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Case Studies - Page 4

If there are no obvious physical causes, I encourage my depressed patient to find a physician who can look for and treat a variety of conditions less commonly diagnosed, which may be implicated in depression, anxiety, and chronic fatigue. These include nutrient deficiencies, food sensitivities, subclinical hypothyroidism, heavy-metal toxicity, and small intestinal bacterial overgrowth. I sometimes test for these myself. More often, I refer to other physicians who practice "integrative" or "functional" medicine.

Unless you're a physician or trained nutritionist, you shouldn't "prescribe" complex dietary changes. Nonetheless, you can certainly suggest basic guidelines for healthier eating. I always encourage patients to eat whole foods (preferably organic), little or no processed food, less sugar, protein primarily from vegetarian or fish sources, poultry rather than red meat, and increased doses of fiber. (We consume about one tenth as much as our Palaeolithic ancestors and our indigenous brothers and sisters.) Because our food supply is so depleted, and given the ordinary stress of living in modern society, virtually anyone can benefit from a high-dose multivitamin and multimineral supplement (without iron, unless anemia is present). People suffering from depression or bipolar disorder will benefit from supplementation with omega 3 fish oil, 2-6 grams a day. Those with gastrointestinal as well as emotional upset may well find relief from both kinds of symptoms by taking supplements with "probiotic" bacteria (Bifidus and Lactobacillus) that normally live in a healthy gut.

Exercise is critical for mood regulation. In fact, next to speaking with an experienced, reliable, and compassionate listener, exercise is probably the most effective of all the antidepressants. As a therapist, you can provide information about the benefits of exercise from a wealth of studies in peer-reviewed journals and help your patients develop individualized exercise programs. The effectiveness of jogging is well-researched, but if your patient hates doing it, it won't happen. Walking, running, dancing, and yoga have been demonstrated to be enormously helpful. Theresa was already doing yoga, and I encouraged her to continue. Later, I suggested that each morning she put on fast music and dance for 15 minutes.

From the first session on, I give my patients detailed instruction in guided imagery, focusing most often on two images: the creation of a "safe place" where they can find calming sanctuary in difficult, stressful times; and consultation with an "inner" or "wise" guide—an emblem of their intuition and imagination, on which they can call for advice and counsel. I often teach "Dialogue with a Symptom, Problem, or Issue (SPI)," a Gestalt-like exercise, in which a rapid, written dialogue between my patient and her physical, emotional, spiritual, social, or interpersonal SPI often reveals both its origins and possible solutions. I work, too, with journaling, drawing, and movement to express and reveal feelings and release them. The message to my patients is clear and consistent: you can mobilize your own mind and body to help and heal yourself; I'm here to help, to equip you to do it, and to support you as you do.

There may come times, especially when working with seriously depressed people, when the increased hopefulness and good feelings you've helped stimulate seem to dissolve. Often, I find that this is a good time to ask my patient to consult her "wise guide," or to use the dialogue with the SPI to mobilize her capacity for healing. Sometimes, I use expressive techniques—fast deep breathing, pounding pillows, and holding yoga postures at length—to bring up suppressed feelings, facilitate emotional release, break up physical rigidity, and mobilize energy.

Occasionally, someone's distress is so great that she insists on what one of my patients called "a physiological boost," something beyond the holistic approaches already tried. At this point, I may well use the natural "precursor" supplements that directly increase the levels of the neurotransmitters serotonin and norepinephrine, including S-adenosylmethionine (SAMe) and tryptophan, and the herb St. John's wort. While these can produce side effects similar to those of drugs, they're usually far less severe. I don't regard the use of these precursors as signs of treatment failure, but as necessary, quite often temporary, therapeutic aides.

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