Incorporating Integrative Incorporating Integrative Therapies into Primary Therapies into Primary

Care for the Treatment of Care for the Treatment of DepressionDepression

Evan W. Kligman, MDEvan W. Kligman, MD

Professor of Public Health, FCMProfessor of Public Health, FCM

Co-Director, Arizona Center on AgingCo-Director, Arizona Center on Aging

How Common is Depression in How Common is Depression in Primary Care Settings?Primary Care Settings?

• Up to 50% of all patients seen report symptoms• 48% with severe post-election traumatic

depression• Up to 20% meet diagnostic criteria for

depression• 12 million women in US experience depression –

twice the rate of men• Half of all patients with depression receive

treatment from primary care clinicians; increases with age

Typical Somatic and Behavioral Typical Somatic and Behavioral ComplaintsComplaints

• Sleep disturbance

• Fatigue

• Pain

• Anxiety

• Behavioral and cognitive problems

Principle Diagnoses SeenPrinciple Diagnoses Seen

• Major depression

• Bipolar depression

• SAD (seasonal affective disorder)

• Dysthymia

• Depression associated with medical illness

• Grief adjustment disorder

Principles to Consider in Integrating Principles to Consider in Integrating TherapiesTherapies

• Important to take into consideration the type of depression, its natural history and pathophysiology, in determining what type(s) of integratives therapies to consider

• Important to consider whether such therapies are treating the symptoms or altering the underlying pathophysiology

• Many presentations are multifactorial; thus, multiple interventions may be appropriate

Major DepressionMajor Depression

• Sleep disturbance

• Appetite and/or weight change

• Fatigue or loss of energy

• Psychomotor agitation or retardation

• Feelings of guilt

• Suicidal ideation• At least four of the above

Major Depression PathophysiologyMajor Depression Pathophysiology

• Alterations of neurotransmitter function or imbalance

• Medications inhibit pre-synaptic reuptake of neurotransmitters or stimulate post-synaptic receptors (dopamine, serotonin, norepinephrine)

• Elevated cortisol levels and decreased cortisol suppression in response to dexamethasone during depression episode

• Medication-induced CNS depression

Other Mechanisms of Causation Other Mechanisms of Causation and Effectand Effect

• Genetic propensities (eg, TRP homeostasis)

• Neurochemical and anatomic alterations due to environmental/toxic exposures and stressors

• Alterations in energy fields

Bipolar IllnessBipolar Illness

• Episodes of depression alternating with mania or hypomania

• Manic episodes are discrete periods of elevated mood when patient irritable, engages in excessive or risky behaviors

• May sleep very little for days or weeks, without fatigue

• Hallucinations and delusions

DysthymiaDysthymia

• Mild but chronic symptoms of depression

• Presence of depressed mood most of time for a minimum of 2 years

• Appetite change, sleep disturbance, fatigue, poor self-esteem, difficulty with concentration or decision-making, or hopelessness (at least 2 of the above)

EvaluationEvaluation• Iatrogenic causes, eg medications

• Comorbid conditions

• Physical Exam

• Ancillary Tests: TFTs, Screening instruments

• “Profiling” or algorithm for diagnosis and treatment; identifying individuals and populations most appropriate for integrative therapies

Questions to IncludeQuestions to Include

• Lifestyle (relaxation, exercise, nutritional, supplements, meditation, spiritual practice, etc.)?

• Environmental stressors?

• Comorbid medical conditions?

• Self-image?

Integrating TherapiesIntegrating Therapies

Self-Directed Efforts – Step 1Self-Directed Efforts – Step 1

• Evaluate for failed attempts by substance abuse (EtOH,15%), inappropriate alternatives

• Self-help groups, meetings, online• “Foundation” lifestyle strategies, esp. dietary

changes and/or supplements, physical exercises, stress reduction techniques, breathing exercises, spiritual practice

Integrative Therapies – Step 2Integrative Therapies – Step 2• Nutritional, botanical, and vitamin therapies• Functional medicine• Homeopathy• Spiritual counseling/direction• Traditional chinese medicine (acupuncture, herbs)• Yoga• Chi Gong• Energetic clearing techniques• Narrative therapies• Reiki • EcoPsychology

Typical Vitamins and Minerals Typical Vitamins and Minerals UsedUsed

• Vitamins A, B6, B12,C, D, E

• Thiamine• Riboflavin• Niacinamide• Folic acid• Biotin• Pantothenic acid• Calcium

• Iron• Phosphorus• Iodine• Magnesium• Zinc• Selenium• Copper• Manganese• Chromium

Typical Minerals Used - contTypical Minerals Used - cont

• Molybdenum• Potassium• Dl-Phenylalanine• Glutamine• Choline• Citrus bioflavonoids• Inositol• Grape seed extract• Gingko biloba extract

• Methionine• Organic germanium• Boron• Vanadium• Nickel

Integrative Therapies - contIntegrative Therapies - cont

• Testosterone (androgen supplementation) in resistant cases

• Light therapy and 5-HTP for SAD as well unipolar and bipolar illness

• Physical Activity• Mind-body therapies• Animal assisted therapies (Delta Society)

Mind-Body TherapiesMind-Body Therapies

• Meditation (neuroplasticity)

• Hypnosis

• Guided Visualization/Imagery

• Relaxation therapies

• Biofeedback

Integrative Therapies - contIntegrative Therapies - cont

• Expressive therapies (art, dance/movement, music/sound, eg. music thanatology)

• Other culturally based healing arts (ayurveda, native american traditional practices, cuentos)- efficacy transculturally?

• Other massage therapies• Technology-based applications (telemedicine,

telephone counseling, e-mail, radio psychiatry)

““Radical Healing”*Radical Healing”*

• Movement

• Cleansing

• Breathing

• Remedies

• Psychotherapy

• Meditation• Rudolph Ballentine, MD

Integration StrategiesIntegration Strategies

• Determine type and severity of depression• Least invasive and “foundation” self-help

therapies first if mild depression; recommend modalities complementary to conventional treatment if severe

• Deliver modalities practitioner is most experienced and comfortable with

• Use a method of profiling to determine which integrative modalities appropriate to refer for

Benefits of Integrative Primary Benefits of Integrative Primary Care Approach to TreatmentCare Approach to Treatment

• Longitudinal with frequent follow-ups for monitoring symptoms and talk therapy

• Able to better monitor other comorbid or chronic conditions

• Emphasizes interrelationship between mind, body, and spirit

When to Refer and To Whom?When to Refer and To Whom?

• Modalities delivered by primary practitioner not successful or inadequate to reach goals

• Cultural contexts - Homer the Hopi Medicine Man – keep within the patient’s cultural context or refer to culturally sensitive modality/practitioner

• Patient acceptance potential

When to Consider Conventional When to Consider Conventional Treatments?Treatments?

• Consider type and severity of depression and response to self-directed and integrative therapies

• Suicidal ideation• Nonresponsive to steps 1 and 2, and secondary

to severe comorbid condition (eg, stroke, heart disease)

• Low risk of side effects (age, other medications, etc.)

Conventional Treatments-Conventional Treatments-Step 3 Step 3

• Medications• Psychotherapy and counseling (cognitive

behavioral therapy and interpersonal therapy)

• Electroconvulsive treatments• Transcranial magnetic stimulation

(topographically selective mild electrical stimulation to left anterolateral prefrontal cortex)

Typical Medications Side EffectsTypical Medications Side Effects

• Drowsiness or disorientation 10-18%• Decreased sexual interest or performance 21-51%• Weight gain 12-22%• Cost per month $68-140

• Consumer Reports. Drugs vs. talk therapy. October 2004

Best Psychotherapy OptionsBest Psychotherapy Options

• Cognitive behavioral therapy – train patient to identify and consciously correct distorted thought patterns causing symptoms; homework assignments, such as becoming more assertive on the job

• Interpersonal therapy – focuses on patient’s relationship problems with others; especially effective wit major life transitions; in therapy, one learns to adapt better to changing circumstances

Transcranial Magnetic StimulationTranscranial Magnetic Stimulation

• 10 sessions over two – three weeks, cumulative 18,000 - 30,000 magnetic impulses

• Consider if failed steps 1 and 2, and resistant to medications and counseling

• Change in Ham-D scores from 22 to 12 (goal = under 7)

• Best studied outcomes with post-stroke patients (Robinson RG): significant improvement in recovery of ADLs and cogntive function, and decreased mortality

Case StudyCase Study• 60 year old female speech pathologist with history of

SAD and hypothyroidism. GDS score of 17 at baseline. Developed neuropathic chronic pain syndrome approximately one year ago. Ongoing sleeplessness due to mood disorder and pain. Significant adverse effects from multiple SSRIs (diarrhea, GI upset, confusion, unacceptable lethargy). Has tried St. John’s Wort and DHEA supplements in the past without much benefit. Intermittent psychotherapy/analysis over several years, with short-term, but limited benefit. Positive support system of friends and husband.

Case Study - 2Case Study - 2

• Drinks 1 glass of red wine about every other night with dinner. Enjoys a Starbuck’s coffee drink almost daily. Diet “pesco-vegetarian”. Aerobic exercise once or twice a week. Meditates daily. Menopausal for 3-5 years and refuses HRT. Major stressors include daughter and mother. Works part-time. Spiritual practice consists of tonlin meditation and regular retreats.

Case Study - 3Case Study - 3

• Initial recommendations included: high quality fish oil up to 4000 mg with meals TID; changing from levoxyl to thyrolar and monitoring T3 with TSH; vitamins B12, B6 and folic acid SL 2000 mcg daily; aerobic exercise every other day; continue about 1 hour of MBSR and breathwork daily, followed by a short chi gong exercise; weekly jin-shin jyutsu; weekly yoga class; monthly CST;

Case Study - 3Case Study - 3

• Seen monthly to monitor progress; after 3 months, moderate progress with integrative treatments: added Sam-e to begin at 200 mg daily and advanced by increasing by an additional 200 mg per day weekly until max of 1200 mg per day; advised to avoid alcohol and Starbuck’s; GDS scale down to 7 after 6 months

Protocol to FollowProtocol to Follow

• 1. Remove exacerbating factors

• 2. Improve nutrition

• 3. Institute physical activity

• 4. Dietary supplements and botanicals

• 5. Psychotherapy, counseling, and/or other mind-body therapies

• 6. Pharmaceuticals

BibliographyBibliography

• Schneider C. Depression. Chapter 3 in Integrative Medicine. Saunders. 2003

• Magill MK. Depression. Chapter 8 in 20 Common Problems – Primary Care. McGraw-Hill. 1999

• Alternative approaches to mental health care. www.mentalhealth.samhsa.gov. NCCAM. 2004

Bibliography - 2Bibliography - 2

• Ballentine R. Radical Healing. Harmony Books. 1999

• Delgado PL (editor). Primary Psychiatry (journal). Neurotransmitter Depletion.June 2004; 11(6)

• Consumer Reports. Drugs vs. talk therapy. October 2004