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HOLISTIC HEALING FOR THE MIND: COMPLEMENTARY AND ALTERNATIVE THERAPIES IN PSYCHIATRY Sudha Prathikanti, MD University of California, San Francisco www.prathikanti.com/teaching INTEGRATIVE PSYCHIATRY A healing approach that uses both conventional and complementary / alternative medicine to understand and treat psychiatric conditions. NIH DEFINITION OF COMPLEMENTARY & ALTERNATIVE MEDICINE (CAM) Healthcare systems, practices, and products not presently considered to be part of conventional medicine. Complementary: together with conventional practice Alternative: in place of conventional practice NIH CLASSIFICATION OF CAM Alternative Medical Systems Ayurveda Traditional Chinese Medicine Homeopathy Mind-Body Therapies Meditation Biofeedback Hypnosis and Guided Imagery Biologically-Based Therapies Botanicals and Herbs Nutritional Supplements Energy Therapies Reiki Qi Gong Magnets Manual Therapies Massage Chiropractic USE OF CAM IN THE UNITED STATES General public’s use of CAM: --42% (Eisenberg 1998) --36% when prayer excluded (Barnes et al, 2004) --62% when prayer included (Barnes et al, 2004) Among people with self-reported anxiety or depression, CAM use exceeds conventional care (Eisenberg 2001) --For anxiety, CAM 57% vs conventional 41% --For depression, CAM 54% vs conventional 35% Among people with self-reported anxiety or depression who seek conventional care -- 66% with anxiety also use CAM -- 67% with depression also use CAM CAM use by patients with anxiety / depression -- Mind-body therapies 34% -- Spiritual healing 10% -- Manual therapies 8% -- Herbs / supplements 7% EVOLUTION OF MODERN BIOMEDICINE European Enlightenment Germ Theory of Disease Flexner Report THE BIOMEDICAL PARADIGM Body, mind, spirit are discrete Body can be treated independently Body is like machine Isolate & eradicate source of malfunction Physician is specialized technician Treatment is specific to illness Treatment should pass scientific tests Physician -patient relationship has little bearing on outcome as long as adherence to treatment prevails Emphasis on fighting disease LIMITATIONS OF BIOMEDICINE Poorer results when condition - Chronic - Non-bacterial - Non-mechanical - Autoimmune - Unknown or multifactorial etiology Adverse effects of biomedical therapies Rigid treatment delivery systems Less time with physician Possible sense of de-humanization & compartmentalization THE “RE-DISCOVERY” OF ALTERNATIVE MEDICINE The more I learn of physics, more I am drawn to metaphysics. Albert Einstein the THE APPEAL OF CAM THERAPIES Acknowledge body, mind, and spirit Emphasis on preventing disease Treatment is specific to the person Knowing cause of illness less criticaL Physician activates self-healing capacity SOME LIMITATIONS OF CAM Quality of Care: often unregulated practice Quality of Product: no stringent monitoring Quality of Science: often unverified efficacy INTEGRATIVE MEDICINE: THE BEST OF BOTH WORLDS Integrative Medicine might restore the soul to medicine… the soul being that part of us that is most important but the least easy to delineate. Richard Smith British Medical Journal January 2001 PSYCHIATRY AS BIOMEDICINE SPECIALITY Historical Roots Conventional medical school training Vocabulary (e.g. case history, prevalence, pathogenesis, prognosis, cure) syntonic with biomedicine Reductionism of classical Drive Theory Separation from religion Current Developments Information explosion about brain and its function Discovery of biochemical etiologies for mental illness Creation of powerful psychotropic medications PSYCHIATRY AS DEPARTURE FROM BIOMEDICINE Conversion disorders & early affirmation of mind-body connection Consultation Psychiatry & more elucidation of mind-body and body-mind syndromes Psychoanalysis as self-healing process with physician as catalyst Acceptance of psychoanalysis despite lack of scientific tests DSM recognition of cultural & spiritual dimensions in diagnosis and treatment CROSSING THE CARTESIAN DIVIDE But what is quackery? It is commonly an attempt to cure the diseases of man by addressing the body alone. Henry David Thoreau Psychiatry is uniquely situated to integrate healing paradigms. SOME UNIVERSITY-BASED INTEGRATIVE MEDICINE CENTERS IN THE UNITED STATES Columbia Cornell Duke George Washington Harvard Stanford Thomas Jefferson Tufts University of Arizona University of Maryland University of Miami University of Michigan University of Pittsburg University of Texas University of Washington University of California, San Francisco EVIDENCE BASE FOR CAM REMEDIES IN PSYCHIATRY MEDITATION HATHA YOGA ACUPUNCTURE HERBS & SUPPLEMENTS MEDITATION Chronic anxiety Chronic pain Chronic insomnia Recurrent depression Overall emotional well-being Less anxiety and depression Increased sense of control Increased empathy HATHA YOGA Randomized controlled trials Depression Anxiety Opiate Dependence Non-randomized controlled trials Mood benefits equivalent to swimming Mood benefits superior to muscle relaxation and visualization Higher life satisfaction, better overall mood, better coping with stress ACUPUNCTURE Primary therapy in acute musculoskeletal pain Adjuvant therapy in chronic musculoskeletal pain Perhaps some efficacy in depression Scant data in anxiety disorders No convincing data re: efficacy in smoking cessation or drug detox/rehab HERBAL REMEDIES St. John’s Wort Equivalent to low-dose tricyclic mild-mod depression in Two large negative studies compared to SSRI’s Typical dose 900-1800 mg/day three divided doses) Watch for photoxicity and drug interactions (in herb- NIH Minor Depression study pending Hypericum perforatum HERBAL REMEDIES Gingko Gingko Biloba More than 30 double-blind trials show promise in slowing dementia symptoms May delay Alzheimer progression by 6-12 months Most effective in Alzheimer’s , not vascular dementia Full effect may require one year at 120-240 mg/day No head-to-head comparison with anti-cholinesterases Some prelim positive results in young, healthy subjects Watch for seizure in epileptics, hemorrhage in patients on anti-coags HERBAL REMEDIES Rhodiola Rhodiola Rosea Many classified Russian studies during Cold war Enhances cognitive performance under stress Reduces mental fatigue Improves sexual function Improves overall well-being 300-900 mg/day for depression Caution with bipolar and post-MI patients HERBAL REMEDIES Valerian Root Used for hundreds of years for anxiety / insomnia Seven placebo-controlled trials (400-900 mg/day) 6 of 7 studies found statistically significant, dose-related sedative effects Not benzodiazapine, so little abuse potential Avoid if liver dysfunction Valeriana officinalis HERBAL REMEDIES FROM AYURVEDA Rauwolfia serpentina Valeriana jatamansi Centella asiatica Antipsychotic Effect Jatamansi -- Rauwolfia * -- Centella (in polyherbal) Anxiolytic Effect Sarpagandha Mandukparni -- Valeriana -- Centella -- Withania -- Convolvulus -- Bacopa * Antidepressant Effect --- Withania --- Convolvulus Soporific Effect -- Valeriana * -- Centella (in polyherbal) Cognitive Enhancement Shankpushpi Ashwagandha Withania somnifera Brahmi Convolvulus pluricaulis Bacopa Monniera -- Centella -- Withania * -- Convolvulus -- Bacopa * DIETARY SUPPLEMENTS Omega-3 Fatty Acids Worldwide, lower serum omega-3 fatty acids significantly correlate with depression Double-blind, placebo-controlled studies show efficacy of omega 3 (from fish oil) in unipolar and bipolar depression Eicosapentanoic acid (EPA) more critical omega-3 fatty acid than docosahexanoic acid (DHA) Typical EPA dose 2.5 gm/day Flaxseed oil also source for omega-3 fatty acids, but no controlled studies to date on use in psych conditions Food increases omega-3 absorption Do not heat fish oil Vitamin E may help in vivo potency Caution with anti-coagulants and hi-dose NSAIDS DIETARY SUPPLEMENTS S-Adenosyl-Methionine (SAMe) Several placebo-controlled trials for use in depression Meta-analysis shows SAMe (400mg-1600 mg by mouth) may be equivalent to tricyclics No data on comparison to SSRI’s Risk of mania, serotonin syndrome DIETARY SUPPLEMENTS Folic Acid Folate deficiency appears significantly correlated with higher rates of depression Data suggest low serum folate may hinder antidepressant response Folate (0.5 mg/day) may be important adjuvant in treating women (but not men) with resistant depression Folate may help prevent relapse during & after depression tx Watch for reduced efficacy of concurrent phenobarb/phenytoin DUTY TO PROTECT Proven danger with specific CAM use No proven benefit with CAM use and clear benefit with conventional treatment DUTY TO PROMOTE Likely Low benefit with specific CAM use risk of harm DUTY TO PARTNER Benefit / harm of CAM unknown per scientific studies Conventional diagnosis / treatment inadequate Symptoms fit CAM healing paradigm Competent CAM practitioner / product available Optimistic patient / healer expectation Joint monitoring of CAM therapeutic trial RESOURCES FOR CAM EDUCATION RESOURCES FOR CAM EDUCATION Journals Alternative Therapies in Health and Medicine Journal of Alternative and Complementary Medicine Integrative Medicine Evidence Based Complementary and Alternative Medicine Websites CAM on PubMed Cochrane Collaboration NCCAM Website Herb Research Foundation American Botanical Council Consumer Lab NIH Office of Dietary Supplements