Fish Oil and Depression: Choosing the Best Omega-3 Supplement
Omega-3 Supplements Are Not Simple or Cheap
TV shows, magazines, and physicians have been recommending fish oil for depression for several years, but they never give the specifics of choosing the right supplement and dosage. If you saw the doctor for an ear infection, it would be unacceptable if he gave a vague recommendation like “take antibiotics daily.” Some antibiotics don’t treat the right bacteria and even the right ones don't work at inadequate doses. Read on and you will see that the details are just as crucial for fish oil and depression.
Based on the uninformed notion that I should be taking fish oil for my health, particularly for my heart, I went to the pharmacy section and bought the supplement with the most "fish oil" for the lowest price. This is the supplement I will use as an example for the rest of this hub. I was in medical school at the time, and I should have realized how silly it is to pay such close attention to the details for prescriptions and completely ignore the details with supplements, especially when many supplements cost more per month than a prescription copay.
People struggling with issues of mental health are often hesitant to try prescription medications and are more comfortable with trying supplements. This is what has prompted me to go back and review the data on fish oil and depression. In the rest of this hub, I will walk you through some of the research supporting the use of omega-3 supplementation for clinical depression and how to buy an appropriate supplement for treating mood symptoms. For the nuts and bolts, you can just skip to the section titled "Choosing The Right Supplement For Depression." Hopefully, you can avoid the mistakes that I and many others have made.
Should I Take Fish Oil For Depression?
Does it work? This is the first question you should ask about any supplement. The ingredients in supplements are reviewed by the FDA for safety not effectiveness, so you should be skeptical of any claims. The only way to be fully informed is to look at the research yourself. Early studies of omega-3 supplementation for depression showed positive results, but since 2005, several randomized controlled trials showed negative results. All these trials used different dosages and ratios of the key Omega-3 fatty acids - eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). To better understand the conflicting outcomes, a 2011 meta-analysis combined the results of many of these trials. This is the most comprehensive study to date, so we will focus on it for much of this article. When this larger study adjusted for the ratios of EPA and DHA in different trials, it showed positive results for supplements with at least 60% EPA.* Even more importantly, the study found that the amount of EPA in excess of DHA mattered. This dose of "unopposed EPA"** started showing benefits at 200mg a day. The effects increased as the dose increased up to 2200mg unopposed EPA daily. Doses greater than 2200mg of unopposed EPA didn't show benefits, so don't go overboard because it won't help.
Here are links to some additional studies addressing specific issues about which you may be concerned. Omega-3 supplementation has been shown to be helpful in:
*This is not EPA divided by the total "fish oil" listed on the front of the bottle as in the picture above. Rather 60% EPA means EPA/(EPA+DHA) = 0.6 or more.
**Unopposed EPA = EPA - DHA
How Do Omega-3's Help With Depression
The short answer is “we don’t know.” Of course, that is the answer for almost any intervention for depression, including prescription anti-depressants. The brain is so complex that we just can’t say for certain, but here are some theories if it helps you sleep at night.
The neuron's in your brain have a plasma membrane that is 50 percent DHA by weight. Since the plasma membrane is crucial for the transmission of electric signals in your brain, it would make sense that healthy plasma membranes = healthy neurons = a healthy brain.
A second theory is based on the growing evidence that depression may be related to inflammation in the brain, so a plausible explanation is that anti-inflammatory activity is the reason fish oil is effective. Omega-3 fatty acids are involved in some of the same inflammatory metabolic pathways as aspirin, which is why at very high doses it also shares a worrisome side effect - bruising and bleeding.
Don't Be Fooled By Omega-3 Labels
Fish oil supplement labels can be tricky, so pay close attention. If you look at the very first picture in this hub, you will notice that it advertises 1200mg of fish oil... 360mg Omega-3. And if you flip the bottle around you will see completely different numbers since the serving size is two capsules and the fatty acids are broken down into different categories.
Here is how we can apply the research to my supplement. You will see my supplement had 360mg EPA and 240mg DHA, so EPA/(EPA+DHA) = 0.6 or 60%. This meets the first criteria. The EPA in excess of DHA is 120mg (360-240=120). Remember, that is for two pills. The minimum effective dosage is 200mg unopposed EPA, so this supplement would require two servings or four pills, just to reach the minimum dose. If you set a higher goal dose closer to the ceiling of 2200mg unopposed EPA, the amount of pills would be completely impractical and unhealthy. It would require 33 pills to get 1980mg unopposed EPA (see picture below). YIKES! Don't do this. So much fish oil would be incredibly inconvenient and would put you at much higher risk for unwanted side effects. This supplement might be reasonable if it were cheap and you just wanted to reach the low threshold dose of 200mg, but if you wanted to go to the most effective dose, you would need to find a better supplement.
Fish Oil Bar Graph
Finding The Right Brand
In addition to the numbers, you should be aware of a second aspect in choosing a supplement - trust. Since supplements aren't overseen by the FDA, you want to buy from a company you trust. The Dr. Oz video below talks about a company consumerlab.com that independently tests supplements. Their reports cost money, and it is unclear to me how reputable the company really is. It might be worth checking out. If you have any experience with them, please leave a comment.
Also, take anything from Dr. Oz with a grain of salt. He recommends omega-3 supplements high in DHA, touting their benefit for your mood, which you now know is completely wrong. Also, the supplements he recommends at the end of the video clip each contain 100mg unopposed EPA per pill, so for maximum effectiveness you would have to take 22 capsules. There are much better options than these.
Nordic Naturals is a brand that has been used in several research trials, and they have many options for high EPA formulas. Well known brands like Nature Made, are probably a safe bet as well. They make the supplement in my example, but also have high EPA formulations that could be a good choice for depression.
Choosing The Right Supplement For Depression
To make the best decision, take the following steps. It may seem like a bit of work, but the alternative is staying depressed and wasting your money.
- Choose a goal dosage somewhere between 200mg and 2200mg excess EPA (EPA minus DHA). Remember higher is more effective.
- Browse online or at the store and look for supplements with at least 60% EPA. Generally, if they have more EPA than DHA, you will meet this criteria. The more EPA in excess of DHA the better.
- Once you have a handful of potential supplements, write down the amount of EPA and DHA, the pills per serving, the capsules in a bottle, and the price per container.
- Compare how many pills you would need to take and how much it will cost at different doses.
- Check online to see how much you trust the different manufacturers and read customer reviews.
- Buy the fish oil supplement that has the best combination of trust, price, and convenience for your goal daily dosage.
OK, Now What?
Take the capsules with meals. If you have to take 4 or more to achieve your goal dose, it can be helpful to split up doses with breakfast and dinner. Some people freeze their pills to help avoid "fish burps."
Don't expect a change immediately. One of the studies listed above that showed fish oil was beneficial in addition to an SSRI, also noted that it didn't change the amount of time to symptom relief. If you think back to the theories on how fish oil might work, this makes sense. You can't replenish a nutrient or eliminate chronic inflammation immediately. In the same way, you won't have acute changes with a missed dose, so just take your next dose like you normally would. And if you want to stop for whatever reason, then stop. You don't need to taper and you shouldn't experience withdrawal, but your symptoms may return.
Based on this, I think it is fair to approach fish oil supplementation in a manner similar to traditional antidepressants - don't expect immediate results, you may notice some benefits within weeks but shouldn't expect the full benefits until at least six weeks. In the same way, I would wait a month before increasing the dose. There isn't a lot of data to back that up, so I could be wrong. If you have experience, please vote in the pole to help future readers.