Chapter 36 Mental Health

Holistic nursing is

all nursing that has healing the whole person as a goal

Exercise

alters levels of dopamine, serotonin, NE increases cerebral flow helps to treat: substance use disorders reduces weight gain reduces symptoms of ADHD decrease anxiety levels

ANA recognizes holistic nursing as

an official specialty within the nursing profession

Ginseng

anti-coagulant effects can increase the effects of prescription anticoagulants and can seriously affect blood clotting

4. A patient reports frequent sleep disturbances. Which interventions could be considered to help improve the patient's sleep pattern? (Select all that apply.) a. Melatonin b. Chamomile c. Vitamin C d. Valerian e. SAM-e

ANS: A, B, D Melatonin, chamomile, and valerian have relaxant effects that help sleep. SAM-e may help with mild depression. Vitamin C has no effect on sleep.

22. During an assessment interview, a patient diagnosed with inflammatory bowel disease accompanied by frequent episodes of diarrhea says, "I've been using probiotics in small doses for about a week." When the nurse assesses mental status, expected findings would be a. intact cognitive function. b. slow verbal responses. c. paranoid thinking. d. slurred speech.

ANS: A Probiotics may reduce inflammation and heal the gut. No effect on cognitive function would be associated with use of microbiomes, including probiotics. The patient has taken small doses, so response times would be normal. It does not usually produce the effects cited in the distracters.

10. A patient asks, "What is the major difference between conventional health care and complementary and alternative medicine (CAM)?" The nurse's best reply is that conventional health care a. focuses on what is done to the patient, whereas CAM focuses on body-mind interaction with an actively involved patient. b. has been tested by research so less regulation is needed, but CAM is religiously based and highly regulated. c. is controlled by the health care industry, but CAM is the people's medicine and not motivated by profit. d. is holistic and focused on health promotion, whereas CAM treats illnesses and is symptom-specific.

ANS: A Conventional health care focuses primarily on curative actions implemented on a mostly passive patient, whereas CAM focuses more on the mind-body aspects of health, along with the active involvement of the patient. Conventional health care is largely grounded in scientific research, and its various components are heavily regulated; the opposite tends to be true of CAM. Some forms of CAM have their roots in religious or cultural practices, but this is not characteristic of CAM as a whole. Both conventional health care and CAM can focus on health promotion and treatment of illness. Although critics express concern about the role of profit in conventional health care, the profit motive can also apply in CAM.

17. A nurse plans health education for a patient who will be receiving warfarin for several weeks after knee-replacement surgery. Which substance should the nurse caution the patient to avoid? a. Fish oil b. Black cohosh c. Lavender d. Mandarin

ANS: A Fish oil may increase bleeding time and therefore has a potentially hazardous interaction with the anticoagulant warfarin. Black cohosh is an herbal treatment for hot flashes. Mandarin and lavender may have calming effects, which may be helpful, but would not cause increased risk of bleeding.

13. For which patient would it be most important for the nurse to urge immediate discontinuation of kava? A patient with a comorbid diagnosis of a. cirrhosis. b. osteoarthritis. c. multiple sclerosis. d. chronic back pain.

ANS: A Kava should be used with caution in patients with liver disease because of its potentially hepatotoxic effects. The other health problems do not pose immediate dangers.

8. A patient diagnosed with major depressive disorder tells the nurse, "I want to try supplementing my selective serotonin reuptake inhibitor (SSRI) with St. John's wort." Which action should the nurse take first? a. Advise the patient of the danger of serotonin syndrome. b. Suggest that aromatherapy may produce better results. c. Assess the patient for depression and risk for suicide. d. Suggest the patient decrease the antidepressant dose.

ANS: A Research has suggested that St. John's wort is a mild inhibitor of serotonin reuptake and could lead to serotonin syndrome; this risk is increased if the patient is taking other medications that increase serotonin activity. Assessing the depression would be a secondary intervention. Aromatherapy has not been shown to be an effective adjunct or treatment for depression. Although a dosage reduction in her SSRI medication might reduce the risk of serotonin syndrome, this intervention is not in the nurse's scope of practice.

7. A patient reports good results from taking an herb to manage migraine headache pain. The nurse confirms there are no hazardous interactions between the herb and the patient's current prescription drugs. Select the nurse's best comment to the patient. a. "Thanks for telling me. I'll make a note in your medical record that you take it." b. "You are experiencing a placebo effect. When we believe something will help, it usually does." c. "Self-management of health problems can be dangerous. You should have notified me sooner." d. "Research studies show that herbals actually increase migraine pain by inflaming nerve cells in the brain."

ANS: A The nurse should reinforce the patient for reporting use of the herb. Many patients keep secrets about use of alternative therapies. If it poses no danger, the nurse can document the use. The patient may also get placebo effect from the herb, but it is not necessary for the nurse to point out that information. The distracters are judgmental and may discourage the patient from openly sharing in the future.

1. A patient in good health and without any major health needs says, "I want to try some techniques to improve my mental and physical well-being but I'm overwhelmed by all the suggestions on the Internet." Which techniques would be appropriate for the nurse to suggest? (Select all that apply.) a. Yoga b. Exercise c. Meditation d. Aromatherapy e. Acupuncture f. Spinal manipulation

ANS: A, B, C, D Yoga, exercise, meditation, and aromatherapy are self-help techniques that may have a positive effect on the patient's physical and mental well-being. These techniques are unlikely to cause harm. The patient is in good health; therefore, acupuncture and spinal manipulation are not indicated.

3. Which important points should the nurse teach a patient about using herbal preparations? (Select all that apply.) a. Check active and inactive ingredients. b. Discontinue use if side or adverse effects occur. c. Avoid herbals during pregnancy and breast-feeding. d. Buying from online sources is preferable and cheaper. e. Inform your health care provider about the use of herbals.

ANS: A, B, C, E All of the instruction is correct except regarding purchase of herbals. Herbals should be purchased from a reputable firm. Internet purchasing might not be the best plan, unless the reputation of the firm can be confirmed.

2. A patient who emigrated from India is hospitalized. The patient and family use ayurvedic medicine. The nurse wants to adjust this patient's care so that it is more comfortable and familiar. What changes from usual Western practice should be considered? (Select all that apply.) a. In preparation for discharge, include a significant focus on preventive practices. b. Spend time exploring the patient's life overall, focusing on broader issues than health. c. Involve the patient's entire family and treatment team in decisions about treatment options. d. Anticipate that the patient will prefer and value interventions with high technology features. e. Provide relevant health-related information and then encourage the patient to determine which course of action to pursue.

ANS: A, B, E Ayurvedic medicine, an ancient practice that originated in India, stresses individual responsibility for health, is holistic, promotes prevention, recognizes the uniqueness of the individual, and offers natural methods of treatment. Ayurvedic medicine does not require spiritual cleansing or the involvement of family and the treatment team in all decisions.

11. A patient has tried a variety of CAM approaches to manage health concerns. The nurse asks, "How is going to CAM practitioners different from seeing your medical doctors?" The patient is most likely to respond, "The CAM practitioners a. usually prescribe a course of invasive and sometimes painful treatments." b. spend more time talking with me and not just about my symptoms." c. say I need to become much more spiritual to be well." d. order many tests to determine my diagnoses."

ANS: B CAM practitioners often spend considerable time assessing the person in a holistic way. Visits typically involve lengthy discussions, in contrast to traditional physician visits, where contact is often brief. CAM remedies can sometimes be invasive or slightly painful, but usually they are noninvasive and well-tolerated. Some CAM practices are very spiritually focused, but most do not have overt religious elements. Conventional health care involves more diagnostic testing than CAM

9. A patient tells the nurse, "I get sick so much, so I started taking ginseng to boost my immune system." The patient's only other medication is warfarin daily. Which potential complication should be included in the nursing assessment? a. Gastrointestinal distress b. Spontaneous bleeding c. Thromboembolism d. Drowsiness

ANS: B Ginseng may interact with anticoagulants and cause spontaneous bleeding. Warfarin is such an agent and can predispose the patient to spontaneous bleeding. It would not increase the risk of thromboembolism. Drowsiness and gastrointestinal complaints are common side effects

20. Select the best desired outcome for a patient who uses valerian. The patient will report a. stress level is lower. b. undisturbed sleep throughout the night. c. increased interest in recreational activities. d. early morning waking without an alarm clock.

ANS: B Valerian decreases sleep latency, nocturnal waking, and leads to a subjective sense of good sleep. Sleeping through the night is the best indicator the herb was effective. Although the patient's stress level may be lowered by use of valerian, the problem is insomnia; outcomes should relate to the problem. Early morning waking is indicative of depression or anxiety.

19. A patient had a venous thrombosis 3 weeks ago and is now taking warfarin. When visiting the laboratory to have a prothrombin time drawn, the patient reports drinking ginseng tea to stimulate the immune system. Which nursing diagnosis applies? a. Impaired memory related to neurological changes b. Deficient knowledge related to potentially harmful drug interactions c. Ineffective denial related to consequences of mismanagement of therapeutic regime d. Effective management of the therapeutic regime related to augmentation of anti-coagulant therapy

ANS: B Ginseng tea is amongst the top 10 herbal products used in the United States and believed to have multiple beneficial properties. Because it antagonizes platelet-activating factor, it should not be taken by patients who are receiving anticoagulants or who have other potential bleeding problems. Thus, deficient knowledge is an appropriate nursing diagnosis.

16. Which CAM method is associated with using allergy injections of small amounts of an allergen in solution? a. Naturopathy b. Homeopathy c. Chiropractic d. Shiatsu

ANS: B Homeopathy uses small doses of a substance to stimulate the body's defenses and healing mechanisms to treat illness. Naturopathy emphasizes health restoration rather than disease. Chiropractic uses manipulation of the body to restore health. Shiatsu is a type of massage.

18. A patient report, "Last night I had several mixed drinks at a party. When I got home, I had difficulty falling sleep. I made two cups of herbal tea with lavender. This morning, I feel very groggy and have a headache." The nurse should explain that a. lavender should be delayed at least 1 hour after using alcohol to avoid side effects. b. lavender may increase sedation from other central nervous system depressants. c. herbal teas often cause nervous system side effects such as headaches. d. these feelings are actually a hangover from excessive alcohol intake.

ANS: B Lavender has sedative properties that are potentiated when used in combination with other central nervous system depressants. Headaches are another possible side effect of this herbal medicine. The nurse should advise caution in ingesting alcohol and lavender for these reasons. Taking lavender an hour after alcohol will not prevent these interactions, and it is likely that the lavender played a role in her feeling perhaps worse than usual after this episode of drinking. Herbal teas cause headaches in some cases, but it is not characteristic of this group of herbal remedies.

5. A patient says, "I have taken mega doses of vitamins for 3 months to improve my circulation, but I think I feel worse." Which action should the nurse take first? a. Explain to the patient that vitamin mega doses may be harmful and advise caution. b. Assess the patient for symptoms and signs of toxicity from excess vitamin exposure. c. Assess for signs of circulatory integrity to determine whether improvement has occurred. d. Educate the patient that research has not shown that megadoses of vitamins

ANS: B Mega doses of many vitamins, especially when taken over long periods, may produce dangerous side effects or toxicity. The priority for the nurse is to assess for signs of any dangerous consequences of the patient's use of such a regimen. Secondary interventions would include patient education about research findings related to the practice, along with any benefits and undesired effects associated with the practice. A health care provider should also assess the patient for cardiovascular concerns.

1. A patient tells the nurse, "I've been having problems getting a good night's sleep. I read some information on the Internet and started taking kava kava." Select the nurse's priority response. a. "The Internet does not have reliable health information for consumers." b. "The Food and Drug Administration warned against using it due to the link to severe liver damage." c. "Melatonin has been shown to have better effects for treating sleep disturbances." d. "Your sleep disturbances are related to your problems with anxiety. Herbs will not help."

ANS: B The Food and Drug Administration (FDA) warned against using kava kava due to the link to severe liver damage. The nurse has responsibilities to educate patients regarding safe use of complementary therapies. Melatonin may be useful for sleep disturbances, but the patient's safety is a higher priority. The other distracters are misleading.

12. An older male patient has suffered with episodic pruritus and skin eruptions for over 2 years. This patient tells the nurse, "When my skin gets better for a few days, I start worrying that it's going to start itching again soon. I think my worry may actually trigger the problems to start all over again." Which self-help technique should the nurse consider suggesting for this patient? a. Melatonin b. Meditation c. Purification d. Acupuncture .

ANS: B The patient's comment suggests an element of anxiety accompanies the skin problem. Meditation is a popular self-help method recommended to reduce physical and emotional stress and to promote wellness. Purification, associated with ayurvedic practices, may or may not appeal to this patient. Acupuncture is performed by a professional practitioner, so it is not a self-help technique. The scenario does not indicate the patient is experiencing insomnia, so melatonin is not indicated

23. Which complementary and alternative therapy may be safely combined with traditional Western medicine in the treatment of anxiety disorder? a. Electroconvulsive therapy b. Mega doses of vitamins c. Meditative practices d. Herbal therapy

ANS: C Yoga, meditation, and prayer are considered to be beneficial adjuncts to treatment for anxiety disorder. Research supports this with findings of lower catecholamine levels following meditation. Patient self-reports suggest patient satisfaction, with increased ability to relax. Meditation and spiritual practices have no associated untoward side effects. Herbal therapy and megadoses of vitamins have potential associated side effects and interactions. Electroconvulsive therapy is not CAM.

6. Acupuncture is a traditional Chinese medical treatment based on the belief that a. insertion of needles in key locations will drain toxic energies. b. pressure on meridian points will correct problems in energy flow. c. insertion of needles modulates the flow of energy along body meridians. d. taking small doses of noxious substances will alleviate specific symptoms.

ANS: C Acupuncture involves the insertion of needles to modulate the flow of body energy (qi) along specific body pathways called meridians. Acupressure uses pressure to affect energy flow. Homeopathy involves the use of microdosages of specific substances to effect health improvement. Traditional Chinese medicine (TCM) is more concerned with energy and life force balance, and acupuncture is not predicated on the removal of toxic energies.

14. A patient tells the nurse, "I prefer to treat my physical problems with herbs and vitamins. They are natural substances, and natural products are safe." Which response by the nurse would be most appropriate? a. "Natural substances tend to be safer than conventional medical remedies." b. "Natural remedies give you the idea that you are controlling your treatment." c. "The word natural can be a marketing term used to imply a product is healthy, but that's not always true." d. "You should not treat your own physical problems. You should see your health care provider for these problems."

ANS: C CAM remedies are usually natural substances, but it is a fallacy that products labeled natural are safer than conventional medicines. Some natural products contain powerful ingredients that can cause illness and damage to the body if taken inappropriately and, for some persons, can be dangerous even when used as directed. This is the most important message for the nurse to convey to the patient. So-called natural substances can have a number of significant side effects. Natural substances may give one the belief that he is controlling his own treatment, but that is not the message that most needs to be communicated here. Many patients can safely self-manage minor physical problems.

2. A patient shows a nurse this advertisement: "Our product is a scientific breakthrough helpful for depression, anxiety, and sleeplessness. Made from an ancient formula, it stimulates circulation and excretes toxins. Satisfaction guaranteed or your money back." Select the nurse's best response. a. "Over-the-counter products for sleep problems are ineffective." b. "Do not take anything unless it's prescribed by your doctor." c. "Let's do some additional investigation of that product." d. "It sounds like you are trying to self-medicate."

ANS: C Helping consumers actively evaluate the quality of information available to them is important. It is important for the nurse to work with the patient and include the patient's preferences regarding management of health. Advertisements indicating scientific breakthroughs or promising miracles for multiple ailments are usually for products that are useless and being fraudulently marketed. Some may even be harmful. Some over-the-counter products can be useful, and patients do not need a prescription for these products. The broader issue is safety and efficacy, rather than whether the patient is trying to self-medicate

24. A patient diagnosed with depression confidently tells the nurse, "I've been supplementing my paroxetine with St. John's wort. It has helped a great deal." What is the nurse's priority action? a. Assess changes in the patient's level of depression. b. Remind the patient to use a secondary form of birth control. c. Educate the patient about the risks of selective serotonin syndrome. d. Suggest adding valerian to the treatment regimen to further improve results.

ANS: C St. John's wort inhibits serotonin reuptake by elevating extracellular sodium; thus, it may interact with medication, particularly selective serotonin reuptake inhibitors, to produce serotonin syndrome. Discussing the patient's birth control method is a secondary priority.

21. Which patient would most likely benefit from taking St. John's wort? A patient with a. mood swings. b. hypomanic symptoms. c. mild depressive symptoms. d. panic disorder with agoraphobia.

ANS: C St. John's wort may be effective in treating mild to moderate depression. St John's wort has not been found to be effective in treatment of cyclothymic, bipolar, or anxiety disorders.

15. An immigrant from China needs a colonic resection but is anxious and reluctant about surgery. This patient usually follows traditional Chinese health practices. Which comment by the nurse would most likely reduce the patient's anxiety and reluctance? a. "Surgery will help rebalance the yin and yang forces and return you to harmony." b. "The surgery we are recommending will help you achieve final transformation." c. "I know this is new to you, but you can trust us to take very good care of you." d. "If you would like, we could investigate using acupuncture to help control pain."

ANS: D It would be helpful to incorporate elements of TCM as appropriate; such as acupuncture for pain control. TCM has the goal of healing in harmony with one's environment and all of creation in mind, body, and spirit, as well as balance of yin and yang energies and a state of transition. However, it would not be helpful to suggest that surgery will balance the yin and the yang, since this is not how balance is achieved in TCM. Transformation is recognized as a stage of healing occurring when mutual, creative, active participation occurs between healers and the patient toward changes in the mind, body, and spirit; but "final transformation" could imply the end of corporeal life and might be perceived as hastening his demise. Appealing to him to trust persons whose practices are foreign to him conflicts with the patient's values and would not likely be effective.

Energy therapies

Shamanic healing rituals Therapeutic touch - therapist never physically touches patient (lowers BP, decreases edema, ease abd. pain, resolve fevers, accelerate healing) Healing touch - gentle laying on of hands on a clothed body or moving over the body in the energy field Reiki - energy based that is transferred to a recipient for physical or spiritual healing (effective in treating pain and anxiety)

4. A patient with a history of asthma says, "I've been very nervous lately. I think aromatherapy will help. I am ordering $250 worth of oils from an Internet site that promised swift results." Select the nurse's best action. a. Support the patient's efforts to become informed and to find health solutions. b. Suggest the patient check with friends who have tried aromatherapy for treatment of anxiety. c. Remind the patient, "If you spend that much on oils, you may not be able to buy your prescribed medication." d. Tell the patient, "Aromatherapy can complicate respiratory problems such as asthma. Let's consider some other options."

ANS: D Safety is paramount, and aromatherapy may cause complications for a patient with asthma. The nurse should view alternative treatments with an open mind and try to recognize the importance of the treatment to the patient while trying to give the patient accurate, reliable information about the treatment. Although efforts to become health literate should be supported, educating the patient about the pitfalls of relying on the Internet is essential. The opinions of others, whether they are positive or negative, lack a scientific basis and are subject to confounding variables such as the placebo effect and individual factors such as age and health history. Admonishing the patient may jeopardize the relationship.

3. A patient wants to learn more about integrative therapies. Which resource should the nurse suggest for the most reliable information? a. Internet b. American Nurses Association (ANA) c. Food and Drug Administration (FDA) d. National Center for Complementary and Integrative Health (NCCIH)

ANS: D The NCCIH provides reliable, objective, and scientific information to help in making decisions about use of these practices. NCCIH supports not only research, but also the development and sharing of this kind of information. The FDA has information, but it is not as extensive as NCCIH. The Internet has many resources but some are unreliable. The ANA does not provide extensive information about this topic.

Manipulative Practices

Chiropractic Massage Healing touch homeopathy aromatherapy Osteopathic manipulation

Ayurvedic

Indian philosophy of balancing life and the body through various methods ranging from massage to eating habits. It is based on three doshas, or mind and body types.

Expressive therapies

Music and art

A nursing student in her last semester has increasing test anxiety. Her professor suggests the student try some integrative therapies. The student reported successful test anxiety reduction with which of the following therapies? a. Aromatherapy and breathing exercises b. Megavitamin therapy and yoga c. Naturopathy d. Reiki

a

When considering the goals of complementary and alternative medicines, which patient would be of particular interest to researchers studying advances in symptom management? a. One who experiences chronic pain related to a neck injury b. A patient diagnosed with an acute gastrointestinal infection c. A pregnant woman diagnosed with gestational diabetes d. A child requiring surgery for a clubbed foot

a

Which statement made by the patient demonstrates an understanding of the foundational principle of integrative care? a. "My body has the ability to heal itself if we have the knowledge to give it the right tools." b. "The integrative care I'm getting is primarily a combination of complementary, alternative, and mainstream medicines." c. "Much of the knowledge that integrative care is based on comes from Western cultural traditions." d. "The most important focus of my integrative care is the cure of my cardiac illness."

a

Traditional Chinese Medicine (TCM)

a system of ancient Chinese medicinal treatments including acupuncture, diet, herbal therapy, meditation, physical exercise (tai chi and qigong), and massage to prevent, diagnose, and treat disease

Which assessment question regarding a patient's report of pain demonstrates the nurse's attention to the principles of holistic nursing care? a. "When did your pain begin?" b. "Are you taking any herbal supplements for the pain?" c. "Has anyone else in your family ever experienced this kind of pain?" d. "How has the pain affected your daily ability to care for yourself?"

b

Which factor is likely to attract a patient to complementary and alternative medicine? Select all that apply. a. This nonmainstream approach is always less expensive than conventional medical treatment. b. A desire to choose personal healthcare practices c. Using these approaches carries a lower risk than many pharmaceuticals. d. Traditional medicine has been unsuccessful in providing effective treatment. e. Integrative medication practices tend to produce desired results more quickly than conventional practices.

b, c, d

Reviewing prescription medications in the discharge instructions for a patient with a diagnosis of major depression, the nurse would caution the patient about which over-the-counter supplement(s)? Select all that apply. a. Fish oil b. SAMe c. St. John's wort d. Melatonin

b, d

Mind and body approaches

built on theories that focus on the interaction between mind and body

In contrast to most Western medicine, integrative care takes into consideration: a. The physician's diagnosis and the patient's response b. The nurse's ideas about healing in addition to the physician c. A whole-person perspective: body, mind, and spirit d. The diagnosis before beginning spirit work

c

What medication education should the nurse provide to a patient who has expressed an interest in taking St. John's wort? a. Allergic reactions to this herb are common. b. Due to liver toxicity, regular liver function test should be conducted while taking it. c. St. John's wort should not be taken in combination with antidepressants. d. This medication results in gastrointestinal symptoms including bleeding.

c

The nurse is caring for a patient who has a question about the safety of an herbal supplement. Which nursing response is best? a. "Herbal supplements are regulated by the FDA." b. "Natural ingredients in herbal supplements are harmless." c. "Your primary care provider needs to be aware of any supplements you take." d. "Marketing for herbal supplements demonstrates that all supplements are safe."

c Herbal supplements are not regulated by FDA

A patient asks the nurse if exercise and what she eats can impact her mood. The nurse's best response is which of the following? a. "There is no need to be concerned about exercise and nutrition if you take your antidepressant." b. "Limited studies are available on exercise and nutrition and mood." c. "Exercise is helpful, but you don't need to worry about nutrition." d. "Extensive research has shown that exercise and proper nutrition greatly improve mood symptoms."

d

omega-3 fatty acids

effective for depressed patients showing positive effect for bipolar disease

Bioelectromagnetic - based therapies and bright light therapy

electromagnetic fields (pulsed fields), magnetic fields, alternating-current or direct current fields all are USDA approved Bright light for SAD and non-seasonal depression

Microbiomes

healing the gut with proper nutrition and probiotics has shown promise in treating depression and anxiety

Natural products

herbal medicine (botanicals), vitamins, minerals, probiotics herbal therapy for preventative and therapeutic purposes

Acupuncture

modulate the flow of qi. acts by stimulating and altering patients physical responses including those affecting cardiac, endocrine, neurological, and immune functions

Classification for integrative care

natural products mind and body approaches other CAM therapies

complementary and alternative medicine (CAM)

outside of standard medical care includes complementary medicine, alternative medicine, and integrative medicine

Diet and nutrition

psychiatric diet are often deficient in proper nutrition Anemia is associated with depression

Meditation and mindfulness

reduce physical and emotional stress and to promote wellness. Yoga - helps to increase dopamine and GABA levels in the brain decreases depression Good Treatment for anxiety and pain

Prayer and spirituality

rely on a higher power as their source of strength and maintain a deep abiding faith despite the circumstances of illness

integrative practices are patient centered

the patient participates with the provider to heal the body and mind

Kava

used for anxiety or insomnia can be hepatoxic

St. John's Wort

used for depression, can result in serotonin syndrome with pro-serotonergic meds (antidepressants, triptans, methadone)

Viramin D

vitamin D supplementation reduced levels of depression too much can cause high levels of calcium in the blood