Depression and Panic Attacks
Case Background Summary
49 year old female with complaints of depression. Suffered a major loss with the death of a close loved one two years ago and has had trouble coping with life since then. She was put on a SSRI antidepressant to assist which she is not taking regularly.
Panic attacks are another presenting complaint, these attacks occur randomly and she experiences 2-3 attacks per week. The attacks started when she was 21 with palpitations and shortness of breath being chief symptoms when she is having an attack. She also sweats profusely and cant has to sit down when a panic attack occurs. The attacks last for 5-10 minutes with pain and twitching in her leg muscles and feels the attacks are stress related.
At night, she often feels her heart beating rapidly and this makes her feel nervous and often prevents her from having a good night’s sleep. She often feels like she doesn’t get enough air; generally she also sweats a great deal and has to sit down as her legs won’t hold her up.
Since the loss of her close family member, she has withdrawn from social activities, including spending time with her husband and now spends most of her time indoors watching television. She has lost motivation for normal daily activities such as cooking and shopping. She often misses meals or just snacks on toast and jam, breakfast cereals and processed snack foods. Dinner is often a take-away which her husband picks up on the way home from work.
The client is suffering from a number of nervous system issues. The depression started around the time of the loss of her family member and this event seems to be an obvious trigger for this however she has been suffering panic attacks for most of her life indicating a very long standing nervous system complication.
Depression is a disorder that is characterised by a sadness that is severe and persistent enough to interfere with function and often by decreased interest of pleasure in activities. There are a number of signs and symptoms that can be common with depression, these can be categorised under the following headings;
Not getting things done at work or school
Not going out anymore
Inability to concentrate
Use of alcohol and sedatives
Not participating in activities
Sick and run down|
Headaches and muscle pain
Change in appetite
Many people have the feelings and behaviours in the above table from time to time however depression is diagnosed when these feelings and behaviours have been going on for a number of weeks and disrupting life. The client has noticeably withdrawn herself and has lost motivation for general life activities and socialisation.
It is common for other disorders to coexist with depression, panic and anxiety disorders are a common condition that coexists with depression. The client’s anxiety and panic attacks are regular and quite severe, Common symptoms of anxiety and panic attacks include;
- Shortness of breath
- Excessive sweating
- Chest pain
- Numbness of face and/or extremities
- Fear of dying
Panic attacks start suddenly and unpredictably, the cause of anxiety disorders and panic attacks is not well understood. Traumatic life events, personality traits and medication can be contributing factors. Over stimulation of the hypothalamus-pituitary-adrenal (HPA) axis is thought to be involved with increased cortisol, adrenaline, noradrenaline and dopamine output.
The client’s diet is very poor with skipped meals, multiple processed food snacks and many takeaways. A diet that is deficient in key nutrients, notably essential vitamins and minerals and omega 3 fatty acids can contribute to the effects of depression, anxiety and panic disorders.
The prescription drug Zoloft that the client is taking is a selective serotonin reuptake inhibitor (SSRI) that is commonly prescribed to treat depression and panic and anxiety disorders. The effectiveness of this drug may be hard to measure with the client as she often forgets to take it. There are a number of side effects attributed to this drug, these include fatigue, dizziness, insomnia, dyspepsia and nausea. Some of these symptoms the client is currently experiencing. The client indicated she would like to come off this medication, this needs to be done in conjunction with the prescribing doctor if it is not benefitting her, particularly as she is not taking it regularly.
As there are often a number of contributing factors that affect depression, anxiety and panic disorders, a multifaceted treatment approach is required. With regards to a naturopathic framework, brain function can be affected by a range of factors including hormone balance, digestion, insulin levels, liver function, infection, gut health, inflammation and diet.
The client’s diet is very poor and requires much attention. Assistance was sought from the husband in this area to assist with the organisation of meals and to stop enabling the consistent takeaway consumption. He was more than happy to assist. A whole food, Mediterranean based diet that is balanced with complex carbohydrates, adequate lean protein and healthy fat that promotes blood sugar regulation is beneficial. There are numerous studies supporting this including a study involving over 10,000 Spanish adults that showed a lower incidence of depression is those consuming a Mediterranean diet when compared to a more heavily processed food diet.
Tryptophan à 5HTP
Tryptophan is an essential amino acid that is used in the biosynthesis of proteins. Tryptophan is required in the synthesis of serotonin, a neurotransmitter associated with mood improvement. Tryptophan converts to 5HTP in the body, naturally increasing levels of serotonin in the brain. Foods high in tryptophan include pumpkin seeds, cheese, turkey, lamb, beef, tuna, oats and egg white and are to be increased in the client’s diet. Foods that deplete or block serotonin in the body include sugars and refined carbohydrates and food additives, these should be avoided. Tryptophan has also been linked to improving sleep duration and quality. A number of studies have been performed with increasing the consumption of tryptophan. Results showed an improved quality of sleep, decrease in the time taken to fall asleep and a decrease in total wakefulness. The studies also found that the patients were more alert and clearer upon waking in the morning.
GABA is a neurotransmitter responsible for calming and can assist greatly with anxiety, panic attacks, poor sleep and stress in general. GABA works by inhibiting nerve transmission in the brain, therefore exhibiting a calming effect.
Activated B Vitamins
A quality B complex including activated B6, B9 (folate) and B12 would be of great benefit. B vitamins are required for the synthesis of neurotransmitters such as serotonin and dopamine and help support the body when under stress. B vitamins work together synergistically so it is advisable to always take a B complex by itself or in addition to single B formulas. Activated B vitamins are readily available to the body when consumed and can assist in clients that are not converting the vitamins, or methylating the vitamins effectively, therefore increasing the bioavailability of the vitamin to the client. Clients with methylation issues, COMT polymorphisms or other neurotransmitter related snps will need special consideration here. See my other articles on the different types of folate and various snp polymorphisms. (link to MTHFR specialty page)
Vitamin B6 is a cofactor in the tryptophan-serotonin pathway and may have a positive influence on depression. A study on 869 individuals assessing activated B6 blood levels, pyridoxyl-5-phospate (P5P), found that low plasma levels of P5P below 20nmol/L doubled the likelihood of depressive symptoms.
Folate is another major B vitamin that has been found to be effective in the management of depression. Folate is required for the synthesis of noradrenaline, dopamine and serotonin. Studies show that low plasma or serum folate is linked to patients with depression, alcohol disorders, and other mood disorders. Folate has been used in the form or calcium folinate or methylfolate (5MTHF) to assist in the treatment of depression. Studies have shown that it appears to enhance the effect of SSRI’s and to assist in reducing the symptoms of depression. Folic acid is he synthetic form of folate and should generally be avoided.
Magnesium and Zinc
Magnesium is required for a range of cellular functions including supporting the regulation of neurotransmitters. It is required for energy production and is often burned up quickly in stressed and anxious people. Zinc is an essential nutrient that is part of many enzyme reactions in the body and brain. A study that gave 25mg of zinc as an adjunct treatment with an antidepressant found that depressive symptoms were reduced significantly vs placebo suggesting zinc plays a role in the reduction of depressive symptoms.
Omega 3 fatty acids are required by the brain both functionally and structurally. A systematic review conducted in 2010 found that levels of DHA and EPA were found to be significantly lower in depressed patients. DHA appears to be associated with serotonin and dopamine transmissions and EPA is understood to produce antidepressant effects through antagonising arachidonic acid and reducing prostaglandin E2, stabilising neuronal function.
Chromium is another supplement that is well regarded for assisting with blood sugar stabilisation. Low levels of chromium can contribute toward blood sugar instability, a common occurrence in depressed individuals. Regulating blood sugar can assist in balancing mood, sweet cravings and control appetite.
Probiotics have long been used to treat digestive issues, however there is evidence to suggest they have a role in mental illness. Stress influences the gut microbiota balance and several studies and reviews suggest that alterations in the microbiota modulate plasticity related serotonergic and GABAergic signalling systems in the central nervous system. The positive alteration of the gut microbiota may play a large role in the influence on positive mood and the reduction of depression and anxiety related symptoms.
Herbal medicine also played a vital part in this case. Chief actions sought included nervines, tonics, adaptogens, mild sedatives, anti-depressants and antioxidants.
The link between mood and exercise is well researched and strong. Exercise assists in the release or endorphins and fires up neurotransmitters, improving mood. Exercise has been shown to assist with the reduction of depression and anxiety symptoms and should be included in and plan to combat there illnesses. In addition, calming exercise such as tai chi or meditation is recommended.
Homoeopathically, for this case I prescribed Nat Mur at a 200C potency. Nat Mur is indicated for sadness after the death of a loved one with particular mention of silent grieving, being alone and loss of interest in life.
Specific B Complex – with activated B6, B9, B12
Nat Mur – 200C
Specific liquid herbal formula
Exercise – 3+ times/week
Multiple, including neurotransmitter and methylation support
Energy, cramps/muscle pain
Blood sugar stability
Support gut/brain axis
Mood, anxiety, sadness
Nervous system support
Endorphin release, mood
After 4 weeks of the modified diet and lifestyle, nutritional supplements, targeted herbal medicine and homeopathic, the clients symptoms had improved a lot with the panic attacks ceasing, some anxiety was still being experienced but much less. Overall mood had increased with the client reporting that she “felt a big improvement and feel I am able to do things and no longer stuck with a dark cloud over my head”. Additional testing was requested to assess thyroid function, heavy metal accumulation and methylation status.
***This case and dosages prescribed were specific to the individual and presenting condition, this protocol may not suit everyone with these symptoms. A consultation with a suitably qualified practitioner should be undertaken before commencing any treatment ***