Complementary and Alternative Medicines (CAMs): What Do We Know?

Here at Mind Study Center, we approach mental health care holistically by incorporating all aspects of our patients’ lives and goals into our treatment plan, and base decisions about medications on robust and current scientific evidence for both effectiveness and safety. Medications and treatment options include those that are approved by the FDA (such as SSRIs for depression and anxiety, stimulants for ADHD, etc), as well as a group of treatments known as “Complementary and Alternative Medicines” (or CAMs for short). CAMs encompass a wide range of treatments, medicines/products, and therapies; some that have been practiced and used for centuries or longer (such as traditional Chinese and Aruyvadic medicine/practices), and others that are relatively new (such as electrotherapy). About a quarter of all individuals with mental health disorders utilize at least one CAM, and use is on the rise especially in children, with over 2 million children in the US using at least one CAM therapy per year (based on 2020 data). Given this, it is vital to hold up every treatment option (regardless of FDA-approval) to a consistent and stringent level of scrutiny. In this article, we will provide an overview of the most commonly used medicinal CAMs in mental health treatment with the hopes of providing useful information to individuals and their families. As always, please consult with a licensed clinician prior to using any of these (or other) CAMs or medications to help determine safety and if started, dosing and monitoring for response and tolerance.

Omega-3 Fatty Acids

General:

• Supplement derived from plant/marine sources, involved in brain development and functioning, cellular communication, and immune functioning.

Risks/considerations:

• Generally well-tolerated, some reports of GI upset
• Be aware of different formulations with varying components. The recommended formulation for mental health indications consists of active ingredients EPA and DHA, with the amount of EPA being at least 1.5 times that of DHA.
• Also confirm product is “pharmaceutical grade” (very high quality, pure, and without exposure to oxygen)

Current evidence for use:

• Studies with fair-to-good methodologies have shown modest benefit in adults and children/adolescents with mood disorders and ADHD.
• Not currently recommended as replacement for conventional treatments, but considered a reasonable option for use as additional supplementation to traditional medication options (especially for depression).

Gingko Biloba

General:

• Product derived from a species of tree native to East Asia

Risks/considerations:

• Can interact and interfere with the metabolism of certain medications, including increasing levels of certain benzodiazepines and antidepressants.
• Inhibits platelet functioning, therefore recommended to avoid use in individuals with risk of bleeding, on anticoagulation or other medications that increase the risk of bleeding.

Current evidence for use:

• Studies (including 2 randomized controlled trials) have shown positive results in reducing ADHD symptoms, both when used on its own and when added to an existing stimulant. However, the effect size was significantly less than the standard medication for ADHD (methylphenidate).

N-Acetyl-L-Cysteine (NAC)

General:

• Modified version of cysteine, an amino acid present in food.
• Antioxidant that has been extensively studied for a variety of mental health conditions.
• In western medicine, it is most often used in the treatment acetaminophen overdose.

Risks/considerations:

• Generally well-tolerated, the most commonly reported side effects include gastrointestinal upset (nausea, vomiting, abdominal pain, etc), rashes, fatigue, headaches, dizziness, and confusion.
• Recommended to avoid use in individuals with conditions where stomach may be irritated such as gastric ulcers and esophageal varices.
• Reports of worsening asthma (when used as an infusion).

Current evidence for use:

• May be effective/helpful when combined with conventional medication (risperidone) for reducing behavioral disturbances and irritability related to autism spectrum disorder.
• Some evidence for use as adjunctive treatment for trichotillomania (hair-pulling) and excoriation (skin picking) disorders
• May help reduce negative symptoms of schizophrenia.
• Studies in the treatment of obsessive compulsive disorder have not shown consistent positive effects, and it is therefore not currently recommended for use.

St. John’s Wart

General:

• Plant extract used for various remedies/purposes in traditional medicine throughout history

Risks/considerations:

• Has many different active ingredients, and has established clinically significant interactions with various medications, these include:
• Interacts with medications that increase serotonin, such as those commonly used for depression and anxiety (SSRIs, SNRIs, etc), and can lead to the life-threatening condition called serotonin syndrome.
• Can reduce levels of various other psychiatric medications including benzodiazepines, buspirone, methadone, quetiapine (Seroquel), amongst many others
• Can reduce effects of immunosuppressants
• Can reduce levels of medications for HIV
• Can reduce effectiveness of oral contraceptives

Current evidence for use:

• Studies show possible positive effects in depression, but the evidence base is weak (no randomized controlled trials).
• Given significant risk of interactions/side effects, it is not currently recommended for use.

Ginseng

General:

• Plant-based supplement, most common version used is “Korean Red Ginseng”

Risks/considerations:

• Generally well-tolerated, and most commonly reported side effects include insomnia, headaches, vomiting.
• Avoid using NSAIDs and other medications that affect clotting due to risk of excessive bleeding.

Current evidence for use:

• May be considered an effective alternative for children with ADHD, especially when used with other supplements such as Omega-3 and Gingko Biloba.
• Findings are preliminary and require further investigation.

Ashwagandha

General:

• Plant-based supplement grown primarily in India, used in traditional Eastern medicine traditions. Sometimes referred to as “Indian Ginseng”.

Risks/considerations:

• Common side effects include GI upset, headache, and sedation.
• Rare reports of liver injury, arrhythmias, and increase in thyroid hormone.

Current evidence for use:

• Some evidence for reduction in anxiety symptoms, however the evidence base is limited and requires further investigation.
• Not currently recommended as an alternative treatment option for anxiety or other mental health disorders.

S-Adenosyl Methionine (SAMe)

General:

• Compound present throughout the brain (and other parts of the body) and involved in myriad of metabolic processes.

Risks/considerations:

• Generally well-tolerated, most common reported side effects include anxiety, insomnia, agitation, sweating, dry mouth, and gastrointestinal upset (recommended to buy enteric-coated formulation).
• Some reports of induction of mania/hypomania, therefore use with caution if there is a risk of bipolar disorder (strong family history, history of manic/hypomanic symptoms).
• Should be kept in punch-out or bubble packaged until it used, as it is easily degradable (avoid storing as “loose” tablets in bottle or pill boxes).

Current evidence for use:

• Evidence (including randomized controlled trials) for positive effects in depression when used as both monotherapy and as adjunctive treatment with conventional medications.

L-theanine

General:

• Amino Acid, active ingredient in green tea.

Risks/considerations:

• Well-tolerated with minimal reported side effects or risks.
• May (in theory) reduce blood pressure, so it is recommended to be used with caution in patients taking anti-hypertensive medications.

Current evidence for use:

• Very limited evidence base, with some weak evidence for positive effects/reduction in anxiety and general “stress” levels.

Valerian Root

General:

• Plant derivative native to Europe and Asia.

Risks/considerations:

• Generally well-tolerated

Current evidence for use:

• May be helpful as an option for mild-moderate insomnia, but the evidence base is weak/preliminary.
• Not recommended for use in treatment of anxiety disorders.

L-Tryptophan and 5-Hydroxytryptophan (5-HTP)

General:

• Amino acids (found in animal and plant proteins) and precursors of the neurotransmitter serotonin (L-Tryptophan → 5-HTP → serotonin).
• Serotonin is the primary target of medicines used in depression, anxiety, and other mental health conditions (SSRIs, SNRIs, etc).

Risks/considerations:

• Most common side effects include gastrointestinal upset (nausea, vomiting, diarrhea, flatulence) and headache.
• Use with caution with other medicines/products that increase serotonin levels due to risk of serotonin syndrome.
• L-Tryptophan more readily crosses blood-brain barrier

Current evidence for use:

• Some evidence for use in smoking cessation and premenstrual dysphoric disorder, however requires further investigation to make recommendations.
• Limited evidence and therefore not currently recommended in the treatment of depression.

Resources:

• FDA statement on CAMs
• National Center for Complementary and Integrative Medicine
• National Cancer Institute CAM site
• Memorial Sloan Kettering Integrative Medicine Department