Complementary and Alternative Complementary and Alternative Therapies for DepressionTherapies for Depression

Sudha Prathikanti, MDUniversity of California, San Francisco

www.prathikanti.com/teaching

MAJOR DEPRESSIONMAJOR 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

COMMON CONVENTIONAL TREATMENTSCOMMON 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

COMPLEMENTARY & ALTERNATIVE COMPLEMENTARY & ALTERNATIVE MEDICINE (CAM): NIH DEFINITIONMEDICINE (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

USE OF CAM THERAPIES USE OF CAM THERAPIES FOR DEPRESSIONFOR DEPRESSION

CAM use is high among people with depression

CAM use may even exceed conventional care

CAM use is often combined with conventional care

CAM THERAPIES COMMONLY USED IN DEPRESSIONCAM THERAPIES COMMONLY USED IN DEPRESSION

Biologically-Based TherapiesBiologically-Based Therapies Botanicals and HerbsBotanicals and Herbs Diet and Nutritional SupplementsDiet and Nutritional Supplements

Spiritual TherapiesSpiritual Therapies Prayer Prayer Healing ritualsHealing rituals

Manual TherapiesManual Therapies MassageMassage ChiropracticChiropractic

Mind-Body TherapiesMind-Body Therapies Yoga Yoga MeditationMeditation Relaxation TechniquesRelaxation Techniques

ExerciseExercise AerobicAerobic Weight-training / resistanceWeight-training / resistance

THE APPEAL OF CAM THERAPIESTHE APPEAL OF CAM THERAPIES

Acknowledge body, mind, and spiritAcknowledge body, mind, and spirit

Emphasis on preventing disease Emphasis on preventing disease

Treatment is specific to the personTreatment is specific to the person

Knowing cause of illness less criticaLKnowing cause of illness less criticaL

Physician activates self-healing capacityPhysician activates self-healing capacity

SOME LIMITATIONS OF CAMSOME LIMITATIONS OF CAM

Quality of Care: often unregulated practiceQuality of Care: often unregulated practice

Quality of Product: no stringent monitoringQuality of Product: no stringent monitoring

Quality of Science: often unverified efficacyQuality of Science: often unverified efficacy

SOME UNIVERSITY-BASEDSOME UNIVERSITY-BASEDINTEGRATIVE MEDICINE CENTERSINTEGRATIVE MEDICINE CENTERS

IN THE UNITED STATESIN THE UNITED STATES ColumbiaColumbiaCornellCornellDukeDukeGeorge WashingtonGeorge WashingtonHarvardHarvardStanfordStanfordThomas JeffersonThomas JeffersonTuftsTuftsUniversity of ArizonaUniversity of ArizonaUniversity of MarylandUniversity of MarylandUniversity of MiamiUniversity of MiamiUniversity of MichiganUniversity of MichiganUniversity of PittsburgUniversity of PittsburgUniversity of TexasUniversity of TexasUniversity of WashingtonUniversity of Washington

University of California,San Francisco

EVIDENCE BASE FOR EVIDENCE BASE FOR CAM THERAPIES IN DEPRESSIONCAM THERAPIES IN DEPRESSION

MEDITATIONMEDITATION

HATHA YOGAHATHA YOGA

ACUPUNCTUREACUPUNCTURE

HERBS & SUPPLEMENTSHERBS & SUPPLEMENTS

EXERCISEEXERCISE

MEDITATIONMEDITATION

Concentration Practice (TM, RR)Concentration Practice (TM, RR)Mindfulness Practice (MBSR, MBCT)Mindfulness Practice (MBSR, MBCT)

Some indications:Some indications: Recurrent Depression (MBCT)Recurrent Depression (MBCT) Chronic anxiety (TM, MBSR)Chronic anxiety (TM, MBSR) Chronic insomnia (RR)Chronic insomnia (RR) Overall emotional well-being (RR, MBSR)Overall emotional well-being (RR, MBSR)

HATHA YOGAHATHA YOGA

Most common yoga practice in U.S. Most common yoga practice in U.S.

Includes asanas (body postures) &Includes asanas (body postures) &pranayama (breathing exercises)pranayama (breathing exercises)

Randomized controlled trialsRandomized controlled trials Pranayama + asana reduces symptoms Pranayama + asana reduces symptoms

in depressed college students in depressed college students Pranayama comparable to tricyclic Pranayama comparable to tricyclic

in treating depressed psych inpatientsin treating depressed psych inpatients Asanas superior to wait-list Asanas superior to wait-list

in reducing depressive symptomsin reducing depressive symptoms Short-term antidepressant effects of Short-term antidepressant effects of

pranayama + asana comparable to pranayama + asana comparable to PMR and superior to control PMR and superior to control

ACUPUNCTUREACUPUNCTURE

Electro-acupunctureElectro-acupunctureManual acupunctureManual acupunctureLaser acupunctureLaser acupuncture

Randomized controlled trialsRandomized controlled trials Luo et al: EA equivalent to tricyclic in Luo et al: EA equivalent to tricyclic in

depression (unipolar + bipolar subjects)depression (unipolar + bipolar subjects) Allen et al : EA group only marginally better than Allen et al : EA group only marginally better than

wait-list control wait-list control Roschke et al: EA no better than sham EA Roschke et al: EA no better than sham EA

as adjuvant to antidepressantas adjuvant to antidepressant Quah-Smith et al: Laser acupuncture superior Quah-Smith et al: Laser acupuncture superior

to sham in treating depressive symptomsto sham in treating depressive symptoms

HERBAL REMEDIESHERBAL REMEDIES

St. John’s WortSt. John’s Wort

Equivalent to low-dose tricyclic Equivalent to low-dose tricyclic in mild-mod depressionin mild-mod depression

Three large negative studies Three large negative studies compared to SSRI/placebocompared to SSRI/placebo

Typical dose 900-1800 mg/day Typical dose 900-1800 mg/day (in three divided doses)(in three divided doses)

Watch for photo-toxicity and Watch for photo-toxicity and herb-drug interactionsherb-drug interactions

NIH Minor Depression study pendingNIH Minor Depression study pending Hypericum perforatumHypericum perforatum

HERBAL REMEDIESHERBAL REMEDIES

RhodiolaRhodiola

Many classified Russian studies Many classified Russian studies during Cold warduring Cold war

Enhances cognitive performance Enhances cognitive performance under stressunder stress

Reduces mental fatigueReduces mental fatigue Improves sexual functionImproves sexual function Improves overall well-beingImproves overall well-being 300-900 mg/day for depression300-900 mg/day for depression Caution with bipolar and post-MI Caution with bipolar and post-MI

patientspatients

Rhodiola RoseaRhodiola Rosea

HERBAL REMEDIESHERBAL REMEDIES

Valerian RootValerian Root

Used for hundreds of years for Used for hundreds of years for anxiety / insomniaanxiety / insomnia

Seven placebo-controlled trials Seven placebo-controlled trials (400-900 mg/day)(400-900 mg/day)

6 of 7 studies found statistically 6 of 7 studies found statistically significant, dose-related sedative effectssignificant, dose-related sedative effects

Not benzodiazapine, Not benzodiazapine, so little abuse potentialso little abuse potential

Avoid if liver dysfunctionAvoid if liver dysfunction Avoid concurrent use with benzoAvoid concurrent use with benzo

Valeriana officinalisValeriana officinalis

DIETARY SUPPLEMENTSDIETARY SUPPLEMENTS

Omega-3 Fatty AcidsOmega-3 Fatty Acids

Worldwide, lower serum omega-3 fatty acids significantly correlate with Worldwide, lower serum omega-3 fatty acids significantly correlate with depression depression

Double-blind, placebo-controlled studies show efficacy of omega 3 (from fish oil) Double-blind, placebo-controlled studies show efficacy of omega 3 (from fish oil) in unipolar and bipolar depressionin unipolar and bipolar depression

Eicosapentanoic acid (EPA) more critical omega-3 fatty acid than docosahexanoic Eicosapentanoic acid (EPA) more critical omega-3 fatty acid than docosahexanoic acid (DHA)acid (DHA)

Typical EPA dose 2.5 gm/day Typical EPA dose 2.5 gm/day Flaxseed oil also source for omega-3 fatty acids, Flaxseed oil also source for omega-3 fatty acids,

but no controlled studies to date but no controlled studies to date re: use in psych conditionsre: use in psych conditions

Food increases omega-3 absorptionFood increases omega-3 absorption Do not heat fish oilDo not heat fish oil Vitamin E may help in vivo potency Vitamin E may help in vivo potency Caution with anti-coagulants and hi-dose NSAIDSCaution with anti-coagulants and hi-dose NSAIDS

DIETARY SUPPLEMENTSDIETARY SUPPLEMENTS

Folic AcidFolic Acid

Folate deficiency appears significantly correlated with Folate deficiency appears significantly correlated with higher rates of depression higher rates of depression

Data suggest low serum folate may hinder antidepressant responseData suggest low serum folate may hinder antidepressant response

Folate (0.5 mg/day) may be important adjuvant in treating womenFolate (0.5 mg/day) may be important adjuvant in treating women (but not men) with resistant depression(but not men) with resistant depression

Folate may help prevent relapse during & after depression txFolate may help prevent relapse during & after depression tx

Watch for reduced efficacy of concurrent phenobarb/phenytoinWatch for reduced efficacy of concurrent phenobarb/phenytoin

DIETARY SUPPLEMENTSDIETARY SUPPLEMENTS

S-Adenosyl-Methionine (SAMe)S-Adenosyl-Methionine (SAMe)

Several placebo-controlled trials Several placebo-controlled trials for use in depressionfor use in depression

Meta-analysis shows SAMe Meta-analysis shows SAMe (400mg-1600 mg by mouth) (400mg-1600 mg by mouth) may be equivalent to may be equivalent to tricyclics tricyclics

No data on comparison to SSRI’s No data on comparison to SSRI’s

Risk of mania, serotonin syndromeRisk of mania, serotonin syndrome

EXERCISEEXERCISE

Aerobic exercise most studiedAerobic exercise most studied

Adherence rates in exercise Adherence rates in exercise studies comparable to those in studies comparable to those in medication trialsmedication trials

Randomized controlled trialsRandomized controlled trials Antidepressant effects Antidepressant effects

comparable to CBTcomparable to CBT Feasible in older subjectsFeasible in older subjects Total caloric expenditure/wk more Total caloric expenditure/wk more critical than frequency/wk critical than frequency/wk

DUTY TO PROTECTDUTY TO PROTECT

Proven danger with specific CAM useProven danger with specific CAM use

No proven benefit with CAM use No proven benefit with CAM use and and clear benefit with conventional treatment clear benefit with conventional treatment

DUTY TO PROMOTEDUTY TO PROMOTE

Likely benefit with specific CAM useLikely benefit with specific CAM use

Low risk of harm Low risk of harm

DUTY TO PARTNERDUTY TO PARTNER

Conventional diagnosis / treatment inadequate Conventional diagnosis / treatment inadequate

Symptoms fit CAM healing paradigm Symptoms fit CAM healing paradigm

Risk- Benefit of CAM therapy unknown Risk- Benefit of CAM therapy unknown per scientific studies per scientific studies

Competent CAM practitioner / product availableCompetent CAM practitioner / product available

Optimistic patient / healer expectation Optimistic patient / healer expectation

Co-monitor patient undergoing CAM therapy trialCo-monitor patient undergoing CAM therapy trial

RESOURCES FOR RESOURCES FOR CAM EDUCATIONCAM EDUCATION

CAM on PubMed CAM on PubMed

Cochrane CollaborationCochrane Collaboration

NCCAM WebsiteNCCAM Website

NIH Office of Dietary NIH Office of Dietary SupplementsSupplements

Herb Research FoundationHerb Research Foundation

American Botanical CouncilAmerican Botanical Council

Consumer LabConsumer Lab

JournalsJournals Alternative Therapies in Health Alternative Therapies in Health

and Medicineand Medicine Journal of Alternative and Journal of Alternative and

Complementary MedicineComplementary Medicine Integrative MedicineIntegrative Medicine Evidence Based Complementary Evidence Based Complementary

and Alternative Medicineand Alternative Medicine

INTEGRATIVE MEDICINE:INTEGRATIVE MEDICINE:THE BEST OF BOTH WORLDSTHE 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