Alternative Therapies In Health And Medicine

over usual treatment. 24,92 In many cases, the use of a biological
intervention (eg, SJW or SAMe) as a standard approach may be
considered, as taking a pill may not be as onerous for some as
embarking on dietary modification, reducing alcohol, initiating
exercise, or engaging in psychotherapy.
An important consideration regarding prescription of
CAM products concerns quality, safety, and dosage levels.
Prescribed herbal medicines products should be from trusted
companies that manufacture them according to pharmaceutical
standards, standardizing the product for active constituents
where possible. Safety considerations involve potential drugherb/nutrient
interactions and side effects; thus, people prescribing
herbal medicines should have adequate qualifications
in this area. Dosages for CAM products are often debated and
may be influenced by the type and quality of a product; the
patient’s weight, age, and metabolism; and modifying factors
such as current medication, comorbid disease, or genetics.
Ideally, adequate vitamins and minerals will be sufficiently
found in the diet, and if not, supplementation with nutraceuticals
can be considered. It should be noted, however, that in the
case of folic acid, supplementation studies have shown a slight
increase in cancer rates. 93 The 5-methyltetrohydrofolate
(5-MTHF) form may be safer to use in major depression. 93
Various interventions may be of use adjuvantly to address
co-occurring conditions or complications; these include the hormone
DHEA in the case of low androgens, therapeutic massage
for comorbid muscular tension and pain, and omega-3 fish oils
in comorbid inflammatory and cardiovascular conditions. 14,47,94
Evening doses of L-tryptophan or 5-HTP (with relevant cofactors,
eg, B 6
,
B 12
, folate, magnesium) may be of benefit in cases of
depression with co-occurring insomnia. 47 In such cases, sleep
hygiene techniques may also be of assistance, 95 in addition to
relaxation techniques, morning light therapy (primarily in seasonal
affective disorder), 96 and yoga. 69,97
Prescriptive considerations regarding exercise are important,
as increased physical activity may have negative health consequences,
especially in people with comorbid medical
conditions such as heart disease or arthritis. 98 Evidence currently
favors anaerobic over aerobic activity to gain the greatest benefits,
and the intensity needs to be moderate to high and performed
two to three times per week. 99 Clinicians should be aware
that depression may be worsened if the person is unable to meet
high expectations regarding level and frequency of exercise,
potentially promoting a sense of failure and guilt. This may be
more likely to occur in severe MDD, especially where psychomotor
retardation, hypersomnia, somnolence, marked fatigue, or
anhedonia are present. Exercise plans should be instituted after a
medical assessment and initially commenced at a low intensity to
allow for physical and psychological adaptation to occur to the
new stimulus. 68 Clinical considerations regarding dietary modification
also should be observed. Though general dietary advice
on healthy eating is benign, modifying factors such as vegetarian/veganism,
current nutritional deficiencies, eating disorders,
pregnancy, the age of the patient, and cultural factors need to be
considered. Finally, important advice sometimes overlooked by
clinicians is to encourage exploration of fun activities in the
patient’s life. Pleasurable euthymic activities (especially involving
social contact) offer a powerful antidote to life’s stressors.
Discussion
As a review of the literature details, in the treatment of clinical
depression, many nonpharmaceutical options with grade A–
or B–level evidence exist. The ALPS model may provide a clinical
framework to apply these interventions in practice. It is noted,
however, that though the individual interventions have RCT evidentiary
support, the overall model using a combination of these
treatments has not yet been clinically validated. This remains a
key area of future research and reflects an overall methodological
challenge for the area of CAM: to test holistic models as practiced
by clinicians using sound methodology. Though RCTs are vital in
validating individual therapeutic interventions, it is an important
step in the evolution of CAM research to move beyond
reductive methodology. Options may include a “whole systems”
research format, 100 whereby evidence-based components are
combined into an individualized treatment package that can be
disseminated to patients according to a systematic clinical decision
tree. This decision tree could provide an algorithm whereby
certain presentations could “trigger” treatment options and
could be achieved in part by information elicited from an interview
form based on this algorithm (in addition to personalized
case taking). In a clinical trial, this could be compared to treatment
as usual, conventional pharmacotherapy, or a waitlist or
placebo arm, with assessment being performed by blinded independent
researchers who perform the assessments with no
knowledge of the study particulars.
A potential drawback with multiple interventions is increased
cost (eg, healthy foods, gym memberships, psychologist/counseling,
CAM products), while physical discomfort and/or injury may
in rare instances occur with exercise or acupuncture. While these
limitations and weaknesses are acknowledged, strengths exist in the
creation, study, and implementation of an integrative model. It is
hoped that the tailored combination of treatments would be effective
in the treating depression, with potentially fewer side effects
than conventional pharmacotherapies. Importantly, this approach
may provide a sustained long-term effect, thus increasing long-term
remission of MDD. This may be especially so when psychological
techniques are employed, dietary advice is adhered to, exercise is
incorporated into the person’s daily routine, and social skills (where
warranted) are taught to increase resilience and enhance self-esteem.
The ALPS depression treatment model can be employed by
CAM or allied health practitioners (eg, nurses, clinical psychologists)
or medical physicians as a stand-alone model, or it can be
applied in conjunction with antidepressants as an adjuvant.
In conclusion, the future of clinical research into depression
needs to provide a greater emphasis on integrative working models.
The next step is to design a detailed comprehensive treatment algorithm
and trial methodology to study the ALPS depression treatment
model within a rigorous methodological framework.
An Evidence-based Integrative CAM Model for Depression
ALTERNATIVE THERAPIES, jul/aug 2011, VOL. 17, NO. 4 35