Managing depression post-COVID-19

Photo Cred: Anthony Tran/Unsplash

By Kellie Blake, RDN, LD, IFNCP

The novel coronavirus (COVID-19) has been challenging and possibly devastating for many. Once the immediate threat is over, the lasting psychological effects will need to be managed. We, as integrative providers, can be a resource for patients navigating this trying time.

Some of our patients may be out of work, others working from home while juggling family responsibilities, and still others who are still working in different capacities on the frontlines. In addition, patients may have gotten ill and recovered from the virus or may have experienced the death of a loved one. While we are each having a unique experience, many of us are, or will likely, experience increased stress and anxiety, and possibly depression surrounding this pandemic.

As reported in JAMA Network Open, one survey of 1,257 healthcare workers in China during the COVID-19 crisis reported significant numbers of mental health symptoms including depression, anxiety, insomnia, and psychological distress. Depressive disorders are already common in the United States, but unlike with major depressive disorder where there isn’t necessarily a specific trigger, situational depression is associated with a significant trauma and can occur up to three months after the event. Patients with situational depression often recover within six months, and while it can be debilitating, it is completely manageable often with targeted lifestyle strategies.

Over the next several months, we will likely see an increase in patients with mental health complaints associated with COVID-19 and we as providers may even experience our own symptoms. Most of us are already using lifestyle medicine to help empower patients to improve depressive symptoms and this situation is no different. We can use the tools in our toolbox to remove the roadblocks COVID-19 has set before us to help the body and brain naturally heal itself.

While every patient will need a personalized plan, some basic strategies can be utilized to help practitioners make the most of their time with patients. If not already in place, I recommend a depression screening tool as part of the initial paperwork. This will help the practitioner better understand how to prioritize patient complaints and helps to guide the customized plan. Possible depression screening questions include:

1. Do you have little interest or pleasure in doing things you normally like to do?
2. Are you feeling down, depressed, or hopeless?
3. Do you have trouble falling or staying asleep? Are you sleeping too much?
4. Do you feel more tired than usual or have little energy?
5. Has your appetite changed? Are you eating poorly or overeating?
6. Do you feel bad about yourself or feel like you let those you love down?
7. Do you have difficulty concentrating on simple activities like reading a magazine or watching the news?
8. Have you had thoughts of harming yourself?
9. Do you feel your life has meaning and purpose?

Once the screening process is in place, I encourage practitioners to recognize and eliminate any personal bias or stigma associated with depressive symptoms. As a psychiatric dietitian, I am at ease discussing mental health symptoms with my patients, but other providers may feel awkward or uncomfortable. It’s important to validate and discuss patient symptoms whether they be physical or psychological in an honest, open way. Helping patients acknowledge the very real psychological distress of COVID-19 is important for symptom reversal but will also help to minimize its disruption in our patients lives.

In the same way, highlighting just how much control patients have when it comes to improving depressive symptoms can be empowering. I work with patients to create a plan that is attainable and provides significant relief quickly. I use a mix of nutrition and lifestyle-related strategies to attack symptoms of depression.

Nutrition-related strategies

Focusing on gastrointestinal health is an easy target when it comes to improving symptoms of depression. Gut dysbiosis affects brain function in several ways, one being neuroinflammation. An imbalanced gut microbiome also affects neurotransmitter, hormone and vitamin production in the gut making optimal brain function impossible. I often implement the 5-R protocol to improve gut health and function, which naturally improves depressive symptoms.

Blood sugar fluctuations and elevated insulin levels are implicated in depression. I help my patients normalize blood sugar and reach and maintain optimal insulin levels by choosing a meal plan that is high in plant-based fiber and adequate in healthy fat and protein. I encourage patients to avoid high glycemic-low fiber and processed foods, artificial dyes, sweeteners, and food additives, as well as allergic or sensitive foods such as gluten, dairy, soy, and corn to help keep blood sugar and insulin levels in control.

I also focus on brain-boosting nutrients like omega-3 fatty acids, vitamin D, the B vitamins, magnesium, and zinc. While all of these can be obtained from food, I often supplement, at least short-term, to achieve a therapeutic benefit. Omega-3 fatty acids, particularly docosahexaenoic acid (DHA), is important for neural cell signaling and quieting neuroinflammation. I prescribe 1,000 milligrams to 4,000 milligrams per day depending on the need. Vitamin D deficiency and insufficiency is very common, especially in those with mental health issues. I supplement based on vitamin D level and aim to achieve 50 to 80ng/mL with my depression patients.

I recommend 1,000 international units to 10,000 international units of vitamin D3 depending on need. The B vitamins act as coenzymes in many cellular processes and deficiency predisposes patients to neurological disease. A large portion of the population are either deficient or marginally deficient in one or more B vitamins, so I often provide a methylated B-complex. Magnesium is a co-factor required for many of the pathways, enzymes, hormones, and neurotransmitters associated with regulating mood and most Americans have inadequate intake of this important brain nutrient. I often supplement with 200 to 400 milligrams of magnesium glycinate before bed. Inadequate zinc intake and low zinc levels can create symptoms of depression and anxiety. I recommend zinc up to 25 milligrams per day if indicated.

Finally, I utilize intermittent fasting, which has been shown to reduce neuroinflammation. I typically recommend a 12-hour overnight fast for patients but personalize based on symptoms and need.

Lifestyle-related strategies

While nutrition can dramatically improve symptoms of depression, lifestyle modification in several areas can work in conjunction with nutrition-related changes to enhance results. In addition to referring patients to the necessary mental health specialists, I use the following tips with my patients suffering depressive symptoms:

1. Create and maintain a routine schedule. Even when job and family situations are temporarily altered, it can be very comforting to maintain a healthy routine. I discuss the importance of healthy sleep, exercise, and mealtime routines.
2. Create time for daily self-care to effectively manage stress. I encourage patients to come up with several options for self-care and participate in at least one option every day. Some examples include a relaxing bath, gratitude journaling, healthy exercise, yoga, meditation, reading, listening to music, cooking healthy meals, and prayer.
3. Create a healthy social support system and avoid isolating. While social distancing may be in place for quite some time, there are numerous options for patients to stay connected and engaged with those they love. I encourage patients to create a list of people in their life who can provide emotional support and maintain routine contact with those people.
4. Learn a new hobby or volunteer. I encourage patients to challenge themselves with a new hobby, but also encourage volunteering to help boost confidence and take the focus off the internal struggle they may be experiencing.
5. Seek individual or group therapy when necessary. This can easily be accomplished online via telehealth and can be an additional support for patients with symptoms of depression.

The integrative medicine community can help effectively manage the likely increase in depression cases post COVID-19. While you may not specialize in mental health, all integrative providers can utilize the same framework used to reverse other chronic diseases for managing symptoms of depression. Be supportive, provide the necessary tools, and refer to a mental health specialist when needed and we will all get through this together.

References

Amen, Daniel. (2020). The End of Mental Illness. Tyndale Momentum

Kennedy, D. (2016). B Vitamins and the Brain: Mechanisms, Dose, and Efficacy – A Review. Nutrients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772032/

Lai J, Ma S, Wang Y, et al. (2020). Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. Retrieved from: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763229

La Rosa, F., Clerici, M., Ratto, D., Occhinegro, A., Licito, A., Romeo, M., Di Lorio, C., & Rossi, P. (2018) The Gut-Brain Axis in Alzheimer’s Disease and Omega-3. A Critical Overview of Clinical Trials. Nutrients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6164598/

Mattson, M., Moehl, K., Ghena, N., Schmaedick, M., & Cheng, A. (2018) Intermittent metabolic switching, neuroplasticity and brain health.  Nature Reviews Neuroscience.   Retrieved from: https://www.nature.com/articles/nrn.2017.156

Mikkelsen, K., Stojanovska, L., Apostolopoulos, V. (2016). The Effects of Vitamin B in Depression. Current Medicinal Chemistry. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/27655070

National Institutes of Health Office of Dietary Supplements. Zinc.  Accessed 04/09/20. Retrieved from: https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/    

Tarleton, E., Kennedy, A., Rose, G., Crocker, A., & Littenberg, B. (2019). The association between serum magnesium levels and depression in an adult primary care population. Nutrients. Retrieved from: https://www.mdpi.com/2072-6643/11/7/1475/htm