Transcript Natural Therapies for Mental Health: An Evidence-Based

Natural Therapies for
Mental Health:
An Evidence-Based Guide
17 May 2012
Tim Desmond, LMFT
Dr. Mark Foster, DO
The Wild World
of Natural
Treatments
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Some have solid
research.
Some do not.
Popularity does
not correlate well
with evidence.
Fact #1 Placebos Work
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No matter how good it is, it's mostly placebo.
o No mental health treatment works like antibiotics.
o We are talking about relatively small differences
between "effective" and "ineffective" treatments.
Placebo can be understood as expectancy.
o What we think is going to help is more likely to help.
o Some placebos are better than others.
Placebo can be understood as the mind's
ability to heal itself.
Fact #2 Side Effects Can Be Serious
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Do no harm.
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If no treatment has dramatically greater benefits
than placebo, there is no reason to expose someone
to great risk.
All classes of psychiatric medications have
serious and potentially life threatening side
effects.
Some alternative treatments such as Vagus
Nerve Stimulation and Electroconvulsive
also have serious side effects.
Fact #3 Not All Science is Created Equal
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The quality of the control group determines the
quality of the study.
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Placebo control is vital when we know most of the effects come
from placebo.
Placebos must be "structurally equivalent."
People can "penetrate the blind."
The best studies control for expectancy.
Most studies are performed by parties with a
vested interest in the results.
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Independent replication is key!!!
There is a not enough high-quality evidence to
predict which treatment will help an individual.
How to Choose...
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Evidence Isn't
Everything
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There is little research on
potentially great
treatments.
What Looks Good to
You?
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Expectancy is important
Experiment
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Try different things and
track your progress
Show Me the Science!!
Therapies With Strong
Evidence:
1. Exercise
2. Nutrition
3. Sunlight/PhotoTx
4. Volunteering
5. Social Support
6. Negative Ions
7. Adequate Sleep
8. Spirituality/Meaning
9. Counseling
Therapies With Weak
Evidence:
1. St. John's Wort
2. 5-HTP
3. Chromium Picolate
4. Homeopathy
5. Melatonin
6. SAMe
7. Selenium
8. Vagus Nerve Stimulation
Exercise
Verdict: Strong
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More than 20 years
of evidence.
Ties or beats meds.
Lower relapse than
meds.
Jogging & lifting
weights are most
studied.
Nutrition
Verdict: Strong
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More than 50 years of
evidence.
Nutritional deficiencies
cause psychological
problems.
Unhealthy foods can
contribute to
psychological problems.
Nutrition Cont.
Foods and Nutrients Associated with Mental Health
(sources in parentheses)
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Antioxidants (green vegetables and fruits)
Omega-3 fats (fish, supplements)
Folate (beans, especially chickpeas)
Vitamin D (supplements safest, also sun)
B vitamins (supplements, whole foods)
Starchy roots (potatoes, parsnips, carrots)
o Correlated, but no causal evidence.
Nutrition Cont.
Dietary Choices Associated with Psychological
Problems.
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Caffeine
Alcohol
High-fat diet
Sugar
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Correlated, but no causal evidence.
Dairy
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Correlated, but no causal evidence.
Sunlight & Phototherapy
Evidence: Strong
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Most research is on
therapeutic lightboxes.
Fastest acting treatment
(4X faster than meds).
Effective for all forms of
depression.
At least 30 mins/day.
Volunteering
Verdict: Strong
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Most research has
focused on people over
65, but effective for all
ages.
Increases overall
health, life functioning,
optimism and control.
Also helps chronic pain.
Social Support
Verdict: Strong
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Every form of illness and
emotional distress is
worsened by inadequate
social support.
Both depth and breadth
are important.
Some social circles can
be negative.
Negative Ions
Verdict: Strong
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Artificially creating ions is
effective and fast acting.
Increases serotonin in
mice.
Level of negative ions in
air is thousands of times
greater near ocean or
forest.
Adequate Sleep
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Sleep, serotonin and
depression have a
complicated
relationship.
Advancing sleep phase
and sleep deprivation
have been shown to
treat depression.
Lack of sleep causes
several mood
problems.
Spirituality/Meaning
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Spiritual and nonspiritual ways of
creating meaning in
life are
psychologically
protective.
Religious behaviors
are not.
People credit
spirituality in
recovery from mental
health problems.
Counseling
Verdict: Strong
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By far the best researched mental health
treatment.
Ties or beats medication.
Therapist's individual qualities matter more
than type of therapy or licensure.
No research comparing counseling and
drugs to counseling and another adjunct.
St. John's Wort
Verdict: Mixed
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Some studies show real
antidepressant properties.
Some show only placebo.
Negative side effects exist.
Effect could be
experimenter bias.
Could be hyperforin
content.
Selenium
Verdict: Unlikely
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Selenium deficiency
does cause mood
problems.
It is rare in the US.
No trials of selenium for
mental health in nondeficient population.
SAMe
Verdict: Not enough info.
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SAMe is a liver coenzyme.
Trials have been too
small.
Deficiency could be
caused by B12
deficiency.
5-HTP and Tyrosine
Verdict: Complicated
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Neurotransmitters
and mood are poorly
understood.
Trials of 5-HTP and
Tyrosine are of poor
quality.
Could help some
people.
Chromium Picolate
Verdict: Weak
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Very few trials
Some evidence it
could help people with
depression and strong
carbohydrate cravings.
Homeopathy
Verdict: Poor quality of
research
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Plenty of anecdotes.
Weak or no control
groups.
No side effects.
Melatonin
Verdict: Poor research, potentially dangerous.
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Many people with depression have delayed
Melatonin cycle.
Some research indicates they can have a
deficit, but it's far from consistent.
Treatment studies have poor design and too
few subjects.
Most show small benefit, but at least one
showed strong negative effect.
Vagus Nerve Stimulation
Verdict: Poor research
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No research that has
a credible control.
Many authors admit it
could be entirely
placebo.
Surgery has a huge
placebo response.
What interventions to recommend
to patients in mental distress?
Cost: Effectiveness
Ratio
One-size doesn't fit all
in mental health.
Each intervention has a relative
cost and effectiveness that must
be applied to the individual
situation and capacity of the
patient.
"What is the best way to help this
specific patient achieve mental
and physical wellness?"
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A Proposal:
Quadrants of Cost and Effectivenss
We need a new way of conceptualizing the
relative cost and effectiveness of mental
health interventions.
Ideally, we would focus on those therapies that
are:
MOST EFFECTIVE
BEST PROVEN
LEAST COSTLY
LEAST HARMFUL
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(Slide with Quadrant Diagram)
Barriers: for Patients
Patient expectations: "Just give me a pill."
informed by cultural norms
faith in technology, "magic bullets"
pharmaceutical propaganda
information dissymmetry
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Social barriers and toxic lifestyles
poverty, lack of resources
"life in the fast lane"
poor physical health
lack of role models
substance abuse
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Barriers: for Physicians
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Doctors feel the need to justify the
cost of their services by utilizing their
exclusive prescribing authority.
"Prescription pressure."
Uninformed about the side effects
and withdrawal effects of medicines
Lack of knowledge/confidence in
effective alternatives
Infatuation with technological
interventions
Inertia: difficult to undiagnose or
withdraw patients from meds once on
Barriers: for Physicians
Poor cost incentives.
Discussing lifestyle changes is timeconsuming, often frustrating, and less likely
to result in repeat customers.
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Doctors assume that somebody else in the
system will be making these
"common-sense recommendations."
(Odds are, if they're not hearing it from you,
they're not hearing it from anybody!)
Overcoming
the Barriers
First: Perspective Shift for Doctors
We must move away from reductive
diagnoses and reflexive prescribing,
and move towards an integrative
holistic model of mental health.
Overcoming
the Barriers
"Physician, heal thyself."
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Doctors must first attain,
then convey to patients these traits:
o Wisdom
o Patience
o Empathy
o Optimism
Doctors are less likely to recommend lifestyles choices
that they are not familiar with or not personally
practicing.
Overcoming
the Barriers
“Help patients remove themselves
from toxic influences,
empower them with an integrative perspective,
teach them lifestyle choices that lead to wellness,
be wise, patient, empathic, and hopeful,
walk with them when they suffer,
celebrate with them when they are well,
and then see what symptoms are left over
that would require your intervention.”
Overcoming
the Barriers
Million Dollar Question
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How can the system incentivize doctors and
patients to pursue healthy lifestyle
interventions rather than ineffective and
harmful "magic bullets"?
Remember:
First, do no harm!
Unlocking the Power of Placebo
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Acknowledge and appreciate the therapeutic
power of placebo effect.
It applies to medications, counseling, and
any other intervention.
Placebo is likely the most powerful
therapeutic tool we have.
Placebo: Don't fear it. Honor and respect it.
Our minds and bodies want to heal.
"Interventions" are often tools that unlock the
latent placebo power within us.
Unlocking
the Power
of Placebo
Unlocking the Power of Placebo
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Placebo Power=Spontaneously Healing Capacity
"How can we access our Spontaneous Healing
Capacity in the least harmful way?"
Twelve Natural Therapies
for Mental Health
Evidence-based Therapy
Provider Recommendation
1) Exercise
1) Exercise everyday.
2) Nutrition
2) Eat healthy food. Avoid toxic substances.
3) Sunlight and Phototherapy
3) Get sunlight everyday.
4) Volunteering
4) Volunteer weekly.
5) Social Support
5) Be with trusted friends.
6) Negative Ions
6) Interact with nature.
7) Adequate Sleep
7) Get plenty of sleep.
8) Spirituality and Meaning
8) Meditate. Live with purpose and meaning.
9) Counseling
9) Work with an empowering counselor.
Other Useful Approaches/Paradigms
Provider Recommendation
10) Yoga / Acupuncture
10) Practice yoga. Try acupuncture.
11) Positive Thinking
11) Be inspired.
12) Emotional Awareness
12) Keep your emotions in perspective.
Exercise
Exercise everyday
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30 minutes a day.
At least 5 days a week.
Sustain heart rate at >110 bpm.
Break a sweat every day.
Do cardio everyday.
Weight/resistance training at least twice a week.
Pick activities you enjoy.
Consider competitive and team sports.
Train with a purpose.
Two weeks to make a habit.
Exercise
Nutrition
Nutrition
Eat healthy food
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5 fresh fruits and vegetables per day
3 balanced meals
Whole grains, lean meats, fish
Snack on tree nuts, fruits and vegetables
Stay well-hydrated with water
Supplements
o Fish Oil 3 g daily
o Vitamin D 2000 units daily
o B-complex Vitamin
o Multivitamin
Nutrition
Avoid toxic substances
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Stop smoking
Limit refined sugars
Limit artificial flavoring/colorings/sweeteners
Limit soda pop to once per week
Limit fast food to once per week
Limit coffee to no more than 2 cups per day
Limit or avoid alcohol--less than one drink/day
No illicit drugs. Careful with medical marijuana
Sunlight/PhotoTherapy
Get sunlight everyday
o Thirty minutes of
direct sunlight per day
o Go for a walk at lunch
o Purchase a sunlamp
for the winter months
o Supplement with
Vitamin D
o Plan a trip to a sunny
climate in the winter!
Volunteering
Volunteer weekly
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at schools
at churches
with non-profits
with community organizations
with international missions
What are you passionate about?
What causes have impacted your own life?
Invest yourself in a worthy cause!
"Forget about your own problems, and
make a difference in somebody else’s life."
Social Support
Be with trusted friends
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Seek out healthy, nurturing
relationships.
Limit time with negative people.
Be with people who inspire you.
Listen, and let yourself be listened
to, if only for a few minutes every
day.
Email and texting are great, but go
for face-to-face conversation.
Give and receive hugs!
Negative Ions
Interact with nature
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Stop and smell the roses. Catch
a sunset.
Grow flowers.
Cultivate a garden.
Keep houseplants.
Plant trees.
Get a pet.
Ride and take care of horses.
Surround yourself with things
that are alive, that give and
receive love.
Adequate Sleep
Get plenty of sleep
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7-9 hours each night
Have a regular bedtime routine.
Don’t go to bed too late or get up too late
Power naps--twenty minutes to
rejuvenate.
Pay attention to your dreams
Write them down.
o Figure out what they mean for you.
o Be surprised by the wisdom of your dreams.
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Spirituality/Meaning
Spirituality/Meaning
"Man's Search For Meaning"
by Viktor Frankl
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“Spend less time as a human doing,
and more time as a human being.”
--Dr. Foster's nurse
Spirituality/Meaning
Meditate.
Live with purpose and meaning
Meditation
Prayer
Deep breathing.
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Sit in a quiet room and close your eyes.
Take long slow breaths, in through your nose, completely expanding
your lungs, hold it for a few seconds, then slowly and completely
exhale through your mouth, making a quiet whooshing sound.
Do this for 10 minutes everyday.
Clear your mind. Just breathe.
Spirituality/Meaning
Journaling
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Reflect on your life, describe your successes
and your struggles, dream about the future.
Be a hero on your journey through life!
Be creative
Try painting or sculpture, crocheting or
cooking, music or poetry.
Release the artist within.
Leave your unique mark on the world.
You have something to say. Say it!
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Counseling
Work with an empowering counselor
Sometimes we need a coach.
There is no "one best way" to do talk
therapy.
Find something and someone that works for
you, that matches with your life experiences,
values, and expectations.
Get recommendations, interview potential
therapists until you find one that's a good fit.
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Counseling
Counseling
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The most important ingredients in successful
therapy are trust, empathy, and flexibility.
If it's not working for you, then look
elsewhere.
Remember, your counselor is human, too.
They have their own ingrained habits,
preconceptions, and personal feelings. They
will have bad days, too.
Accept their shared humanity and their
flaws, and find a way to make the
relationship mutually beneficial.
Yoga
Practice yoga
Great for your
body and mind.
Physical flexibility
translating to
mental and
emotional
flexibility.
Studios, gyms,
retreats, DVDs.
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Acupuncture
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Acupuncture works great for
many people.
Helps get patients to
engage with a non-western,
non-mechanistic approach
to their health.
Many acupuncturists will
make herbal and nutritional
recommendations as well.
Acupuncture
Positive Thinking
Be inspired
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Read good books
Watch inspiring movies
Listen to uplifting music
Try a "news fast" for a week.
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Turn off the news. Don't read the newspaper.
Stay away from the blogosphere.
Live within your own sphere of influence for a week.
Much anxiety comes from internalizing news events that
are beyond our influence.
Brighter days ahead!
Emotional Awareness
Keep your emotions in
perspective
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To be human is to feel
emotions, both positive and
negative.
Don't be numb to life.
Be fully alive and responsive
to your emotional state.
Emotional Awareness
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Relish moments of joy and peace.
Give yourself permission to
feel depressed, anxious, scared,
confused.
Work through your negative feelings.
Learn something valuable about
yourself.
Harness the intensity of your
emotions. Let them propel you
towards emotional growth.
Emotional Awareness
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"You are a soul traveling through
time, and your emotions are the
changing weather patterns you
encounter. There will be both
sunny and rainy days, summer
vacations and winter blues."
Accept the inevitable changes in
your internal weather as
temporary, meaningful, cyclical
and essential to being fully
human.
"Prayer of Serenity"
"Desiderata"
Emotional Awareness
Changing Paradigms,
Changing Discussions
Decentralize the doctor.
Empower the patient.
Let's move from:
"Doctor, what outside interventions can you
prescribe in order to eradicate my mental
distress?"
to:
"Together, how can we cultivate
an environment in which mental health will
manifest itself?"
Two Anecdotes
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The Woman Who Did None of These
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Dog Park Magic
Additional reading
for patients and providers
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"Mental Health Naturally" by Dr. Kathi Kemper, MD
"The Depression Cure" by Stephen Ilardi
"Spontaneous Happiness" by Dr. Andrew Weil, MD
"Man's Search For Meaning" by Viktor Frankl
"Please Don't Label My Child" by Dr. Scott Shannon, MD
"Transforming the Difficult Child" by Howard Glasser
"ADHD Without Drugs" by Sanford Newmark
"The Happiness Trap" by Russ Harris
"Your Drug May Be Your Problem" by Dr. Peter Breggin, MD
and Richard Cohen
"Mad in America" by Robert Whitaker
"Anatomy of an Epidemic" by Robert Whitaker
"They Say You're Crazy" by Paula Caplan
(Slide with Quadrant Diagram)
Natural Therapies for Mental Health
“Help patients remove themselves
from toxic influences,
empower them with an integrative perspective,
teach them lifestyle choices that lead to wellness,
be wise, patient, empathic, and hopeful,
walk with them when they suffer,
celebrate with them when they are well,
and then see what symptoms are left over
that would require your intervention.”
Thank you.