Complementary and Alternative Medicine and Psychiatry

A moderately depressed patient steadfastly refused to take any prescription antidepressants. I tried to treat her with psychotherapy alone, while urging her to try a selective serotonin reuptake inhibitor (SSRI). When her depression improved in few weeks, I attributed it to my psychotherapeutic skills. Then she told me, in passing, that she had started taking St. John’s wort shortly after she started seeing me in psychotherapy! I hastily looked up St. John’s wort. Surely this nonapproved “food supplement” is ineffective, or at best a placebo. Or is it? What if it has active ingredients that might interact with an SSRI that I’ve been trying to prescribe for her?

Complementary or alternative medicine has become an extremely popular phenomenon that we in the helping professions can no longer ignore. According to Catherine Crone and Thomas Wise in chapter 5 of this book, the annual expenditure for complementary or alternative medicine in the United States is estimated to be $27 billion, and surveys in the general population show that the lifetime prevalence rates of use are greater than 60% and annual rates between 15% and 50%. Although there are many publications concerning different aspects of complementary or alternative medicine written by their strong advocates, this volume is an important contribution for psychiatrists who are interested in a reasonably objective discussion of the place of complementary or alternative medicine in the practice of psychiatry. A strong advantage of this volume, in this respect, is that all the chapters are written by credible and well-established physicians who are affiliated with universities (mostly Columbia University) and who are also familiar with complementary or alternative medicine.

Complementary and Alternative Medicine and Psychiatry is one of the books that make up volume 19 of the Review of Psychiatry series. In their introduction, series editors John M. Oldham, M.D., and Michelle B. Riba, M.D., set the tone by describing the volume as one that contributes to the state of our knowledge at the interface between normality and pathology. This is fitting because the rationale for much of complementary or alternative medicine is based on wellness (herbal extracts as food supplements and meditation to achieve inner peace) as opposed to illness, the treatment of which requires medical license and methods approved by the Food and Drug Administration.

In “Introduction to Herbs and Hermeneutics,” Philip Muskin gives a lucid overview of the types of complementary or alternative medicine. He states, “What differentiates CAM [complementary or alternative medicine] approaches from conventional, or allopathic, medicine is the idea of using the individual’s own resources as well as energy within and outside of the person in order to maintain wellness.” Muskin’s colorful narratives concerning the origins of some complementary or alternative medicine, and his lucid discussion about the fallacy of the widely held belief that natural is safer and natural is better, are both interesting and illuminating.

I found chapter 1, “Integrative Psychopharmacology: A Practical Approach to Herbs and Nutrients in Psychiatry,” by Richard Brown and Patricia Gerbarg, to be the most useful and best written part of the volume. The authors systematically discuss complementary or alternative medical substances used in mood disorders, anxiety, insomnia, migraine, obesity, the endocrine and reproductive system, cognitive enhancement, and athletic enhancement. Their analyses of the efficacy of the substances are level-headed, presenting well-designed studies when they are available. St. John’s wort (Hypericum perforatum) seems demonstrably effective in treatment of mild depression, particularly in seasonal affective disorder. Its side effects seem to be similar to those of SSRIs. S-Adenosylmethionine (SAMe) seems to be convincingly effective in depression with practically no side effects. SAMe is a physiological substance concentrated in the brain and liver, which is involved in three major central pathways (transmethylation, transsulfuration, and transaminopropylation). Brown and Gerbarg discuss its use in detail, including for fibromyalgia, attention deficit hyperactivity disorder, and osteoarthritis. The reader will find discussions on most complementary or alternative medical substances here, including gingko, kava, ginseng, and saw palmetto.

Chapters 2 (“Acupuncture for Mental Health”), 3 (“Uses of Yoga in Psychiatry and Medicine”), and 4 (“Meditation and Psychotherapy: Stress, Allostasis, and Enriched Learning”) deal with what one might call complementary or alternative medical procedures (as opposed to substances or drugs) and their underlying beliefs. “Acupuncture for Mental Health” has an interesting discussion of the theories of traditional Chinese medicine as well as a discussion of the difficulty in doing research with a cross-cultural healing procedure such as acupuncture. One learns about the Hindu beliefs of the unconscious in chapter 3, and in chapter 4 an extensive discussion about an attempted integration of Indo-Tibetan meditation and neurophysiology is interesting but difficult to comprehend. I found these middle chapters to be more like what I might expect from adherents of respective schools of complementary or alternative medicine; the procedures in question seem to be presented as inextricably wedded to the underlying beliefs.

The last chapter, “Complementary Medicine, Implications Toward Medical Treatment and the Patient-Physician Relationship,” by Crone and Wise, is an excellent, comprehensive, and scientific overview of complementary or alternative medicine, both chemical and procedural, and, together with chapter 1, makes the book worth buying. As I finished reading this volume, I found myself astonished at both the potency of some of the treatments derived from complementary or alternative medicine as well as the degree of heterogeneity in this area. The question to me is whether the effectiveness of the chemicals or procedures of complementary or alternative medicine are intrinsically and inextricably tied to their underlying beliefs.

Medicine is omnivorous. Therefore, it makes perfect sense for it to ingest herbs as well as acupuncture needles and sit in a yoga position while digesting them. Modern medicine has never been averse to investigating and refining the essence of what works in folk medicine without swallowing the folklore. For example, according to Muskin’s introduction, Reverend Edward Stone, an adherent of homeopathy, reasoned that because willow grows in swamps where fevers occur, willow would have curative powers for fevers (agues) because the doctrine of homeopathy is derived from the Hippocratic notion, similia similibus curantur (like cures like). In fact, salicin was isolated from willow bark in 1829, and acetylsalicylic acid, aspirin, was synthesized in late 1800s. Muskin states,

It seems to me, however, that the demonstrated efficacy of willow bark used by native peoples rather than homeopathic principles, which were current only after 1796 (after all, plants other than willow grow in swamps), led to the discovery of aspirin.

Medicine is pantheoretical. Unlike osteopathy, chiropractic, or homeopathy, medicine is not based on a single all-encompassing theory. Therefore, what counts in medicine is the efficacy of the drug or procedure and the underlying mechanisms of action, regardless of the theory (or religion) that might have embraced it. There is much to be gained by having an open mind, and, ideally, modern medicine should incorporate the effective substances and techniques of complementary or alternative medicine, so that it will be neither complementary nor alternative but a part of medicine itself. Until then, this book may point to the location of the bridge.