When it comes to improving mood, most of us will do anything, including taking boatloads of pills.
One of the challenges I face as a naturopathic doctor is choosing which supplements to prescribe my patients; in the realm of natural medicine we have what seems like an infinite amount of options.
I can prescribe herbs for regulating the stress response, calming inflammation, or Zen-ing out the brain. I can prescribe amino acids, like 5HTP, which help regulate chemicals in the brain. I can recommend the hottest new products, like collagen, or a greens powder, or the newest Superfood. There are also a host of nutrients that the brain and body need for optimal functioning.
I try to keep my list of supplement recommendations to a maximum of 5, letting diet and lifestyle do the rest of the heavy-lifting. This means that I work in layers. When I see a new patient, I start by prescribing nutrients that fill in nutritional gaps. Perhaps my patients are showing signs of deficiency, based on their health histories, diet diaries or blood results; Or perhaps they just need a bit more nutrient support in the face of physical, mental, emotional and environmental stressors. After they start to notice improvement, we might move on to clearing more layers using herbs or therapies, like acupuncture or Mindfulness-Based Cognitive Therapy.
Naturopathic medicine does not believe in one-size-fits all treatment plans. If I see two patients with depression on the same day, both may receive entirely different plans. I base my recommendations on the person and her unique biography and biology, not the condition. However, because I try to keep my supplement suggestions to a minimum, when I work with patients with depression, I find these 5 nutrients continue to appear on my list.
1. Fish Oil
While most anti-depressant therapies target the brain, we know that depression isn’t simply a brain disorder. Depression is a complex condition impacted by our genes, physical health, social and physical environments, early childhood traumas, current stressors, nutrients status, and many other factors. Our minds and bodies are connected and therefore depression is as much a product of the health of our bodies and our environments, as it is of our brains.
Mounting evidence shows that inflammation in the body plays a major role in depression. Since the 90’s, scientist have found inflammatory cytokines (immune system molecules that cause inflammation), like IL-6 and TNF-a, elevated in depressed individuals.
When pro-inflammatory substances, like lipopolysaccharide (LPS) or interferon-a, traditionally used to treat hepatitis C, are injected into healthy individuals they cause symptoms of depression like lack of motivation and pleasure, and feelings of sadness.
Anti-inflammatory substances are effective anti-depressants. The omega-3 fatty acid eicosapentaenoic acid, or EPA, found in fatty fish like salmon and sardines, is a well-known anti-inflammatory nutrient. One study found that supplementing with EPA prevented depressive symptoms in individuals who were injected with interferon-a.
Fish oil contains the omega-3 fatty acids EPA and docosahexaenoic acid, or DHA. Both of these marine omegas are found in certain fatty fish, which can be remembered by the acronym SMASH: sardines, mackerel, anchovy, salmon and herring (also trout). Fish oil supplements combine EPA and DHA. DHA is a component of our brain mass. It is needed for developing the brain and nervous system of growing babies, and is indicated in pregnant and breastfeeding women. EPA confers the anti-inflammatory benefits.
A meta-analysis composed of 15 randomized control trials involving almost 1000 participants, found that fish oil was an effective therapy for treating depression as long as the fish oil contained over 60% EPA relative to DHA.
Another review of three studies, showed that omega-3 fish oil supplementation reduced depressive symptoms in children and adults by 50%.
When it comes to supplementing with fish oil for depression, it’s the EPA that counts, not the DHA. Also, more fish oil seems to be better than less. Studies that showed the best anti-depressant actions dosed participants with at least 1 gram of EPA per day. Some studies gave patients 2 grams of EPA or more per day. Supplements that showed the most benefit contained higher amounts of EPA relative to DHA.
A 100-gram serving of wild Atlantic salmon contains about 400 mg of EPA, while farmed Atlantic salmon, surprisingly contains more: 700 mg of EPA per 100 grams. While consuming fatty fish, like sardines, and pasture-raised, rather than grain-fed, animals can increase our dietary ratio of omega 3 to omega 6, which has general health benefits, supplementation with a high-EPA fish oil is probably necessary to supply the 1 to 2 grams of EPA per day that have been shown to reduce depression.
2. An Active B Complex
B vitamins are cofactors for thousands of reactions in the body. Cofactors are “helpers”. They help enzymes and cellular process work—without these helpers, important jobs just don’t get done. This can have major implications for our mental health.
For example, the vitamins B6 and folate are needed to convert the amino acids tryptophan and 5HTP to serotonin, the “happy hormone”. Serotonin is a neurotransmitter responsible for managing mood: soothing depression and anxiety; and regulating appetite, memory, and sexual desire. Serotonin is the main target of conventional anti-depressant therapies, SSRI (selective serotonin reuptake inhibitor) medications, which raise brain levels of this chemical.
Both B12, which is important for energy production and neuronal health, and folate, which is important for DNA repair, detoxification and reducing inflammation, have been found to be low in patients with depression. A B12 deficiency, resulting in fatigue, memory loss and low mood, can also mimic the symptoms of depression.
It’s important to supplement with an active form of the B vitamins. This means buying and consuming a B complex or multivitamin that contains B12 and folate in their active forms: methylcobalamin and methyl-folate (or 5-methyltetrahydrafolate, or 5-MTHF), respectively.
Individuals who have a genetic mutation that prevents them from efficiently converting folic acid (a synthetic vitamin found in cheap supplements and fortified grains, like wheat and rice) to active folate, are highly represented in the major depressive disorder population. This gene is called MTHFR C677T and is associated with lower blood levels of folate and an increased risk of depression. To learn more about folic acid and MTHFR mutations, read my article here.
B vitamins are also needed by the mitochondria, the “powerhouses” of our cells. By helping our mitochondria work properly, they help reduce inflammation, boost energy production and promote antioxidant synthesis.
We can find B vitamins in egg yolks and liver. The only dietary sources of B12 are found in animal foods, making it difficult for vegans and vegetarians to get without supplementing. Folate is abundant in leafy greens.
Physical, mental, emotional and environmental stressors create a higher demand for the B vitamins. The B vitamins are water soluble, excreted in the urine and not stored. Therefore, to support neurotransmitter synthesis and energy levels in my depressed patients, I often prescribe a good-quality B complex supplement to complement their diets.
3. Magnesium
Because my clinical focuses are mental health, hormones and digestion, I prescribe magnesium to virtually every patient I see—magnesium is an important nutrient for all of these conditions.
Like the B vitamins, magnesium is a cofactor. It’s involved in helping with over 800 chemical process in the body that simply won’t get done without it. We need magnesium to make cellular energy in the mitochondria, to produce neurotransmitters, like serotonin, and to repair DNA, among many other jobs.
Due to soil deficiency, low intake, stress and decreased absorption, it’s estimated that about 40 to 60% of North Americans are magnesium deficient. Only 1% of the magnesium in our bodies is present in blood. Blood levels don’t reflect the body’s magnesium stores, and so testing for deficiency is unreliable.
Magnesium is a potent muscle relaxer. Deficiencies show up wherever muscles are contracted, rather than relaxed: this can include constipation because of poor intestinal motility, muscle aches and pains, frequent urination due to contracted bladder muscles, menstrual cramps, and headaches and high blood pressure from constricted blood vessels. Insomnia, anxiety and sensitivity to loud noises can also all be signs of a magnesium deficiency. PMS, insulin resistance and sugar cravings are all further indications for magnesium supplementation.
Magnesium can be obtained from leafy greens like spinach and chard. However, most individuals need to supplement to stock up their magnesium levels, particularly if experiencing stress, fatigue, anxiety or depression. Like the B vitamins, magnesium is water soluble, excreted in the urine in response to stress.
A 2017 randomized control trial published in PloS One, found that 248 mg of magnesium chloride decreased the PHQ-9 score of those with mild-moderate depression by almost 5 points. This result compares to standard anti-depressant medications. Despite the relatively low dose and inferior form of magnesium, the effects were well-tolerated and benefits were seen in 2 weeks.
I prescribe magnesium glycinate, a much better-absorbed form, before bed to help patients sleep better. This means starting with 100 to 200 mg per night and increasing by that amount every 3 to 4 days or until patients are having a bowel movement on waking—this is called “prescribing to bowel tolerance”.
A side effect of taking too much magnesium is loose stools, or soft stools that fall apart in the toilet on flushing, which can be corrected by lowering the dose. I personally take about 900 mg of magnesium at night to manage my stress, mood, energy levels and muscle tension.
4. Vitamin D
About 70 to 90% of North Americans are deficient in vitamin D, which acts like a steroid hormone rather than an actual vitamin, and regulates over one thousand genes in the body. Our skin makes vitamin D when it comes into contact with UVB radiation from the sun. Those of us who live in northern climates with limited sun exposure don’t make enough vitamin D and need to supplement, especially during the Winter months.
Vitamin D is needed to regulate the gene Tryptophan Hydroxylase 2, which converts the amino acid tryptophan (a component of protein that can only be obtained from diet and is found in foods like turkey and pumpkin seeds) to serotonin in the brain.
Low vitamin D concentration has been associated with depression, however researchers aren’t sure if the relationship is causal: does low vitamin D status put someone at risk for developing depression? Or do depressed individuals have low vitamin levels in their bodies because of some other factor?
Studies have failed to show that taking vitamin D supplements impacts depression. I also haven’t found vitamin D to impact my patients’ moods as a solo therapy. It’s likely that nutrients like vitamin D acts as part of a network, in conjunction with other vitamins, like magnesium, which is responsible for converting supplemental vitamin D into the active form. Vitamin D is a fat-soluble vitamin, and taking it in chalky tablet form may not raise levels. I prescribe vitamin D3, the active form of the vitamin, in drop form. Vitamin D drops are suspended in fats like coconut or flax oil, which makes them easier for the body to absorb.
Whether a case of the chicken or the egg, when it comes to vitamin D and mood, we know that supporting vitamin D status is essential for achieving optimal health, managing immune function, reducing inflammation, reducing the risk of osteoporosis, and regulating mood, given vitamin D’s role in serotonin synthesis.
The Framingham study found that patients who had low levels of vitamin D had poorer mental functioning and reduced volume of a brain region called the hippocampus, which is responsible for memory formation and mood regulation. Reduced hippocampal volume is a risk factor for and consequence of major depression.
There is a “sweet spot” to optimal vitamin D levels; because it’s a fat-soluble vitamin and can be stored, too much vitamin D may be as bad as too little. Therefore, I like to measure my patients’ blood levels in the Fall to determine the right dose for supplementation. 4000 IU a day is a good, safe dose for most people during the Winter months.
5. Zinc
Zinc is the catalyst for hundreds of enzymes in the brain, including making serotonin, norepinephrine and dopamine, all of which are brain chemical targets of anti-depressant therapies.
There is a major concentration of zinc in the hippocampus, a brain region affected by depression. Studies show that zinc plays a role in supporting neurogenesis (the creation of new brain cells) by stimulating Brain Derived Neurotrophic Factor (BDNF). BDNF creates new brain cells and boosts mood. Anti-depressants may work by increasing brain levels of BNDF, protecting the brain against stress.
Plasma zinc concentrations are lower in major depressive disorder. Animal studies also show that depleting zinc can lead to major depression.
Zinc supplementation has been shown to boost mood. A study of 50 overweight or obese patients were assigned to receive either 30 mg of zinc or placebo. After 12 weeks, the group who received zinc experienced a greater reduction in the severity of their depression and an increase in the levels of BDNF in their brains.
Zinc is also an important nutrient for supporting the immune system and managing inflammation.
Besides depression, other signs of zinc deficiency include skin issues, like dry skin and acne, infertility, issues with gut membrane integrity (leaky gut), hair loss, low testosterone, poor immune function and fatigue.
Dietary sources of zinc are harder to come by for vegans and vegetarians, who are at a higher risk for developing a zinc deficiency. Zinc can be found in red meat, shellfish, lentils and pumpkin seeds.
I typically prescribe zinc the way I prescribe iron, in pulse doses: I recommend that patients work their way through a bottle of zinc (taking 30 to 100 mg per day), while we assess whether symptoms improve. Unlike iron (which we can measure more accurately by looking at its storage molecule ferritin), zinc can’t be accurately measured in blood. Like magnesium, zinc deficiency in the body’s tissues may be present long before low zinc levels show up in blood.
While this list can be a great tool for anyone interested in supporting their mood through boosting nutrient status, keep in mind that this information is not a substitute for medical advice.
I believe it’s essential to work with a naturopathic doctor, or a functional medical doctor, who can make the appropriate recommendations for your individual health needs. A personalized consultation that assesses your diet, blood work, health history and specific symptoms, can help you hone your list to come up with a dynamite nutrient plan that’s specifically tailored to you.
