HOLISTIC HEALING FOR THE MIND: COMPLEMENTARY AND ALTERNATIVE THERAPIES IN PSYCHIATRY

1. HOLISTIC HEALING FOR THE MIND:COMPLEMENTARY AND ALTERNATIVE THERAPIES IN PSYCHIATRY Sudha Prathikanti, MD University of California, San Francisco www.prathikanti.com/teaching

2. INTEGRATIVE PSYCHIATRY A healing approach that uses both conventional and complementary / alternative medicine to understand and treat psychiatric conditions.

3. NIH DEFINITION OF COMPLEMENTARY & ALTERNATIVE MEDICINE (CAM) Healthcare systems, practices, and products not presently considered to be part of conventional medicine. Complementary: together with conventional practice Alternative: in place of conventional practice

4. Mind-Body Therapies Meditation Biofeedback Hypnosis and Guided Imagery Biologically-Based Therapies Botanicals and Herbs Nutritional Supplements Energy Therapies Reiki Qi Gong Magnets Manual Therapies Massage Chiropractic NIH CLASSIFICATION OF CAM Alternative Medical Systems • Ayurveda • Traditional Chinese Medicine • Homeopathy

5. 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%

6. EVOLUTION OF MODERN BIOMEDICINE European Enlightenment Germ Theory of Disease Flexner Report

7. THE BIOMEDICAL PARADIGM • 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

8. 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

9. THE “RE-DISCOVERY” OF ALTERNATIVE MEDICINE The more I learn of physics, the more I am drawn to metaphysics. Albert Einstein

10. 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

11. SOME LIMITATIONS OF CAM Quality of Care: often unregulated practice Quality of Product: no stringent monitoring Quality of Science: often unverified efficacy

12. 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

13. PSYCHIATRY AS BIOMEDICINE SPECIALITY • Historical Roots • Conventional medical school training • Vocabulary (e.g. case history, prevalence, pathogenesis, prognosis, cure) syntonic with biomedicine • Reductionism of classical Drive Theory • Separation from religion • Current Developments • Information explosion about brain and its function • Discovery of biochemical etiologies for mental illness • Creation of powerful psychotropic medications

14. PSYCHIATRY AS DEPARTURE FROM BIOMEDICINE • 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

15. 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

16. Psychiatry is uniquely situated to integrate healing paradigms.

17. SOME UNIVERSITY-BASEDINTEGRATIVE MEDICINE CENTERSIN THE UNITED STATES • 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

18. EVIDENCE BASE FOR CAM REMEDIES IN PSYCHIATRY MEDITATION HATHA YOGA ACUPUNCTURE HERBS & SUPPLEMENTS

19. MEDITATION Chronic anxiety Chronic pain Chronic insomnia Recurrent depression Overall emotional well-being • Less anxiety and depression • Increased sense of control • Increased empathy

20. 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

21. 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

22. HERBAL REMEDIES St. John’s Wort • Equivalent to low-dose tricyclic in mild-mod depression • Two large negative studies compared to SSRI’s • Typical dose 900-1800 mg/day (in three divided doses) • Watch for photoxicity and herb-drug interactions • NIH Minor Depression study pending Hypericum perforatum

23. HERBAL REMEDIES Gingko • 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 Gingko Biloba

24. HERBAL REMEDIES Rhodiola • 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 Rhodiola Rosea

25. HERBAL REMEDIES Valerian Root • 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

26. HERBAL REMEDIES FROM AYURVEDA Rauwolfia serpentina Valeriana jatamansi Centella asiatica Antipsychotic Effect -- Rauwolfia * -- Centella (in polyherbal) Anxiolytic Effect -- Valeriana -- Centella -- Withania -- Convolvulus -- Bacopa * Antidepressant Effect --- Withania --- Convolvulus Soporific Effect -- Valeriana * -- Centella (in polyherbal) Cognitive Enhancement -- Centella -- Withania * -- Convolvulus -- Bacopa * Jatamansi Sarpagandha Mandukparni Shankpushpi Ashwagandha Brahmi Withania somnifera Convolvulus pluricaulis Bacopa Monniera

27. DIETARY SUPPLEMENTS Omega-3 Fatty Acids • 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

28. DIETARY SUPPLEMENTS S-Adenosyl-Methionine (SAMe) • Several placebo-controlled trials for use in depression • Meta-analysis shows SAMe (400mg-1600 mg by mouth) may be equivalent to tricyclics • No data on comparison to SSRI’s • Risk of mania, serotonin syndrome

29. DIETARY SUPPLEMENTS Folic Acid • 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 • Folate may help prevent relapse during & after depression tx • Watch for reduced efficacy of concurrent phenobarb/phenytoin

30. DUTY TO PROTECT • Proven danger with specific CAM use • No proven benefit with CAM use and clear benefit with conventional treatment

31. DUTY TO PROMOTE • Likely benefit with specific CAM use • Low risk of harm

32. 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

33. RESOURCES FOR CAM EDUCATION

34. RESOURCES FOR CAM EDUCATION Journals Alternative Therapies in Health and Medicine Journal of Alternative and Complementary Medicine Integrative Medicine Evidence Based Complementary and Alternative Medicine Websites CAM on PubMed  Cochrane Collaboration  NCCAM Website  Herb Research Foundation  American Botanical Council  Consumer Lab  NIH Office of Dietary Supplements