Complementary and Alternative Therapies for Depression

Complementary and Alternative Therapies for Depression

اسلاید 1: www.tabaye.ir

اسلاید 2: Complementary and Alternative Therapies for DepressionSudha Prathikanti, MDUniversity of California, San Franciscowww.prathikanti.com/teaching

اسلاید 3: MAJOR DEPRESSION Most disabling medical condition in U.S.Chronic / recurrent course is commonSignificant medical / psych co-morbidityContribution to mortality: Suicide risk of death in med conditions

اسلاید 4: COMMON CONVENTIONAL TREATMENTSSome Limitations:  Disappointing remission rates High rates of non-adherence due to Expense & duration of treatment Social / cultural stigma Medication side effectsPsychotherapyAnti-depressant Medication

اسلاید 5: COMPLEMENTARY & ALTERNATIVE MEDICINE (CAM): NIH DEFINITIONHealthcare systems, practices, and products not presently considered to be part of conventional medicine. Complementary: along with conventional careAlternative: in place of conventional care

اسلاید 6: USE OF CAM THERAPIES FOR DEPRESSIONCAM use is high among people with depressionCAM use may even exceed conventional careCAM use is often combined with conventional care

اسلاید 7: CAM THERAPIES COMMONLY USED IN DEPRESSIONBiologically-Based TherapiesBotanicals and HerbsDiet and Nutritional SupplementsSpiritual TherapiesPrayer Healing ritualsManual TherapiesMassageChiropractic Mind-Body Therapies Yoga Meditation Relaxation TechniquesExercise Aerobic Weight-training / resistance

اسلاید 8: THE APPEAL OF CAM THERAPIES Acknowledge body, mind, and spiritEmphasis on preventing disease Treatment is specific to the personKnowing cause of illness less criticaL Physician activates self-healing capacity

اسلاید 9: SOME LIMITATIONS OF CAMQuality of Care: often unregulated practiceQuality of Product: no stringent monitoringQuality of Science: often unverified efficacy

اسلاید 10: SOME UNIVERSITY-BASED INTEGRATIVE MEDICINE CENTERS IN THE UNITED STATES ColumbiaCornellDukeGeorge WashingtonHarvardStanfordThomas JeffersonTuftsUniversity of ArizonaUniversity of MarylandUniversity of MiamiUniversity of MichiganUniversity of PittsburgUniversity of TexasUniversity of WashingtonUniversity of California,San Francisco

اسلاید 11: EVIDENCE BASE FOR CAM THERAPIES IN DEPRESSIONMEDITATIONHATHA YOGAACUPUNCTUREHERBS & SUPPLEMENTSEXERCISE

اسلاید 12: MEDITATIONConcentration Practice (TM, RR)Mindfulness Practice (MBSR, MBCT)Some indications: Recurrent Depression (MBCT) Chronic anxiety (TM, MBSR) Chronic insomnia (RR) Overall emotional well-being (RR, MBSR)

اسلاید 13: HATHA YOGAMost common yoga practice in U.S. Includes asanas (body postures) &pranayama (breathing exercises)Randomized controlled trialsPranayama + asana reduces symptoms in depressed college students Pranayama comparable to tricyclic in treating depressed psych inpatientsAsanas superior to wait-list in reducing depressive symptomsShort-term antidepressant effects of pranayama + asana comparable to PMR and superior to control

اسلاید 14: ACUPUNCTUREElectro-acupunctureManual acupunctureLaser acupunctureRandomized controlled trialsLuo et al: EA equivalent to tricyclic in depression (unipolar + bipolar subjects)Allen et al : EA group only marginally better than wait-list control Roschke et al: EA no better than sham EA as adjuvant to antidepressantQuah-Smith et al: Laser acupuncture superior to sham in treating depressive symptoms

اسلاید 15: HERBAL REMEDIESSt. John’s WortEquivalent to low-dose tricyclic in mild-mod depressionThree large negative studies compared to SSRI/placeboTypical dose 900-1800 mg/day (in three divided doses)Watch for photo-toxicity and herb-drug interactionsNIH Minor Depression study pendingHypericum perforatum

اسلاید 16: HERBAL REMEDIESRhodiolaMany classified Russian studies during Cold warEnhances cognitive performance under stressReduces mental fatigueImproves sexual functionImproves overall well-being300-900 mg/day for depressionCaution with bipolar and post-MI patientsRhodiola Rosea

اسلاید 17: HERBAL REMEDIESValerian RootUsed for hundreds of years for anxiety / insomniaSeven placebo-controlled trials (400-900 mg/day)6 of 7 studies found statistically significant, dose-related sedative effectsNot benzodiazapine, so little abuse potentialAvoid if liver dysfunctionAvoid concurrent use with benzoValeriana officinalis

اسلاید 18: DIETARY SUPPLEMENTSOmega-3 Fatty AcidsWorldwide, 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 depressionEicosapentanoic 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 re: use in psych conditionsFood increases omega-3 absorptionDo not heat fish oilVitamin E may help in vivo potency Caution with anti-coagulants and hi-dose NSAIDS

اسلاید 19: DIETARY SUPPLEMENTS Folic AcidFolate deficiency appears significantly correlated with higher rates of depression Data suggest low serum folate may hinder antidepressant responseFolate (0.5 mg/day) may be important adjuvant in treating women (but not men) with resistant depressionFolate may help prevent relapse during & after depression txWatch for reduced efficacy of concurrent phenobarb/phenytoin

اسلاید 20: DIETARY SUPPLEMENTSS-Adenosyl-Methionine (SAMe)Several placebo-controlled trials for use in depressionMeta-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

اسلاید 21: EXERCISEAerobic exercise most studied Adherence rates in exercise studies comparable to those in medication trialsRandomized controlled trials Antidepressant effects comparable to CBT Feasible in older subjects Total caloric expenditure/wk more critical than frequency/wk

اسلاید 22: DUTY TO PROTECT Proven danger with specific CAM use No proven benefit with CAM use and clear benefit with conventional treatment

اسلاید 23: DUTY TO PROMOTE Likely benefit with specific CAM use Low risk of harm

اسلاید 24: DUTY TO PARTNER Conventional diagnosis / treatment inadequate  Symptoms fit CAM healing paradigm  Risk- Benefit of CAM therapy unknown per scientific studies Competent CAM practitioner / product available Optimistic patient / healer expectation  Co-monitor patient undergoing CAM therapy trial

اسلاید 25: RESOURCES FOR CAM EDUCATIONCAM on PubMed Cochrane CollaborationNCCAM WebsiteNIH Office of Dietary SupplementsHerb Research FoundationAmerican Botanical CouncilConsumer LabJournalsAlternative Therapies in Health and MedicineJournal of Alternative and Complementary MedicineIntegrative MedicineEvidence Based Complementary and Alternative Medicine

اسلاید 26: INTEGRATIVE MEDICINE: THE BEST OF BOTH WORLDSIntegrative 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