Complementary%20and%20Alternative%20Therapies%20for%20Depression

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Complementary and Alternative Therapies for
Depression

• Sudha Prathikanti, MD
• University of California, San Francisco
• www.prathikanti.com/teaching

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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

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COMMON CONVENTIONAL TREATMENTS
Psychotherapy Anti-depressant Medication

• Some Limitations
• ? Disappointing remission rates
• ? High rates of non-adherence due to
• Expense duration of treatment
• Social / cultural stigma
• Medication side effects

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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

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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

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CAM THERAPIES COMMONLY USED IN DEPRESSION

• Mind-Body Therapies
• Yoga
• Meditation
• Relaxation Techniques

• Biologically-Based Therapies
• Botanicals and Herbs
• Diet and Nutritional Supplements

• Spiritual Therapies
• Prayer
• Healing rituals
• Manual Therapies
• Massage
• Chiropractic

• Exercise
• Aerobic
• Weight-training / resistance

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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

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SOME LIMITATIONS OF CAM

• Quality of Care often unregulated practice
• Quality of Product no stringent monitoring
• Quality of Science often unverified efficacy

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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
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EVIDENCE BASE FOR CAM THERAPIES IN DEPRESSION

• MEDITATION
• HATHA YOGA
• ACUPUNCTURE
• HERBS SUPPLEMENTS
• EXERCISE

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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)

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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

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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

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HERBAL REMEDIES

• St. Johns 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
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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
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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
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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

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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

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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 SSRIs
• Risk of mania, serotonin syndrome

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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

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DUTY TO PROTECT

• ? Proven danger with specific CAM use
• ? No proven benefit with CAM use and
  clear benefit with conventional treatment

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DUTY TO PROMOTE

• ? Likely benefit with specific CAM use
• ? Low risk of harm

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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

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RESOURCES FOR CAM EDUCATION

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

• Journals
• Alternative Therapies in Health and Medicine
• Journal of Alternative and Complementary Medicine
• Integrative Medicine
• Evidence Based Complementary and Alternative
  Medicine

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INTEGRATIVE MEDICINETHE 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