Transcript PowerPoint Presentation - INTEGRATIVE PSYCHIATRY: HOLISTIC

Complementary and Alternative
Therapies for Depression
Sudha Prathikanti, MD
University of California, San Francisco
www.prathikanti.com/teaching
MAJOR DEPRESSION
Most disabling medical condition in U.S.
Chronic / recurrent course is common
Significant medical / psych co-morbidity
Contribution to mortality:
Suicide
 risk of death in med conditions
COMMON CONVENTIONAL TREATMENTS
Psychotherapy
Anti-depressant Medication
Some Limitations:
 Disappointing remission rates
 High rates of non-adherence due to
Expense & duration of treatment
Social / cultural stigma
Medication side effects
COMPLEMENTARY & ALTERNATIVE
MEDICINE (CAM): NIH DEFINITION
Healthcare systems, practices, and products not
presently considered to be part of conventional medicine.
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Complementary: along with
conventional care
Alternative: in place of
conventional care
USE OF CAM THERAPIES
FOR DEPRESSION
CAM use is high
among people with depression
CAM use may even exceed
conventional care
CAM use is often combined
with conventional care
CAM THERAPIES COMMONLY USED IN DEPRESSION
Mind-Body Therapies
Yoga
 Meditation
 Relaxation Techniques
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Biologically-Based Therapies
Botanicals and Herbs
Diet and Nutritional Supplements
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Exercise
Aerobic
 Weight-training / resistance
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Spiritual Therapies
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Prayer
Healing rituals
Manual Therapies
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Massage
Chiropractic
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
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 THERAPIES IN DEPRESSION
MEDITATION
HATHA YOGA
ACUPUNCTURE
HERBS & SUPPLEMENTS
EXERCISE
MEDITATION
Concentration Practice (TM, RR)
Mindfulness Practice (MBSR, MBCT)
Some indications:
Recurrent Depression (MBCT)
Chronic anxiety (TM, MBSR)
Chronic insomnia (RR)
Overall emotional well-being (RR, MBSR)
HATHA YOGA
Most common yoga practice in U.S.
Includes asanas (body postures) &
pranayama (breathing exercises)
Randomized controlled trials
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Pranayama + asana reduces symptoms
in depressed college students
Pranayama comparable to tricyclic
in treating depressed psych inpatients
Asanas superior to wait-list
in reducing depressive symptoms
Short-term antidepressant effects of
pranayama + asana comparable to
PMR and superior to control
ACUPUNCTURE
Electro-acupuncture
Manual acupuncture
Laser acupuncture
Randomized controlled trials
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Luo et al: EA equivalent to tricyclic in
depression (unipolar + bipolar subjects)
Allen et al : EA group only marginally better than
wait-list control
Roschke et al: EA no better than sham EA
as adjuvant to antidepressant
Quah-Smith et al: Laser acupuncture superior
to sham in treating depressive symptoms
HERBAL REMEDIES
St. John’s Wort
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Equivalent to low-dose tricyclic
in mild-mod depression
Three large negative studies
compared to SSRI/placebo
Typical dose 900-1800 mg/day
(in three divided doses)
Watch for photo-toxicity and
herb-drug interactions
NIH Minor Depression study pending
Hypericum perforatum
HERBAL REMEDIES
Rhodiola
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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
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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
Avoid concurrent use with benzo
Valeriana officinalis
DIETARY SUPPLEMENTS
Omega-3 Fatty Acids
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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
re: 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
Folic Acid
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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
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Folate may help prevent relapse during & after depression tx
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Watch for reduced efficacy of concurrent phenobarb/phenytoin
DIETARY SUPPLEMENTS
S-Adenosyl-Methionine (SAMe)
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Several placebo-controlled trials
for use in depression
Meta-analysis shows SAMe
(400mg-1600 mg by mouth)
may be equivalent to tricyclics
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No data on comparison to SSRI’s
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Risk of mania, serotonin syndrome
EXERCISE
Aerobic exercise most studied
Adherence rates in exercise
studies comparable to those
in medication trials
Randomized controlled trials
 Antidepressant effects
comparable to CBT
 Feasible in older subjects
 Total caloric expenditure/wk more
critical than frequency/wk
DUTY TO PROTECT
 Proven
 No
danger with specific CAM use
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
 Conventional
diagnosis / treatment inadequate
 Symptoms fit CAM healing paradigm
 Risk- Benefit of CAM therapy unknown
per scientific studies
 Competent CAM practitioner / product available
 Optimistic patient / healer expectation
 Co-monitor patient undergoing CAM therapy trial
RESOURCES FOR
CAM EDUCATION
CAM on PubMed
Cochrane Collaboration
NCCAM Website
NIH Office of Dietary
Supplements
Herb Research Foundation
American Botanical Council
Consumer Lab
Journals
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Alternative Therapies in Health
and Medicine
Journal of Alternative and
Complementary Medicine
Integrative Medicine
Evidence Based Complementary
and Alternative Medicine
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