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HOLISTIC HEALING FOR THE MIND: COMPLEMENTARY AND ALTERNATIVE THERAPIES IN PSYCHIATRY. Sudha Prathikanti, MD University of California, San Francisco www.prathikanti.com/teaching. INTEGRATIVE PSYCHIATRY.

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HOLISTIC HEALING FOR THE MIND:COMPLEMENTARY AND ALTERNATIVE THERAPIES IN PSYCHIATRY

Sudha Prathikanti, MD

University of California, San Francisco

www.prathikanti.com/teaching


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INTEGRATIVE PSYCHIATRY

A healing approach that uses both conventional and complementary / alternative medicine to understand and treat psychiatric conditions.


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NIH DEFINITION OF COMPLEMENTARY & ALTERNATIVE MEDICINE (CAM)

Healthcare systems, practices, and products not presently considered to be part of conventional medicine.

Complementary: together with

conventional practice

Alternative: in place of

conventional practice


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Mind-Body Therapies

Meditation

Biofeedback

Hypnosis and Guided Imagery

Biologically-Based Therapies

Botanicals and Herbs

Nutritional Supplements

Energy Therapies

Reiki

Qi Gong

Magnets

Manual Therapies

Massage

Chiropractic

NIH CLASSIFICATION OF CAM

Alternative Medical Systems

  • Ayurveda

  • Traditional Chinese Medicine

  • Homeopathy


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USE OF CAM IN THE UNITED STATES

General public’s use of CAM:

--42% (Eisenberg 1998)

--36% when prayer excluded (Barnes et al, 2004)

--62% when prayer included (Barnes et al, 2004)

Among people with self-reported anxiety or depression,

CAM use exceeds conventional care (Eisenberg 2001)

--For anxiety, CAM 57% vs conventional 41%

--For depression, CAM 54% vs conventional 35%

Among people with self-reported anxiety or depression

who seek conventional care

-- 66% with anxiety also use CAM

-- 67% with depression also use CAM

CAM use by patients with anxiety / depression

-- Mind-body therapies 34%

-- Spiritual healing 10%

-- Manual therapies 8%

-- Herbs / supplements 7%


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EVOLUTION OF MODERN BIOMEDICINE

European Enlightenment

Germ Theory of Disease

Flexner Report


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THE BIOMEDICAL PARADIGM

  • Body, mind, spirit are discrete

  • Body can be treated independently

  • Body is like machine

  • Isolate & eradicate source of malfunction

  • Physician is specialized technician

  • Treatment is specific to illness

  • Treatment should pass scientific tests

  • Physician -patient relationship has little bearing on outcome as long as adherence to treatment prevails

  • Emphasis on fighting disease


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LIMITATIONS OF BIOMEDICINE

Poorer results when condition

- Chronic

- Non-bacterial

- Non-mechanical

- Autoimmune

- Unknown or multifactorial etiology

Adverse effects of biomedical therapies

Rigid treatment delivery systems

Less time with physician

Possible sense of de-humanization & compartmentalization


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THE “RE-DISCOVERY” OF ALTERNATIVE MEDICINE

The more I learn of physics, the more I am drawn to metaphysics.

Albert Einstein


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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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INTEGRATIVE MEDICINE:THE 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


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PSYCHIATRY AS BIOMEDICINE SPECIALITY

  • Historical Roots

    • Conventional medical school training

    • Vocabulary (e.g. case history, prevalence, pathogenesis, prognosis, cure) syntonic with biomedicine

    • Reductionism of classical Drive Theory

    • Separation from religion

  • Current Developments

    • Information explosion about brain and its function

    • Discovery of biochemical etiologies for mental illness

    • Creation of powerful psychotropic medications


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PSYCHIATRY AS DEPARTURE FROM BIOMEDICINE

  • Conversion disorders & early affirmation of mind-body connection

  • Consultation Psychiatry & more elucidation of mind-body and body-mind syndromes

  • Psychoanalysis as self-healing process with physician as catalyst

  • Acceptance of psychoanalysis despite lack of scientific tests

  • DSM recognition of cultural & spiritual dimensions in diagnosis and treatment


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CROSSING THE CARTESIAN DIVIDE

But what is quackery?

It is commonly an attempt to cure the diseases of man by addressing the body alone.

Henry David Thoreau


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Psychiatry is uniquely situated to

integrate healing paradigms.


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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 REMEDIES IN PSYCHIATRY

MEDITATION

HATHA YOGA

ACUPUNCTURE

HERBS & SUPPLEMENTS


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MEDITATION

Chronic anxiety

Chronic pain

Chronic insomnia

Recurrent depression

Overall emotional well-being

  • Less anxiety and depression

  • Increased sense of control

  • Increased empathy


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HATHA YOGA

Randomized controlled trials

  • Depression

  • Anxiety

  • Opiate Dependence

    Non-randomized controlled trials

  • Mood benefits equivalent to swimming

  • Mood benefits superior to muscle relaxation and visualization

  • Higher life satisfaction, better overall mood, better coping with stress


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ACUPUNCTURE

Primary therapy in

acute musculoskeletal pain

Adjuvant therapy in

chronic musculoskeletal pain

Perhaps some efficacy in depression

Scant data in anxiety disorders

No convincing data re: efficacy in

smoking cessation or drug detox/rehab


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HERBAL REMEDIES

St. John’s Wort

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

  • Two large negative studies compared to SSRI’s

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

  • Watch for photoxicity and herb-drug interactions

  • NIH Minor Depression study pending

Hypericum perforatum


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HERBAL REMEDIES

Gingko

  • More than 30 double-blind trials show

    promise in slowing dementia symptoms

  • May delay Alzheimer progression

    by 6-12 months

  • Most effective in Alzheimer’s ,

    not vascular dementia

  • Full effect may require one year

    at 120-240 mg/day

  • No head-to-head comparison with anti-cholinesterases

  • Some prelim positive results in

    young, healthy subjects

  • Watch for seizure in epileptics,

    hemorrhage in patients on anti-coags

Gingko Biloba


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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

Valeriana officinalis


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HERBAL REMEDIES FROM AYURVEDA

Rauwolfia serpentina

Valeriana jatamansi

Centella asiatica

Antipsychotic Effect

-- Rauwolfia *

-- Centella (in polyherbal)

Anxiolytic Effect

-- Valeriana

-- Centella

-- Withania

-- Convolvulus

-- Bacopa *

Antidepressant Effect

--- Withania

--- Convolvulus

Soporific Effect

-- Valeriana *

-- Centella (in polyherbal)

Cognitive Enhancement

-- Centella

-- Withania *

-- Convolvulus

-- Bacopa *

Jatamansi

Sarpagandha

Mandukparni

Shankpushpi

Ashwagandha

Brahmi

Withania somnifera

Convolvulus pluricaulis

Bacopa Monniera


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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 on

    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

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 SSRI’s

  • Risk of mania, serotonin syndrome


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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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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

  • Benefit / harm of CAM unknown per scientific studies

  • Conventional diagnosis / treatment inadequate

  • Symptoms fit CAM healing paradigm

  • Competent CAM practitioner / product available

  • Optimistic patient / healer expectation

  • Joint monitoring of CAM therapeutic trial


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RESOURCES FOR CAM EDUCATION


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RESOURCES FOR CAM EDUCATION

Journals

Alternative Therapies in Health and Medicine

Journal of Alternative and Complementary Medicine

Integrative Medicine

Evidence Based Complementary and Alternative Medicine

Websites

CAM on PubMed

 Cochrane Collaboration

 NCCAM Website

 Herb Research Foundation

 American Botanical Council

 Consumer Lab

 NIH Office of Dietary

Supplements