Natural Therapies for Mental Health:

An Evidence-Based Guide

17 May 2012Tim Desmond, LMFT Dr. Mark Foster, DO

The Wild World of Natural

Treatments

• Some have solid research.

• Some do not.

• Popularity does not correlate well with evidence.

Fact #1 Placebos Work

• No matter how good it is, it's mostly placebo.o No mental health treatment works like antibiotics. o We are talking about relatively small differences

between "effective" and "ineffective" treatments.

• Placebo can be understood as expectancy.o What we think is going to help is more likely to help.o Some placebos are better than others.

• Placebo can be understood as the mind's ability to heal itself.

Fact #2 Side Effects Can Be Serious

• Do no harm.o If no treatment has dramatically greater benefits

than placebo, there is no reason to expose someone to great risk.

• All classes of psychiatric medications have serious and potentially life threatening side effects.

• Some alternative treatments such as Vagus Nerve Stimulation and Electroconvulsive also have serious side effects.

Fact #3 Not All Science is Created Equal

• The quality of the control group determines the quality of the study.o Placebo control is vital when we know most of the effects come

from placebo.o Placebos must be "structurally equivalent."o People can "penetrate the blind."o The best studies control for expectancy.

• Most studies are performed by parties with a vested interest in the results.o Independent replication is key!!!

• There is a not enough high-quality evidence to predict which treatment will help an individual.

How to Choose...

• Evidence Isn't Everythingo There is little research on

potentially great treatments.

• What Looks Good to You?o Expectancy is important

• Experiment o Try different things and

track your progress

Show Me the Science!!

Therapies With Strong Evidence:

1. Exercise

2. Nutrition

3. Sunlight/PhotoTx

4. Volunteering

5. Social Support

6. Negative Ions

7. Adequate Sleep

8. Spirituality/Meaning

9. Counseling

Therapies With Weak Evidence:

1. St. John's Wort

2. 5-HTP

3. Chromium Picolate

4. Homeopathy

5. Melatonin

6. SAMe

7. Selenium

8. Vagus Nerve Stimulation

Exercise

Verdict: Strong

• More than 20 years of evidence.

• Ties or beats meds.

• Lower relapse than meds.

• Jogging & lifting weights are most studied.

Nutrition

Verdict: Strong

• More than 50 years of evidence.

• Nutritional deficiencies cause psychological problems.

• Unhealthy foods can contribute to psychological problems.

Nutrition Cont.

Foods and Nutrients Associated with Mental Health

(sources in parentheses)

• Antioxidants (green vegetables and fruits)

• Omega-3 fats (fish, supplements)

• Folate (beans, especially chickpeas)

• Vitamin D (supplements safest, also sun)

• B vitamins (supplements, whole foods)

• Starchy roots (potatoes, parsnips, carrots)o Correlated, but no causal evidence.

Nutrition Cont.

Dietary Choices Associated with Psychological Problems.

• Caffeine

• Alcohol

• High-fat diet

• Sugaro Correlated, but no causal evidence.

• Dairyo Correlated, but no causal evidence.

Sunlight & Phototherapy

Evidence: Strong

• Most research is on therapeutic lightboxes.

• Fastest acting treatment (4X faster than meds).

• Effective for all forms of depression.

• At least 30 mins/day.

Volunteering

Verdict: Strong

• Most research has focused on people over 65, but effective for all ages.

• Increases overall health, life functioning, optimism and control.

• Also helps chronic pain.

Social Support

Verdict: Strong

• Every form of illness and emotional distress is worsened by inadequate social support.

• Both depth and breadth are important.

• Some social circles can be negative.

Negative Ions

Verdict: Strong

• Artificially creating ions is effective and fast acting.

• Increases serotonin in mice.

• Level of negative ions in air is thousands of times greater near ocean or forest.

Adequate Sleep

• Sleep, serotonin and depression have a complicated relationship.

• Advancing sleep phase and sleep deprivation have been shown to treat depression.

• Lack of sleep causes several mood problems.

Spirituality/Meaning

• Spiritual and non-spiritual ways of creating meaning in life are psychologically protective.

• Religious behaviors are not.

• People credit spirituality in recovery from mental health problems.

Counseling

Verdict: Strong

• By far the best researched mental health treatment.

• Ties or beats medication.

• Therapist's individual qualities matter more than type of therapy or licensure.

• No research comparing counseling and drugs to counseling and another adjunct.

St. John's Wort

Verdict: Mixed

• Some studies show real antidepressant properties.

• Some show only placebo.

• Negative side effects exist.

• Effect could be experimenter bias.

• Could be hyperforin content.

Selenium

Verdict: Unlikely

• Selenium deficiency does cause mood problems.

• It is rare in the US.

• No trials of selenium for mental health in non-deficient population.

SAMe

Verdict: Not enough info.

• SAMe is a liver co-enzyme.

• Trials have been too small.

• Deficiency could be caused by B12 deficiency.

5-HTP and Tyrosine

Verdict: Complicated

• Neurotransmitters and mood are poorly understood.

• Trials of 5-HTP and Tyrosine are of poor quality.

• Could help some people.

Chromium Picolate

Verdict: Weak

• Very few trials

• Some evidence it could help people with depression and strong carbohydrate cravings.

Homeopathy

Verdict: Poor quality of research

• Plenty of anecdotes.

• Weak or no control groups.

• No side effects.

Melatonin

Verdict: Poor research, potentially dangerous.

• Many people with depression have delayed Melatonin cycle.

• Some research indicates they can have a deficit, but it's far from consistent.

• Treatment studies have poor design and too few subjects.

• Most show small benefit, but at least one showed strong negative effect.

Vagus Nerve Stimulation

Verdict: Poor research

• No research that has a credible control.

• Many authors admit it could be entirely placebo.

• Surgery has a huge placebo response.

What interventions to recommendto patients in mental distress?

Cost: Effectiveness Ratio

One-size doesn't fit all

in mental health.

•Each intervention has a relative cost and effectiveness that must be applied to the individual situation and capacity of the patient.

"What is the best way to help this specific patient achieve mental

and physical wellness?"

A Proposal: Quadrants of Cost and Effectivenss

We need a new way of conceptualizing the relative cost and effectiveness of mental health interventions.

Ideally, we would focus on those therapies that are:

• MOST EFFECTIVE

• BEST PROVEN

• LEAST COSTLY

• LEAST HARMFUL

(Slide with Quadrant Diagram)

Barriers: for Patients

Patient expectations: "Just give me a pill."

• informed by cultural norms

• faith in technology, "magic bullets"

• pharmaceutical propaganda

• information dissymmetry

Social barriers and toxic lifestyles

• poverty, lack of resources

• "life in the fast lane"

• poor physical health

• lack of role models

• substance abuse

Barriers: for Physicians

• Doctors feel the need to justify the cost of their services by utilizing their exclusive prescribing authority. "Prescription pressure."

• Uninformed about the side effects and withdrawal effects of medicines

• Lack of knowledge/confidence in effective alternatives

• Infatuation with technological interventions

• Inertia: difficult to undiagnose or withdraw patients from meds once on

Barriers: for Physicians

Poor cost incentives.

• Discussing lifestyle changes is time-consuming, often frustrating, and less likely to result in repeat customers.

Doctors assume that somebody else in the system will be making these

"common-sense recommendations."

(Odds are, if they're not hearing it from you, they're not hearing it from anybody!)

Overcomingthe Barriers

First: Perspective Shift for Doctors

We must move away from reductive diagnoses and reflexive prescribing, and move towards an integrative

holistic model of mental health.

Overcoming the Barriers

"Physician, heal thyself."

• Doctors must first attain,

then convey to patients these traits: o Wisdomo Patienceo Empathyo Optimism

• Doctors are less likely to recommend lifestyles choices that they are not familiar with or not personally practicing.

Overcoming the Barriers

“Help patients remove themselves from toxic influences,

empower them with an integrative perspective,teach them lifestyle choices that lead to wellness,

be wise, patient, empathic, and hopeful,walk with them when they suffer,

celebrate with them when they are well,and then see what symptoms are left over

that would require your intervention.”

Overcoming the Barriers

Million Dollar Question

• How can the system incentivize doctors and patients to pursue healthy lifestyle interventions rather than ineffective and harmful "magic bullets"?

Remember:First, do no harm!

Unlocking the Power of Placebo

• Acknowledge and appreciate the therapeutic power of placebo effect.

• It applies to medications, counseling, and any other intervention.

• Placebo is likely the most powerful therapeutic tool we have.

• Placebo: Don't fear it. Honor and respect it.

• Our minds and bodies want to heal.

• "Interventions" are often tools that unlock the latent placebo power within us.

Unlocking the Power of Placebo

Unlocking the Power of Placebo

• Placebo Power=Spontaneously Healing Capacity

• "How can we access our Spontaneous Healing Capacity in the least harmful way?"

Twelve Natural Therapies for Mental Health

Evidence-based Therapy Provider Recommendation

1) Exercise 1) Exercise everyday.

2) Nutrition 2) Eat healthy food. Avoid toxic substances.

3) Sunlight and Phototherapy 3) Get sunlight everyday.

4) Volunteering 4) Volunteer weekly.

5) Social Support 5) Be with trusted friends.

6) Negative Ions 6) Interact with nature.

7) Adequate Sleep 7) Get plenty of sleep.

8) Spirituality and Meaning 8) Meditate. Live with purpose and meaning.

9) Counseling 9) Work with an empowering counselor.

Other Useful Approaches/Paradigms Provider Recommendation

10) Yoga / Acupuncture 10) Practice yoga. Try acupuncture.

11) Positive Thinking 11) Be inspired.

12) Emotional Awareness 12) Keep your emotions in perspective.

Exercise

Exercise everyday

• 30 minutes a day.

• At least 5 days a week.

• Sustain heart rate at >110 bpm.

• Break a sweat every day.

• Do cardio everyday.

• Weight/resistance training at least twice a week.

• Pick activities you enjoy.

• Consider competitive and team sports.

• Train with a purpose.

• Two weeks to make a habit.

Exercise

Nutrition

Nutrition

Eat healthy food

• 5 fresh fruits and vegetables per day

• 3 balanced meals

• Whole grains, lean meats, fish

• Snack on tree nuts, fruits and vegetables

• Stay well-hydrated with water

• Supplementso Fish Oil 3 g dailyo Vitamin D 2000 units dailyo B-complex Vitamino Multivitamin

Nutrition

Avoid toxic substances

• Stop smoking

• Limit refined sugars

• Limit artificial flavoring/colorings/sweeteners

• Limit soda pop to once per week

• Limit fast food to once per week

• Limit coffee to no more than 2 cups per day

• Limit or avoid alcohol--less than one drink/day

• No illicit drugs. Careful with medical marijuana

Sunlight/PhotoTherapy

Get sunlight everydayo Thirty minutes of

direct sunlight per dayo Go for a walk at luncho Purchase a sunlamp

for the winter monthso Supplement with

Vitamin Do Plan a trip to a sunny

climate in the winter!

Volunteering

Volunteer weekly• at schools

• at churches

• with non-profits

• with community organizations

• with international missions

What are you passionate about?

What causes have impacted your own life?

Invest yourself in a worthy cause!

"Forget about your own problems, and

make a difference in somebody else’s life."

Social Support

Be with trusted friends• Seek out healthy, nurturing

relationships.

• Limit time with negative people.

• Be with people who inspire you.

• Listen, and let yourself be listened to, if only for a few minutes every day.

• Email and texting are great, but go for face-to-face conversation.

• Give and receive hugs!

Negative Ions

Interact with nature• Stop and smell the roses. Catch

a sunset.

• Grow flowers.

• Cultivate a garden.

• Keep houseplants.

• Plant trees.

• Get a pet.

• Ride and take care of horses.

• Surround yourself with things that are alive, that give and receive love.

Adequate Sleep

Get plenty of sleep

• 7-9 hours each night

• Have a regular bedtime routine.

• Don’t go to bed too late or get up too late

• Power naps--twenty minutes to rejuvenate.

• Pay attention to your dreamso Write them down.o Figure out what they mean for you. o Be surprised by the wisdom of your dreams.

Spirituality/Meaning

Spirituality/Meaning

by Viktor Frankl

**************

“Spend less time as a human doing,

and more time as a human being.”

--Dr. Foster's nurse

"Man's Search For Meaning"

Spirituality/Meaning

Meditate.

Live with purpose and meaning

• Meditation

• Prayer

• Deep breathing. o Sit in a quiet room and close your eyes.o Take long slow breaths, in through your nose, completely expanding

your lungs, hold it for a few seconds, then slowly and completely exhale through your mouth, making a quiet whooshing sound.

o Do this for 10 minutes everyday. o Clear your mind. Just breathe.

Spirituality/Meaning

Journaling

• Reflect on your life, describe your successes and your struggles, dream about the future.

• Be a hero on your journey through life!

Be creative

• Try painting or sculpture, crocheting or cooking, music or poetry.

• Release the artist within.

• Leave your unique mark on the world.

• You have something to say. Say it!

Counseling

Work with an empowering counselor

• Sometimes we need a coach.

• There is no "one best way" to do talk therapy.

• Find something and someone that works for you, that matches with your life experiences, values, and expectations.

• Get recommendations, interview potential therapists until you find one that's a good fit.

Counseling

Counseling

• The most important ingredients in successful therapy are trust, empathy, and flexibility. If it's not working for you, then look elsewhere.

• Remember, your counselor is human, too. They have their own ingrained habits, preconceptions, and personal feelings. They will have bad days, too.

• Accept their shared humanity and their flaws, and find a way to make the relationship mutually beneficial.

Yoga

Practice yoga

• Great for your body and mind.

• Physical flexibility translating to mental and emotional flexibility.

• Studios, gyms, retreats, DVDs.

Acupuncture

• Acupuncture works great for many people.

• Helps get patients to engage with a non-western, non-mechanistic approach to their health.

• Many acupuncturists will make herbal and nutritional recommendations as well.

Acupuncture

Positive Thinking

Be inspired

• Read good books

• Watch inspiring movies

• Listen to uplifting music

• Try a "news fast" for a week. Turn off the news. Don't read the newspaper. Stay away from the blogosphere. Live within your own sphere of influence for a week. Much anxiety comes from internalizing news events that

are beyond our influence.

Brighter days ahead!

Emotional Awareness

Keep your emotions in perspective

• To be human is to feel emotions, both positive and negative.

• Don't be numb to life.

• Be fully alive and responsive to your emotional state.

Emotional Awareness

• Relish moments of joy and peace.

• Give yourself permission to

feel depressed, anxious, scared, confused.

• Work through your negative feelings.

• Learn something valuable about yourself.

• Harness the intensity of your emotions. Let them propel you towards emotional growth.

Emotional Awareness

• "You are a soul traveling through time, and your emotions are the changing weather patterns you encounter. There will be both sunny and rainy days, summer vacations and winter blues."

• Accept the inevitable changes in your internal weather as temporary, meaningful, cyclical and essential to being fully human.

• "Prayer of Serenity"

• "Desiderata"

Emotional Awareness

Changing Paradigms,Changing Discussions

Decentralize the doctor.

Empower the patient.

Let's move from:

"Doctor, what outside interventions can you prescribe in order to eradicate my mental

distress?"

to:

"Together, how can we cultivate

an environment in which mental health will manifest itself?"

Two Anecdotes

• The Woman Who Did None of These

• Dog Park Magic

Additional reading for patients and providers

• "Mental Health Naturally" by Dr. Kathi Kemper, MD

• "The Depression Cure" by Stephen Ilardi

• "Spontaneous Happiness" by Dr. Andrew Weil, MD

• "Man's Search For Meaning" by Viktor Frankl

• "Please Don't Label My Child" by Dr. Scott Shannon, MD

• "Transforming the Difficult Child" by Howard Glasser

• "ADHD Without Drugs" by Sanford Newmark

• "The Happiness Trap" by Russ Harris

• "Your Drug May Be Your Problem" by Dr. Peter Breggin, MD and Richard Cohen

• "Mad in America" by Robert Whitaker

• "Anatomy of an Epidemic" by Robert Whitaker

• "They Say You're Crazy" by Paula Caplan

(Slide with Quadrant Diagram)

Natural Therapies for Mental Health

from toxic influences,empower them with an integrative perspective,

teach them lifestyle choices that lead to wellness,be wise, patient, empathic, and hopeful,

walk with them when they suffer,celebrate with them when they are well,

and then see what symptoms are left over that would require your intervention.”

Thank you.“Help patients remove themselves