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Depression and Bipolar Disorder
The Increasing Rates of Depression and bipolar depression
Something has been going on since 1945: the rates of depression have increased world wide, and the age of onset is shifting downward - younger people are being affected. This trend called "the cohort phenomenon" was noted in the 1980s by Drs. Gerald Klerman, Myrna Weissman, and Elliot Gershon who found that each successive generation of individuals born since World War II appears to have a higher incidence and earlier age of onset of both major depression and bipolar depression.
While there are many theories attempting to explain this striking increase, one of them points to the increase in our diets of sources of omega-6 oils (corn and soy as two examples) and the corresponding marked decrease in omega-3 fats (this has not been proven, however).
The association between depression and the types of fats we consume was made when Joseph R. Hibbeln, of the National Institute of Health examined the consumption rate of omega-3 in countries around the world. In an important paper published in 1998 in the British Journal The Lancet, he reported that the rates of depression were lower in countries that consumed a lot of fish. He found that rates of depression could actually be predicted based on fish consumption.
An association had been established. A year later, in April 1999, in the Archives of General Psychiatry, Dr. Andrew Stoll from Harvard and his colleagues published the first double-blind placebo study which examined what happens when rapidly-cycling bipolar patients had their medications supplemented with high doses of fish oils. (It should be noted that eight of the 30 were not on medications of any type.)
The thirty patients were divided into two groups and one group got a placebo of olive oil capsules; the other 9 grams of pharmaceutical quality EPA and DHA fatty acids. While the study was designed for a nine-month period, a preplanned preliminary analysis of the data found a significant discrepancy between the placebo control group and the omega-3 fatty acid group: the patients on the placebo relapsed or failed to improve, while many of the patients taking the omega 3 supplements experienced dramatic recoveries.
Why might this be? To paraphrase Dr. Stoll in his book The Omega Connection: When a neurotransmitter binds to a receptor, the receptor sets in motion within the cell a series of chemical processes known as signal transduction,amplifying the original signal and ultimately altering the activity of theca. We know that mood stabilizers inhibit signal transduction.
He goes on to say that "inhibiting signal transduction in bipolar disorder would be analogous to building a dam across a raging river, quieting the downstream waters."
Lithium and the anticonvulsants inhibit signal transduction....so too do omega-3 fatty acids.
A Host of Questions
Since the Stoll findings were published and received a lot of media attention, a number of parents have placed their children suffering with bipolar disorder on fish oil supplements. Some parents report a difference in their children's behaviors: they seem less explosive, calmer and their moods appeared more stable. One mother whose very young child was being given only omega-3's said: "He went from a 10 (in severity) to a two."
Another mother wrote of her child's diagnosis at eight following a hospitalization. Her daughter was stabilized on lithium, but last year - at the age of 13 - she began taking 1 g of an enriched EPA omega-3 product in addition to the lithium." She's gained a higher level of stability than we'd ever seen before," the mother reported.
But questions abound about this treatment. How many grams of omega-3's a day must a child ingest (often in addition to many pills and capsules of prescription medications)? Which brand should they take? How much EPA and DHA should they be taking (what should the ratio of one to the other be)?
We turned to a neuroendocrinologist in Scotland,David Horrobin, MD who is a pioneer in lipid metabolism, and who has been researching and reporting on essential fatty acids for over two decades.
First we told him that many parents want to know how they are supposed to get their children to swallow so many capsules of omega-3's. (They are extrapolating from Dr. Stoll's study which gave 9 grams of omega-3's to the patients with bipolar disorder.)
Dr. Horrobin responded that he could answer dosing questions only about unipolar depression and schizophrenia because he and his research team had conducted dose ranging studies with pure ethyl-EPA looking at 1g, 2g, and 4 g per day. In schizophrenia the optimum dose was 2g per day with 4 g giving less benefit. In depression, the optimum dose was 1g, with 2g and 4g giving less benefit.
In other words, there were diminishing returns when giving higher doses - in those two illnesses.
Then we raised the question about the amounts of EPA and DHA in each capsule: what should they be?; and why, if the brain is constructed of mostly DHA, is the impression growing that pure EPA, or ratios high in EPA compared to DHA may be preferable. (This has also not been proven in bipolar disorder.)
He answered that the impression of EPA's greater importance is derived from the conclusions of three studies in depression and schizophrenia which compared placebos to an EPA-rich oil and a DHA-rich oil and found that the EPA preparation was effective, but the DHA preparation was not. In some studies, mixed EPA/DHA preparations were effective, however.
Why should EPA be more important? Dr. Horrobin replied: "The whole issue of EPA versus DHA is a controversial one. There is no doubt that in the brain there is an abundance of DHA whereas EPA levels are very low and possibly mainly found in the microvessals. There is no doubt at all that DHA is vital when the brain is growing rapidly in utero and in the first 2-3 years of independent life. But beyond that it looks as though EPA is more important.
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