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5. Religious and Spiritual Practice
According to Walsh, approximately 90% of the world's population participates in religious or spiritual practices. For many individuals, having a religious or spiritual focus improves their ability to manage the stresses of life. When the focus of such practices centers on concepts like love and forgiveness, it can be very helpful, as opposed to notions of punishment and guilt that can undermine psychological well-being.
Numerous health indicators have been shown to benefit from spiritual practices. These include improved psychological, relational, and marital well-being, as well as lowered rates of anxiety, depression, substance abuse, and suicide. Attending a weekly religious service increases lifespan by approximately 7 years compared with individuals who do not commit to some type of weekly religious service.
Mary used to attend church on Sundays, but after her husband pronounced that type of involvement "silly," she stopped going. There is nothing silly about a person's religious or spiritual practice, especially since such practices can bolster resilience and facilitate a more positive psychological outlook. Mary would benefit from reengaging with her faith on a regular basis. I often discuss such ideas with patients despite that fact that, as Walsh points out, few professional do. It is important for clinicians to ask patients about their religious and spiritual practices. Simply reminding patients can be a powerful way to reinvigorate such practices and promote psychological well-being.
Even though this appears to be mostly positive, clinicians need to consider deeper issues when discussing religious and spiritual practices with patients. Only through lengthy discussions will clinicians begin to understand how a patient endorses the religious concepts and ideas that he/she was exposed to over time. These types of discussions affect a patient's development and psychological health, for they range from prepersonal notions (i.e., literal acceptances of how one should conduct his/her life) to personal ones, and even transpersonal beliefs and ideas. It is easy to imagine the types of psychological distress that can ensue if various life issues run counter to a patient's religious beliefs. For example, how would a person of strong Catholic faith deal with having had sex prior to marriage or an abortion? Along the same lines, what is someone of strong Catholic faith to do when he no longer wants children and yet wishes to have sexual relations with his wife? These situations can challenge a patient's prepersonal, personal, and even transpersonal religious notions; and, if not dealt with, they can be a constant source of psychological distress. Clinicians need to be aware that while religion and spiritual practices can be a tremendous source of psychological health, simply telling a patient to reconnect to his/her faith might not be complete advice unless a patient works through religious or spiritual issues that have been negatively affecting his/her state of mind.
6. Getting Sufficient Sleep
Patients do better when they can get at least 6 to 8 hours of minimally interrupted sleep. Many patients lack an adequate understanding of good sleep hygiene, so they should be educated and encouraged to develop good sleep habits. Some patients sleep during the day and are awake all hours of the night, which further isolates and impairs them from interacting with people. Some patients cannot quiet their minds due to continual ruminations, and feel so anxious that regular sleep becomes impossible. Some patients worry so much about sleeping that this anxiety undermines their capacity to fall and remain asleep during the night. Of course, many other mental incarnations can impair sleep or cause disrupted sleep patterns. Nevertheless, it is essential that sleep be improved, since prolonged impaired sleep will undermine anyone's mental state.
If a patient's mental state does not improve despite a sound holistic sleep plan, the patient may have an undiagnosed sleep disorder. For example, obstructive sleep apnea is commonly comorbid with psychiatric disorders, especially depression and anxiety.53 Also, having a psychiatric illness and/or taking psychotropic medication typically increases a patient's susceptibility to sleep disorders such as insomnia, obstructive sleep apnea, and REM sleep disorders.54 While a thorough discussion of sleep architecture and its proper assessment is beyond the scope of this article, it is important that sleep issues are addressed when managing patients who have mental health challenges. Patients should be referred to a sleep clinic when treatment progress is slow or uneventful, or when it appears that an underlying sleep issue is present or probable.
Orthomolecular Interventions
The body (which includes the brain) demands a constant supply of micronutrients found in foods and through supplementation. If the body's needs are not met, then the individual will suffer from the consequences of micronutrient insufficiency and, in more extreme cases, malnutrition. Based on these known facts, the body is physiologically dependent on receiving a complete "sum" of around 40 micronutrients on a daily basis; otherwise, signs and symptoms of nutritional inadequacy will manifest and can be responsible for a myriad of physical and psychological perturbations.
In addition to micronutrient insufficiencies, our bodies have their own unique biochemical needs that cannot be met from diet alone and demand the proper provision of micronutrient supplementation. This is where orthomolecular therapies (i.e., combinations of diet modifications and/or supplementing vitamins, minerals, amino acids, and/or essential fatty acids) can have a tremendous impact, since they can moderate symptoms of mental distress and improve a patient's capacity to emotionally (i.e., affectively) regulate.55–66
Many orthomolecular clinicians have witnessed the beneficial effects of optimal orthomolecular therapies. Patients often return weeks or months later feeling much better, attributing much of their progress to the prescribed orthomolecular regimens. Putting together the proper orthomolecular regimen requires a comprehensive history, physical examination, laboratory testing (when indicated), and meticulous trial and error. Patients need to understand implicitly and explicitly that finding the "right" mix of orthomolecules takes time and can only be achieved through an effective collaborative process with their treating clinicians.
Here I will reference select publications which show benefits from single or combination orthomolecules upon general stress and/or extreme psychological stress (i.e., suicidality and subthreshold psychosis). Even though each treating clinician will prescribe specific orthomolecular therapies according to the process described above, these select publications support the use of several "core" orthomolecules either alone or in combination with other orthomolecules and should form the backbone of any individualized patient plan.
1. Vitamin C
When 3 grams of timed-release vitamin C was given in divided doses throughout the day to 60 healthy adults for 14 days, blood pressure, cortisol, and subjective response to acute psychological stress were all palliated.67 In another study, when 500 mg of vitamin C was included in a multiple vitamin/mineral preparation (i.e., Berocca) that also included modest amounts of B-complex vitamins, 100 mg of both calcium and magnesium, and 10 mg of zinc, at the end of the trial the 40 men randomly assigned to take the nutrients for 28 days demonstrated statistically significant reductions in perceived stress.68 Even though the latter study did not rely on vitamin C exclusively, preliminary human research has shown this vitamin to moderate stress both physiologically and subjectively. Basic animal research has shown that the adrenal cortex and the adrenal medulla both accumulate high levels of vitamin C, and that vitamin functions as a crucial cofactor in catecholamine biosynthesis and adrenal steroidogenesis.69
Based on these data, it appears that 500 to 3000 mg/day of vitamin C should be prescribed as a treatment to attenuate stress. Timed- or sustained-release vitamin C might be preferable, since it is retained longer within the body, even though research has shown considerable intersubject variation in vitamin C absorption from different formulations.70–72
2. B-Complex Vitamins with a Broad-Spectrum Multiple Vitamin/Mineral Supplement
Optimum doses of B vitamins should be prescribed (in combination with a multiple vitamin/mineral supplement), since these essential nutrients are particularly susceptible to cortisol mobilization that results in their depletion, and they also possess stress-moderating effects.68,73–75 At the end of a 12-week study, during which 42 adults were randomized to the nutritional treatments (B-complex vitamins plus modest amounts of vitamin C, vitamin E, calcium, magnesium, potassium, lecithin, choline bitartrate, inositol, and the botanical medicines Avena sativa and Passiflora incarnata), there were significant reductions in personal strain, confusion and depressed/dejected mood.74
Another of these studies evaluated the effects of a B-complex supplement (i.e., a whole nutrient natural source extract from probiotic colonies containing vitamins B1–12, folate, PABA, biotin, and inositol) on depressive and anxiety symptoms among adults diagnosed with major depression or other forms of depressive disorders.75 The 30 study participants taking the B-complex vitamins had notable continuous improvements in depressive and anxiety symptoms compared with the participants in the placebo group. The B-complex group also showed significant improvements on the mental health scale of the Study Short Form 36 (i.e., SF-36).
Another study involving micronutrients is worth mentioning, since it dealt with the effects of a broad-spectrum multiple vitamin/mineral supplementation combined with herbal extracts (i.e., B-complex vitamins, lysine, antioxidants, minerals, and some herbal extracts) upon mood and stress levels.76 In this study, 25 men randomized to the nutritional-herbal treatment for 8 weeks showed a significant reduction in their overall score on a depression anxiety stress scale (i.e., DASS), as well as improvements in their alertness and general daily functioning.
To combat stress, it appears that optimum doses of a well-rounded B-complex supplement should be combined with a daily broad-spectrum multiple vitamin/mineral supplement to support patients' psychological well-being.
3. Omega-3 Essential Fatty Acids
When patients feel suicidal, they typically experience acute distress and discomfort. No matter how well clinicians monitor patients for suicidal ideation, there are no reliable ways to be certain that patients won't attempt suicide. In a study that evaluated 33 medication-free depressed subjects over a 2-year period, 7 of the subjects attempted suicide.77 Testing showed that their lower docosahexaenoic acid (DHA) percentage of total plasma polyunsaturated fatty acids and higher omega-6-to-omega-3 ratio predicted suicide attempts among the depressed patients over the 2-year study period. Even though these results are preliminary, there is no reason to wait for larger trials, since this data might suggest the need to moderate suicide risk among psychologically distressed patients. It makes sense to ensure that all patients' diets are modified to minimize levels of omega-6 fatty acids and maximize foods high in omega-3 essential fatty acids, and take a daily omega-3 essential fatty acid supplement (i.e., providing ample amounts of DHA such as 500 mg or more).
Outside of suicidality, patients can experience other distressing symptoms, including psychosis. A trial investigated the impact of an omega-3 essential fatty acid supplement among subjects who were having psychotic symptoms (i.e. subthreshold psychosis), but had yet to progress to having a primary psychotic disorder (e.g., schizophrenia, schizophreniform, bipolar, and schizoaffective disorders).78 The subjects were randomized to receive a daily dose of 700 mg of EPA, 480 mg of DHA, and 7.6 mg of mixed tocopherol for 12 weeks, and then monitored for 40 weeks. The total study period was 12 months. At the conclusion of the trial, 2 of 41 subjects in the treatment group transitioned to psychotic disorder compared with 11 of 40 subjects in the placebo group (4.9% versus 27.5% respectively; p = 0.007). Compared with the placebo group, the use of omega-3 essential fatty acids reduced positive symptoms (p = 0.01), negative symptoms (p = 0.02), and general symptoms (p = 0.002), and enhanced general functioning (p = 0.002).
Given how important it is to moderate suicidality and/or symptoms of subthreshold psychosis, it behooves orthomolecular clinicians to prescribe an omega-3 essential fatty acid with at least a 2-to-1 ratio of EPA to DHA (e.g., 1000 mg of EPA and 500 mg of DHA).
Conclusion
There are many reasons why patients struggle to cope when they experience medical, metabolic, and psychological issues that negatively affect their mental health. Many patients have difficulty achieving adequate allostasis after traumatic experiences or prolonged distress. It is imperative that we upgrade our current standard of care by assessing, monitoring, and providing ongoing encouragement and support to complement the provision of orthomolecular medicines. We must be mindful and sensitive to patients' unique life experiences and consider whether oppressive forces may undermine their quality of life. We must engage our patients to develop holistic recovery plans that include the appropriate use of psychosocial strategies and TLCs as well as "core" orthomolecular therapies.
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