence of depression.

Let’s begin by trying to make some sense of hunger. In other posts we will be talking about how stress and the hormone system relates to diet, hunger and weight gain. We will also talk about what influences how many calories we burn. And finally we will talk about how diet affects weight. .

Regulating how much we eat is a basic function of the human brain and body and the systems that have developed to maintain our body weight are remarkably effective. Unfortunately, they may not be as well adapted to modern life, with instant access to unlimited highly dense foods, as they were to our distant past when there was an ever-present risk of going hungry.

There are a few key hormones that are involved in regulating hunger and satiety –

  • Leptin
  • Ghrelin
  • Neuropeptide Y
  • Melanocyte Stimulating Hormone
  • Cortisol – which we will discuss in another post.

Leptin is a hormone that is tightly regulated by how much body fat you have. As you put on fat there is more and more circulating leptin. And low leptin is a trigger for various behaviors designed to allow you to gain weight.

However, leptin is best not thought of as primarily a weight regulating hormone. It is a hormone that is primarily designed to encourage maintaining enough weight that it is safe to have children. At very low levels of leptin, people are incredibly hungry (low leptin is one of the strongest triggers for hunger) and their reproductive system is shut down, until a normal body weight is reached. In other words, low leptin shuts down the reproductive system and drives us to eat enough so that can be ready to have children. Then, as we gain fat, our leptin levels increase. But for some of us we remain hungry as we become obese, even though our leptin levels are very high. There are a number of theories about this. One suggests that, just as we can be insulin resistant when we begin to have diabetes, we can be leptin resistant as we get fat.

To confuse things further, leptin may also be involved in anxiety regulation. High levels of leptin may be 8-27-2013 6-04-46 AMassociated with lower anxiety (perhaps the reason why overeating can be helpful, in the short run, as a way of dealing with anxiety). In other words, our brains may be conditioned to reach as high a level of leptin as possible, a strategy that might have made sense when scarcity was the norm, but might be part of the reason for  the obesity epidemic we face.

Think of leptin as the “Big Momma” hormone. Designed to make you feel secure and enabling you to have a family safely in a world where not having enough food is always a possibility. But perhaps not your friend in a world where starvation is rare.

Ghrelin is a hormone that does two things – it increases the release of growth hormone and it increases food intake. If leptin is the “Big Momma” hormone, ghrelin is the big strong person hormone. Unlike leptin, where low levels stimulate appetite, ghrelin works the other way, high levels of ghrelin stimulate appetite, and it has both short term and long term effects. In the short term, it is part of what drives hunger as you get close to meal time, in the long run, it appears that ghrelin is part of the problem many of us wrestle with after we lose weight. It now appears that our bodies keep trying to return to the former (unhealthy) weight for at least five years, and perhaps indefinitely. And ghrelin is involved in the long term problem of increased hunger when you get down to a healthy weight.

Neuropeptide Y is one of the most potent stimulators of appetite known. It is also involved in regulating a number of aspects of the stress response system. Just as with leptin, neuropeptide Y affects both anxiety and appetite. Unlike leptin, high levels of neuropeptide Y are associated with reduced anxiety (perhaps including reduced PTSD symptoms) and increased appetite. There is a very close relationship between neuropeptide Y and the stress system (cortisol, cortisol releasing hormone) and some of the effects of neuropeptide Y may be indirect, due to how it affects the stress or cortisol system.

Melanocyte Stimulating Hormone is perhaps the most mysterious of these hormonal influences on appetite. In fact, MSH is named because of its effects on skin pigmentation (it stimulates melanocytes, which are the cells that lead to darker skin when tanning). However, it turns out that MSH is also involved in regulating appetite and sexual behavior. MSH inhibits food intake. And animals without the MSH system intact become morbidly obese. How this relates to humans is less clear. Stay tuned to new stories about how this system may be involved in the human obesity epidemic…

In summary…

Our brain and body developed in a time where the main challenge was gaining enough weight so that we could grow strong and have children. It did not really develop to help us deal with too much food, and particularly too much high density food (food with lots of calories and little fiber).

Our body and brain remain fixated on making sure that we are getting enough food, and thus we need to think about strategies for living that do not expose us to too much temptation (high calorie foods).

In this area, as in so many other areas of medicine, it is much better to prevent obesity than it is to try to get back to a normal weight. Once you have become obese, parts of your brain will try to take you back to obesity for a very long time.

There is a very intimate relationship (as if you didn’t know this already) between stress response systems, reproductive systems and appetite regulating systems. This may be part of why it has taken so long to come up with good treatments for obesity. Things that reduce weight are not hard to find, but those things tend to disrupt other extremely important body functions.


ginsengIf you are a ginseng believer, then ginseng is the one supplement that all of us should be taking.

Russian scientist Israel Brekhman coined the term “adoptegens” to refer to agents that helped individuals deal with stress. The prime example of this, in his view, was ginseng.

[If you are interested in an example of the controversy that surrounds many topics related to natural supplements, go to the wikipedia article about Brekhman and follow the link to the “Prime One” adoptogenic formula…]

But, let’s say you are just trying to figure out if Ginseng makes sense for you, what kind of information can you get from reliable sources?

First, you should know that there are three different plants that are called “ginseng”… and despite their similar name they are quite different. Panax ginseng is the Asian herb that has been the best studied. There is a related herb called Panax quinquefolius which is grown in the United States. And then there is an unrelated herb, Eleutherococcus senticosus, which is called Siberian “ginseng.”

In this brief article we will talk primarily about Panax ginseng, or Asian ginseng.

Several, but not all, studies, have suggested that Panax ginseng can enhance mental function. However, the specific nature of this enhancement is often quite variable from clinical trial to clinical trial.

Other studies suggest that it may contribute to an overall sense of “well-being” and that it may help with erectile dysfunction and postmenopausal symptoms.

There don’t appear to be any safety issues, so the main concern is whether or not the supplement is worth the cost.

If you are interested in taking a test drive, you should know that some studies suggest a negative interaction with antidepressants. And you might also want to know that, in a recent article in our favorite resource for information about natural supplements (Consumer Labs – if you use supplements you really should prescribe – 33$ per year but well worth it in potential savings from not buying worthless or even harmful supplements) the Nature Made formulation was highly rated.

Life Energy

energyFreud came up with the term libido to describe the sum of all the human instincts related to love.

In his view, there was a limited amount of this libidinal energy and it was important to use it wisely. Invest it in the wrong activities and you could end up with nothing to show for it. This notion of limits and scarcity seems to suffuse Freud’s thinking and could perhaps reflect a somewhat depressive aspect of his personal character.

Later, Carl Jung expanded the meaning of the term to encompass not just love and sex, he felt that libidinal energy was really life energy.

I have been thinking about life energy for a while. Noticing how there are some people who seem to overflow with it, how it crests when people are manic and falls when people are depressed, but also how illness and aging affect it.

I met with an older attorney this afternoon. He’s a delightful widower who recently returned to world of dating. One of the challenges that he has had to face is the reduction in his capacity for sex. This is a very important issue, pleasure and libido has always been important to him.

There is a strong relationship between life energy, pleasure and vitality, not only psychological vitality, but physical health as well. One of the observations that I have often made about people who are getting older is that the decline in their physical health is often preceded by a decline in their life energy, their interest in creative and pleasurable activity, traveling, sex, romance, etcetera.  I think this may not be a coincidence.

Recently I came across an intriguing study that suggested that levels of gonadotropin releasing hormone (the brain hormone that regulates the levels of the sex hormones estrogen and testosterone in the body) correlated with memory and brain function. Of course, this intriguing finding is no more than a tantalizing hint about how libido and aging may interrelate.

Another interesting relationship is between exercise and life energy.

Recently, the New York Times ran an article highlighting new research that shows how exercise radically affects how our genes are transcribed. This provides a biological explanation for the long noticed fact that continued exercise, or physical activity, is one of the most important predictors of healthy aging. Physical exercise is, in fact, a better way of preventing brain atrophy than doing puzzles or challenging the brain in other ways.

Talking with the widower attorney, I noticed that his reduced sexual ability correlated with a shift in his mood towards a mild depression. Along with that shift, had come a noticeable reduction in physical exercise and how much he was involved in pleasurable activities such as going to concerts and listening to music.

I suggested that he might focus on reversing some of these changes (getting more physically active, going outdoors more, doing more pleasurable things) before he turned to focus on the more purely physical aspects of sexuality.

Freud’s notion of a limited amount of libidinal energy seems clearly contradicted by the evidence that the more we do, the more active we are (in many spheres and dimensions) the more we seek and use life energy, the healthier and stronger we are. In other words, husbanding our energy, leading more and more constricted and constrained lives, is exactly the opposite of what science suggests leads to long life and health.

The Loving Brain

BRAINGet ready, because the month of July has an exciting event coming up! Rick Hanson, PH.D. is hosting a free interview series called the Loving Brain starting July 15. For the 8 following Mondays, experts will be giving talks on how to develop positive relationships with others and establish a healthy self image. If you happen to miss a speaker that you were really interested in seeing, do not be discouraged! All the interviews will be available for free downloads once they are posted. The purpose of these interviews is to give people the advice and tools they need to build strong relationships and enhance their overall quality of life.
The fun starts with a presentation from Rick Hanson that explores themes similar to the book he published called Hardwiring Happiness. Some topics that he will be covering are the relationship between who we are today and our childhood, how to become more caring and practice self-love, learning to let go of unfair self criticism, the neurochemistry of love, the role of hormones in relationships, working on parent-child relationships, and how relationships can actually change our brains in positive ways.
Many experts will be featured speaking on specific topics as well. The specialists will explore areas that include building the foundation of relationships, being mindful in a relationship, demonstrating self-compassion, the effect of our inner feelings on eating habits, the neurotransmitters involved with love, understanding the role of hormones in relationships, and the formula for creating happy families.
If any of these topics have sparked your interest, sign up at this website to gain access to the talks:
All you have to do is give your email address, and the talks are absolutely free. Take some time this July to reexamine new relationship strategies, and feel refreshed by a new positive outlook on life.


Runner’s High

runner's highA great way to gain both physical and mental strength is to make running a part of your workout. A lifestyle that includes running promotes well being and reaps both cognitive and mental benefits. When running, the body releases endogenous opioids, like endorphins, that relieve stress. The feeling some people call a runner’s high is due to the activation of the frontolimbic brain areas that improve mood.

Running also increases personal self esteem and confidence. After conquering a huge distance, individuals feel unstoppable and as if they could accomplish anything. Running can help establish a sense of discipline or motivation that will translate to many different facets of life.

A lot of people also don’t realize how helpful running is to our mental health as well. Along with endorphins, running sparks the production of the neurotransmitters serotonin and dopamine.  When running, your brain takes a break from the worries, stress, and anxiety that we sometimes face in every day life. The increased oxygen we are exposed to makes the body more alert and attentive.
Cognitive benefits can also surface from running. Running has been shown to cause structural changes in the hippocampus that lead to increased learning, memory, and neurodegeneration prevention.

If you find you are spending too much time sitting at home and are looking for a new activity, then running is definitely worth a shot!  A good run will help you look great, feel balanced, and learn how to channel self discipline and motivation.

Know Your Body

bodyGeneen Roth talks about how infatuated she was with her imperfections while growing up. She was constantly thinking of how much better looking she would be if she didn’t have certain features. If only she could cut out all the flaws, so just her best features would remain she could be happy.  Roth tried to reach self improvement through shaming and judging herself.

She was under the impression that if she self critiqued and dieted enough, she would achieve a better body and a better life. Roth now realizes that changing an external appearance does not mean having a different life.  The way to achieve an end of happiness is not through self loathing but through kindness.

We must accept the body that we have and truly love and embrace it. If you are born with a particular body type, you must love and embrace it. Trying to force your body to be a shape that it is not will only result in greater unhappiness and distress. Changing your body is only possibly if you understand what your body needs. Do not shame or deprive yourself to the point where you are scarred emotionally.

Roth tells those struggling with body image to eat when they are hungry and feel what it’s like when they are not.

A lot of people have the misconception that they are sad or depressed because of what they weigh. In reality, the heart of the problem is what you eat in the time that you are not actually hungry. People use food to cope with different emotions like boredom, grief, or rejection. Food is a way to suppress the real problem by acting as a distraction. People fall into the trap where they will claim to start making changes once they are thin.

Phew… That’s Done: Sustaining Attention

attentionIt is such a relief, after worrying about some health problem for a long time, to suddenly realize that that problem no longer needs acute and urgent attention. This is as true for an ankle or knee injury in sports as it is of anxiety or depression, or any other mood state that impairs our ability to function.

There is a natural wish to put the thoughts that have consumed so much time and caused so much worry aside and move on with your life.

That strategy works reasonably well for an acute injury that completely heals. It works less well for something like a recurring injury like an ankle sprain or a chronic knee problem…  or a depression that has come and gone before.

The wish to close the book on a problem solved is a tendency shared by much of American medicine. It has been noted elsewhere that the American healthcare system is not very good at helping people deal with chronic health problems. The goal is usually to fix a problem and move on, and many doctors interest in helping is markedly reduced when such a “quick fix” is not possible.

And it is a tendency that crops up often in my practice. Thursday I saw a woman who has been depressed for a couple of years. Our latest treatment plan finally seemed to be working, but rather than encouraging her to continue the effort, she seemed to have decided that it was time to take a break from paying attention to her depression.

With a chronic problem like recurrent depression, turning away from thinking about the problem as soon as the symptoms are better more or less guarantees that the problem will come back sooner.

As a young man I had several sprains to my right ankle. I was a runner at the time, and irritated with having to stop my training. As soon as each sprain was healed I went back to my regular routine… But it gradually became clear that I needed to do something to stop this from happening again and a gain… and I was able to really return to full functioning only when I devoted a small amount of attention to preventing this injury from happening again on an ongoing basis.

The same thing is true of depression.

The challenge is how to find a sustainable level of ongoing attention. You can’t worry about a chronic problem all the time or it begins to dominate your life. The challenge is how to go from anxious thoughts to preventative thinking.

A few months ago, I decided that I was going to start mood charting. I’ve been recommending it to others for so long that it only seemed fair that I do it myself.

What I discovered is that it was important to connect the activity of charting to a sense of reflecting on the day. That way filling out the daily entry was a way of achieving a sense of peace and clarity about how things turned out. Peace and clarity.

In other words, I needed to make mood charting an activity that was an exercise in mindfulness. If I didn’t do that then filling out the chart seemed like a moment to reflect on failures. And when I did that, I found that I enjoyed taking that moment at the end of the day to write a few notes and reflect on my mood and my sleep.