HOLISTIC HEALING FOR THE MIND: COMPLEMENTARY AND ALTERNATIVE THERAPIES IN PSYCHIATRY

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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

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INTEGRATIVE PSYCHIATRY

• A healing approach that uses both
  conventional and complementary / alternative
  medicine to
  understand and treat psychiatric conditions.

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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

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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

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USE OF CAM IN THE UNITED STATES

• General publics 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

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EVOLUTION OF MODERN BIOMEDICINE

• European Enlightenment
• Germ Theory of Disease
• Flexner Report

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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

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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

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THE RE-DISCOVERY OF
ALTERNATIVE MEDICINE

• The more I learn of physics,
  the more I am drawn to metaphysics.
• Albert Einstein

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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

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SOME LIMITATIONS OF CAM

• Quality of Care often unregulated practice
• Quality of Product no stringent monitoring
• Quality of Science often unverified efficacy

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INTEGRATIVE MEDICINETHE 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

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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

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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

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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

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• Psychiatry is uniquely situated to
• integrate healing paradigms.

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SOME UNIVERSITY-BASEDINTEGRATIVE MEDICINE
CENTERSIN 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
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EVIDENCE BASE FOR CAM REMEDIES IN PSYCHIATRY

• MEDITATION
• HATHA YOGA
• ACUPUNCTURE
• HERBS SUPPLEMENTS

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MEDITATION

• Chronic anxiety
• Chronic pain
• Chronic insomnia
• Recurrent depression
• Overall emotional well-being
• Less anxiety and depression
• Increased sense of control
• Increased empathy

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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

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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

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HERBAL REMEDIES

• St. Johns Wort
• Equivalent to low-dose tricyclic in
  mild-mod depression
• Two large negative studies compared to SSRIs
• Typical dose 900-1800 mg/day (in three
  divided doses)
• Watch for photoxicity and herb-drug
  interactions
• NIH Minor Depression study pending

Hypericum perforatum
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HERBAL REMEDIES

• Gingko
• More than 30 double-blind trials show
• promise in slowing dementia symptoms
• May delay Alzheimer progression
• by 6-12 months
• Most effective in Alzheimers ,
• 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

Gingko Biloba
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HERBAL REMEDIES

• Rhodiola
• 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

Rhodiola Rosea
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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
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HERBAL REMEDIES FROM AYURVEDA
Valeriana jatamansi
Rauwolfia serpentina
Centella asiatica
Antipsychotic Effect -- Rauwolfia --
Centella (in polyherbal) Anxiolytic
Effect -- Valeriana -- Centella
-- Withania -- Convolvulus -- Bacopa
Antidepressant Effect --- Withania
--- Convolvulus Soporific Effect --
Valeriana -- Centella (in
polyherbal) Cognitive Enhancement --
Centella -- Withania --
Convolvulus -- Bacopa
Jatamansi
Mandukparni
Sarpagandha
Shankpushpi
Ashwagandha
Brahmi
Bacopa Monniera
Withania somnifera
Convolvulus pluricaulis
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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

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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 SSRIs
• Risk of mania, serotonin syndrome

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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

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DUTY TO PROTECT

• Proven danger with specific CAM use
• No proven benefit with CAM use and
  clear benefit with conventional
  treatment

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DUTY TO PROMOTE

• Likely benefit with specific CAM use
• Low risk of harm

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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

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RESOURCES FOR CAM EDUCATION
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RESOURCES FOR CAM EDUCATION

• Websites
• ? CAM on PubMed
• ? Cochrane Collaboration
• ? NCCAM Website
• ? Herb Research Foundation
• ? American Botanical Council
• ? Consumer Lab
• ? NIH Office of Dietary
• Supplements

Journals ? Alternative Therapies in Health and
Medicine ? Journal of Alternative and
Complementary Medicine ? Integrative Medicine ?
Evidence Based Complementary and Alternative
Medicine