What about complementary (also known as integrative, holistic, integrative) treatments for mental illness?

In recent years we have seen increasing interest and use of complementary treatments in medicine in general and mental health in particular, in the U.S. and around the world. Many people are disappointed with either the results, the side effects, or the cost of traditional (also known as allopathic) medicine. Are these alternative treatments something you should explore?

Like almost all physicians today, I am a strong believer in “evidence-based medicine.” What this means is that medical treatments should be supported by scientific evidence that they work and that they’re safe. Science isn’t everything in life- it doesn’t tell us what our meaning and purpose in life is, or how we should live our lives. What it does do is give us guidance as to what treatments for illnesses are likely to have a good chance of working, and which ones are likely to be safe to use.

The placebo response is strong in medicine and in mental health- if you do something that you are convinced is going to help you there’s a good chance that it will, at least for a while. Ferreting out which treatments work better than placebo is the job of medical research and science- our gold standard for evidence is “double-blind randomized placebo controlled trials.” What this means is that an active treatment should be compared to a placebo, patients in the trial should be assigned by chance to either active treatment or a placebo, and neither the patient nor the treating and rating physicians should know until the trial is over whether the patient is receiving active treatment or not.

This is my main beef with the complementary medicine approach. Many vitamins, supplements, herbs, and other substances may work, or may not, or may be safe, or may not- we just don’t have the scientific evidence at this point to say one way or another. Very few of the complementary medicine treatments have been proven to be safe and effective in gold-standard trials. Furthermore, unlike prescription medicines, over-the-counter supplements aren’t regulated by the FDA- so they may contain what they say they have in them, or they may not, and they may have unsafe contaminants in them, or they may not.

The one exception in psychiatry is St. John’s Wort for depression. St. John’s Wort is a plant extract which has been widely used for decades, particularly in Germany, for depression. There are 35 trials of St. John’s Wort in depression which show it is safe and effective. If you’ve had trouble tolerating prescription antidepressants or they haven’t worked for you, I think St. John’s Wort is a reasonable, evidence-based alternative. Note that for women on hormonal contraceptives there’s good evidence that St. John’s Wort may interact and interfere with the contraceptive effectiveness.

SAM-E is another over-the-counter supplement used for depression, with some evidence (not as good as SJW) for effectiveness. CBD oil is used for pain, anxiety, and sleep, which I’ve covered in another post. Folate (a type of vitamin B) is a cofactor in the synthesis of the monoamine neurotransmitters (such as serotonin and norepinephrine) and there’s some evidence it can help with depression, in conjunction with other treatments. With these limited exceptions, the evidence is just not there for complementary treatments in mental health.

My rather cynical, but unfortunately reality and experienced-based, advice to patients considering going to an alternative practitioner is to “hold on to your wallets.” I have seen patients in those settings get extensive laboratory testing (much of which is not scientifically validated and based) that’s not covered by insurance, and also be sold multiple expensive supplements, also not covered by insurance. It’s a free country and you can do what you want, but I would urge you to use common sense, be skeptical, and hold on to your wallet!