Flowers of Hibiscus (rosa-sinensis Linn) popularly known as “China-rose flowers” contain significant flavonoids (such as anthocyanin and quercetin) known to have antidepressant activity.
The antidepressant effect may be from its antioxidant activity; there are few controlled studies on human populations. Hibiscus has been used in Hawaiian cultures to treat postpartum depression.
Another herbal tea, made from the sepals of Hibiscus flowers are beautiful, showy red flowers that are harvested and dried like most teas. This plant contains bioflavonoids, which are believed to help prevent an increase in LDL cholesterol, and to lower blood pressure. The research is quite clear on these effects. It may work by boosting nitric oxide production, generally an advantage for cardiovascular activities (aerobic exercise).
Again, why bother to make tea with this food and limit the nutrient availability when you can eat it! I use a heaping tablespoon in my morning smoothie. I also like to blend it with green tea and ice, then strain it into water bottles as a drink during exercise.
 Butterweck, V., Jürgenliemk, G., Nahrstedt, A., & Winterhoff, H. (2000). Flavonoids from Hypericum perforatum Show Antidepressant Activity in the Forced Swimming Test. Planta Medica, 66(1), 3-6. doi:10.1055/s-2000-11119.
 Vanzella, C., Bianchetti, P., Sbaraini, S., Vanzin, S. I., Melecchi, M. I., Caramão, E. B., & Siqueira, I. R. (2012). Antidepressant-like effects of methanol extract of Hibiscus tiliaceus flowers in mice. BMC Complementary and Alternative Medicine, 12(1). doi:10.1186/1472-6882-12-41.
 Kobayashi, J. (1976). Early Hawaiian Uses of Medicinal Plants in Pregnancy and Childbirth. Journal of Tropical Pediatrics, 22(6), 260-262. doi:10.1093/tropej/22.6.260.
 Siddiqui, A., Wani, S., Rajesh, R., & Alagarsamy, V. (2006). Phytochemical and pharmacological investigation of flowers of hibiscus rosasinensis linn. Indian Journal of Pharmaceutical Sciences Indian J Pharm Sci, 68(1), 127. doi:10.4103/0250-474x.22986.
Lithium was once used as a key ingredient in a soft drink invented in 1929 by Charles Leipe Grigg, an American from Price Branch, Missouri. He initially called his drink “Bib-Label Lithiated Lemon-Lime Sodas”. He later changed the name to ” 7 Up Lithiated Lemon-Lime”.
The “7” in the name comes from the atomic mass of lithium. He called his drink 7-Up presumably because of the ability of lithium to elevate the mood. These were obviously low concentrations of lithium citrate; as in deep warm springs yielding lithium salts that have been used for centuries to calm visitors at spas.
In 1962, George Winokur introduced lithium to Washington University in St. Louis (where I happened to do my adult psychiatric residency and child fellowship), having the Barnes Hospital pharmacy make up the pills and achieving an “amazing remission” in a patient who had failed on thorazine treatment and eighteen sessions of electroconvulsive therapy. This was the beginning of the widespread use of lithium in the United States for bipolar disorder and later for mania prophylaxis and still later as an adjunctive treatment for depression; it is today the only psychotropic medication that does not carry the “black box” disclaimer of potentially leading to suicidal thoughts.
The lithium ion is the third element on the periodic table and as it is just above sodium, it does have similar chemical properties to sodium. In the beginning of the twentieth century, lithium salt was prescribed as a substitute for table salt because it was not associated with high blood pressure; however, use in high arbitrary doses could lead to toxicity, so was discontinued for that purpose.
Lithium appears to be a nutritionally essential trace element found predominantly in plant-derived foods and drinking water, although its function has not been fully described. This trace element is typically present in all human organs and tissues, and is equally distributed in body water, as lithium is absorbed from the intestinal tract and excreted by the kidneys.
Recent research studies measuring the effects of trace levels of lithium, commonly found in lithia waters (on the order of 2 mg/liter compared to typical pharmacologic doses of 900 mg/ day), have demonstrated neuroprotective abilities, as well as improvements in mood and cognitive function.
Studies on the local concentration of lithium in some municipal water supplies suggest that lithium has moderating effects on suicidal and violent criminal behaviors. In addition to a whole-food varied-plant diet four 12 ounce glasses of water is recommended. I keep a paper cup dispenser near every source of water in my home and drink a five-ounce cup or two each time I wash my hands.
 Dr. Winokur, together with colleagues Eli Robbins and Samuel Guze — with whom I studied while at Washington University — established the first written formalized criteria for mental disorders, the so-called Feighner criteria, establishing the basic model for the Diagnostic and Statistical Manual series (DSM). The motivation for these criteria was totally as a way to compare research studies on similar patients and not to be taken too literally, a position lost in the many later DSM versions and now falling in disrepute. Dr. Winokur is credited with the statement “Making up new sets of diagnostic criteria in American psychiatry has become a cottage industry with little attempt at quality control”, source Glicksman, A. (2009). “Jesus Loves Me, that I Know, for the Chi-Square Tells Me So” Privileged and Non-Privileged Approaches to the Study of Religion and Aging: A Response. Journal of Religion, Spirituality & Aging, 21(4), 316-317. doi:10.1080/15528030903127155.
 Schrauzer GN (2002) Lithium: occurrence, dietary intakes, nutritional essentiality. J Am Coll Nutr 21:14–21.
 Xu, J., Culman, J., Blume, A., Brecht, S., & Gohlke, P. (2003). Chronic Treatment With a Low Dose of Lithium Protects the Brain Against Ischemic Injury by Reducing Apoptotic Death. Stroke, 34(5), 1287-1292. doi:10.1161/01.str.0000066308.25088.64.
 Schrauzer, De Vroey. Effects of Nutritional Lithium Supplementation on Mood. Biological Trace Element Research Volume 40 1994 pages 89-101.
 Schrauzer, G. N., & Shrestha, K. P. (1990). Lithium in drinking water and the incidences of crimes, suicides, and arrests related to drug addictions. Biological Trace Element Research, 25(2), 105-113. doi:10.1007/bf02990271
 Armstrong, L. E., Ganio, M. S., Casa, D. J., Lee, E. C., Mcdermott, B. P., Klau, J. F., . . . Lieberman, H. R. (2011). Mild Dehydration Affects Mood in Healthy Young Women. Journal of Nutrition, 142(2), 382-388. doi:10.3945/jn.111.142000.
Iodine, an essential nutrient, is an intrinsic component of the thyroid hormone regulating metabolism at all ages and critical for fetal, infant, and child development, including neurodevelopment . Iodine deficiency is the leading cause of preventable intellectual developmental disability in the world. If iodine intake is chronically too low or too high, prevalence of hypothyroidism and hyperthyroidism may be elevated.
The daily Dietary Reference Intake (DRI) recommended by the United States Institute of Medicine is between 110 and 130 µg for infants up to 12 months, 90 µg for children up to eight years, 130 µg for children up to 13 years, 150 µg for adults, 220 µg for pregnant women and 290 µg for lactating mothers. The Tolerable Upper Intake Level for adults is 1,100 μg /day (1.1 mg/day).
Hypothyroidism results in symptoms that appear similar to clinical depression, such as low mood, low energy levels, weight gain, forgetfulness, and personality changes; it can also lead to elevated cholesterol levels.
Hyperthyroidism mimics mania and anxiety disorders, with increased activity and weight loss, difficulty sleeping, and irritability.
Reduction in the prevalence of iodine deficiency worldwide has been achieved through the fortification of sodium chloride (“table salt”; sea salt and salted processed foods are not fortified with iodine), but salting foods leads to increase in blood pressure, the major risk factor for death worldwide. Therefore, if we are not eating salted food or fish, as recommended in our whole-food varied plant diet, are we getting enough iodine?
In fact, making the dietary iodine sufficiency even more challenging, soy, flaxseeds, spinach, sweet potatoes, pears, peaches, raw cruciferous vegetables (broccoli, Brussels sprouts, cauliflower, and cabbage) and other fruits and vegetables disrupt the production of thyroid hormones by interfering with iodine uptake in the thyroid gland, acting as so-called goitrogens.
There are fruits and vegetables that may contain significant levels of iodine, but this is highly dependent on the soil from which the plant was grown. Organic farming tends to yield higher amounts of iodine because there is a greater tenancy for proper soil management and crop rotation. Some foods that may contain significant amounts of iodine include:
- Dried seaweed; a quarter ounce serving may contain as much as 4500 µg of iodine – four times the Tolerable Upper Intake Level. Unless you are a regular consumer of high purity seaweed and can adjust the amount to close to the DRI, this should probably not be your dietary source of iodine.
- Potatoes; the skin of a medium size common potato can harbor as much as 60 µg of iodine, so three potatoes could provide adequate daily intake. However, again, it depends on the soil and farming methods as well as the accompanying dietary goitrogens.
- Cranberries; can be rich in iodine with the same provisos as those listed for potatoes.
There are limited data on the dietary iodine intake of vegetarians and vegans in the United States; however, the iodine content of a Swedish vegan diet was found to be 39 µg iodine per 1000 kcal compared to a mixed diet of 156 µg per 1000 kcal. This was similar to the iodine content of German vegan diets.
The first report of iodine nutrition and thyroid function in vegans in the United States stated that Americans are at risk for low iodine intake, and these were for vegans that did allow use of iodine-enriched sodium chloride.
Therefore, for those individuals with whole-food varied-plant dietary patterns not using iodine-enriched sodium chloride, an iodine supplement is recommended. An example supplement of potassium iodide contains 225 µg.
 Delange, F. (2007). Iodine requirements during pregnancy, lactation and the neonatal period and indicators of optimal iodine nutrition. Public Health Nutrition, 10(12A). doi:10.1017/ s1368980007360941.
 Zimmermann, M. B., & Boelaert, K. (2015). Iodine deficiency and thyroid disorders. The Lancet Diabetes & Endocrinology, 3(4), 286-295. doi:10.1016/s2213-8587(14)70225-6.
 United States National Research Council (2000). Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academies Press. pp. 258–259.
 Vanderpas J (2006). “Nutritional epidemiology and thyroid hormone metabolism”. Annu. Rev. Nutr. 26: 293–322. doi:10.1146/annurev.nutr.26.010506.103810.
 AbdullaM, Andersson I, Asp NG, Berthelsen K, Birkhed D, Dencker I, Johansson CG, Ja¨ gerstad M, Kolar K, Nair BM, Nilsson-Ehle P, Norde´n A, Rassner S, Akesson B, Ockerman PA (1981) Nutrient intake and health status of vegans. Chemical analyses of diets using the duplicate portion sampling technique. Am J Clin Nutr 34:2464 – 2477.
 Waldmann A, Koschizke JW, Leitzmann C, Hahn A 2003 Dietary intakes and lifestyle factors of a vegan population in Germany: results from the German Vegan Study. Eur J Clin Nutr 57:947–955.
 As an example, Pure Encapsulations – Iodine (potassium iodide) – Hypoallergenic Supplement contains capsules of 225 µg at a daily cost of $0.12 per capsule.
The fourth vitamin to be discovered, vitamin D, is technically not a vitamin as one’s body can produce it – it just requires sunlight. No one is suggesting that sunlight is a vitamin per se. And only a relatively short span of radiation from the sun is involved, the so-called UVB of the ultraviolet spectrum. The intensity of UVB available depends on the weather, season, location on earth, and time of day; in the United States it maximizes between 10 am and 4 pm between April and October.
With moderate direct exposure to the summer sun (say 5 – 30 minutes twice a week), the body will make 10,000 to 20,000 IU. Sunscreen can effectively block UVB absorption; for an individual with frequent sun exposure (greater than twice per week), it might be prudent to place sunscreen after the first 10 – 15 minutes of sun exposure to avoid skin cancer but allow vitamin D production. As our bodies can store vitamin D, it is thought that sufficient exposure during spring, summer, and early fall should be sufficient to provide needed vitamin D during the winter months.
So this is another recent modification in our evolution – to stay indoors a lot more than our ancestors, decreasing our vitamin D production. The National Academies Institute of Medicine has no guidelines for vitamin D through sun exposure; they do have RDA but it is based on food intake.
The reaction of cholesterol (in the form of 7-dehydrocholesterol) in the skin with sunlight actually produces several fat-soluble related compounds, the most important being cholecalciferol, vitamin D3, and ergocalciferol, vitamin D2. The term “vitamin D” includes both of these compounds.
Very few foods in nature contain vitamin D, although some food products have vitamin D as an additive. To manufacture vitamin D industrially, 7-dehydrocholesterol, a substance typically obtained from fish liver,or lanolin extracted from shorn sheep wool, is exposed to UVB light, producing vitamin D3. Vitamin D cannot be manufactured directly; it requires the photochemical process.
To become biologically active, vitamin D has to undergo two transformative reactions, one in the liver, then another in the kidney.
Vitamin D deficiency to the extent of causing rickets or osteomalacia is rare in the developed world but what we might call vitamin-D insufficiency, a lower than ideal biologically active form of vitamin D, appears to be quite common, particularly in the elderly.
Vitamin D toxicity is also rare. There is a feedback loop associated with vitamin D production in the skin that lowers its production as adequate amounts are reached. This natural regulatory mechanism doesn’t apply to supplementation but for daily supplemental intake of 2,000 IU (about 50 micrograms) per day, there is very little risk of toxicity.
As vitamin D is fat soluble, it requires the presence of fat for absorption; some supplements encapsulate cholecalciferol, vitamin D3, with fat; otherwise often it is recommended to take with a meal containing some degree of fat.
We have learned relatively recently that vitamin D has a lot larger effect on the body than just calcium absorption; for example, it has to do with modulation of cell growth, neuromuscular and immune function, and reduction of inflammation. And mood states.
Vitamin D and psychiatric disorders
Vitamin D acts on receptors in a variety of regions in the brain such as the prefrontal cortex, hippocampus, cingulate gyrus, thalamus, hypothalamus, and substantia nigra and as such can influence neurochemistry cognition, emotion, and behavior. Vitamin D deficiency in early life affects neuronal differentiation, and brain structure and function and appears to have some influence on disorders with a developmental basis, such as autistic spectrum disorder and schizophrenia ontogeny and brain structure and function.
The initial suggestion that vitamin D may be linked to clinical depression was based on the relation between low vitamin D and high prevalence of seasonal affective disorder (now considered to be a depressive disorder with seasonal pattern) in winter at high latitudes. One treatment modality for clinical depression with seasonal pattern is light therapy, although no ultra-violet light is used. Vitamin D insufficiency is not considered to be directly causative for this disorder.
However, vitamin D concentrations have been shown to be low in many patients suffering from mood disorders and have been associated with poor cognitive function . For example, data from the third National Health and Nutrition Examination Survey were used to assess association between serum vitamin D and depression in 7,970 residents of the United States. In that study, the likelihood of having depression in persons with vitamin D deficiency was found to be significantly higher compared to those with vitamin D sufficiency.
One thorough systematic review and meta-analysis of observational studies and randomized controlled trials was conducted and found that vitamin D insufficiency was strongly associated with clinical depression. Another systematic review and meta-analysis showed a statistically significant improvement in depression with Vitamin D supplements.
Use of vitamin D as adjunctive therapy, i.e. together with an antidepressant medication in patients with vitamin D insufficiency has shown to be superior to an antidepressant alone
What to do
This is another situation where recent changes in human lifestyle – here being indoors more than outdoors, can lead to a nutrient deficiency. Because it is so common to have a vitamin D insufficiency and the health consequences, specifically mood states, I recommend more time in the outdoors, including some limited time (say 10 minutes a day) with face and arms without sunscreen.
If you do not spend regular time in the sun, I do recommend a vitamin D3 supplement to be taken before, during, or directly after a meal. I think it wise to take these supplements during the winter months in any case.
Should you question whether or not you may be clinically depressed, professional assessment certainly is recommended as always; initial workup may include serum vitamin D levels (usually 25(OH)D is measured but various labs use different techniques resulting in varying “normal” level ranges).
A strict ethical vegan, however, faces a dilemma as the sources of vitamin D3 supplementation (and all “fortified products such as almond milk and tofu) are animal-based. Some literature supports vitamin D2 intake as sufficient, but good studies are too scarce to suggest this as the sole source for supplementation; vitamin D2 can be obtained from certain mushrooms set out in the sun for 10 minutes or so prior to consumption and there are supplements available from this source. It would appear that lifestyle emphasis on “fun in the sun” is indicated for vegans.
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 Ross, A. C., Manson, J. E., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., . . . Shapses, S. A. (2011). The 2011 Dietary Reference Intakes for Calcium and Vitamin D: What Dietetics Practitioners Need to Know⁎⁎This article is a summary of the Institute of Medicine report entitled Dietary Reference Intakes for Calcium and Vitamin D (available at http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx) for dietetics practitioners; a similar summary for clinicians has also been published (Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, Durazo-Arvizu RA, Gallagher JC, Gallo RL, Jones G, Kovacs CS, Mayne ST, Rosen CJ, Shapses SA. The 2011 report on Dietary Reference Intakes for calcium and vitamin D from the Institute of Medicine: What clinicians need to know. J Clin Endocrinol Metab. 2011;96:53-58).Journal of the American Dietetic Association, 111(4), 524-527. doi:10.1016/j.jada.2011.01.004
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 Yue, W., Xiang, L., Zhang, Y., Ji, Y., & Li, X. (2014). Association of Serum 25-Hydroxyvitamin D with Symptoms of Depression After 6 Months in Stroke Patients. Neurochem Res Neurochemical Research, 39(11), 2218-2224. doi:10.1007/s11064-014-1423-y
 Eyles, D. W., Burne, T. H., & Mcgrath, J. J. (2013). Vitamin D, effects on brain development, adult brain function and the links between low levels of vitamin D and neuropsychiatric disease. Frontiers in Neuroendocrinology, 34(1), 47-64. doi:10.1016/j.yfrne.2012.07.001
 Gabbard, Glen O. Treatment of Psychiatric Disorders. 2 (3rd ed.). Washington, DC: American Psychiatric Publishing. p. 1296.
 Stumpf WE, Privette TH: Light, vitamin D and psychiatry. Role of 1,25 dihydroxyvitamin D3 (soltriol) in etiology and therapy of seasonal affective disorder and other mental processes. Psychopharmacology (Berl) 1989, 97:285–294.
 Wilkins, C. H., Sheline, Y. I., Roe, C. M., Birge, S. J., & Morris, J. C. (2006). Vitamin D Deficiency Is Associated With Low Mood and Worse Cognitive Performance in Older Adults. The American Journal of Geriatric Psychiatry, 14(12), 1032-1040. doi:10.1097/01.jgp.0000240986.74642.7c
 Przybelski, R. J., & Binkley, N. C. (2007). Is vitamin D important for preserving cognition? A positive correlation of serum 25-hydroxyvitamin D concentration with cognitive function. Archives of Biochemistry and Biophysics, 460(2), 202-205. doi:10.1016/j.abb.2006.12.018
 Ganji, V., Milone, C., Cody, M. M., Mccarty, F., & Wang, Y. T. (2010). Serum vitamin D concentrations are related to depression in young adult US population: The Third National Health and Nutrition Examination Survey. Int Arch Med International Archives of Medicine, 3(1), 29. doi:10.1186/1755-7682-3-29
 Anglin, R. E., Samaan, Z., Walter, S. D., & Mcdonald, S. D. (2013). Vitamin D deficiency and depression in adults: Systematic review and meta-analysis. The British Journal of Psychiatry, 202(2), 100-107. doi:10.1192/bjp.bp.111.106666
 Spedding, S. (2014). Vitamin D and Depression: A Systematic Review and Meta-Analysis Comparing Studies with and without Biological Flaws. Nutrients, 6(4), 1501-1518. doi:10.3390/nu6041501
 Khoraminya, N., Tehrani-Doost, M., Jazayeri, S., Hosseini, A., & Djazayery, A. (2012). Therapeutic effects of vitamin D as adjunctive therapy to fluoxetine in patients with major depressive disorder. Australian & New Zealand Journal of Psychiatry, 47(3), 271-275. doi:10.1177/0004867412465022