Transcript Incorporating Integrative Therapies into Primary Care for

Incorporating Integrative
Therapies into Primary
Care for the Treatment of
Depression
Evan W. Kligman, MD
Professor of Public Health, FCM
Co-Director, Arizona Center on Aging
How Common is Depression in
Primary Care Settings?
• Up to 50% of all patients seen report symptoms
• 48% with severe post-election traumatic
depression
• Up to 20% meet diagnostic criteria for
depression
• 12 million women in US experience depression
– twice the rate of men
• Half of all patients with depression receive
treatment from primary care clinicians; increases
with age
Typical Somatic and Behavioral
Complaints
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Sleep disturbance
Fatigue
Pain
Anxiety
Behavioral and cognitive problems
Principle Diagnoses Seen
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Major depression
Bipolar depression
SAD (seasonal affective disorder)
Dysthymia
Depression associated with medical
illness
• Grief adjustment disorder
Principles to Consider in Integrating
Therapies
• Important to take into consideration the type of
depression, its natural history and
pathophysiology, in determining what type(s) of
integratives therapies to consider
• Important to consider whether such therapies
are treating the symptoms or altering the
underlying pathophysiology
• Many presentations are multifactorial; thus,
multiple interventions may be appropriate
Major Depression
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Sleep disturbance
Appetite and/or weight change
Fatigue or loss of energy
Psychomotor agitation or retardation
Feelings of guilt
Suicidal ideation
• At least four of the above
Major Depression Pathophysiology
• Alterations of neurotransmitter function or
imbalance
• Medications inhibit pre-synaptic reuptake of
neurotransmitters or stimulate post-synaptic
receptors (dopamine, serotonin, norepinephrine)
• Elevated cortisol levels and decreased cortisol
suppression in response to dexamethasone
during depression episode
• Medication-induced CNS depression
Other Mechanisms of Causation
and Effect
• Genetic propensities (eg, TRP
homeostasis)
• Neurochemical and anatomic
alterations due to environmental/toxic
exposures and stressors
• Alterations in energy fields
Bipolar Illness
• Episodes of depression alternating with
mania or hypomania
• Manic episodes are discrete periods of
elevated mood when patient irritable,
engages in excessive or risky behaviors
• May sleep very little for days or weeks,
without fatigue
• Hallucinations and delusions
Dysthymia
• Mild but chronic symptoms of depression
• Presence of depressed mood most of time
for a minimum of 2 years
• Appetite change, sleep disturbance,
fatigue, poor self-esteem, difficulty with
concentration or decision-making, or
hopelessness (at least 2 of the above)
Evaluation
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Iatrogenic causes, eg medications
Comorbid conditions
Physical Exam
Ancillary Tests: TFTs, Screening
instruments
• “Profiling” or algorithm for diagnosis and
treatment; identifying individuals and
populations most appropriate for
integrative therapies
Questions to Include
• Lifestyle (relaxation, exercise, nutritional,
supplements, meditation, spiritual practice,
etc.)?
• Environmental stressors?
• Comorbid medical conditions?
• Self-image?
Integrating Therapies
Self-Directed Efforts – Step 1
• Evaluate for failed attempts by substance abuse
(EtOH,15%), inappropriate alternatives
• Self-help groups, meetings, online
• “Foundation” lifestyle strategies, esp. dietary
changes and/or supplements, physical
exercises, stress reduction techniques,
breathing exercises, spiritual practice
Integrative Therapies – Step 2
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Nutritional, botanical, and vitamin therapies
Functional medicine
Homeopathy
Spiritual counseling/direction
Traditional chinese medicine (acupuncture, herbs)
Yoga
Chi Gong
Energetic clearing techniques
Narrative therapies
Reiki
EcoPsychology
Typical Vitamins and Minerals Used
• Vitamins A, B6, B12,C, D,
E
• Thiamine
• Riboflavin
• Niacinamide
• Folic acid
• Biotin
• Pantothenic acid
• Calcium
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Iron
Phosphorus
Iodine
Magnesium
Zinc
Selenium
Copper
Manganese
Chromium
Typical Minerals Used - cont
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Molybdenum
Potassium
Dl-Phenylalanine
Glutamine
Choline
Citrus bioflavonoids
Inositol
Grape seed extract
Gingko biloba extract
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Methionine
Organic germanium
Boron
Vanadium
Nickel
Integrative Therapies - cont
• Testosterone (androgen supplementation) in
resistant cases
• Light therapy and 5-HTP for SAD as well
unipolar and bipolar illness
• Physical Activity
• Mind-body therapies
• Animal assisted therapies (Delta Society)
Mind-Body Therapies
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Meditation (neuroplasticity)
Hypnosis
Guided Visualization/Imagery
Relaxation therapies
Biofeedback
Integrative Therapies - cont
• Expressive therapies (art, dance/movement,
music/sound, eg. music thanatology)
• Other culturally based healing arts (ayurveda,
native american traditional practices, cuentos)efficacy transculturally?
• Other massage therapies
• Technology-based applications (telemedicine,
telephone counseling, e-mail, radio psychiatry)
“Radical Healing”*
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Movement
Cleansing
Breathing
Remedies
Psychotherapy
Meditation
• Rudolph Ballentine, MD
Integration Strategies
• Determine type and severity of depression
• Least invasive and “foundation” self-help
therapies first if mild depression; recommend
modalities complementary to conventional
treatment if severe
• Deliver modalities practitioner is most
experienced and comfortable with
• Use a method of profiling to determine which
integrative modalities appropriate to refer for
Benefits of Integrative Primary
Care Approach to Treatment
• Longitudinal with frequent follow-ups for
monitoring symptoms and talk therapy
• Able to better monitor other comorbid or
chronic conditions
• Emphasizes interrelationship between
mind, body, and spirit
When to Refer and To Whom?
• Modalities delivered by primary
practitioner not successful or inadequate
to reach goals
• Cultural contexts - Homer the Hopi
Medicine Man – keep within the patient’s
cultural context or refer to culturally
sensitive modality/practitioner
• Patient acceptance potential
When to Consider Conventional
Treatments?
• Consider type and severity of depression and
response to self-directed and integrative
therapies
• Suicidal ideation
• Nonresponsive to steps 1 and 2, and secondary
to severe comorbid condition (eg, stroke, heart
disease)
• Low risk of side effects (age, other medications,
etc.)
Conventional TreatmentsStep 3
• Medications
• Psychotherapy and counseling (cognitive
behavioral therapy and interpersonal
therapy)
• Electroconvulsive treatments
• Transcranial magnetic stimulation
(topographically selective mild electrical
stimulation to left anterolateral prefrontal
cortex)
Typical Medications Side Effects
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Drowsiness or disorientation
Decreased sexual interest or performance
Weight gain
Cost per month
10-18%
21-51%
12-22%
$68-140
• Consumer Reports. Drugs vs. talk therapy. October 2004
Best Psychotherapy Options
• Cognitive behavioral therapy – train patient to
identify and consciously correct distorted thought
patterns causing symptoms; homework
assignments, such as becoming more assertive
on the job
• Interpersonal therapy – focuses on patient’s
relationship problems with others; especially
effective wit major life transitions; in therapy, one
learns to adapt better to changing circumstances
Transcranial Magnetic Stimulation
• 10 sessions over two – three weeks, cumulative
18,000 - 30,000 magnetic impulses
• Consider if failed steps 1 and 2, and resistant to
medications and counseling
• Change in Ham-D scores from 22 to 12 (goal =
under 7)
• Best studied outcomes with post-stroke patients
(Robinson RG): significant improvement in
recovery of ADLs and cogntive function, and
decreased mortality
Case Study
• 60 year old female speech pathologist with history of
SAD and hypothyroidism. GDS score of 17 at
baseline. Developed neuropathic chronic pain
syndrome approximately one year ago. Ongoing
sleeplessness due to mood disorder and pain.
Significant adverse effects from multiple SSRIs
(diarrhea, GI upset, confusion, unacceptable
lethargy). Has tried St. John’s Wort and DHEA
supplements in the past without much benefit.
Intermittent psychotherapy/analysis over several
years, with short-term, but limited benefit. Positive
support system of friends and husband.
Case Study - 2
• Drinks 1 glass of red wine about every
other night with dinner. Enjoys a
Starbuck’s coffee drink almost daily. Diet
“pesco-vegetarian”. Aerobic exercise once
or twice a week. Meditates daily.
Menopausal for 3-5 years and refuses
HRT. Major stressors include daughter and
mother. Works part-time. Spiritual practice
consists of tonlin meditation and regular
retreats.
Case Study - 3
• Initial recommendations included: high
quality fish oil up to 4000 mg with meals
TID; changing from levoxyl to thyrolar and
monitoring T3 with TSH; vitamins B12, B6
and folic acid SL 2000 mcg daily; aerobic
exercise every other day; continue about 1
hour of MBSR and breathwork daily,
followed by a short chi gong exercise;
weekly jin-shin jyutsu; weekly yoga class;
monthly CST;
Case Study - 3
• Seen monthly to monitor progress; after 3
months, moderate progress with
integrative treatments: added Sam-e to
begin at 200 mg daily and advanced by
increasing by an additional 200 mg per
day weekly until max of 1200 mg per day;
advised to avoid alcohol and Starbuck’s;
GDS scale down to 7 after 6 months
Protocol to Follow
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1. Remove exacerbating factors
2. Improve nutrition
3. Institute physical activity
4. Dietary supplements and botanicals
5. Psychotherapy, counseling, and/or
other mind-body therapies
• 6. Pharmaceuticals
Bibliography
• Schneider C. Depression. Chapter 3 in
Integrative Medicine. Saunders. 2003
• Magill MK. Depression. Chapter 8 in 20
Common Problems – Primary Care.
McGraw-Hill. 1999
• Alternative approaches to mental health
care. www.mentalhealth.samhsa.gov.
NCCAM. 2004
Bibliography - 2
• Ballentine R. Radical Healing. Harmony
Books. 1999
• Delgado PL (editor). Primary Psychiatry
(journal). Neurotransmitter Depletion.June
2004; 11(6)
• Consumer Reports. Drugs vs. talk therapy.
October 2004