By Michael Gerber, MD, HMD It was a dark and stormy night in northern Montana when Fred (not his real name) was driving over 120 mph with his lights off. (“You know they can’t see you when your lights are off.”) After a police chase he went through a guardrail and down a ravine. As emergency workers cut him from his car he became very violent with EMT responders. Amazingly he escaped with many bumps and bruises and a broken arm. His, girl friend/fiancée drove to Montana, bailed him out and brought him to see us. Fred is a 38 year old journeyman construction worker who puts up big box stores around the United States. He has also been bipolar since childhood with multiple psychiatric hospitalizations. His self medication of choice was drinking up to a case of beer per day. I had seen him three years before when he was not as acute and had made great progress with the help of his girl friend who kept him on the straight and narrow with healthy foods, seeing that he took his supplements and limited his beer consumption. As he was separated from his girl friend on his trips around the country he deteriorated. Doctors occasionally ask me about acute mental illness. “Amino acids work well as neurotransmitter precursors and agonists but they take time to work. What do you do when somebody is really acute?” I responded that you can give a lot of the same nutrients and amino acids intravenously as well as orally and it works in several hours or less. We have a number of IV formulas for different conditions but for anxiety, depression and mania our usual pick is one we call the SSRI. Not that there are SSRI’s or SNRI’s in the bag but we use the amino acids and nutrients to help people refill their neurotransmitter gas tanks and assist them in reducing their anti depressant medication, slow them down and make them happier on the spot. Fred presented in the office red faced, with multiple contusions and his arm in a sling. He was not happy barely answering question. An hour into his SSRI drip he said, “Hey Doc this is alright I sure am feeling mellow.” His girl friend commented that he was much more relaxed and even cracked a few jokes. He fell asleep in the chair and slept well that night. After another IV the next day we refashioned his nutritional and hormonal support program and he again improved clinically. The IV recipe is included with this article. By the way you can, of course, modify this recipe anyway you wish, perhaps more tryptophan, taurine, glycine and magnesium for more sedation and increase the phenylalanine for more stimulation. Last week a 48 year old health professional was emotionally “coming apart” with anxiety and depression after losing her job, death of a parent and severe injury to her child. During the SSRI IV she said “I feel much calmer. Is this IV supposed to do that?” From my perspective when patients present with depression, anxiety and insomnia the other accompanying complaint is almost always fatigue. How do we repair these patients who are frequently chronically stressed with no adrenal reserve, obvious hypothyroidism with normal blood tests, huge grief and loss issues, financial obliteration, environmental toxicity, physical toxicity, scars, allergy, childhood traumas, dental poisoning, parasites, chronic viral or bacterial infections, abuse, chronic physical pain, addictions to drugs and sugar and allopathic medications which are frequently ineffective and can do much harm (weight gain, loss of libido, suicidal ideation, anxiety and worse depression) is to start removing or improving as many of these straws on the camel’s back as one can. First, the body must have energy which is, at the cellular level, called ATP, adenosine triphosphate, the body’s energy currency. How do we make ATP? We must go back to physiology and biochemistry and take care of getting energy to our mitochondria and improve their size and number. Each of our 75 or so trillion cells has from 100 to 1000 mitochondria; every aspect of healthy functioning can be involved in restoring mitochondria and energy balancing. How can one make neurotransmitters without ingesting and absorbing protein to make the amino acid precursors? Or, how about the vitamin, minerals, fats and sugars that make the Kreb’s cycle and cytochrome oxidase system which gives us the ATP? Adrenal Weakness and Depression What about blood sugar modulation? The adrenal gland is my first stop to repair health, it is the stress gland. Almost all depressed, anxious and insomnia patients have weak adrenal cortical health. Remember the cortex, see plate, is on the outside of the adrenal gland and makes all the hormones from cholesterol and the medulla, the inside, makes the catecholamines, nor epinephrine (adrenalin) et all, which causes racy thoughts, heart palpations, gastritis, depression, anxiety, insomnia, IBS, confusion, poor memory and anger. The medulla is the last thing to go in adrenal health. It is the will power. The patient feels awful but will get the job done, take care of the kids and work on will power even though she feels emotionally down. When the adrenal cortex gets worn out, the adrenalin has to kick in from the medulla if it can otherwise the patient never gets out of bed or off the couch. One can diagnose adrenal fatigue from the history, the appearance, puffy and dark circles under the eyes, low blood pressure, low or absent kidney pulse in Chinese medicine, over dependence on coffee, cigarettes, prescription drugs, amphetamines, alcohol, marihuana or do saliva cortisol tests at eight AM, 11 AM, four PM and before bed for laboratory diagnosis. Although it takes longer, the cortisol rhythm is very helpful in prescribing. Twenty-four hour urine collections for hormones are also great for fine tuning all the patient’s hormones. However, I always say that if looks like an elephant, feels like an elephant and smells like an elephant it is probably an elephant. One of my great friends, Frank Shallenberger, MD, HMD says that if a patient is in your office his adrenals are stressed (he used a stronger term). Adrenal fatigue has received a lot more attention in the last few years, thank heavens, and some authors recommend large doses of vitamins (especially B5 pantothenic acid) and minerals, herbs and multiple glandular supplements. This is all well and good but it is accompanied by the expectation of getting patients adrenals better in six months to a year or longer. I figure that I have two or three visits with a depressed patient to make noticeable improvement or they will go across town and give someone else a try. I still, after 36 years, love our adrenal complex shot with hydroxycobalamin and folic acid in time released sesame oil. This shot lasts one week for most and can be done daily or several times per week for weaker patients. The usual dose is one, 1 ½ or two cc’s of Hydrocortisone 2 mg/cc with DHEA .2 mg/cc and pregnenolone .2 mg/cc and can be provided by your compounding pharmacy. It must be given in upper, outer quadrant of the buttocks. Smaller more sensitive people take smaller amounts. Remember, the adrenal gland size goes by body weight. Babies and small women have little adrenals and the guy that’s 6’5” and 250 lbs. has big ones. He can also drink two quarts of whiskey per day, 20 cups of coffee, 3 packs of cigarettes and other drugs and feel totally fine. Some little ladies can’t detox alcohol at all and can get really sick from a ½ glass of wine. Alcohol intolerance is another low adrenal symptom. Oral adrenal tablets come from many companies. Some products contain adrenal cortex only and some have both cortical hormones and medullary catecholamines which are more stimulating. I have used Isocorts from Bezweken for decades. The dose varies between ½ tablet once per day to 8 tablets three or four times per day which is a full replacement dose depending on the patients ability to handle stimulation. Many physicians use Cortef (hydrocortisone tablets) and follow the procedure suggested by co-discoverer of hydrocortisone in 1949, William McK. Jefferies, M.D., F.A.C.P., in his book Safe Uses of Cortisone 1. He prescribes 5 mg 4 x/d for patients with chronic adrenal fatigue and 10 mg 4x/d if they have a virus or other illness. I generally start with low doses and work up if the patient isn’t feeling stronger. Hydrocortisone is one of our major hormones and when it is needed in larger doses such as 5 mg 4 x/d or 10 mg 4x/d works brilliantly without Cushing’s issues. Depression takes a toll on the adrenals. There are legions of great nutrients, hormones and herbs to support adrenal functioning. Progesterone is also an adrenal hormone and is magical for depression and mood disturbances especially related to PMS. Menopausal women who are weeping for no reason need estrogen. Vitamins such as Vitamin A, Vitamin C (highest concentration of vitamin C in the human body is in the adrenal gland) B vitamins especially pantothenic acid B5 and even stronger pantethine, liquid chromium up to 6,000 mcg/day for the 1st month and 3,000 mcg/day subsequently (according to Jonathan Wright, MD), SAMe, and many herbs such as Cordyceps, Rhodiola rosea, Ashwaganda, Ginseng, St. John’s Wort, Vervain, Avena sativa, Maca, licorice and dozens more. Of course, the amino acid precursors to neurotransmitters such as tryptophan, 5-HTP, tyrosine, phenylalanine, GABA and other amino acids such as phosphatidyl serine, glutamine are important and acetylcholine precursors such as acetyl L. carnitine, acetyl L carnitine arginate, cytidine 5- diphosphocholine will help with failing memory which can be very depressing. If adrenal dysfunction is more chronic the mineralcorticoids also become weakened and it is hard to maintain enough aldosterone to keep up the blood pressure and energy. When the adrenals are weak you leak. If the patient feels faint on standing it is also helpful to take ½ tsp of good sea salt (Celtic or Real Salt, Himalayan salt may be high in fluoride and bromide and regular table salt is high in aluminum as a drying agent) in one glass of water morning and early afternoon. Florinef .1mg per day may also be important to supplement. Thyroid and Depression To turn on metabolism there is nothing better than supplementing thyroid or supporting thyroid functioning. We know many environmental toxins block thyroid release or receptor activity such as PCB’s 2,3, fluoride, bromide, cruciferous vegetables, soy and many more. The fetal thyroid makes antibodies against the maternal thyroid and I feel that most post partum depression is due to a functionally low thyroid state and their mood improves very rapidly with thyroid repletion. Many articles have been written suggesting that the TSH is a very poor screening test for thyroid sufficiency. We always use the free T3 and free T4 as well as TSH, TPO, antithyroglobulin antibody and reverse T3. Borderline low thyroid tests should always be considered as needing supplementation if other physical symptoms are present. Axillary temperatures in the morning, normal should be 98 +/-.2 4, low and very low body temperature can help diagnose hypothyroidism as does a puffy, myxedamtous appearance, loss of hair or eyebrows, sensation of cold, heavy periods or abnormal menstrual bleeding without another obvious cause or mildly thickened endometrial stripe, infertility, loss of Achilles reflex, absence of triple warmer pulse, dry eyes, dry skin, dry mouth, depression, headache, anemia, constipation, low stomach acid, high cholesterol, weight gain are among the many symptoms of functional hypothyroidism. I have used Nature-Throid desiccated, porcine thyroid for 36 years. Some patients prefer Armour thyroid. There have studies done at Harvard and NIH that showed patients preferred T3 and T4 combination and felt subjectively better than T4 alone. Remember, there are no T4 receptors in the human body only T3. Dosing the hypothyroid patient is an art form. Thyroid and adrenal always go together so if the patient has a very compromised adrenal then one must begin the thyroid very gradually at 1/16th grain or less and increase every week or so to not cause tachycardia, anxiety, insomnia or anger. Some patients need to be started on adrenal support for several weeks before beginning thyroid supplementation. EAV or ART testing helps the practitioner to know when the patient is ready. I also have a “cup of coffee” rule of thumb. If the patient is very intolerant to coffee and becomes anxious and insomniac from smelling coffee, start very gradually. If the patient can drink a pot of coffee and go to bed without a problem one can begin dosing at around ½ grain and increase by ½ grains over one month. We always say if you are feeling great at one grain of thyroid and at 1 ½ grains the Wicked Witch of the East comes out, return to the previous dose that felt comfortable. Thyroid alone will cure or improve most cases of depression. Homeopathy and Depression Of course constitutional homeopathy is a very powerful tool to heal the whole body including depression and has been reviewed in great depth by the Ulman’s in previous issues. I have found several remedies to be outstanding for acute and chronic depression and anxiety in my practice. For acute weepy or hysterical depression after grief and loss I like to mix Ignatia-Homaccord from Heel with my adrenal complex, B12 and folic acid shot. The homaccord contains Ignatia amara 6X, 10X, 30X and 200X with Moschus 8X, 30X and 200X. Years ago six or seven family members were in hysterical tears in my waiting room. They were all on their way to Hawaii from the central valley of California to celebrate the 75th birthday of the head of the family. Unfortunately, he committed suicide the night before. After the above injection of Ignatia, adrenal complex, B12 and folic acid, everyone calmed down and said,”OK, we have to get it together and develop a plan”. They proceeded to Hawaii and celebrated his life. I have many cases of tears slowed down very quickly with this injection. I also usually send the patient home with some Ignatia 200 C pellets to take daily for a few weeks. For patients troubled by chronic grief and loss, Natrum Mur is a great remedy. Anxious patients who are chronic worriers, especially with very unrealistic fears (I worry the freeway walls will fall on my husband), with low adrenal reserves have frequently benefited from Argentum Nitricum. Staphysagria is indicated for guilt, abuse and shame. A 58 year old woman who had been a patient for about five years was doing alright with sinus issues and recurrent infectious diseases but her low energy and recurrent depression were still a problem. She had been exposed to family violence in childhood, couldn’t stand any injustice and couldn’t watch TV, especially the news. After beginning Causticum 6C and gradually increasing her dilutions every four to 6 weeks she is transformed. I get big hugs from her whenever she is in the office because her energy and mood are so much improved. Most depression can be treated with integrative means. Occasionally, the patient does prefer to stay on their medications but most of the people we see are happy to come off medication and it is very satisfying for the practitioner to facilitate this process. Citatations: Safe Uses of Cortisone William McK. Jefferies, M.D., F.A.C.P Charles C. Thomas Publisher, 1981 Haggmar L, Rylander L, Dyremark E, et al. Plasma concentrations of persistent organochlorines in relation to thyrotropin and thyroid hormone levels in women. Int Arch Occup Environ Health 2001; 74:184-188. Osius N, Karmaus W, Kruse H, Witten J. Exposure to polychlorinated biphenyls and levels of thyroid hormones in children. Environ Health Perspect 1999;107:843-849. 4. Hypothyroidism, The Unsuspected Illness by Broda Barnes, M.D.