Differential naturopathic diagnoses
Supportive evidence
Counter-indications
Monoamine theory of depression, e.g. low serotonin
Presents with depression and anxiety
Lack of efficacy of SSRIs and TCAs
Neuro-inflammation
Long-term detectable CRP
Elevated neutrophil counts since 2010
Lack of raised monocytes
Lack of “sickness like behaviour” [1]
Hx of elevated neutrophils could potentially be related to specific infections at the time rather than general inflammation
High histamine
Elevated blood histamine
Clinical features consistent with this:
Chronic anxious features
Difficulty with relaxing, winding down, initiating sleep
Highly motivated, good cognition
Initial partial benefit from SSRIs
GI bloating and diarrhoea [2]
No inhalant or seasonal allergies which are typical of high histamine cases
HPA over-activation
Marked anxiety with sweating, trembling, early morning waking, racing thoughts, tachycardia
High morning cortisol
Anxiety symptoms are worst in morning and tend to reduce by late afternoon
Evidence of low magnesium and potassium which result from high cortisol due to increased renal losses
Unclear as to whether this is a cause or consequence
Low GABA
Anxiety features
Efficacy of benzodiazepines
Unclear as to whether this is a cause or consequence
Zinc deficiency
Evidence of low plasma zinc since at least since 2009
The naturopathic diagnosis was that Imogen’s constitutional tendency to high histamine was the key underpinning driver behind her depression and anxiety. This was being compounded by a zinc deficiency and suboptimal magnesium and potassium levels, the latter two being secondary to the significant HPA activation that is characteristic of anxiety.
Initial lifestyle and behavioural recommendations included:
Reduce or eliminate all sources of caffeine
Try to eat regularly (e.g. every 4 h)
Include a high-quality protein at every meal (e.g. tinned salmon with lunch)
Increase fish consumption to 3/7 days
Consume “smoothies” (high protein/fibre/antioxidant) for breakfast 3/7 days to address low appetite and improve overall nutrient density
Consume one glass of vegetable juice every day to get around low appetite and improve overall nutrient density
Maintain regular gentle, pleasurable, social, exercise with walking, yoga, and swimming
Following full washout of the last TCA, the initial prescription was stand-alone magnesium repletion and simple use of kava (Piper methysticum) as Mediherb tablets extract equivalent to dry root containing kava lactones 50 mg 3.2 g administered as two tablets up to three times a day; however, this was ineffective. Subsequently, the following interventions were recommended, which were introduced in a staggered fashion over approximately 1 month.
Intervention | Dose per Serve | Daily dosage regime | Brand | Rationale |
|---|---|---|---|---|
Zinc | 25 mg elemental | One capsule | Double strength zinc picolinate (Thorne) | Correction of zinc deficiency |
Magnesium | 175 mg elemental | One tablet BD | Organic magnesium (Thompsons) | Magnesium repletion in the context of ongoing excess HPA activity which can then help to reduce HPA activation [5]
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