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Clinical naturopathy: An evidence-based guide to practice

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An evidence-based
guide to practice




Clinical Naturopathy:
an evidence-based guide
to practice
Clinical Naturopathy:
an evidence-based guide
to practice
Jerome Sarris Jon Wardle
Sydney Edinburgh London New York Philadelphia St Louis Toronto
Churchill Livingstone
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
© 2010 Elsevier Australia
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This publication has been carefully reviewed and checked to ensure that the content is as
accurate and current as possible at time of publication. We would recommend, however, that
the reader verify any procedures, treatments, drug dosages or legal content described in this
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publication.
National Library of Australia Cataloguing-in-Publication Data
Sarris, Jerome.
Clinical naturopathy: an evidence-based guide to practice/
Jerome Sarris, Jon Wardle.
ISBN: 978 0 7295 3926 5 (pbk.)
Includes index.
Bibliography.
Naturopathy.
Wardle, Jon.
615.535
Publisher: Sophie Kaliniecki
Developmental Editor: Sabrina Chew
Publishing Services Manager: Helena Klijn
Editorial Coordinator: Eleanor Cant
Edited by Joy Window
Proofread by Tim Learner
Design by Lisa Petroff
Index by Master Indexing
Typeset by TNQ Books and Journals
Printed by 1010 Printing International
v
CONTENTS
Foreword ix
Preface xiii
Acknowledgments xvi
About the editors xvii
Contributors xviii
Reviewers xxi
Part A: Naturopathic clinical skills 1
1 Naturopathic case taking 2
Greg Connolly
2 Naturopathic diagnostic techniques 19
Niikee Schoendorfer
Part B: Common clinical conditions 49
Section 1: Gastrointestinal system 50
3 Irritable bowel syndrome:
constipation-predominant (C-IBS) 52
Jason Hawrelak
4 Gastro-oesophageal reflux disease 75
Jason Hawrelak
5 Food allergy/intolerance 88
Jane Daley
Section 2: Respiratory system 102
6 Respiratory infections and immune insufficiency 104
David Casteleijn and Tessa Finney-Brown
7 Asthma 132
David Casteleijn and Tessa Finney-Brown
8 Congestive respiratory disorders 151
David Casteleijn and Tessa Finney-Brown
Section 3: Cardiovascular system 171
9 Atherosclerosis and dyslipidaemia 173
Michael Alexander
10 Hypertension and stroke 190
Michael Alexander
11 Chronic venous insufficiency 203
Matthew Leach
Section 4: Nervous system 215
12 Clinical depression 216
Jerome Sarris
CONTENTS
vi
13 Chronic generalised anxiety 238
Jerome Sarris
14 Insomnia 257
Jerome Sarris
Section 5: Endocrine system 274
15 Adrenal exhaustion 275
Tini Gruner
16 Diabetes type 2 299
Tini Gruner
17 Thyroid abnormalities 325
Tini Gruner
Section 6: Female reproductive system 344
18 Dysmenorrhoea and menstrual complaints 346
Jon Wardle
19 Endometriosis 363
Jon Wardle
20 Polycystic ovarian syndrome 383
Jon Wardle
21 Menopause 401
Jon Wardle
Section 7: Musculoskeletal system 420
22 Osteoarthritis 422
Paul J. Orrock
23 Fibromyalgia 443
Leslie Axelrod
Section 8: Integumentary system 462
24 Acne vulgaris 463
Amie Steel
25 Inflammatory skin disorders—atopic eczema and psoriasis 477
Amie Steel
Section 9: Urogenital system 494
26 Benign prostatic hypertrophy 495
Kieran Cooley
27 Recurrent urinary tract infection 515
Michelle Boyd
Part C: Specialised clinical conditions 529
28 Autoimmunity 530
Joanne Bradbury
29 Cancer 569
Janet Schloss
CONTENTS
vii
Part D: Clinical naturopathy across the life cycle 601
30 Paediatrics 602
Vicki Mortimer
31 Fertility, preconception care and pregnancy 622
Jon Wardle and Amie Steel
32 Ageing and cognition 653
Christina Kure
Part E: Integrative naturopathic practice 679
33 Bipolar disorder with psychotic symptoms 680
James H. Lake
34 Attention deficit and hyperactivity disorder (ADHD) 693
James H. Lake
35 Chronic fatigue syndrome 707
Gary Deed
36 Human immunodeficiency virus 721
Jennifer Hillier
37 Polypharmacy and pain management 736
Justin Sinclair
Part F: Appendices 753
Appendix 1 Drug–herb interaction chart 754
Appendix 2 Chemotherapy drugs and concurrent
complementary therapy 785
Appendix 3 Food sources of nutrients 816
Appendix 4 Laboratory reference values 818
Appendix 5 Factors affecting nutritional status 825
Appendix 6 Taxonomic cross-reference of major herbs 831
Appendix 7 Traditional Chinese medicine: the six evils 838
Appendix 8 Traditional Chinese medicine: tongue diagnosis 840
Appendix 9 Traditional Chinese medicine: pulse diagnosis 841
Appendix 10 Systematic review of herbal immunomodulators 842
Index 845
2
1
Naturopathic case
taking
Greg Connolly
BA, ND
NATUROPATHIC PHILOSOPHY AND PRINCIPLES
For naturopaths, the patient-centred approach to case taking with its emphasis on
rapport, empathy and authenticity is a vital part of the healing process. It is based not
just on current accepted health practices but on the philosophy and principles that have
underpinned naturopathy since its beginnings.  is chapter examines how to establish
and maintain a therapeutic relationship with patients through the process of a holistic
consultation in the light of these values and practices.  is chapter also presents a model
of the structure and process of holistic case taking that will facilitate this consultation
and provide both patient and naturopath with the knowledge and insight needed for
healing and wellness.
Historical precursors
Having a philosophy by which to practice gives a clearer understanding of what consti-
tutes good health, how illness is caused, what the role of the practitioner should be, and
the type of treatments that should be given.
1 Naturopathy has a loosely defi ned set of
principles that have arisen from three interrelated philosophical sources.  e rst main
source is the historical precursors of eclectic health-care practices that formed naturopathy
in the 19th and 20th centuries.
2 Allied to this are two other essential philosophical con-
cepts intertwined with the historical development of naturopathy: vitalism 3,4 and holism 5 .
e tenets of naturopathic philosophy have developed from its chequered histori-
cal background, which includes the traditions of Hippocratic health, herbal medi-
cine, homoeopathy, nature cure, hydrotherapy, dietetics and manipulative therapies.
6
In modern times naturopathic philosophy has borrowed from the social movements
of the 1960s and 1970s that fostered independence from authoritative structures and
challenged the dependency upon technology and drugs for health care.  ese social
movements emphasised a holistic approach to the environment and ecology with a
yearning for health care that was natural and promoted self-reliance harking back to
late 19th- century principles of nature care philosophy.
7 Naturopathy also borrowed
from other counterculture movements and began to be suff used with New Age themes
1
 Naturopathic case taking
3
of transpersonal and humanistic psychology, spirituality, metaphysics and new science
paradigms.
8 Since the 1980s naturopathy has increasingly used scientifi c research to
increase understanding of body systems and validate treatments.
9,10
From this variety of sources, naturopathy has consolidated a number of core prin-
ciples.  ese principles have had many diverse adherents and an eclectic variety of
blended philosophies. Notwithstanding this, there are key concepts within naturopathy
that are agreed upon and are fl exible enough to accommodate a broad range of styles in
naturopathic practice.
11
e historical precursors of naturopathy emphasise the responsibility of the patient
in following a healthy lifestyle with a balance of work, recreation, exercise, meditation
and rest; eating healthily, and having fresh air, water and sunshine; regular detoxifi ca-
tion and cleansing; healthy emotions within healthy relationships; an ethical life; and
a healthy environment.  ese views highlight the fact that each patient is unique and,
in light of this, naturopathic treatments for each patient are tailored to addressing the
individual factors that cause their ill health. An essential part of a holistic consultation
is the education of the patient to promote healthy living, self-care, preventive medicine
and the unique factors aff ecting their vitality.
12
Vitalism
A fundamental belief of naturopathy is that ill health begins with a loss of vitality.
Health is positive vitality and not just an absence of medical fi ndings of disease. Health
is restored by raising the vitality of the patient, initiating the regenerative capacity for
self-healing.  e vital force is diminished by a range of physical, mental, emotional,
spiritual and environmental factors.
13
Vitalism is the belief that living things depend on the action of a special energy or
force that guides the processes of metabolism, growth, reproduction, adaptation and
interaction.
14 is vital force is capable of interactions with material matter, such as a
persons biochemistry, and these interactions of the vital force are necessary for life to
exist.  e vital force is non-material and occurs only in living things. It is the guiding
force that accounts not only for the maintenance of life, but for the development and
activities of living organisms such as the progression from seed to plant, or the develop-
ment of an embryo to a living being.
15
e vital force is seen to be diff erent from all the other forces recognised by physics
and chemistry. And, most importantly, living organisms are more than just the eff ects
of physics and chemistry. Vitalists agree with the value of biochemistry and physics in
physiology but claim that such sciences will never fully comprehend the nature of life.
Conversely, vitalism is not the same as a traditional religious view of life. Vitalists do not
necessarily attribute the vital force to a creator, a god or a supernatural being, although
vitalism can be compatible with such views.  is is considered a ‘strong’ interpretation
of vitalism. Naturopaths use a ‘moderate’ form of vitalism: vis medicatrix naturae, or the
healing power of nature.
1
Vis medicatrix naturae defi nes health as good vitality where the vital force fl ows ener-
getically through a persons being, sustaining and replenishing us, whereas ill health is
a disturbance of vital energy.
3 While naturopaths agree with modern pathology about
the concepts of disease (cellular dysfunction, genetics, accidents, toxins and microbes),
naturopathic philosophy further believes that a persons vital force determines their sus-
ceptibility to illness, the amount of treatment necessary, the vigour of treatment and the
speed of recovery.
16 ose with poor vitality will succumb more quickly, require more
treatment, need gentler treatments and take longer to recover.
17
PART A NATUROPATHIC CLINICAL SKILLS
4
Vis medicatrix naturae sees the role of the practitioner as fi nding the cause ( tolle causum )
of the disturbance of vital force.  e practitioner must then use treatments that are gentle,
safe, non-invasive techniques from nature to restore the vital force; and to use preventative
medicine by teaching ( docere doctor as teacher) the principles of good health.
18
Vitality and disease
Vitalistic theory merges with naturopathy in the understanding of how disease pro-
gresses (see Table 1.1 ). e acute stages of disease have active, heightened responses to
challenges within the body systems. When the vital force is strong it reacts to an acute
crisis by mobilising forces within the body to ‘throw off ’ the disease.
17 e eff ect on
vitality is usually only temporary as the body reacts with pain, redness, heat and swell-
ing. If this stage is not dealt with appropriately where suppressive medicines are used the
vital force is weakened and acute illnesses begin to become subacute . is is where there
are less activity, less pain and less reaction within the body, accompanied by a lingering
loss of vitality, mild toxicity and sluggishness.  e patient begins to feel more persis-
tently ‘not quite right’ but nothing will show up on medical tests and, in the absence
of disease, the patient will be declared ‘healthy’ in biomedical terms. If the patient con-
tinues without addressing their health and lifestyle in a holistic way they can begin to
EFFECTS ON HEALTH AND VITALITY
Constitutional strength familial, genetic, congenital
Diet
excess and defi ciency
Fresh air, water, sunlight, nature
Lifestyle
work, education, exercise, rest, recreation
Disease
Injury
Toxaemia external (such as pollution, pesticides and drugs) and internal
(such as metabolic byproducts and cell waste)
Organs of detoxifi cation
liver, kidney and lymph
Organs of elimination
bowel, gallbladder, bladder, respiratory, skin
Emotions and relationships
Culture, creativity, arts
Philosophy, religion and an ethical life
Community, environment and ecology
Social, economic and political factors
Table 1.1 Stages of disease
STAGE ACUTE SUBACUTE CHRONIC DEGENERATIVE
Symptoms Pain, heat, red-
ness, swelling, high
activity, discharges,
sensitivities
Lowered activ-
ity, relapsing
symptoms
Persistent symptoms,
constant discomfort,
accumulation of
cellular debris
Overwhelmed with
toxicity, cellular
destruction, mental
and spiritual decay
Toxicity Toxic discharges Toxic absorption Toxic encumbrance Toxic necrosis
Vitality Temporarily weak
vitality Variable vital-
ity, ill at ease,
not quite right,
sluggish
Poor vitality, malaise,
susceptible to other
physical, mental or
spiritual distress
Very low vitality,
pernicious disrup-
tion of life pro-
cesses at all levels
1
 Naturopathic case taking
5
experience chronic diseases where there are long-term, persistent health problems.  is
is highlighted by weakened vitality, poor immune responses, toxicity, metabolic slug-
gishness, and the relationships between systems both within and outside the patient
becomes dysfunctional.  e nal stage of disease is destructive where there are tissue
breakdown, cellular dysfunction, low vitality and high toxicity.
19
In traditional naturopathic theory the above concepts emphasise the connections
between lowered vitality and ill health. Traditional naturopathic philosophy also empha-
sises that the return of vitality through naturopathic treatment will bring about healing.
e stages of this healing are succinctly summarised by Dr Constantine Hering, a 19th-
century physician, and these principles of healing are known as Hering’s Law of Cure.
19,20
Holism
Another essential principle of naturopathy developed from its eclectic history is the
importance of a holistic perspective to explore, understand and treat the patient.
Holism comes from the Greek word holos , meaning whole.
21,22 e concept of holism
has a more formal description in general philosophy and has three main beliefs.
23
First, it is important to consider an organism as a whole.  e best way to study the
behaviour of a complex system is to treat it as a whole and not merely to analyse the
structure and behaviour of its component parts. It is the principles governing the
behaviour of the whole system rather than its parts that best elucidate an understand-
ing of the system.
Secondly, every system within the organism loses some of its characteristics when
any of its components undergo change.  e component parts of a system will lose their
nature, function, signifi cance and even their existence when removed from their inter-
connection with the rest of the systems that support them. An organism is said to diff er
from a mere mechanism by reason of its interdependence with nature and its parts in
the whole. For instance, any changes that occur in the nervous system can cause changes
in other systems such as musculoskeletal, cognition and mood, and digestion. Or, more
widely, any changes that occur in social relationships have an eff ect on the nervous sys-
tem and vice versa.
irdly, the important characteristics of an organism do not occur at the physical
and chemical levels but at a higher level where there is a holistic integration of systems
within the whole being.  ere are important interrelations that defi ne the systems and
these may be completely missed in a ‘parts-only perspective’.  ese interrelations are
completely independent of the parts. For instance, the digestive tract is functional only
HERING’S LAW OF CURE
Healing begins on the inside in the vital organs fi rst, from the most important
organs to the least important organs. The outer surfaces are healed last.
Healing begins from the middle of the body out to the extremities.
Healing begins from the top and goes down the body.
Retracing
healing begins on the most recent problems back to the original
problems.
Healing crisis as retracing and healing take place the body will re-experience any
prior illness where the vital force was inappropriately treated. In re-experiencing
the symptoms the patient will awaken their vitality and have an inner sense that
the cleansing ‘is doing them good’. A healing crisis is usually of a brief duration.
PART A NATUROPATHIC CLINICAL SKILLS
6
when its blood supply, nerve supply, enzymes and hormones are integrated and unifi ed
by complex interrelationships.
In naturopathic health care, holism is the understanding that a person’s health func-
tions as a whole, unifi ed, complex system in balance. When any one part of their human
experience suff ers, a person’s entire sense of being may suff er.
PATIENT-CENTRED APPROACH TO HOLISTIC
CONSULTATION
One of the most diffi cult duties as a human being is to listen to the voices of those
who suff er listening is hard but fundamentally a moral act.
24
e holistic consultation and treatment of the whole person includes emotional, mental,
spiritual, physical and environmental factors, and it aims to promote wellbeing through
the whole person rather than just the symptomatic relief of a disease. To best enhance
this holistic consultative process a ‘patient-centred’ approach is used.  is is where the
emphasis is on patient autonomy; the patient and practitioner are in an equal relation-
ship that values and respects the wants and needs of the patient.
25 e role of the prac-
titioner is to develop a therapeutic relationship of rapport, empathy and authenticity to
serve the patient’s choices and engender the healing process.
An essential component of developing a therapeutic relationship with the patient
is the ability to listen.
26 Naturopaths must never forget that each patient is an indi-
vidual with their own unique story of illness and treatment.  e patient needs to be
allowed to tell that story and in turn the naturopathic practitioner needs to listen
with sensitive, authentic attention and empathy.  is disciplined type of therapeu-
tic listening bonds the patient and practitioner and enhances the eff ectiveness of
treatment. 27
When patients feel listened to, they open up and declare hidden information that
can be clinically signifi cant to the type of treatment given and to how well that treat-
ment works. A clinical example is where a stressed fi nal year secondary student wanted
‘something natural’ to help her sleep. As she spoke about her situation, another deeper
narrative slowly unfolded in which she divulged that she had been sexually assaulted by
an ex-boyfriend and her current anxiety centred upon thoughts of self-harm.  e act of
listening not only deepened rapport and established trust and empathy but also led to
better clinical support for her with a referral to a psychologist.
If a naturopath does not holistically enquire into the causes of a patient’s presenting
complaint and merely follows a protocol in this case, an insomnia prescription they
may be, at the very least, clinically ineff ective in treating insomnia or, worse, prolonging
the patient’s suff ering and increasing her risk of self-harm.
A practitioner needs to be aware that a holistic consultation is not a routine event
for the patient. It is dense with meaning and can represent a turning point for them.
28
Fully listening to a patient’s concerns in a patient-centred holistic consultation helps the
naturopath to explore and understand what is at stake and why it matters so much.
29
With this knowledge it is then possible to provide appropriate and eff ective treatment.
Establishing rapport, empathy and authenticity in a patient-centred holistic consulta-
tion also enhances the practitioner’s ongoing ability to assess recovery and to achieve the
patient-centred aim of independent self-care.
30
1
 Naturopathic case taking
7
is therapeutic relationship depends upon the practitioner being profi cient in con-
sulting skills, communication skills and counselling skills.  is chapter now focuses on
consulting skills and the reader is recommended to the ‘Further reading’ section at the
end of this chapter for texts discussing communication skills and counselling skills.
It should also be noted that some patients present to clinic with little or no prior
understanding of what the naturopathic consultation involves. Some preliminary steps
can be taken to facilitate a better understanding for the patient. Initially, a practitioner’s
website can provide explanatory details of naturopathic philosophy, treatment modali-
ties and the consulting process.  is can be reinforced with clinic brochures in the
reception area of the clinic. As the holistic consultation begins the practitioner can sen-
sitively enquire as to the patient’s level of understanding of naturopathy and what their
expectations about the consultation are.
Phases of the holistic consultation
Adapting the Nelson-Jones
31 model, there are fi ve phases to the holistic patient centred
consultation.  ese are to:
1 . explore the range of problems
2 . understand each problem
3. determine the goals
4. provide treatments , and
5. consolidate the patient’s independence.
In a brief acute case of a minor condition, such as a minor head cold, these fi ve phases
can be completed over a single session. In a complex case with multiple pathologies and
a myriad of personal issues, the phases discussed below can occur and recur over a long
period of time and completion may entail many sessions.
Explore
e task here is to establish rapport with the patient and to help the patient reveal,
identify and describe their problems.  e naturopath can facilitate this by providing a
structure for the interview and fostering an ambience where the patient’s views are valued
and important.  e naturopath’s empathy with the patient will sensitise the practitioner
to the tone, pace, depth and breadth of their enquiry into the patient’s health issues.  e
enquiry should be patient-centred, where the patient sets the parameters of what they
feel comfortable discussing while the naturopath maintains a heightened awareness of the
clinical signifi cance of what they are saying or indeed not saying.  e patient in this
process has an opportunity to share their thoughts and feelings and for the naturopath to
join with them in identifying the problem areas in their health from a holistic perspective.
Understand
Understanding the problems involves a focused attempt to gather more specifi c
details of the problems experienced by the patient.  e naturopath’s facilitation skills
will help the patient accurately focus on symptoms while also using the naturopaths
clinical skills in physical examination, body sign observations, reviewing medical
reports and completing a systems history to gain and impart a holistic overview.  e
knowledge gained from this helps the patient to acknowledge areas of strength and
weakness in their health and to develop new insights and perceptions that will help
them to relate to their health issues holistically. It is also appropriate in this phase to
seek referrals for further diagnosis where necessary from biomedical or allied health
professionals.
PART A NATUROPATHIC CLINICAL SKILLS
8
Set goals
e next step is to work with the patient to negotiate goals and strategies to achieve
positive outcomes for their health.  e naturopath needs to discuss with the patient the
types of modalities that can be used and which treatments are expected to be effi cacious.
It is appropriate at this juncture to give a prognosis of what can be reasonably achieved
within a specifi ed time.  e patient has now an opportunity to ask questions, discuss
costs and be in an active position to make an informed choice in setting goals and decid-
ing on the best treatment options.  e patient should be encouraged to acknowledge
their active participation in their health improvement.  ey can also discuss with the
naturopath their preferences for various modalities, and the naturopath can highlight
what they can expect as their health improves.
Treatment
e task now is to assist the patient in gaining better vitality, building health resources
and skills, and lessening health defi cits.  e patient’s role is to acquire self-help skills.
Active encouragement is crucial in developing and maintaining the patient’s self-
motivation. Encourage the patient to acquire books, internet resources and community
resources and to undertake courses to further self-support the recovery.  e issues of
compliance, or how well the patient can follow a treatment plan, can be discussed with
the patient in a supportive way by identifying any possible diffi culties. e treatment
plan may need to be modifi ed or strategies developed to ensure the patient gains the full
benefi t of their treatment program.
Potential barriers to treatment need to be anticipated, assessed and discussed, with
contingencies put in place within the treatment plan to account for these. For example,
if the treatment goal is weight loss and exercise is suggested as a primary treatment strat-
egy, then the attitude of the patient towards exercise needs to be assessed. If those poten-
tial barriers are anticipated, plans can be suggested that overcome them and improve
compliance, for example by exercising with a friend rather than alone.
Also in this phase the need for ‘follow-up’ is assessed.  e patient may require further
appointments to refi ne the processes of exploring, understanding, goal setting and treat-
ment of their health issues. At this point, referrals to other practitioners for treatment
may also be necessary where it can be seen that this would be benefi cial.
Independence
e nal step in the patient-centred therapeutic process is to consolidate the patient’s
independence.  e task is to ensure the patients have the necessary self-help skills and
are prepared for the naturopath’s helping role to end. At this stage, both the naturopath
and the patient review the progress and goal achievements.  e naturopath can assist
the patient plan independent control of their health.  e patient should be encouraged
to share their thoughts on their own progress, as well as any exit issues, such as their
readiness for self-management.  e patient now can consolidate all their learning and is
ready to implement self-help skills in daily life.
STRUCTURE AND TECHNIQUE OF CASE TAKING
Basic case-taking skills take 1 or 2 years to develop and a diligent naturopath over the
years will be constantly improving and refi ning techniques.
32 It may be overwhelming
in the fi rst few cases for novice practitioners, especially if the case (or the patient!) is
complex. At times a patient may be diffi cult, angry or demanding and a practitioner
1
 Naturopathic case taking
9
needs to have insight and strategies for dealing with this (see ‘Further reading’ at the end
of this chapter, which highlights useful texts discussing these issues).
Novice practitioners may wish to begin any case, no matter how chronic or complex,
by starting with a good case history of one key ailment that bothers the patient.  is is
designated as the ‘presenting complaint’.
34 For example if the patient has fi ve health issues
to discuss, negotiate with the patient what is most important to them to work on fi rst.
The presenting complaint
Location : Ask about the nature of the problem. Get an idea of the physical, emotional,
spiritual and environmental dimensions of the problem. Note if it aff ects a certain
location of the anatomy or a physiological system. Be aware that certain conditions
have multiple locations, such as arthritis or systemic lupus erythematosus (SLE).
Onset : Ask about the factors that seemed to initiate or trigger the problem. In a holis-
tic manner, enquire as to what was occurring for the patient before and at the start of
the problems. When did the problems fi rst start?
Course : Ask whether the problem seems to be constant (there all the time with mini-
mal variation) or fl uctuating (there all the time but varies in presentation and inten-
sity) or intermittent (it stops and starts or happens occasionally).  e treatment of
headaches, for example, could be quite diff erent if they are constant or fl uctuating or
happen twice a week or twice a year.
Duration : Ask when the problem fi rst started if it has been constant or fl uctuating,
and also how long an episode of the problem endures if it is intermittent.
Sensation/quality : Ask the patient to describe in their own words how the patient
experiences their symptoms via the fi ve senses of feeling (such as ache, burn, numb,
pinch, stab, throb, hot, cold, itch, anxious, sad, dizzy, nauseous, twisting, wrenching
or tingling); sight (such as colour, consistency, texture or shape); sound (such as crepi-
tation, rattling, gasping, rumbling or buzzing), odour (such as fetid, ketosis, fi shy,
FROM NOVICE TO EXPERIENCED NATUROPATH
Novice naturopaths: tend to use learned protocols that give treatment programs
for a disease or syndrome.
Advanced beginners: soon fi nd that the ‘one-size-fi ts-all’ approach, besides
being counter to naturopathic philosophy, is problematic and begin to adapt
and vary the protocols to each patient.
Competent naturopaths: begin to develop their own independent strategies
for patients.
Professional naturopaths: develop treatments based on traditional learning,
evidenced-based practice and their intuition in selecting treatments that best
align with the patient’s individual holistic causes of ill health.
Experienced naturopaths: are immersed in an intuitive profi ciency where they
understand tradition and evidence; can listen carefully and sensitively to the
patient’s issues; adapt readily and easily to the patient’s personality; motivate
and educate the patient; are aware of the nuances in patient rapport, red fl ags
and need for referrals; and are calm, gentle and understanding in the face of
uncertainty and suffering.
Source: Adapted from Boon et al. 2006.
33
PART A NATUROPATHIC CLINICAL SKILLS
10
yeasty or sharp) and taste (such as bitter, salty, rancid, bloody or metallic). Note that
a loss of any sensation is also clinically signifi cant.
Intensity : Ask about how mild, moderate or severe the problem is. Be aware that
diff erent personalities may under-report or over-report the severity. You can get the
patient to give it a score out of 10 to make a useful comparison on follow-up visits.
Modalities : What makes it better or worse? Time of day, week, season, or year; situ-
ation, such as in bed, at work, in hot weather; or certain activities may trigger it; or
certain emotional or spiritual crises may trigger the problem.
Radiates : Does the problem shift, extend or move around one location or between
other locations?
Concomitants : When the problem occurs is there any other part of the person that
seems to be aff ected? Examples are irritability with hot fl ushes; loss of appetite with
depression; and headaches with existential crises.
Past history : In an acute case this can be a previous history of this presenting com-
plaint. It can also include a general past history of all health issues.
Family history : As above, this can be a family history of the presenting complaint as
well as a general history of all health issues in the family.
Medications : Include all medical, naturopathic, Chinese medicine and other health
modalities, including self-prescribed supplements. It often occurs that the presenting
complaint is directly linked to a side eff ect or interaction of medications.
Diet : Discuss a typical day’s diet. For a more comprehensive approach the naturopath
can give the patient a diet diary to record their diet and symptoms over a 1- or 2-week
period and review this in a follow-up appointment.
Observation of body signs and relevant physical examinations (refer to Chapter 2 on
diagnosis).
Timeline: e information gathered can also be represented in the format of a time-
line that illustrates the sequence of events.
is single issue case-taking process can take 20 45 minutes for novice practitioners
in the early days of training or practice. It is always important not to spend an overly
long time in getting the case details.  ere has to be suffi cient time also for explaining
the holistic diagnosis and naturopathic understanding of why this problem is occur-
ring; treatment goals; prognosis; remedy preparation and label instructions; doing the
account; and booking the patient for the next appointment. Bear in mind that the
patient is likely to be unwell, tired, in pain or have restless children in tow and it is a
strain on the patient to have them there for 1 or 2 hours while trying to pack too much
into the fi rst session. It is more appropriate to use the second and third appointments to
gather further information. Psychologists, for example, may spend at least the fi rst ve
to 10 sessions getting a general background and then may spend the next year or more
listening to the patient’s life narrative on a once-a-week basis.
Holistic review
As part of a holistic consultation it is essential to enquire into a broad range of factors.
is is where the consultation moves beyond the presenting complaint.
35 It encom-
passes a review of the patient’s:
past history
family history
lifestyle history
mind/emotion/spirit history, and
body systems.
1
 Naturopathic case taking
11
is can be done in any order that seems most comfortable between practitioner and
patient. A holistic assessment is made of the patient’s vitality and symptoms by explor-
ing the physical, mental, social and spiritual factors that aff ect them. A simple model
of holistic assessment is fi rst to explore the factors aff ecting the patient’s constitutional
strength, which are the physical and mental attributes they are born with.  is includes
genetics, temperament and the inherent strengths and weaknesses of diff erent physi-
ological systems. Secondly, factors that occur over time are considered.  ese include the
family and culture that the patient grew up with and the socioeconomic status and envi-
ronment that they live in.  ey also include the types of diseases or traumas the patient
has had, the diets and lifestyle they have followed and the patterns of adaptive behaviour
that they have adopted.  irdly, a holistic assessment needs to consider important, dra-
matic events that have overwhelmed an otherwise healthy person, such as severe stress,
trauma or toxicity. Fourthly, the factors that trigger disturbances to vitality such as stress,
injury, infection, toxicity, allergens and drugs need to be considered. Finally, a holistic
assessment of the factors that sustain ongoing health issues, such as psychological, social,
economic, environmental and ecological factors, is made.
36
Galland 37 cautions that care must be taken in holistic assessments. Careful listening to
the patient is required, as the range of possibilities is extensive.  e assessment needs to
be comprehensive as there can be multiple factors that reinforce each other and the prac-
titioner needs to constantly reassess the patient who has complex symptoms to avoid mis-
diagnosis.  e practitioner also needs to be fl exible as the same symptom in two diff erent
people, for example joint pain, may have diff erent triggers; conversely, the same trigger,
for example hot weather, may induce headache in one person and asthma in another.
Past history
General level of vitality and health in infancy, childhood, teens, twenties and subse-
quent decades; the eff ect on vitality of life stages such as puberty, education, relation-
ships, marriage, pregnancy, parenting, work, menopause/andropause, retiring
Immunisations, vaccinations, reactions
Allergies, intolerances
Childhood illnesses; either minor but persistent, or major, episodes requiring medical
supervision, hospitalisation, surgery, medication
Major illnesses, accidents, genetic issues, hospitalisations, disabilities
Past use of medications
Family history
Major diseases, syndromes and level of vitality that aff ect family members
Causes of mortality in family
Familial, hereditary, genetic issues
Lifestyle history
Exercise, tness, coordination, mobility, fl exibility, strength, stamina, aerobic
capacity
Recreation, entertainment, rest, holidays
Alcohol consumption, coff ee/tea consumption, smoking, recreational drug use
Daily exposure to toxins, pollutants, chemicals
Education
Work conditions (exposure to toxins; stress, injury)
Home conditions
PART A NATUROPATHIC CLINICAL SKILLS
12
Social, economic, nancial and political conditions
Health issues with class, race, religion or gender
Travel
Military service
Mind/emotion/spirit
Life satisfaction; relationships; connectedness to friends, family, colleagues, commu-
nity, society
Reactions to stress, grief, trauma; coping mechanisms; resilience, vulnerability
Moods, perceptions, sensitivities, motivation, will, intensity, personal characteristics,
attachments, obsessions
Attitudes, optimism
Mental capacities, performance, confi dence, procrastinations, decision making ability
Speech, gesture, posture, thinking, feeling, behaviour
Creativity, arts, music, dance, theatre, sculpture, hobbies, collecting
Religion, spirituality, philosophy, self-discovery, ethics, purpose of existence, world
view, meditation, revelation, prayer, metaphysics
Spiritual and cultural issues in health care
Body systems
In each of these sections, if there are relevant symptoms to discuss then follow the
format as given regarding the presenting complaint, such as location, duration, onset,
course, sensation and so forth:
general : fatigue, pallor, fever, chills, sweats; proneness to infection; allergies, intoler-
ances; weight, posture, build; age, stage of life; gender
gastrointestinal : problems with mouth, gums, tongue, oesophagus, swallowing, refl ux,
eructation, stomach pain, gastritis, ulcers, bloating, fullness, appetite, nausea, vomit-
ing, cramping, fl atulence, stool (frequency, consistency, colour, odour, blood), haem-
orrhoids, fi ssures; infections (viral, bacterial, fungal, protozoal); polyps, tumours
hepatic-biliary: jaundice, cirrhosis, gallstones, abnormal liver function tests, bile duct
infl ammation or obstruction, right shoulder or fl ank pain, ascites
respiratory : pain; diffi culty or obstruction in breathing; wheezing, shortness of breath;
cough; sputum; smoking; asthma
head/neurologic : headaches, migraines, dizziness, fainting, epilepsy, head trauma, con-
fusion, memory loss; eyes (vision, discharge, pain, redness, change in appearance of
eye such as unequal pupils, cataracts, glaucoma)
ear, nose, throat : pain, hearing problems, sense of smell, sense of taste, sinus, rhinitis,
allergens, discharges, change in voice, gums, teeth, lips, tongue, tonsils, adenoids,
mouth ulcers
cardiovascular : chest pain; palpitations, arrhythmias; oedema; dyspnoea; blood pres-
sure; cholesterol; anaemia; blood disorders; claudication; varicosities; circulation
cold hands/feet; bruising; bleeding
lymph nodes : sore, swollen, infected
endocrine : pituitary/hypothalamus; thyroid (hyper and hypo symptoms); thymus;
pancreas (pancreatitis, diabetes, hypoglycaemia); adrenal (Addison’s, fatigue, immune,
oedema); ovary/testes
female : breast pain, tender, lumps, change in appearance, galactorrhea; menses,
menarche, hormonal contraceptives, frequency, duration, volume, colour, consistency,
pain, PMT; libido, sexual function, pain, itch, discharge, infections, Pap smears,
1
 Naturopathic case taking
13
surgery, investigations, uterine, ovarian, fallopian, cervical, vaginal; polycystic ovar-
ian syndrome, endometriosis; fertility, pregnancies, births; menopause, hot fl ushes,
headaches, mood, vaginal dryness, weight gain
males : infection, discharge, lesions, sexual dysfunction (libido, erection, ejaculation),
pain, infertility, testes, prostate (benign prostate hyperplasia, prostatitis, cancer), vari-
cocele, phimosis, balanitis
genitourinary : frequency, volume, colour, odour, infections, blood, urgency, incon-
tinence, pain (fl ank, suprapubic, urethral), rigors; dribbling, hesitancy; calculi; kid-
neys, ureters, bladder, urethra; abnormal urinary test results; renal eff ects on sodium,
blood pressure, acid/base balance, fl uid retention
peripheral neurologic : weakness, abnormal sensation, numbness, coordination, loco
motor, paralysis, tremor
musculoskeletal : bone deformities, ligament, tendon, muscle, joints, discs, infl ammation,
pain, swelling, redness, hot, cold, stiff ness, crepitation, range of motion, functional loss
Skin , hair , nails : rash, itch, eruption, discharge, fl aking, erosive, pitting, peeling,
lumps, cysts, change in colour, texture, shape; hair loss, dandruff .
In chronic, complex cases with multiple symptoms and pathologies it may take two
or three sessions to get a complete and accurate history. As a novice practitioner gains
more experience, all the details of complex cases can be gained in one to two sessions.
POSOLOGY
Posology is the determination of the appropriate dosage of remedies for the patient. In
general terms if a patient has good vitality they can handle the rigour of more remedies
at higher doses and more aggressive treatment regimens of exercise and detoxifi cation
if required. For those patients with moderate vitality their treatment is modifi ed with
milder doses of tonics and supplements in an eff ort to strengthen vitality and prevent
relapses occurring. Patients with weakened vitality are best administered treatments that
off er gentle relief of symptoms and the mildest of programs to support the aff ected sys-
tems.  is is done through toning, building and adaptogenic remedies.
ese general guidelines for dosages and range of remedies are modifi ed by the pace ,
intensity , location and natural history of the illness. First, vary the treatment according
to the pace of the symptoms.  e dosage and range of remedies will vary according
to the symptoms being slow and sluggish as compared to symptoms that are rapid in
onset. Secondly, the intensity of the symptoms dictates that a higher dose is required for
symptoms of a fl orid, aggressive nature with a potential for pathological sequelae.  e
naturopath may also have to factor in that some patients are particularly stressed by the
symptoms and demand more urgent treatment programs than is necessarily required.
irdly, the location of the illness may change the posology as symptoms in the eye, for
example, are more sensitive than in the heel of the foot. Fourthly, treatments will vary
according to the natural history of an illness where dosages change between the onset,
middle and resolution of an illness.
SIGNPOSTS FOR RECOVERY
Patients always ask ‘When will I get better?’ Prognosis is the forecast of the course of a
disease. With illnesses that are familiar, such as a head cold, it is relatively predictable how
long it takes for symptoms to resolve with treatment. As a novice practitioner progresses
through their career and experiences a wider range of patients, the ability to give an
PART A NATUROPATHIC CLINICAL SKILLS
14
accurate prognosis of a variety of health problems improves. However, there are always
instances when it is very diffi cult to predict how a patient’s illness will respond to treat-
ment and over what period of time. In instances of diffi culty with predicting how long
a patient will take to recover it is better to approach the issue from another angle.  at
is, rather than trying to give the patient a defi nitive time frame of amelioration of the
illness it is better to give estimations of what signposts or stages the patient is expected
to experience and leave the issue of duration open-ended.  is prevents the frustration a
patient may experience when told they should be better by a certain date but they are not.
e rst signpost for recovery is that the condition has stabilised and is no longer dete-
riorating. Secondly, the intensity of symptoms begins reducing.  irdly, the symptoms
are no longer constant. Fourthly, the symptoms no longer fl uctuate. Fifthly, there are
longer periods of intermittence and, if they do return, the symptoms are milder and of
shorter duration. And fi nally there is remission or cure.  e patient is asked to watch for
these stages as signs of improvement. Discuss with the patient the fact that it is often too
diffi cult to give an exact time estimation as to how long each stage of recovery will take.
To assist in prognostic skills the following practice tips will be useful. For a known
disease or syndrome there is excellent information in pathology texts and medical jour-
nals that indicates the natural history of a disease that is, how a disease behaves and
over what period of time. Secondly, check the naturopathic information from academic
notes, texts, journals and seminars on the action of naturopathic remedies and how long
these remedies take to reduce symptoms. Also enquire further from senior naturopathic
colleagues, mentors and academic staff who can give information of how this disease
normally behaves and how it responds to the proposed treatments.  irdly, having estab-
lished a good knowledge of how the disease behaves and the effi cacy of the treatments,
make an assessment of the patient’s capabilities and compliance with following the treat-
ment plan.  is is where a holistic understanding of the patient’s vitality, preferences for
modalities and personal circumstances will help in judging when the patient will improve.
CASE TAKING THE RETURN VISIT
Novice practitioners can sometimes feel confusion as to what they are supposed to say or
do in the return visit. For ‘follow-up’ of acute, minor cases, use the guidelines below. For
‘follow-up’ of complex, chronic cases see the following section, ‘Case taking advanced’.
At the end of the fi rst session
e return visit is made easier for novice practitioners if they get into the habit of mak-
ing notes at the end of the initial visit as a reminder of what needs to be done at the
next session. At the end of the fi rst visit history form, make a box with the heading
Follow-up’. In this box write down any items the practitioner promised the patient to
look into. Also in this box write down the patient’s symptoms to review in follow-up;
for example, check temperature, mucus (colour, consistency), sneezing and fatigue to
compare with the fi rst session to gauge treatment response. Also write in this box any
other issues that the practitioner or the patient wanted to explore for the second session
but did not get time for in the fi rst session.
What to do in the second session
Before the patient arrives the practitioner needs to re-familiarise themselves with the
patient’s case.  is can include the patient’s personal and social anecdotes of things that
they were going to be doing during the week, such as family functions, outings with
1
 Naturopathic case taking
15
friends, work issues or relationship issues. To quickly re-establish rapport the practitio-
ner can remind themselves of how the patient was feeling in the fi rst session.
An important feature of the follow-up session is to review the patient’s symptoms.
is enables the practitioner to make comparisons of the patient’s progress and to gauge
the eff ectiveness of the treatment program. Make new notes on what changes have
occurred in signs and symptoms since the previous visit. It may be necessary to repeat
any physical examinations that were done in the fi rst session, such as vitals.  e practi-
tioner needs to enquire how the patient managed with the remedies and lifestyle advice
and check whether the patient was taking the remedies in the manner prescribed.
If acute symptoms have resolved, then reiterate to the patient holistic, preventive
measures to maintain good health and to avoid the symptoms reoccurring. If acute
symptoms have not resolved, then explore the reasons for this. Confi rm that the original
diagnosis and naturopathic understanding were correct.  is may require referrals to
other health professionals for further diagnostic assessment and testing. Check anteced-
ents, triggers and mediators as discussed earlier. For example, the patient may still be
under the same stresses at work, or their diet may need further support. Check materia
medica selection and posology and that the patient knows how to take the remedies
properly; check patient compliance or any diffi culties with taking the remedies, manag-
ing the diet or following exercise programs. Check information on the expected prog-
nosis and natural history of the condition.  at is, how long does a particular condition
normally take to clear up? For example, some sinus conditions take a few weeks to heal
and there may be little change in the fi rst week. Often the reason for lack of improve-
ment is obvious and it is easy to make adjustments to the treatment program or support
the patient with ways to achieve their health goals. At other times, there are cases that,
even with the best intentions of the practitioner and the patient, are not responding very
well. It is appropriate here to seek the patient’s permission to discuss their case with col-
leagues or a mentor with experience in similar cases. It can happen that the practitioner
needs to refer the patient to another modality that might have more success with that
particular condition. For example with persistent back pain the patient can be referred
to remedial massage, chiropractic, physiotherapy or osteopathy.
e second visit also allows the opportunity to discuss if there are any other diff erent
issues or symptoms not mentioned in the fi rst visit. First, ask the patient if there are
other concerns they have that they wish to talk about.  is needs to be done every ses-
sion. It may take some patients many repeated sessions to gain the trust to discuss sensi-
tive issues like a past history of bulimia, sexual abuse or a worrisome ailment they feel
embarrassed about.  e practitioner can also initiate discussion on any issues that are
apparent, for example if the patient looks pale or jaundiced or their thyroid looks swol-
len, or has signs of body systems under stress that were not part of the initial discussions.
e second session allows completion of any further history that may have not been
obtained in the fi rst session or going into issues in more depth if that seems appropriate.
At the end of the second session the practitioner always has to remember to draw up a
‘Follow-up’ box on the end of the history forms so they know what needs to be done in
the third session.  is needs to be done for every subsequent session.
CASE TAKING ADVANCED
Getting the details of chronic complex cases requires careful attention. As previously
stated getting these details could take a number of sessions for novice practitioners.  e
written data obtained need to be accurate, comprehensive and easily recoverable.  e
PART A NATUROPATHIC CLINICAL SKILLS
16
practitioner should be able to quickly fi nd any data on any question from any session
because all the data are put into specifi c locations in the history form.
e case history requires the patient’s words verbatim if possible. However, this does
not mean that every word is written in the order that the patient has said it. Patients
tend to talk by random association where one thing reminds them of something else
and will jump from topic to topic and back again.  e skill is allowing this to occur to
obtain rich information but also to do three other things simultaneously.  e rst is
to write or type fl uently key words or phrases while maintaining eye contact and rap-
port.  e second is to write in such a way that the practitioner does not end up with
line after line of the patient’s words on a blank sheet in a disorganised fashion. After
six or seven sessions there will be 10 or 20 pages of notes and it is very embarrassing
when it takes 5 minutes to check some detail the patient has asked about! Instead,
the history forms should have predefi ned sections where the patient’s verbatim data
can go. If the answers and details about, say, body systems are put in predefi ned sec-
tions on the history form under the heading ‘Body systems’, the information can be
located in a matter of seconds. For example, information on coughing goes under
‘Respiratory’; information on depression goes under ‘Mind’. In later sessions when
the practitioner wants to compare coughs or depressive symptoms the information
is easy to fi nd. Also, by following a format for history taking the practitioner can see
the gaps in the history form.  is then is a reminder to get the relevant information
for those sections that have been missed. For example there may be a blank space on
the history form under ‘Circulation’ and this will prompt the practitioner to complete
this part of the history.
irdly, the art of patient interviews is to gauge when to gently direct or turn
the patient’s conversation towards information that the practitioner wishes to gain.
If the practitioner is too directive the patient will learn only to briefl y answer in a
perfunctory way and to wait for the next question.  is static style is quite mechani-
cal and only emphasises to the patient that the practitioner’s questions are more
important than the patient’s needs.  is could stifl e much rich information about
the patient’s personal thoughts, symptoms and motivations that can be discovered
by a spontaneous, free-fl owing conversation. On the other hand, if the practitioner
is too non-directive the patient may digress into sessions of repetitive minutiae on
one symptom; or random generalisations that do not articulate context or specifi c-
ity; or the conversation is extended into blander areas to avoid enquiry into sensitive
issues.
Complex cases: an example of how to summarise
complex data
Case Study
‘John’ is an 84-year-old male. He is a very friendly and cheerful fellow of slim build
and, considering the range of health issues he has, he is mobile and independent
and pursues hobbies in music and literature. He has health issues with diabetes,
asthma, insomnia, stress, headaches, elevated cholesterol, palpitations, skin rash, sci-
atica, sinusitis, depression, refl ux and diarrhoea. Other issues can come and go, and
these are recorded in a similar fashion, as in the box below, by adding more bot-
tom rows. All symptoms are chronic, some are constant, some fl uctuate and some are
intermittent.
1
 Naturopathic case taking
17
After taking a couple of sessions to get full details of his complete case history the
practitioner’s subsequent sessions now involve tracking and reviewing his symptoms
and response to treatment.  is can be done on a simple spreadsheet by asking specifi c
questions in each category and recording it in a summary table (such as Table 1.2 ). Every
month the practitioner checks these symptoms and adds or subtracts other symptoms
that come and go.
is simple method keeps track of the patient’s 12 or more symptoms and patholo-
gies. Within each session the treatment program can be reviewed and adjusted to address
the patient’s changing circumstances. If clarifi cation or comparison of the past history of
the patient’s symptoms is required it can be readily accessed in the written history form
in good detail. Discussion can then be directed to what symptoms bother the patient
the most and to jointly decide whether or not to treat particular symptoms, given that
the patient is already on multiple medications.  us the patient’s wishes and values
are respected and the patient feels secure in the knowledge that all his issues are being
addressed in a holistic way.
Further reading
e following texts provide more specifi c strategies to enhance communication skills and counselling skills
to add to your consulting skills as outlined in this chapter.
Active listening. Australian Family Physician, 2005. Online. Available: http: // www . racgp . org . au / afp /
200512 / 200512robinson . pdf
Cava R . Dealing with diffi cult people . Sydney : Pan Macmillan , 2000 .
Egan G . e skilled helper: a problem management approach to healing . 6th edn. Pacifi c Grove : Brooks
Cole Publishing , 1998 .
Table 1.2 Case history summary table
SYMPTOMS FEBRUARY MARCH APRIL
Diabetes Stable (6 7 on rising) Same
Asthma Stable (same) Same
Insomnia > 8/10; herbs good > 9/10
Stress > 8/10; herbs good Same
Headache > 4/10; occurs 2/7 mild > 8/10
Cholesterol No data this month Total 5.8; LDL 2.6; Tryg 2.6
Palpitation > 8/10 for magnesium Same
Skin rash > 4/10 shrunk 1 cm < 2/10; increased 2 cm; hot weather
Sinusitis > generally; but worse in last 2 days Clear
Depression > 8/10 with herbs All good
Refl ux Same still occurs after meals Same
Diarrhoea Variable no incontinence this month Same
Note : > means ‘better’. Improvement or deterioration is given a score out of 10. For example > 8/10
means that symptoms have improved and are now 80% of normal.
PART A NATUROPATHIC CLINICAL SKILLS
18
Geldard D , Geldard K . Basic personal counselling: a training manual for counsellors . 5th edn. Frenchs
Forest : Pearson Prentice Hall , 2005 .
Interpersonal counselling in general practice. Australian Family Physician, 2004. Online. Available: http: //
www . racgp . org . au / afp / 200405 / 20040510judd . pdf
Ivey A E , Ivey M B . Intentional interviewing and counselling: facilitating client development in a
multicultural society . Pacifi c Grove : omson Brooks Cole , 2003 .
Murtagh J E . General practice . 3rd edn. North Ryde : McGraw-Hill Australia , 2006 . Chapter 4
Communication skills. Chapter 5 Counselling skills. Chapter 6 Diffi cult, demanding and trying patients .
Navigating through the swampy lowlands. Dealing with the patient when the diagnosis is unclear.
Australian Family Physician, 2006. Online. Available: http: // www . racgp . org . au / afp / 200612 / 20061205
stone . pdf
Nelson-Jones R . Human relating skills . 3rd edn. Marrickville : Harcourt Brace , 1996 .
Surviving the ‘heartsink’ experience. Family Practice, 1995. Online. Available: http: // fampra . oxfordjournals .
org / cgi / content / abstract / 12 / 2 / 176
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216
12
Clinical depression
Jerome Sarris
ND, MHSc, PhD
CLASSIFICATION, EPIDEMIOLOGY AND AETIOLOGY
Depression is associated with normal emotions of sadness and loss, and can be seen as
part of the natural adaptive response to life’s stressors. True ‘clinical depression’, however,
is a disproportionate ongoing state of sadness, or absence of pleasure, that persists after
the exogenous stressors have abated. Clinical depression is commonly characterised by
either a low mood, or a loss of pleasure, in combination with changes in, for example,
appetite, sleep and energy, and is often accompanied by feelings of guilt or worthless-
ness or suicidal thoughts.
1 e Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) classifi es ‘Major Depressive Disorder’ (MDD) as a clinical depressive episode
that lasts longer than 2 weeks, and is uncomplicated by recent grief, substance abuse or
a medical condition.
2 Depression presents a signifi cant socioeconomic burden, with
the condition being projected by the year 2020 to eff ect the second greatest increase in
morbidity after cardiovascular disease.
3 e lifetime prevalence of depressive disorders
varies depending on the country, age, sex and socioeconomic group, and approximates
about one in six people.
4,5 e 12-month prevalence of MDD is approximately 5 8%,
with women approximately twice as likely as men to experience an episode.
4,5
e pathophysiology of MDD is complex, and to date no unifi ed theory explaining
the biological cause exists.
1 e main premise concerning the biopathophysiology of
MDD centres on monoamine impairment, involving:
6 – 10
dysfunction in monoamine expression and receptor activity, or a lowering of mono-
amine production
secondary messenger system malfunction, for example G proteins or cyclic AMP
neuroendocrinological abnormality concerning hyperactivity of the hypothalamic –
pituitary adrenal axis (HPA axis), which increases serum cortisol and thereby
subsequently reduces brain-derived neurotropic factor (BDNF) and neurogenesis
impaired endogenous opioid function
changes in GABAergic and/or glutamatergic transmission, and cytokine or steroidal
alterations
abnormal circadian rhythm.
From a holistic perspective, the biological causes of depression are unique to the
individual, and can be viewed biochemically as varying impairment of monoamine
12
 □  Clinical depression
217
activity, homocysteine, cortisol and BDNF, and infl ammatory interactions. Psycho-
logically, cognitive and behavioural causes (or manifestations) of MDD are also com-
monly present in variations of negative or erroneous thought patterns, or schemas,
impaired self-mastery, challenged social roles, and depressogenic behaviours or lifestyle
choices. 11 – 13
Several biological and psychological models theorising the causes of depression have
been proposed (reviewed below).  e predominant biological model of depression in
the last 60 years is the monoamine hypothesis.
14 Other key biological theories involve
the homocysteine hypothesis,
15 and the infl ammatory cytokine depression theory.
8
A prominent psychological model is the stress-diathesis model, which promulgates the
theory that a combination of vulnerabilities (genetic, parenting, health status and cog-
nitions) are exploited by a life stressor, for example relationship break-up, job loss and
family death.
13,16 ese stressful events may trigger a depressive disorder. Some scholars
have advanced the theory of a biopsychosocial model, which aims to understand depres-
sion in terms of a dynamic interrelation between the biological, psychological and social
causes (discussed later).
12
RISK FACTORS
Various factors that increase the risk of MDD exist, and such an episode may in
turn cause certain health disorders/issues. Genetic vulnerability may play an
important part in the development of MDD. Genetic studies have revealed that
polymorphisms relevant to monoaminergic neurotransmission exist in some people
who experience MDD.
19 Recent hypotheses suggest that genes related to neuro-
protective/toxic/trophic processes, and to the overactivation of the hypothalamic
pituitary axis may be involved in the pathogenesis of MDD.
19 Early life events or
proximal stressful events increase the risk of an episode.
20 Twin studies provide
evidence of the eff ect of environmental stressors on depression and many studies have
revealed that a range of stressful events are involved, aff ecting remission and relapse
of the disorder. Recurrence of depressive episodes and early age at onset present with
the greatest familial risk.
21 Current evidence suggests that the primary risk factors
involved in MDD are a complex interplay of genetics and exposure to depressogenic
life events.
THE FOUR HUMORS
A traditional view of depression terms the condition ‘melancholia’. This is
based on the humoral model, which depicts four ‘humors’ (choleric, sanguine,
phlegmatic and melancholic).
17
Depression falls under the auspices of the melancholic humor, being embodied
as ‘black bile’.
The liver from an energetic perspective in traditional Western folkloric
medicine and from traditional Chinese medicine is considered to be the organ
primarily involved with depression, and is seen to regulate emotions.
17,18
Western medicine views the liver purely from a biomedical perspective, and
research has not yet been conducted to examine any correlation between liver
function/health and depression.
PART B COMMON CLINICAL CONDITIONS
218
A consistent theme revealed by epidemiological data is that females have higher
rates of MDD than men, approximating two times higher in some community sam-
ples. 4 This is associated with a higher risk of first onset, and not due to differential
persistence or recurrence. It appears that hormonal factors are not responsible (for
example, oestrogen levels, pregnancy or the use of oral contraceptives). Biological
vulnerabilities and environmental psychosocial factors appear to be responsible for
the increased incidence of depression among women. Initial psychosocial triggers
may occur in early teen years upon the onset of puberty, whereby gender differ-
ence markedly presents. As Kessler states,
23 it is conceivable that MDD presents
more commonly in females due to social and psychological influences, such as
sex-role differences and an intrinsic propensity to ruminate. Another method-
ological possibility is that mens depression may present with irritability rather
than anhedonia, and as depression scales place less weight on irritability this may
skew the results.
Practitioners should be aware of the existence of conditions that commonly co-
occur with MDD. People who are clinically depressed have a far greater risk of having
co-occurring generalised anxiety, sleep disorders and substance abuse or depen-
dency. 23 It should be noted that these conditions may cause MDD and may also
result from MDD. Depression is also often misdiagnosed as ‘unipolar’ when in fact
it is the presentation of the depressive phase of ‘bipolar’ depression.
24 Appropriate
screening needs to occur in patients presenting with depression. Initial question-
ing should assess the length and frequency of previous and current episodes, the
severity, what triggers an episode, and whether they think about death regularly or
have felt so low lately that they have considered suicide. Assessment should also
include a drug and alcohol screen in addition to reviewing their sleep pattern and
level of anxiety and stress. To assess any bipolarity of the depression, it is important
to determine whether they have ever experienced several days or more of feeling very
happy or ‘high’ in addition to behavioural changes such as a decreased need for sleep,
rapidity of cognition or ideas, and any increases in planning, spending money or
sexual drive (the bipolar spectrum discussed further below).
24 Appropriate referral
in the case of suspected alcohol/substance abuse or dependency or bipolar disorder
is recommended, as complementary or alternative medicine (CAM) currently lacks
evidence as a primary intervention in these areas (although CAM may be adjuvantly
benefi cial).
DEPRESSION: AT-RISK GROUPS
4,5,22
Females
Younger people
Previously married or unmarried people (especially for men)
Unemployed or under fi nancial pressure
People with disabilities
Possibly those living in large urban areas
Major health conditions (especially cardiovascular disease)
Obesity/metabolic disorders
Chronic insomnia
Alcohol/drug abuse or dependency
12
 □  Clinical depression
219
CONVENTIONAL TREATMENT
Current medical treatment strategies for MDD primarily involves synthetic antide-
pressants (for example, tricyclics, monoamine oxidase inhibitors or selective serotonin
reuptake inhibitors), and psychological interventions (for example, cognitive behavioural
therapy (CBT), interpersonal therapy (IPT) and behavioural therapy (BT)).
1,25 Medi-
cal treatment guidelines usually involve options such as providing counselling, CBT
or IPT for mild depression, antidepressants and/or CBT for moderate depression,
and antidepressants and ECT (and possibly hospitalisation) for severe depression.
26,27
As only 30 40% of people achieve a satisfactory response to fi rst-line antidepres-
sant prescription, and approximately 40% do not achieve remission after several anti-
depressant prescriptions, further pharmacotherapeutic developments are currently
being pursued. 14,28 Future novel antidepressant mechanisms of action may involve
modulating cytokines, secondary messengers, and glucocorticoid, opioid, dopaminer-
gic or melatoninergic pathways.
9
KEY TREATMENT PROTOCOLS
From a clinical perspective, the goal of
treating MDD is to ameliorate the depres-
sion as safely and quickly as possible. Sui-
cide is a great concern, and is a devastating
potential consequence of MDD. If suicidal
ideation is signifi cant, or if self-harm is a
distinct possibility at any stage, referral to
a medical practitioner or to an emergency
ward of hospital for immediate psychiat-
ric assessment is crucial.  e socioeconomic cost of untreated MDD is massive, and
treated depression reduces the burden on health-care systems.
29 Evidence advocates
early intervention to eff ectively treat MDD, to enhance remission, and thereby subse-
quently decrease human suff ering and socioeconomic burden.
29
Although medical research has not currently advanced to the state of tailoring
pharmacotherapy prescriptions to individual neurochemical or genetic profi les,
‘whole-system’ naturopathic diagnosis and treatment has an advantage in being
able to prescribe in an individualised manner. First, in order to treat depression
eff ectively, it helps to understand the psychological and biological factors that are
NATUROPATHIC TREATMENT AIMS
Reduce depression and improve mood.
Improve energy level.
Promote positive balanced cognition.
Encourage benefi cial lifestyle changes.
Educate about depressogenic factors and
create a plan to combat them.
SUICIDE
Screen for presence of a clearly articulated plan to suicide, any preparations
being made, and any past serious attempts.
If patient is suicidal, refer immediately to an emergency department of a hospi-
tal for psychiatric assessment.
Extreme caution should be observed for patients who in light of a recent
suicidal disposition suddenly appear happy with no clear reason (they may
be at peace with their decision to suicide).
Initial antidepressant use may increase risk of suicide. Be especially aware of
antidepressant use in adolescents.
PART B COMMON CLINICAL CONDITIONS
220
involved. Causes of depression are multifaceted, and individual presentations vary
markedly. Because of this, tailoring the prescription for the individual may assist in
compliance and recovery. Causative factors can be classifi ed into pre-existing ‘vul-
nerabilities’ to depression, which may be ‘triggered’ by a stressor (commonly a series
of stressors or one key event), then ‘maintaining’ factors may exacerbate or prolong
the episode.
Several herbal medicines are particularly adept at aff ecting neuroreceptor binding
and activity to achieve an antidepressant eff ect. Herbal medicines used to treat mental
health disorders usually have central nervous system or endocrine-modulating activity.
6
Common actions can involve monoamine activity modulation, stimulation or sedation
of central nervous system activity, and regulation or support of healthy hypothalamic
pituitary adrenal axis function (see Table 12.1 ). 30
Biopsychosocial model of depression
e most suitable model consistent with the holistic paradigm is a biopsychosocial
model. 12 e essence of the model is that the cause of depression is multifactorial,
with many interrelated infl uences involved in its growth. Genetics and biochem-
istry (biological), cognitions and personality traits (psychological), environmental
factors (environmental) and social interactions (sociological) all aff ect the level of
a persons ‘vulnerability’ to a depressive disorder, which is commonly triggered by
chronic or acute stressors. Protective factors are considered to be good genetics, bal-
anced positive cognitions, healthy interpersonal relations and social support, and
spirituality. 11,31
A balanced and integrative naturopathic treatment plan needs to address all aspects
concerning the biopsychosocial model. Herbal, nutraceutical and dietary prescription
can modulate the biological component of depression; psychological therapies and
counselling support is advised to reconfi gure negative cognitions, resolve underlying
issues, and build resilience; and social concerns (for example, healthy work, lifestyle,
exercise, rest balance, and suffi cient family/friend/community interaction) should also
be addressed. Depression may provide a context for developing meaning from the
experience, thereby promoting spiritual growth. Displayed below is a model developed
Table 12.1 Nervous system herbal medicine actions
30
TRADITIONAL ACTION PROPOSED MECHANISMS APPLICATIONS
Nervines (tonics, stimulants) HPA-modulation, beta-
adrenergic activity Depression, fatigue,
convalescence
Adaptogens, thymoleptics,
antidepressants, tonics Monoamine interactions
HPA-modulation Depression, fatigue,
convalescence
Anxiolytics, hypnotics, sedatives GABA or adenosine-receptor
binding or modulation Anxiety disorders, insomnia
Antispasmodics, analgesics Calcium/sodium channel
modulation
Substance P or enkephalin
effects
Muscular tension
(dysmenorrhoea, irritable
bowel syndrome, headaches),
visceral spasm, pain
Cognitive enhancers Cholinergic activity
Acetylcholine esterase
inhibition
Cognitive decline, dementia
12
 □  Clinical depression
221
by the author for treating depression: the ALPS model (see Figure 12.1 ).  is treatment
model is based on the biopsychosocial model, outlining specifi c strategies for treating
depression holistically.  e model advocates a combined approach of antidepressant
agents (natural or synthetic); lifestyle adjustments such as dietary improvement, and
reduction of alcohol and caff eine, and increased relaxation and exercise; psychological
interventions; and improved social functioning and integration.
Monoamine hypothesis
e monoamine hypothesis concerns the theory that depression is primarily caused by
dysregulation of serotonin, dopamine and noradrenaline pathways (receptor activity and
density, neurotransmitter production and neurochemical transport and transmission).
9
Herbal and nutritional/dietary modulation may be helpful in modulating monoami-
nergic transmission. To date, the phytotherapy with the most evidence of monoamine
modulation is Hypericum perforatum . Enough human clinical trials have been con-
ducted for several meta-analyses to be conducted (see Table 12.2). All meta-analyses
have revealed that H. perforatum provides a signifi cant antidepressant eff ect compared
to placebo, and an equivalent effi cacy compared to synthetic antidepressants. H. perfo-
ratum has demonstrated several benefi cial eff ects on modulating monoamine transmis-
sion. Although initial in vitro experiments suggested monoamine oxidase-inhibition
by H. perforatum , further conducted experiments have not confi rmed this activity.
32
In vivo and in vitro studies have, however, revealed non-selective inhibition of the neu-
ronal reuptake of serotonin, dopamine and norepinephrine.
33 is activity is likely to
occur in part via modulation of neurotransmitter transport systems (for example, via
Na
+ gradient membranes). Increased dopaminergic activity in the prefrontal cortex has
been documented.
34 A decreased degradation of neurochemicals and a sensitisation of
and increased binding to various receptors (for example, GABA, glutamate and adenos-
ine) have also been observed.
35 – 37 It should be noted that some of the pharmacody-
namic studies used intraponeal rather than oral administration; caution in extrapolating
to humans is advised.
Antidepressants
(Natural or
synthetic)
Lifestyle
(Diet, exercise)
Psychology
(CBT, IPT,
counselling)
Social
(Network support,
friends, family)
Figure 12.1 The ALPS model
PART B COMMON CLINICAL CONDITIONS
222
Aside from H. perforatum, Rhodiola rosea and Crocus sativus currently possess
the most evidence as monoamine and neuroendocrine modulators, and have provided
preliminary human clinical evidence of effi cacy in treating MDD.
38,39 R. rosea is a stim-
ulating adaptogen, which possesses antidepressant, anti-fatigue and tonic activity.
39,40 A
6-week, phase III, three-arm randomised controlled trial (RCT) involving 91 subjects
comparing R. rosea SHR-5 standardised extract (680 mg and 340 mg/day) with placebo
demonstrated signifi cant dose-dependent improvement on depression.
41 It should be
noted that the eff ect size was small, with a low response in comparison to a very low pla-
cebo response (usually there is a 20 50% reduction of depression in a placebo group);
further studies need to be conducted to confi rm effi cacy.  e phytochemicals salidro-
side, rosvarin, rosarin, rosin and tyrosol are considered to be the active constituents.
42 I n
animal models, R. rosea has been documented to increase noradrenaline, dopamine and
serotonin in the brainstem and hypothalamus, and to increase the blood brain perme-
ability to neurotransmitter precursors.
43 Crocus sativus is developing clinical evidence as
an eff ective antidepressant (reviewed later). Crocin and safranal are currently regarded
as the constituents responsible for C. sativus ’s antidepressant action.
38 e mechanisms
responsible for the antidepressant actions are purported to be mediated via reuptake
inhibition of dopamine, norepinephrine and serotonin, and NMDA receptor antag-
onism.
38 Safranal is posited to exert selective GABA- α agonism, and possible opioid
receptor modulation, as demonstrated via intracerebroventricular administration in an
animal model.
44
Other herbal medicines that have been documented to exert monoamine modula-
tion include Bacopa monnieri , Ginkgo biloba , Panax ginseng and Convolvulus pluricaulis ;
however, to date insuffi cient clinical trials have confi rmed antidepressant eff ects in
humans.
45,46
HPA-axis modulation
In the last two decades, cortisol has achieved increased attention in the study of the
pathogenesis of depression. Substantial evidence exists for the role of cortisol and
the HPA axis in depression.
47 Postmortem studies and cerebral spinal fl uid sampling
have found that corticotrophin-releasing hormone (CRF) can be elevated in samples
from depressed patients.
48 A combination of vulnerability factors (genetic, age and early
life events) and precipitating factors (psychological, physiological stressors, substance
misuse and comorbid disease) may provoke an increase in CRF.  is stimulates the secre-
tion of adrenocorticotropin hormone (ACTH), and subsequent cortisol release from the
adrenal glands (see Section 5 on the endocrine system). In vitro and animal models have
demonstrated that HPA-axis dysfunction and increased cortisol attenuate the produc-
tion of BDNF in the brain.
9 BDNF is an important growth factor that nourishes nerve
cells, and lower BDNF is correlated with depressive states.
1,19 Synthetic antidepressants
and electroconvulsive therapy appear to regulate the HPA axis and increase the pro-
duction of BDNF.
47 In animal models, hypericin and the fl avonoid derivatives have
demonstrated to down-regulate plasma ACTH and corticosterone levels.
31 In particular,
an animal model demonstrated that 8 weeks of H. perforatum or hypericin administra-
tion decreased the expression of genes involved in the regulation of the HPA axis, and
signifi cantly decreased levels of CRH mRNA by 16 22% in the hypothalamic para-
ventricular nucleus (PVN) and serotonin 5-HT(1A) receptor mRNA by 11 17% in
the hippocampus. Human studies have, however, found that H. perforatum increases
salivary and serum cortisol levels.
49,50 Importantly, while in vivo studies have shown that
synthetic antidepressants can increase BDNF, H. perforatum does not prevent a decrease
12
 □  Clinical depression
223
in stress-reduced BDNF.
51 It should be noted that while evidence does suggest that HPA
modulation does occur with H. perforatum administration, the complex pharmaco-
dynamics of the eff ect has not been fully elucidated to date, with variables such as dif-
fering human or animal models, stress study methodology and types of H. perforatum
extracts obfuscating the conclusion.
Herbal adaptogens and tonics may play a benefi cial role in modulating ACTH (refer
further to Section 5 on the endocrine system). Stimulating adaptogens such as Eleuthero-
coccus senticosus , Schisandra chinensis and Rhodiola rosea have demonstrated signifi cant
adaptogenic eff ects, posited as occurring from HPTA modulation.
42 Although E. sen-
ticosus, S. chinensis and other adaptogens such as Panax ginseng and Withania somnifera
have not demonstrated specifi c antidepressant activity, they may provide a supportive
role in depressive presentations with HPA-axis dysregulation.
Homocysteine hypothesis
e homocysteine hypothesis centres on the theory that genetic and environmental
factors elevate levels of homocysteine, which in turn provokes changes in neuronal
architecture and neurotransmission, resulting in depression.
15,52 e sulfur compound
homocysteine (formed from methionine) has been demonstrated to be directly toxic to
neurons, and can induce DNA strand breakage. Higher serum levels of homocysteine
have been noted in depressive populations compared to healthy controls.
52 Metab-
olism of homocysteine to S-adenosyl methionine (SAMe) or back to methionine
requires folate , B6 and B12 . Folate is involved with the methylation pathways in the
‘one-carbon’ cycle, and is responsible for the metabolism and synthesis of various
monoamines. 52 Folate is also most notably involved with the synthesis of SAMe, an
endogenous antidepressant formed from homocysteine. Folate defi ciency is implicated
in causing increased homocysteine levels, and has been consistently demonstrated in
depressive populations and in poor responders to antidepressants.
53,54 Folate defi ciency
has been reported in approximately one-third of people suff ering from depressive dis-
orders. 54 Finally, a correlation has been discovered between methylenetetrahydrofolate
reductase (a folate-metabolising enzyme) polymorphisms and depression, indicating a
genetic link.
55
Several studies exist assessing the antidepressant eff ect of folic acid in humans with
concomitant antidepressant use.
1,56,57 All of these studies yielded positive results with
regard to enhancing antidepressant response rates or increasing the onset of response.
An example of folic acid’s antidepressant activity is refl ected in a controlled study using
500 μ g of folic acid or placebo adjuvantly with 20 mg fl uoxetine in 127 subjects with a
Hamilton Depression Rating Scale (HDRS) of 20. 57,58 e study demonstrated a sta-
tistically signifi cant reduction after 10 weeks on the HDRS for women.  is eff ect was
not, however, replicated in the male sample. Along with a good dietary intake of folate-
rich leafy vegetables or folic acid supplementation, a multivitamin high in B vitamins
(especially B6 and B12) may assist in reducing homocysteine, and maintaining ade-
quate levels of SAMe.  is will also assist in maintenance of energy production, adrenal
function and the creation of neurotransmitters.
Infl ammatory factors causing depression
A cytokine-mediated pro-infl ammatory event has been considered as a factor involved
with the pathophysiology of MDD.
8 Studies have demonstrated that otherwise healthy
patients with depression have presented with activated infl ammatory pathways.
59 I t
has been posited that pro-infl ammatory cytokines produced from infl ammation may
PART B COMMON CLINICAL CONDITIONS
224
infl uence neuroendocrine function via entry through the ‘leaky regions’ of the brain (for
example, the circumventricular organs), and subsequent modulation of cytokine spe-
cifi c transport molecules, or cytokine stimulation of vagal aff erent fi bres.
8 Modulation
of both CRT and neurotransmitters is known to be eff ected by cytokines.  e main
pro- infl ammatory cytokines implicated in depressogenesis centres on IFN- α producing
IL-1 β , IL-6 and TNF- α cytokines (see Chapter 28 on autoimmunity). In laboratory
studies, animals exposed to a variety of stressors have demonstrated an increase in these
pro-infl ammatory cytokines. Synthetic antidepressants have been shown to inhibit the
production of various infl ammatory cytokines, and to stimulate the production of anti-
infl ammatory cytokines.
8 Although in its infancy, nascent research is evolving towards
developing synthetic medicines that modulate cytokines with a regard to ameliorating
depression. 9
Attenuation of pro-infl ammatory cytokines may be of benefi t in individuals who
present with either a preceding or comorbid infl ammatory condition, or a chronic latent
infection. Appropriate screening to determine any infections, or infl ammatory process,
with reference to the chronology of the onset of depression is advised. If an association
is plausible, herbal medicines and nutrients that dampen the infl ammatory cascade and
attenuate the production of pro-infl ammatory cytokines may be advised (see Section 2
on the respiratory system and and Section 1 on the gastrointestinal system). In brief,
herbal and nutritional medicines that may potentially benefi t the treatment of pro-
infl ammatory evoked MDD include Albizzia spp., Echinacea spp. , vitamin C and
biofl avonoids , and zinc . Albizzia spp. (in particular A. lebbeck ) have been documented
to exert anti-infl ammatory and antiallergic activity.
60 In addition to this activity, anx-
iolytic and antidepressant eff ects have been demonstrated in animal models, and in the
case of Albizzia julibrissan , the plant curiously is known as ‘happy bark’ in traditional
Chinese medicine.
61 – 63
Aside from the previously mentioned herbal and nutritional medicines, omega-3
fatty acids also have a role in reducing infl ammation-based MDD.
59 Epidemiological
studies have demonstrated that a rise in depressive symptoms may be correlated with
lower dietary omega-3 fi sh oil (eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA)).
64 – 67 Studies have also demonstrated that people with depression have a ten-
dency towards a higher ratio of serum arachidonic acid to essential fatty acids, and an
overall lower serum level of omega-3 compared to healthy controls.
59,68– 70 Urbanised
Western cultures tend to have a far higher ratio of dietary omega-6 oils compared to
omega-3 oils, and this has been regarded as a possible factor in the rise of depression over
the last several decades.
64,67 e pathophysiology occurring from a pro-omega-6 diet may
involve an increased promotion of infl ammatory eicosanoids, a lessening of BDNF and
a decrease in neuronal cell membrane fl uidity and communication.
67,71 Evidence cur-
rently suggests that omega-3 fatty acids exert antidepressant activity via benefi cial eff ects
on neurotransmission.
72 is may occur via modulation of neurotransmitter (norepi-
nephrine, dopamine and serotonin) reuptake, degradation, synthesis and receptor bind-
ing. 73,74 Animal models have demonstrated that omega-3 fatty acids increase serotonin
and dopamine concentrations in the frontal cortex, and that a diet defi cient in the nutri-
ent decreases catecholamine synthesis.
73,75,76 A recent human clinical trial demonstrated
a signifi cant increase in plasma concentrations of norepinephrine in healthy humans.
74
Several human clinical trials have been conducted assessing the effi cacy of EPA, DHA
or a combination of both of these essential fatty acids.
77 Clinical evidence regarding the
use of essential fatty acids as a monotherapy is equivocal, with a mixture of positive and
negative trials (see Table 12.2 at the end of the chapter for a review of the evidence).
12
 □  Clinical depression
225
ADDITIONAL THERAPEUTIC OPTIONS
S-adenosyl methionine (SAMe)
It is an endogenous compound produced from methionine and various
methylators (e.g. B6, B12 and folate) in the body.
80
It serves as a necessary methyl donor of methyl groups involved with the
metabolism and synthesis of neurotransmitters.
81,82
In vivo studies have consistently shown that SAMe possesses antidepressant
activity.
2 Many human clinical trials using SAMe in MDD have been conducted,
and all have revealed benefi cial antidepressant effects, and comparable effects
to synthetic antidepressants.
83 88 Studies, however, are heterogenous in terms
of dosage, trial length and methodology.
80
Most clinical studies involved parenteral or intramuscular injections of SAMe,
rather than oral preparations.
82
Considering pharmacokinetic variability between administration techniques,
oral preparations may not provide the same effect.
SAMe should be used with caution in patients with a history of (hypo)mania
due to concerns over switching from unipolar depression to mania.
SAMe is expensive and the cost may be prohibitive for some people.
L-tryptophan
It is an essential monoamine precursor required for the synthesis of
serotonin.
89,90 L-tryptophan has been studied extensively as an antidepressant.
Although many positive studies exist, only one RCT of suffi cient methodological
rigour exists. An RCT involving 115 participants with depression comparing
L-tryptophan to placebo, an L-tryptophan-amitriptyline combination or
amitryptyline demonstrated that the amino acid was equally as effective to the
antidepressants and superior to placebo.
91
Eight controlled adjuvancy studies using L-tryptophan with antidepressants
provide encouraging evidence. Tryptophan augmentation was found
to be effective in increasing the antidepressant response with phenezine sul-
fate,
92 clomipramine,
93,94 tranylcypromine
95 and fl uoxetine.
96 However, other
clinical studies using tricyclics discovered no additional benefi t compared to
placebo.
97 100
Evening dosing of L-tryptophan (with relevant cofactors such as B6 and B12,
folate and magnesium), taken with fructose and without protein, may have a
role in treating depression, especially with co-occurring insomnia.
Always take amino acids without food to avoid competitive absorption with
other amino acids, and prescribe them with the relevant cofactors. Use caution
in high dosage and with antidepressants (potential serotonin syndrome).
Crocus sativus (saffron)
Saffron is a Persian traditional plant medicine with reputed antidepressant
activity.
Clinical trials comparing the herbal medicine with synthetic agents, imipramine
and fl uoxetine have demonstrated equal effi cacy.
101 103
Extracts standardised to exert antidepressant action are usually standardised
for at least 5% safranal. Crocin and safranal are currently regarded as the
constituents responsible for the antidepressant activity.
104 105
No defi nitive safety data currently exist. Traditional knowledge of adverse
reactions includes nausea, vomiting and diarrhoea.
38 Clinical trials have detailed
anxiety, tachycardia, nausea, dyspepsia and changes in appetite as possible side
effects.
104 105
PART B COMMON CLINICAL CONDITIONS
226
is may in part be due to many studies using olive oil as an ‘inert’ control, and some
studies using higher DHA to EPA ratios or DHA alone.
78 Clinical trials using essential
fatty acids adjuvantly with antidepressants have provided positive evidence of additional
increased reduction of depression level.
79 Current evidence supports the use of essential
fatty acids adjuvantly with antidepressants, in cases of defi ciency or if comorbid cardio-
vascular or infl ammatory disorders are present.
The mood spectrum versus categorical diagnosis
Naturopathic diagnosis of mood disorders refl ects the holistic psychiatric medicine
model, whereby individuals present with unique presentation of MDD, often oscillat-
ing between varying levels of depression and anxiety, and sometimes present with peaks
of hypomania (for example, increased mental activity, socialisation, work and planning,
and decreased sleep). An advantage of naturopathic practice is that prescriptions can be
altered to fl exibly accommodate the natural rhythm of mood disorders. While it is more
applicable to treat the patient holistically (not just ‘the depression’), if the condition is
viewed in terms of a discrete medical diagnosis, then specifi c treatment protocols and
prescriptions can be instigated (see Figure 12.3 ).
e concept of the ‘mood spectrum’, advocated by academics such as Akiskal, Angst,
Cassano and Benazzi, promotes the theory that depressive presentations occur along
a continuum, rather than existing as specifi c discrete diagnostic categories.
106,107
Evidence supports the idea that unipolar depression and bipolar II depression occur
across a spectrum, with 30% of MDD patients experiencing various bipolar symp-
toms (for example, agitation, racing thoughts and decreased sleep).
106
Individual depressive subtype classifi cations (for example, melancholic, atypical and
co-thymic) are diagnostically unstable, with studies showing that people with mood
disorders commonly move between various depressive presentations.
107
e eff ect of seasonal infl uence on MDD should also be considered. While seasonal
aff ective disorder (SAD) is a specifi c type of depressive disorder, low light and cold
weather may exacerbate non-SAD diagnosed depression.
108 Although evidence spe-
cifi cally supports light therapy only in treating SAD, exposure to morning sunlight
is a commonsense recommendation. Sunlight intuitively lifts the mood, and causes
increased serotonin turnover in the brain.
109
INTEGRATIVE MEDICAL CONSIDERATIONS
As detailed above, an integrative treatment plan should ideally be provided. Other
treatments include acupuncture and psychological interventions. If the patient is unre-
sponsive to CAM treatment (after 2 4 weeks of treatment), the prescription should be
altered or additional interventions provided. Synthetic antidepressants may be required
if the depressive episode worsens and suicidal ideation is present, or if symptoms persist
after several prescription modifi cations to non-response.
Acupuncture and massage
e use of acupuncture to treat depressive disorders has been documented in tradi-
tional Chinese medicine (TCM) texts.
110 In TCM the two main organs (energetically)
involved in depression are the liver and the heart.
18 Two primary patterns of depression
are diagnosed in TCM: ‘Stagnation of Liver Qi’ (excess pattern) and ‘Defi ciency of Qi,
Blood, or Kidney Jing’ (defi cient pattern).
110 In principle, physical activity and exercise
are regarded to ‘Move Qi and Blood’, thereby alleviating ‘Stagnation’, and to ‘Tonify Qi’
12
 □  Clinical depression
227
Referral
• Immediate hospital assessment if plans to
suicide.
• Signicant suicidal ideation / monitor closely
• Send for medical tests or referral if comorbid
medical conditions are apparent.
• Refer to support services in cases of substance
or alcohol abuse/dependency.
• Immediate referral to a clinical psychologist for
a psychologically based intervention may be
advised.
Diagnostic interventions
• Judicious use of blood tests:
– cortisol, homocysteine, folate, amino acids.
• Naturopathic examinations:
– iridology (constitutional values)
– tongue, pulse
– skin, nails
– observe gait, speech, complexion.
Assess risk and establish
particulars
Previous episodes (number, timing,
response to treatment, risk signs)?
• Duration and timing of this
episode?
• Intensity?
• Presentation?
• Suicidal ideation?
• Self–harm?
• Comorbidities?
Determine causative factors
• Family history/emetics
• Life event triggers
• Psychological vulnerabilities
• Acute/chronic stressors
• Poor diet/lifestyle
• Substance misuse
• Inammation/immune dysfunction
Formulate an integrative
treatment plan
The ALPS model:
Antidepressants (natural or
synthetic)
Lifestyle
Psychological
Sociological.
Communication of the integrative
treatment plan with the patient
• Treatment preferences
• Achievable compliance
• Possible side eects
• Potential realistic benets
• Possible ‘plan B’ options
Implement integrative treatment plan
• Use the ALPS model.
• Individualise—consider:
causation
– age, sex, culture
– current lifestyle and diet
– current medications
– work and family situation
– health and digestive status.
CAM treatments
• Herbal: Hypericum perforatum, Rhodiola rosea,
Lavandula spp., Crocus sativus
• Nutraceutical: SAMe, folate, omega-3,
L-tryptophan
• Dietary adjustment (if required)
• Exercise (graded) and relaxation techniques
• Emotional support via therapeutic relationship
Communication
• Discuss the treatment plan and prognosis
honestly, realistically and compassionately.
• Encourage the patient to call if they worsen.
• Monitor mood closely and always follow up
shortly after initiating a new treatment plan.
Figure 12.2 Naturopathic treatment decision tree—depression
PART B COMMON CLINICAL CONDITIONS
228
(lung and spleen), thereby improving energy and vigour. A review of eight small-
randomised controlled trials confi rmed that acupuncture could signifi cantly reduce the
severity of depression on the HDRS or Beck Depression Scale.
111 However, no sig-
nifi cant eff ect of active acupuncture was found on the response rate or remission rate.
Another review
112 found a total of four RCTs meeting a minimum standard of meth-
odological rigour (for example, a randomised sample and control groups used). Results
of these studies revealed signifi cant eff ects on reducing depression versus non-specifi c
or sham acupuncture, and equivocal effi cacy to tricyclic antidepressants. In one study,
although acupuncture was equally eff ective to massage and sham acupuncture, only
the true acupuncture provided sustained antidepressant eff ects. Acupuncture has been
documented to interact with opioid pathways, and substances which modulate these
pathways have been shown to have antidepressant activity.
9,113,114 Other possible anti-
depressant mechanisms of action include the increased release of serotonin and norepi-
nephrine, and CRT and cortisol modulation.
113
Massage may also be of benefi t in improving mood and reducing depression. Studies
of varying methodological rigour have shown that massage increases relaxation, decreases
stress and elevates the mood.
115 A rigorous review of massage techniques in treating
clinical depression commented that, while positive studies exist, a lack of evidence from
RCTs does not support this intervention.
116 While evidence currently does not support
massage as a primary monotherapy in treating MDD, use of massage adjuvantly can be
advised, especially in cases of co-occurring muscular tension.
Psychological intervention
As outlined under the ALPS model, psychological intervention is an important com-
ponent in treating MDD. Guidelines support the use of psychological interven-
tions such as cognitive behavioural therapy (CBT) and interpersonal therapy (IPT)
in mild depression rather than synthetic medication.
27 CBT and IPT are accepted
psychological interventions, both having equal evidence of effi cacy in treating
MDD. 25 CBT involves learning cognitive skills to ‘reprogram’ erroneous or nega-
tive thought patterns with positive balanced cognitions, and to institute positive
behavioural modifi cations.
117 e theory is based on the concept that a person’s
negative, critical, erroneous thought patterns provoke deleterious emotional and
physiological responses. By intervening before this cascade occurs, and establishing
a positive balanced inner dialogue, this spiral can be avoided. IPT focuses on iden-
tifying problematic social situations that are depressogenic, and developing inter-
personal techniques (such as social skills) to manage interpersonal relationships.
117
By increasing confi dence and competency in managing social interactions, a robust
self-esteem may develop.
Other techniques, such as teaching problem-solving skills to identify and deal with
depressogenic triggers, may be of assistance. Finally, it is important to assist the patient
to identify external triggers that may cause an episode (for example, the anniversary of
a death, or a change in weather), and help them to formulate a ‘pro-euthymic’ plan to
combat this. Naturopaths may learn basic skills in teaching CBT and IPT, and a caring
humanistic approach should always be present. However, for skilled psychological inter-
vention, referral to a clinical psychologist or highly trained counsellor is advised.
Adjuvant CAM treatments with antidepressants
If the patient is taking antidepressant medication, adjuvancy options are recom-
mended (see Sarris et al.
118 for a review). Adjuvant strategies with antidepressants
12
 □  Clinical depression
229
involve combining an additional thymoleptic intervention to directly increase
the antidepressant eff ect, or use a supplementary therapy to enhance activity, or
reduce side eff ects by a synergistic interaction. Such prescription should be dis-
cussed between the physician and naturopath, and be closely monitored.  e
evidence regarding combining synthetic antidepressants and herbal medicines is
currently unknown. Potential exists in combining antidepressant herbal medicines
to increase the therapeutic eff ect in absent or partial responders to synthetic anti-
depressants. Consideration of serotonin syndrome or switching to bipolar (hypo)
mania should, however, be given. Co-administration of herbal medicines may also
have a potential role in addressing individual presentations or comorbid features of
• Adjuvant use of anxiolytic and nervine HMs,
e.g. Piper methysticum, Passiflora incanata,
Scutellaria lateriflora, Withania somnifera
• Lifestyle advice, e.g. reduce stimulants and
external stressors, moderate exercise and
tailored relaxation techniques or massage.
Referral for psychological treatment may also
be helpful.
• Dietary increase of magnesium, B vitamins,
folate, zinc-containing foods, e.g. whole grains,
leafy vegetables and lean protein
• Utilise stimulating tonics and adaptogens,
e.g. Panax ginseng, Rhodiola rosea, Glycyrrhiza
glabra.
• Address any blood sugar abnormalities
e.g. Gymnema sylvestra, chromium, vitamins
B1, B2, B3, B5.
• Psychological interventions, e.g. IPT, CBT,
counselling
Anxious depression
Co-occurring anxiety
• Physical tension/stress
• Insomnia
Atypical depression
• Hypersomnia
• Hyperphagia
• Mood reactivity
• Assess via salivary cortisol test.
• Address insommnia—good sleep hygiene, lower
caeine/stimulants. Referral for psychological
treatment may also be helpful.
• Support function of the HPA axis using
adaptogens and nervine tonics, e.g. Withania
somnifera, Avena sativa, Scutellaria lateriflora
(Glycyrrhiza glabra is contraindicated—may
raise cortisol).
• Refer to a medical practitioner.
• Adjuvant treatment may be useful with
synthetic medications, e.g. omega-3, folic acid,
Ginkgo biloba.
Melancholic depression
• Anhedonia, anxiety
• Psychomotor agitation, insomnia
• Raised CRT and serum cortisol
Sever depression, bipolar
depression, psychotic depression
• Delusions, hallucinations
• Euphoria, bahavioural changes
(when in a manic phase)
• Signicant suicidal ideation
Figure 12.3 Psychiatric diagnostic depressive presentations and example treatment
options
2,100,130
PART B COMMON CLINICAL CONDITIONS
230
depression (see Figure 12.3 ), or to reduce side eff ects of antidepressants. Note the
following:
Strong evidence exists for combining SAMe , L-tryptophan , folic acid or omega-3
with SSRIs or tricyclic antidepressants to increase response or speed the onset of
action. 79
Novel adjuvant prescription includes the use of aromatic or bitter herbs such as
Zingiber offi cinale or Cynara scolymus to reduce nausea and relieve dyspepsia.
119,120
Co-occurring fatigue could potentially be reduced via co-administration of adapto-
gens such as Rhodiola rose a 39 or Panax ginseng . 121
Insomnia and irritability could be treated via herbal anxiolytics such as Passifl ora
incanata 122 or Piper methysticum . 123
Sexual dysfunction may be alleviated in some patients by using Ginkgo biloba , 124 – 126
although not all studies show positive results.
128
e occurrence of hepatotoxicity could be potentially reduced by using antioxidant
hepatics such as Silybum marianum or Schisandra chinensis . 129
Case Study
A 28-year-old female presents with persistent low mood . She says that for the last few
months she lacks motivation, and has lost pleasure in activities that she usually enjoys.
Her energy is very low and says she just wants to sleep . Her diet is poor, lacking in
leafy vegetables and fi sh.
SUGGESTIVE SYMPTOMS
Persistent low mood
Loss of pleasure in work and hobbies
Weight and appetite change
Sleep disturbance, Insomnia
Altered cognitions (guilt, low self-worth,
suicidal ideation)
Psychomotor agitation or slowness
Fatigue
Example treatment
Herbal and nutritional prescription
In the above case, the primary prescriptive
protocol is to provide an antidepressant
action to treat the depression.  e co-occur-
ring manifestations of fatigue, amotivation
and hypersomnia can be addressed via stim-
ulating tonics and adaptogens. In the above
case, a dysregulation of serotonin may be
responsible for the low mood; norepineph-
rine dysregulation may aff ect amotivation,
hypersomnia and fatigue; while dopamine
dysregulation may be responsible for anhe-
donia. Hypericum perforatum , Rhodiola rosea
and Lavandula angustifolia should aid in the
elevation of her mood. Panax ginseng , Rhodi-
ola rosea and Glycyrrhiza glabra will assist in
enhancing adrenal activity and invigorating her energy and motivation.
101 Omega-3 may
be of benefi t in treating her depression (especially if she is defi cient in it), and a multivita-
min high in folate will provide the nutrients involved in the manufacture and transmission
of neuroreceptors, while assisting the methylation pathway.
Herbal formula
Hypericum perforatum 1:2 25 mL
Rhodiola rosea 2:1 25 mL
Lavandula angustifolia 1:2 20 mL
Panax ginseng 1:1 15 mL
Glycyrrhiza glabra 1:1 15 mL
7.5 mL morning and
afternoon
100 mL
100 mL
Nutritional prescription
Omega-3 fi sh oil
3 tablets (3 g) 2× day
Multivitamin 1 per day
(high in B vitamins and folic acid)
12
 □  Clinical depression
231
Dietary and lifestyle advice
Dietary programs designed to treat depression have to date not been rigorously
evaluated. Although evidence supporting specifi c dietary advice is currently absent,
a basic balanced diet (see Section 1 on the gastrointestinal system) including foods
rich in a spectrum of nutrients can be recommended. Foods rich in folate, omega-3,
tryptophan, B and C vitamins, zinc and magnesium are necessary for the production
of neurotransmitters and neuronal communication.
77 ese include whole grains,
lean meat, deep-sea fi sh, green leafy vegetables, coloured berries and nuts (walnuts,
almonds). 65,130
General lifestyle advice should focus on encouraging a balance between meaningful
work, adequate rest and sleep, judicious exercise, positive social interaction and
pleasurable hobbies. Behavioural therapy techniques have shown positive eff ects on
reducing depression by training the person to reduce or better manage stressful situations,
and to increase pleasurable activities that enhance self-esteem and self-mastery. If sub-
stance or alcohol dependence or misuse is apparent, supportive advice on curtailing this,
or appropriate referral, should be communicated (see the case in Chapter 13 on chronic
generalised anxiety for more detail).
Exercise or physical activity
Increasing physical activity is advised in cases of underactivity. Associations between
greater physical activity and improved mood and wellbeing have been documented,
131
and several RCTs support exercise as eff ective in managing MDD. A meta-analysis of
11 treatment-outcome studies of exercise on the treatment of depression showed a sig-
nifi cant eff ect in favour of physical exercise compared with control conditions (routine
care, wait list, meditation/relaxation or low-intensity exercise).
132 A very large average
eff ect size was obtained with all but two studies obtaining superior results from exercise
than from control. However, many of these studies had methodological failings (for
example, not using blind assessment or intention-to-treat analyses). Research strongly
suggests that anabolic exercise of high intensity is more eff ective than low intensity.
133
e biological antidepressant eff ects of exercise include a benefi cial modulation of the
HPA axis, increased expression of 5-HT, and increased levels of circulating testosterone
(which may have a protective eff ect against depression).
134 Evidence also exists for the
use of yoga to reduce depression and improve mood. A review documented fi ve RCTs
using various types of yoga to treat MDD.
135 While the studies reviewed all concluded
positive results, the methodologies were poorly reported and thereby no fi rm conclusion
can be reached. It is worthwhile highlighting that certain types of yoga may actually
have greater antidepressant eff ect. ‘Mindfulness’ in exercise techniques such as yoga may
potentially have greater effi cacy than low-intensity, low-focus yoga, although evidence
does not currently confi rm this theory.
136
Evidence for the type and amount of exercise for the management of MDD, cur-
rently favours anabolic over aerobic activity to gain the greatest benefi ts, and the
intensity needs to be moderate to high and performed two or three times per week.
133
Caveats exist regarding exercise prescription for MDD. Depression may be worsened if
the person is unable to meet expectations, potentially promoting a sense of failure and
guilt.  is may be more likely to occur in severe MDD, especially where psychomo-
tor retardation, hypersomnia, somnolescence, marked fatigue or anhedonia are present.
Exercise plans should be instituted after a medical assessment, and initially commenced
at a low intensity to allow for physical and psychological adaptation to occur to the new
stimulus.
PART B COMMON CLINICAL CONDITIONS
232
Table 12.2 Review of the major evidence
INTERVENTION KEY LITERATURE SUMMARY OF RESULTS COMMENT
St John’s wort
( Hypericum
perforatum )
Meta-analyses
Linde et al. 2005
137
Roder et al. 2004
138
Werneke et al. 2004