Complementary and Alternative Medicine (CAM): Considerations for the Treatment of Major Depressive Disorder

Complementary and Alternative Medicine (CAM): Considerations for the Treatment of Major Depressive Disorder

Marlene P. Freeman, MD

The use of complementary and alternative medicine (CAM) has increased among patients with psychiatric disorders, as it has in the general population, over recent decades. Psychiatrists, therefore, need to inquire about and discuss the use of these treatments with patients and offer up-to-date information about risks and benefits. However, evidence-based information is limited. To address the needs of practicing psychiatrists and the public, the American Psychiatric Association has set up a task force on CAM to review the evidence for the efficacy and safety of CAM treatments in major depressive disorder (MDD). Some CAM treatments have known general health benefits but currently equivocal evidence of benefit in MDD. Exercise, folate, and omega-3 fatty acids can be recommended to most patients with MDD for their general health benefits, and St John’s wort and S-adenosyl-l-methionine (SAM-e) may be appropriate to treat depression in some patients. In all instances, use of CAM therapies should not take the place of diagnostic assessment and evaluation for MDD and consideration of standard treatment use. Patients should receive advice about all available treatment options, including risks, benefits, and possible drug interactions, as well as full evaluations and regular monitoring.

(J Clin Psychiatry 2009;70[suppl 5]:4-6)

From the Center for Women’s Mental Health, Massachusetts General Hospital, Boston.

This article is derived from the planning teleconference series "The Use of Complementary and Alternative Medicines to Achieve Remission in Major Depressive Disorder," which was held in May 2009 and supported by an educational grant from Pamlab, LLC.

During the past 3 years, Dr Freeman has received research funding from Forest, GlaxoSmithKline, Eli Lilly, and the US Food and Drug Administration, and has received CME/honorarium from KV Pharmaceuticals, AstraZeneca, Forest (APA Industry-Supported Symposium at annual meeting), DSM Nutritionals (for medical editing), Consulting-Reliant, Ther-Rx, and Pamlab.

Corresponding author: Marlene P. Freeman, MD, Center for Women’s Mental Health, Massachusetts General Hospital, Simches Research Building, Floor 2, 185 Cambridge St, Boston, MA 02114 (mfreeman@partners.org).

doi:10.4088/JCP.8157su1c.01

© Copyright 2009 Physicians Postgraduate Press, Inc.

Individuals with psychiatric disorders, consistent with the general population of the United States, commonly use complementary and alternative medicine (CAM) therapies. Clinicians need to be able to discuss these treatments with patients and offer advice about risks and benefits. Although data from rigorous studies are limited, some preliminary recommendations about CAM can be given to patients with major depressive disorder (MDD). Patients should receive full evaluations, ongoing monitoring, and advice about all available treatment options. While CAM options can be part of a comprehensive treatment plan, it is important that individuals receive appropriate evaluation and information about standard treatment options.

Definitions of Complementary and Alternative Medicine

The US National Institutes of Health, National Center for Complementary and Alternative Medicine (NCCAM) defines complementary and alternative medicine as "a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine."1(p1) The term complementary medicine is used when discussing treatments that are considered not to be mainstream or conventional medicine but that are consistent with Western concepts and the biomedical model. According to the NCCAM, complementary medicine is used together with conventional medicine.1(p1) The term alternative medicine is used to refer to concepts that are considered to be outside of the Western biomedical framework and, according to the NCCAM, these treatments are used instead of conventional medicine.1(p1) Integrative medicine is the use of CAM strategies that have evidence of safety and efficacy in combination with conventional treatments.1(p1)

Why Psychiatrists Should Know About CAM Treatments

In psychiatry, the use of CAM treatments is increasing. Research continues, and patients and health care providers need up-to-date information. Therefore, psychiatrists need to understand the risks, benefits, and public health significance of these treatments.

In the United States, the use of CAM treatments has increased over recent decades.2-4 The latest epidemiologic survey of CAM use demonstrated that approximately 40% of adults used at least 1 CAM therapy in the previous 12 months.5 A survey6 of CAM use in 82 psychiatric inpatients, most of whom had MDD, found that over the previous year, 63% of patients had used at least 1 CAM treatment. Most of the respondents said that they did not disclose the use of CAM to their psychiatrists.6 Therefore, psychiatrists need to feel comfortable raising the subject of CAM use with patients and discussing the risks and benefits of these treatments.

Although CAM use is prevalent, many patients have difficulty ascertaining the risks and benefits of these treatments. The Internet and other sources sometimes inflate perceptions about the quantity of data supporting different therapies. Patients often have strong preferences for CAM and may be determined to select natural or easily available treatments. While clinicians need to respect patient preferences, they should also ensure that patients receive full evaluations and accurate information about the risks and benefits of all therapies available to them.

American Psychiatric Association Task Force on CAM

To date, few CAM treatments have been systematically studied for clear psychiatric indications using adequate outcome measures. While some controlled trials have provided information about selected CAM treatments, limitations of some studies include lack of adequate control conditions; for example, creating appropriate control conditions for exercise and acupuncture is challenging. Further, some treatments have long-standing historical use in cultural frameworks and hold a highly valued place in a societal setting. Cultural biases, different philosophical approaches to medicine, and language barriers can complicate the understanding of some alternative treatments from a Western biopsychosocial perspective.

To gather and disseminate information about complementary, alternative, and integrative care in psychiatry, the American Psychiatric Association (APA) has developed a task force. Currently, the task force is working on a review of the evidence base for the efficacy and safety of CAM treatments in MDD.

The topic of MDD was selected for study by the task force for several reasons. Many of the randomized, placebo- controlled trials of CAM treatments in psychiatry have been in patients with MDD. The task force also considered MDD to have clinical relevance and high public health significance because it is common and disabling and has significant morbidity and mortality. The disorder is also a definable psychiatric condition.

The task force is using the following process: (1) identify CAM therapies widely used for MDD and for which randomized controlled trials have been published, (2) review the evidence of efficacy from published trials and review the trials’ merits and limitations regarding methodology, (3) consider evidence regarding safety, and (4) prepare clinically useful, evidence-based treatment recommendations on the basis of the review of efficacy and risks, and make suggestions for future research directions.

Overview of CAM Treatments for MDD

Complementary and alternative medicine treatments that have been studied in patients with MDD and are discussed in this supplement include omega-3 fatty acids,7 St John’s wort (Hypericum perforatum),8 S-adenosyl-l– methionine (SAM-e),9 and folate.10 Although bright light therapy, acupuncture, and exercise are also sometimes used to treat MDD and have been topics of clinical research, they are not discussed here.

Studies that have assessed CAM treatments for MDD have used various methodologies. Some studies have limitations; for example, disorders are not clearly defined and verified at study entry, and outcome measures are often unclear in terms of assessment of efficacy. However, for some of these therapies, randomized, placebo-controlled trials have demonstrated promise for the treatment of MDD. Some CAM strategies have been better studied as adjunctive treatment rather than monotherapy in MDD. While clinicians need to consider the efficacy of CAM treatments specifically for psychiatric disorders and understand the risks and benefits, some of the therapies have general health benefits and may be important for overall treatment planning with individuals with MDD.

Clinical and Psychoeducational Considerations

Patients may not realize that they should tell their psychiatrists about CAM treatments they are using, or they may not feel comfortable bringing up the topic. Therefore, clinicians should systematically inquire about CAM use. Patients also need to understand that natural treatments are not always safe and that CAM treatments may have side effects or drug interactions.

Both psychiatrists and patients should realize that, although many CAM therapies can be obtained without prescriptions, which may be appealing, the burden should not be placed on patients to self-diagnose and self-treat a serious disorder like MDD. Patients should receive education about all the treatment options available and understand that treatment with a CAM therapy does not necessarily take the place of a standard treatment. Regardless of what types of treatment are pursued, appropriate assessment and monitoring is essential in the treatment of MDD, a disorder that is associated with serious morbidity and mortality.

Preliminary Recommendations

Some CAM treatments have well-established general health benefits and should be recommended to patients as part of a comprehensive treatment plan. Exercise, for example, could be considered for most patients, both for general health benefits and for a possible impact on depressive symptoms. Omega-3 fatty acids are well established as improving cardiovascular risk profiles, and folate is especially important for women because it is well established as decreasing the risk of birth defects. Other therapies may be appropriate only for some patients with depression after careful consideration of treatment options (eg, clinicians need to be vigilant for drug interactions with St John’s wort).

Summary

Psychiatrists and patients need a better understanding of the evidence regarding the use of CAM in psychiatric disorders such as MDD. Some CAM treatments may be beneficial for depression, and some may offer benefits for overall health. More high-quality, systematic, controlled trials are needed. Individuals with MDD should be made aware of the full range of treatment options, including the possible health benefits and risks associated with CAM treatments. Although CAM therapies may play a role in overall treatment plans, they should not be substituted for standard treatments without careful consideration, full evaluation, and ongoing monitoring in psychiatry.

Disclosure of off-label usage: The author has determined that, to the best of her knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration-approved labeling has been presented in this article.

References

1. National Center for Complementary and Alternative Medicine, National Institutes of Health, US Department of Health and Human Services. What is CAM? Bethesda, MD: National Center for Complementary and Alternative Medicine; 2007. NCCAM publication D347. http://nccam.nih.gov/health/whatiscam/overview.htm. Accessed June 2, 2009.

2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280(18):1569-1575. PubMed doi:10.1001/jama.280.18.1569

3. Kessler RC, Davis RB, Foster DF, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med. 2001;135(4):262-268. PubMed

4. Tindle HA, Davis RB, Phillips RS, et al. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med. 2005;11(1):42-49. PubMed

5. Barnes PM, Bloom B, Nahin R. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. Hyattsville, MD: National Center for Health Statistics; 2008. National Health Statistics Report No 12.

6. Elkins G, Rajab MH, Marcus J. Complementary and alternative medicine use by psychiatric inpatients. Psychol Rep. 2005;96(1):163-166. PubMed doi:10.2466/PR0.96.1.163-166

7. Freeman MP. Omega-3 fatty acids in major depressive disorder. J Clin Psychiatry. 2009;70(suppl 5):7-11.

8. Shelton RC. St. John’s wort (Hypericum perforatum) in major depression. J Clin Psychiatry. 2009;70(suppl 5):23-27.

9. Papakostas GI. Evidence for S-Adenosyl-l-Methionine (SAM-e) for the treatment of major depressive disorder. J Clin Psychiatry. 2009;70(suppl 5):18-22.

10. Fava M, Mischoulon D. Folate in depression: efficacy, safety, differences in formulations, and clinical issues. J Clin Psychiatry. 2009;70(suppl 5):12-17.