Transcript Document

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.
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Complementary: together with
conventional practice
Alternative: in place of
conventional practice
NIH CLASSIFICATION OF CAM
Alternative Medical Systems
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Ayurveda
Traditional Chinese Medicine
Homeopathy
Mind-Body Therapies
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Meditation
Biofeedback
Hypnosis and Guided Imagery
Biologically-Based Therapies
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Botanicals and Herbs
Nutritional Supplements
Energy Therapies
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Reiki
Qi Gong
Magnets
Manual Therapies
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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
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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
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Historical Roots
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Conventional medical school training
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Vocabulary (e.g. case history, prevalence,
pathogenesis, prognosis, cure) syntonic
with biomedicine
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Reductionism of classical Drive Theory
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Separation from religion
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Current Developments
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Information explosion about brain and its
function
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Discovery of biochemical etiologies for
mental illness
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Creation of powerful psychotropic
medications
PSYCHIATRY AS
DEPARTURE FROM BIOMEDICINE
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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
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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
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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
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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
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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
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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
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
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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 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)
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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
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
DUTY TO PROTECT
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Proven danger with specific CAM use
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No proven benefit with CAM use and
clear benefit with conventional treatment
DUTY TO PROMOTE
 Likely
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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
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RESOURCES FOR
CAM EDUCATION
RESOURCES FOR
CAM EDUCATION
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
Websites
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CAM on PubMed
Cochrane Collaboration
NCCAM Website
Herb Research Foundation
American Botanical Council
Consumer Lab
NIH Office of Dietary
Supplements