Question: I am an HIV positive man on HAART who has been suffering with depression for several years. My doctor wants to prescribe antidepressants, but when I tried them in the past, I had side effects, insomnia and loss of sex drive. What might be some naturopathic alternatives?
Answer: I suggest that you please read "Depression and HIV in the Era of HAART" by Dr. Elliott in this issue. Depression is multifactorial. The ideal goal of all healthcare practitioners is treat the underlying cause of the diagnosis or disease rather than chasing after and treating symptoms, whether with synthetic antidepressants or with herbal medicines. While such treatments can be helpful in reducing the symptoms, it never addresses the underlying cause. For instance, if the theory is that the person is depressed due to a biochemical imbalance, the fundamental question remains -- What is the cause of the biochemical disruption in the brain? Let me be clear, this does not suggest such treatments are without merit or necessity. Many people who have a history of chronic alcohol or recreational drug use (ecstasy, cocaine, crystal, marijuana) have an altered level of neurotransmitters level in their brain. Although there may be some alternative treatments that I will discuss, if this is the case, treatment with synthetic antidepressants may be the only way to correct this imbalance, and hence give some relief from depression, which, if left untreated, could be more damaging to the health of the individual than HIV alone.
So what exactly causes changes in brain chemistry? The simple answer -- everything! Depending upon the person to whom you are talking, the cause may be genetics, thought processes, nutrition, electromagnetic waves, sleep, breathing, etc. Copious studies, such as the numerous ones conducted at the University of Miami, continually show that cognitive reframing, the retraining your thought process in order to create new, more affirmative beliefs, has long-term, positive outcomes for health. Studies with HIV-positive participants in group cognitive therapy reveal improvement in immune system parameters such as an increase in CD4 cells, NK cells and macrophages (all cells that fight infection), a decrease in serum cortisol levels (the stress related hormone which breaks down tissues), an increase in growth hormone (a hormone necessary for growth and rebuilding), and an increase in DHEA hormone (a precursor to all other sex hormones and connected with longevity). Biofeedback, which teaches you how to actively relax the body, is a form of reframing. Although it does not deal with the mental thought processes that lead to stress, it is a form of meditation in that it gives the mind something to focus on. When you are concentrating on one thing, lowering your heartbeat, for example, the mind is unable to fixate on negative, and hence depressing thoughts. Whenever you begin to imagine an unpleasant situation, and you feel your pulse or blood pressure rise, you are, in essence, creating a biochemical change in your body. Such a change will result in biochemical changes in the brain. Try this: imagine driving down the highway, thinking about a wonderful movie you had just seen. You are in the flow of traffic, which is jogging along at a fast clip. Suddenly, out of the corner of your eye, you spot a flashing red light. As you focus on it, you realize it is a police car. As you continue to notice it, you determine that it is in your lane, and that it is approaching you with increasing speed. Now it is right behind you. Before you continue to read further, what is happening to you? Most people who report reacting physically and emotionally to this visualization, describe sensations like sweaty palms, rapid pulse, shallow or held breath, and a feeling of butterflies in the stomach. However, they were not driving at the time they were visualizing this, such as you are not now. If such a thought, which is what visualization is, can trigger biochemical changes, what occurs throughout our daily lives when our minds wander all over the place? To finish, imagine that you pull over to the side of the road as the police car speed right past you and tickets the person in front of you. What is happening to you now? The point -- if we can learn to focus our mind, our attention and our thoughts, we can influence our brain chemistry.
In studies of depression, one treatment actually stands alone in its effectiveness in elevating depressed mood. Exercise has been consistently shown to help patients deal with mild to severe depression. Although the mechanism is not known for certain, some hypothesize that moving the body, in any form, releases endorphins, chemical compounds similar to opiates, which elevate mood. Additionally, as you exercise, your breathing deepens. People suffering from depression have been shown to breathe either shallowly or hold their breath for prolonged periods of time. Such breathing patterns decreases the oxygen concentration while it increases the carbon dioxide concentration in the blood. Decreased oxygen to the brain can impair cognition, and hence, depress mood. Exercise also requires you to get up and not sit on the couch or bed, continually repeating negative thoughts about yourself. Like biofeedback, while exercising, you must massage your muscle of concentration, your brain, by focusing on what you are doing.
Nutritional deficiencies are also linked to biochemical imbalances. Both reverse transcriptase inhibitors and non-reverse transcriptase inhibitors deplete the body of several nutrients, such as copper, zinc, vitamin B12, and carnitine. Deficiencies in each of these are linked to depression. Copper deficiency, which is mild in the general population due to the deficiencies in the standard American diet, increases with medication use. When the body is deficient in copper, symptoms can range from anemia, hair loss, decreased body temperature, and depression. Since copper is required to generate and regulate hemoglobin, it is necessary to ensure that oxygen is transported efficiently throughout the body. Furthermore, copper is a fundamental component of two enzymes in the body. The first one is copper-zinc superoxide dismutase (SOD) which is a major antioxidant system in the body, while the second is dopamine beta-hydroxylase, which synthesizes norepinephrine, a major stress related hormone, and influences the neurotransmitters in the brain.
Zinc is required for growth and development of the cell in the body. It is a major factor in DNA and RNA synthesis, cell division, protein synthesis, and the expression of genes. In order for many of the enzyme systems in the body to function, zinc is necessary. Such systems include, but are not limited to, those that detoxify alcohol and drugs in the liver (alcohol dehydrogenase), excrete carbon dioxide (carbonic anhydrase), facilitate energy production in the mitochondria (cytochrome C), and breakdown proteins from food (carboxypeptidase). Regarding the immune system, zinc helps regulate CD4 cells, natural killer cells, and interleukin-2.
Like zinc, vitamin B-12 is also necessary for cell growth, maturation and development through its effect on DNA and RNA. B-12 is necessary for nerve function as well as the development of red blood cells. B-12 helps in the digestion of carbohydrates, fats and proteins. (For more detail about B-12, please read "Mitochondrial Damage," STEP Perspective, Volume 2, Issue 2, 2002.)
When these nutrients are reduced in the system, depression may occur. Such depression, which may be treated with synthetic antidepressant agents, is linked to biochemistry. However, the mechanism is due to nutritional deficiencies, which, in turn, can affect serotonin, dompamine, and acetylcholine levels in the brain. Since each of these require a complex system of enzymes and cofactors in order to be synthesized, it is important not to overlook the other ingredients in the recipe. Some other nutritional deficiencies linked to depression are deficiencies in calcium, magnesium, folic acid, pyroxidine (B6), riboflavin, thiamine, and vitamin C. As mentioned in my article on mitochondrial damage, reverse transcriptase inhibitors negatively affect certain enzymes that allow the mitochondria to replicate. Supplementations with some of the above listed nutrients may reduce such toxicity. Pleasantly, these nutrients, especially the B vitamins, can possibly provide relief in depression.
In addition to HAART medication, many of the prophylactic medications, such as Bactrim and Dapsone, also deplete the body of folic acid and almost all the other B vitamins. Furthermore, recreational drugs will rob the body of vital nutrients as well as have the potential to irreparably damage brain cells. Ecstasy oxidizes, or breaks down, dopamine in the brain. When this occurs, the oxidized dopamine can destroy nerve endings and neurotransmitters in the brain. For individuals already suffering from depression, this can exacerbate their condition, after they come down from their high.
Another nutrient in need of discussing is tryptophan. When the FDA had all forms of this essential amino acid removed from the counters of all health food stores across this country, it was done so out of fear and without much basis. One strain of tryptophan produced in Japan was contaminated. However, in their zeal and wielding the full scope of their political power, they banned all forms of tryptophan from being sold in the U.S. This amino acid is essential, meaning it cannot be produced in the body, and is required by the body in order to produce niacin (vitamin B3), proteins, and the neurotransmitter serotonin. People who are HIV-positive have been shown to have lower levels of tryptophan, niacin, and serotonin in their blood. Deficiency in tryptophan can lead to symptoms that mirror vitamin B3, known as pellagra, such as dry skin, diarrhea, dementia, and possible death. Serotonin deficiency is considered one of cornerstones in the rationale for prescribing the class of drugs called selective serotonin re-uptake inhibitors. Levels of tryptophan can increase through supplementation of nicotinamide, a better tolerated form of niacin. Interestingly, studies suggest that supplementation with serotonin itself inhibits HIV from replicating in CD4 cells. Subjects taking AZT (zidovudine) had their serum and cerebrospinal fluid levels of tryptophan return to normal while on therapy. Not only would supplementation with tryptophan be beneficial for balancing moods, it may very well have a positive influence on HIV.
The issue of diet and lifestyle factors cannot be overlooked in dealing with depression. Repeated studies reveal the positive correlation between those who consume sugar and caffeine (in the form of coffee, cola and teas) and those who suffer from mild to moderate depression. Sugar does not include fresh, whole fruit, but does include fruit juice, honey, and molasses sweetened foods. Over-consumption of sugar and caffeine can put undo stress on the sympathetic nervous system, and can lead to hypoglycemia and potential hypothyroidism. Often the symptoms of both of these maladies are identical to symptoms of depression, and therefore these conditions needs to be explored further.
Essential fatty-acids, especially omega-3 fatty acids, tend to be low in patients with depression. Essential fatty acids, in the form of flax seed, borage and other plant oils, are important in regulating the lipid bi-layer of the cells of the body. Low fat diets have been shown to correlate to higher rates of suicide in people following such a dietary program. For people who are HIV-positive with elevated triglycerides and cholesterol, essential fatty-acids are actually beneficial and can improve your mood.
So the take home message is this:
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Brad S. Lichtenstein, N.D. is licensed naturopathic physician, personal trainer, and yoga and meditation teacher. In private practice, he specializes in HIV care, counseling, and yoga therapy. Brad works with people interested in taking an active role in their lives and looking beyond their diagnosis and illness in order to create meaning purpose in their lives. Brad continues to offer meditation, yoga and movement classes as well as offering workshops on naturopathic approaches to living well with HIV and AIDS. He can be reached at (206) 545-7133 or at his Web site at www.naturopathiclifecoach.com.