Safe and Effective Non-medication Ways to get Through the Winter Blues

Dealing with depression over the holidays

Many people who struggle with chronic depressed feel more depressed as the holidays approach, the weather gets colder, and the days get shorter. If you currently take an antidepressant but you are having disappointing results or side effects, and you’re interested in learning about evidence-based non-pharmacologic treatments of depressed mood, research findings show that select natural supplements and other complementary and alternative (CAM) approaches may help you feel and function better.

Complementary and alternative therapies for depressed mood

This is the first in a series of blog posts on complementary and alternative (CAM) treatments of depressed mood. This post is offered as an overview of natural supplements and other CAM approaches widely used to treat depression. Future posts will focus on specific CAM modalities including natural supplements such as St. John’s wort (Hypericum perforatum) S-adenosyl-methionine (SAMe), 5-hydroxytryptophan, Omega-3 fatty acids, mind-body approaches, acupuncture, EEG-biofeedback, and others. In addition to reviewing the evidence for particular CAM modalities, I will comment on emerging research findings for combining specific natural supplements or other CAM modalities with antidepressants aimed at improving response or mitigating adverse effects.

Available mainstream treatments often fail to alleviate depressed mood

Depression is one of the most serious and costly health problems facing the world today. Because of the high incidence of suicide and other medical or mental illnesses in depressed individuals, depression is regarded as the leading cause of death and disability from adolescence through middle age. Although available mainstream treatments such as medications and psychotherapy are often beneficial, existing conventional approaches fail to alleviate depressed mood in many cases. These problems have resulted in ongoing debate over the efficacy and safety of antidepressants in the medical community and in the public at large.

Research findings on the efficacy of antidepressants are inconsistent and disappointing. Several independent analyses have concluded that most trials of antidepressants sponsored by pharmaceutical companies fail to show significant response differences between antidepressants and placebos. It is estimated that in United States, the U.K., and West European countries more than two thirds of depressed patients never receive adequate treatment with antidepressants. This is due to both inadequate screening of depressed mood by physicians and under-reporting by patients. Over half of all patients who take antidepressants are not treated by psychiatrists and have never been formally diagnosed with depression. Among those who are diagnosed and receive recommended doses of antidepressants, between 40% and 70% fail to respond.

Select CAM modalities have been validated as effective treatments of depression

Several non-pharmacologic treatment modalities used to treat depression and other mental health problems have been empirically investigated in well designed placebo-controlled studies and fulfill biomedical criteria for efficacy and safety but are not in widespread use in Western countries because of economic, social or ideological factors, including limited post-graduate training in the evidence-based use of complementary and alternative (CAM) therapies in mental health care, and widespread prescribing of antidepressants by physicians. Many CAM modalities are widely used to treat or self-treat depressed mood, and–as is true for widely used antidepressants–CAM therapies have limitations and drawbacks. However, select natural products and other non-pharmacologic treatments have been substantiated by consistent positive findings from large, well-designed placebo-controlled, double-blind studies, and in some cases, systematic reviews and meta-analyses.

Examples of empirically validated CAM treatments of depressed mood include St. John’s Wort, S-adenosyl methionine (SAMe), the amino acid 5-hydroxytryptophan (5-HTP), a form of the B vitamin folic acid, the essential fatty acid ecosapentanoic acid (EPA), and to a lesser extent, the amino acid Acetyl-L-carnitine and the pro-hormone dehydroepiandrosterone (DHEA). Placebo-controlled double blind studies and meta-analyses show that SAMe has equivalent or superior anti-depressant efficacy compared to tricyclic antidepressants. In contrast CAM therapies with a known biological mechanism of action, mindfulness, mind-body approaches, and other CAM modalities that do not have a clearly defined biological mechanism of action, have not been as rigorously examined by Western science, and therefore have relatively weaker empirical evidence supporting claims of efficacy.

Integrative strategies may be more effective than single conventional or CAM treatments

In addition to the use of single CAM therapies, emerging research findings support that taking an antidepressant while engaging in a mind-body practice, exercising, using bright light exposure therapy, or taking certain natural product supplements may accelerate the rate of treatment response or improve overall outcomes. This is the perspective of integrative mental health care, which is the focus of all my posts.

You can find out more about CAM and integrative treatments of depression by reading my e-book “Depression: The Integrative Mental Health Solution.”

Essential Oils and Aromatherapy for Anxiety

Prescription anti-anxiety medications are limited by safety problems

Prescription medications used to treat generalized anxiety include the benzodiazepines such as diazepam and clonazepam, and SSRI antidepressants such as paroxetine and sertraline.  Chronic benzodiazepine use is associated with dependence, sedation and mental slowing. The SSRI antidepressants often interfere with normal sexual functioning and cause weight gain.

Wide use of herbals in response to a need for safer, more effective anti-anxiety medications

Beneficial effects of the essential oils or aqueous extracts of certain herbals including English Lavender (Lavandula angustifolia), Passion flower (Passiflora incarnata) and other herbals used to treat anxiety include a general calming effect achieved in the absence of sedation, and avoidance of the risk of tolerance or dependence with prolonged use. The differences between many anti-anxiety drugs and herbals are related to the fact that calming effects of the essential oils of Lavender and other fragrant herbals are mediated by many underlying mechanisms and do not act only on GABA/benzodiazepine receptors in the brain. The limited efficacy and safety concerns associated with many conventionally prescribed anti-anxiety medications have stimulated animal research on several plant-derived molecules that have many mechanisms of action and may lead to safer, more effective anti-anxiety medications (De Sousa et al 2015)

Inconsistent findings on Lavender

Oral preparations and essential oils (e.g., used in massage or aromatherapy) derived from several species of Lavender and other fragrant herbs are widely used to treat anxiety however research findings are inconsistent. Very few placebo-controlled studies have been done on different preparations of Lavender for anxiety, most studies are small or methodologically flawed and reported findings are often inconclusive. A review of randomized clinical trials reported that oral preparations of Lavender may be more effective than aromatherapy or topical application of the essential oil (Perry 2012).

Different effects from aromatherapy using Lavender or Rosemary

Some studies report significant anxiety-reducing effects in response to Lavender or Rosemary aromatherapy. A randomized controlled trial evaluated changes in electroencephalographic activity and subjective emotional states in 40 adults exposed to Lavender or Rosemary aromatherapy. Individuals receiving lavender aromatherapy showed increased activity in the beta frequency range (12 to 30 cycles per second) and reported decreased overall anxiety. Patients receiving rosemary aromatherapy showed decreased frontal alpha and beta power and reported diminished anxiety and increased alertness. These findings show that lavender aromatherapy promotes a relaxed drowsy state, while Rosemary aromatherapy promotes a relaxed alert state. Although other essential oil preparations are sometimes used to treat anxiety, there is not enough evidence to support their use.

Promising findings for Passion flower

Passion flower (Passiflora incarnata) contains an active ingredient called chrysin that has been demonstrated to bind to benzodiazepine receptors in the brain resulting in a general calming effect. Although Passion flower extract is commonly used to treat anxiety, few double blind placebo-controlled studies have been done. In one small study, Passion flower extract 45 drops per day and oxazepam (a benzodiazepine) were equally effective in reducing generalized anxiety. Patients taking oxazepam reported significant impairments in job performance at doses that lowered anxiety however there were no reports of performance impairment among patients taking effective doses of Passion flower extract. Another study reported similar findings when comparing Passion flower with the SSRI sertraline in patients with generalized anxiety (Yeung & Hernandez 2018).

Few safety issues

Different species of Lavender are well tolerated and are not associated with serious adverse effects or toxic interactions. Mild transient adverse effects irritation to the skin and a mild photo-sensitive rash, have been reported when Lavender and other essential oils are applied topically. There are a few reports that Lavender may increase the risk of bleeding when used together with an anticoagulant. Because of potential synergistic interactions, individuals taking an anti-seizure medication or a benzodiazepine should exercise caution when using the essential oil of Lavender or other calming herbals.

Healing Touch and Therapeutic Touch for Anxiety and Stress

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.”

Acupuncture of Anxiety: A Safe and Effective Therapy

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.

Heart Rate Variability (HRV) Biofeedback for Anxiety Conditions

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.

Massage Therapy 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.

Regular Physical Activity Improves Anxiety

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.”

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.” In

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.

Conventional Treatments of Anxiety Disorders: 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.”