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Mental Health

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

Complementary and Alternative Medicine

A look at some common unconventional mental health treatments

Lloyd Oppel, MD, MHSc, CCFP (EM)

Reprinted from "Treatments: What Works?" issue of Visions Journal, 2015, 11 (1), pp. 32-34

Complementary and alternative medicine (CAM) is often defined as a collection of various health treatments and diagnostic practices that generally fall outside of what most doctors and scientists would consider standard proven care.1 Some examples of CAM treatments include herbal remedies, homeopathy, Traditional Chinese Medicine, taking vitamins, massage therapy, chiropractic, relaxation and practising meditation or yoga. Many people use at least one of the products or services that fall under the umbrella of CAM.2

CAMs are incredibly diverse. For example, take two ingestible CAMs: homeopathy and St. John’s wort. Homeopathy, which is said by some3 to be effective for treating attention-deficit hyperactivity disorder (ADHD), uses remedies that are so dilute that they contain nothing but water. Most scientists agree that such remedies cannot have an effect beyond placebo. (The placebo effect describes benefits even after a research subject unknowingly takes fake medicine; studies8 have shown that when people already believe the medication they are taking will work, they tend to report better symptoms in research studies.)4 Another CAM therapy taken orally, like St. John’s wort, actually contains a chemical (hypericin) that has biological effects that warrant clinical research to see if it can truly treat depression.

There are many forms of CAM that are used in an effort to treat mental illness. Some of the more common ones are: St. John’s wort, homeopathy, SAMe, acupuncture, valerian and exercise therapy. Let’s look at the evidence for these as a primary treatment for mental health problems.

St. John's wort (SJW) for depression

This herbal remedy has been in use for hundreds of years.5 Proponents say it’s useful for treating depression. Sales of SJW are booming6—it’s one of the most popular herbs for sale in health food stores.

A number of studies have been done to see if SJW works better than placebo. What does the research say? According to the National Institutes of Health, “the evidence is not definitive”5 and there can be serious side effects from using the herb.5

Why isn’t the evidence clear? A 2008 analysis of many research studies found that SJW was as good as standard antidepressants for people with major depression.7 However, the herb only appeared to have this effect in people from German-speaking countries. This strange finding highlighted concerns about whether the studies had ensured a fair comparison was made between SJW and the comparison treatments (proper controls). Adding to this concern is the fact that two very well-controlled trials found no difference between SJW and placebos (sugar pills).9,10

As with any treatment, it’s important for patients to let their doctors and pharmacists know what they are taking. If SJW is combined with antidepressant drugs, it can cause serious problems—like serotonin syndrome. Also, other medications one is taking may be less effective if they are combined with SJW: birth control pills, certain cancer medications, and blood thinners, for example.

Homeopathy for ADHD

Homeopathy is a very popular form of alternative medicine.2 It is a system of practice where it is believed that very tiny amounts of an often harmful substance will act as a remedy for the types of symptoms that a large amount of that same substance would produce. Homeopaths often liken this approach to immunizations. Vigourous shaking and pounding of the dilutions is also said to “activate” the remedies. In the case of homeopathy, however, the preparation of the remedies involves so many repeated dilutions that there is usually not a single atom left of the original substance.4 Despite this, homeopathy has been claimed to be able to treat a wide range of illnesses, including mental illness.

The treatment of attention deficit/hyperactive disorder (ADHD) with homeopathy is currently in the Canadian news. The University of Toronto is planning to conduct a study of homeopathy for ADHD.11 Previously, three clinical trials have been performed on homeopathy for ADHD: two done by a practitioner of homeopathy were positive,3,12 and another found that homeopathy had no effect.13 This latter study, however, did find that all the patients felt better for having seen a health care provider, which is a very common phenomenon even with treatments known to be effective in their own right.14

The proposal has generated controversy because most scientists agree that homeopathy, due to its lack of active ingredient, is really just placebo treatment.11 Proponents of the study feel that determining the placebo effect in homeopathy may, in itself, be useful.

SAMe for depression and ADHD

SAMe is about as natural a treatment as they come. SAMe is a modified amino acid and is found normally in the body.15 It has been studied for potential benefits in osteoarthritis and liver disease, but what about mental health?

There have been a handful of clinical trials testing the effect of SAMe on depression and ADHD. Some are positive, but more and higher quality research is needed before solid recommendations for its use can be made.15-19 For ADHD, not as much clinical trial information is available as for depression.15

SAMe does have some side effects. Most notable are increased blood pressure and lower blood sugar.

Acupuncture for depression

Acupuncture is a traditional Chinese practice where needles are inserted into the skin at special points believed to correspond to the flow of “chi” or “vital energy” in the body. Acupuncture has been claimed to be useful for treating a large variety of illnesses from migraines and nausea to schizophrenia and dementia.

While acupuncture does not fit with what modern science knows about how the body works, thousands of clinical trials have been performed to see if it may have some effect. Most trials that have tested traditional acupuncture versus needles inserted at non-acupuncture points (“sham controls”) have found no difference in effect.20 Acupuncture trials that don’t use sham controls are usually positive – but this may simply be because of strong placebo effects. In such trials, unless the comparison group also gets needles inserted, both patients and providers will know who received the ‘real’ treatment. Many serious biases come into play unless both patients and evaluators are unaware of who is getting the genuine acupuncture treatment (this is known as a “double blind” study, see the related article, Evidence of Treatment Efficacy).

Acupuncture has been studied for depression. The most recent and objective review of the evidence to date determined that there was not good evidence for recommending acupuncture for depression.21

Valerian for anxiety

Valerian is a plant that has been noted for centuries to have sedating effects. There isn’t enough evidence to decide whether valerian can treat anxiety or depression. A number of trials have looked at whether valerian can be used to treat insomnia,22 common in anxiety and depression, but an analysis of those trials found that objective proof of effectiveness was still lacking.23

Exercise therapy for depression

A growing body of evidence points to the enormous benefits of regular physical activity. Quite aside from the personal satisfaction one can gain from staying fit, exercise is credited with improving heart health, reducing blood pressure, controlling high blood sugar—and helping a host of other issues, including mental well-being.

Most of us have seen the benefit of exercise on energy and mood, but can it be used to treat clinical depression? A 2013 review of 39 trials found some indications that exercise was better than no treatment in reducing the symptoms of depression.24 While it appeared that exercise was not as helpful as medication or counseling, the authors cautioned that better trials were needed.

That said, there are a number of advantages to exercising that make it well worth trying:

  • it puts the patient in the ‘driver’s seat’

  • it can be free

  • it can be done safely alongside other treatments unless you overdo it, there are no side effects

Can CAM be a useful adjunct?

Adjunctive therapy is a term that applies to treatments that, while not the primary treatment, can make the healing process go more smoothly.

Exercise is an excellent example of an adjunctive therapy. Although the direct benefits on clinical depression might be quite small, for many people just getting out and being active is something they see as part of getting better. Exercising also gives the patient a sense of contributing to their recovery; of being an active partner in their health care—something that many people desire.

From the treatment provider’s point of view, recommending a CAM therapy might be a good way to maintain rapport with a patient. It would be important, of course, to monitor the treatment for side effects or interaction with medications.

Some last words

Not all types of CAM are the same. Some—like homeopathy—lie so far outside the limits of reasonable science that they can be considered disproven. Others—like relaxation, yoga and exercise therapy—may have limited symptom-reducing effects but certainly form part of an overall wellness plan.

Patients who wish to use CAM treatments need to speak with their mainstream health care provider about any CAM treatment they want to use. These health care providers will need to walk a fine line between the rights of the patient to choose and their own professional duty to offer the best advice and information possible. But foremost, they need to ensure their patients get the benefits of proven therapy.

 
About the author

Dr. Oppel is a physician. For 20 years he has worked in the area of complementary and alternative medicine provincially and nationally. He has a degree in public health and teaches at UBC medical school. For many years, Lloyd chaired the Doctors of BC allied health practices committee, which monitors issues relating to controversial medical therapies

Footnotes:
  1. National Institutes of Health. (2015). Complementary, Alternative, or Integrative Health: What’s In a Name?

  2. Clarke, T. (2015). Trends in the Use of Complementary Health Approaches Among Adults: United States, 2002–2012 National Health Statistics Reports (Vol. 79).

  3. Frei, H., & Thurneysen, A. (2001). Treatment for hyperactive children: homeopathy and methylphenidate compared in a family setting. Br Homeopath J, 90(4), 183-188.

  4. Wikipedia. Homeopathy. Retrieved May 12, 2015, from http://en.wikipedia.org/wiki/Homeopathy

  5. National Centre for Complementary and Integrative Health (NIH). (2015). St. John's Wort and Depression. Retrieved April 14, 2015, 2015, from https://nccih.nih.gov/health/stjohnswort/sjw-and-depression.htm

  6. American Botanical Council. (2012). The 40 Top-Selling Herbal Dietary Supplements...for 2012. HerbalGram. Retrieved May 12, 2015, 2015, from http://cms.herbalgram.org/herbalgram/issue99/hg99-mktrpt.html

  7. Linde, K., Berner, M. M., & Kriston, L. (2008). St John's wort for major depression. Cochrane Database Syst Rev(4), CD000448. doi: 10.1002/14651858.CD000448.pub3

  8. Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40(11), 1189-1202.

  9. De Smet, P. A. (2002). Herbal remedies. N Engl J Med, 347(25), 2046-2056. doi: 10.1056/NEJMra020398

  10. Lecrubier, Y., Clerc, G., Didi, R., & Kieser, M. (2002). Efficacy of St. John's wort extract WS 5570 in major depression: a double-blind, placebo-controlled trial. Am J Psychiatry, 159(8), 1361-1366.

  11. CBC. (2015). Scientists question research on homeopathic treatment for ADHD. The Current. Retrieved May 12, 2015, from http://www.cbc.ca/radio/thecurrent/the-current-for-march-5-2015-1.2982500/scientists-question-research-on-homeopathic-treatment-for-adhd-1.2982505.

  12. Frei, H., Everts, R., von Ammon, K., Kaufmann, F., Walther, D., Hsu-Schmitz, S. F.,... Thurneysen, A. (2005). Homeopathic treatment of children with attention deficit hyperactivity disorder: a randomised, double blind, placebo controlled crossover trial. Eur J Pediatr, 164(12), 758-767. doi: 10.1007/s00431-005-1735-7

  13. Jacobs, J., Williams, A. L., Girard, C., Njike, V. Y., & Katz, D. (2005). Homeopathy for attention-deficit/hyperactivity disorder: a pilot randomized-controlled trial. J Altern Complement Med, 11(5), 799-806. doi: 10.1089/acm.2005.11.799

  14. McCarney, R., Warner, J., Iliffe, S., van Haselen, R., Griffin, M., & Fisher, P. (2007). The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol, 7, 30. doi: 10.1186/1471-2288-7-30

  15. Drugs and Supplements. SAMe. from http://www.mayoclinic.org/drugs-supplements/same/evidence/hrb-20059935

  16. Pancheri, P., Scapicchio, P., & Chiaie, R. D. (2002). A double-blind, randomized parallel-group, efficacy and safety study of intramuscular S-adenosyl-L-methionine 1,4-butanedisulphonate (SAMe) versus imipramine in patients with major depressive disorder. Int J Neuropsychopharmacol, 5(4), 287-294. doi: 10.1017/S1461145702003085

  17. Salmaggi, P., Bressa, G. M., Nicchia, G., Coniglio, M., La Greca, P., & Le Grazie, C. (1993). Double-blind, placebo-controlled study of S-adenosyl-L-methionine in depressed postmenopausal women. Psychother Psychosom, 59(1), 34-40.

  18. Sarris, J., Papakostas, G. I., Vitolo, O., Fava, M., & Mischoulon, D. (2014). S-adenosyl methionine (SAMe) versus escitalopram and placebo in major depression RCT: efficacy and effects of histamine and carnitine as moderators of response. J Affect Disord, 164, 76-81. doi: 10.1016/j.jad.2014.03.041

  19. Sood, A., Prasad, K., Croghan, I. T., Schroeder, D. R., Ehlers, S. L., & Ebbert, J. O. (2012). S-adenosyl-L-methionine (SAMe) for smoking abstinence: a randomized clinical trial. J Altern Complement Med, 18(9), 854-859. doi: 10.1089/acm.2011.0462

  20. Ernst, E. (2006). Acupuncture—a critical analysis. J Intern Med, 259(2), 125-137. doi: 10.1111/j.1365-2796.2005.01584.x

  21. Smith, C. A., Hay, P. P., & Macpherson, H. (2010). Acupuncture for depression. Cochrane Database Syst Rev(1), CD004046. doi: 10.1002/14651858.CD004046.pub3

  22. Fernandez-San-Martin, M. I., Masa-Font, R., Palacios-Soler, L., Sancho-Gomez, P., Calbo-Caldentey, C., & Flores-Mateo, G. (2010). Effectiveness of Valerian on insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Med, 11(6), 505-511. doi: 10.1016/j.sleep.2009.12.009

  23. National.Institutes.of.Health. (2015). Valerian. Retrieved May 12, 2015 from https://nccih.nih.gov/health/valerian

  24. Cooney, G. M., Dwan, K., Greig, C. A., Lawlor, D. A., Rimer, J., Waugh, F. R., Mead, G. E. (2013). Exercise for depression. Cochrane Database Syst Rev, 9, CD004366. doi: 10.1002/14651858.CD004366.pub6

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