What are Complementary and Alternative Medicine Therapies?
Complementary and alternative medicine (CAM) therapies are finding increasing use these days in mood disorders. The word “Complementary” refers to approaches that are not considered mainstream or conventional but are consistent with Western concepts based on the biomedical model. “Alternative” approaches are usually considered outside of the traditional Western medical conceptual framework.
Mood disorders are common mental health problems, afflicting 154 million people around the world. In fact, the prevalence of mood disorders is higher than that of any other chronic medical condition. As it turns out, more and more people are turning to CAM therapies to help manage their mood disorders. So, no wonder that CAM treatments are now widely available. The National Health Interview Survey (NHIS) showed that almost 40% of adults use CAM.
CAM therapies used in mood disorders can include:
- Herbs (St. John’s wort)
- Dietary supplements (vitamins, minerals, and probiotics)
- Mind-body practices
- Tai chi
- Qi gong
- Deep breathing exercises
In general, CAM therapies are safe and cost-effective. And they are well tolerated by patients with physical and mental disorders. But, they have limited comparative efficacy to modern allopathic treatments.
Herbs as Complementary and Alternative Medicine Therapies in Mood Disorders
The use of medicinal herbs had been widespread across many cultures since ancient times. A university student survey found that most herb use was self-prescribed (60%) and undisclosed to health providers (75%), and 34% of users took herbs to treat a mood disorder. Although many herbs contain bioactive substances, further investigation is needed into their clinical significance.
St. John’s wort (Hypericum perforatum)
St. John’s wort inhibits monoamine reuptake and downregulates monoamine receptors in the brain. Its active constituents are hypericin and hyperforin. This herb is generally superior to placebo. In comparison with standard antidepressants, St. John’s wort showed comparable severity reductions, response, remission, and relapse rates. And, there is greater consensus and support for use of St. John’s wort in mild to moderate mood disorders. But, it is less for more severe mood disorders. Since it is better tolerated, it is much sought after by many patients. The dose is typically around 900-1800 mg/day Hypericum extract WS® 5570.
One side effect is photosensitivity at high doses. Also, the herb can cause decreased absorption and increased clearance of certain drugs. These drugs include antiretrovirals, benzodiazepines, oral contraceptives, digoxin, phenobarbital, and theophylline. Also, there is potential toxicity with traditional antidepressants that can lead to serotonin syndrome. Unintended pregnancies have been reported with concomitant St. John’s wort and oral contraceptive use.
There are several other herbs that are used, but there is really no supportive data. These herbs include Rhodiola rosea, Crocus sativus, Lavandula angustifolia, and Ginkgo biloba.
Dietary Supplements as Complementary and Alternative Medicine Therapies in Mood Disorders
Over-the-counter dietary supplements (nutraceuticals) are used extensively by patients with mood disorders. Nutraceuticals have also been used to promote mental and physical health, to prevent illness, and to treat diseases, with substantial benefits.
S-adenosylmethionine (SAMe) is the major donor of the methyl group in human metabolism. This appears to be a safe adjunctive treatment for patients with major depression who do not respond to SSRIs. Some studies have found marked improvement of depression in over half of patients given SAMe. The antidepressant response is rapid and without significant side-effects with IV SAMe. We should do more studies to determine the efficacy of SAMe and its comparative efficacy to standard antidepressants.
The oral doses of SAMe are between 800-1600 mg/day and the parenteral doses of SAMe are usually 100-200 mg/day. Overall, SAMe is found to be generally well-tolerated in most studies, and relatively free of adverse effects. Side effects include mild insomnia, lack of appetite, constipation, nausea, dry mouth, sweating, dizziness, and nervousness.
Vitamins in Mood Disorders
Vitamins B and D, folate, and trace elements are essential for the functioning of neurons. They afford protection against certain types of mental disorders, particularly depression.
Folate: Nonresponse to antidepressants has been linked with low levels of folate. A study with fluoxetine supplemented with folate 400 mg/day or placebo reported a 94% response rate to fluoxetine plus folate compared with a 61% response to fluoxetine plus placebo. Be that as it may, the efficacy of folate monotherapy for major depression has yet to be extensively and adequately tested.
Vitamin D: Low levels of vitamin D are present in patients with major depressive and other mood disorders. However, vitamin D supplementation in these patients has not yielded unequivocal results.
Omega-3 Fatty Acids in Mood Disorders
The human body is unable to synthesize essential fatty acids and so they must be ingested. Fish-derived omega-3 fatty acids provide eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These help to maintain the fluidity of the cell membrane, reduce inflammatory eicosanoids, and prevent the release of proinflammatory cytokines. They are important in the functioning of the neural networks involved in mood regulation.
A meta-analysis of relevant studies reported that >60% EPA had a positive impact on symptoms of depression. And, an increased risk of suicide occurs in omega-3 fatty acid deficiency. But, we need more evidence to establish a definitive role for omega-3 fatty acids in the treatment of major depression.
Omega-3 fatty acids are also safe for use in children and adolescents with bipolar disorder. Moreover, these acids also have a preventive role. Interestingly, greater consumption of seafood correlates with lower lifetime prevalence of bipolar II disorder.
Other Nutrients Used in CAM Therapies for Mood Disorders
Choline: Choline is effective in ameliorating symptoms of mania. The dose is free choline 2000–7200 mg/day. We should do larger studies before recommending the use of oral choline in the treatment of mania in bipolar I disorder.
5-hydroxytryptophan: This is an immediate precursor in the synthesis of serotonin. We know that a deficiency of serotonin can cause major depression. There is some support for 5-hydroxytryptophan 200–300 mg/day being more effective than a placebo when given alone in adults with major depression.
Inositol: Inositol is more effective than a placebo in the treatment of depression and other psychiatric illnesses, including panic disorder. Doses in the relevant studies have ranged from 12,000 to 20,000 mg/day. However, at therapeutic doses, inositol frequently causes flatulence and occasionally induces mania.
N-acetylcysteine: N-acetylcysteine is a precursor of glutathione. Hence, it is an important antioxidant in the brain and reduces oxidative stress. Increased oxidative stress and altered glutathione metabolism are present in bipolar and major depressive disorder. In one study, adjunctive N-acetylcysteine 2 g/day showed a significant improvement in depression, mania, quality of life, and social and occupational functioning compared with placebo.
Mind-Body Practices as Complementary and Alternative Medicine Therapies in Mood Disorders
Mind-body practices have become very popular for treatment for mood disorders. According to the National Institute of Mental Health (NIMH) study group, the most commonly employed practices include yoga, meditation, acupuncture, qi-gong, tai-chi, and deep breathing exercises.
Yoga: Numerous studies have looked at yoga in the treatment of depression. And they suggest that improvement in depression may relate to changes in brain waves and decreases in the stress hormone cortisol.
Meditation: Mindfulness meditation forms the core of Buddhist meditation. Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) now incorporate mindfulness meditation. So, these are the most studied interventions of this type in mood disorders. And, meta-analyses of RCTs of MBSR and MBSR-like interventions show a significant large short-term effect on depression severity. In one study, MBCT showed a significantly reduced risk of depressive relapse compared with those receiving antidepressant drugs.
Acupuncture: This remains controversial. However, a recent meta-analysis showed that acupuncture did significantly reduce depressive symptoms measured by the Hamilton Rating Scale & Beck Depression Inventory.
Final Word on Complementary and Alternative Medicine Therapies in Mood Disorders
Many patients with mood disorders do not seek conventional treatment. Moreover, it has been shown that the benefit of antidepressants compared with placebo in patients with mild or moderate symptoms was minimal. Though, the benefit does increase with the severity of depression symptoms. Hence, the popularity of CAM therapies in mood disorders within the general Western population continues to grow. A few CAM therapies such as omega-3 fatty acids and mindfulness meditation may have a role in the overall treatment plan of patients with depressive mood disorders. In summary, we need to do more rigorous and larger studies to determine whether any of the CAM therapies should be formally indicated for the treatment of mood disorders.