Do you routinely ask your patients with some form of clinical depression (depressive disorders) or bipolar disorder to take an omega-3 fatty acid supplement? If not, why not? There is data to support use of such supplementation as an adjunct in the treatment of these disorders.
However, many clinicians may not be clear about which omega-3 fatty acids to recommend, in what ratio, and in what dose. Here is some practical information about how to recommend this supplement:
1. Which omega-3 fatty acids?
The omega-3 fatty acid mental health clinicians are most interested in is eicosapentaenoic acid (EPA). The other commonly used omega-3 fatty acid is docosahexaenoic acid (DHA).
Do not recommend other omega-3 fatty acids like alpha linolenic acid (found in flaxseed) since they have not been shown to be helpful for mental health problems.
2. What should the ratio of EPA to DHA be?
For benefit in clinical depression, it is important that the amount of EPA in the supplement should be at least 1.5 times the amount of DHA. Preferably, the amount of EPA should be double that of DHA (or more).
3. Anything else to look for?
The manufacturing process should be “pharmaceutical grade”, i.e., very high quality. Firstly, the fish oil supplement should be highly pure, with mercury removed. Secondly, it should be manufactured without exposure to oxygen because fish oil deteriorates upon exposure to air.
3. What should the total daily dose be?
The total amount of omega-3 fatty acids in the supplement should be about 1000 mg per day; perhaps up to 2000 mg/day.
4. Is a higher dose harmful?
Supplements are not harmless! Do not usually exceed 3000 mg per day of omega-3 fatty acids as it may increase the risk of bleeding. Even at lower doses, we should be aware of this possibility, especially in patients on warfarin or otherwise at increased risk of bleeding.
5. How to improve gastric tolerability
The manufacturers often recommend that the entire dose can be given in a single dose, but I recommend splitting the total daily dose into two doses and to take them after meals for better gastric tolerability.
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References
1. Mischoulon D, Freeman MP. Omega-3 fatty acids in psychiatry. Psychiatr Clin North Am. 2013 Mar;36(1):15-23. PubMed PMID: 23538073.
2. Sarris J, Mischoulon D, Schweitzer I. Omega-3 for bipolar disorder: meta-analyses of use in mania and bipolar depression. J Clin Psychiatry. 2012 Jan;73(1):81-6. PubMed PMID: 21903025.
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Yes, I’ve been using omega-3 supplements (EPA/DHA) with my patients for years. I typically prescribe the EPA fatty acid to be at least 60% of the total fatty acid content. Agree, I also dose between 1-3 grams daily and state they can divide with meals. To avoid unwanted fish burps, I tell patients to keep their omega-3 supplement in the refrigerator and take right before meals. ConsumerLab.com is a great resource to find quality brands of omega-3 supplements and a wide variety of other supplements.