As medical providers, we want to make sure our patients get the best medicinal agents we recommend, regardless if they are a prescription or a natural health product/dietary supplement. In the US, the FDA does not regulate supplements with the same regulatory rigor as prescription medications. Natural health products may be contaminated with other herbs, pesticides, or metals, or even adulterated with unlabeled, illegal ingredients such as prescription drugs. To mitigate these risks, providers should only recommend products that have been through third party product verification and are considered pharmaceutical grade. Some well known regulatory agencies include (but are not limited to) the National
Sanitation Foundation, US Pharmacopeia, Good Manufacturing Practice Certified, and ConsumerLab.com.
Below is a list of well-established and researched pharmaceutical grade supplement companies that have third party product verification. This list does not include all companies that may apply. PNPs are able to sign up as providers for an individual companies and receive all of their products at wholesale prices (typically 50% off MSRP).
Metagenics
Pure Encapsulations
Nordic Naturals
Gaia Herbs
Designs for Health
Douglas Labs
Integrative Therapeutics
DiVinci Labs
Transformation Enzymes
Master Supplements
Thorne Research
Nu Medica
Another avenue for recommending supplements without stocking them in your office is using a “virtual dispensary” service. HealthWave (https://www.healthwavehq.com) is a virtual dispensary and treatment plan delivery software. The software allows you to easily prescribe and sell natural health products to your patients without the hassle and overhead of carrying physical inventory.
Supplements with evidence for Depression/Anxiety/OCD
5-Hydroxytrptophan (5-HTP)
5HTP is produced naturally from the seeds of an African plant, Griffonia simplifolia. This amino acid can act as an intermediate in mood regulation by converting to serotonin. Serotonin is necessary for regulating sleep, appetite, and providing a sense of calmness (Birdsall, 1998[DMS1] ). Turner and Associates conducted a review and found efficacy for depression treatment in all studies reported (Turner, 2005[DMS2] ). Common dosages used are between 50-200mg QD-BID. Just as clinicians should use caution in SSRI's with patients with underlying bipolar disorder, the same applies for 5HTP as it has the potential to trigger mania. Turner and Associates conducted a review and found efficacy for depression treatment in all studies reported (Turner, 2005 ). Common dosages used are between 50-200mg QD-BID. Just as clinicians should use caution in SSRI's with patients with underlying bipolar disorder, the same applies for 5HTP as it has the potential to trigger mania.
Inositol
Inositol is a vitamin-like substance linked to various neurotransmitters used clinically for anxiety primarily. Studies on inositol's efficacy are lacking, however some appear promising. Inositol (and NAC) have been found to been an effective agent for excoriation disorder (skin picking) (Torales, 2017). Patients with trichotillomania were given 6-18 grams/day of inositol and 41% demonstrated improvement in controlling their pulling behavior (Leppink, 2017). A meta-anlysis by Makai and Associates evaluated inositol for depression and anxiety and found it beneficial for depressed patients but not as effective for anxiety (Mukai, 2014). Inositol typically comes in a white powder substance that is tasteless and easy to mix in a beverage. Side effects are rare and it is generally well tolerated.
L-Theanine
L-Theanine is an amino acid found in green tea known to increase resilience and decrease stress perception. L-theanine has been shown to increase alpha waves in the brain and promote a sense of calmness and relaxation. A systematic review by Mancini and Associates in 2017 concluded L-theanine can also improve working memory, cognition, and improve attention (Mancini, 2017). Typical doses of L-theanine studied are from 100-400mg daily. When L-theanine was given daily at 250mg over 8 weeks, subjects with major depressive disorder showed an improvement in anxiety, sleep, and depression (Hidese, 2017). One cup of green tea typically has approximately 25mg of L-theanine, so a therapeutic dose might need to be achieved through supplementation.
Methyl folate (5-MTHFR)
Methyl folate is the most biologically active form folate. It is a water-soluble B vitamin. Along with B12 and B6, the body uses these vitamins in monoamine neurotransmission. When folate (or B6 and B12) is insufficient, the nervous system does not have the tools for optimal functioning (Venn, 2003 ). Uses methyl folate bypasses genetic SNPs that may impair folate synthesis and it reduces the potential for masking B12 deficiency (which can happen with synthetic folic acid) (Koury, 2004 ). Studies support altered folate metabolism contributing to major depression and higher homocysteine. When subjects were given active B vitamins, their homocysteine lowered and they had a reduction in their depressive symptoms (Mech, 2016). Numerous studies have demonstrated a reduction in depression with using methyl folate, given both with and without SSRI medications (Fava, 2009 & Stahl, 2008 ). There are now many different prescription only medical foods providers can prescribe to their patients that contain methyl folate. Examples are Deplin, XaQuil, and Enylte.
S-Adenosylmethionine (SAMe)
Promising research shows efficacy with many neuropsychiatric conditions and osteoarthritis with oral administration of SAMe (Galizia, 2016 & Sharma, 2017). SAMe is a methyl donating amino acid that occurs naturally in the body and helps break down neurochemicals such as dopamine, serotonin and melatonin. It is thought to work by influencing neuronal membrane fluidity. Studies in SAMe are primarily in adults, however lower doses may be tolerated and effective in children. GI upset is the most common side effect. Dosages should start at 200mg QD-BID. Dosages as high as 800mg BID have been given in adults with depression (Green, 2012).
NAC (N‐Acetyl Cysteine)
NAC is a derivative of the amino acid L-cysteine. It is a precursor to the potent antioxidant glutathione, and used for a variety of clinical indications. Perhaps clinicians know NAC best for its IV rescue ability for Tylenol overdose. Studies also reveal NAC can help with obsessive compulsive disorder, skin picking, gambling, and hair pulling. It has also been shown to improve irritability in with children in autism when given 900mg TID over 4 weeks (Harden, 2012). Due to its wide variety of efficacy with multiple disorders, clinicians should consider NAC, especially in children with anxiety.
Omega 3 Essential Fatty Acids
Researchers convey omega-3s fatty acids could potentially normalize membrane structure in the brain and improve neurotransmitter uptake.10870,10871 There have been links to low omega 3 levels and depression10859,10860,10866 Both EPA and DHA (contained in Omega 3 fatty acids) have shown benefit in improving depression. For children >12, consider giving 1.5-3 grams of a combination of EPA/DHA daily to promote mood stabilization. Children ages 6-12 where given 1 gram of fish oil over a period of 16 weeks and have depression improvement greater than placebo. 65712
St. Johns's Wort
St. John's wort might be the most well studied nutraceutical known for depression. It is a flowering plant native to Europe. Its function inhibits the reuptake of serotonin, norepinephrine and dopamine. 763,3553,4521,6474 It also appears to affect other neurochemicals such as glutamate and gamma-aminobutyric acid (GABA).3553,4521 St. John's wort might also have synergistic effects with GABA receptors in the brain and mitigation of the excitatory neurotransmitter glutamate. St. John's work has been proven effective for mild to moderate depression. St. Johns wort has been given to children (<12 years) with dosages ranging 300-1800mg/day and showed an improvement in depressive symptoms after six weeks (Hubner, 2001 ). Strong caution is advised with St. Johns wort due to its multiple drug/herb interactions.