Expand Compounded Options to Include Evidence-Based Nutritional Treatment for Depression
If you’ve studied nutrition and incorporate it into treatment plans, you belong to a small but growing group of health professionals. With the rising prevalence of metabolic diseases such as diabetes and obesity, attention to nutrition has blossomed, but now a large medical group has embraced the role of nutrition. The American Psychiatric Association is poised to release evidence-based recommendations for using nutrition to treat depression. Outreach from compounding pharmacists can reinforce the importance of nutritional treatment for depression, while ensuring adherence to psychotropic medications.
Psychiatric Professionals Recognize the Role of Nutrients
The 2016 annual meeting of the American Psychiatric Association (APA) marked the fourth year a session was offered about foods that nourish the brain. During the session, Drew Ramsey, MD, assistant clinical professor of psychiatry at Columbia University, talked about an evidence-based food rating scale he developed based on a systematic review of studies exploring the impact of nutrients on depression.1 When his research is published—and results are released from the SMILES trial, which is studying the effect of diet on major depression—the mental health community will have their first nutritional guidelines to use when treating patients for depression.
The significant headline is all about helping patients overcome depression with nutritional support. Yet the most notable piece of news is that the APA has taken a giant step toward acknowledging the value of nutrition for treating a medical condition. It’s important to note that the APA currently supports adjunctive use of nutrients. By comparison, some evidence supports the efficacy of nutrients such as omega-3 fatty acids when used without psychotropic medications.
Nutrient and Dietary Recommendations for Depression
The systematic review of nutrients, which was published in the American Journal of Psychiatry in June 2016, reported that the current evidence supports adjunctive use of omega-3 fatty acids, S-adenosylmethionine (SAMe), methylfolate and vitamin D with antidepressants.2
- Omega-3 fatty acids: Low levels of omega-3 fatty acids are associated with depression. Neurons depend on omega-3’s as they affect phospholipid membrane fluidity and ion channels. They also regulate neuroendocrine activity and serve as precursors for potent anti-inflammatory lipids. Of the two long-chain polyunsaturated fatty acids that comprise omega-3s—docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)—evidence points to the efficacy of EPA over DHA. One meta-analysis found that supplements containing 60 percent more EPA than DHA, with EPA in the dose range of 200 to 2,200 milligrams, improved symptoms of depression.3
- S-adenosylmethionine: As a methyl-donating compound, SAMe is essential for metabolic reactions, cell signaling and the production of neurotransmitters and hormones. After a build-up period of one to two months, supplemental SAMe in doses of 800 to 1,600 milligrams daily may be as potent as some antidepressants. A study published in the Journal of Affective Disorders in 2014 found that SAMe was as effective as escitalopram, although there was some discrepancy between different sites.4
- Methylfolate: The link between folate and depression isn’t new—it has been studied for about 50 years. Low levels of folate aren’t just associated with depression; early studies suggested they may also be linked with poor response to pharmaceutical treatment. Folate’s biologically active form, L-methylfolate, is the only folate metabolite that crosses the blood brain barrier where it’s used to synthesize serotonin, norepinephrine and dopamine. High-dose L-methylfolate may achieve better results in patients who don’t respond to SSRIs.
- Vitamin D: Many studies report an association between vitamin D deficiency and depression. A small study with 40 patients randomized into a double-blinded and placebo-controlled clinical trial found that high-dose vitamin D supplementation reduced depressive symptoms, reported the Journal of Nutrition in February 2016.5
Key Points for Pharmacists When Counseling Patients with Depression
In January 2016, the US Preventive Services Task Force updated its recommendations on screening for depression in adults. The task force said that all adults should be assessed at the primary care level, although it didn’t offer recommendations about frequency. A subsequent article in Pharmacy Times encouraged pharmacists to engage in depression screenings so that patients who might avoid seeking help have a professional they can approach.6 This step is especially important for increasing adherence to psychotropic medications.
- Start a discussion about nutrition: Whether you bring up the value of nutrients or begin by asking patients taking antidepressants whether their physician has recommended supplements, nutrition is a positive and non-threatening way to engage patients who are uncomfortable talking about mental health issues.
- Medication plus therapy: The diverse medical options—SSRIs, SNRIs, NDRIs, atypical antidepressants, tricyclic antidepressants and monoamine oxidase inhibitors—often require trial-and-error to find the right med and dosage, which is frustrating for patients. Medications combined with psychotherapy generally result in the quickest and most effective treatment, but most patients don’t receive therapy. Noncompliance is also high, whether due to side effects from psychotropic meds, costs or because patients want to avoid the association with a stigmatizing illness. During your nutrition discussion or medication review, ask patients whether they’ve considered psychotherapy and remind them not to stop taking meds until they talk with you or their physician.
- Nutrition is complex: Nutrition seems like a straightforward topic, but research is evolving and everyone has an opinion, so information must be carefully filtered to be sure patients receive the best guidance. As just one example, the group that developed the food-rating scale highlighted the importance of organ meats, according to Medscape. Liver and kidneys are good sources of folate and vitamin D, as well as B vitamins, but considering their saturated fat and cholesterol content—not to mention they’re seldom included in a typical diet—it’s hard to imagine why they’d be recommended. When patients have in-depth questions, refer them to a registered dietitian.
- Advice about supplements: Stock your pharmacy with quality supplements and be prepared to field questions about vitamins recommended by the APA, as well as vitamins B12 and B6, which may also relieve depression.
Compounded Options May Improve Adherence and Outcomes
Patients perceive compounding pharmacists as a safe and reliable resources—and quite possibly the only person they’ll talk to about their illness. Nutrition is a neutral topic and it has now gained acceptance as part of depression treatment, which makes it the perfect way to open communication. Once you’ve connected with these patients, be sure to offer compounded options that improve adherence, such as combining multiple meds into a single dose. Every step you take improves their chance for healing and develops a loyal patient.
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- “New ‘Brain Food’ Scale Flags Best Nutrients for Depression,” May 2016, http://www.medscape.com/viewarticle/863887#vp_1 ↩
- “Adjunctive Nutraceuticals for Depression: A Systematic Review and Meta-Analyses,” June 2016, http://www.ncbi.nlm.nih.gov/pubmed/27113121 ↩
- “Meta-analysis: Effects of Eicosapentaenoic Acid in Clinical Trials in Depression,” September 2011, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534764/ ↩
- “S-adenosyl Methionine (SAMe) Versus Escitalopram and Placebo in Major Depression RCT: Efficacy and Effects of Histamine and Carnitine as Moderators of Response,” August 2014, http://www.ncbi.nlm.nih.gov/pubmed/24856557 ↩
- “Vitamin D Supplementation Affects the Beck Depression Inventory, Insulin Resistance, and Biomarkers of Oxidative Stress in Patients with Major Depressive Disorder: A Randomized, Controlled Clinical Trial,” February 2016, http://www.ncbi.nlm.nih.gov/pubmed/26609167 ↩
- “Pharmacists Can Play Important Role in Depression Screening,” February 2016, http://www.pharmacytimes.com/news/pharmacists-can-play-important-role-in-depression-screening ↩