Complementary and Integrative Therapies for Psychiatric Disorders
PSYCHIATRIC CLINICS OF NORTH AMERICA
www.psych.theclinics.com/issues
March 2013 • Volume 36 • Number 1
Contributors
EDITORS
PHILIP R. MUSKIN, MD
Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, Chief, Consultation-Liaison Psychiatry, NY-Presbyterian Hospital/Columbia Campus, New York, New York
PATRICIA L. GERBARG, MD
Assistant Professor of Clinical Psychiatry, Department of Psychiatry, New York Medical College, Valhalla, New York
RICHARD P. BROWN, MD
Associate Professor of Clinical Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York
AUTHORS
RYAN ABBOTT, MD, JD, MTOM
Associate Professor of Law at Southwestern Law School, Los Angeles, California
SHAHIN AKHONDZADEH, PhD, FBPharmacolS
Professor of Clinical Neuroscience, Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
MARY R. BAILEY, MA
Clinical Research Assistant, Neuropsychology, Cognitive Neuroscience, and Clinical Outcomes Laboratory, Department of Psychology, William Paterson University, Wayne, New Jersey
TEODORO BOTTIGLIERI, PhD
Principal Investigator, Adjunct Professor of Biomedical Sciences, Institute of Metabolic Disease, Baylor Research Institute, Baylor University, Dallas, Texas
KELLY BROGAN, MD, ABIHM
Clinical Instructor, NYU/Bellevue Hospital Center, New York, New York
RICHARD P. BROWN, MD
Associate Professor of Clinical Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York
BRUCE J. DIAMOND, PhD
Professor, Graduate Program Director, Director of Neuropsychology, Cognitive Neuroscience, and Clinical Outcomes Laboratory, Department of Psychology, William Paterson University, Wayne, New Jersey
LESTER G. FEHMI, PhD
Clinical Director, Princeton Biofeedback Centre, Princeton, New Jersey
MARLENE P. FREEMAN, MD
Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School; Director of Clinical Services, Perinatal and Reproductive Psychiatry Program, Harvard Medical School, Boston, Massachusetts
PATRICIA L. GERBARG, MD
Assistant Professor of Clinical Psychiatry, Department of Psychiatry, New York Medical College, Valhalla, New York
DANIEL L. KIRSCH, PhD
President, The American Institute of Stress, Fort Worth, Texas
STEPHEN LARSEN, PhD
LMHC, Licensed Mental Health Counselor, NY, BCN, Board Certified in Neurofeedback (BCIA), Stone Mountain Center, New Paltz; Psychology Professor Emeritus, SUNY, Ulster, Stone Ridge, New York
HELEN LAVRETSKY, MD, MS
Professor of Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, California
WILLIAM R. MARCHAND, MD
Psychiatrist, George E. Wahlen Veterans Administration Medical Center; Associate Professor (Clinical), Department of Psychiatry, University of Utah, Salt Lake City, Utah
DAVID MISCHOULON, MD, PhD
Director of Research, Depression Clinical and Research Program, Massachusetts General Hospital, Associate Professor of Psychiatry, Harvard Medical School; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
AMIRHOSSEIN MODABBERNIA, MD
Psychiatry Research Fellow, Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
FRED MUENCH, PhD
Assistant Professor of Psychology, Columbia University College of Physicians and Surgeons, New York, New York
FRANCINE NICHOLS, RN, PhD
Professor (retired), Georgetown University, Washington, DC
ALEXANDER G. PANOSSIAN, PhD, DSci
Head of Research and Development, Research and Development, Swedish Herbal Institute, Vallberga, Halland, Sweden
JEROME SARRIS, MHSc, PhD
NHMRC Clinical Research Fellow, Faculty of Medicine, Department of Psychiatry, The University of Melbourne, The Melbourne Clinic, Richmond; Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia
STUART N. SEIDMAN, MD
West End Medical Associates, New York, New York; Department of Psychiatry, Sheba Medical Center, Tel-Hashomer, Israel
Contents
Preface: Along Roads Less Traveled: Complementary, Alternative,
and Integrative Treatments
Philip R. Muskin, Patricia L. Gerbarg, and Richard P. Brown
SECTION 1. NUTRIENTS
Folate, Vitamin B12, and S-Adenosylmethionine1
Teodoro Bottiglieri
Folate (vitamin B9) and cobalamin (vitamin B12) are essential for the normal development and function of the central nervous system. The metabolism of these vitamins is intimately linked and supports the synthesis of S-adenosylmethionine (SAMe), the major methyl group donor in methylation reactions. This article reviews the metabolic and clinical importance of folate, vitamin B12, and SAMe, as well as clinical trials in relation to depression
and dementia.
Omega-3 Fatty Acids in Psychiatry . . . . 15
David Mischoulon and Marlene P. Freeman
Over the past 2 decades, omega-3 fatty acids (n-3FAs) have been increasingly used and studied in the United States and worldwide for various medical and psychiatric indications. Numerous published clinical trials have examined applications of different n-3FA preparations, primarily in mood disorders but also in psychotic disorders, attention-deficit disorder, obsessive-compulsive disorder, and personality disorders. Focusing on clinical issues, this article reviews the impact of n-3FAs on these conditions and covers the relevant research, side effects, dosage guidelines, and drug interactions; clinicians should thus be able to better advise patients who are already taking n-3FAs or are interested in trying them.
Nutrients for Prevention and Treatment of Mental Health Disorders . . . . 25
Shahin Akhondzadeh, Patricia L. Gerbarg, and Richard P. Brown
The choice of nutrients for review is based on clinical evidence of efficacy in neuropsychiatric disorders and biochemical effects that are neuroprotective or reparative. Vitamins, minerals, amino acids, and metabolites have been shown to augment antidepressants, improve symptoms in anxiety disorders, depression, neurodegenerative diseases, brain injury, ADHD, and schizophrenia, and to reduce medication side effects. Detection and correction of vitamin and mineral deficiencies can be essential for recovery. Generally low in adverse effects when taken in therapeutic doses, nutrients can be combined for greater benefits. Further studies are warranted to validate these promising treatments.
SECTION 2. HERBAL MEDICINES
Phytomedicines for Prevention and Treatment of Mental Health Disorders . . . . 37
Patricia L. Gerbarg and Richard P. Brown
Herbal medicines supported by evidence of safety and efficacy in the treatment of anxiety, insomnia, fatigue, cognitive enhancement, mental focus, and sexual function are useful as monotherapies, multiherb combinations, and as adjuncts to prescription psychotropics. Relevant mechanisms of action and clinical guidelines for herbs in common use can assist clinicians who want to enhance treatment outcomes by integrating phytomedicinals into their treatment regimens. Research is needed to strengthen the evidence base and to expand the range of disorders that can be treated with herbal extracts. Studies of herbal genomic effects may lead to more targeted and effective treatments.
Adaptogens in Mental and Behavioral Disorders . . . . 49
Alexander G. Panossian
This article focuses on the most extensively studied adaptogens: Rhodiola rosea, Eleutherococcus senticosus, and Schisandra chinensis. Clinical studies, evidence for stress-protective and simulative effects, and molecular mechanisms of action on metabolic and other processes regulated by the neuroendocrine system are discussed.
St. John’s Wort for the Treatment of Psychiatric Disorders . . . . 65
Jerome Sarris
St. John’s wort (Hypericum perforatum) has been extensively studied and reviewed for its use in depression; however, there is less salient discussion on its clinical application for a range of other psychiatric disorders. This article outlines the current evidence of the efficacy of St John’s wort in common psychiatric disorders, including major depression, bipolar depression, attention-deficit hyperactivity disorder, obsessive-compulsive disorder, social phobia, and somatization disorder. Mechanisms of action, including emerging pharmacogenetic data, safety, and clinical considerations are also detailed.
Ginkgo biloba: Indications, Mechanisms, and Safety . . . . 73
Bruce J. Diamond and Mary R. Bailey
Ginkgo biloba special extract (EGb761) is used in most randomized control trials. Indications include cognition and memory in Alzheimer disease, age-associated dementia, cerebral insufficiency, intermittent claudication, schizophrenia, and multi-infarct dementia. Dosages range from 80 to 720 mg/d for durations of 2 weeks to 2 years. Mechanisms of action include increasing cerebral blood flow, antioxidant and antiinflammatory effects, with antiplatelet effects attributed to flavone and terpene lactones. Possible interactions with monoamine oxidase inhibitors, alprazolam, haloperidol, warfarin, and nifedipine have been reported. Optimal dosage/duration, dose-response characteristics, drug interactions, bioavailability, long-term effects, and optimal intervention timing should be the focus of future work.
Saffron, Passionflower, Valerian and Sage for Mental Health . . . . 85
Amirhossein Modabbernia and Shahin Akhondzadeh
Many cultures have developed folk herbal remedies to treat symptoms of mental illness. An evidence-based view is now being developed for some of these so-called alternative herbal treatments. This article discusses clinically relevant scientific information on medicinal extracts of 4 herbs: saffron, passionflower, valerian, and sage.
SECTION 3. MIND-BODY
Science of the Mind: Ancient Yoga texts and Modern Studies . . . . 93
Shirley Telles and Nilkamal Singh
The practice of yoga is gaining in popularity with a wide range of practices. Recent research and descriptions from the ancient texts are often concurrent with regard to the effects of the practice, taking into account expected differences between modern scientific terms and those used in the original texts. Voluntarily regulated yoga breathing practices form a bridge between physical and mental changes. The voluntarily regulated yoga breathing has distinct effects on metabolism, the autonomic nervous system, higher brain functions, and mental state. The effects of meditation on the nervous system and mental state are even clearer.
Tai Chi and Qigong for the Treatment and Prevention of Mental Disorders . . . . 109
Ryan Abbott and Helen Lavretsky
Tai Chi and Qigong are traditional Chinese exercises that are widely practiced for their health benefits and as martial arts. Evidence suggests that these practices may be effective at treating a range of physical health conditions, and at improving health-related quality of life. There is growing interest in the use of Tai Chi and Qigong to treat mental disorders, because they are noninvasive, exercise-based therapies, and because patients with mental disorders frequently use complementary and alternative medicine. Evidence is promising that these treatments may be effective in reducing depressive symptoms, stress, anxiety, and mood disturbances.
Breathing Practices for Treatment of Psychiatric and Stress-Related Medical Conditions . . . . 121
Richard P. Brown, Patricia L. Gerbarg, and Fred Muench
Neurophysiological studies may explain how breathing techniques normalize stress response, emotion regulation, and autonomic and neuroendocrine system function. Breath practices have been shown to reduce symptoms of stress, anxiety, insomnia, post-traumatic stress disorder, mass disasters, depression, and attention deficit disorder. Technology assisted breathing interventions facilitate therapeutic breathing by using either static cues such as a breath pacer or real-time feedback based on physiological parameters such as heart rate variability. The empirical literature indicates that technology-assisted breathing can be beneficial in mental health treatment, though it may not be appropriate for all individuals. Initial in-person training and evaluation can improve results.
Mindfulness Meditation Practices as Adjunctive Treatments for Psychiatric Disorders . . . . 141
William R. Marchand
Mindfulness meditation-based therapies are being increasingly used as interventions for psychiatric disorders. Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) have been studied extensively. MBSR is beneficial for general psychological health and pain management. MBCT is recommended as an adjunctive treatment for unipolar depression. Both MBSR and MBCT have efficacy for anxiety symptoms. Informed clinicians can do much to support their patients who are receiving mindfulness training. This review provides information needed by clinicians to help patients maximize the benefits of mindfulness training and develop an enduring meditation practice.
Open Focus Attention Training . . . . 153
Lester G. Fehmi and Susan B. Shor
This article describes the role of attention training and brainwave synchrony training in the resolution of stress- and pain-related symptoms. It describes the origin of Open Focus attention training as it was distilled from observations of space-generated brain wave activity. It provides a map of the various attentional styles and associated EEG activity.
SECTION 4. TECHNOLOGIES
Neurofeedback: An Emerging Technology for Treating Central Nervous System Dysregulation . . . . 163
Stephen Larsen and Leslie Sherlin
Neurofeedback is a machine-mediated noninvasive treatment modality based on the analysis and “feeding back” of electroencephalogram brainwaves, which has shown efficacy with a variety of central nervous system–based problems. It has special application where patients have adverse reaction to psychopharmacologic treatments and psychotherapy, cognitive behavioral therapy, and dialectical behavior therapy have proved ineffective. Treatment modalities include active forms based on operant conditioning, involving a subject’s response to stimuli. Neurofeedback is strong in clinical confirmations of efficacy (case studies) and has thus far limited controlled studies in the peer-reviewed journals.
Cranial Electrotherapy Stimulation for Treatment of Anxiety, Depression, and Insomnia . . . . 169
Daniel L. Kirsch and Francine Nichols
Cranial electrotherapy stimulation is a prescriptive medical device that delivers a mild form of electrical stimulation to the brain for the treatment of anxiety, depression, and insomnia. It is supported by more than 40 years of research demonstrating its effectiveness in several mechanistic studies and greater than 100 clinical studies. Adverse effects are rare (<1%), mild, and self-limiting, consisting mainly of skin irritation under the electrodes and headaches. Often used as a stand-alone therapy, because results are usually seen from the first treatment, cranial electrotherapy stimulation may also be used as an adjunctive therapy.
SECTION 5. HORMONAL TREATMENTS
Testosterone and Mood in Aging Men . . . . 177
Stuart N. Seidman and Mark Weiser
Age-associated hypothalamic-pituitary-gonadal (HPG) axis hypofunction, or partial androgen deficiency of the aging male, is thought to be responsible for various age-associated conditions such as reduced muscle and bone mass, mobility limitations, frailty, obesity, sleep apnea, cognitive impairment, sexual dysfunction, and depression. It has been difficult to establish consistent correlations between these symptoms and plasma testosterone levels in middle-aged men, but testosterone replacement does lead to improved muscle strength, bone density, and sexual function. This article focuses on the relationship between testosterone and mood in older men, and the treatment of age-related depression with exogenous testosterone.
SECTION 6. PREGNANCY
Perinatal Depression and Anxiety: Beyond Psychopharmacology . . . . 183
Kelly Brogan
A discussion of pharmacologic and nonpharmacologic management of mental disorders in the pregnant woman is presented, with the focus on alternative health approaches and nutrition awareness. The article explores some considerations of modifiable risk factors thought to play a role in epigenetic manifestations of infant and child illness. Several case examples show the potential for integrative medicine in patients of reproductive age.
Index . . . . 189
Along Roads Less Traveled: Complementary, Alternative, and Integrative Treatments
Psychotropic medications have revolutionized the treatment of serious mental disorders, yet in a significant number of cases, they are partially effective or ineffective. Psychotropics are necessary for many patients but they can contribute to the burden of side effects, and the cost of psychotropics contributes to the cost of health care and disposal of these medications may cause environmental pollution. Phytomedicines, nutrients, and mind-body practices tend to be less costly and to have fewer side effects. Furthermore, much of the world’s population has no access to prescription pharmaceuticals. Although psychotropics and psychotherapies will continue to be mainstays of psychiatric practice, specific combinations of herbs and nutrients can enhance the effectiveness of prescription drugs or reduce the necessary doses. Moreover, nutritional and phytomedicinal compounds can prevent or counteract various acute and long-term side effects of medications such as fatigue, Parkinsonian symptoms, akathisia, and elevated hepatic enzymes. Integrative psychiatrists are finding that mind-body practices can facilitate progress in psychotherapy. Identifying safe and effective nutrients, phytomedicines, and mind-body practices is therefore vital to better mental health care. Integrative treatments provide the clinician with additional therapeutic tools and empower the patient to participate actively in recovery.
We have invited authors to focus on treatments supported by an evidence base of significant benefits, associated with few and modest side effects. From the wide array of complementary, alternative, and integrative medicines (CAIM), we chose to include diverse points of view from experts who are well known, as well as from those whose work is not widely read by mainstream psychiatrists but who are highly regarded in their fields. The authors have been tasked with discussing the evidence base, neurophysiology, risks, benefits, and clinical applications for each treatment. Due to space limitations, commonly accepted and widely published treatments such as hypnosis and acupuncture are not included. To accommodate as much content as possible, several authors have opted to allow the publisher to post most of their reference lists online, retaining only key references with their articles.
Modern research is rediscovering and improving on the benefits of nutrients, herbs, and mind-body practices. Every culture has used local medicinal plants whose active constituents can now being analyzed. The neurophysiologic changes that underlie psychiatric disorders involve multiple mechanisms, metabolites, anatomic structures, and neuro-endocrine networks. Nutrients and herbal extracts contain bioactive substances that can scavenge free radicals, protect cellular structures, enhance mitochondrial energy transport, increase production of neurotransmitters, upregulate or downregulate genes, and replenish vital metabolites. The rationale for integrating treatments is that targeting multiple etiologic factors often results in better outcomes than targeting only one, such as a particular neurotransmitter.
The scientific measurement of psycho-neuro-immuno-hormonal and genomic changes induced by mind-body practices opens a vast domain for treatments derived from spiritual, meditative, fitness, and brain stimulation techniques. Studies are finding that mind-body interventions can activate or mute neural networks involved in emotion regulation. Such interventions act to balance stress response systems, including the autonomic nervous system and the hypothalamic-pituitary-adrenal axis. Among thousands of mind-body practices, one can discern certain common healing elements, for example, breathing practices. Initially developed prior to 5000 BC in India as well as in Asia, Africa, Polynesia, and the Americas, these techniques reappeared in medieval monasteries and martial arts. Today such practices are used in yoga classes and in Special Forces training. It is not surprising that such time-tested treatments show significant clinical benefits in randomized controlled trials. Developing specific mind-body programs for various psychiatric conditions and treatment settings is an appealing future direction.
Political, economic, and environmental forces are driving large-scale natural and man-made disasters. Relying solely on expensive pharmaceuticals or one-on-one therapies will not address the global epidemic of depression and posttraumatic stress disorder. Affected populations need inexpensive, accessible, safe, sustainable treatments. The large-scale cultivation of medicinal herbs is increasing available supplies. Local teachers, care providers, clergy, and community leaders can be trained to provide and to train others in self-healing mind-body practices. Resiliency training could help at-risk communities prevent or recover from the psychological sequelae of traumatizing events. Mind-body programs could also enable members of the military to endure combat stress better and recover from service-related posttraumatic stress disorder.
Integrative psychiatry seeks to enrich mainstream mental health care with valuable treatments from global healing traditions as well as from modern laboratories in related fields, such as neurofeedback, breath pacing, and genomics. Interest, support, and research are growing, but much more is needed to strengthen the evidence base and to refine treatments for specific conditions. Educating ourselves, our peers, and our patients is essential for the safe and optimal use of CAIM approaches. This volume introduces treatments that the authors and editors deem to be worthy of consideration and future development. References provide avenues for further learning. As in any therapeutic endeavor, the journey starts with hearing what those who are experts have to say, followed by self-education and clinical experience. Along these less traveled roads, each of us has learned and used many of these methods successfully in treating patients who were unresponsive to standard approaches.
We wish to thank the authors for contributing their knowledge and experience to this volume. Elsevier also deserves appreciation for making available to their readership material not often included in mainstream publications.
Philip R. Muskin, MD
Columbia University Medical Center
Consultation-Liaison Psychiatry
NY-Presbyterian Hospital/Columbia Campus
622 W. 168th Street, Mailbox #427
New York, NY 10032, USA
Patricia L. Gerbarg, MD
New York Medical College
86 Sherry Lane
Kingston, NY 12401, USA
Richard P. Brown, MD
Columbia University College of Physicians and Surgeons
86 Sherry Lane
Kingston, NY 12401, USA
E-mail addresses:
prm1@cumc.columbia.edu (P.R. Muskin)
PGerbarg@aol.com (P.L. Gerbarg)
rpb1@columbia.edu (R.P. Brown)