Integrative Medicine and Pediatric Mental Health
Anxiety and Depression: Lifestyle Basics
Anxiety and depression account for the vast majority of cases of mental/emotional illness in our society, affecting people of all ages and, increasingly, children. Over 1 out of 5 children between the ages of 13 and 18 have had a seriously debilitating mental disorder, either currently or at some point during their life. Also, according to the CDC, about 13% of children aged 8-15 had a diagnosable mental disorder within the year prior to a large survey. Depression in children is estimated at approximately 2% of school age children and 8% of adolescents.
The rates of use of prescription [anti-anxiety] anxiolytic and antidepressant drugs have skyrocketed and are of great concern. The anti-anxiety medications suppress anxiety but do not get to its root cause or give patients greater control of moods. Many can also create stubborn dependence, interfere with normal sleep and dreaming, and impair memory and other mental functions. Many anti-depressants have significant adverse effects and may turn out to be no more effective than placebos. Conventional medicine relies almost exclusively on these medications for the management of anxiety and depression.
Practitioners of integrative medicine have many more options. They can adjust patients’ diets (including their use of caffeine and alcohol), recommend dietary supplements (especially fish oil), suggest trials of botanical remedies, prescribe regimens of aerobic exercise, teach methods of stress reduction, attend to sleep hygiene, refer to cognitive behavioral therapists, mindfulness trainers, and other practitioners, and inquire about the spiritual lives of patients. Thoughtful combinations of these approaches are often more efficacious, more cost effective, and less harmful than pharmacological interventions alone.The fundamental goal of an integrative approach to mental health is to find appropriate approaches (conventional and complementary) to safely and effectively address an individual’s symptoms, while taking into account personal preferences, cultural beliefs, and financial constraints. This model approach is endorsed American Psychiatric Association.
The ideas expressed in this article are meant to encourage an informed and balanced approach to these common mental health problems, and is not intended to imply that one approach (complementary or conventional) supersedes the other. The goal is to help patients and families identify situations in which a blend of conventional and complementary approaches might benefit them. There are certainly many cases in which referral to a mental health specialist such as a psychiatrist, psychologist, or licensed counselor may be the most appropriate and advisable action. Severe depression with suicidal or homicidal ideation, for example, would be best addressed, at least initially, within the conventional model. But for mild and even moderate case severity, conventional care can often be done in conjunction with an integrative treatment plan.
Lifestyle Basics
Physical activity, healthy nutrition, and restorative sleep provide the basis for healthy lifestyle, and although they seem like relatively routine and unremarkable factors, accruing research shows that they are each vital to wellbeing. As a general rule, as long as there are no known physical contraindications, physical activity is encouraged for optimal wellbeing in all their patients, old and young.
Physical Activity
The powerful positive effects of exercise on general health and wellness are widely recognized, especially when combined with time in nature. Exercise was found to have a dose response benefit in depressive symptoms in a controlled study of 207 overweight sedentary children randomized to 20 or 40 minutes of aerobic exercise per day versus control group. Children in the 40-minute group showed more significant improvement in depressive symptoms.
Current recommendations from the US Center for Disease Control and Prevention include:
Children and adolescents: 60 minutes or more each day.
It’s important to include variety to address aerobic, resistance, flexibility, balance and agility, and endurance elements and to keep the time enjoyable. The goal is to build skills over time, with careful attention to avoiding overuse or chronic injury.
Nutrition
Nutrition is a fundamental element of good health and is relevant to every patient’s well-being. Historically, most research into the role of nutrition in mental health has focused on the role of specific nutritional deficiencies and supplementation with single nutrients. The concept of “food is medicine” is emerging. A focus on the anti-inflammatory benefits of foods is becoming increasingly important in mental health, as studies accrue linking inflammation with stress, anxiety, and depression.
There is good evidence to support the fact that nutrition is an important factor in mental health, for both children and adults, especially with respect to omega-3 fatty acids in the clinical treatment of depression. In several well designed studies involving over 900 patients in which depression was the primary complaint, supplements of omega-3 fatty acids were shown to be effective against primary depression. An Integrative Medicine practitioner can provide guidance on specific products and dosing.
Other factors that may be impact mood are meal spacing, sensible distribution of food groups (high quality carbohydrates, protein, healthy fats), a good variety of fresh vegetables and fruits, adequate hydration, and an enjoyable social setting at meal time. A study of almost 3,500 individuals (mean age 55.6 years) found that a whole foods diet comprised of fruits, vegetables and fish affords protection against the onset of depressive symptoms, whereas a diet rich in processed meat, chocolates, sweet desserts, fried food, refined cereals and high-fat dairy products increases vulnerability. This is consistent with another large study of more than 10,000 healthy adults that found adherence to a Mediterranean dietary pattern was protective against major depression.
Another positive of the anti-inflammatory/Mediterranean diet approach is that it encourages regular intake of healthy whole foods (including dark chocolate). This approach, based on abundance of nutrients with a wonderful emphasis on variety, can do much to curb cravings and keep energy level stable throughout the day. This may help the patient avoid energy dips and reliance on sugar and caffeine as a primary fuel as the day progresses. Recommendation of a balanced anti-inflammatory diet in proportion to caloric needs is a fundamental element of an integrative treatment plan for optimal well-being.
Dietary Balance is also an important consideration in assessing nutritional impact on well-being. Balance is the key to a healthy meal plan, although socioeconomic realities can make it very difficult for patients to access or afford quality foods. Caffeine and sugar excess do impact mental health.
Too much: Caffeine
On average, Americans consume 2-3 servings of caffeinated beverages per day, primarily in the form of coffee and soda. This is equivalent to roughly 200-400 mg caffeine. Energy drinks are growing in popularity, especially among children and adolescents, and are loaded with caffeine. People who are prone to feeling stress have reported that they experience increased anxiety from even small amounts of caffeine.
In a study evaluating patients with panic disorder (PD), generalized social anxiety disorder (GSAD), and performance social anxiety disorder (PSAD), none of whom had been on medication for the previous month, the intake of 480 mg of caffeine resulted in increased rates panic attacks. These occurred primarily in the PD and PSAD groups. None of the control group subjects had panic attacks. This study confirmed what many clinicians and nutritionists had long known—that patients with PD and PSAD are more sensitive to the stimulant effects of caffeine than those without these issues.
Too Much: High Glycemic Index/Load Foods
The Glycemic Index is a measure of how quickly a food breaks down into simple sugars in the bloodstream. A better measure is the Glycemic Load, which is a weighted value based on the Glycemic Index that takes into consideration the total amount of carbohydrate in a serving of a particular food. This is important because some foods have a high GI, but because of high water/fiber content, have a lower GL (e.g. carrots, watermelon). A study looking at the effect of high glycemic (HG) and low glycemic (LG) load on cognition and mood revealed that those on the HG diet experienced worsening of mood and depression at six months, as compared to an improvement in these two parameters of mood for those on the LG diet.
Too Little: Micronutrients/Macronutrients
Lack of critical micronutrients such as magnesium, folate, vitamin B12, vitamin D, and omega-3 fatty acids, can have negative impact on mental health. Integrative practitioners often evaluate levels of these micronutrients as part of a work up for mental health concerns.
Emerging Research: Gut Flora
One very interesting area of new research involves the connection between gut bacteria (flora) and psychiatric disorders. This area of study evolved in part from research on the link between inflammatory bowel disease and anxiety and depression in adults and children. Studies in mice have demonstrated a complex interaction between gut flora and levels of a brain neuropeptide which correlated to behavioral changes consistent with anxious states. It has been demonstrated that the intestinal flora can influence behavior independent of factors such as the autonomic nervous system, gastrointestinal neurotransmitters, or inflammation. Further studies demonstrated that a specific strain of probiotic, Bifidobacterium longum NCC3001 normalized anxiety-like behavior and levels of this brain neuropeptide in mice with infectious colitis. Probiotics may prove beneficial for the treatment of mental health disorders. For now, more research is needed.
Sleep
Sleep disorders are of epidemic proportions today with more than 40 million Americans struggling with insomnia. Sleep disorders are very common in women and affect up to 25% of children. It is estimated that 80% of psychiatric patients have sleep disorders. Mental health issues such as anxiety, depression, PTSD, and ADHD are strongly linked to insomnia. Insomnia may be a prodomal symptom of both depression and anxiety disorders. The severity of insomnia often correlates with the intensity of symptoms. The presence of insomnia itself may exacerbate anxiety, which often leads to a vicious cycle of sleeplessness compounded by worry about the inability to fall asleep.
The initial phase of insomnia is typically associated with a stressful event. Lack of sleep coupled with concerns about subsequent performance lead to additional stress that is perpetuated by linking worry and frustration with both the sleep environment and the process of falling asleep. Poor sleep leads to increasing tension and persistent insomnia by the pairing
of sleep-related stimuli and the stress response. Cognitive-Behavioral Therapy (CBT) can be very effective in breaking the linkage of this stimulus-response cycle. CBT in combination with FDA-approved medications and/or herbal therapies is a reasonable option.
Tips for good sleep hygiene:*
- Be mindful of the individual daily rhythms of life by establishing a regular bed and rising time, obtaining exposure to early morning light and evening dim light, and maintaining regular times for meals and exercise.
- Manage caffeine, nicotine, alcohol and other drugs. Caffeinated foods and drinks can affect some people up to 12 hours later.
- Although regular and adequate cardiovascular exercise promotes healthy sleep, it should be avoided at least 3–4 hours prior to bed because it raises core body temperature which can interfere with sleep.
- Avoid high glycemic and harder to digest foods as bedtime snacks. As an alternative, consider complex carbohydrates that may help transport tryptophan, a precursor to melatonin, across the blood-brain barrier.
- Create a healthy sleep environment by keeping the bedroom cool (about 68 degrees F), completely dark, quiet, psychologically safe and as green as is fiscally feasible. If possible, use HEPA filtration for clean air and, whenever possible, organic and non-toxic bedding.
- Avoid clock watching at night as this activity stimulates wakefulness. Ideally, position the clock away from the bed or use a non-illuminated battery operated clock to avoid light and subtle EMF radiation.
- Manage hyper-arousal and anxiety with cognitive behavioral therapy (CBT) and body-mind techniques. CBT, which is more effective than hypnotics over the long term, addresses sleep-related dysfunctional thoughts and beliefs that trigger arousal. For some, self-help workbooks may prove helpful. CBT is best coupled with body-mind techniques such as mindfulness meditation, muscular relaxation; neurofeedback, self-hypnosis, breathing exercises and guided imagery.
- Manage bed and bedroom stimulation, which can condition these areas for wakefulness, by using the bed only for sleep. Minimize wakeful time spent there by going to bed only when sleepy and getting out of bed if an extended period (15–20 minutes or more) of nighttime wakefulness occurs, returning to bed once sleepiness occurs again.
- When discontinuing hypnotics or otherwise indicated, consider supplementing sleep for a short term with botanicals like valerian, lemon balm, lavender, chamomile, and/or hops. Melatonin is useful in aging populations and/or with circadian irregularities. Always couple supplementation with other sleep hygiene recommendations.
- Emphasize the key process of letting go or surrender in sleep onset. In the end, we cannot finagle sleep. We can set the stage and be receptive to it, but we cannot intentionally “go to sleep.” Efforts to do so typically backfire.
*An Integrative Approach to Sleep. Arizona Center for Integrative Medicine
Dr. Donnelly practices Integrative Medicine in Portland. Information about his practice can be found at www.theMCIM.com. Schedule an appointment today at the Maine Center for Integrative Medicine by calling 207-899-0386.
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