How to Use Complementary and Alternative Medicine Treatments

JOSEPH M. REY

KEY POINTS

Use of complementary and alternative medicine (CAM) is widespread. For example, St. John’s wort is the most commonly prescribed antidepressant for children in Germany.
A host of CAM interventions have been recommended or used for the treatment of depression. Hardly any are supported by credible evidence of effectiveness, particularly in children and adolescents.
CAM remedies have to satisfy less rigorous efficacy and safety criteria than prescription drugs, lack standardized preparation, and are more prone to contamination, adulteration, and inaccurate dosage, among other problems.
Excessive concern about liability is unwarranted. An open, informed stance by clinicians often leads to disclosure of use by patients, acknowledgment of patients’ dislikes and beliefs, and better patient education and outcomes.
Clinicians recognize patients’ and families’ interest in CAM therapies, but they often do not feel comfortable asking about, discussing, or recommending them.
Clinical evaluation should include routine questioning about CAM use.
Despite heterogeneous findings, extrapolation of adult data showing that omega-3 fatty acids are effective and safe appears to justify their use for the treatment of depression and bipolar disorder in children and adolescents.
Inconsistencies notwithstanding, it appears that St. John’s wort is helpful for mild depression. It may be useful when parents or adolescents refuse taking or have not benefited from conventional antidepressant treatment and after discussion of risks.
Treatment with St. John’s wort requires monitoring because of side effects and, more importantly, a multitude of potential interactions with other treatments, such as the contraceptive pill, selective serotonin reuptake inhibitors (SSRIs), and anticoagulants.
Although S-adenosyl methionine (SAMe) appears to be effective and well tolerated in adults, little data are available for children and adolescents. SAMe could be used by extrapolating adult findings, but it should be done with close supervision.
Although lacking empirical evidence in childhood depression, physical exercise is such a well known health-enhancing practice that appropriate physical activity should be part of any management plan for depressed children and adolescents.

Introduction

Alternative medicine refers to a collection of treatments—often very disparate—that exists largely outside the institutions where mainstream health care is provided.1 Alternative medicine is increasingly seen as complementing standard medical practice and often referred to as “complementary and alternative medicine” (CAM). The boundary between CAM and conventional medicine is becoming blurred because of some c linicians using CAM treatments, inclusion in health insurance packages, incorporation in medical curricula, and a growing use of the scientific method
(e.g., randomized, placebo-controlled trials) to test the effectiveness of these treatments. So-called integrative medicine2 combines treatments from mainstream medicine and from CAM. In Asia, CAM (e.g., Chinese, Ayurvedic) is often a component of primary health care: Scientific medicine is used to suppress symptoms and traditional medicine to restore the body to its “natural balance.” Many studies show high rates of CAM use in Western countries, including the United States, particularly to deal with chronic conditions.3 For example, St. John’s wort is by far the most commonly prescribed antidepressant for children in Germany.4

Herbal remedies have contributed greatly to the advancement of medicine (e.g., aspirin, quinine) and psychopharmacology. For example, Rauwolfia serpentina was used in Indian medicine for centuries. The active alkaloid, reserpine, was introduced into Western medicine as an antipsychotic in 1954. Although effective, side effects lessened its popularity. The ability of reserpine to induce depression and deplete brain amines became one of the foundations of the biogenic amine theory of mood disorders.5

Clinicians treating children and adolescents ought to have a good working knowledge of CAM for the following reasons:

CAM remedies are consumed extensively in the community, and use is growing.3 For example, a survey of over 2,000 persons in the United States reported a 45% increase in use from 1990 to 1997.6
Many patients (or their parents) are interested in CAM.
Knowingly or not, clinicians often treat children and adolescents who are taking CAM substances. That is, concurrent use of CAM and prescription medicines is common.3
Some CAM interventions might be effective and useful.
CAM treatments may induce side effects and interact with prescription drugs.

In spite of this and although recognizing patients’ interest in CAM, many physicians do not feel comfortable asking about, discussing, or recommending CAM treatments and wish to know more about them.7 Negative physicians’ attitudes and prejudice can occasionally be a problem and may result in not inquiring about CAM use, resulting in avoidable harmful interactions with prescription drugs, and alienation of patients.

The U.S. government established the National Center for Complementary and Alternative Medicine (NCCAM) in 1998 to explore CAM practices in the context of rigorous science, train CAM researchers, and disseminate authoritative information to the public and professionals.8 State-supported organizations with similar aims exist in many other countries. NCCAM8 groups CAM practices into these categories:

Whole medical systems, which are built on a body of theory and practice, such as homeopathic medicine (which seeks to stimulate the body’s ability to heal itself by giving very small doses of highly diluted, often toxic substances) and naturopathic medicine (that aims to support the body’s ability to heal itself through the use of dietary and lifestyle changes together with therapies such as herbs, massage, and joint manipulation). Non-Western systems include traditional Chinese medicine (based on the concept that disease results from imbalance in the forces of yin and yang, among others) and the Indian-origin Ayurveda (which aims to integrate body, mind, and spirit to prevent and treat disease).
Mind-body medicine uses a variety of techniques designed to enhance the mind’s capacity to affect bodily function and symptoms, such as meditation and the use of art, music, or dance.
Biologically based practices use substances found in nature, such as herbs, foods, and vitamins. Examples include dietary supplements and herbal remedies.
Manipulative and body-based practices include chiropractic or osteopathic manipulation and massage.
Energy medicine involves the use of energy fields. Biofield therapies seek to influence energy fields that supposedly surround and penetrate the human body. Bioelectromagnetic-based therapies involve the use of electromagnetic fields.

This chapter focuses on biologically based treatments, particularly herbal products and supplements, which are of more relevance to child and adolescent mental health practitioners.

SAFETY

Many people believe that natural remedies—because they are natural—are safe this is often not the case. One of the main concerns refers to the fidelity of botanical and nutritional products. Apart from having to satisfy less rigorous efficacy and safety criteria than prescription drugs, herbal remedies and dietary supplements lack standardized preparation and are more prone to contamination, substitution, adulteration, incorrect packaging and storage, wrong dosage, and inappropriate labeling and advertising.9 That is, consumers often cannot be sure they are ingesting the amount they are supposed to take or an uncontaminated substance; this has been a particular problem in products sourced from India and China. Examples include contamination of anti-inflammatory Chinese herbal remedies with the plant Aristolochia (aristolochic acid is a potent nephrotoxic, carcinogenic, and mutagenic agent, which has caused the so-called Chinese herb nephropathy and several deaths) and lead and other heavy metal contamination in Ayurvedic herbal medicines. Of all the dietary supplements, preparations containing ephedra have caused the most adverse events,10 so much so that the Food and Drug Administration banned them in 2004. Ephedra, an alkaloid obtained from the plant Ephedra sinica, is of limited direct relevance for mental health. However, many adolescents use ephedra preparations to enhance performance in sports or, more often, to lose weight.3

LIABILITY

Although malpractice liability exists in theory, it has been extremely rare in practice.11 It may include prescribing supplements known to be ineffective or unsafe or clinicians directing patients to a negligent CAM practitioner. In these cases, clinicians may also be disciplined by their professional body. One of the most important considerations is whether the use of alternative medicine treatments deprives the child of an effective mainstream therapy, occasionally resulting in the child’s death; questions of child abuse or neglect have arisen in these circumstances.11

To avoid problems, Cohen and Kemper11 suggest asking the following questions:

Do parents elect to abandon effective care when the child’s condition is serious or life threatening?
Will use of the CAM therapy deprive the child from imminently necessary conventional treatment?
Are the CAM therapies selected known to be unsafe and/or ineffective?
Have the proper parties consented to the use of the CAM therapy?
Is the risk/benefit ratio of the proposed CAM therapy acceptable to a reasonable clinician?
Does the therapy have at least minority acceptance or support in the medical literature?

COMPLEMENTARY AND ALTERNATIVE MEDICINE REMEDIES USED FOR DEPRESSION

A huge number of CAM interventions are recommended or used for the treatment of depression; some of the more popular are listed in Appendix 12.1. Apart from case reports, none of them are supported by credible evidence of effectiveness. Table 12.1 summarizes CAM interventions for which there is some evidence of effectiveness for the treatment of depression, generally in adult patients. It is emphasized that, at this time, systematic evidence is largely lacking for children and adolescents. The ratings and recommendation in Table 12.1 are extrapolated from adult data to a greater or lesser extent.

TABLE 12.1 COMPLEMENTARY AND ALTERNATIVE MEDICINE TREATMENTS^a

Treatment	Quality of Evidence	Strength of Recommendation	Comments
Omega-3 fatty acids (EFAs)	**	[check mark][check mark][check mark]	Several RCTs in adults of heterogeneous quality but few in children.¹² Meta-analyses suggest that EFAs are effective.¹³,¹⁴
St. John’s wort (Hypericum)	**	[check mark][check mark]	Many RCTs in adult patients, mostly with mild depression. Results inconsistent; larger, better designed studies with more severely depressed patients show negative results more often than smaller ones.¹⁵ Very limited data for children.¹⁶ Hypericum might be as beneficial as antidepressants in mild depression.
S-Adenosyl methionine (SAMe)	**	[check mark][check mark]	Adult data, of inconsistent quality, showing that SAMe might be as effective as tricyclic antidepressants.¹⁷,¹⁸ No evidence for children.
^aTreatments listed here are those with some evidence of effectiveness, generally in adult patients, for the treatment of depression.
EFA, essential fatty acid; RCT, randomized controlled trial.
***Multiple high-quality scientific studies with homogeneous results.
**At least one relevant high-quality study or multiple adequate studies.
*Expert opinion, case studies, or standard of care.
[check mark][check mark][check mark]Useful and effective.
[check mark][check mark]Weight of evidence/opinion is in favor.
[check mark]Usefulness not established.

OMEGA-3 FATTY ACIDS

There is growing interest in the possible benefits of long-chain polyunsaturated fatty acid supplementation in childhood mental disorders as well as in many other health problems. Neuronal membranes are rich in these compounds, called “essential” because the body does not manufacture them and must therefore be acquired through the diet. It is well known that changes in the Western diet
have resulted in a reduced intake of essential fatty acids (EFAs), which are hypothesized as a factor contributing to an increase in the rates of depression. Also, epidemiologic studies suggest that a diet rich in EFAs is associated with lower rates of depression.12

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