What does it mean, and why does it matter?
Reprinted from the "Treatments: What Works?" issue of Visions Journal, 2015 15 (4), pp. 5-7
With any illness, patients and those caring for them want treatment that works. At first blush that seems a simple enough idea, but what does “works” mean? For a simple sliver in the skin, works may just mean taking the sliver out and using soap and water to clean the wound. That seems pretty straightforward and measurable.
But what does “works” mean when it comes to a diagnosis like depression? That isn’t so easy. You cannot see depression on an X-ray or in a blood test.
To diagnose and monitor depression and prescribe treatments, most professionals use a series of questions that touch on areas like energy level, sleep pattern, enjoyment of life, a sense of feeling ‘low’ and appetite. But all of these areas can be affected by factors ranging from antidepressant medication, to living circumstances, to simply having a friend to confide in. Lots of things impact our mental well-being—only some of them involve treatments by professionals.
There is always more to the patient experience, journey and recovery from mental illness than just the specific mainstream professional treatments. While different kinds of non-traditional treatments can provide support, using them can also cloud our ability to know what treatments are actually effective in and of themselves, or which treatments add value for other reasons. The practice of meditation, for example, can make cancer patients feel less anxious, more energetic, and better able to manage symptoms without medication—all things that would also go along with effective medical treatment.
In spite of the challenges of assessing what ‘works’ means for something like depression, we do have ways to gather and assess scientific evidence in a way that reduces biases.
People seek health treatments for a number of reasons. For many people, it’s important to choose a treatment they understand, makes ‘sense’ and fits with their view of the world. For some groups of people, it’s important that treatment matches their cultural or religious views, such as Aboriginal people turning to First Nations health practices. Teaching health professionals to offer “culturally safe” care is now an important part of medical training.
Patients also tend to value a sense of control when it comes to choosing treatments. Being given choices, and feeling as though they are partners in their recovery, can play a large role in the selection—and perceived benefit—of therapy.
For many people, if not all, it is very important to be offered hope. In emergency rooms, I’ve seen patients who leave the ER with medical problems that remain undiagnosed, but who are happy with the reassurance that their problem isn’t life-threatening.
In cases where the outlook is more grim (or felt to be), it can be difficult to deliver bad news in a way that keeps hope alive, though health professionals have a duty to be honest with patients. As a result, patients may be drawn to therapies that exist outside the realm of proven treatment—if hope is offered there.
We all tend to seek the things mentioned above: hope, understanding and control. These are things that can be offered by many types of treatment—including those that don’t actually work.
One article in this issue will deal with what it takes to prove that a treatment really works. Other articles explore the evidence for various treatments, including proven treatments that aren’t as widely used and often misunderstood like electroconvulsive therapy or light therapy. And another large area on the health landscape that bears special mention is complementary and alternative medicine (CAM). This is not a Visions issue devoted to CAM but given readers’ interest and my experience in this area, I’d like to provide more background below. Please also see my CAM article.
CAM vs. conventional medicine
In the last 25 years, there has been a large increase in the numbers of CAM therapies—and in the number of people using these therapies. There are so many different kinds of CAM that asking people “have you ever used CAM?” will very likely be answered “yes.” A survey done in 2006 by BC’s Fraser Institute produced figures saying that three-quarters of people in Canada have used CAM during their lifetimes and half in the last year.1
So what is CAM? CAM is a loose collection of health treatments and diagnostic techniques that generally fall outside the realm of what is considered safe and effective by most doctors and scientists. These are generally unavailable in hospitals or health authority clinics, usually aren’t taught in medical schools, and most often are considered to be unproven, or even disproven.
Some examples of CAM treatments include herbal remedies (e.g., St. John’s wort, claimed to be useful for depression), homeopathy, Traditional Chinese Medicine, taking vitamins, massage, practising meditation, chiropractic and prayer.
CAM is often contrasted with conventional medicine. Conventional medicine is sometimes called “modern medicine,” “mainstream medicine,” “Western medicine,” or “scientific medicine.” It generally refers to a system of prevention and treatments of disease that incorporates the best available scientific evidence. Some examples of conventional medicine would be vaccinations to prevent infectious diseases, surgery, use of insulin to treat diabetes, medications to control high blood pressure, and cognitive-behavioural therapy to treat depression or anxiety.
Deciding what constitutes CAM versus conventional medicine can be tricky; grey areas exist.
For example, it can take time for new treatments to be tested to the point where they become accepted practice. Some people would argue that conventional medicine adopts any new treatment once it is proven safe and effective. For example, treating stomach ulcers with antibiotics was initially greeted with skepticism until there was evidence that a bacterium called helicobacter pylores was responsible for most cases.
Another grey area is in public policy. For example, people assume CAM must be as safe and effective as conventional treatment if they are covered in provincial-government or private insurance plans. Yet political priorities are actually not always tied to scientific evidence. There are economic and advocacy pressures to ensure that natural remedies do not need to meet the same standards of proof and effectiveness as pharmaceutical drugs. Provincial governments license practitioners of various forms of CAM where the evidence of effectiveness is far from clear. Government assurances that this offers the public access to more choices in ‘quality’ health care is hard to reconcile with the standards of safety and efficacy that apply in most realms of conventional medicine. The insurance industry understandably responds to public demand and offers plans that cover many forms of treatment—many of which fall outside the bounds of proven medicine. But popular doesn’t always mean effective.
So why do people choose CAM?
There are a variety of reasons. As mentioned above, we all seek hope. CAM is often portrayed as safe and ‘natural,’ and many people feel that using CAM is less risky than using conventional medicine. People can often access it right away, which is enticing if there are long waitlists for conventional treatment. Also, it’s comforting to get treatment in a way that matches our philosophical and cultural outlook. And many people want to feel somewhat in control of their recovery and treatment. CAM, like conventional medicine treatments, can offer these things regardless of whether the treatments are effective.
Keeping the public safe
It’s important to consumers that their treatments are safe and effective. CAM is particularly in the spotlight here if only because the therapies falling under its umbrella do not enjoy the sort of proof that is more typical of conventional medicine.
In some cases, CAM treatments are innocuous, and one might say “what’s the harm?” In other cases, the treatments may be very expensive, may interact with mainstream medications, and might even be directly harmful. Additionally, taking an unproven treatment might cause the patient to delay getting effective care or reject it entirely. For example, a decade ago headlines were made when numerous cases of people with serious mental illnesses reported harms after taking a vitamin supplement instead of their psychiatric medication.
What can be done?
Whether CAM or conventional medicine, consumers deserve to be protected by meaningful truth-in-advertising rules. For example, CAMs like homeopathy, Traditional Chinese medicine or Ayurvedic medicine that are considered “traditional” because of long-standing use within certain cultures do not have to provide any experimental evidence that they work to Health Canada if they are not claiming to help a serious disease. These rules need to change.
We need to close the gap in provincial rules and regulations that allows CAM health practitioners onto the field without examining whether the treatments they offer are truly beneficial.
Encourage patients to let their health care provider know all the CAM treatments they are using.
Where can CAM fit in? The case for compassion
Even in a situation where a patient chooses a therapy that is ineffective, it may be useful to incorporate it into a treatment plan that will be acceptable for the patient. Doing so may make the patient more satisfied with their care, foster a sense of partnership with their physician, and allow patients to feel more in control of their situation.
The caveat? The mainstream health care provider has to realize that the complementary treatment being provided is being used alongside (as an adjunct) to more effective treatment. It goes without saying that medical treatments are just a part of the patient journey and recovery process. Just as a warm hug can make the day’s worries seem less, the use of unconventional treatments may help patients cope with the illness at hand.
About the author
Dr. Oppel is a family physician who works in emergency medicine in Vancouver. For 20 years Lloyd has worked in the area of complementary and alternative medicine for both Doctors of BC (formerly BC Medical Association) and the Canadian Medical Association. He has a degree in public health and taught experimental design in the UBC medical school. For many years, Lloyd chaired the Doctors of BC allied health practices committee, which monitors public use of, and issues relating to, controversial medical therapies
- Esmail, N. (2007). Complementary and alternative medicine in Canada: Trends in use and public attitudes, 1997-2006. Public Sources Policy, 87(occasional paper). Vancouver, BC: Fraser Institute.