Homeopathy and Its Applications in Psychiatry

Iris R. Bell

Pamela A. Pappas

Homeopathy is a 200-year-old system of complementary and alternative medicine (CAM) developed by the German physician Samuel Hahnemann (1,2). Like other whole systems of CAM such as traditional Chinese medicine (TCM) and Ayurveda, homeopathy differs from conventional Western medicine with unique theoretic foundations, diagnostic approaches, treatments, and outcomes assessment (3,4) (Table 16.1). Use of homeopathy has been limited in the United States [assessed at 3.4% utilization rate in 1997 (5,6)], partly as a historic consequence of the Flexner report in the early 1900s and the rise of pharmaceutically based mainstream care.

Nevertheless, the field of homeopathy has survived and even thrived in many other countries as a treatment for patients with various psychiatric and medical conditions. Conventional neuropsychiatric diagnoses in which case reports and/or research studies present outcomes of homeopathic treatment include anxiety, depression, attention-deficit hyperactivity disorder, autism, premenstrual syndrome, traumatic brain injury, and overlapping somatoform-spectrum psychophysiologic disorders such as fibromyalgia and chronic fatigue syndrome. Posttraumatic stress disorder is yet another common diagnostic area for which successful homeopathic case reports exist (7,8). Animal studies also raise the possibility of investigating the potential use of homeopathy adjunctively in treating a subset of patients with alcohol addiction and some types of stroke (9, 10, 11).

A 1996 review paper indicated that over 500 million people worldwide had used homeopathic remedies (12). A recent survey showed that homeopathy is the most frequently used form of CAM in Norway (13). One in four primary care physicians in Belgium offers CAM; and homeopathy leads the list of therapies at 59% of CAM-provider MDs, followed by acupuncture and phytotherapy (14). Homeopathy is also a common modality in Latin America, the United Kingdom, the rest of Europe, and India. The potential advantages of homeopathy include its low cost, accessibility even in rural areas via self-care applications in acute illnesses and availability of telemedicine, high levels of patient satisfaction and acceptability (15,16), and low rates of adverse effects (17, 18, 19). Disadvantages include the ongoing controversies about the nature of homeopathic remedies themselves (20, 21, 22), the difficulty of mastering the clinical art of the field for treatment of chronic illnesses, and the variable reproducibility of research findings (23).

Practitioners of the classical or Hahnemannian form of homeopathy elicit symptom histories and identify patterns of mental, emotional, and physical manifestations to select a single remedy indicated for an individual’s entire clinical picture at a given time. Complex patients with biopsychosocial diagnoses across multiple systems, who are often difficult to treat with conventional care because of polypharmacy problems, are claimed to be among the most responsive clinical populations to classical homeopathy’s whole-person, singletreatment approach (19). From a purely heuristic perspective, homeopathy offers a truly
patient-centered rather than disease-centered and individualized treatment approach, consistent with the concepts of Engel’s biopsychosocial model for modern health care (24) and the literature on bidirectional mind-body and body-mind interactions in mainstream fields such as psychoneuroimmunology (25,26).

TABLE 16.1 Comparison of Homeopathy and Conventional Medical/Psychiatric Models of Disease, Treatment, and Outcome

Feature	Homeopathic Model	Conventional Medical/Psychiatric Model
Implicit scientific world view	Holism	Reductionism
Focus of diagnosis	Patient as a unique indivisible dynamic individual	Specific disease entity
Likely mechanism of action for medicines	Unknown. Possibly includes electromagnetic or epitaxic information transfer from the individualized medicine (remedy) to the body water and cells of the person, globally and locally; macro-entanglement hypothesis.	Probably involving specific biochemical ligand-receptor interactions
Goals of treatment	Cure of person’s tendency toward disease at any level of organizational scale, mental, emotional, physical	Suppression of expression of disease in each local body part as dysfunctions or lesions develop
Clinical strengths	Chronic diseases with multiple comorbidities involving dysfunction	Life-threatening emergencies, acute illnesses, and injury/physical trauma
Clinical limitations	Minimal effects on established structural changes	Significant safety risks of side effects and drug-drug interactions

Homeopathy has also engendered intense controversy throughout its lengthy history. The debates that have arisen around homeopathy are fervent, with documentation of negative publication biases in mainstream journals (27) and sometimes irrational evaluation of the full body of basic, preclinical, and clinical evidence by both proponents and skeptics. Furthermore, although conventional medicine often focuses on asking whether or not a given intervention “works” in the general population, research has shown that the people who gravitate to using homeopathy may not be representative of the general population in the first place. That is, persons who score high on the big five personality dimension of Openness to Experience are significantly more likely to seek CAM treatment with whole systems of care such as acupuncture or homeopathy (28). Then, as in psychotherapy research, preliminary studies also indicate that patient-practitioner alliance plays a helpful nonspecific, but not completely explanatory, role in long-term clinical outcomes of homeopathy patients (29). The question as to the specific contribution of the homeopathic remedy itself to clinical outcomes, above
and beyond common factors such as an empathic and enabling patient-provider relationship, remains unresolved to date (30,31). Initial electroencephalographic (EEG) evidence raises the possibility of objectively measurable, remedy-specific responsivity, at least in fibromyalgia (32,33).

BACKGROUND

The basic approach of homeopathy involves the principle, originally articulated by early physicians such as Hippocrates, that “like cures like” (the law of similars). That is, a substance that can cause illness at a higher dose in a healthy person can cure the same pattern of illness in a sick person, often at a much lower dose. In fact, homeopaths develop their medicines by testing low doses in healthy human subjects in phase I-like trial protocols called “provings.” Homeopaths prescribe their medicines at the lowest possible dose to catalyze a healing response without doing harm (law of the minimum dose). Notably, in conventional toxicology, these types of nonlinear dose-response phenomena abound, i.e., termed “hormesis,” and occur most often at dose levels below the lowest observed adverse effect level. Yet, even hormesis researchers distance themselves from homeopathy to avoid the stigma, rejection, and ridicule that have dogged homeopathy since its inception (34, 35, 36).

Homeopaths also report that the healing process itself is patterned and hierarchical, rather than necessarily an abrupt “miraculous,” placebo-like disappearance of symptoms in general (37). This patterning of response is a unique feature of homeopathy that mainstream researchers on patient-centered care and placebo effects have not yet investigated. Hering’s Law of Cure states that recovery under homeopathic treatment proceeds in a self-organized manner across the person as an indivisible whole, from above downward and from most important to less important organs, and in reverse order in time of original symptom appearance. Thus, for homeopaths, mental and emotional symptoms represent the most serious and deep form of disease that any individual can experience (38).

Homeopathic theories include a dynamic quality of shift and movement of the expression of disease (39,40). Practitioners report that progressive emergence of manifestations of disease in other organs, e.g., lungs or skin, may occur during spontaneous or homeopathically facilitated recovery from a serious mental illness. Homeopaths also postulate that suppression of symptoms in one local organ, e.g., eczema, can lead to emergence of (other) symptoms in a different organ, e.g., lung (asthma) or brain (depression or anxiety), potentially one more critical for well-being and survival of the organism as a whole. Similarly, early observers in psychiatry and medicine indeed reported parallel phenomena as an alternation between the expression of psychoses versus allergic diagnoses, as an example (41,42). Interestingly, asthma, depression, allergic rhinitis, and dermatitis are among the top 10 conventional diagnoses that American homeopathic physicians report treating most often in their practices (43).

Homeopaths undergo years of training and often rigorous certification examinations to prepare for treating patients with chronic illnesses (44). Nonetheless, lay people can learn enough in a short period of time about a small number of acute remedies for minor self-limiting conditions such as colds and flu. Psychiatric acute care from practitioners or as part of self-care can include remedies for adjunctive treatment in traumatic stress (e.g., the remedy Aconite) or in grief reactions (e.g., the remedy Ignatia) (45).

Although homeopathic practice and its underpinnings may seem foreign to conventional psychiatrists, therapeutic encounters with patients show similarities in both fields (46, 47, 48). For instance, many psychiatrists and other psychotherapists hope to understand their patients in depth; they know that similar DSM-IV-TR symptomatic expressions may evolve from different psychodynamic starting points and processes. Homeopaths understand symptomatic
complaints similarly, recognizing that these are the final common pathways of unseen but powerful processes. Seeking patterns in these symptoms, they look for points of confluence in the language and gestures patients use to describe their physical, mental, and emotional complaints (40,48, 49, 50, 51). Such confluence leads to more accurate and effective remedy prescription. If the remedy does not cover these deeper aspects of the patient’s state, it is less likely to help more superficial complaints as well. Many psychiatrists (particularly subspecialists in psychosomatic medicine) also value such pattern searches and language revelations, since this deeper understanding can help tailor treatments that are acceptable to the patient, exhibit effectiveness, and maintain improvement over time (52).

REMEDY PREPARATION AND CHARACTERIZATION

Skeptics’ ridicule of homeopathy appears to have derived largely from the practitioners’ process of preparing remedies themselves, rather than their clinical practice. Homeopathic remedies are made from animal, mineral, and plant sources. Over 3,000 different remedies are available, and determining the correct prescription for a given patient is challenging (38). Homeopathy differs from herbal or pharmaceutic drug-like medicine (53).

The remedy preparation process entails serial dilution and succussion (vigorous shaking) steps of the source material in a water-alcohol solvent, such that very few and, ultimately, no molecules of the original source substance remain in solution after a dose (potency) of 12c (dilution factor of [1/100]¹²) or 24c (dilution factor of [1/10]²⁴), where Avogadro’s number is 6 × 10²³. In a final step for convenient storage and oral administration to patients, manufacturers typically spray or embed the remedy liquid on or within small round pellets of sucrose and/or lactose. Patients dissolve the pellets under the tongue, a procedure which fosters high levels of patient acceptability, especially in children and adults who dislike swallowing capsules or tablets. In some clinical situations, remedies are kept in liquid form and administered orally or by nasal inhalation in that form.

On the one hand, in the United States, homeopathy is one of the few forms of CAM that already undergoes regulatory oversight by the Food and Drug Administration (FDA), via the Homeopathic Pharmacopoeia of the United States. As a result, homeopathic remedy preparation is more standardized than that of herbal or nutritional over-the-counter products. On the other hand, skeptics typically seize on the dilution issue as de facto proof that homeopathy is implausible as an active therapy apart from placebo effects.

Yet, homeopaths assert that the higher potencies, i.e., more dilute and succussed forms of a given remedy are longer lasting and more powerful in their actions than those closer to materially measurable doses. Findings of one animal study are consistent with the latter claim. Sukul et al. (54) showed that higher remedy potencies of several different remedies (e.g., 200c), i.e., those prepared at a dilution factor of [1/100]²⁰⁰, far beyond Avogadro’s number, prolonged haloperidol-induced catalepsy in rats than did lower potencies (e.g., 30c, prepared at a dilution factor of [1/100]³⁰). If validated in future studies, these data suggest that, in striking contrast with mainstream pharmaceutic agents, it is unlikely that the mechanisms of homeopathic remedies will involve ligand-receptor interactions between remedy source molecules and bodily receptors. The fact that homeopathic remedies appear to exert effects in laboratory animals and in vitro preparations certainly raises questions about the ability of placebo effects or patient expectation to account for all of the reported findings.

What then might be a testable biologic mechanism by which homeopathy could exert any effects? The answer may lie in the structure of the water-alcohol solvent itself. Little is known about possible mechanisms of action (55) (but see section on Complex Adaptive Systems). Transmission of electromagnetic information from remedy solution to bodily cells is
one hypothesis for how homeopathy might affect the function of living tissues (55,56). Epitaxy, a well-documented phenomenon in modern materials science, is another testable hypothesis for the interface between homeopathic remedies and living systems (20). Epitaxy is the transfer of information, not material, from the surface of one material (usually solid) to another material, usually liquid. For example, basic science data suggest an ordering of solvent molecules in homeopathic remedies prepared with both dilution and succussion, an ordering that irradiation or strong alkali can disrupt (57, 58, 59). In this model, dynamically metastable, remedy-structured clusters or networks of solvent molecules, not actual material from the remedy source itself, would convey specific information to the individual’s body water (60). In turn, the body water, which comprises over 70% of human beings, serves as a hub member and modulator for the majority of biochemical network processes throughout the body (61).

The actual evidence from multiple different basic science laboratories has demonstrated that remedies diluted beyond Avogadro’s number and succussed can exhibit thermodynamic and other measurable properties distinguishable from control solvents or plain dilutions prepared without succussion (58,59,62, 63, 64, 65). Moreover, the field of materials science indicates that the succussion aspect of remedy preparation can generate persistent changes in the water/alcohol solvent used in manufacturing process consistent with the findings (20,66). A limited amount of in vitro data and animal studies also indicate that homeopathic remedies can exert effects beyond those of placebo (see below). Nonetheless, the plausibility argument in homeopathy remains the key point of contention in evaluating results of clinical studies. A major problem hindering acceptance of the basic science studies is a history of variable reproducibility of initially promising findings on homeopathic remedies (67). Technical issues, low levels of research funding, and a lack of a critical mass of homeopathic researchers internationally have slowed progress in the field.

COMPLEX ADAPTIVE SYSTEMS MODEL FOR LOCAL AND GLOBAL OUTCOMES IN HOMEOPATHY

Although the nature of homeopathic remedies per se is currently unresolved, recent conceptual advances in modeling homeopathic healing of the patient as a whole system offer a promising framework for moving past the longstanding impasse between proponents and skeptics (53). The conceptual progress stems from convergent recognition by multiple investigators worldwide of the relevance of nonlinear dynamic, complex adaptive systems theory and network science to the clinical claims of homeopathy (and other whole systems of CAM) (3,53,55,68, 69, 70, 71, 72, 73, 74, 75). Theory-driven research in homeopathy has the potential to accelerate progress in the field through improved basic, preclinical, and clinical study designs.

Briefly, the interrelationships and interactions of the parts within a complex system lead to emergent properties of the whole, rather than predicted by a reductionistic understanding the properties of the parts in isolation from one another. Complex adaptive systems such as living organisms (people, animals) are indivisible (holistic) systems that change their behavior as a function of interactions with the environment, and, in turn, form a larger interactive system within the larger ecosystem and beyond, in terms of organizational levels of scale (ultimately the universe). The complexity occurs not only in the interrelationships and interactions of the parts, but also the dynamic, iterative multicausal, multidirectional feedback loops across a system (or network). The complexity renders determination of simple linear causeeffect relationships moot (76). A change in one local part will have direct and indirect ramifications across the rest of the network—both the global behaviors of the whole system and the local behavior of a given part (77,78).

A major problem for conventional physicians to comprehend homeopathy as a clinical field is that the words and tools of linear causality and reductionism, which serve pharmaceutically based medical care and research reasonably well, are a poor fit for the nonlinear and holistic clinical aspects of homeopathy (3).

First, a homeopathic remedy acts nonlinearly by definition—it catalyzes large magnitude changes globally (energy, sense of well-being) and locally in multiple body parts (output) disproportionate to the magnitude of the input (Law of the Minimum Dose) and often in the opposite direction from the toxicologic properties of the source material (Law of Similars) (79).

Second, the homeopathic Law of Cure and corollary notions of adverse effects of suppressive treatments shifting disease from a local body part into other body parts distant to the one under local treatment involve assumptions of the holistic nature of the person as an indivisible system or network. In a network, a local perturbation will have emergent consequences both locally and across the rest of the system (77,80). The consequences will vary, however, in terms of the relative interconnectedness and influence of the part(s) affected. The whole is more than the sum of the parts (81). Thus, a brain is a hub of the body; a toe is a minor node rather than a major hub. Human beings are hierarchically organized networks in which some parts are more important than others, a point made in both the homeopathic (38) and systems/network (61,76) literatures. Clearly, disturbances in brain function usually have far more serious consequences for the organism compared to damage to a toe.

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