Besides the oxygen we breathe, all that we need to survive comes from what we eat. Food nourishes both the body and the brain. In fact, the brain has first call on the available supply of nutrients. Therefore, the first effects of nutritional deficiencies are often mental symptoms.

When orthomolecular psychiatrists refer to a nutritional deficiency, they are not necessarily talking about the prevention of a traditional deficiency disease, such as beriberi, a once-common illness that is fortunately now rare due to vitamin B1 food supplementation. However, lesser subclinical deficiencies are quite common. While not enough to bring on overt physical symptoms, they are often sufficient to stimulate changes in brain chemistry, and affect mood. Antidepressants, including St. John's wort, are not likely to be successful in treating these cases until the specific deficiency is corrected.

In this chapter, I will introduce you to someone who was helped by nutritional therapy, and present information on vital depression-fighting nutrients. I'll then discuss other possible causes of depression-including illnesses that St. John's wort can help alleviate.

Treating the Entire Person
When treating depression, it is important to address all of a patient's problems, both biochemical and psychological, if healing is to take place. Jeff is a good example.

Jeff, a 19-year-old college freshman with no prior history of emotional problems, was brought to see me by his concerned father. "I don't know what to think. Jeff has been withdrawing more and more lately, won't join us at the dinner table, hasn't been finishing his assignments, and says there's nothing wrong." Further questioning revealed that Jeff had been popular in high school, a good student, and a member of the basketball team. Yet he was now failing at the local college he was attending, and according to his father, was "not his old self."

As his father talked, the tall, somewhat thin, young man sat across from me, looking sullen. I asked his father to leave the room so I could see Jeff alone. There was little change in his demeanor. A series of questions went through my mind: Was he depressed? Was he psychotic, hearing voices that he would not admit to? Or, putting on my orthomolecular hat, was he eating a typical teenage diet of fast food and soft drinks, which could leave him deficient in nutrients needed for adequate brain function?

I determined from his rather brief answers that he was not in any immediate danger, but that he would need more time before he trusted me enough to talk more freely. Given his good prior history, I was willing to wait another week or so before doing anything more definitive, such as prescribing medication. My philosophy is "natural is preferable," since it addresses the root of the problem, and not the symptoms. Also, young people often feel stigmatized by a psychiatric diagnosis, especially when it is accompanied by a prescription.

Jeff agreed to take some daily vitamins, minerals, and herbs. When he came alone to see me two weeks later, he was far more communicative, and appeared to have gained some weight. He had indeed been going through a difficult time, with inner conflict about life issues that he had not had to deal with in high school. He was also feeling that he had let down his parents in some way by not being as competent, decisive, and independent as he expected himself to be. This confusion and depression is not unusual for first-year college students, who face a radical change from familiar high school surroundings. However, he admitted that he had been helped by my advice despite himself. While he had "resented my Dad's dragging me to some shrink," he had followed my instructions by taking the vitamins and herbs three times daily with meals. This instruction also assured that he would eat regularly, and likely, with the family. He said that the supplements seemed to calm his worried mind, and gave him energy and clarity at the same time. He turned out to be quite bright and articulate, in contrast to our initial contact.

What were these pills? The basic multivitamin/multimineral capsules are standard fare in my office, often restoring energy and emotional balance in depleted individuals. The herbs were St. John's wort, the herbal antidepressant, and kava-kava, a South Pacific herb used to help relieve stress. As his depression and anxiety lifted, Jeff was able to think more clearly, and began to seek my advice. Psychotherapy, or any learning, can take place much better when the brain is working properly. Any prior attempts at therapy with Jeff would probably have driven him further away. However, with the proper brain food, he was able to have some insight into his situation, and move in the direction of healing.

Jeff's moodiness might have been ignored by those around him, as friends and family of depressed people often rationalize that while something is not quite right, the person remains healthy in most respects. But sweeping these difficult issues under the carpet may lead to catastrophic consequences. Fortunately for Jeff, early intervention on several levels prevented his disturbance from becoming chronic.

Nutritional Balance and Depression: Amino Acids, Vitamins, Minerals, and Other Nutrients
Like Jeff's diet, the standard American diet is deficient in many of the nutrients we need to stay healthy, both physically and mentally.

What causes these deficiencies? We need only consider the high-sugar, low-fiber, additive-preserved foods that many people consume on a regular basis, combined with the impaired absorption of nutrients that accompanies such poor nutrition. Many people simply do not get the important nutrients needed for good health. They are at once overfed and undernourished, and a poorly nourished body contains a malnourished brain.

In my own practice, I prefer to begin psychotherapy only after excluding an underlying physical cause. In fact, deficiencies in almost any of the vitamins and minerals can show up first as emotional or mental symptoms, such as depression, anxiety, or impaired memory and concentration. Because lab tests to determine specific deficiencies can be costly, I most often recommend the use of multivitamin/multimineral supplements. (For more information on vitamins and minerals, see Prescription for Nutritional Healing by James and Phyllis Balch(Avery) and The Real Vitamin and Mineral Book by Shari Lieberman and Nancy Bruning (Avery)).

Let's look at the amino acids, vitamins, minerals, and other nutrients that are especially important for mental health. (The essential fatty acids are also significant in the prevention and treatment of depression and other disorders.)

Amino Acids
Depression can result if brain messengers called neurotransmitters are in short supply. Synthetic antidepressants work by raising neurotransmitter levels in the brain, and it is likely that St. John's wort does the same thing. Amino acids, the building blocks of protein, are the precursors, or raw materials, for neurotransmitters and other mood-regulating compounds. It is possible to reverse depression by loading up on these amino-acid precursors.

There are three amino acids that are most directly related to mood and depression: phenylalanine, tyro-sine, and tryptophan. Phenylalanine and tyrosine produce the neurotransmitter norepinephrine, and tryptophan is eventually converted to serotonin.

Research has proven the effectiveness of amino acid therapy in fighting depression. Both phenylalanine and tyrosine-which is created in the body from phenylalanine-have been found to be as effective as the antidepressant drug imipramine. Phenylalanine has also been shown to reduce pain by preserving brain levels of endorphins, the body's natural painkiller. Tyrosine is helpful in the treatment of PMS and chronic fatigue syndrome. Tryptophan, which the body converts into the precursor 5-hydroxytryptophan (5-HT), has also been found to be as effective as the synthetic antidepressants.

Since amino acids are found in such high-protein foods as meat, fish, and eggs, you might think that the way to increase your amino-acid levels would be to eat more of these foods. However, disorders such as depression are caused by specific amino-acid imbalances. I recommend that you work with your physician to determine which amino acids you are deficient in before undertaking a supplementation program (see The Way Up From Down by Pricilla Slage (Random House)). If you are already taking antidepressant medication, you can keep taking it while your biochemistry is being brought into balance, and then discontinue the medication after the amino acid therapy takes effect. Amino acids can be combined with St. John's wort. It is important to take sufficient a-mounts of the amino-acid cofactors, such as vitamin B6, which your body needs to properly process amino acids. Tryptophan is available only by prescription at compounding pharmacies or pharmacies that carry natural medicines, but 5-HT is now available from a limited number of suppliers. I still recommend that amino acid therapy be carried out under professional supervision, to insure correct product and dosage.

Vitamins
Our bodies cannot create vitamins, so a well-balanced, supplemented diet is necessary to obtain adequate amounts of these essential nutrients. Vitamins act as catalytic agents in the body, helping to speed up the chemical processes that are vital for both survival and brain function. As a result, vitamin deficiencies can sometimes manifest themselves as depression. Fortunately, when these deficiencies are treated with supplements, there is a reversal in symptoms.

The Recommended Daily Allowance (RDA) is inadequate. These figures are based on the minimal requirements for prevention of severe deficiency disease, rather than on the requirements for optimum health or deficiency correction. My recommendations exceed the RDA. For vitamins B1, B3, and B6, I recommend a daily dose of 50 milligrams (mg), with higher doses for specific disorders.

Important vitamins for mental health include:

• Vitamin B1 (thiamine). The brain uses this vitamin to help convert glucose, or blood sugar, into fuel, and without it the brain rapidly runs out of energy. This can lead to fatigue, depression, irritability, anxiety, and even thoughts of suicide. Deficiencies can also cause memory problems, loss of appetite, insomnia, and gastrointestinal disorders. The consumption of refined carbohydrates, such as simple sugars, drains the body's B1 supply.
• Vitamin B3 (niacin). Pellagra-which produces psychosis and dementia, among other symptoms-was eventually found to be caused by niacin deficiency. Many commercial food products now contain niacin, and pellagra has virtually disappeared. However, subclinical deficiencies of vitamin B3 can produce agitation and anxiety, as well as mental and physical slowness. Mega-doses of the vitamin have been found to reduce these symptoms.
• Vitamin B6 (pyridoxine). This nutrient is essential for the creation of neurotransmitters. Studies have found a strong correlation between vitamin B6 deficiency and depression. Shortages can also produce anemia, numbness, tingling in the limbs, and convulsions. Vitamin B6 has been shown to help women with premenstrual syndrome (PMS). Malabsorption diseases and certain drugs, including MAOI antidepressants (see Prozac and Beyond-The Synthetic Antidepressants) and birth control pills, can cause deficiencies. I recommend that all women on birth control pills take 50 mg of vitamin B6 daily.
• Vitamin B12 (cobalamin). Because vitamin B12 is important to red blood cell formation, deficiency leads to an oxygen-transport problem known as pernicious anemia. This disorder can cause mood swings, paranoia, irritability, confusion, dementia, hallucinations, or mania, eventually followed by appetite loss, dizziness, weakness, shortage of breath, heart palpitations, diarrhea, and tingling sensations in the extremities. Deficiencies take a long time to develop, since the body stores a three- to five-year supply in the liver. When shortages do occur, they are often due to a lack of intrinsic factor, an enzyme that allows vitamin B12 to be absorbed in the intestinal tract. Since intrinsic factor diminishes with age, older people are more prone to B12 deficiencies. Thus, this vitamin is often given as an injection, or as tablets that dissolve under the tongue, to bypass the digestive tract. Vitamin B12 can benefit the 10 to 30 percent of depressed individuals who are deficient. The dose is 1,000 micrograms (mcg).