The Unmedicated Mind

Backlash against antidepressants is fueling new interest in alternative treatments.
By Nancy Keates, The Wall Street Journal, July 13, 2007

The treatments go beyond needles and spinal manipulation. They include Emotional Freedom Techniques -- tapping on the body's "energy meridians" as the patient thinks about upsetting incidents -- and craniosacral therapy, which involves a gentle rocking of the head, neck, spine and pelvis. In cranial electrotherapy stimulation, a AA-battery-powered device sends mild electrical currents to the brain. (The procedure has its roots in ancient Greek medicine, when electric eels were used.) Clinicians are also prescribing supplements like omega-3 fatty acids, found in fish oil, or amino acids like L-theanine, found in green tea.

Sarah Spring had been in therapy with a psychiatrist and on the antidepressant Wellbutrin for four years to work through a childhood trauma, but felt she wasn't making any progress. So she went to a naturopath -- a practitioner trained in holistic therapy and alternative treatments like herbal medicine and nutrition. (They attend a four-year naturopathic school -- a bachelor's degree is a prerequisite -- but only 15 states license naturopaths.) After two sessions of Emotional Freedom Techniques, the tapping treatment that is meant to clear emotions and restore balance, Ms. Spring says she doesn't get the same shortness of breath and accelerated heart rate she used to. "It's remarkable," says the Portland, Ore., marketing manager, who just started to decrease her dose of Wellbutrin.

To address the growing interest from professionals, Harvard Medical School's Department of Continuing Education will have three classes on complementary and alternative medicine in psychiatry over the next year, up from one a year since the class was introduced in 2003. David Mischoulon, an assistant professor of psychiatry at Harvard, says doctors who have attended the class report that more patients are asking for alternative treatments -- due to the side effects of antidepressants, as well as a lack of response to the medication. Only about half of patients who take antidepressants respond, he says. "It is time to broaden the horizons," he says.

But there is no proof that many of these methods work for treating mental illness. One large study found Emotional Freedom Techniques were no more effective than a placebo, while evidence is limited for acupuncture and fish oil (thought to reduce some types of depression) in the treatment of mental health problems. Using herbal supplements with conventional medicine can be dangerous, psychiatrists say. "There are always snake oil salesmen," says Carolyn Rabinowitz, president of the American Psychiatric Association.

Traditional therapists worry that alternative treatments might sway patients to give up conventional treatments too quickly. "People with very little data often say, 'This works,' " says Philip Muskin, Chief of Consultation-Liaison Psychiatry at Columbia-Presbyterian Medical Center in New York. A psychiatrist and trained hypnotist, Dr. Muskin believes that wellness techniques like yoga, herbs and acupuncture can make people feel better psychologically. But he says alternative providers don't have adequate training to diagnose or treat severe mental-health disorders. "Many think if you get your liver and spleen into the right balance that will help," he says.

Safety Concerns


In any one-year period, 9.5% of the population, or about 20.9 million American adults, suffer from a mood disorder, according to the National Institute of Mental Health. A study by the World Health Organization, Harvard University School of Public Health and the World Bank found that by the year 2030, depression will be second only to HIV/AIDS in terms of disability caused world-wide.
A backlash against antidepressants sparked by concerns about their safety, efficacy and side effects is helping drive patients to alternative methods. Some 80% of antidepressants are currently prescribed by primary doctors who often diagnose depression in a 20-minute visit and don't provide accompanying therapy or help manage side effects.

Sales of all classes of antidepressants were $13.5 billion in 2006, down from a peak of $13.8 billion in 2004, according to IMS Health, a health-care information company. Usage of selective serotonin-reuptake inhibitors (SSRIs) dropped in 2005 after warnings about side effects -- particularly the risk of suicidal behavior in people aged 25 and under, which prompted the Food and Drug Administration to order drug makers to add warnings to their packaging in 2004. The introduction of generics onto the market (most recently, for Zoloft) also contributed to lower sales.

A spokesman for the Pharmaceutical Research and Manufacturers of America says pharmaceuticals like antidepressants undergo a rigorous assessment of benefits and risks by the FDA. Other methods have been used to treat depression historically, he says, but pharmaceuticals do and will continue to play a large role in therapy.

At the same time, the rise of managed care and changes in Medicaid and Medicare have resulted in companies paying far less for mental health coverage. Employer spending on mental health care dropped to 1.3% of an employee's medical care costs in 2006, from 10.9% in 1988, according to employee-benefits firm Towers Perrin. While most employees with health insurance have some mental-health coverage, only 13% have coverage for an unlimited number of outpatient visits to providers such as psychiatrists, psychologists and social workers, says a 2006 survey of employers by the Kaiser Family Foundation. That's down from 19% in 2004. Most insurance policies pay for a limited number of visits, often 20 or 30 per year, and some put a cap on the dollars they'll pay.

Over the past decade, insurers have started covering more alternative procedures. Plans vary, from unlimited visits to 12 or 20 visits per year, according to Doug Metz, Chief Health Services Officer at American Specialty Health, which runs complementary medicine benefits plans for insurance companies. Co-payments typically run $10 to $20, and plans limit the reasons for visits to scientifically proven techniques -- which generally does not include treatments for mental health. While coverage for visits to naturopaths is mandated by law in Connecticut, Vermont and Washington, employers can still limit the number of visits and restrict it to a network.

Aetna, for one, will cover acupuncture used to treat migraine headaches or chronic lower back pain, but not for depression; it will cover biofeedback for migraines, but not stress. The options are growing: Starting this month, members can get at least 25% off standard fees for visits to an approved list of 19,000 credentialed "natural therapy professionals," including massage therapists and dietetic counselors, for any condition. (Standard fees for a first-time acupuncturist visit can be $90 to $120.)

The shift comes as scientific research sheds new light on the causes of depression. The use of SSRIs, introduced in the 1980s, aim to increase levels of serotonin in the brain. More recent research suggests that a range of factors -- including genetic predisposition and hormones linked to stress -- can play a role.

Proponents of alternative medicine say the wide range of treatments used address broader causes like hormonal imbalances and stress. Treatment can mean spending time talking to patients about their physical and emotional problems, examining their diet and exercise habits, and doing blood tests to look for medical or environmental causes for depression, such as Lyme disease, toxic chemicals or mold.

In Los Angeles, naturopath Holly Lucille has seen 30% more patients in the past two years whose chief complaint is mental-health-related, while Sara Thyr, a naturopath in Manchester and Concord, N.H., has seen a 20% rise. Margot Longenecker's naturopathy practice in Branford and Wallingford, Conn., now has half of its patients come for anxiety and depression, compared with 25% three years ago.

"Half the time you feel like you have a psychiatric degree more than a chiropractic degree," says Basking Ridge, N.J., chiropractor Jerry Szych, who's seen a 25% rise in patients seeking counseling services over the same period. Columbus, Ohio, chiropractor Ronald Farabaugh says he has seen an increase of 20% over the past three years in those cases.

Melissa Mannon, a 36-year-old photographer in Bedford, N.H., saw psychologists for years about her depression and anxiety. Then she visited a naturopath for help with infertility, and was diagnosed with an intolerance to 90 different foods, including gluten. She changed her diet and within seven months, she got pregnant and most of her anxiety and depression went away, she says. She still sees her naturopath if she's feeling down and to discuss what's happening in her life. "She understands me," says Ms. Mannon.

Some say the extra time and intimacy of the treatments can encourage patients to open up. Naturopath Mark Sanders, who has seen the number of patients coming for mental health rise threefold to about 60% since he started his practice five years ago, says patients tend to open up when he performs craniosacral therapy. (It is meant to ease stress and improve physical movement.) "I've had people tell me stuff they don't tell their therapist," he says.

'I don't dig into childhood stuff,' says naturopath Samantha Brody.
Stanford University Medical School clinical professor of medicine Kenneth Pelletier says chiropractors and naturopaths aren't adequately trained to recognize true psychopathology. But Dr. Pelletier believes most of these practitioners are ethical about remaining within the scope of their practice and refer patients to licensed mental-health-care practitioners when they think the diagnoses are severe.

That's what Portland, Ore., naturopath Samantha Brody has been doing as she increasingly sees patients with eating disorders, anxiety and depression. While the stigma of seeing a shrink may have declined in cities like New York and Los Angeles, it is alive and well in Portland, and some patients won't follow up on her referrals. Still, Ms. Brody steers away from serious counseling. "I don't dig into childhood stuff," she says.

Cheryl Higgins started seeing Ms. Brody three years ago for acupuncture because her back hurt. She was also driving her friends crazy by trying to use them as therapists and needed an outlet for her anxiety and depression. "I spilled my guts to her at the first session," says the 26-year-old office manager. Her treatment: chemical and amino-acid supplements, plus acupuncture three times a week.

Ms. Higgins hesitated to follow Ms. Brody's referral to a psychologist, but eventually she did see one who recommended that her primary care doctor put her on an antidepressant. She went on Lexapro for nine months, then went back to the naturopath to help her get off of it. "It made me yawn all the time," she says.

While the research is limited, some studies have shown promise in using alternative methods to treat mental illness. A recent study at Boston University School of Medicine and McLean Hospital in Belmont, Mass., showed a neurochemical response to the practice of yoga that's similar to neurochemical responses seen when people are treated with antidepressants.

Even pharmaceutical companies are starting to look at ingredients that have traditionally been part of natural medicine. Last year, Novartis bought the U.S. rights to a drug called agomelatine -- a melatonin-related agonist that is thought to influence mood in part through the sleep-wake cycle.

Of course, alternative medicine has been used for mental health issues for years. A 2001 study by Ron Kessler and David Eisenberg at Harvard Medical School found that among those with anxiety and or depression, more than half used alternative medicine therapies; among those who sought the treatment of a licensed conventional provider, two-thirds also used alternative medicine during the prior year. The perceived helpfulness of the alternative therapies was similar to the perceived helpfulness of conventional therapies.

Some critics say the growing interest is, in a sense, a step backwards. As people become frustrated with the shortcomings of new treatments, they become more inclined to try age-old therapies, regardless of whether they've been rigorously tested. The treatment of depression is "a constant succession of hyped theories and overall pathetically little progress," says John Horgan, director of the Center for Science Writings at the Stevens Institute of Technology in Hoboken, N.J.

Serious Applications

Now, community clinics are using the approach. The Mental Health Center of Greater Manchester, N.H. -- which combines traditional psychiatry with naturopathic treatments for seriously mentally ill patients -- received a two-year grant last summer from the New York-based Ittleson Foundation to promote the intermingling of naturopathy and psychiatry. "It's just a better way to approach the problem," says Ronald Parks, an internist and psychiatrist in Asheville, N.C., who uses alternative methods and was just approached to create a community-based model near his practice.

Aliza Sherman Risdahl agrees. She began experiencing uncontrollable rage, irritation and anxiety after the birth of her daughter. Though the 42-year-old Anchorage, Alaska, consultant was already seeing a therapist, she didn't want to go on antidepressants. She turned to a naturopath, who diagnosed her with overactive adrenal glands and suggested an amino acid to spray under her tongue.

Now she's no longer throwing dirty plates from the dinner table up in the air, screaming at her husband to "give me the baby, you can't keep her from me!" and running through the house slamming doors and cursing at him. "I am so grateful," she says.
Evaluating the Treatments

Alternative medical practitioners say the techniques they use depend upon each individual's history. However, there are some common methods for treating depression and anxiety.

TREATMENT WHAT IT IS REPORT CARD

Acupuncture

Sticking needles in acupoints The theory is that acupoints along invisible meridians act as channels for the flow of vital energy. Benefits in treating depression are limited; more research is needed.
Craniosacral Therapy A gentle rocking massage of the head, neck, spine and pelvis It's meant to ease stress and improve physical movement. A 1999 study by the British Columbia Office of Health Technology Assessment concluded that the theory is invalid and that practitioners cannot reliably measure results. A 2002 study found no diagnostic reliability.
Emotional Freedom Techniques Tapping on the body's "energy meridians" Several studies (including from Queens College in New York) found that it relieved fear in people with phobias of small animals more effectively than deep breathing relaxation. A larger trial subsequently found that EFT had the same effect as a placebo.
Valerian An herb Several studies have reported benefits in reducing non-specific anxiety symptoms. However, most studies have been small and poorly designed, and are considered inconclusive.
SAM-e A chemical sold as a dietary supplement Found in all human cells, it's thought to increase levels of serotonin and dopamine. In an analysis of 39 unique studies, SAM-e to was found to be more effective than a placebo in reducing depression but no more effective than treatment with antidepressants.
5-Hydroxytryptophan A chemical in a spray or pill One of the raw materials that your body needs to make serotonin. Some believe that boosting 5-HTP will elevate levels of serotonin, but there's not enough evidence to determine if it is effective and safe. Larger studies than have been conducted to date are needed.
Omega-3 Fatty Acids Found in fish oil and certain plants Several studies on its use in depression don't provide enough evidence to form a clear conclusion. One recent study of 20 children between ages 6 and 12, conducted at Ben Gurion University of the Negev in Israel, reported therapeutic benefits in childhood depression.
St. John's Wort An herbal preparation from the Hypericum perforatum plant Recent studies suggest the herb is of no benefit in treating major depression of moderate severity. More research is required to determine whether it is effective in treating other forms of depression, according to the National Institutes of Health.

Sources: National Library of Medicine, Mayo Clinic, American Cancer Society