Natural Therapies for Mental Health: An Evidence-Based Guide

1. Natural Therapies for Mental Health:An Evidence-Based Guide 17 May 2012 Tim Desmond, LMFT Dr. Mark Foster, DO

2. The Wild World of Natural Treatments • Some have solid research. • Some do not. • Popularity does not correlate well with evidence.

4. Fact #1 Placebos Work • No matter how good it is, it's mostly placebo. • No mental health treatment works like antibiotics. • We are talking about relatively small differences between "effective" and "ineffective" treatments. • Placebo can be understood as expectancy. • What we think is going to help is more likely to help. • Some placebos are better than others. • Placebo can be understood as the mind's ability to heal itself.

5. Fact #2 Side Effects Can Be Serious • Do no harm. • 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.

6. Fact #3 Not All Science is Created Equal • The quality of the control group determines the quality of the study. • 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. • Independent replication is key!!! • There is a not enough high-quality evidence to predict which treatment will help an individual.

7. How to Choose... • Evidence Isn't Everything • There is little research on potentially great treatments. • What Looks Good to You? • Expectancy is important • Experiment • Try different things and track your progress

8. Show Me the Science!! • Therapies With Strong Evidence: • Exercise • Nutrition • Sunlight/PhotoTx • Volunteering • Social Support • Negative Ions • Adequate Sleep • Spirituality/Meaning • Counseling • Therapies With Weak Evidence: • St. John's Wort • 5-HTP • Chromium Picolate • Homeopathy • Melatonin • SAMe • Selenium • Vagus Nerve Stimulation

9. Exercise Verdict: Strong • More than 20 years of evidence. • Ties or beats meds. • Lower relapse than meds. • Jogging & lifting weights are most studied.

10. Nutrition Verdict: Strong • More than 50 years of evidence. • Nutritional deficiencies cause psychological problems. • Unhealthy foods can contribute to psychological problems.

11. Nutrition Cont. Foods and Nutrients Associated with Mental Health (sources in parentheses) • 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) • Correlated, but no causal evidence.

12. Nutrition Cont. Dietary Choices Associated with Psychological Problems. • Caffeine • Alcohol • High-fat diet • Sugar • Correlated, but no causal evidence. • Dairy • Correlated, but no causal evidence.

13. Sunlight & Phototherapy Evidence: Strong • Most research is on therapeutic lightboxes. • Fastest acting treatment (4X faster than meds). • Effective for all forms of depression. • At least 30 mins/day.

14. Volunteering Verdict: Strong • 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.

15. Social Support Verdict: Strong • 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.

16. Negative Ions Verdict: Strong • 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.

17. Adequate Sleep • 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.

18. Spirituality/Meaning • Spiritual and non-spiritual ways of creating meaning in life are psychologically protective. • Religious behaviors are not. • People credit spirituality in recovery from mental health problems.

19. Counseling Verdict: Strong • 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.

20. St. John's Wort Verdict: Mixed • Some studies show real antidepressant properties. • Some show only placebo. • Negative side effects exist. • Effect could be experimenter bias. • Could be hyperforin content.

21. Selenium Verdict: Unlikely • Selenium deficiency does cause mood problems. • It is rare in the US. • No trials of selenium for mental health in non-deficient population.

22. SAMe Verdict: Not enough info. • SAMe is a liver co-enzyme. • Trials have been too small. • Deficiency could be caused by B12 deficiency.

23. 5-HTP and Tyrosine Verdict: Complicated • Neurotransmitters and mood are poorly understood. • Trials of 5-HTP and Tyrosine are of poor quality. • Could help some people.

24. Chromium Picolate Verdict: Weak • Very few trials • Some evidence it could help people with depression and strong carbohydrate cravings.

25. Homeopathy Verdict: Poor quality of research • Plenty of anecdotes. • Weak or no control groups. • No side effects.

26. Melatonin Verdict: Poor research, potentially dangerous. • 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.

27. Vagus Nerve Stimulation Verdict: Poor research • No research that has a credible control. • Many authors admit it could be entirely placebo. • Surgery has a huge placebo response.

28. What interventions to recommendto patients in mental distress?

29. 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?"

30. 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

31. (Slide with Quadrant Diagram)

32. Barriers: for Patients Patient expectations: "Just give me a pill." • informed by cultural norms • faith in technology, "magic bullets" • pharmaceutical propaganda • information dissymmetry Social barriers and toxic lifestyles • poverty, lack of resources • "life in the fast lane" • poor physical health • lack of role models • substance abuse

33. Barriers: for Physicians • 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

34. Barriers: for Physicians Poor cost incentives. • Discussing lifestyle changes is time-consuming, often frustrating, and less likely to result in repeat customers. 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!)

35. Overcomingthe 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.

36. Overcoming the Barriers "Physician, heal thyself." • Doctors must first attain, then convey to patients these traits: • Wisdom • Patience • Empathy • Optimism • Doctors are less likely to recommend lifestyles choices that they are not familiar with or not personally practicing.

37. 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.”

38. Overcoming the Barriers Million Dollar Question • 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!

42. Unlocking the Power of Placebo • 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.

43. Unlocking the Power of Placebo

44. Unlocking the Power of Placebo • Placebo Power=Spontaneously Healing Capacity • "How can we access our Spontaneous Healing Capacity in the least harmful way?"

45. Twelve Natural Therapies for Mental Health

46. Exercise Exercise everyday • 30 minutes a day. • At least5 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.

47. Exercise

48. Nutrition

49. Nutrition Eat healthy food • 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 • Fish Oil 3 g daily • Vitamin D 2000 units daily • B-complex Vitamin • Multivitamin