Incorporating Integrative Therapies into Primary Care for the Treatment of Depression

1. 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

2. 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

3. Typical Somatic and Behavioral Complaints • Sleep disturbance • Fatigue • Pain • Anxiety • Behavioral and cognitive problems

4. Principle Diagnoses Seen • Major depression • Bipolar depression • SAD (seasonal affective disorder) • Dysthymia • Depression associated with medical illness • Grief adjustment disorder

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

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

13. Integrating Therapies

14. 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

15. 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

16. 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 Typical Vitamins and Minerals Used

17. Molybdenum Potassium Dl-Phenylalanine Glutamine Choline Citrus bioflavonoids Inositol Grape seed extract Gingko biloba extract Methionine Organic germanium Boron Vanadium Nickel Typical Minerals Used - cont

18. 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)

19. Mind-Body Therapies • Meditation (neuroplasticity) • Hypnosis • Guided Visualization/Imagery • Relaxation therapies • Biofeedback

20. 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)

21. “Radical Healing”* • Movement • Cleansing • Breathing • Remedies • Psychotherapy • Meditation • Rudolph Ballentine, MD

22. 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

23. 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

24. 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 patient’s cultural context or refer to culturally sensitive modality/practitioner • Patient acceptance potential

25. 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.)

26. 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)

27. 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

28. 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 patient’s relationship problems with others; especially effective wit major life transitions; in therapy, one learns to adapt better to changing circumstances

29. 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

30. 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. John’s 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.

31. Case Study - 2 • Drinks 1 glass of red wine about every other night with dinner. Enjoys a Starbuck’s 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.

32. 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;

33. 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 Starbuck’s; GDS scale down to 7 after 6 months

34. 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

35. 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

36. 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