Healing Touch and Therapeutic Touch for Stress and Anxiety

Ancient healing techniques but unknown mechanism 

Non-contact and so-called ‘energy’ healing techniques have been used in all world regions for thousands of years. Although widely used to treat a range of medical and mental health problems, research findings are difficult to interpret because of problems inherent in measuring a putative mechanism of action and quantifying outcomes. From a Western scientific perspective non-contact and hands-on healing techniques are referred to as ‘biofield therapies’ based on the assumption that an energetic principle exists in humans and all life forms, imbalances in ‘energy’ manifest as diverse physical or emotional symptoms, and the skillful manipulation of ‘energy’ by healers can correct such imbalances restoring good health. To date, Western style research studies have not been able to demonstrate a mechanism underlying Healing Touch, Therapeutic Touch or other biofield therapies. It has been suggested that failure to empirically confirm a mechanism of action may reflect the limitations of current science which lacks methods capable of verifying the role of quantum mechanics or other postulated non-local phenomena that may play a role in energy therapies.

Research findings are mixed

In Healing Touch (HT) the practitioner does not actually have physical contact the patient but positions the hands above different parts of the body with the intention of facilitating healing. In contrast, in Therapeutic Touch (TT) the practitioner uses gentle touch. Most studies done on Healing Touch (HT) and Therapeutic Touch (TT) are small pilot studies or small open trials in individuals who report anxiety or other mental health problems in the context of chronic pain, cancer or other medical conditions. TT may have beneficial effects in chronically anxious patients, and in non-demented elderly nursing home patients, but there is limited evidence for anxiety reducing effects of TT in healthy adults. The findings of two early studies using sham healers in the control group suggest that both contact and non-contact healing reduces state anxiety in patients hospitalized for heart problems. Unfortunately, neither study adequately controlled for anxiety reducing effects of medications taken by some patients.

Findings of two small open studies suggest that patients who receive HT therapy experience significant reductions in emotional and physical symptoms of trauma. A small double-blind sham-controlled trial did not find significant differences in self-reported levels of stress in students treated by Healing Touch practitioners compared to students treated by sham practitioners. In one 4 week study 3rd year nursing students assigned to one weekly session of HT plus music versus music only reported significant reductions in transient and chronic stress and improved sleep. However, among 1st year students, no significant differences between stress levels in the HT and control group were reported.

Negative results of controlled studies raise the question of a general beneficial effect or possibly a threshold anxiety level above which HT is ineffective, or a placebo effect related to the quality or frequency of contact between the HT practitioner and the patient. It has been suggested that different outcomes reflect different skill levels of healers who participate in different studies (Ferguson 1986). Because of the heterogeneity in study designs, small study sizes, and methodological limitations of studies on biofield therapies, systematic reviews of published studies report that HT and TT sometimes improve overall quality of life but report inconclusive findings on outcomes studies of both modalities in the treatment of anxiety, other mental health problems and medical disorders that have been investigated (Anderson & Taylor 2011; Robinson & Biley 2007). An important exception is TT for cancer as many cancer patients who receive regular TT experience improvements in overall health and emotional well-being.

High perceived effectiveness

Despite the absence of compelling empirical evidence for Healing Touch, patient satisfaction surveys show that most patients complaining of anxiety or pain who receive HT treatments report significant subjective benefits. For example, in one small open study on the perceived effectiveness of Healing Touch, 40% of patients reported that calming effects lasted more than 2 weeks following the end of treatment, and 60% experienced feelings of “spiritual well-being” lasting at least 2 weeks after treatment ended. The significance of these findings is difficult to interpret because established rating scales were not used to grade symptom severity before and after the trial.

In sum, research findings suggest that Healing Touch has general beneficial effects on stress and anxiety associated with pain and some medical disorders as well as trauma, however small sample sizes, inadequate controls and potential biases preclude generalizations about the clinical benefits of HT and TT for anxiety. Despite the paucity of empirical evidence for HT, TT and other energy therapies, consistent patient reports show that biofield therapies often result in significant improvement in life quality and help improve the individual’s ability to cope with chronic stress and anxiety.

You can find information about energy therapies and other complementary and alternative treatments of stress and anxiety in my e-book “Anxiety: The Integrative Mental Health Solution.”

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Acupuncture: A Safe and Effective Treatment of Anxiety

Acupuncture has diverse mechanisms of action

Animal and human studies suggest that the beneficial effects of acupuncture on health including mental and emotional functioning are related to different mechanism of action including changes in neurotransmitters involved in emotional regulation such as serotonin, and others; modulation of the autonomic nervous system; and changes in immune function. Some researches have argued that the placebo effect plays a significant role in clinical response to acupuncture, however sham-controlled studies do not support this hypothesis.

Research findings support acupuncture as a treatment of anxiety

Acupuncture and acupressure are widely used to treat anxiety in both Asia and Western countries. Extensive case reports from the Chinese medical literature suggest that different acupuncture protocols are reduce the severity of  generalized anxiety and panic attacks (Lake & Flaws 2001).

In a small double-blind sham-controlled study 36 mildly depressed or anxious patients were randomized to an acupuncture protocol traditionally used by Chinese medical practitioners to treat anxiety versus a sham acupuncture protocol (i.e. acupuncture points believed to have no beneficial effects). All patients received three treatments. Heart rate variability (HRV) and mean heart rate were measured at 5 and 15 minutes following treatment. Resting heart rate was significantly lower in the treatment group but not in the sham group, and changes in HRV measures suggested that acupuncture may have changed autonomic activity resulting in reduction of overall anxiety. The significance of these findings is limited by the absence of measures of baseline anxiety before and after treatment.

In another double-blind study 55 healthy adults (i.e., who had not been previously diagnosed with an anxiety disorder) were randomized to a bilateral auricular (i.e. a school of acupuncture in which only points on the ears are treated) acupuncture protocol called the “shenmen” point—a protocol believed to be effective against anxiety (the so-called “relaxation” point)—versus a sham acupuncture point. In all subjects acupuncture needles remained in place for 48 hours. The “relaxation” group was significantly less anxious at 30 minutes, 24 and 48 hours compared to the other two groups, however there were no significant inter-group differences in blood pressure, heart rate or electrodermal activity (Wang 2001).

Reviews report mainly positive findings

An early narrative review of controlled studies, outcomes studies and published case reports on acupuncture as a treatment of anxiety and depressed mood was published by the British Acupuncture Council. Sham-controlled studies yielded consistent improvements in anxiety using both regular (i.e. body) acupuncture and electro-acupuncture. The authors remarked that significant differences existed between protocols used in both regular and electro-acupuncture suggesting that acupuncture may have general beneficial effects or possibly placebo effects. Although most controlled studies reviewed reported a general anxiety-reducing effect of acupuncture, the reviewers regarded these findings as inconclusive because of study design problems including the absence of standardized symptom rating scales in most studies, limited follow-up, and poorly defined differences between protocols used in different studies.

A recently published systematic review (Amorim 2018) compared findings of studies on traditional (body) acupuncture, ear acupuncture (ariculotherapy) and electro-therapy in the treatment of anxiety. Some studies included in the review reported that acupuncture enhances response to prescription anti-anxiety medications and may also reduce medication side effects. The authors found good evidence that different styles of acupuncture reduce symptoms of anxiety in general, and recommended additional sham-controlled studies to help determine whether certain protocols are more beneficial than others.

For more information about complementary and alternative treatments of anxiety read my e-book “Anxiety: The Integrative Mental Health Solution.”

Few mild adverse effects

Uncommon transient adverse effects associated with acupuncture include bruising, fatigue and nausea. Very rare cases of pneumothorax (i.e. a potentially life-threatening condition caused when an acupuncture needle results in the collapse of a lung) have been reported.

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Heart Rate Variability (HRV) Biofeedback for Anxiety

Several mechanisms are involved

Abnormal low heart rate variability (HRV) is associated with both medical and psychiatric disorders. HRV biofeedback is a recently developed technique that aims to modulate HRV in ways that have beneficial effects on mental and emotional functioning. The magnitude and specific characteristics of HRV are related to the body’s ability to adapt to stress. Low HRV generally corresponds to relatively greater susceptibility to stress. HRV is probably related to several underlying mechanisms that work together to ensure the healthy ‘adaptive’ functioning of the body’s cardiovascular system. Abnormal HRV signifies that the body’s stress response is not optimal resulting in potentially more harmful effects of chronic stress and increased risk of stress-related medical or mental disorders such as heart disease, depressed mood, generalized anxiety, panic disorder and post-traumatic stress disorder (PTSD). HRV biofeedback is a technique that has grown out of this insight, and aims to optimize HRV so that individuals can better manage stress and have fewer and less severe diseases caused by chronic stress.

Regular HRV biofeedback training reduces stress and improves general well-being

Findings of a few studies done to date suggest that chronically anxious patients who undergo HRV biofeedback training experience significant improvements in general emotional well-being and reduced baseline anxiety. In one study healthy adults (45 total subjects) were randomized to an emotional self-management program versus a wait list group that received no treatment (McCraty 1998). Significant reductions in cortisol levels and increased coherence in heart rate variability were found in individuals in the experimental group but not in the comparison group. The experimental group reported significant decreases in measures of guilt, hostility, burnout, anxiety and stress. These psychological changes correlated with significant reductions in serum cortisol levels and beneficial increases in measures of coherence in heart rate variability.

In one 4-month controlled trial the most of a group of 29 police officers who trained in biofeedback techniques based on HRV reported significantly greater improvements in baseline anxiety compared to 36 officers who were assigned to a wait-list group and received no treatment. In another study (McCraty 2009) that enrolled 75 correctional officers, those individuals randomized to a group that received training in emotional self-regulation and HRV biofeedback reported significant reductions in overall stress, had a more positive outlook, and had significant reductions in physiological indices of stress including reduced cortisol levels, reduced resting heart rate and blood pressure. Individuals in the treatment group had significant increases in productivity, motivation and perceived support.

Findings of a 5-week open study suggest that daily HRV biofeedback training, vigorous physical activity and mindfulness meditation may be equally effective for stress reduction in healthy adults (Van der Zwan 2015).

More studies are needed

Large long-term prospective sham-controlled studies are needed to confirm the magnitude and type of physiological and psychological benefits of HRV biofeedback, and to optimize HRV biofeedback protocols addressing different medical and mental health problems.

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Massage for Chronic Stress and Anxiety

Massage alters EEG activity, increases parasympathetic activity and decreases cortisol levels

Massage is widely used in all cultures to evoke feelings of deep relaxation and reduced anxiety. The anxiety reducing and mood enhancing benefits of massage are probably related to changes in EEG activity, decreased levels of cortisol and increased activity of the parasympathetic nervous system, which acts automatically to calm the body and brain during stress. Numerous studies show that moderate pressure massage is more effective than light pressure massage for reducing pain associated with different medical problems including fibromyalgia and rheumatoid arthritis. Moderate pressure massage also improves attention and enhances the body’s immune response by increasing the activity of natural killer cells. Functional brain imaging studies show that changes take place in many areas of the brain involved in regulating emotions and stress response including the amygdala and the hypothalamus. For an excellent review on the research evidence for massage therapy see “Massage Therapy Research Review” by Field (Field 2014).

Challenges to designing studies on massage

It is difficult to examine the beneficial effects of massage therapy using contemporary research methods because it is impossible to design a double-blind study in which the person receiving massage therapy is ‘blinded’ to treatment. Also, the physical and psychological benefits of massage are difficult to quantify in controlled trials. Findings of many studies are limited by the absence of a sham control group i.e., a group treated by someone who poses as a massage therapist but has no training. The situation is further complicated by the fact that few massage therapists are trained in research methods or work in institutional settings where sham-controlled trials can be conducted.

Massage is widely used for anxiety and has a strong record of success

In spite of the paucity of published research evidence, regular massage is a widely used technique in many cultures to treat chronic stress and anxiety and deserves serious consideration. Consistent anecdotal evidence, a long history of widespread use of massage for stress reduction, and positive findings of open trials support the view that regular massage therapy reduces the severity of chronic moderate anxiety in general, and specifically when anxiety is related to test-taking or problem-solving, work stress or the anticipation of invasive medical procedures.

In my own clinical experience working with patients who complain of chronic stress, test-taking stress and generalized anxiety, regular massage therapy effectively reduces anxiety, improves emotional resilience and enhances feelings of general well-being in anxious patients.

Few safety issues

Massage is safe when done by a trained therapist, seldom resulting in injuries. However, individuals who have chronic pain disorders or other medical conditions that involve the musculoskeletal system should consult with their physician before receiving regular massage therapy.

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Exercise Improves Anxiety and Reduces the Frequency of Panic Attacks

Psychological and physiological mechanisms are involved

The relationship between physical activity and anxiety is multi-factorial. Many hypotheses have been proposed to explain the anxiety reducing benefits of regular exercise. Psychological theories include distraction, enhanced self-efficacy, mastery and psychological benefits of regular social interaction. Physiological mechanisms include beneficial effects of regular exercise on the levels of several neurotransmitters that affect anxiety including serotonin, norepinephrine, dopamine and the endorphins.

Regular exercise alleviates chronic anxiety and may reduce the frequency and severity of panic attacks

Individuals who report chronic anxiety frequently engage in strenuous physical activity in efforts to alleviate their symptoms. Open studies suggest that both aerobic exercise and strength training improve anxiety when done on a regular basis (Paluska 2000). The beneficial effects of exercise are similar to those of meditation and regular relaxation. Acute onset anxiety generally responds better to exercise than long-standing symptoms of anxiety.

A work-out program consisting of at least 20 to 30 minutes of daily exercise can significantly reduce symptoms of generalized anxiety. Findings of a prospective 10 week study of exercise in individuals prone to panic attacks show that regular walking or jogging (4 miles three times a week) reduces the severity and frequency of panic attacks (Stevinson 1999).

Most studies on the effects of physical activity on anxiety have been done in healthy adults. Although some studies have been done in children, adolescents and the elderly more studies need to be done to determine the kind, intensity, frequency and duration of physical activity that are most effective in reducing anxiety in these age groups.

In my own 20+ year clinical practice I have observed that chronically anxious patients who follow a regular exercise program usually pay more attention to their health in general, and tend to respond more rapidly to both prescription medications and integrative treatments compared to patients who are not physically active.

Safety issues

Individuals in good health can engage in vigorous exercise with few limitations. However, individuals with heart disease, chronic pain, or other serious medical problems should consult with their physician before starting an exercise program.

To read more

To find out more about non-medication treatments for anxiety read my short e-book “Anxiety: The Integrative Mental Health Solution.”

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Inositol: a promising treatment of panic disorder

Inositol: a promising treatment of panic disorder

Inositol has been the focus of renewed research interest because it is a necessary building block of phosphatidyl-inositol, a molecule in the brain that plays a central role in the functioning of receptors that bind with several neurotransmitters including serotonin, norepinephrine and others. Research findings support that inositol taken in doses up to 20 grams per day reduces the severity and frequency of panic attacks by interfering with a molecule called m-CPP. The potential role of inositol as a treatment of panic disorder is important in view of the fact that currently available prescription medications are effective in only two thirds of patients who report panic attacks, have adverse effects and may lead to dependence (e.g. benzodiazepines).

A one month double-blind placebo controlled study enrolling 20 patients concluded that inositol (up to 18g/day) and fluvoxamine (up to 150 milligrams per day) were equally effective in reducing the frequency of panic attacks (Palatnik 2001). The average number of weekly panic attacks in the group taking inositol decreased by 4, compared to an average decrease by 2 in the group treated with fluvoxamine.

Emerging research findings for inositol as a treatment of other anxiety disorders

Findings of several small double-blind placebo-controlled studies show that large doses of inositol improve different anxiety conditions that respond to serotonin reuptake inhibitors (SSRIs), including for example panic attacks, agoraphobia, and symptoms of obsessive-compulsive disorder. A 4-week double-blind crossover study concluded that inositol taken at a dose of 12 grams per day and imipramine, a prescription medication, are equally effective in reducing the frequency and severity of panic attacks and agoraphobia. Two small double-blind studies have been done on inositol for symptoms of obsessive-compulsive disorder (OCD). In one study patients taking inositol 18 grams per day showed significantly greater improvement compared to patients taking a placebo. In another small study, patients taking inositol 18 grams per day plus a placebo or a SSRI medication reported equivalent responses. 

Small study sizes limit significance of findings

Although many studies report beneficial effects of inositol on panic disorder and other anxiety disorders, the significance of findings is limited by the small number of studies completed and the small size of studies. Large prospective placebo-controlled studies are needed to confirm the above findings and to clarify the most effective and appropriate dosing strategies of inositol for panic disorder, agoraphobia and obsessive-compulsive disorder. 

Few adverse effects

Some individuals who take inositol report mild transient side effects. Serious adverse effects have not been reported at doses of inositol that are effective against panic attacks.

To learn more about natural supplements and other non-pharmacologic treatments of anxiety check out my book “Anxiety: The Integrative Mental Health Solution.” 

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The amino acid 5-HTP is a natural, safe and effective treatment of anxiety

The brain needs L-tryptophan and 5-hydroxytryptophan (5-HTP) to manufacture serotonin

L-tryptophan and 5-HTP are widely used alternative treatments of generalized anxiety. Both amino acids are essential for manufacture of serotonin in the brain. Serotonin is a neurotransmitter that plays a central role in the regulation of mood and anxiety. Greater research evidence supporting the use of 5-HTP for anxiety, together with smaller effective doses and increased CNS availability generally make 5-HTP the preferred choice over L-tryptophan.

5-HTP reduces the severity of generalized anxiety  

More research has been done on 5-HTP than l-tryptophan. In a double-blind study, 58% of generally anxious patients (79 total subjects) randomized to L-tryptophan 3 grams per day reported significantly greater reduction in baseline anxiety compared to individuals who received a placebo. Both animal studies and human clinical trials show that 5-HTP has anti-anxiety effects. There is some evidence that 5-HTP may inhibit panic attacks induced by carbon dioxide.

Uses of 5-HTP in integrative psychiatry

In the rapidly growing field of integrative psychiatry prescription medications and natural supplements are often used in combination to improve treatment response and reduce side effects when medications are taken alone. 5-HTP is an example of a natural supplement that may be safely combined with a prescription anti-anxiety medication with little risk of adverse effects. In one study patients randomized to 5-HTP in combination with carbidoba (a drug that inhibits the enzyme that breaks down 5-HTP in the peripheral blood supply, thus increasing the amount of 5-HTP that enters the brain) reported reductions in anxiety comparable to patients treated with an anti-anxiety medication. In contrast, patients who received a placebo did not improve. 

Starting 5-HTP at a low dose reduces the risk of side effects

Some individuals who take 5-HTP report daytime fatigue or sleepiness. There have been infrequent reports of mild serotonin syndrome, a condition caused by excessive brain serotonin associated with insomnia, agitation and nervousness. The risk of serotonin syndrome and other adverse effects is minimized when 5-HTP is started at low doses such as 25 milligrams per day and gradually increased over several weeks to a daily regimen that is well tolerated and produces beneficial anti-anxiety effects.

In over 20 years of experience as an integrative psychiatrist I have found that 5-HTP 50 milligrams to 100 milligrams taken three times a day is a safe and effective approach for chronic generalized anxiety that is well tolerated without excessive daytime sedation. 5-HTP may be taken alone or in combination with anti-anxiety medications.

Taking 5-HTP at bedtime improves sleep and reduces daytime anxiety

Gradually increasing a bedtime dose of 5-HTP from 50 milligrams to 200 to 300 milligrams over a period of 2 to 3 weeks often improves the quality of sleep in chronically anxious patients who complain of insomnia while also reducing the severity of daytime anxiety.

Finding a quality brand of 5-HTP

When considering taking 5-HTP or any natural supplement it is important to find a quality brand known to be both effective and safe. I do not recommend particular brands to my patients. However my website includes links to web resources that will help you identify quality brands. 

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Conventional Treatments of Anxiety: Benefits and Limitations

In this post I review the benefits and limitations of conventional treatments of anxiety disorders. Future posts in this series will discuss complementary and alternative approaches used to treat different anxiety disorders. 

Conventional treatments of anxiety

Cognitive-behavioral therapy (CBT), supportive psychotherapy, and psychopharmacology are widely used conventional treatments of anxiety. Double-blind studies have established the efficacy of prescription medications such as benzodiazepines and serotonin-selective reuptake inhibitors (SSRIs) in the short-term treatment of recurring panic attacks and generalized anxiety. Certain prescription drugs are effective treatments of social phobia, however there are no effective psychopharmacological treatments of specific phobias such as arachnophobia (i.e., ‘fear of spiders,), fear of flying or others. Behavioral therapies including graded exposure and flooding are beneficial in social anxiety and performance anxiety. The conventional treatment approaches of obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) rely on both psychotherapy and medications.

Limitations of conventional treatments

Conventional treatments of anxiety are often beneficial but also have significant limitations. A meta-analysis of high-quality studies concluded that the efficacy of conventional treatments varies widely depending on the core symptom being treated. Panic attacks tend to improve and remain improved in response to medications like lorazepam and clonazepam, but patients who use these medications or other benzodiazepines chronically to control panic symptoms are at significant risk of dependence and withdrawal. Most individuals with generalized anxiety initially have positive responses to conventional treatments but remain symptomatic over the long-term. Phobias, obsessions and compulsions, and symptoms of post-traumatic stress are often poorly responsive to conventional Western treatments. This is complicated by the fact that many patients who experience chronic anxiety are too impaired to seek treatment and frequently have other mental health problems such as depressed mood, sleep disturbances and substance abuse.

Inter-individual differences and no standard care model

In general, anxiety is difficult to treat because of significant inter-individual differences in the type and severity of symptoms and incomplete understanding of medical, psychological, social and cultural factors that cause or exacerbate anxiety symptoms. Finally, standards of care for the acutely or chronically anxious patient are difficult to achieve because of differences in training, experience and skill of conventionally trained mental health professionals.

To learn more about complementary and alternative treatments of anxiety check out my e-book, “Anxiety: The Integrative Mental Health Solution.” 

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Preliminary findings for choline in bipolar disorder

Choline for bipolar disorder

This post is the 4th in a series on bipolar disorder. Previous posts briefly reviewed conventional pharmacologic treatments, uses of select amino acids and omega-3 fatty acids and a proprietary nutrient formula. This post reviews research findings of studies on the B vitamine choline in the treatment of bipolar disorder. 

Findings on choline and phosphatidylcholine in bipolar disorder 

Choline is a naturally occurring B vitamin necessary for the biosynthesis of the neurotransmitter acetylcholine (Ach). It has been postulated that abnormal low brain levels of acetylcholine cause some cases of mania. Findings of a small placebo-controlled trial suggest that phosphatidylcholine (15 g to 30 g/day) may reduce the severity of mania and depressed mood in bipolar patients. Case reports and case series suggest that choline reduces the severity of mania. 

In a small case study of treatment-refractory, rapid-cycling bipolar patients who were taking lithium, four out of six patients responded to the addition of 2000–7200 mg/day of free choline. It should be noted that two non-responders were also taking high doses of thyroid medication at the same time. Clinical improvement correlated with higher levels of choline in a part of the brain called the basal ganglia as measured using magnetic resonance imaging (MRI). The effect of choline on depressive symptoms in these patients was inconsistent. 

Case reports, open trials and one small double-blind study suggest that supplementation with phosphatidylcholine 15 g to 30 g/day reduces the severity of both mania and depressed mood in bipolar patients, and that symptoms recur when phosphatidylcholine is discontinued.

Choline and phosphatidylcholine are safe and generally well tolerated when taken at doses used to treat bipolar disorder.

Because of the limited number of studies and small study size, findings on choline and phosphatidylcholine in the treatment of bipolar disorder should be regarded as preliminary. 

To learn more about non-pharmacologic treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution” by Dr. Lake 

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Select amino acids and Omega3s are beneficial and safe treatments of Bipolar Disorder

Integrative Management of Bipolar Disorder: Amino Acids and Omega-3s

This is the second post in a series on integrative management of bipolar disorder. Previous post reviewed conventional psychiatric management of bipolar disorder. The focus of this post is on amino acids and omega-3 essential fatty acids. Future posts will provide concise reviews of evidence for a range of non-pharmacologic treatments of this disorder. 

Amino acids have beneficial effects on depressed mood, anxiety and insomnia in bipolar patients.

Taking the amino acid L-tryptophan 2–3 gm/day or 5-hydroxytryptophan (5-HTP) 25 to 100 mg up to three times a day may have beneficial effects on anxiety associated with mania. L-tryptophan 2 gm can be safely added to mood stabilizers such as lithium and valproic acid at bedtime improving sleep quality in agitated manic patients. Doses of L-tryptophan as high as 15 gm may be required when insomnia is severe (although individuals who take doses this high should be closely monitored by a psychiatrist, and this dosage may be restricted in some countries). Research findings suggest that when added to sedating antidepressants (such as trazodone) taken at bedtime L-tryptophan 2 gm may accelerate antidepressant response and improve sleep quality. Serious adverse effects have not been reported using this protocol. The amino acid L-theanine, a natural constituent of green tea, reduces anxiety by increasing alpha activity and increasing synthesis of the inhibitory neurotransmitter GABA. Noticeable anxiety reduction is generally achieved within 30 to 40 minutes and effective doses range between 200 mg and 800 mg/day. There are no contraindications to taking L-theanine in combination with mood stabilizers. 

Omega-3 fatty acids are beneficial in the depressive phase but do not lessen symptoms of mania.

Countries where there is high fish consumption have relatively lower prevalence rates of bipolar disorder. In a systematic review of controlled trials on omega-3 fatty acids in bipolar disorder only one study was identified in which omega-3s were used adjunctively with a mood stabilizer. The combined treatment protocol resulted in a differential beneficial effect on depressive but not manic symptoms. The reviewers cautioned that any conclusions about the efficacy of omega-3 fatty acids in bipolar disorder must await larger controlled studies of improved methodological quality. Large doses of omega-3 fatty acids may be more effective in the depressive phase of the illness.

Some studies suggest that the omega-3 essential fatty acid ecosapentanoic acid (EPA) at doses between 1 and 4 gm/day may have enhance the effectiveness of atypical antipsychotics used to treat acute mania, however, one placebo-controlled trial failed to confirm an adjuvant effect. The appropriate management of a severely depressed bipolar patient might include a mood stabilizer, an antidepressant and omega-3 fatty acids. 

There are few safety issues.

Rare cases of increased bleeding times, but not increased risk of bleeding, have been reported in patients taking aspirin or anti-coagulants together with omega-3s.

To learn more about non-pharmacologic treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake MD.

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