Abstract
Introduction
Mood and anxiety disorders are highly prevalent and often chronic in nature. Conventional treatment of mood and anxiety disorders involves the use of pharmacotherapy or psychotherapy or a combination. Despite receiving appropriate treatment, many individuals fail to achieve remission from their illness. 1 Additionally, many find the side effects prohibitive. As a result, many seek out complementary and alternative therapies for the treatment of mood and anxiety disorders. 2
Numerous non-pharmacologic therapies have preliminary yet promising evidence for their use in the treatment and prevention of mood and anxiety disorders. These include the use of herbal medicines such as Hypericum perforatum 3 and Passiflora incarnata 4 ; supplementation of nutrients such as omega-3 fatty acids, 5 folic acid, and vitamin D 6 ; dietary changes such as lowering glycemic index, achieving adequate protein and fiber intake, reducing processed food, and providing nutrient-dense whole foods 7,8 ; as well as life-style and behavioral changes such as improving sleep 9 and exercising. 10 Many of these therapeutic approaches are well tolerated by patients, and they result in benefits to other health outcomes in addition to improving mental-health symptoms.
While many non-pharmacologic interventions exist, it can be challenging to implement a protocol that prioritizes the patient's needs while attempting to improve overall health. The purpose of this case report is to demonstrate the use of a multimodal, non-pharmacologic approach to the treatment of mood and anxiety disorders in a young adult, which focused on managing symptoms as well as correcting underlying imbalances that may have been contributing.
Case Presentation
B.C. is a 22-year-old female who presented for naturopathic medical treatment with a chief concern of managing major depressive disorder and social anxiety disorder. These concerns began at 19 years of age, including a decreased interest in hobbies, persistent sadness, increased crying, decreased appetite, decreased energy, difficulty with sleep initiation, decreased concentration, body aches, and suicidal thoughts. She experienced significant anxiety in social situations including somatic symptoms, and as a result she avoided situations. She had previously completed short trials of two antidepressant medications—venlafaxine and escitalopram—but had chosen to discontinue use. She had attended a group cognitive–behavioral therapy intervention for anxiety but had not found it to be helpful. Her symptoms were presently impacting her life in her ability to attend class and study and attend social functions, and thus could be considered moderate to severe.
Clinical Findings
A diet history revealed the following typical daily intake: breakfast—nothing; lunch—turkey sandwich or pizza; dinner—rice and chicken; snacks—cookies, chips, or candy; water—eight to nine glasses per day; coffee—two cups per day.
Medical History
B.C. experienced asthma in the past. She presently suffered from headaches and dysmenorrhea.
Psychosocial History
B.C. lives with her mother and her mother's husband. She is a college student. She goes to bed at 3:00am and it takes 30 minutes to fall asleep.
Diagnostic Focus and Assessment
Laboratory testing at the third visit revealed the following levels: ferritin 33 μg/L (reference range 10–291 μg/L), vitamin B12 348 pmol/L (reference range 198–615 pmol/L), and thyroid stimulating hormone 0.74 mIU/L (0.30–4.00 mIU/L).
Therapeutic Approach and Outcomes
The initial treatment plan consisted of a herbal supplement containing 60 mg of Hypericum (dry extract 4.6–6.5:1), 32 mg of Passiflora (dry extract 3.8–5.6:1), and 28 mg of Valeriana officinalis (6.25–7.1:1) at a dose of two capsules taken twice a day. Additionally, the patient was instructed to make a smoothie for breakfast (containing fruit, protein powder, flax seeds, and water) and to include a vegetable at lunch and dinner. She was asked to attempt to begin getting ready for bed earlier.
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At the first follow-up appointment 2 weeks later, the patient reported an increase in energy on days when she had the smoothie for breakfast. She reported that since starting the herbal formula, she experienced an improvement in mood but no change in anxiety and no adverse events. She also reported that she had not experienced any headaches during the follow-up period.
B.C.'s second prescription included the addition of a fish-oil supplement containing 750 mg of eicosapentaenoic acid and 500 mg of docosahexaenoic acid once per day, and instructions to resume exercise (at least twice a week for 45 minutes) and to continue to increase her dietary vegetable intake.
At the second follow-up appointment, B.C. reported that her moods were more regulated and that she only experienced headaches on days when she did not drink enough water. She reported that she had started a part-time job and was spending more time in social situations that would have previously caused significant anxiety or avoidance. At this visit, B.C.'s laboratory assessment results were available, and she was prescribed an iron formula containing 36 mg of ferrous bisglycinate chelate (iron), 300 μg of methylcobalamin (vitamin B12), 400 μg of L-5-methyltetrahydrofolate (folate), 5 mg of pyridoxal 5′-phosphate (vitamin B6), and 15 mg of ascorbic acid (vitamin C), one capsule per day, and 1000 μg/day sublingual vitamin B12 (methylcobalamin).
At the third follow-up visit, B.C. reported a more stable mood, increased tolerance to anxiety-provoking situations and less use of coping behaviors, an increase in energy, and no headaches.
Discussion
The treatment of mental illness is complex and challenging. This case demonstrates an example of a multimodal non-pharmacologic approach to the treatment of mood and anxiety symptoms, which focuses on both ameliorating symptoms and addressing possible contributing factors.
Although poorly understood, it is hypothesized that low levels of serotonin contribute to mood disorders and that antidepressant medications act by increasing brain levels of serotonin. 11 Hypericum also acts to increase serotonin levels. 12 Passiflora acts on GABA receptors similar to benzodiazepine medications with rapid onset of action and is thus useful in managing anxiety disorders. 13
Newer research in the field of mental health is revealing mechanisms by which neurotransmitter imbalances may arise. Suggested factors include elevated systemic inflammation, nutritional (macronutrient and micronutrient) deficiencies, poor sleep habits, and a sedentary life-style. 14 In B.C.'s case, several of these factors may have been involved. Because of the patient's symptom severity at baseline, the herbal formula was selected to have a rapid onset of action. At the same time, improvements in dietary macronutrient composition, micronutrient supplementation, anti-inflammatory supplementation, and increased sleep and exercise were targeted at addressing contributing factors. B.C.'s improvement in energy and headaches may be related to these improvements. While the patient will be advised to continue the herbal formula until her symptoms fully resolve, the long-term goal is to address and balance the factors that may be contributing to neurotransmitter imbalance so that the formula can be tapered and discontinued.
Conclusion
This case demonstrates that non-pharmacologic therapies can be useful in the treatment of mood and anxiety symptoms with a rapid onset of therapeutic benefit and high patient tolerability. While many combinations of interventions can be utilized, an approach that addresses symptomatic management, contributing factors, and overall wellness concurrently may be beneficial. ■