AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset When did you start experiencing your current symptoms? When I got laid off. It’s been getting worse since I can’t find another job. Understanding the cause (client)

I get the impression you have not been satisfied with the explanations that have been given to you previously for your symptoms, is that correct?

What do you think is the cause?

Yeah, I get annoyed when my doctor thinks there is something wrong with me, when I know I am just feeling trapped and bored.

Because I’m at home doing nothing.

Exacerbating factors Is there anything that makes them worse? When I argue with my wife or when we have trouble paying bills. Relieving factors Is there anything that makes them better? Not really. Examination and inspection Mark appears passive and withdrawn. His face is inexpressive, his face is red and he has dark rings under his eyes.

TABLE 10.2 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Has anyone else in your family ever experienced similar symptoms?	I don’t think so.
Obstruction and foreign body
Do you snore during the night and wake up feeling fatigued and unrested? (sleep apnoea)	Yeah. I snore a lot but I think it’s because I drink too much alcohol at night.
Recreational drug use
Are you taking any recreational drugs?

No. The fact I have taken up smoking again is causing friction at home.

Occupational toxins and hazards Could you have been exposed to any potentially toxic chemicals or heavy metals in your previous job? I don’t know. I suppose I could have been but nobody ever said anything about it. Functional disease Did the fatigue begin after losing your job or did you feel it before? (functional origin) Yeah, I used to have loads of energy. Supplements and side effects of medication Are you taking any supplements or medication at the moment? No. Stress and neurological

Have you experienced any associated symptoms to the tiredness such as decreased libido and vague aches and pains along with disturbed sleep? (depression)

Have you experienced other symptoms such as headaches, chest pain, palpitations, dizziness, or feelings of nervous foreboding? (anxiety related)

All of those things.

No chest pains or dizziness, I don’t feel anything much.

Eating habits and energy Tell me about your diet and energy levels. Mark tells you he knows his diet isn’t particularly good at the moment. He is eating a lot of junk food and drinking too much coffee and beer out of boredom. His wife gives him healthy food but he often doesn’t have much appetite for it.

TABLE 10.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Support systems
Do you have a supportive social or family network? Are you aware of the support agencies available to you?	If I really needed help I think the family would do something, but don’t I like to ask anyone for help. Centrelink gave me a list of places, but I haven’t gone to any of them.
Emotional health
Do you think you are depressed?	I don’t think so, I’m just bored and out of work.
Daily activities
Tell me about your daily routine.	Mark tells you he sleeps late, watches TV when he gets up. He might go out to get the paper or shopping with his wife during the day. He is usually in bed by 10 pm.
Stress release
How do you deal with your stress?	Smoking and drinking. I know it’s not good.
Home life
How are things at home right now?	There is a fair bit of tension with my wife. She says she understands, but I think it’s my fault we’re having problems paying the bills. I’m washed up and unemployable at 48. Not a good example to set for the kids.
Action needed to heal
How do you think I can help you? [76]	I don’t know, it was the wife’s idea.
Long-term goals
Do you have any long-term goals?	To be working again.

TABLE 10.4 MARK’ S SIGNS AND SYMPTOMS [1, 6, 7]

Pulse	70 bpm
Blood pressure	125/78
Temperature	36.6°C
Respiratory rate	14 resp/min
Body mass index	29
Waist circumference	97.7 cm
Face	Lack of facial expression, red face, dark rings under the eyes
Urinalysis	No abnormality detected (NAD)

TABLE 10.5 RESULTS OF MEDICAL INVESTIGATIONS [1–5]

TEST/INVESTIGATION	RESULT
Full blood count: To rule out infection, tumour, inflammation, anaemia	All cells appear normal
Epstein-Barr/Ross River virus blood test	Negative for postviral infection
Cholesterol blood test	Within normal range
Thyroid function test	NAD
CRP (C-reactive protein): infection, inflammation, tumour, bacteria	Normal range
Liver function test	NAD
Serum electrolyte blood test	NAD
Serum cortisol blood test	NAD
Toxicology screen	NAD
Lead level	NAD

TABLE 10.6 UNLIKELY DIAGNOSTIC CONSIDERATIONS [1–5, 8–11, 62, 67, 68, 71–73]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Bronchogenic carcinoma	CRP normal
Chronic cardiorespiratory disease	No shortness of breath, hypertension, electrolyte balance normal
RECREATIONAL DRUG USE
*Causal factor:* Liver damage due to alcohol excess	LFT normal
OCCUPATIONAL TOXINS AND HAZARDS
*Causal factor:* Toxins	Toxicology screen clear
*Causal factor:* Lead toxicity	Lead levels within normal range
FUNCTIONAL DISEASE
Electrolyte imbalance (hyponatraemia, hypokalaemia, hypercalcaemia)	Blood test and urinalysis within normal range
DEGENERATION AND DEFICIENCY
Anaemia	Full blood count normal
*Causal factor:* Nutritional deficiency: Mark is pale	No sign of smooth glossy tongue or cheilosis on sides of mouth
*Causal factor:* Organic fatigue: tired, sleep disturbances, no major physical abnormalities	Shorter duration than functional fatigue; Mark’s fatigue does not generally worsen during the day
INFECTION AND INFLAMMATION
*Causal factor:* Current viral infection: glandular fever, Ross River virus	Full blood count normal, no fever
*Causal factor:* Current bacterial infection	Full blood count normal, no fever
Hepatitis	LFT normal, no sign of jaundice
ENDOCRINE/REPRODUCTIVE
Hypothyroidism/hyperthryoidism	Thyroid function test normal
Adrenal insufficiency/Cushing’s syndrome	No low blood pressure or skin pigmentation, serum cortisol within normal range
Diabetes	Urinalysis NAD
AUTOIMMUNE DISEASE
Rheumatoid arthritis/systemic lupus erythematosus	CRP normal
STRESS AND NEUROLOGICAL DISEASE
Causal factor: Psychological depression: adjustment disorder, tiredness, hypersomnia, low mood due to a particular life-changing event or psychological cause	Depression does not continue for more than 2 months; not considered major depression
Physiological depression: postviral infection, depression, fatigue [73]	Blood tests reveal no viral illness such as glandular fever during the past 6 months
Type 2 – minor depression: can be mild or moderate depression	Need to show 2–4 symptoms of depression that have lasted at least 2 weeks; Mark shows more than 4 signs of depression currently

TABLE 10.7 CONFIRMED DIAGNOSIS [1–3, 10, 11]

CONDITION	RATIONALE
Depression: important differential diagnosis to rule out before exploring other possibilities of mental or organic causes for fatigue symptoms	Tiredness that has lasted several months, feelings of guilt, watching excessive amounts of television, excess coffee, alcohol and junk food, feeling like wanting to cry; anxiety began after the trauma of losing his job; fatigue generally improves during the day
Primary origins: primary depression and endogenous depression are associated with conditions that are regarded as primary disorders, i.e. that do not occur secondarily to other medical or psychiatric disorders; these terms refer to depression that is caused by internal chemical and biological factors rather than external stressors	Type 1: major (clinical) depression; has at least five symptoms of depression for more than 2 weeks and causes considerable incapacity with daily activities; can be moderate or severe depression; people often describe symptoms in physical terms

Case analysis

TABLE 10.8 POSSIBLE FURTHER DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [1–5, 8–11, 16, 62–76]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
ALLERGIES AND IRRITANTS
Food intolerance/allergy	Fatigue, depression, recent dietary change since feeling low; Mark may be eating foods he did not previously eat	Need to gain more insight into Mark’s previous and current diet and associated symptoms
OBSTRUCTION AND FOREIGN BODIES
Obstructive sleep apnoea [63]	Daytime naps, tired; sufferers are often obese and Mark’s BMI is 29; can be made worse by drinking alcohol prior to sleeping; Mark wakes up feeling unrefreshed and snores during the night	Do not usually complain of ‘sleepiness’ but rather fatigue generally
FUNCTIONAL DISEASE
Chronic fatigue syndrome: fatigue for at least 6 months that has no physical explanation when there is no diagnosis of psychoses, bipolar affective disorder, eating disorder or organic brain disease [65, 72]	Severe disabling fatigue affects both mental and physical functioning for at least 6 months; Mark is sleeping more, has depression, feelings of guilt, social withdrawal and crying spells	Need to determine whether Mark experiences muscular and mental fatigue for at least 24 hours after exertion before some level of recovery; need to determine if fatigue improves during the day; need to determine if Mark experiences at least two neurological/cognitive manifestations of chronic fatigue syndrome such as impaired concentration and muscle weakness; no significant autonomic, neuroendocrine or immune manifestations of the disorder present for Mark; often due to postviral infection, which Mark has not had
Causal factor: Seasonal affective disorder	Secondary to the winter months; symptoms include increased sleep, tiredness, increased appetite, weight gain	Need to determine if Mark has experienced episodes of depression during the winter months in the past
Causal factor: Physiologic fatigue	Can be caused by depression, caffeine, alcohol, excess sleep, intense emotions; recent diagnostic studies are within normal limits; could be feeling physiologic fatigue concurrently with functional fatigue from depression	Symptoms present for less than 14 days and are not usually associated with changes in self-esteem, social difficulties or overall mood
Causal factor: Functional fatigue	Tiredness that has lasted several months, began after the trauma of losing his job; feeling of fatigue generally improves during the day
STRESS AND NEUROLOGICAL DISEASE
Bipolar disorders: mental illness where individual alternates between manic episodes and major depression [66, 74]	May not think he needs help or there is anything out of balance mentally	Need to determine if there are episodes of manic behaviour that may include restlessness, fast speech, weight loss, difficulty sleeping; not sure if there is any family history of mental illness
Dysthymia: mild depressive illness [70]	Mark could be experiencing ‘double depression’ if he has had intermittent periods of depression in the past; symptoms include tiredness, lack of interest in life, low mood	Lasts intermittently for 2 years or more; need to determine if Mark had episodes of feeling low prior to losing his job
Mixed anxiety and depressive disorder	Depressive disorder often associated with an experience of loss; symptoms of fatigue, apathy or intense sadness; Mark has mentioned a significant incapacity to continue daily activities for work and family	Numerous physical complaints associated with depression such as restlessness, headaches, insomnia, shortness of breath, gut or skin disorders
Posttraumatic stress disorder (PTSD): symptoms often develop within 6 months of the stressful event	Family tension could indicate emotional detachment from his family; Mark’s symptoms developed after he was made redundant; Mark has mentioned anxiety about re-training and finding a new job	Has not mentioned flashbacks to a particular traumatic event such as losing job
Causal factor: Emotional stress	Tired, concerns about job security, financial difficulties, family strain; longer duration than acute organic origin of tiredness	No irritability or shortness of breath reported
Causal factor: Suicidal tendencies	Secondary to anxiety and depression; more common in males over 45 years of age; Mark appears emotionally depressed	Need to determine if Mark has had thoughts of suicide, a history of suicide attempts, long history of alcohol abuse, family history of substance abuse or has experienced any psychotic symptoms

Working diagnosis

Mark and depression

Mark is a 48-year-old man who was laid off work six months ago. Since this time Mark has experienced increased fatigue, sleepiness and a lack of interest in daily activities. Mark has started smoking again and is eating unhealthy food, not exercising, is emotionally detached from his wife and is experiencing feelings of guilt and worthlessness. Mark recently had a series of blood tests that ruled out several organic causes for his current symptoms of depression. His doctor would like him to begin a course of antidepressants but Mark does not believe he is depressed.

Depression is diagnosed when a person has had a shift in their self-esteem and are more self-critical, feel hopeless and helpless, guilty and pessimistic. Other signs of depression include negative physical and cognitive symptoms. Types of depression may be categorised under several terms that include whether the depression is primary, secondary, major, minor, mild, moderate, severe and psychological or physical. Major and minor depression are defined on a rating scale dependent on how many symptoms of depression are present every day for at least two weeks.

Mark’s symptoms have now developed into what appears to be a primary major depression with severe symptoms present for more than two weeks. The clinical definition of major depression involves a prominent and persistent depressed or low mood that interferes with daily functioning almost every day for at least two weeks, and normally includes at least four of the following symptoms:

• depressed mood most of the day nearly every day

• diminished interest or pleasure in everyday activities most of the day nearly every day

• insomnia or hypersomnia nearly every day

• significant change in appetite nearly every day with weight loss or gain

• fatigue or loss of energy nearly every day

• psychomotor agitation or retardation such as restlessness or slower movements

• lack ability to think or concentrate nearly every day

• feelings of worthlessness or guilt nearly every day

• recurrent thoughts of death or suicide.

It can be common for a person not to recognise they actually have major (clinical) depression and may only understand their symptoms from the perspective of physical changes rather than psychological. Although Mark may have initially had reactive depression that was a secondary response to a life event, his symptoms have continued and present as a potential chemical and biological imbalance that is difficult to restore to equilibrium.

General references used in this diagnosis: 1–5, 62, 67–69

TABLE 10.9 DECISION TABLE FOR TREATMENT PRIOR TO REFERRAL

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to improve symptoms of depression • Physical therapy suggestions to help improve symptoms of depression • Dietary recommendations to increase intake of essential nutrients for optimal production of serotonin and other neurotransmitters • Dietary recommendations to eliminate foods that may be having an adverse effect on Mark’s mental health • Herbal tonic, tablets or tea with antidepressant, anxiolytic, tonic and adaptogenic action

• Lifestyle recommendations to eliminate unhelpful habits or behaviours and improve general health and fitness

• Dietary recommendations to improve general health and nutrition and avoid consuming food or drinks that may be adversely affecting his mental health

• Herbal tonic, tea or tablets with adaptogenic and tonic actions

• Recommendation for Mark to attend counselling

• Recommendation for Mark to consult a careers advisor

• Prioritising herbal and nutritional supplement recommendations to help with affordability

• Emphasise dietary changes and lifestyle modifications that are more affordable

• Nutritional supplements to improve symptoms of depression

NB: the use of 5-HTP, l-tryptophan or s-adenosylmethionine (SAMe) must be monitored to ensure there are no adverse reactions; if Mark decides to take l-tryptophan, 5-HTP or SAMe in conjunction with the herbal tonic, tea or tablets, the herbal formula should be reformulated due to the potential for interaction between 5-HTP, l-tryptophan and SAMe with St John’s wort

• Nutritional supplements to increase intake of essential nutrients

TABLE 10.10 DECISION TABLE FOR REFERRAL [1–5, 8–11, 16]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Untreated symptoms of major depression as Mark has not chosen to follow his doctor’s advice to take antidepressants • Depressed mood most of the day nearly every day • Diminished interest or pleasure in everyday activities most of the day nearly every day • Hypersomnia nearly every day • Significant change in appetite nearly every day with no weight loss or gain • Fatigue or loss of energy nearly every day • Feelings of worthlessness or guilt nearly every day	• Increased alcohol intake • Taken up smoking again	• Relationship tension with Mark’s wife • Doesn’t feel he can talk to his wife • Low self-esteem • Financial stress; will affect Mark’s ability to afford treatment recommendations • Concerns about employability and retraining options • Unwilling to share the extent of his emotional feelings
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
Nil	• Poor diet resulting in inadequate intake of essential nutrients • Lack of physical activity	• Sleeping during the day because he is ‘bored’ • Watching TV excessively and isolating himself
REFERRAL DECISION	REFERRAL DECISION	REFERRAL DECISION
• Recommendation for mental health assessment and clear information to be provided to Mark regarding choice of taking antidepressants and working collaboratively with a doctor, psychotherapist and counsellor support symptoms of major depression [69]	• Dietary assessment and evaluation to ensure adequate intake of nutrients for nervous system support	• Counselling and mental health assessment [70] • Family counselling

Confirmed diagnosis

Major clinical depression with functional fatigue

Prescribed medication

• Antidepressant medication – previously prescribed. Mark has decided not to take the antidepressant medication at this stage and wants to try natural therapies.

TABLE 10.11 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–5, 7, 10, 11, 16]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Referral for counselling	Emotional assessment and support
Referral for mental illness assessment	If it is felt Mark is in danger of hurting himself or someone else; it is important that other health professionals are also aware a client may have suicidal thoughts and tendencies
IF NECESSARY:
Sleep clinic observation	Sleep apnoea
Anti-nuclear antibody	Autoimmune disorders
Vitamin D [22, 23]	Vitamin D deficiency
Heavy metal toxicity screening: mercury, cadmium, arsenic, nickel, aluminium [8, 9]	Heavy metal toxicity can cause neurological and behavioural changes [24]; lead levels are within normal range, but other heavy metals have not been tested for
Serum test for biotin, folic acid, vitamin B6, B2, B3, B12 and C, calcium, copper, iron, magnesium and potassium	Deficiency can cause depression [8, 9]
Brain scan	Brain tumour

TABLE 10.12 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Continue with lifestyle recommendations to improve symptoms of depression • Continue with physical therapy suggestions to help improve symptoms of depression • Continue with dietary recommendations • Continue with herbal tonic, tablets or tea • Continue with essential nutritional supplements NB: If Mark decides to take prescribed antidepressant medication his herbal formula will need to be reformulated to remove St John’s wort; if he is taking l-tryptophan, 5-HTP or SAMe, they will need to be discontinued if he decides to take the prescribed antidepressant; Mark must be monitored collaboratively with his GP to ensure his treatment program is effective and to adjust the program where necessary

• Continue with lifestyle recommendations to eliminate unhelpful habits or behaviours and improve general health and fitness

• Continue with dietary recommendations to improve general health and nutrition

• Continue with herbal tonic, tea or tablets to support Mark’s stress response

• Continue with essential nutritional supplements; supplement recommendations may be altered depending on the results of serum and/or hair tissue mineral tests for nutrient deficiencies and heavy metal toxicity

• Recommend Mark continues with counselling

• Encourage Mark to continue seeing a career advisor and consider retraining options

• Ensure initial and ongoing treatment recommendations are prioritised to ensure affordability

• Maintain emphasis on dietary changes and lifestyle modifications to help keep the program affordable

Treatment aims

• Identify and address the factors contributing to Mark’s depression [8, 9].

• Balance Mark’s neurotransmitter levels [8, 9, 17, 38].

• Improve Mark’s stress response and adrenal function [9, 17, 49]. Stress-related adrenal dysfunction can result in depression [9, 49].

• Support normal function of Mark’s hypothalamic-pituitary-adrenal axis [9, 17, 49].

• Optimise Mark’s nutritional status. Nutritional deficiencies may contribute towards depression [8, 9, 17, 22, 45, 46].

• Direct Mark to therapies that help the development of a positive mental attitude [8, 47] and skills to improve quality of life [9, 47].

• Improve Mark’s lifestyle to reduce or eliminate factors such as excessive alcohol consumption, smoking, poor diet and lack of physical activity, which may be contributing towards his depression [8, 9, 21, 35, 47].

Lifestyle alterations/considerations

• Refer Mark for counselling utilising cognitive behavioural therapy that aims to help him develop a positive mental attitude, set realistic goals, avoid negative behavioural patterns and find ways to include laughter and humour into his life [8, 9, 17, 47].

• Regular daily exercise is an effective method of treating depression [8, 9, 17, 47]. Aerobic exercise such as brisk walking, running [21] or weight training [9] has been shown to reduce depression [9, 21].

• Stress-management techniques [49], such as relaxation therapy [9, 47] and yoga breathing exercises [47], might be helpful to Mark.

• Encourage Mark to spend time outside in the fresh air and sunshine to get sufficient sun exposure for adequate vitamin D production. Vitamin D deficiency is associated with depression [22, 23].

• Test Mark for heavy metal toxicity and treat if necessary [9, 24].

• Encourage Mark to live a more healthy lifestyle, incorporating healthy eating, reduced alcohol consumption, quitting smoking and daily physical activity [21, 35, 45, 47].

• Encourage Mark to consult with a careers advisor to help him consider his employment and retraining options.

• Encourage Mark to take up an activity that gives him a purpose and has a positive effect on his family. Planting a vegetable garden may help him to feel he is contributing to the family and may facilitate a greater level of involvement and engagement with his children if they are encouraged to work with him in the garden. Eating home grown vegetables will provide significant nutritional benefits.

Dietary suggestions

• Encourage Mark to follow a Mediterranean-style, nutrient-dense, antioxidant-rich whole-food diet that contains plenty of vegetables, whole grains, legumes, nuts and seeds and cold-water fish [9, 45]. Mediterranean diets have a protective role against depression [45].

• Encourage mark to increase consumption of tryptophan-containing foods such as turkey, salmon, bananas, legumes, fish, whole oats, nuts and seeds, soy and dairy products [8, 9, 17, 40]. Also increase dietary intake of tyrosine from dairy foods, nuts and seeds, oats, whole grains, eggs, fish and soy products [25].

• Encourage mark to increase his dietary intake of omega-3 fatty acids [9, 17, 19, 25, 34].

• Encourage mark to significantly reduce or eliminate refined and processed foods, sugar [9, 17, 19, 46], coffee and other stimulants [9, 17].

• Encourage mark to significantly reduce or eliminate alcohol consumption [9, 35, 56].

• Identify and eliminate foods to which Mark is sensitive or allergic [9, 57].

• Encourage Mark to eat a low GI/GL diet. There is evidence of a link between hypoglycaemia or altered glucose metabolism and depression [19, 20].

Physical treatment suggestions

• Mark may benefit from massage therapy [47, 50, 51]. Massage therapy can reduce anxiety and depression [50, 51]. The use of lavender oil during massage therapy may be particularly helpful [25, 41].

• Electroacupuncture may be of benefit to Mark [42].

• Hydrotherapy: 2–3-minute cold (no less than 55°F/12°C) showers twice a day [18, 52, 55], alternating hot and cold showers with 1–2 minute of hot and 15–30 seconds of cold. Repeat 3–4 times twice a day [18, 54]. Neutral bath from ¼ –1 hour daily for several days [53], full body cold mitten friction [53], constitutional hydrotherapy daily or weekly [53]. Dry skin-brushing prior to bath, followed by wet skin-brushing in the bath with a loofah [54].

TABLE 10.13 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
St John’s wort Hypericum perforatum	60 mL	Antidepressant [25, 26, 47]; anxiolytic [25, 26]; inhibits synaptic reuptake of serotonin, noradrenalin and dopamine [25, 26]; upregulates serotonin receptors [25, 26]; clinical trials indicate use in treating mild to moderate depression [25, 26] Caution should be exercised if Mark decides to take the prescribed antidepressant medication, his formula should be reformulated to remove St John’s wort [25, 26]
Siberian ginseng Eleutherococcus senticosus	40 mL	Adaptogenic [25, 28]; tonic [28]; theoretical application in depression is due to the herb’s ability to increase serotonin and noradrenalin [29]; clinical indications include stress [25, 28], fatigue [25, 28] and to increase vitality [28]
Damiana Turnera diffusa	60 mL	Traditionally used in Western herbal medicine as an antidepressant and anxiolytic [27, 28]; particularly beneficial where there is a sexual factor involved [25]
Rhodiola Rhodiola rosea	40 mL	Adaptogenic [31]; tonic [31]; traditionally used to treat fatigue, depression and nervous system disorders [31]; effective in reducing symptoms of depression [32]; effective in reducing symptoms of generalised anxiety disorder [33]
Supply:	200 mL	Dose: 10 mL twice daily

TABLE 10.14 TABLET ALTERNATIVE TO HERBAL LIQUID: MAY IMPROVE COMPLIANCE

HERB	DOSE PER TABLET	RATIONALE
St John’s wort Hypericum perforatum	750 mg	See above
Damiana Turnera diffusa	675 mg	See above
Schisandra Schisandra chinensis	625 mg	Adaptogenic [25, 44]; hepatoprotective [25]; nervine tonic [44]
Skullcap Scutellaria lateriflora	500 mg	Nervine tonic [43]; mild sedative [27, 43]; indicated for use in nervous tension [27]

Dose: 2 tablets twice daily

TABLE 10.15 HERBAL TEA

A less expensive option if Mark has concerns about the cost of the herbal tonic or tablet
HERB	FORMULA	RATIONALE
St John’s wort Hypericum perforatum	2 parts	See above
Damiana Turnera diffusa	1 part	See above
Lavender Lavandula angustifolia	1 part	Antidepressant [27, 28]; anxiolytic [25, 28]; improves sleep [25], mood [25] and concentration [25]
Oats seed Avena sativa	1 part	Antidepressant [27]; nutritive [25]; traditionally used in depressive states and general debility [27]
Vervain Verbena officinalis	1 part	Indicated for use in depression and melancholia [27]

Decoction: 1 cup 4 times daily

TABLE 10.16 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Omega-3 fish oil supplement containing 2000 mg EPA daily [36] An essential and affordable supplement	Effective in treating depression [8, 9, 17, 25, 34]; supplemental EPA provides significant benefits in treating depression [36, 61]
High-potency practitioner-strength multivitamin, mineral and antioxidant supplement containing therapeutic doses of essential micronutrients, particularly B-group vitamins and vitamin D [22, 25, 59, 60] An essential and affordable supplement	Nutritional deficiency can lead to depression [22, 25, 59]; because Mark’s current diet is nutrient poor supplementation is advisable B-group vitamins are essential for serotonin production [17, 25, 40]; vitamin D deficiency is associated with depression [22, 60]; because Mark spends most of his time inside he may not be getting sufficient sun exposure to maintain healthy vitamin D levels
Tryptophan supplement providing 400 mg tryptophan daily in divided doses [40] NB: In Australia doses of tryptophan exceeding 100 mg are included in Schedule 4 of the Standard for the Uniform Scheduling of Drugs and Poisons (SUSDP) and require a medical, dental or veterinary prescription [37] or 5-hydroxytryptophan [5-HTP] 75 mg daily [17] Alternative to herbal treatment; important supplement, but secondary to essential nutritional supplements and dietary recommendations if finances are tight; alternative to herbal formula; the availability and sale of 5-HTP is restricted in many Australian states and territories	Tryptophan deficiency is associated with depression [38, 40]; using contaminated l-tryptophan has been linked to the development of eosinophilia-myalgia syndrome (EMS); caution should be exercised to ensure only high-quality tryptophan products are supplied [9] Immediate serotonin precursor [40]; increases endorphins and catecholamine and is an effective alternative to SSRI medications and tricyclic antidepressants [9]; 5-HTP has a therapeutic use in depression [17, 40];
S-adenosylmethionine (SAMe) 200 mg 3 times daily [40]; an alternative to tryptophan or 5-HTP if difficulties obtaining or prescribing at the recommended dose are experienced; important supplement, but secondary to essential nutritional supplements and dietary recommendations if finances are tight; alternative to herbal treatment	Effective for mild to moderately severe depression [17, 47]; therapeutic use in depression [17, 40, 47]
Magnesium 800 mg elemental magnesium daily in divided doses [37, 40]; important supplement, but secondary to essential nutritional supplements and dietary recommendations if finances are tight	Supplemental magnesium is an effective treatment for depression [25, 37, 39]; magnesium deficiency may be a causative factor in the development of depression [25, 37, 40]