Mood and anxiety symptoms occur normally in the course of any eventful life and likely have important evolutionary functions. However, they become pathologic when they interfere with daily functioning, maintenance of relationships, work or school performance, and other important activities of daily living.

Mood and anxiety disorders are distinct conditions, but their biological underpinnings and clinical presentations frequently overlap. Because the nutritional considerations related to these disorders are similar, the conditions are described in a single chapter.

Major Depressive Disorder is common and is marked by sadness and loss of interest or pleasure (anhedonia) occurring throughout the vast majority of the time for at least two weeks. Associated symptoms may include poor concentration, excessive feelings of guilt or worthlessness, abnormal sleep patterns, fatigue or loss of energy, appetite disturbance, sexual dysfunction, delusions, psychomotor changes (e.g., slowed thoughts and movements, slumped posture), and/or recurrent thoughts of death. The pathophysiology of depression is believed to involve a combination of abnormal neurotransmitter (e.g., serotonin, norepinephrine, and dopamine) activity, genetic traits, and environmental and psychological factors.

Bipolar disorders include 1 or more manic episodes (when the mood is abnormally elevated, expansive, or irritable) or hypomanic episodes (when manic symptoms are present, but they are mild enough that they do not substantially interfere with a person’s functioning). Associated symptoms may include grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, and risky behavior such as excessive spending and sexual indiscretions.[1] Symptoms of depression and mania often occur together. When this happens, the episode is described as having mixed features.

Anxiety is marked by physiological arousal (motor tension, autonomic hyperactivity) and psychological arousal (excessive worry, increased vigilance). Norepinephrine, serotonin, and gamma-aminobutyric acid (GABA) may be involved in its pathophysiology, and both genetic predispositions and environmental factors are believed to play a role.

Risk Factors

Significant mood symptoms are present in up to 40% of primary care patients in the United States. Major depression occurs in about 16% of people (lifetime risk), and medical inpatients have increased prevalence.

The following factors are associated with increased risk:

Gender. There is approximately a two-fold greater incidence of depression in women than in men, independent of country or culture. Lifetime prevalence of major depressive disorder is 10%-25% for women and 5%-12% for men.[1] In contrast, Bipolar I Disorder has an equal prevalence in men and women, and manic episodes are more common in men. Women also have a higher incidence of the rapid cycling subtype (> 4 episodes/year) of bipolar disorder than men.

Family history. It is important to consider both diagnosed and undiagnosed indicators of mood disorder, especially in first-degree relatives.

Inadequate social supports. Examples include living alone or having few friends.

Stressful life events. These include life transitions such as retirement and events of painful loss, such as divorce or the death of a spouse.

Coexisting medical illness. Some studies show that up to 30% of patients who present to physicians with a physical symptom had either a depressive or anxiety disorder.[2] Common coexisting illnesses associated with depression include coronary disease, cancer, neurologic disease, and endocrine disease (e.g., hypothyroidism). Common coexisting illnesses associated with anxiety include angina, myocardial infarction, arrhythmias, congestive heart failure, mitral valve prolapse, asthma, chronic obstructive pulmonary disease (COPD), hyperthyroidism, hypoglycemia, Cushing syndrome, Parkinson disease, and cancer. Depression and anxiety often occur concurrently.

Medications. Drugs associated with exacerbation of anxiety include bronchodilators and theophylline, antidepressants (anxiety symptoms associated with starting an antidepressant usually abate after several weeks of use), various antihypertensive medications (although beta-blockers are sometimes used to decrease the physical symptoms of anxiety), steroids, psychostimulants (e.g., methylphenidate), over-the-counter medications that contain caffeine, and pseudoephedrine.

Drug intoxication or withdrawal. Drugs that may contribute to symptoms of anxiety include caffeine, alcohol, cannabis, cocaine, methamphetamine, and nicotine. Some medications that are used to treat anxiety, notably benzodiazepines, can cause rebound anxiety, in which individuals feel more anxious after the medication wears off than they did before taking it. This often leads to a cycle of escalating use.

Suicide attempts are common in individuals with depression or bipolar disorders, as well as in those with other psychiatric illnesses. One-quarter to one-half of bipolar patients attempt suicide, and approximately 15% will die as a result.[3] The mortality rate is increased in elderly patients and those with a rapidly cycling bipolar pattern.[4] Additional risk factors for suicide include the following:

  • A history of suicide attempts.
  • Suicidal ideation.
  • Family history of suicide or attempts.
  • Access to weapons.
  • Substance abuse.
  • Underlying medical illness.
  • Male gender.
  • Increasing age.
  • Presence of panic attacks.

Diagnosis

A detailed history, including psychiatric history, medication use, substance abuse, and social history, should be taken for all patients. Physical examination should include a thorough neurologic examination and should rule out disorders that are associated with depression or anxiety, especially cardiac and endocrine disease.

Particular attention should be paid to medication history as many medications may contribute to mood and anxiety disorders. Steroids, anticonvulsants, and narcotic use may increase likelihood of depressive symptoms. Some older antihypertensive medications cause depression that is indistinguishable from primary depression.

All patients should be asked about suicidal ideation, which is common in depression. Suicidality is often occurs as thoughts without an actual desire to die, or it may be passive (“sometimes I wish I would wake up dead.”) In patients deemed at high risk, however, immediate psychiatric attention (which may include hospitalization) is necessary. High risk is characterized by a well-thought-out plan for committing suicide, an actual intent to carry out that plan, or making arrangements for one’s death.

Physiologic or laboratory testing is generally not necessary except to evaluate for medical disorders (e.g., thyroid function tests, complete blood count, blood chemistries). A urine toxicology screen may be appropriate in some patients to evaluate for illicit drug use.

Diagnostic criteria for major depressive disorder, bipolar disorder, and generalized anxiety disorder are listed in the Diagnostic and Statistical Manual of Mental Disorders.

Treatment

Treatment usually includes pharmacologic and nonpharmacologic therapies, along with treatment of any coexisting medical and psychiatric conditions.

For depressive disorders, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and bupropion are most commonly used. Up to 6-8 weeks of treatment are usually necessary before the full benefit of medications is apparent, but improvements may be seen within the first 2 weeks.[5] Successful relief of symptoms occurs in about half of patients who are prescribed an antidepressant. For those who do not get better, serial trials of other antidepressants may successfully identify one that works.

For anxiety disorders, antidepressants, benzodiazepines, and buspirone are commonly used.

For bipolar disorders, atypical antipsychotics, valproate, lithium, and carbamazepine are used as preventives. Antipsychotics may also be used during exacerbations with or without psychotic features, and hospitalization may be required. Lab work may be required to monitor drug levels and physiological functioning.

In many cases of mood or anxiety disorders, psychotherapy may be effective, used alone or in combination with medications, and it improves the outcome of medication treatments. Interpersonal psychotherapy and cognitive-behavioral therapy used alone can be as effective as medications in the acute treatment of mild to moderately depressed outpatients, and the latter has an enduring effect that reduces the risk for relapse. Treatment with a combination of medication and psychotherapy may enhance the probability of response over either treatment alone, especially in persons with chronic depression.[6] Cognitive-behavioral therapy is also a well-established effective treatment for generalized anxiety disorder.[7]

Studies suggest that exercise may be as efficacious as medications for the treatment of mild to moderate depression over both the short term and the long term. The apparent antidepressant effect of exercise has been attributed to anti-inflammatory effects, the correction of dysregulation of the central monoamines, reduction of stress-induced hypothalamic-pituitary axis hyperactivity, distraction from negative emotions, and improvement in self-esteem and self-efficacy.[8]

Avoidance of caffeine, alcohol, and recreational drugs can help prevent exacerbations of mood disorders and anxiety. In addition, self-hypnosis, meditation, exercise, and relaxation techniques are helpful in treating anxiety disorders.[9]

Due to the evidence that major depression and anxiety disorders are associated with nicotine dependence,[10] referral to a smoking cessation program may be indicated. Treatment with the antidepressant bupropion may facilitate smoking cessation.[11]

Nutritional Considerations

Diet may influence mood in several ways. Caffeine and alcohol have pronounced nervous system effects. In addition, certain amino acids and other nutrients act as cofactors in the production of neurotransmitters. The following nutritional considerations apply to the prevention or management of mood disorders:

A healthy body weight. Obesity and mood disorders are often co-morbidities, and new research suggests a possible “metabolic-mood syndrome” based on the 2 disorders’ interconnected pathophysiology.[12] ,[13] Additionally, excess body weight may reduce the efficacy of some medications, pointing out the need for obesity treatment in tandem.[14] Weight loss in obese persons is associated with improvement in mood.[15]

Preventing or treating diabetes. People with type 2 diabetes are more likely to develop depression, compared with the general population.[16] Poor metabolic control may exacerbate depression and diminish the response to antidepressants, and clinical studies have shown that, as metabolic control improves, so does depression.[17] In addition, persons who are depressed are at increased risk for diabetes.[18] A meta-analysis of 9 longitudinal studies found that individuals with major depressive disorder have a 37% increased risk of developing diabetes, compared with other persons.[19]

Complex carbohydrate consumption. Dietary carbohydrate and protein influence the rate at which neurotransmitter precursors enter the central nervous system from the blood. Specifically, carbohydrate-containing meals that raise blood glucose and insulin secretion result in a drop in plasma amino acids. In turn, this means that fewer amino acids compete with tryptophan for transport through the blood-brain barrier. Tryptophan is a serotonin precursor.[20] One study with children found that poor diet generally and low carbohydrate intake specifically were closely associated with depressive symptoms.[21] Some weight loss diets recommend extreme carbohydrate restriction, which may cause problems for some people who are vulnerable to depression or anxiety.

Adequate intake of B vitamins. Low blood concentrations of folate and vitamin B12 correlate with depression in the general population.[22] The association between folate and depression may be mediated in part by elevated homocysteine levels, which are frequently found in depressed persons.[22],[23] High plasma homocysteine has been associated with reduced levels of cerebrospinal fluid amine metabolites 5-hydroxyindole acetic acid (5-HIAA), homovanillic acid (HVA), and 3-methyl, 4-hydroxy phenylglycol.[24] A common variant of the enzyme 5, 10-methylenetetrahydrofolate reductase (MTHFR) is significantly more common in individuals with elevated homocysteine or depression.[25]

Folic acid is important in the production of tetrahydrobiopterin (BH4), a cofactor in the conversion of phenylalanine to tyrosine and in the hydroxylation of tyrosine and tryptophan, rate-limiting steps in the synthesis of dopamine, norepinephrine, and serotonin. BH4 is also involved in regulating the presynaptic release of neurotransmitters from nerve terminals.[22] Low blood-folate concentrations are associated with significantly greater risk for relapse in persons on antidepressant therapy,[26] and folate status predicts response to antidepressant treatment in the elderly.[27] Two clinical trials adding methyltetrahydrofolate (one at 500 μ g/d, the other at 15 mg/d) to an antidepressant regimen further reduced depressive symptoms, as indicated by the Hamilton Depression Rating Scale.[28]

Observations that depression is associated with low levels of both vitamin B 12[29] and pyridoxal phosphate[30] indicate that increasing dietary (and perhaps supplemental) intakes of these vitamins may be important in preventing or treating depression.[31] Higher folate intake has been found to be protective against depressive symptoms in men,[32] but a long-term follow-up study on folic acid supplementation in women found no benefit compared to a placebo, despite decreased homocysteine levels.[33] Limited evidence suggests that geriatric patients with depression and cognitive dysfunction respond better to antidepressant medication when given supplemental vitamins B 1, B 2, and B 6, compared with antidepressant treatment alone.[34] Some have suggested that a high folate intake may help explain the low prevalence of depression in China.[22]

Omega-3 Fatty Acids. Depression is associated with lower levels of long-chain omega-3 fatty acids (i.e., eicosapentaenoic and docosahexaenoic acids) in red blood cell membranes.[35] Some, but not all, studies have found that in countries where intake of these fatty acids is higher, depression is less prevalent.[36]

Blood levels of polyunsaturated fatty acids have predicted cerebrospinal fluid levels of both 5-HIAA and HVA.[37] Limited trials have indicated improvements in depression rating scales when fish oils were administered along with standard antidepressants,[35],[38] ,[39] although a 2015 systematic review found that there is insufficient evidence to recommend supplementation as treatment.[40]

These fatty acids may play an anti-inflammatory role and it is possible that botanical sources of omega-3s, such as flax oil, might have the same effect.[41]

Botanical Treatments

St. John’s Wort is effective in 50%-70% of outpatients with mild depression.[42] For major depression, results have been mixed, with some reviews indicating minimal benefits,[43] some suggesting an efficacy similar to antidepressant medications,[44] ,[45] and others calling for more research.[46]

Passion flower ( Passiflora incarnata), chamomile ( Matricaria recutita), and lemon balm (Melissa officinalis) contain flavonoids that bind to benzodiazepine receptors, but evidence of their anxiolytic effects is modest.[7] , [43] In double-blind randomized trials, passion flower was as effective as a benzodiazepine for generalized anxiety disorder[47] and also adds to treatment benefits when used as a supplemental treatment.[48]

Kava is an herbal treatment with an apparent anxiolytic effect.[49] Some kava users have developed liver toxicity, which may have been attributable to excessive doses or to contamination. However, the safety of the compound is not yet established.[50]

It is important to ask patients if they are using any herb treatment. St. John’s Wort, for example, taken at high doses in addition to an SSRI may cause serotonin syndrome, which is potentially fatal.[51]

The following treatments may be helpful but require more study:

S-adenosylmethionine (SAMe)

Elevated concentrations of homocysteine often found in depressed persons (see above) may increase central nervous system (CNS) levels of S-adenosylhomocysteine, which has been shown to influence monoamine neurotransmitter metabolism. As the sole methyl donor in the CNS, SAMe is involved in the creation of monoamine neurotransmitters, membrane phospholipids, and proteins and nucleoproteins. However, available research findings do not yet support supplementation.[52] One study found an increased incidence of mania when SAMe was given to patients with bipolar disorder, so it should be avoided in this population.

Inositol

Inositol, a substance found in many foods (e.g., whole-grain cereals and legumes) is a key intermediate of the phosphatidyl-inositol (PI) cycle, a second-messenger system used by several noradrenergic, serotonergic, and cholinergic receptors. Limited studies have suggested that at doses of 8-12 g per day, inositol reduces anxiety symptoms as effectively as selective serotonin reuptake inhibitors, with a low incidence of side effects.[53] ,[54]

Orders

See Basic Diet Orders Chapter

What to Tell the Family

It is important for the family to understand that mood disorder symptoms are not simply volitional or temporary states of mind that can be easily changed. Depression in particular may arise from other medical conditions, and may indicate a need for additional treatment. Although they are medical disorders, depression, anxiety, and bipolar illnesses respond well in many cases to both medication and psychotherapy, which will often include a role for the family. Combining pharmacologic and psychotherapeutic treatments may be particularly effective. Family members can also assist the patient in informing the physician about any worsening behavioral status.

References

  1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. DSM-5 . 5 th ed. Arlington, VA: American Psychiatric Pub; 2013.
  2. Kroenke K, Jackson JL, Chamberlin J: Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med 103:339, 1997  [PMID:9375700]
  3. Jamison KR: Suicide and bipolar disorder. J Clin Psychiatry 61 Suppl 9:47, 2000  [PMID:10826661]
  4. Coryell W et al: The long-term course of rapid-cycling bipolar disorder. Arch Gen Psychiatry 60:914, 2003  [PMID:12963673]
  5. Papakostas GI et al: A meta-analysis of early sustained response rates between antidepressants and placebo for the treatment of major depressive disorder. J Clin Psychopharmacol 26:56, 2006  [PMID:16415707]
  6. Hollon SD et al: Psychotherapy and medication in the treatment of adult and geriatric depression: which monotherapy or combined treatment? J Clin Psychiatry 66:455, 2005  [PMID:15816788]
  7. Butler AC et al: The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev 26:17, 2006  [PMID:16199119]
  8. Barbour KA, Blumenthal JA: Exercise training and depression in older adults. Neurobiol Aging 26 Suppl 1:119, 2005  [PMID:16223547]
  9. Jorm AF, Christensen H, Griffiths KM, Parslow RA, Rodgers B, Blewitt KA . Effectiveness of complementary and self-help treatments for anxiety disorders. Med J Aust . 2004;181 7 Suppl:S29-S46.
  10. Bergen AW, Caporaso N: Cigarette smoking. J Natl Cancer Inst 91:1365, 1999  [PMID:10451441]
  11. Tonstad S, Johnston JA: Does bupropion have advantages over other medical therapies in the cessation of smoking? Expert Opin Pharmacother 5:727, 2004  [PMID:15102559]
  12. Mansur RB, Brietzke E, McIntyre RS: Is there a "metabolic-mood syndrome"? A review of the relationship between obesity and mood disorders. Neurosci Biobehav Rev 52:89, 2015  [PMID:25579847]
  13. Soczynska JK et al: Mood disorders and obesity: understanding inflammation as a pathophysiological nexus. Neuromolecular Med 13:93, 2011  [PMID:21165712]
  14. Woo YS, Seo H-J, McIntyre RS, Bahk W-M. Obesity and its potential effects on antidepressant treatment outcomes in patients with depressive disorders: a literature review. Int J Mol Sci . 2016;17:80-100.
  15. Evans DL et al: Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry 58:175, 2005  [PMID:16084838]
  16. Nouwen A et al: Type 2 diabetes mellitus as a risk factor for the onset of depression: a systematic review and meta-analysis. Diabetologia 53:2480, 2010  [PMID:20711716]
  17. Lustman PJ, Clouse RE: Depression in diabetic patients: the relationship between mood and glycemic control. J Diabetes Complicat 19:113, 2005 Mar-Apr  [PMID:15745842]
  18. Li L et al: Impact of Major Depressive Disorder on Prediabetes by Impairing Insulin Sensitivity. J Diabetes Metab  [PMID:27274905]
  19. Knol MJ et al: Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis. Diabetologia 49:837, 2006  [PMID:16520921]
  20. Huffman DM et al: Effect of n-3 fatty acids on free tryptophan and exercise fatigue. Eur J Appl Physiol 92:584, 2004  [PMID:15052485]
  21. Rubio-López N, Morales-Suárez-Varela M, Pico Y, Livianos-Aldana L, Llopis-González A. Nutrient intake and depression symptoms in Spanish children: The ANIVA study. Int J Environ Res Public Health . 2016;13:352-365.
  22. Coppen A, Bolander-Gouaille C: Treatment of depression: time to consider folic acid and vitamin B12. J Psychopharmacol (Oxford) 19:59, 2005  [PMID:15671130]
  23. Bjelland I et al: Folate, vitamin B12, homocysteine, and the MTHFR 677C->T polymorphism in anxiety and depression: the Hordaland Homocysteine Study. Arch Gen Psychiatry 60:618, 2003  [PMID:12796225]
  24. Paul RT, McDonnell AP, Kelly CB: Folic acid: neurochemistry, metabolism and relationship to depression. Hum Psychopharmacol 19:477, 2004  [PMID:15378677]
  25. Kelly CB et al: The MTHFR C677T polymorphism is associated with depressive episodes in patients from Northern Ireland. J Psychopharmacol (Oxford) 18:567, 2004  [PMID:15582924]
  26. Papakostas GI et al: Serum folate, vitamin B12, and homocysteine in major depressive disorder, Part 2: predictors of relapse during the continuation phase of pharmacotherapy. J Clin Psychiatry 65:1096, 2004  [PMID:15323595]
  27. D'Anci KE, Rosenberg IH: Folate and brain function in the elderly. Curr Opin Clin Nutr Metab Care 7:659, 2004  [PMID:15534434]
  28. Taylor MJ et al: Folate for depressive disorders. Cochrane Database Syst Rev  [PMID:12804463]
  29. Wolters M, Ströhle A, Hahn A: Cobalamin: a critical vitamin in the elderly. Prev Med 39:1256, 2004  [PMID:15539065]
  30. Hvas AM et al: Vitamin B6 level is associated with symptoms of depression. Psychother Psychosom 73:340, 2004 Nov-Dec  [PMID:15479988]
  31. Syed EU, Wasay M, Awan S: Vitamin B12 supplementation in treating major depressive disorder: a randomized controlled trial. Open Neurol J 7:44, 2013  [PMID:24339839]
  32. Nanri A, Mizoue T, Matsushita Y, et al. Serum folate and homocysteine and depressive symptoms among Japanese men and women. Euro J Clin Nutr . 2010;64:289-296.
  33. Okereke OI et al: Effect of long-term supplementation with folic acid and B vitamins on risk of depression in older women. Br J Psychiatry 206:324, 2015  [PMID:25573400]
  34. Bell IR et al: Brief communication. Vitamin B1, B2, and B6 augmentation of tricyclic antidepressant treatment in geriatric depression with cognitive dysfunction. J Am Coll Nutr 11:159, 1992  [PMID:1578091]
  35. Messamore E, McNamara RK: Detection and treatment of omega-3 fatty acid deficiency in psychiatric practice: Rationale and implementation. Lipids Health Dis 15:, 2016  [PMID:26860589]
  36. Nemets B, Stahl Z, Belmaker RH: Addition of omega-3 fatty acid to maintenance medication treatment for recurrent unipolar depressive disorder. Am J Psychiatry 159:477, 2002  [PMID:11870016]
  37. Hibbeln JR et al: Essential fatty acids predict metabolites of serotonin and dopamine in cerebrospinal fluid among healthy control subjects, and early- and late-onset alcoholics. Biol Psychiatry 44:235, 1998  [PMID:9715354]
  38. Su KP et al: Omega-3 fatty acids in major depressive disorder. A preliminary double-blind, placebo-controlled trial. Eur Neuropsychopharmacol 13:267, 2003  [PMID:12888186]
  39. Peet M, Horrobin DF: A dose-ranging study of the effects of ethyl-eicosapentaenoate in patients with ongoing depression despite apparently adequate treatment with standard drugs. Arch Gen Psychiatry 59:913, 2002  [PMID:12365878]
  40. Appleton KM, Sallis HM, Perry R, Ness AR, Churchill R. Omega-3 fatty acids for depression in adults. Cochrane Database Syst Rev . 2015:11;CD004692.
  41. McNamara RK: Role of Omega-3 Fatty Acids in the Etiology, Treatment, and Prevention of Depression: Current Status and Future Directions. J Nutr Intermed Metab 5:96, 2016  [PMID:27766299]
  42. Brown RP, Gerbarg PL: Herbs and nutrients in the treatment of depression, anxiety, insomnia, migraine, and obesity. J Psychiatr Pract 7:75, 2001  [PMID:15990509]
  43. Linde K, Berner MM, Kriston L: St John's wort for major depression. Cochrane Database Syst Rev  [PMID:18843608]
  44. Cui YH, Zheng Y: A meta-analysis on the efficacy and safety of St John's wort extract in depression therapy in comparison with selective serotonin reuptake inhibitors in adults. Neuropsychiatr Dis Treat 12:1715, 2016  [PMID:27468236]
  45. Anghelescu IG et al: Comparison of Hypericum extract WS 5570 and paroxetine in ongoing treatment after recovery from an episode of moderate to severe depression: results from a randomized multicenter study. Pharmacopsychiatry 39:213, 2006  [PMID:17124643]
  46. Apaydin EA et al: A systematic review of St. John's wort for major depressive disorder. Syst Rev 5:, 2016  [PMID:27589952]
  47. Akhondzadeh S et al: Passionflower in the treatment of generalized anxiety: a pilot double-blind randomized controlled trial with oxazepam. J Clin Pharm Ther 26:363, 2001  [PMID:11679026]
  48. Nojoumi M et al: Effects of Passion Flower Extract, as an Add-On Treatment to Sertraline, on Reaction Time in Patients ‎with Generalized Anxiety Disorder: A Double-Blind Placebo-Controlled Study. Iran J Psychiatry 11:191, 2016  [PMID:27928252]
  49. Lakhan SE, Vieira KF: Nutritional and herbal supplements for anxiety and anxiety-related disorders: systematic review. Nutr J 9:, 2010  [PMID:20929532]
  50. Brown AC et al: Traditional kava beverage consumption and liver function tests in a predominantly Tongan population in Hawaii. Clin Toxicol (Phila) 45:549, 2007 Jun-Aug  [PMID:17503265]
  51. Zhou S et al: Pharmacokinetic interactions of drugs with St John's wort. J Psychopharmacol (Oxford) 18:262, 2004  [PMID:15260917]
  52. Galizia I, Oldani L, Macritchie K, et al. S-adenosyl methionine (SAMe) for depression in adults. Cochrane Database Syst Rev . 2016;10:CD01128-CD011414.
  53. Mukai T et al: A meta-analysis of inositol for depression and anxiety disorders. Hum Psychopharmacol 29:55, 2014  [PMID:24424706]
  54. Benjamin J et al: Double-blind, placebo-controlled, crossover trial of inositol treatment for panic disorder. Am J Psychiatry 152:1084, 1995  [PMID:7793450]

Last updated: January 12, 2018

Citation

* When formatting your citation, note that all book, journal, and database titles should be italicized* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Mood Disorders ID - 1342051 Y1 - 2018/01/12/ PB - Nutrition Guide for Clinicians UR - https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342051/all/Mood_Disorders ER -