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What are complementary and alternative mental health treatments?

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Overview

People with psychological problems, including mood, anxiety, eating, sleep, and sexual disorders, seek complementary and alternative medicine (CAM) treatments. In some cases, they rely on these treatments in lieu of extant therapies; in other cases, they use CAM treatments along with traditional therapies.

CAM treatments for mental illness are remarkably diverse in scope. One 2002 review listed more than twenty widely used CAM techniques for mental health. These techniques include aromatherapy, acupuncture, herbal remedies, biofeedback, meditation, yoga, homeopathy, and creative arts (music, art, and dance) therapies. The research evidence for these and other CAM techniques varies in quality and quantity.

Popular Use of CAM

Studies demonstrate that substantial proportions of persons with mental disorders, in the United States use one or more CAM remedies. One large population-based survey conducted in 1997 and 1998 revealed that 22.4 percent of Americans with major depression used one or more CAM therapies. The corresponding proportions of Americans with panic disorder (a condition marked by sudden surges of extreme anxiety), generalized anxiety disorder (a condition marked by high levels of nervousness across many situations), and either mania or psychosis (conditions often marked by a loss of contact with reality) were 32.0, 20.5, and 22.3 percent respectively. Persons with major depression and those with panic disorder were significantly more likely to use CAM treatments than other persons in the general population.

The study also found that people with mental disorders who used CAM treatments were as likely as those without mental disorders to seek conventional mental health treatments, such as psychotherapy and psychotropic medication. This information is important because certain herbal remedies can interfere with the effects of some widely used medications.

The results of another U.S. study from the same time period yielded higher percentages than did the 1997/1998 study. The study’s investigative team found that 53.6 percent of persons with major depression had obtained CAM therapies in the year before the study; the corresponding number for persons with panic attacks was 56.7 percent. Among the most widely used CAM therapies (the percentage in parentheses refers to the proportion of people with major depression and panic attacks, respectively, using these therapies) were spiritual healing (10.5 and 9.9), energy healing (5.4 and 2.8), herbal remedies (4.3 and 3.3), megavitamins (3.4 and 3.6), aromatherapy (3.7 and 2.6), and hypnosis (1.8 and 3.0). Most people with major depression (63.9 percent) and with panic attacks (51.9 percent) who used CAM treatments also obtained conventional treatments. These latter percentages indicate, however, that large minorities of persons with mental disorders use CAM treatments in an alternative rather than complementary fashion. The data are worrisome given that a number of the CAM treatments used by respondents, such as energy therapies, megavitamins, and aromatherapy, are not empirically supported for the treatment of either mood or anxiety disorders.

Later systematic survey data on CAM use among persons with mental disorders is lacking. Nevertheless, the data from the late 1990s study suggest that CAM use is prevalent among people with psychological problems, at least in the United States. As a consequence, it is essential to ascertain whether CAM treatments are effective for psychological problems and whether any could be harmful. The sections that follow briefly examine the scientific evidence concerning four commonly used CAM treatments for mental illness: acupuncture, herbal remedies, yoga and meditation, and creative arts therapies.

Treatments and Techniques

Acupuncture. Several investigators have examined the efficacy of acupuncture for clinical depression. A few early studies suggested that acupuncture may alleviate the symptoms of depression, but most of these studies were not conducted in a double-blind fashion and, therefore, may have been influenced by the expectations of treatment providers or patients, or both.

The most methodologically rigorous study, published in 2006, randomly assigned 151 persons with major depression to one of three “conditions” lasting eight weeks: traditional Chinese medicine acupuncture (condition 1), a sham acupuncture condition involving needles inserted into the “wrong” areas (condition 2), and a wait-list control condition (condition 3). The results revealed that both conditions (1) and (2) outperformed (3), but that (1) and (2) did not differ significantly from each other. Moreover, the effects of both genuine and sham acupuncture on depressive symptoms were relatively weak. These findings raise questions concerning the efficacy of acupuncture for depression and suggest that the effects of acupuncture on mood may be attributable to nonspecific influences, such as placebo effects; that is, improvement was caused by the mere expectation of improvement.

Herbal remedies. Although numerous herbal remedies are available for treating psychological problems, perhaps the two best known are St. John’s wort (Hypericum perforatum) and kava (Piper methysticum). Following the passage of the Dietary Supplement Health and Education Act by the U.S. Congress in 1994, these and other herbal remedies for mood have not been regulated by the U.S. Food and Drug Administration. Therefore, mental health consumers in the United States take them at their own risk.

The data on the efficacy of St. John’s wort for mood disorders have been inconsistent. A 2005 meta-analysis (quantitative review) revealed that St. John’s wort exerted positive effects relative to a placebo among persons with mild to moderate depression. Nevertheless, the analysis also indicated that St. John’s wort may be largely or entirely ineffective relative to placebo for persons with major depression and for those with prolonged depression. The study also found no evidence that St. John’s wort is more effective than standard antidepressants, such as the selective serotonin reuptake inhibitors Prozac and Paxil.

A 2010 randomized-controlled trial of 189 persons suggested that St. John’s wort may be more effective than placebo among persons with atypical depression, namely, among those persons who exhibit “reversed” features, such as overeating and oversleeping. Overall, the findings for St. John’s wort point to potential positive effects on mild to moderate depression, and perhaps atypical depression, but offer little or no support for its use for severe depression.

Moreover, persons who take St. John’s wort should be certain to inform their physicians, because the remedy can interfere with the effects of other medications. For example, St. John’s wort can impede the effectiveness of chemotherapy medications and those used to treat human immunodeficiency virus infection. Evidence also exists that St. John’s wort can interfere with the effects of birth control pills, anticoagulants (blood thinners), and antidepressants.

Kava is an herbal remedy that has been used medicinally in the South Pacific to reduce anxiety. The practice of using kava as an anxiolytic has spread to other regions. A 2009 study revealed that kava is more effective than placebo for generalized anxiety. Other evidence suggests that kava is not more effective than buspirone, an antianxiety agent.

Kava has been deemed unsafe because of its potential to create toxic liver reactions. Researchers have been assessing the efficacy of an aqueous extract of kava to create a mixture that reduces the toxicity of the herb. Further inquiry is required to ascertain this extract’s safety and efficacy.

Meditation. Meditation comprises a heterogeneous array of self-control techniques, stemming largely from Buddhist and Hindu traditions and designed to enhance awareness and attention. A 2010 review of more than sixty studies (spanning thirty-five years) examined the effects of meditation techniques on a host of mental health difficulties, including mood, anxiety, and sleeping problems.

Although several of the studies in the review reported negative findings, most yielded preliminary evidence that various forms of meditation exert beneficial effects across a variety of psychological outcome variables. However, the overall quality of the research was limited, rendering any conclusions tentative. For example, many of the studies neglected to include control groups or included control groups of questionable adequacy. In addition, few of the studies incorporated adequate safeguards against client or therapist expectancy effects. In addition, it remains unclear whether meditation exerts positive effects above and beyond simpler interventions, such as relaxation.

Yoga. Yoga consists of a variety of physical and psychological techniques designed to heighten awareness. Hatha yoga, which originated in India but has substantially influenced Western forms of yoga, comprises postures (such as bending and balancing the body), breathing exercises, and meditation. A 2005 review of five randomized-controlled trials concluded that yoga shows some promise as an intervention for depression. Researchers also revealed that the studies varied considerably in the severity of the depression and nature of the yoga intervention delivered, and often omitted crucial methodological details.

As a consequence, the literature precludes strong conclusions regarding yoga’s potential effectiveness for depression. Moreover, it remains unclear if any beneficial effects of yoga on depression, anxiety, or other psychological difficulties are attributable to yoga per se or to the relaxation or exercise associated with it.

Creative arts therapies. Creative arts therapies encompass a plethora of CAM treatments and are used in various guises to enhance mental health and to improve creativity, productivity, and interpersonal relations. Such therapies include those of art, music, dance, and poetry.

A 1997 review showed that most of the research on the effects of creative arts therapies on mental disorders has been limited in quality and quantity, and few studies have controlled for placebo effects or the nonspecific effects of attention from mental health professionals. Moreover, most investigations of creative arts therapies demonstrate short-term elevating effects on mood rather than improvements in the core features of mental disorders such as schizophrenia, autism, or major depression.

Of all creative arts therapies, music therapy has been perhaps the most extensively investigated. A 2006 review of three studies of music therapy for autism spectrum disorders yielded mixed results. They found positive effects of music therapy on the communicative and gestural deficits of autism, but no significant effects on its behavioral deficits. Still, the small sample sizes (the total number of participants across all three investigations was only twenty-four) and the paucity of long-term follow-up studies make it impossible to draw clear, strong inferences. A 2008 review of five studies of music therapy on depression revealed low rates of dropout and positive results in four of the studies. Nevertheless, as the study’s authors noted, the substantial variations in the populations studied, the nature of the interventions, and the outcome measures administered again render any conclusions tentative.

Conclusions

Survey data demonstrate that large percentages, and perhaps majorities, of people with mental health problems, including mood and anxiety disorders, seek CAM therapies. These findings are troubling, given that most CAM therapies have been insufficiently investigated for such problems. However, preliminary evidence suggests that certain CAM therapies, including some herbal remedies (such as St. John’s wort and kava), meditation, yoga, and music therapy, hold promise for certain psychological difficulties. Still, even these interventions must be regarded as only promising, and all require additional research before they can be regarded as empirically supported and, in the case of herbal remedies, safe for widespread public consumption.

A variety of other widely used CAM methods, including homeopathy, chiropractic, energy therapies, chelation therapy, and craniosacral therapy, are not empirically supported for mental health problems. Therefore, they should not be used in lieu of treatments of established effectiveness.

Mental health consumers should be aware that a host of factors may contribute to erroneous beliefs in the effectiveness of certain CAM treatments for psychological problems. In particular, many emotional difficulties, such as depression, panic disorder, and sleep, sexual, and eating disorders, often wax and wane in severity over relatively short time periods. As a consequence, persons with mental health problems may mistakenly attribute naturally occurring improvement in their symptoms to CAM interventions. In addition, the placebo effect can generate improvement that is independent of the ingredients of the CAM treatments themselves. For these and other reasons, one should rely on controlled studies, rather than subjective judgments or anecdotes, to ascertain whether these treatments are effective.

Bibliography

Hughes, Brian M. “How Should Clinical Psychologists Approach Complementary and Alternative Medicine? Empirical, Epistemological, and Ethical Considerations.” Clinical Psychology Review 28 (2008): 657-675. A critical review of how clinical psychologists should evaluate CAM practices, including ethical, empirical, and epistemological perspectives on CAM.

Kessler, Ronald C., et al. “The Use of Complementary and Alternative Therapies to Treat Anxiety and Depression in the United States.” American Journal of Psychiatry 158 (2001): 289-294. A comprehensive survey of CAM treatments for anxiety and depression, including data on how many participants used CAM treatments in lieu of conventional therapies and the perceived helpfulness of these treatments.

Sarris, Jerome. “Kava and St. John’s Wort: Current Evidence for Use in Mood and Anxiety Disorders.” Journal of Alternative and Complementary Medicine 15 (2009): 827-836. A helpful summary of research on the efficacy of kava and St. John’s wort on anxiety and depression, respectively.

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