Natural Support for Emotional Health
An Interview with Peter Bongiorno, ND, LAc
Peter Bongiorno, ND, LAc, has authored three books on natural approaches to mood disorders, including the textbook Holistic Approaches for Anxiety & Depression in Therapy: Combining Natural Remedies With Conventional Care (W.W. Norton & Co., 2015). He has also participated in research efforts at Yale University and the National Institutes of Health, and is the co-director of Inner Source Health in New York.
Many people with healthy mood concerns don’t seek treatment. Element Senior Writer Sarah Cook, ND, recently chatted with Dr. Bongiorno about his targeted approach to mood support.
SARAH COOK: Thanks so much for joining us, Dr. Bongiorno. Before we jump into specifics, could you give us an overview of how you approach the assessment and support of patients with mood concerns?
PETER BONGIORNO: Sure. I think about mood challenges as symptoms of deeper imbalances in physiology and psychology. There is no single cause or recommendation that will solve the problem. I start with a thorough intake to tease out the potential factors involved, and try to hone in on the five to 10 that are most applicable to that person. The initial intake helps us prioritize where to focus our strategies and what testing to do.
COOK: What lab assessments do you find are most useful for these patients?
BONGIORNO: Lab assessments are very helpful in identifying underlying physiologic dysfunction. Evaluating a vast array of assessments at once is particularly useful because a lot of small imbalances can work synergistically to contribute to a mood disorder. I’ll highlight some of the top categories of lab tests to consider, and why they are relevant to anxiety and depression.
Tests to evaluate blood sugar regulation are at the top of the list. These include glucose, insulin, and hemoglobin A1c (HbA1c). Hypoglycemia is common in patients with anxiety and depression, and epidemiological studies show that people who consume more sugar or higher glycemic foods are at a higher risk.
Symptoms of iron-deficiency anemia, like fatigue, brain fog, and irritability, can mimic or overlap with those of depression. Low levels of vitamin D have been linked with depression, and low levels of vitamin B12 have been linked with psychiatric disorders. Tests include serum iron, ferritin, 25(OH) vitamin D, and vitamin B12.
Mood disorders have been associated with increased circulation of pro-inflammatory cytokines, which modulate mood by reducing brain monoamine levels, promoting excitotoxicity, and impairing brain plasticity.
The relationship between chronic inflammation and mood disorders is an excellent example of how psychology and physiology interact. We do not know for sure which comes first. While there is evidence that inflammatory compounds influence mood, there is also evidence that traumatic events in childhood might contribute to chronic inflammation and then mood issues later in life.
Regardless of which direction the arrow of causation points, we can help balance a person’s physiology and psychology by looking at markers of inflammation. Tests to consider in this category include C-reactive protein (CRP), interleukin-6 (IL-6), and homocysteine.
Mitochondria generate energy for all body functions, so this is a strong consideration for people who have extreme fatigue. Impaired mitochondrial function is closely intertwined with oxidative stress, inflammation, and hence mood. Indirect measurements of mitochondrial function include heavy-metal testing, serum coenzyme Q10 (CoQ10), and lactic acid.
Psychological stress contributes to excessive cortisol production and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. Likewise, HPA axis dysfunction can contribute to fatigue and mood issues.
Hypothyroid, low testosterone, and imbalances of estrogen and progesterone are also known to affect mood. Tests include testosterone, progesterone, estrogen, and thyroid hormones, along with salivary tests for cortisol and dehydroepiandrosterone (DHEA).
Finally, if it seems relevant from the intake, consider testing for mold exposure, Epstein-Barr virus, Lyme disease, or other chronic infections. The more testing you can practically do, the better you will be able to understand each individual’s imbalances and contributing factors.
COOK: Are there foundational supplements you recommend to support healthy mood?
BONGIORNO: I start with the basics: a good multivitamin and multimineral with adequate vitamin D, fish oil, and probiotic. There was a thorough review of studies in 2016 that identified the nutrients that were most helpful in conjunction with prescription medications. The review identified omega-3 fatty acids, vitamin D, methylfolate, and s-adenosyl methionine (SAMe) to be most useful. Except for the SAMe, these nutrients are included in the three foundational supplements I recommend.
Insufficiencies in B vitamins, vitamin D, magnesium, and zinc are widespread. These and other micronutrients are required for neurotransmitter synthesis and balanced mood. A good multivitamin/ mineral can give you the peace of mind that you are providing the micronutrients needed for mental health.
Essential fatty acids support cellular function and many biochemical pathways. Although clinical trials on the use of fish oils with mood disorders remain mixed, epidemiologic studies have reported an inverse relationship between risk of depression and consumption of fatty fish.
In this day and age, most people have some imbalance in their microbiome. Antibiotics, sugary foods, and stress all disrupt the microflora. Via the communication network called the gut-brain axis, intestinal dysbiosis contributes to low-grade inflammation and then disruption of neurotransmitters. That is the reason most people will benefit from a probiotic.
COOK: Are there any other foundational supplements that help optimize healthy mood?
BONGIORNO: I recommend a combination formula to almost all of my patients with mood challenges. The combination includes chromium, berberine HCl, curcumin extract (Curcuma longa), rhodiola extract (Rhodiola rosea), and saffron extract (Crocus sativus L). While these supplements are not treatments for anxiety or depression, these ingredients support many of the biochemical pathways involved with maintaining an optimal, balanced mood.
Chromium addresses blood sugar balance, and the specific form I recommend (chromium dinicocysteinate) is particularly helpful for supporting insulin function.
Berberine supports intestinal health, dopamine neurotransmitter production in the hippocampus, and neuroplasticity in the brain.
Curcumin and saffron support a healthy inflammatory response in the digestive tract, and have both been shown in clinical trials to support healthy mood.
Rhodiola is an adaptogenic herb that balances cortisol and supports healthy HPA axis function.
COOK: Are there any supplements you recommend to support patients with occasional anxiety?
BONGIORNO: Getting to the root cause is powerful and works, but people with mood issues need to feel better sooner. So yes, I do keep a few “quick fixes” in my back pocket. For calming support, I use lithium orotate or serotonin precursors.
Lithium orotate helps calm the brain in people who experience occasional anxiety. The recommended use of nutritional lithium is as low as 5 to 10 mg per day, which is much lower than the way that prescription lithium is used.
Serotonin precursors, such as tryptophan or 5-hydroxy tryptophan (5-HTP), are another option. If a person has previously responded well to selective serotonin reuptake inhibitors (SSRIs), they are more likely to respond well to natural serotonin precursors to support calmness.
COOK: Could you give us more detail about the use of lithium orotate?
BONGIORNO: Lithium orotate has been known as a health-promoting nutrient for more than half a century. It was initially discovered that lithium levels were high in the water supply in places where people were happier and had greater longevity. During the 1940s and 1950s, lithiated water was sold over the counter for its purported ability to support cognition and health.
Lithium orotate is vastly different from prescription lithium. The prescription form of lithium is lithium carbonate. As I mentioned before, it’s prescribed at significantly higher levels than the recommended use of nutritional lithium orotate.
Prescription lithium carbonate also poses a risk of toxicity to the kidneys and thyroid. Clearly, more studies are needed on natural supplements (and we should always monitor for side effects), but I have not observed any adverse effects on the kidneys or thyroid with the small amounts of lithium orotate I recommend.
Finally, lithium is not a supplement I typically recommend indefinitely. As we work to balance the underlying physiology, we can gradually decrease supplements like lithium.
COOK: You mentioned serotonin precursors. Is there a reason to choose 5-HTP over tryptophan?
BONGIORNO: I hear arguments that 5-HTP is a better choice because tryptophan can go down the kynurenine pathway. The theory goes like this: Under inflammatory conditions, tryptophan is shunted toward the production of quinolinic acid rather than serotonin. Quinolinic acid is not what we want because it can have more excitotoxic and neurotoxic effects.
5-HTP bypasses the kynurenine pathway and might, therefore, be a more direct way to support serotonin production. I can appreciate this idea, but I still use tryptophan in some cases because I have seen a good response in my patients.
I particularly like to use tryptophan at night for patients who have trouble staying asleep through the night. It’s good to keep in mind the kynurenine pathway, however, and consider opting for 5-HTP in patients who have evidence of more inflammation.
COOK: What about support for patients who occasionally experience low mood?
BONGIORNO: For patients with occasional low mood, I use a combination of herbs and amino acids to support neurotransmitter production. If you look at conventional medications, some of the ones with the greatest efficacy were the old tricyclic antidepressants because they lifted up all the neurotransmitters. The problem with those medications was that they were also anti-cholinergic and caused sedation, constipation, and other side effects.
Our goal is to use natural compounds in a multimodal approach to boost a number of neurotransmitters. The combination I recommend to my patients includes l-tyrosine, 5-HTP, Mucuna pruriens extract, SAMe, and Venetron (rafuma leaf extract). I have had excellent feedback from physicians around the country who have also used this formula to support healthy mood in their patients.
Tyrosine is a precursor for catecholamines (dopamine, epinephrine, norepinephrine), and 5-HTP is a precursor of serotonin. Mucuna pruriens is an herb from the Ayurvedic tradition that serves as a source of l-dopa, which is a direct precursor of dopamine.
SAMe supports methylation reactions to support the production of dopamine, serotonin, and norepinephrine.
Venetron is a proprietary and standardized extract of rafuma leaf (Apocynum venetum) that contains many of the same bioactive flavonoids present in St. John’s wort. Venetron has been shown to support serotonin concentrations, a sense of calm, and restful sleep.
COOK: For patients who are already taking prescription medications, are there contraindications or drug nutrient reactions to be aware of for the supplements you have mentioned so far?
BONGIORNO: There are always potential interactions and contraindications with any nutritional supplement. It’s important to evaluate each person and the medications or supplements they are already taking. SAMe, for example, may not be appropriate for people with bipolar disorder. Serotonin precursors may interact with medications like SSRIs.
That being said, a 2016 review of nutraceuticals in combination with antidepressants reported no significant drug-nutrient interactions between medications (mostly SSRIs) and SAMe, omega-3s, methylfolate, or vitamin D.
Bottom line: It is possible to use nutraceuticals safely in combination with medications, but always check for potential interactions and monitor closely.
COOK: What recommendations do you have related to alcohol, caffeine, or other specific foods for patients with mood concerns?
BONGIORNO: These questions come up a lot for my patients. Some people with anxiety like to drink wine at night because they feel it helps calm their nerves. Unfortunately, there is almost always a rebound effect. Alcohol can wreak havoc on the blood sugar and disrupt cortisol levels. When I am working with patients on mental health, I recommend avoiding alcohol.
Caffeine is an interesting story. Caffeine can elevate mood in people with depression in a dose-dependent way. In my experience, one or two cups of coffee a day can be a safe way to help elevate mood in non anxious depressed patients.
Some people with depression can benefit from consuming coffee, but it can also disrupt the HPA axis and disrupt sleep. Caffeine does not cause anxiety, but it can exacerbate it. If we are working on supporting adrenal health and sleep, I recommend my patients avoid coffee.
As for other dietary recommendations, the Mediterranean diet has the best evidence for supporting healthy mood and cognition and reducing inflammation. Fish is an excellent food to include as a source of digestible protein and essential fatty acids.
Low-carbohydrate and ketogenic diets have become popular in recent years, but I do not always recommend a particularly low-carbohydrate diet for people with mood disorders. That’s because they can experience hypoglycemia, which has a negative mood impact. Sometimes, it is best to lower the carb load slowly, and work gradually toward a low-carb diet, due to withdrawal effects.
COOK: How do you tease apart the influences of physiology and psychology?
BONGIORNO: Physiology affects psychology and vice versa. We have talked a lot already about the influences of inflammation, mitochondrial function, digestive health, and neurotransmitter balance on psychology.
But the reverse is also true. If a person has a strong trauma history or adverse childhood events, they are more likely to have disrupted cortisol levels, HPA axis dysfunction, and chronic inflammation.
I never pretend to know whether the physiology or the psychology is playing a more significant role in my patients. One will absolutely contribute to the other, so we address both.
COOK: What are some ways to address the psychological component?
BONGIORNO: Cognitive behavioral therapy (CBT) is the most evidence-based approach to mood disorders. We can refer patients to a therapist or use online resources for CBT. I do find that many of my patients come to me after they have already been in therapy for years, and they are ready for something new. That is where addressing the physiology becomes important.
Movement and exercise are also helpful for supporting a healthy mood. Exercise will help balance the stress hormones like epinephrine and cortisol. If you think about the fight-or-flight response, we are evolutionarily programmed to run when under stress. One study compared exercise to an SSRI antidepressant and found that exercise took a longer time to help but was equally effective over time.
Mindfulness and meditation can be helpful for many, but meditating can be a challenge for people with intense anxiety because it can actually make it worse. In those situations, it might be more helpful to combine mindfulness with movement—with activities like yoga, tai chi, or qi gong.
COOK: You have been very generous with your knowledge, Dr. Bongiorno. Are there any pitfalls you can warn new practitioners about when addressing mood support in their patients?
BONGIORNO: We need to be cautious with patients who want to decrease their prescription medications. Even if it’s within your scope of practice, don’t jump to remove medications too quickly. I work to build up the overall health of the body with better diet and foundational nutrition supplements before changing any medications.
That being said, the end goal is to decrease our patients’ reliance on taking medicine of any kind. The act of taking a pill (prescription or otherwise) sends a message to a part of the brain that they need to take pills to experience health. It is important to change that belief and let patients know they can regain control of their health.
In that spirit, we strengthen the foundations of the body first (through sleep, foods, lifestyle, spirit). As a patient improves, we can then look at the medications or supplements a person is taking and decide which ones may no longer be necessary. If there is another prescribing physician, always work closely with that provider to wean medications.
It comes down to one of our foundational tenets of naturopathic medicine: doctor as teacher. My goal is to teach my patients how to nourish themselves and discover health from the inside. When we work on the physiology, the thoughts, and the psychology, the drugs become less and less necessary.