Janet L Cummings

Modern Ayurveda

Ayurveda the Science of Life

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I. Technical Alternatives to Psychotherapy II. Pharmacologic (Herbal) Alternatives to Psychotherapy III. Summary

Further Reading

GLOSSARY

5-hydroxytryptophan (See five-hydroxytryptophan). agonist A drug that works by stimulating its receptor (as opposed to an antagonist, which works by blocking receptors). anesthetics Drugs used for general anesthesia. Aristolochia fangchi Also called guang fang ji, an herb marketed over-the-counter for weight loss in products labeled "Chinese herbs." aristolochic acid A chemical found in the Chinese herb Aristolochia fangchi, which is sold over-the-counter in various weight-loss products. autonomic nervous system The branch of the nervous system that regulates internal body processes requiring no conscious awareness. barbiturates A class of drugs (including pentobarbital and phenobarbital) used to induce sleep, relieve anxiety, treat certain types of seizures, or for general anesthesia. benzodiazepines A class of drugs (including Valium, Librium, and Xanax) that decrease anxiety and induce sleep by facilitating GABA neurotransmission. carbidopa A prescription drug used to treat Parkinson's disease, available in pill form. carcinogenicity Cancer-promoting properties. cyclosporine Prescription immunosuppressant medication used to prevent organ rejection in transplant recipients, available in pills, oral solution, or IV injection.

digoxin A prescription cardiac medication that strengthens and regulates the heartbeat, available as pills, IM injection, or IV injection.

dopamine A neurotransmitter involved in motor control, increased levels of which are associated with psychosis. EMDR (See eye movement desensitization and reprocessing). ephedra Also known as ma huang; an herbal compound with amphetamine-like qualities sold over-the-counter in a number of weight-loss and energy-boosting products. eye movement desensitization and reprocessing (EMDR) An alternative to psychotherapy that utilizes eye movements or other left-right stimulation to treat psychological problems.

five-hydroxytryptophan (5-hydroxytryptophan) Also called 5-HTP, an herbal supplement marketed for the treatment of depression, which is metabolized into serotonin in the body and may enhance serotonin neurotransmission. fluoxetine (Prozac) A selective serotonin reuptake inhibitor. formulary A list of drugs that are included as covered benefits by a particular insurance company, as opposed to non-formulary drugs that must be purchased out-of-pocket or with a higher co-payment. GABA (See gamma-aminobutyric acid). gamma-aminobutyric acid The major inhibitory neurotrans-

mitter of the central nervous system. Griffonia simplicofolia An African plant, the seeds of which are used to derive 5-hydroxytryptophan. guang fang ji (See Aristolochia fangchi). heliotrophe (See Valerianae radix).

hematocrit A measure of the proportion of red blood cells to the total blood volume. hemoglobin The oxygen-carrying component of red blood cells.

homocysteine A substance in the blood, high levels of which are associated with increased risk of heart disease. Hypericum perforatum Also called St. John's wort; an herbal compound marketed over-the-counter for the treatment of depression, which likely affects the serotonin system. immunosuppressant A drug used to prevent transplant rejection or to treat autoimmune disorders or severe allergies, which suppresses the functioning of the immune system. inhibitory neurotransmitter A neurotransmitter, the presence of which decreases the probability of neuronal firing (as opposed to an excitatory neurotransmitter, the presence of which increases the probability of neuronal firing). kava (See Piper methysticum). kava kava (See Piper methysticum).

kavalactones Fatlike compounds with sedative qualities found in Piper methysticum (kava). LeShan An alternative therapy used to heal medical and psychological problems when the treatment provider and patient are a distance apart. ma huang (See ephedra).

MAO inhibitors (See monoamine oxidase inhibitors). MAOIs (See monoamine oxidase inhibitors). monoamine oxidase inhibitors (MAO inhibitors; MAOIs) A class of antidepressants (including Nardil, Marplan, Parnate, and Deprenyl) that work by blocking the enzyme that breaks down serotonin and norepinephrine. noradrenaline (See norepinephrine).

norepinephrine Also called noradrenaline; a neurotransmit-ter that interacts with epinephrine to affect autonomic activity and mood. perturbations Hypothesized structures throughout the body believed by proponents of thought field therapy to contain the energy that creates psychological disturbances. Piper methysticum Also called kava or kava kava; an herbal compound marketed over-the-counter for the treatment of anxiety and insomnia. platelets Cell-like particles in the blood, smaller than red or white blood cells, which clump together and promote clotting.

psychotropic medications Medications used to treat mental and emotional problems, including antidepressants, an-tipsychotics, and tranquilizers. Reiki (Pronounced "ray-key") an ancient Buddhist practice of manual healing therapy, used to treat both medical conditions and psychological problems. REM (rapid eye movement) sleep A stage of sleep characterized by rapid eye movements, behavioral activity, high electrical activity in the brain, increased rate and depth of breathing, and dreaming. S-adenosylmethionine (SAMe) An herbal compound marketed over-the-counter for the treatment of depression and some medical conditions, including osteoarthritis and liver disease; may affect brain levels of serotonin, noradrenaline, and dopamine. SAMe (See S-adenosylmethionine).

scleroderma A chronic disease characterized by blood vessel abnormalities, as well as degenerative changes and scarring of the skin, joints, and internal organs. selective serotonin reuptake inhibitors (SSRIs) A class of antidepressants (including Prozac, Zoloft, and Paxil) that work by blocking the reuptake of the neurotransmitter serotonin.

serotonin A neurotransmitter, decreased levels of which are associated with depression. serotonin syndrome A syndrome caused by high levels of serotonin and associated with agitation, restlessness, insomnia, tremor, nausea, vomiting, rapid heart rate, and seizures. sertraline (Zoloft) A selective serotonin reuptake inhibitor. SSRIs (See selective serotonin reuptake inhibitors). St. John's wort (See Hypericum perforatum). thought field therapy An alternative to psychotherapy in which the practitioner helps the client tap a series of points on the body in order to alter thoughts. transducive points Specific places on the body that the client taps as part of thought field therapy. tricyclic antidepressants A class of antidepressant drugs, including Elavil, Anafranil, Tofranil, and Pamelor, which work by blocking norepinephrine reuptake, with some blocking of serotonin reuptake. tryptophan An amino acid from which serotonin and mela-tonin are manufactured in the body, which was sold as an over-the-counter sleep aide until an impurity in one bad batch caused severe medical problems and death in a number of users. valerian (See Valerianae radix). Valeriana officinalis (See Valerianae radix). Valerianae radix Also called valerian, Valeriana officinalis, or heliotrophe; an herb with mild tranquilizing effects, sold over-the-counter to treat insomnia and mild anxiety. warfarin (Coumadin) A prescription anticoagulant (blood thinner) medication, available in pills or IV injection.

Because of advances in modern medicine during the 20th century, homeopathic and naturopathic medicine had all but vanished in the United States. However, the past few decades have seen a revival of alternative medical treatments, with Americans making an estimated half-billion visits to alternative practitioners annually. Unfortunately, most alternative treatments, although promising, remain unvalidated by well-controlled scientific study at this time.

Many American consumers are now seeking alternative therapies for their psychological problems as well as for their medical problems. Alternative therapies for psychological problems include nutritional programs for the management of mental disorders, various techniques of bodywork and body alignment for clearer thinking and peace of mind, aromatherapy, various types of touch therapy for emotional healing, magnet therapy, moving meditations such as tai chi and yoga, music therapy, and various forms of prayer. Such a vast array of alternatives to psychotherapy exists that it would be impossible to cover them all in detail in this article. Therefore, this article will focus on two types of alternative psychological treatments: technical and pharmacologic (herbal). Examples of each will be offered.

I. TECHNICAL ALTERNATIVES TO PSYCHOTHERAPY

A. Reiki

Reiki (pronounced "ray-key") is an ancient Buddhist practice of manual healing therapy that was rediscovered in Japan by Mikao Usui in the mid 1800s. It has become increasingly popular in the United States during the past few decades and is used for treating heart attacks, emphysema, hemorrhoids, prostate problems, varicose veins, hiccups, nosebleeds, and various mental and emotional problems. It is based on the belief that life is dependent on a universal, nonphysical energy. Because health requires a sustained and balanced flow of this energy throughout the body, disturbances in that flow result in physical, emotional, and mental illnesses. The Reiki practitioner attempts to correct life energy imbalances and blockages by gently resting his or her hands in specific ways on 12 standard sites throughout the body. The practitioner generally begins with the head and spends a few minutes at each site, with a complete session taking an hour or more. In some cases, the practitioner will expand the therapy beyond the standard 12 sites. Advanced practitioners believe themselves to be as effective even when physically absent from their patients by simply visualizing their hand movements with patients. These practitioners believe that they can send spiritual energy to their patients through a process similar to prayer, and thus are able to perform effective Reiki from a distance.

Some researchers have proposed that Reiki changes the blood's oxygen-carrying capability as shown by hemoglobin and hematocrit levels. However, the few studies conducted to date have yielded mixed results and some of those studies showing changes in hemoglobin or hemat-ocrit levels actually show changes for the worse rather than for the better. One study by Wirth and Barrett in 1994 actually showed slower wound healing time in patients receiving a combination of Reiki, therapeutic touch, and LeShan (a distance healing technique) than in controls. Studies by Schlitz and Braud in 1985 and Thornton in 1966 examined the claim that Reiki induces relaxation and found that the autonomic activities of subjects receiving Reiki did not differ significantly from those of controls.

No adverse effects on patients have been reported with Reiki. However, no therapeutic benefits of Reiki have been demonstrated through well-controlled, scientific studies. The few studies on Reiki have generally been poorly designed, with such confounding variables as lighting, candles, and music. Although interest in Reiki is growing among alternative practitioners, there is no strong scientific evidence to date for its effectiveness, and Reiki remains unvalidated.

B. Thought Field Therapy (TFT)

Thought field therapy (TFT) is an alternative to psychotherapy used to treat depression, anxiety, phobias, addictions, anger, trauma, grief, and other emotional and mental conditions. It was developed by Roger Callahan, Ph.D., after his reported discovery of the existence of certain structures of active information (called perturbations) in the bioenergy thought field, which he believes cause psychological disorders. Through a long process of trial and error, Dr. Callahan developed TFT to diagnose and treat these perturbations in the energy field.

Proponents of TFT view psychological change as occurring via quantum leaps rather than by a step-by-step linear process. In order to treat psychological problems, the TFT practitioner is able to see and feel the reality of a perturbation. Once the diagnosis of a perturbation is made, the practitioner helps the client to tap a series of "transductive points" on the body in order to alter the structure of the thought field specific to the problem. Proponents of TFT believe the treatment to be so powerful that it need only be used once to result in significant change for a number of psychological problems.

Although the proponents of TFT claim that it has been proven to be more effective than psychotherapy, its effectiveness has not been demonstrated using well-controlled scientific studies. The evidence presented is generally anecdotal and lacks any comparison (control) groups. For example, Leonoff in 1996 reported a study in which he replicated a 1986 study by Dr. Callahan. Both studies used 68 subjects who called a radio program to receive on-the-air treatment by the researchers, and both studies claim a 97% success rate with a 75%

average improvement based on clients' reports of distress using a 10-point rating scale. However, neither study used a control group, and the comparison of the two studies by Leonoff in 1996 simply compares the use of TFT by practitioners in 1985 to the use of TFT by practitioners in 1996 without comparing TFT to any other treatment modality. Therefore, TFT remains unvalidated at this time.

C. Eye Movement Desensitization and Reprocessing (EMDR)

EMDR was first introduced in 1989 by Francine Shapiro, Ph.D., and has since been taught to thousands of clinicians and has received considerable media attention. It is used for the treatment of trauma and the various psychological symptoms that are believed to result from traumatic experiences. EMDR practitioners use an eight-phase protocol to help trauma victims reprocess distressing thoughts and memories, which includes using eye movements or other left-right stimulation:

Phase I: Phase II:

Phase III:

Phase IV:

Phase V:

Phase VI:

Phase VII:

Phase VIII:

Client history

Preparation (in which the theory is explained, expectations are set, and the client's fears are addressed) Assessment (in which negative cognitions are identified, positive cognitions are developed, emotions are named, and body sensations are identified) Desensitization (in which eye movements are utilized to reduce the client's anxiety about a certain situation or event) Installation (in which a positive cognition is enhanced and linked to the original target issue or event) Body scan (which focuses on any body tension produced by the original memory or the positive cognition that has been linked to it through the treatment) Closure (in which the client is returned to a positive frame of mind and is determined to be able to safely return home before being dismissed) Reevaluation and use of the EMDR standard protocol (in which the clinician assesses how well the trauma has been resolved and determines whether or not the client needs any further processing)

Shapiro in 1995 theorized that EMDR utilizes the same brain processes as REM sleep, although she admits that current knowledge of neurology and neurobi-ology does not provide an explanation of exactly how EMDR works. Even though the precise impact of EMDR on the brain remains unknown, EMDR has received more rigorous, scientific study than the previously mentioned alternatives to psychotherapy. Shapiro and Forrest in 1997 cited a number of case reports and nonrandomized studies in order to demonstrate the efficacy of EMDR. In addition to these studies, the authors cite 12 randomized and controlled studies that serve to validate EMDR. Some of these studies have compared EMDR to other psychological treatment modalities, to no-treatment controls, or to delayed EMDR treatment, while other studies compare standard EMDR to variations of EMDR such as engendering eye movements by tracking a light bar rather than by tracking the clinician's finger or using forced eye fixation, hand taps, and hand waving instead of the standard eye movements.

These randomized and controlled studies indicate that EMDR is superior to other treatment modalities for the populations studied. However, some of the differences are small even though they are statistically significant. They also indicate that, in general, standard EMDR is as effective or more effective than the variations studied. Although this research seems promising, more study is needed before EMDR can be considered a validated treatment method. Shapiro and Forrest in 1997 reported studies that indicate that EMDR is at least as effective as other treatments, but do not state whether or not any studies conducted have indicated that EMDR is less effective than other treatment modalities for any conditions. Furthermore, some of the studies reported are flawed by confounding variables, such as the secondary gains of chronic inpatient veterans receiving compensation from the VA system. Some studies compare EMDR to treatment modalities unlikely to be effective for the condition being studied, such as biofeedback relaxation for veterans who have experienced chronic PTSD symptoms since the Vietnam War. The gains shown from EMDR as compared to no-treatment controls may be due to the EMDR itself or to the placebo effect, which is generally accepted as about 35% in magnitude. It is unknown whether the gains from EMDR are due to the eye movements themselves or to other aspects of the protocol that closely resemble traditional psychotherapy (such as replacing negative cognitions with positive ones). Therefore, EMDR has some supporting evidence, but more research is needed.

II. PHARMACOLOGIC (HERBAL) ALTERNATIVES TO PSYCHOTHERAPY

Herbal remedies have become such a major factor in American health care in recent decades that the Physician's Desk Reference (PDR) has had a companion volume (PDR for Herbal Medicines) updated annually since 1998. In 1997, about 12% of Americans used herbal products, compared to about 3% in 1990. Most consumers who use herbal products do so for the management of chronic conditions, such as psychiatric disorders (particularly anxiety and depression).

Although the American public tends to equate "natural" and "herbal" with "safe," the efficacy and safety of these products have only recently been studied in controlled clinical trials. These recent studies indicate that not all herbal supplements are safe. For example, ephedra (also known as ma huang) is an herbal ingredient found in a number of weight-loss and energy-boosting products available without prescription. It has amphetamine-like qualities and can be dangerous, particularly for people with high blood pressure or heart conditions and is responsible for dozens of deaths. The amino acid tryptophan had been sold as an over-the-counter sleep aid until 1989 when the FDA banned its sale after at least 38 people died and numerous others were left with painful, crippling nerve damage, severe joint pain, and scarring of internal organs from an impurity in a bad batch of the supplement from one manufacturer. Recent evidence indicates that various combinations of herbs marketed as weight-loss products and labeled "Chinese herbs" can cause kidney failure and death. Most likely, aristolochic acid from the Chinese herb Aristolochia fangchi (also called guang fang ji) is a potent kidney toxin responsible for the reported kidney problems and deaths from kidney failure.

Since Congress passed the Dietary Supplement Health Education Act (DSHEA) in 1994, most herbal supplements have not been regulated by the FDA. Products labeled "dietary supplement" are exempt from FDA control, as long as they do not claim to cure any disease. Therefore, herbal products are not subjected to the same rigorous testing and standards as over-the-counter and prescription drugs. Because most herbal supplements are exempt from FDA control, many products sold do not contain the amount of active ingredient indicated on the label. Occasionally the products contain more of the active ingredient than indicated, while often the products contain substantially less of the active ingredient than the label indicates. For this reason, research done using standardized dosages of herbal remedies may not be a valid indication of the efficacy of the unstandardized herbs available to the American public.

Most of the American public is unaware that most herbal products have side effects and interaction effects with medications. Some of the side effects and interaction effects will be discussed with each example of herbal alternatives to psychotherapy.

A. St. John's Wort (Hypericum perforatum)

St. John's wort was used by the ancient Greeks and has been used in Germany for many years as a prescription drug. It has recently become one of the most common herbal products sold in the United States, with retail sales surpassing $140 million in 1998. Its effectiveness has been studied in Europe. Linde provided a meta-analysis of 23 randomized trials in Europe, 15 of which compared St. John's wort to placebo and 8 of which compared it to active treatments. These studies indicate no significant difference in efficacy between St. John's wort and tricyclic antidepressants for mild to moderate depression and that St. John's wort is more efficacious than placebo. However, these studies were generally short (about 6 weeks) in duration. Research comparing St. John's wort to selective serotonin reup-take inhibitors (SSRIs) is in its infancy. One recent trial compared St. John's wort to fluoxetine (Prozac) and showed similar improvements in both groups. A clinical trial sponsored by the National Institute of Mental Health (NIMH) is currently under way to compare St. John's wort to sertraline (Zoloft).

One study by Shelton and colleagues, which appeared in the April 18, 2001 issue of the Journal of the American Medical Association (JAMA), indicated that St. John's wort is no more effective than placebo for treating major depression. The study has gained significant media attention and has called into question previous studies indicating that St. John's wort is effective. However, the recent JAMA study looked at St. John's wort and major depression whereas the previous studies had looked at St. John's wort for the treatment of mild or moderate depression. Taken as a whole, the body of research available to date indicates that St. John's wort may be useful for cases of mild to moderate depression, but that it is ineffective for the treatment of severe depression (major depression).

The mechanism of action of St. John's wort is uncertain. Early studies suggested it was similar to a monoamine oxidase (MAO) inhibitor in its action, but recent data indicate it is closer to an SSRI, except that it does not affect the serotonin system in the spinal cord and, therefore, does not produce the decrease in sexual drive experienced by at least one-third of SSRI users. Use of St. John's wort in conjunction with MAO inhibitors or SSRIs is contraindicated, as the combination increases SSRI-like side effects and could result in serotonin syndrome, a condition causing dizziness, confusion, anxiety, and headaches. The syndrome is potentially fatal.

Side effects of St. John's wort are similar to those of SSRIs and include gastrointestinal symptoms, dizziness, confusion, sedation, dry mouth, photosensitivity, and induction of hypomania according to Barrette, in 2000, and PDR for Herbal Medicines in 2000. A number of drug interactions may occur with St. John's wort. It can reduce blood levels of the HIV drugs (such as indinavir) by more than 50%, which may in turn lead to drug-resistant strains of the virus, noted the University of California, Berkeley, in 2000. It reduces the effects of blood thinners such as warfarin (Coumadin), the heart drug digoxin, some oral contraceptives, and the immunosuppressant drug cyclosporine (which helps prevent organ rejection in transplant recipients). It increases photosensitivity when used in conjunction with other photosensitizing drugs.

B. 5-HTP (5-Hydroxytryptophan)

5-HTP is an herbal supplement manufactured from the seeds of the African plant Griffonia simplicifolia. It is metabolized into serotonin and is thought to alleviate depression by enhancing serotonin neurotransmission. It is also used to treat fibromyalgia, insomnia, binge-eating, attention deficit disorder, and chronic headaches.

Studies conducted in the 1970s and early 1980s have shown 5-HTP to be more effective than placebo in treating depression. Several small studies have compared 5-HTP to standard antidepressant medications. However, these studies have some notable flaws (small sample sizes, short durations, no placebo group, poor definition of depression, and the inclusion of patients with bipolar depression).

The most common side effects of 5-HTP are nausea, vomiting, diarrhea, and anorexia. Euphoria, hypoma-nia, restlessness, rapid speech, anxiety, insomnia, aggressiveness, and agitation have also been reported. It is possible that 5-HTP causes seizures in children with Down syndrome, and its safety for pregnant or nursing women and those with liver and kidney disease has not been established. People with kidney disease, peptic ulcers, or blood platelet disorders should not use 5-HTP

There is some concern about contamination, even though the manufacture of 5-HTP is different from that of the standard tryptophan, which was banned in 1989. There have been a few reports of symptoms similar to those caused by contaminated tryptophan, and researchers have identified at least one contaminant in some batches of 5-HTP

5-HTP interacts with MAO inhibitors, with an increase in risk of hypertension. 5-HTP should not be used in conjunction with tricyclic antidepressants or SSRIs due to the possibility of serotonin syndrome. 5-HTP also interacts with carbidopa (used to treat Parkinson's disease), and the combination can cause skin changes similar to those that occur with scleroderma.

C. SAMe (S-adenosylmethionine)

SAMe (pronounced "Sammy") was first discovered in Italy in 1953. It became commercially available in Europe in 1977, and was not available in the United States until 1999. SAMe is used to treat osteoarthritis and liver disease, as well as depression, as noted by Gaster, and by Tufts University, in 1999. SAMe's mechanism for dealing with depression is not understood, but some researchers speculate that it affects brain levels of the neurotransmit-ters serotonin, noradrenaline, and possibly dopamine.

More than 40 trials have been conducted to evaluate SAMe for the treatment of depression. However, only five trials have tested oral forms of the herb, whereas the remaining studies have tested injectable formulations. Only three of the five trials of oral SAMe were randomized controlled trials. The trials that have tested injectable SAMe have generally shown it to be effective in the treatment of depression, although it is not valid to assume that oral SAMe is effective since it is very poorly absorbed from the gastrointestinal tract. It is too early to tell whether SAMe will prove to be a safe and effective treatment for depression.

Stomach upset is the most common side effect reported with SAMe use. Enteric-coated products are less likely to cause nausea, and are also less likely to break down in the stomach before they reach the small intestine where SAMe is absorbed. SAMe is contraindicated for individuals with bipolar disorder, as it can trigger manic episodes. Those with obsessive-compulsive or addictive tendencies should not take SAMe, as it may worsen their problems.

Safety concerns provide compelling reasons to avoid using SAMe pending further research. Because the research has been very short term, it is not known whether taking the herb long term could cause problems with toxicity or carcinogenicity Because SAMe raises blood levels of homocysteine, it may also raise the risk of coronary disease. Until it is understood how SAMe acts on the central nervous system, it is best to avoid taking SAMe in conjunction with other antidepressants, according to Gaster in 1999.

Even though SAMe's effectiveness and safety remain unvalidated, it is considerably more expensive than other treatments for depression (16 times as costly as St. John's wort, 5 times as costly as most tricyclic antidepressants, and 3 times as costly as SSRIs). SAMe cannot be recommended at this time for the treatment of depression due to its high cost, uncertain absorption, uncertain safety, and potential for inducing mania.

D. Kava, also known as kava kava (Piper methysticum)

Kava is a shrublike plant from the pepper family that is native to the South Pacific. It has traditionally been made into beverages, but can also be purchased in pill form. Kava is marketed in the United States as an over-the-counter drug to treat anxiety and insomnia and to promote relaxation, with millions of dollars being spent annually on the herb. The effectiveness of kava has been researched in placebo-controlled studies conducted in the United States and Germany. Meta-analysis of these studies provides evidence that kava is more effective than placebo for mild to moderate anxiety, but it is not effective for panic disorder. To date, the effectiveness of kava as compared to other antianxiety medications is unknown. Mild gastrointestinal upset is the main side effect of kava, and therapeutic doses are generally well-tolerated. However, large doses or prolonged use can cause rashes (allergic skin reactions); yellow discoloration of skin, hair, and nails; weight loss; and abnormal reflexes.

Kava root contains kavalactones, fatlike compounds that act as sedatives, muscle relaxants, and pain relievers. It is recognized by the FDA as being intoxicating and having abuse potential. Kava most likely works on the neurotransmitter GABA (gamma-aminobutyric acid) as an agonist (much like benzodiazepines), but since it is only a partial agonist it may be somewhat less effective than benzodiazepines. Because GABA is an inhibitory neurotransmitter, stimulation of GABA receptors results in CNS depression, noted Cummings, in 2000.

Use of kava with other central nervous system depressants (such as alcohol, benzodiazepines, or barbiturates) is contraindicated, as the interaction can potentiate the sedative effect and possibly lead to coma. Use of kava with anesthetics is also contraindicated, as it may prolong the sedation time and its use is con-traindicated with antipsychotic medications due to the potentiation of the sedative effects. In Parkinson's patients, it can cause tremors, muscle spasms, or other abnormal movements and may decrease the effectiveness of anti-Parkinson's medications.

E. Valerian, also known as Heliotrope (Valerianae radix or Valeriana officinalis)

Valerian is an herb with mild tranquilizing effects, sold over-the-counter and used to treat insomnia and mild anxiety. It was the 10th most popular herb in the United States in 1998, whereas it was ranked 18th the previous year. It was originally used in ancient Greece, and was used during World War I as a primary treatment for shell shock.

Like kava, valerian likely acts as a GABA agonist to produce its sedative effects, noted Hardy in 1999. Several good placebo-controlled studies indicate that it reduces the time it takes to fall asleep, but the research indicating that it improves sleep quality is very limited. The few available studies indicate that valerian is somewhat more effective than placebo for treating mild anxiety, but is likely ineffective for moderate to severe anxiety or panic disorder.

Valerian's side effects include mild morning sedation and headache, although one case of serious liver toxicity from an over-the-counter sleep remedy containing valerian has been reported. Valerian use in conjunction with other sedative drugs (such as benzodiazepines, barbiturates, or anesthetics) is contraindicated, as the interaction may potentiate the sedation. The research available to date indicates that valerian may not potentiate the effects of alcohol, but until more research is available it is advisable not to combine the two.

III. SUMMARY

In general, good studies demonstrating the effectiveness of most alternatives to psychotherapy are lacking.

In some cases, the research is yet to be conducted. In other cases, the body of available research indicates that the treatments are ineffective or, at best, only slightly more effective than placebo. However, more and more health care dollars are being spent on these and other alternative therapies. This trend toward increased utilization of treatments that are unverified and of dubious scientific validity is likely due to several factors: (1) The American consumer expects modern medicine to be able to cure every ailment and alleviate every pain. When it does not, the consumer often turns to alternative techniques. (2) The public erroneously equates "alternative" with "safe" and "natural." At the same time, the public is concerned about the dangerous side effects that may accompany prescription medications. (3) Many patients believe that managed care is limiting their access to medical treatment and medications. In many cases, the newer psychotropic medications are not included on some insurance companies' formularies. Even though herbal alternatives may be costly, they are often less costly than paying out-of-pocket for non-formulary medications. (4) Many consumers complain that their doctors do not really listen to them and involve them in health care decisions. On the other hand, health food store personnel and alternative practitioners are often much more willing to listen, spend time with patients, and offer patients the opportunity to participate in decisions. (5) Perhaps most important, the public is deluged with health information. Few people have the ability to read health information critically and to distinguish between good science and hype.

Although research to date may not be sufficient to draw conclusions about the effectiveness of many alternative therapies, some alternative therapies have been demonstrated to be effective adjunct treatments for various medical conditions. For example, biofeedback has been shown to be helpful in the treatment of a number of medical conditions, particularly muscle tension headaches and Raynaud's disease. As a result, insurance companies are becoming increasingly willing to pay for such treatments as adjuncts to standard medical treatments.

See Also the Following Articles

Animal-Assisted Therapy ■ Biofeedback ■ Cost

Effectiveness ■ Cultural Issues ■ Effectiveness of

Psychotherapy ■ Eye Movement Desensitization and

Reprocessing ■ Online or E-Therapy

Further Reading

Lam, Y. W. F (2000). Pharmacology update: Efficacy and safety of herbal products as psychotherapeutic agents. Providence, RI: Manisses Communications Group.

Mayo Clinic. (2000). Special report: Alternative medicine. Rochester, MN: Mayo Foundation for Medical Education and Research Publications.

Petter, F A. (1997). Reiki fire: New information about the origins of the Reiki power. Twin Lakes, WI: Lotus Light Publications.

Sachs, J. (1997). Nature's Prozac: Natural remedies and techniques to rid yourself of anxiety, depression, panic attacks and stress. Englewood Cliffs, NJ: Prentice Hall.

Shapiro, F, & Forrest, M. S. (1997). Eye movement desensitization and reprocessing: The breakthrough "eye movement" therapy for overcoming anxiety, stress, and trauma. New York: Basic Books.

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