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Questions and Answers
Which of the following symptoms are associated with serotonin syndrome?
What is the primary mechanism of action of benzodiazepines?
Which receptor is responsible for the sedative effects and anterograde amnesia of benzodiazepines?
What is the recommended tapering schedule to prevent antidepressant discontinuation syndrome?
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What is the half-life of clonazepam?
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What is the role of the Fire of the Gate of Life in relation to the Heart?
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What is the primary function of the Urinary Bladder in TCM?
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What is the consequence of an imbalance in the Urinary Bladder on a mental level?
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What is the role of Kidney-Yang in the Urinary Bladder's function?
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What is the term used in Chinese medicine to describe the Bladder's function of transforming fluids?
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What is the association between food groups and depression according to a study published in the European Journal of Nutrition?
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According to a 2019 study published in the Journal of Affective Disorders, what is the relationship between magnesium intake and depression?
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What is the finding of a 2021 study published in the International Journal of Behavioral Nutrition and Physical Activity regarding the Mediterranean diet and depression?
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According to a 2019 study published in the Journal of Affective Disorders, what is the association between food allergy and depression?
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What is the finding of a 2019 study published in Depression and Anxiety regarding chocolate consumption and symptoms of depression?
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A 35-year-old female is experiencing depression after a recent breakup, with symptoms of mood swings, a lump in the throat, and constant sighing. Which homeopathic remedy is most likely to help her?
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A patient is experiencing restlessness, waking up at 2 am with anxiety, and has a frequent need to drink small amounts of water. Which homeopathic remedy is most likely to resonate with their symptoms?
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What is the primary indication for using Aurum metallicum in homeopathy?
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Which of the following homeopathic remedies is NOT typically used to treat emotional shock, grief, or sadness?
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What is the primary characteristic of a patient who would respond well to Ignatia amara?
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What is the primary action of Withania somnifera as an adaptogen?
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Which of the following is a caution for Withania somnifera?
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What is the recommended daily therapeutic dose of Withania somnifera in tincture form?
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Which of the following botanicals pairs well with Withania somnifera for weakened vitality?
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What is the closest substitute for Withania somnifera?
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What is the primary focus of lifestyle guidance for treatment and prevention of depression and anxiety?
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Which of the following is NOT a key element of creating a treatment plan?
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What is an essential aspect of communicating treatment suggestions to a patient?
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Which of the following lifestyle considerations is NOT mentioned in the content?
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What is the primary goal of group work in this context?
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Study Notes
Anxiety Disorders and Depression
- Anxiety disorders are among the most common psychiatric illnesses, with a lifetime prevalence of around 31%.
- Anxiety disorders are frequently underdiagnosed and remain untreated in about 40% of diagnosed patients.
- Major depressive disorder has a lifetime prevalence of 10% and accounts for over 5% of population illness-related productivity loss.
The Monoamine Hypothesis
- The monoamine hypothesis is an incomplete theory attempting to describe the mechanisms of anxiety and depression, and the mechanism by which antidepressants work.
- The hypothesis states that mood disorders result from abnormalities in serotonin, norepinephrine, and/or dopamine neurotransmission.
- The hypothesis has several limitations, including:
- Antidepressants only work in about 50-70% of people.
- It takes several weeks before antidepressant effects are realized.
- Changes to neurotransmitter levels occur with the first dose.
Reuptake Inhibitors
- Tricyclic antidepressants (TCA) block neuronal reuptake of norepinephrine and serotonin.
- Selective serotonin reuptake inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitors (SNRI) are also types of reuptake inhibitors.
Tricyclic Antidepressants (TCA)
- TCAs are an older class of reuptake inhibitors.
- They increase the time neurotransmitters are present in the synapse and enhance neurotransmission.
- However, TCAs are rather non-specific for the serotonergic and noradrenergic neurons they target, affecting more neuronal targets than necessary.
- They also cross-react with cardiac adrenoreceptors and cause anticholinergic effects.
Imipramine
- Imipramine is a TCA indicated for agoraphobia, generalized anxiety disorder, and panic disorder.
- CNS adverse effects of imipramine include drowsiness, psychomotor impairment, agitation, headache, myoclonus, and seizure.
- Anticholinergic adverse effects of imipramine include dry mouth, constipation, blurred vision, urinary retention, and cognitive impairment.
- Cardiovascular adverse effects of imipramine include orthostatic hypotension, palpitations, dizziness, tachycardia, arrhythmias, and QTc interval prolongation.
- Other adverse effects of imipramine include increased appetite, weight gain, and sexual dysfunction.
SSRIs and SNRIs
- SSRIs and SNRIs are considered first-line agents for anxiety and depression.
- Significant research has been conducted to determine which ones are best for each condition.
Escitalopram
- Escitalopram is an SSRI considered one of the top antidepressants for both generalized anxiety disorder and major depressive disorder.
- It is also indicated for agoraphobia, panic disorder, and social anxiety disorder.
- CNS adverse effects of escitalopram include anxiety, agitation, insomnia, headache, and extrapyramidal effects.
- GI adverse effects of escitalopram include nausea, vomiting, diarrhea, constipation, and increased risk of upper GI bleeding.
- Other adverse effects of escitalopram include dry mouth, increased sweating, sexual dysfunction, and may prolong QTc interval.
Venlafaxine
- Venlafaxine is an SNRI considered one of the top antidepressants for both generalized anxiety disorder and major depressive disorder.
- It is also indicated for social anxiety disorder.
- Adverse effect profile of venlafaxine is very similar to that of escitalopram.
- It is metabolized by CYP3A4 and 2D6.
Serotonin Syndrome
- Serotonin syndrome is a range of symptoms that can occur when a patient takes an antidepressant, such as SSRIs, SNRIs, and TRIs.
- Symptoms usually begin within 24 hours of an increased dose of a serotonergic agent, the addition of another serotonergic agent, or overdosing.
- Mild symptoms include mild hypertension, tachycardia, mydriasis, diaphoresis, shivering, tremor, and myoclonus.
- Moderate symptoms include hyperthermia, hyperactive bowel sounds, horizontal ocular clonus, mild agitation, hypervigilance, and pressured speech.
- Severe symptoms include dramatic swings in pulse rate and blood pressure, delirium, and muscle rigidity.
Antidepressant Discontinuation Syndrome
- Antidepressant discontinuation syndrome occurs with rapid discontinuation or dose reduction of any antidepressant taken for 6 weeks or more.
- Symptoms include anxiety, crying, headache, increased dreaming, insomnia, irritability, myoclonus, nausea, electric shocks, tremor, flulike symptoms, imbalance, and sensory disturbances.
- The syndrome can be reversed by restarting the antidepressant and tapering more slowly.
Benzodiazepines
- Benzodiazepines act as positive allosteric modulators of GABA-A receptors, enhancing inhibitory neurotransmission.
- Benzodiazepines can be classified by their elimination half-life into short-acting (1-12 hours), intermediate-acting (12-40 hours), and long-acting (40-250 hours) agents.
Clonazepam
- Clonazepam is a high-potency long-acting benzodiazepine.
- It is indicated for agoraphobia, panic disorder, and social anxiety disorder.
- Clonazepam has a half-life of 18-50 hours, onset of action of 20-60 minutes, peak concentration of 1-4 hours, and duration of 6-8 hours.
- Lower lipid solubility of clonazepam reduces the risk of anterograde amnesia.
- Long half-life of clonazepam reduces the risk of rebound anxiety.
TCM Kidney Functions
- Stores the Essence and governs birth, growth, reproduction, and development
- Essence (Jing) determines growth, reproduction, development, sexual maturation, conception, pregnancy, menopause, and ageing
- Kidney-Essence controls the various stages of change in life (birth, puberty, menopause, and death)
- Governs growth, reproduction, development, and sexual maturation
- Determines the 7- and 8-year cycles, influences conception, and supports pregnancy
- Its decline induces menopause and determines ageing
- Is the material basis for Kidney-Yin and Kidney-Yang
- Has a Yin aspect (Essence) and a Yang aspect (Minister Fire)
TCM Kidney Functions (Continued)
- Produces Marrow, fills up the brain, and controls bones
- Marrow is the common matrix of bones, bone marrow, brain, and spinal cord
- The brain has a physiological relationship with the Kidneys; a strong Kidney-Essence nourishes the brain, resulting in good memory, concentration, thinking, and sight
- Weak Kidney-Essence results in poor memory, concentration, dizziness, dull thinking, and poor sight
- Brain and spinal cord are referred to as the "Sea of Marrow"
- The Marrow is the basis for the formation of bone marrow, which nourishes the bones
- Kidneys govern the transformation and transportation of Body Fluids
- Kidneys control the gate that opens and closes to regulate the flow of Body Fluids in the Lower Burner
TCM Kidney Functions (Continued)
- Under normal physiological conditions, there is a correct balance between Kidney-Yin and Kidney-Yang, resulting in normal urination
- In disease, there is an imbalance between Kidney-Yin and Kidney-Yang, resulting in a malfunctioning of the "gate" in opening and closing
- Kidneys belong to the Lower Burner, which is concerned with the excretion of impure Body Fluids
- Kidneys provide Qi for the Bladder to store and transform urine
- Control the reception of Qi
- Work with the Lungs to utilize the clear Qi of the air
- Hold Qi down to prevent congestion in the chest, resulting in breathlessness and asthma
- Open into the ears, nourishing the ears and preventing deafness and tinnitus
- Manifest in the (head) hair, relying on the nourishment of the Kidney-Essence for growth and health
TCM Kidney Functions (Continued)
- Control the two lower orifices (front and rear orifices)
- Deficiency of Kidney-Qi or Kidney-Essence may cause spermatorrhoea or nocturnal emissions, diarrhoea, or prolapse of the anus
- House the Willpower (Zhi), including determination, enthusiasm, spirit of initiative, and steadfastness
- Weak Kidneys result in lack of willpower and motivation, often contributing to mental depression
- Control the Gate of Life (Minister Fire, Ming Men), which is the source of physiological Fire for all Internal Organs
- Root of the Original (Yuan) Qi, which relies on heat for its performance
- Provide heat for the Spleen, Stomach, Heart, Lungs, Liver, Intestines, and Gall Bladder to function properly
- Warm the Lower Burner and Bladder, and harmonize the sexual function
TCM Urinary Bladder Function
- Removes water by Qi transformation, separating the clear part of fluids into urine
- Requires Qi and heat, which are provided by Kidney-Yang
- Has a mental aspect, with an imbalance provoking negative emotions such as jealousy, suspicion, and the holding of long-standing grudges
Diet and Depression
- A Mediterranean diet is associated with a 33% lower risk of depression compared to those who do not follow this diet.
- Omega-3 fatty acids with EPA ≥ 60% at a dosage of ≤1 g/d may have beneficial effects on depression.
- Magnesium dietary supplementation may reduce depressive symptoms, and deficiency in magnesium is common among people with depression.
- Vitamin D may reduce the risk of depression by reducing inflammation, regulating mood, and protecting against neurocognitive dysfunction.
- B vitamins play an important role in anabolic and catabolic cellular processes essential for brain function, and supplementation may reduce anxiety and depression.
Supplements and Depression
- SAMe (S-Adenosylmethionine) has shown encouraging and generally positive results in treating depression.
- 5-HTP (5-Hydroxytryptophan) is found in foods such as turkey, chicken, milk, potatoes, and sunflower seeds, and may have a role in treating anxiety.
- Omega-3 fatty acids, B vitamins, magnesium, and vitamin D may be beneficial in treating depression.
- Recommended dosages for supplements include:
- SAMe: 200 mg twice a day up to 400 mg three times a day
- Omega 3 FA: 1-4 gram EPA+DHA /day
- 5-HTP: 200-400 mg/day
- Magnesium: 200-600 mg/day
- Vitamin D: 1000-2500 IU/day
Gut Microbiome and Depression
- Microbiome-derived compounds may play a role in mental health.
- Regulation of intestinal microbiota may have a positive effect on anxiety symptoms.
- Non-probiotic interventions may be more effective than probiotic interventions in treating anxiety symptoms.
Case Study: Sarah
- Sarah is a 25-year-old CCNM student who is experiencing fatigue, low mood, and hopelessness.
- She follows a healthy vegan diet but is not taking any supplements.
- Lab test results may indicate the need for supplements such as vitamin B12, vitamin D, or iron.
Aurum Metallicum
- Characterized as disciplined and highly ambitious, with a conviction of being destined for a superior position in life
- Difficult to establish close friendships, even at an early age
- Ambitious and often attain prominence in their class at school
- Described as serious by their parents
- Sensitive and refined, but vulnerable emotionally
- Intellectually strong, but weak emotionally
- Mind symptoms:
- Feeling of self-condemnation and utter worthlessness
- Suicidal thoughts and talks of committing suicide
- Great fear of death
- Anthropophobia
- Mental derangements
- Over sensitiveness to noise
- Modalities:
- Aggravation: at night, from cold in winter, from noise, and from intellectual over-exertion
- Improvement: cold air (for patients with vascular disease)
Ignatia Amara
- Part of the Loganiaceae family
- Themes: shocked, paralyzed, shattered, torn to pieces, let down, and disappointed
- Triad: suddenness, intensity, and violence
- Affinities: mind, nervous system, cerebro-spinal axis, and right side
- Feeling of Ignatia: trying to maintain control during shock, grief, and disappointment
- Response to shock: undemonstrative (silent) grief
- Ailments from disappointed love or hope
- Mental themes:
- Ailments from anger, anger with silent grief, disappointment, fright, shame, and reproaches
- Sudden change from high to low spirits
- Deeply offended, brooding, but no inclination to violent anger or revenge
- Silent grief and brooding, leading to contradictory and alternating states
- Modalities:
- Worse: position (change of, lying on painful side), profuse urination, alone, hard pressure, warmth, swallowing, physical exertion, and while eating
- Foods:
- Aversion: fruit, tobacco smoke, meat, milk, warm food, wine, and bread
- Desire: cold drinks and food, fruit, sour, bread, bread and butter, cheese, pickles, raw food, tomatoes, and vinegar
Arsenicum Album
- Prepared by diluting aqueous arsenic trioxide, an inorganic colorless crystal
- Sensations:
- Intense burning
- Significant weakness
- Extreme sensitivity to cold
- Modalities:
- Aggravations: between 12 and 3 am, from the cold (except headaches and head congestion)
- Ameliorations: from heat, hot compress, hot food and drinks, changing position (restlessness), and extreme weakness (alternation of agitation with prostration)
- Description:
- Thin, stylish, well-groomed, pale, flushes easily, fine skin, and hair
- Tense, restless, worried about their health or family, great insecurity, needs reassurance, a support system or network of friends, and a plan for every eventuality
- Meticulous attention to details, perfectionist, with an "all or nothing" attitude, may abandon their endeavors if they cannot achieve excellence
- Opiniated, intolerant of the ideas and beliefs of others
- May be elegant, neat, and tidy, kids may hate being messy, sticky, and having stained clothes
- Mind:
- Cannot rest until the house is in order
- Fear of incurable illness, death, for health of the family, being alone, burglars, poverty, dark, and ghosts
- Restlessness and anxiety, with exhaustion at night
- Needs control, compulsive
- Peevish, sensitive, irritable, pessimistic
- Depressed, suicidal, indifferent, despairing, and guilt
- General symptoms:
- Rapid fatigue, despite restlessness, with weakness
- Not while lying down, but upon trying to move, exert self
- Burning pains, yet chilly, and pains better with heat
- Thirsty, for frequent small sips, often for cold water, but better with warm/hot water, so may not dare have cold
- Physical symptoms:
- Acute cases: diarrhea and vomiting from food poisoning, colds, flu, covid, hay fever, from ice cream, cold drinks, fruit, bad meat
- Hot head with cold body (wants cold on head and warm the body, opposite of Phosphorus, its complementary)
- Runny nose and eyes (both discharges acrid); canker sores (ulcers)
- Cancer; ulcers; asthma, pneumonia; palpitations
Other Remedies
- Depression: Natrum muriaticum, Phosphoricum acidum, and Hypericum
- Anxiety: Argentum nitricum, Gelsemium, and Aconitum
Botanicals in Mild-Moderate Depression
- Physical activity is the most effective treatment for depression.
- Key treatment principles: consider using herbs that act as stimulants, expect to use stronger herbs at bigger doses, and have a good prognosis for mild and moderate depression.
Featured Herbs
- Hypericum perforatum (St. John's wort)
- Rhodiola rosea (Rhodiola)
- Panax ginseng (Korean red ginseng)
- Panax quinquefolius (North American ginseng)
- Withania somnifera (Ashwagandha)
- Bupleurum sinensis (Bupleurum)
- Smilax officinalis (Sarsaparilla)
- Coffea arabica (Coffee)
- Theobroma cacao (Chocolate bean)
- Capsicum annua (Cayenne)
- Psilocybin spp. (Psilocybin)
Case Presentation – Depression
- A 32-year-old woman presents with ongoing feelings of depression, manifesting as low mood, lack of joy, no motivation, and feeling of hopelessness.
- Associations: unable to look for work or capable of holding a job.
Outcome Measures
- Improve quality of life and symptoms of depression
- Decrease duration, intensity, and frequency of episodes
- Prevent remission
Relevant Botanical Actions to Consider
- Adaptogen
- Stimulant
- Hepatic/Alterative
- Antiviral
- Euphoric
Featured Herbs by Botanical Action
- Adaptogen:
- Rhodiola rosea (Rhodiola)
- Panax ginseng (Korean red ginseng)
- Panax quinquefolius (North American ginseng)
- Smilax officinalis (Sarsaparilla)
- Withania somnifera (Ashwagandha)
- Hepatic/Alterative:
- Bupleurum sinensis (Bupleurum)
- Stimulant:
- Coffea arabica (Coffee)
- Capsicum annua (Cayenne)
Selected Monographs
- Bupleurum chinensis (Chai hu)
- Primary Actions: Hepatic, alterative, anti-inflammatory, hepatoprotective
- Constituents: Triterpene saponins, sterols, volatile oils, polysaccharides
- Indications: Hepatic congestion, arthritis, chronic inflammation, acute infections with fever
- Cautions/Contraindications: Avoided in cold conditions or constitutions, safety rating during pregnancy and lactation not established
- Capsicum frutescens (Cayenne)
- Primary Actions: Stimulant, circulatory tonic, rubefacient, sialagogue, libido tonic
- Constituents: Capsaicinoids (capsaicin), steroidal saponins
- Indications: Circulatory deficiencies, arthritic conditions, pain relief, depression
- Cautions/Contraindications: Non-toxic, but large doses will cause sweating and possible syncope, safety rating during pregnancy and lactation not established
- Hypericum perforatum (St. John's wort)
- Primary Actions: Adaptogen, immune stimulant, antiviral, antidepressant
- Constituents: Hyperforin, hypericin, flavonoids
- Indications: Depression, anxiety, chronic fatigue, viral infections
- Cautions/Contraindications: Avoided in pregnancy, lactation, and children, interacts with pharmaceuticals
- Panax quinquefolius (American ginseng)
- Primary Actions: Immune stimulant, immune modulator, antiviral, adaptogen, mild lymphatic
- Constituents: Triterpene glycosides (ginsenosides), steroidal saponins
- Indications: Chronic infections, convalescence, debility, ME
- Cautions/Contraindications: Considered safe, safety rating during pregnancy and lactation not established
- Withania somnifera (Ashwagandha)
- Primary Actions: Adaptogen, hypotensive, immune modulator, anti-inflammatory, nootropic
- Constituents: Steroidal lactones (withanolides), alkaloids
- Indications: Fatigue, nervous exhaustion, chronic inflammatory disease, anemia, lowered libido, convalescence, hypothyroid presentations
- Cautions/Contraindications: Considered safe, safety rating during pregnancy and lactation not established
Learning Outcomes
- Discuss lifestyle guidance for treatment and prevention of depression and anxiety
- Practice using electronic resources to support care
- Synthesize elements of creating a treatment plan:
- Comprehensive Naturopathic scope with EBM rationale
- Elements of informed consent
- Requirements of record keeping
- Communicating suggestions to patients verbally and in written form
Lifestyle Considerations
-
Keep it manageable and sustainable to avoid overwhelming and stressing patients
-
Avoid shame and blame, focus on positive, actionable steps
-
Work with patients to discuss interests and approachable next steps
-
Lifestyle considerations include:
Exercise
- Stay active and get outside
Mindfulness
- Practice mindfulness
Sleep
- Importance of sleep
Social Support
- Establish a social support network
Nutrition
- Balanced healthy eating
Substance Management
- Manage alcohol, cigarette, and caffeine consumption
Treatment Goals
- Identify treatment goals
- Propose treatment plan with supported rationale for treatment
- Consider evidence-based suggestions, including:
- ND products
- Nutritional guidance
- Lifestyle modifications
- Collaborative care
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Description
This quiz covers the mechanism of action, adverse effects, and discontinuation syndrome of antidepressants and benzodiazepines in the context of anxiety and depression.
