LA METAFTONIMIA

Acupuncture, yoga, qigong, and other energetic or mind–body modalities are extensively used to treat psychiatric disorders in North America and western Eu- rope. In general, alternative energetic or mind–body modalities have good safety profiles and relatively few contraindications or complications, especially when they are administered by a qualified practitioner. Table 3–4 summarizes safety is- sues pertaining to alternative nonbiological modalities used in mental health care.

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Herb Drug/Supplement Interaction Comment/Reference

Chinese red sage (Salvia miltiorrhiza)

Warfarin Increased bleeding tendency Chan 2001

Dong quai (Angelica sinensis)

Warfarin Increased bleeding tendency Lo et al. 1995

Ginkgo (Ginkgo biloba)

Aspirin Hyphema Case report

Ginkgo is a potent inhibitor of platelet- activating factor

Warfarin Increased bleeding tendency Concomitant use of warfarin and ginkgo is CONTRAINDICATED Preliminary data, based on ginkgo’s

effects on platelet function Other drugs affecting hemostasis

(anticoagulants, antiplatelet agents)

Increased bleeding tendency Hypothetical, based on ginkgo’s anti- platelet activity

Anticonvulsant agents Diminished anticonvulsant effectiveness

Preliminary data, based on possible contamination of ginkgo products with the neurotoxin 4´-O-methylpyridoxine Garlic, phosphatidylserine,

policosanol, vitamin E (at high dosages), ginger

Increased tendency for bleeding Hypothetical, based on the combined anticoagulant effects of these natural products and ginkgo

Co m p le m enta ry a n d A lter na ti ve T rea tm ents i n M ent a l Hea lth C a re Kava (Piper methysticum)

Barbiturates Potentiation of barbiturate sedative effects

Preliminary data

Benzodiazepines Central nervous system depression (lethargy, disorientation)

Case report with alprazolam Concomitant use not recommended

Antipsychotics (e.g.,

phenothiazines, haloperidol)

Increased risk of dystonic reactions

Preliminary data

Case reports indicate that kava may have central dopamine-blocking activity Anti-parkinsonian medications

(e.g., carbidopa/levodopa)

Decreased control of Parkinson’s disease

Hypothetical, based on postulated kava dopamine blockade

Metoclopramide, other dopamine blockers

Increased risk of dystonic reactions

Hypothetical

Hops, passion flower, valerian (sedative herbs)

Increased risk of excessive sedation

Hypothetical

St. John’s wort (Hypericum perforatum)

Cyclosporine Transplant rejection

(subtherapeutic cyclosporine levels)

Case reports

Enzyme induction of CYP3A4 and intestinal p-glyco-protein by St. John’s wort, causing increased drug metabolism and decreased drug absorption

en t S afe ty 53 St. John’s wort (Hypericum perforatum) (continued)

Digoxin Decreased digoxin serum levels Clinical study

Decreased digoxin intestinal absorption Indinavir (other HIV protease

inhibitors?)

Decreased indinavir serum levels (increased risk of treatment failure or antiretroviral resistance in HIV patients)

Small clinical study involving healthy volunteers

Increased indinavir metabolism

Nevirapine (other nonnucleoside reverse transcriptase inhibitors?)

Decreased serum levels of nevirapine

Oral contraceptives Decreased oral contraceptive effectiveness, unwanted pregnancies

Case reports

Increased metabolism of ethinylestradiol

Serotonergic drugs Serotonin syndrome Case reports “Statin” drugs (except pravastatin) Possible decreased statin

effectiveness

Increased metabolism of statins

Theophylline Increased theophylline serum levels after stopping St. John’s wort

Case report

Increased metabolism of theophylline

Co m p le m enta ry a n d A lter na ti ve T rea tm ents i n M ent a l Hea lth C a re St. John’s wort (Hypericum perforatum) (continued)

Tricyclic antidepressants (TCAs) Possible decreased TCA effectiveness

Increased TCA metabolism

Photosensitizing agents and proton pump inhibitors

Increased risk of

photosensitivity reactions

Hypothetical

Warfarin Reduced anticoagulation Case reports Valerian

(Valeriana officinalis)

Barbiturates and benzodiazepines Potentiation of sedative effects Preliminary studies Hops, kava, passion flower

(sedative herbs)

Increased risk of excessive sedation

Hypothetical

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Supplement Adverse effects Comment

5-Hydroxytryptophan Absence of significant side effects in clinical trials At usual dosages (50–100 mg po tid), mild nausea,

dry mouth, stomach irritation, drowsiness can occur

Serotonin precursor

Contaminant “peak X” (previously associated with eosinophilic myalgia with L-tryptophan) found in one product batch in 1998; rare case reports; causality weak; no U.S. Food and Drug Administration action; some recommend obtaining 6-month eosinophil levels; others consider this supplement unsafe Huperzine A Absence of significant side effects in clinical studies in

China; however, inhibition of acetylcholinesterase might cause dry mouth, fatigue, nausea, diarrhea Safely used in short-term clinical trials (1–3 months)

Appears to have fewer side effects than synthetic acetylcholinesterase inhibitor congeners (e.g., donepezil, physostigmine, tacrine)

Co m p le m enta ry a n d A lter na ti ve T rea tm ents i n M ent a l Hea lth C a re

L-Tryptophan Crosses the blood–brain barrier and is synthesized into serotonin; uncommon adverse effects include drowsiness, dry mouth, blurred vision

1,500 cases of eosinophilia-myalgia syndrome (EMS) were attributed to one contaminated batch of L-tryptophan in the late 1980s; L-Tryptophan has remained in widespread use, and no subsequent cases of EMS have been reported

No cases of serotonin syndrome or other serious adverse effects have been reported when L-tryptophan was combined with fluoxetine or other conventional antidepressants

Omega-3 fatty acids (from flaxseed or fish oil)

Generally considered safe; usually well tolerated at low doses taken orally; nausea and loose stools at higher doses; fishy-smelling “burps” common; gastrointestinal side effects may be minimized by taking oil with meals

Mild blood-thinning activity but no bleeding problems caused when used alone or with aspirin Transiently elevates low-density lipoprotein Eicosapentaenoic acid component might suppress

natural killer cell activity (preliminary findings)

Cod liver oil (as a fish oil source) contains high levels of vitamins A and D; increased risk of vitamin toxicity associated with long-term use or high dosages Pharmaceutical grade of product purity required to

avoid contamination from heavy metals, polychlorinated biphenyls, organochlorines Single case report implies that use in patient with

history of major depressive disorder may have caused hypomanic episode

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Phosphatidylcholine Generally considered safe

Oral dosages up to 30 g/day for 6 weeks were well tolerated (one reference)

Gastrointestinal upset (e.g., abdominal discomfort, diarrhea, nausea) and reduced appetite may occur at dosages exceeding 10 g/day

Component of lecithin

Phosphatidylserine Generally considered safe

Side effects rare; higher dosages (300–600 mg/day) can result in gastrointestinal upset, insomnia

Now derived from soy or cabbage; most research based on bovine cortex products, which are no longer available due to concerns over mad cow disease SAMe

(S-adenosylmethionine)

Generally considered safe

Well tolerated orally; mild digestive distress is most common side effect

At high doses, more intense gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea) and central nervous system symptoms (e.g., mild insomnia, nervousness) have been reported Anxiety reported in depressed patients; manic

episodes reported in bipolar patients

Butanedisulfonate salt more bioavailable and more stable than tosylate salt, making product selection extremely important

Co m p le m enta ry a n d A lter na ti ve T rea tm ents i n M ent a l Hea lth C a re

Theanine Generally well tolerated; crosses blood–brain barrier, where it is synthesized into γ-aminobutyric acid, resulting in general calming effect without sedation

No reports of adverse effects or interactions

Vinpocetine Generally well tolerated Clinical studies Reversible agranulocytosis Case report

Vitamin E Few adverse effects at therapeutic doses Safe upper intake limit for adults is 1,500 IU/day α-tocopherol (“natural” vitamin E)

Mild antiplatelet activity at high doses Clinical study (50 IU/day)

Caution required when considering use in patients having surgery or giving birth or who have a bleeding disorder

Inhibition of chemotherapy versus protection against chemotherapy side effects without interference?

Medical controversy

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Modality Overall safety Comments

Acupuncture Generally considered safe when performed by a trained practitioner

Side effects may include transient pain, tiredness, bruising, fainting, vomiting, aggravation of symptoms Serious complications are rare (e.g., pneumothorax,

nerve damage)

Infection from needles is very unlikely in the United States, where only sterile, disposable needles are used

Studies have revealed a slightly higher probability of significant adverse events when acupuncture is delivered by practitioners with limited training (100–200 hours) compared with Chinese medical practitioners who have completed a conventional 4-year program

Pregnant patients should not have certain acupuncture points stimulated

Biofeedback Few safety risks reported Caution should be used in patients who have heart conditions or implantable electrical devices; some biofeedback equipment emits a weak electrical current Chiropractic Generally considered safe

Minor side effects include transient local discomfort after therapy, headache, and fatigue

Serious complications caused by manipulation of neck are rare (e.g., stroke, vertebral fracture)

Complication rate estimated at 1 per million sessions Not recommended in patients with osteoporosis, recent

fractures, bone tumors, bone or joint infections, spinal cord disease, bone marrow disease, ligament damage, fused spine

Guided imagery Generally considered safe Mindfulness techniques such as guided imagery, autogenic training, meditation, and relaxation response have no known safety risks

Co m p le m enta ry a n d A lter na ti ve T rea tm ents i n M ent a l Hea lth C a re

Homeopathy Homeopathic remedies very safe; no toxic reactions reported in 200 years

U.S. Food and Drug Administration is responsible for quality control of homeopathic remedies

Patients may experience a “healing crisis” or “healing aggravation,” a mild worsening of symptoms usually lasting only a few days

Massage Generally considered safe

Can transiently exacerbate pain; bone fractures and other internal injuries are possible if treatment is too forceful

To be avoided on abdomen, legs, and feet during the first 3 months of pregnancy

Not recommended in patients with recent fractures, areas of bleeding, unhealed wounds, rash, phlebitis, skin infections, or varicose veins; to be avoided near tumors, recent surgical incisions

Qigong Generally considered safe Cases of transient psychosis or agitation during qigong practice have been reported by patients diagnosed with personality disorders or schizophrenia Tai chi Considered to be as safe as other exercise or

mind–body practices

Special accommodations are required for patients with reduced mobility, impaired balance, or inability to stand

Yoga Considered to be as safe as other exercise or mind–body practices

Advanced postures may result in injury to inexperienced practitioners

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Integrative Approaches

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