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Complementary and Alternative Therapies for Depression

Complementary and Alternative Therapies for Depression. Sudha Prathikanti, MD University of California, San Francisco www.prathikanti.com/teaching. MAJOR DEPRESSION. Most disabling medical condition in U.S. Chronic / recurrent course is common Significant medical / psych co-morbidity

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Complementary and Alternative Therapies for Depression

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  1. Complementary and Alternative Therapies for Depression Sudha Prathikanti, MD University of California, San Francisco www.prathikanti.com/teaching

  2. MAJOR DEPRESSION Most disabling medical condition in U.S. Chronic / recurrent course is common Significant medical / psych co-morbidity Contribution to mortality: Suicide  risk of death in med conditions

  3. COMMON CONVENTIONAL TREATMENTS Some Limitations:  Disappointing remission rates  High rates of non-adherence due to Expense & duration of treatment Social / cultural stigma Medication side effects Psychotherapy Anti-depressant Medication

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

  5. USE OF CAM THERAPIES FOR DEPRESSION CAM use is high among people with depression CAM use may even exceed conventional care CAM use is often combined with conventional care

  6. Biologically-Based Therapies Botanicals and Herbs Diet and Nutritional Supplements Spiritual Therapies Prayer Healing rituals Manual Therapies Massage Chiropractic CAM THERAPIES COMMONLY USED IN DEPRESSION Mind-Body Therapies • Yoga • Meditation • Relaxation Techniques • Exercise • Aerobic • Weight-training / resistance

  7. 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

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

  9. 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

  10. EVIDENCE BASE FOR CAM THERAPIES IN DEPRESSION MEDITATION HATHA YOGA ACUPUNCTURE HERBS & SUPPLEMENTS EXERCISE

  11. MEDITATION Concentration Practice (TM, RR) Mindfulness Practice (MBSR, MBCT) Some indications: Recurrent Depression (MBCT) Chronic anxiety (TM, MBSR) Chronic insomnia (RR) Overall emotional well-being (RR, MBSR)

  12. HATHA YOGA Most common yoga practice in U.S. Includes asanas (body postures) & pranayama (breathing exercises) Randomized controlled trials • Pranayama + asana reduces symptoms in depressed college students • Pranayama comparable to tricyclic in treating depressed psych inpatients • Asanas superior to wait-list in reducing depressive symptoms • Short-term antidepressant effects of pranayama + asana comparable to PMR and superior to control

  13. ACUPUNCTURE Electro-acupuncture Manual acupuncture Laser acupuncture Randomized controlled trials • Luo et al: EA equivalent to tricyclic in depression (unipolar + bipolar subjects) • Allen et al : EA group only marginally better than wait-list control • Roschke et al: EA no better than sham EA as adjuvant to antidepressant • Quah-Smith et al: Laser acupuncture superior to sham in treating depressive symptoms

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

  15. 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

  16. 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 • Avoid concurrent use with benzo Valeriana officinalis

  17. 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 re: 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

  18. 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

  19. 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

  20. EXERCISE Aerobic exercise most studied Adherence rates in exercise studies comparable to those in medication trials Randomized controlled trials  Antidepressant effects comparable to CBT  Feasible in older subjects  Total caloric expenditure/wk more critical than frequency/wk

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

  22. DUTY TO PROMOTE  Likely benefit with specific CAM use  Low risk of harm

  23. DUTY TO PARTNER  Conventional diagnosis / treatment inadequate  Symptoms fit CAM healing paradigm  Risk- Benefit of CAM therapy unknown per scientific studies  Competent CAM practitioner / product available  Optimistic patient / healer expectation  Co-monitor patient undergoing CAM therapy trial

  24. 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 CAM on PubMed Cochrane Collaboration NCCAM Website NIH Office of Dietary Supplements Herb Research Foundation American Botanical Council Consumer Lab

  25. 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

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