Nontraditional Therapy

Interest in complementary and alternative medicine (CAM) for health disorders has been growing steadily in the last several decades. As a result, a greater number of alternative or complementary agents are being tested in more methodologically rigorous ways, allowing greater scientific assessment of such treatments. Survey evidence suggests that as many as 40% to 60% of patients may be taking CAM therapies, although patients often do not disclose such use to their physicians (Elkins et al., 2005). In addition, because production of alternative agents is unregulated, variability in product strength, dosing, and purity is common, which in turn likely affects the predictability of their outcomes. Given the widespread use of CAM agents and patients' apparent reluctance to spontaneously disclose such use to their providers, it is incumbent on physicians to inquire about such use.

The majority of CAM treatments have been used to treat depression, including St John's wort (Hypericum perforatum), S-adenosyl-methinionine, and omega-3 fatty acids. In a Cochrane review of St John's wort for treatment of major depression, great heterogeneity was found among the 29 analyzed trials (Linde et al., 2005). St John's wort was found to be superior to placebo and similarly effective as standard antidepressants, but findings were more favorable to St John's wort studies from German-speaking countries, where use of the extract has a long tradition. The more positive results may be caused by physician expertise with the medication, patient selection, or flawed methodologies in some research. The larger, placebo-controlled studies have yielded mixed results, although compared to antidepressants, St John's wort has generally been better tolerated (Shelton, 2009).

S-Adenosyl-L-methionine (SAM-e), a dietary supplement, has been used to treat a variety of illnesses, ranging from major depression to osteoarthritis to liver disease. Clinical trials have shown SAM-e to be superior to placebo and equivalent to TCAs in treating patients with depression, although the most robust findings have been shown with parenteral administration of the drug. Studies using the oral form have yielded more variable results. In adjunctive use with antidepressants, only one open-label study has been published to date. SAM-e has been shown to be safe and well tolerated thus far (Papakostas, 2009).

Omega-3 fatty acids have a variety of health benefits and may be helpful as augmenting agents in the treatment of major depression. The best-studied agents are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Findings in depression are limited by variability in study design and small sample sizes, although the majority of evidence favors a positive effect in the treatment of mood disorders (Freeman, 2009).

At present, little robust evidence supports the efficacy of CAM agents in the treatment of anxiety disorders. Kava (Piper methysticum) has preliminary evidence of efficacy in GAD, but further testing is needed to determine its side effects and potential for hepatotoxicity (Sarris and Kavanagh, 2009). A meta-analysis found no statistically significant difference between kava and placebo (Hidalgo et al., 2007). Given the paucity of current evidence, caution should be used when considering kava as a therapeutic agent.

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