Incorporating Integrative Therapies into Primary Care for the Treatment of Depression

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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

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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

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Typical Somatic and Behavioral Complaints

• Sleep disturbance
• Fatigue
• Pain
• Anxiety
• Behavioral and cognitive problems

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Principle Diagnoses Seen

• Major depression
• Bipolar depression
• SAD (seasonal affective disorder)
• Dysthymia
• Depression associated with medical illness
• Grief adjustment disorder

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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

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Major Depression

• 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

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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

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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

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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

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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)

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Evaluation

• 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

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Questions to Include

• Lifestyle (relaxation, exercise, nutritional,
  supplements, meditation, spiritual practice,
  etc.)?
• Environmental stressors?
• Comorbid medical conditions?
• Self-image?

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Integrating Therapies
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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

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Integrative Therapies Step 2

• 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

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Typical Vitamins and Minerals Used

• Vitamins A, B6, B12,C, D, E
• Thiamine
• Riboflavin
• Niacinamide
• Folic acid
• Biotin
• Pantothenic acid
• Calcium

• Iron
• Phosphorus
• Iodine
• Magnesium
• Zinc
• Selenium
• Copper
• Manganese
• Chromium

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Typical Minerals Used - cont

• Molybdenum
• Potassium
• Dl-Phenylalanine
• Glutamine
• Choline
• Citrus bioflavonoids
• Inositol
• Grape seed extract
• Gingko biloba extract

• Methionine
• Organic germanium
• Boron
• Vanadium
• Nickel

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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)

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Mind-Body Therapies

• Meditation (neuroplasticity)
• Hypnosis
• Guided Visualization/Imagery
• Relaxation therapies
• Biofeedback

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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)

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Radical Healing

• Movement
• Cleansing
• Breathing
• Remedies
• Psychotherapy
• Meditation
• Rudolph Ballentine, MD

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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

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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

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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 patients cultural context or
  refer to culturally sensitive modality/practitione
  r
• Patient acceptance potential

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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.)

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Conventional Treatments-Step 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)

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Typical Medications Side Effects

• Drowsiness or disorientation
  10-18
• Decreased sexual interest or performance
  21-51
• Weight gain
  12-22
• Cost per month
  68-140
• Consumer Reports. Drugs vs. talk therapy. October
  2004

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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 patients
  relationship problems with others especially
  effective wit major life transitions in therapy,
  one learns to adapt better to changing
  circumstances

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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

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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. Johns 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.

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Case Study - 2

• Drinks 1 glass of red wine about every other
  night with dinner. Enjoys a Starbucks 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.

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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

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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 Starbucks GDS scale down to 7
  after 6 months

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Protocol to Follow

• 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

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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

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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