Complementary and Alternative Therapies in psychiatry

COMPLEMENTARY AND ALTERNATIVE THERAPIES IN PSYCHIATRY

National Centre for Complementary and Alternative Medicine (NCCAM)

In India, it is Indian Board for Alternative Medicine (IBAM).

IBAM- A Internationally Recognized Government Institution of CAM providing world-wide research in the field of complementary and alternative medicines.

1.CAM: - Group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine.

2.Complementary medicine: - It is used together with conventional medicine.

3.Alternative medicine: - It is used in place of conventional medicine.

4.Integrative medicine: - It combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.

NCCAM classifies CAM therapies into:

Alternative Medical Systems: - Built upon complete systems of theory and practice. Examples Ayurveda, Homeopathy, Acupuncture and Chinese medicine.

Mind-Body Interventions: - Techniques designed to enhance the minds capacity to affect bodily function and symptoms. Examples - Meditation, Spirituality, Creative therapies.

Biologically Based Therapies: - Substances found in nature are used. Examples- Dietary supplements, Herbal products, vitamins.

Manipulative and Body based methods: - Based on manipulation and/or movement of one or more parts of the body. Examples- Yoga, Massage.

Energy Therapies: - Involves the use of energy fields. Two types:

a)Bio field therapies: - Qigong, Reiki, Therapeutic Touch.

b)Bio electromagnetic therapies- pulsed fields, magnetic fields, or alternating-current or directcurrent fields.

AYURVEDA

·         5000 year old Indian system of healing.

·         Derived from Vedic concepts of health and healing 

·         Charaka Samhita is important compilation.

·         Focuses on prevention of illness rather than treatment.

Causes-

·         Improper diet,

·         Actions committed in this birth,

·         Bad deeds done in the last birth,

·         Physical illnesses and overindulgence,

·         Severe mental or physical stress,

·         Un favourable -personal, familial and social environment

Mental Disorders described in Ayurveda-

·         Unmada - Insanity,

·         Apasmara- Epilepsy,

·         Avasada- Depression,

·         Chittoo-Udvega- Anxiety neurosis,

·         Manasa Mandata- Mental Retardation,  

·         Atatva abhinevisha- Obsessive Disorders,  

·         Madatyaya - Intoxication.

ü  Describes three guna of Mind (manas) → Satwa , Raja &Tama.

ü  Disease is due to imbalance of the tamas or rajas in the mind.

ü  Rajas and Tamas are termed as Doshas of mind. Tridosha- Vata, Pitta and Kapha.

ü  They literally mean the darkness and brightness of the mind or negative thoughts in the mind.

ü  These impurities or imbalances are called doshas.

ü  It concentrates on the aspect of mind, body and soul and thus moulds the treating process combining both mind and body.

ü  It declares that health is the result of pure body, happy soul and selfless mind.

Methods of healing-

l . Daivavyaprashya Chikitsa-

·         Mantra- Chanting of Hymns,

·         Gems- Auspicious Stones,

·         Mangala- Auspicious offerings,

·         Homa- Yajna,

·         Niyama- Regulations,  

·         Prayaschita-Atonement,  

·         Upavasa-Fasting.

2. Yukti Vyapashraya (Medicines)-

a.Antah Parimarjana

(a)Shodhana: Cleansing (Panchkarma & Mild purgation , therapeutic Emesis & Purgation in Pitta & Kaphja type).

(b)Shamana: Palliative (Medhya Rasayanas, Diet etc.)

b.Bahir Parimarjnana- Murdha Taila, Ahyanga, Shirodhara.

 3. Satvavajaya Cikitsa (Psychotherapy)-

Aim is to augment the sattva guna in order to correct the imbalance in state of rajas (passion) and tamas (inertia).

NCCAM research- Most clinical trials were small, problems with research designs, or lacked control groups. Researchers have studied Ayurvedic approaches for schizophrenia; however, scientific evidence for its effectiveness is inconclusive.

HOMEOTHERAPY/HOMEOPATHY

Developed in Germany by Samuel Hahnemann at the end of the 18th century.

Three unconventional theories:

·         Like cures like- disease can be cured by a substance that produces similar symptoms in healthy people.

·         Law of minimum dose- lower dose of medication, has greater effectiveness.

·         Remedies are effective when they are selected on the total characteristic set of symptoms, not just those of the disease.

·         Remedies are derived from plants, minerals, or animals, such as red onion, arnica, crushed whole bees, white arsenic, poison ivy, belladonna.

·         Formulated as sugar pellets.

·         Widely used to self-treat generalized anxiety and other anxiety symptoms.

·         Case reports of homeopathic remedies in PTSD, social phobia, panic disorder, and OCD wcrc  published. However, findings of placebo-controlled studies were negative or equivocal.

·         There is no uniform prescribing standard for practitioners.

ACUPUNCTURE

·         It is an ancient Chinese treatment & central to Traditional Chinese Medicine (TCM).

·         TCM promotes a holistic, energy-based approach to well-being, as opposed to the diseaseoriented approach of Western medicine.

·         Acupuncture incorporates use of ultra-fine needles, inserted into specific points on the skin  (acupoints).

·         Concept- The bodys energy/ Qi, flows along series of points called meridians. Each of thc  internal organs has a corresponding meridian, and applying pressure, heat or needles to relevant acupoints is believed to influence each of the internal organs and harmonize the bodys Qi.

·         Exact mechanism is unclear.

·         Research shows that it results in local and systemic effects, such as an increased releasc of pituitary beta-endorphins and ACTH.

MEDITATION

·         It is a psychological state of active passivity and creative quiescence.

·         Meditator purposefully and nonjudgmentally pays attention to the present moment.

·         Focus is on the process, or flow of psychic content, rather than on the content itself.

·         There are many types of meditation, most have originated in ancient religious and spiritual traditions.

·         Meditator generally uses certain techniques, such as a specific posture, focused attention, and an open attitude toward distractions.

·         Two common forms- Mindfulness meditation and Transcendental meditation (TM).

·         Mindfulness- essential component of Buddhism.

·         The meditator is taught to bring attention to the sensation of the flow of the breath in and out of the body.

·         Helps the meditator learn to experience thoughts and emotions in normal life with greater balance and acceptance.

Other physiological effects include

·         ↓Oxygen consumption,

·         ↓Respiratory rate,

·         ↓BP,

·         EEG changes associated with decreased autonomic arousal.

SPIRITUALITY

·         Religion: - Organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent.

·         Spirituality: - Personal quest for understanding answers to the ultimate questions about life.

·         In medieval ages most mental disorders were considered as witchcraft or demonic possession, when natural causes was not considered to mental disorders.

·         Most of the Physicians like Charcot, Maudslay, Sigmond Freud, Albert Ellis had anti religious stance based on their personal experiences.

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CREATIVE THERAPIES

Def: - It is based on the premise that when someone works creatively under the guidance of a qualified therapist, they become more expressive and communicative.

Music therapy: - It is use of music to accomplish individualized goals within a therapeutic relationship by a professional.

Art therapy: - It is a mental health profession who uses the creative process of art making to improve and enhance the physical, mental, and emotional wellbeing of individual.

Drama therapy: - It is the intentional use of drama and/or theatre processes to achieve therapeutic goals.

Dancc therapy: - The psychotherapeutic use of movement to further thc emotional, cognitive, physical and social integration of the individual.

Others- Poetry therapy, Play therapy, Sand-play therapy, Multi-modal therapy.

 Compared to others they have-

·         Self expression,

·         Active participation,

·         Imagination,

·         Mind body connections.

Music therapy is the most widely researched modality, because physiological and behavioural reactions to music can be quantified.

DIET MODIFICATIONS

·         ↓ refined sugar and caffeine→ improves mood in some depressed patients.

·         Caffeine→ ↑ serum Adr, NA, and cortisol→ general feelings of nervousness / ↑risk of panic attacks in predisposed individuals.

·         Consumption of high fat & calorie diet→ ↑ developing Alzheimers disease compared to those who take moderate fat & calories.

·         Excess caloric & fat intake→promote formation of damaging free radicals→ diffuse neuropathological changes in the brain.

·         Moderate but not heavy consumption of wine→↓ risk of Alzheimers disease.

VITAMINS

Deficiencies:

·         Causative role in mental illness and exacerbate symptoms.

·         Symptoms can result in poor nutrition.

·         May compromise patient recovery.

Bl (Thiamine)-

·         Chronic Alcoholism, Eating disorders.

·         'Wernicks encephalopathy, Korsakoffs psychosis.

B2 (Riboflavin)-

·         Excess Alcohol

·         Depression (Glutathione def)

B6 (Pyridoxine)-

·         Hemodialysis, OCPs. 

·         Depression

B9 (folate)-

·         Required for synthesis of 5 H T, NA, DA.

·         Mood disorders, Depression, Psychosis.

·         Augmentation with L-Methylfolate in antidepressant rx.

B12 (Cobalamin)-

·         Associated with ↑Homocysteine.

·         Depression, Irritability, Agitation, Psychosis, Obsessive symptoms, Cognitive decline, Alzheimers dis.

·         Compromises antidepressant efficacy.

C (Ascorbic acid)-

·         Drug/ Alcohol abuse, Eating disorders.

·         Depression, Schizophrenia.

A-

Excess- Aggression, Depression, Psychosis, Suicide.

D-       

·         Role in brain function and development.

·         Depression, Cognitive dysfunction, Seasonal Affective disorder.

Supplementation of Folate (l to 15mg), Thiamine (50mg), Inositol (up to 20gm/ d) →↑Efficacy of conventional antidepressants.

Supplementation of Folate, Choline, Phosphatidylcholine →↑ T efficacy of lithium in acute mania.

In Schizophrenia, daily Folate & Niacin + antipsychotic→fewer +ve & -ve symptoms and respond more rapidly.

MINERALS

·         Rapid recovery from severe depressed mood,

·         Ameliorate symptoms of anxiety, irritability, insomnia, postpartum depression and short-term memory,

·         Improve neuropsychological deficits,

·         Low in ADHD and supplementation can help inattention.

·         high copper levels may be a causative factor in the pathogenesis of Alzheimers

·         disease.

·         Deficiencies in Zinc, Manganese and Iron are common in alcoholics and worsen with chronic heavy use.

AMINO ACIDS

L-tryptophan

            Effective in treatment of moderate depression and as adjuvant in treatment resistant depression.

            Combined with antidepressant→rapid response in insomnia.

            ↓levels→BPAD in genetic predisposed.

Omega 3 fatty acids

·         2 main omega-3 FA - Eicosapentaenoic acid (EPA) & docosahexaenoic acid (DHA).  

·         Studies suggest that PUFAs- EPA and DHA- Ameliorate symptoms associated with many psychiatric disorders.

·         Studies→ Association b/n depression and low omega-3 F A.

ST.JOHNS WORT

·         Hypericum perforatum aka St Johns wort, is a flowering plant.

·         Called so because traditional flowering and harvesting takes place on St Johns day, 24 Junc.

·         Constituents (Hyperforin) function as            

·         SRIs,

·         Weakly inhibit MAO,

·         Current evidence→ treatment of mild to moderate depression and Somatisation disorder with tentative support in Seasonal affective disorder.

·         Studies were conducted to explore its use in other psychiatric disorders like ADHD, Dysthymia, OCD, GAD, Social phobia etc.., but the evidence is not conclusive.

GINKGO BILOBA

·         The ginkgo is a living fossil, with fossils recognisably dating back 270 million years.

·         It is one of the most frequently prescribed herbal preparation in Germany and over the counter herbal preparation in US.

·         MOA- Antioxidant and Anti PAF activity

·         Induces→ Modulatory effects on Cerebro-Vasculature tone, receptor activity and EEG activity.

·         Indications- Alzheimers age associated dementia, Traumatic brain injury, Multi infarct dementia, Cerebral edema etc..,

·         Adverse effects- Bleeding tendencies.

YOGA

·         Yoga is a Sanskrit word, meaning to join.

·         Sub-types and incorporates physical postures (asanas), controlled breathing (pranayama), dccp relaxation and meditation.

·         Effects in mental illness- Calming effects, increasing awareness, increasing the attention span, Acceptance and adaptability and a sense of security.

MASSAGE

·         Def- The manipulation of the soft tissue of the body to bring about generalised improvements in health.

·         Variety of strokes- effleurage, petrissage and kneading.

·         Touch- thought to be therapeutic in those with less physical contact like those without intimate friends or family or who have painful physical conditions.

·         Different ways- Lower stress, Increase immune function, Boost mental health and wellness,  Manage pain and Improve physical fitness.

·         Increasingly being used as supplement to pharmacotherapy to counteract anxiety, agitated behaviour, and depression.

ENERGY THERAPIES

Believes healer can channel healing energy into the person seeking help by different methods.

REIKI

·         Provides healing energy to recharge and rebalance the human energy fields, creating optimal conditions needed by the bodys natural healing system.

·         Japanese term for universal life energy,.

·         Originated thousands of years ago in Tibet and re-established in the 180s.

·         Administered through a gentle lying of hands.

·         Practitioner maintains a meditative presence and allows the Reiki energy to flow to where the patient needs it.

TAI CHI

·         Traditional Chinese exercises widely practised for health benefits.

·         Involves sequences of flowing movements coupled with changes in mental focus, breathing coordination and relaxation.

·         Relatively safe, non-pharmacological practices which can be used for treatment and proven benefit for psychosomatic diseases with few adverse events reported.

·         Showed improvement in immune function, vaccine response, increased endorphins and baroreceptor sensitivity, decreased inflammatory markers, ACTH and cortisol.

·         Most logical clinical application is for stress reduction.

Why people use Complementary and Alternative therapies?

Three theories have been proposed to explain the use of CAM

1. Dissatisfaction: - Dissatisfied with conventional treatment because it has been ineffective, has produced adverse effects, or too costly.

2.Need for personal contact: - They see them less authoritarian, more empowering, offering them offer personal autonomy over their health care decisions.

3-Philosophical congruence: - More attractable because they are seen as more compatible with patients values, spiritual/ religious philosophy, or beliefs.