If fortunate, we find teachers in our lives who enhance the way we work and how we see the world. During my training in psychiatry, I found one such teacher, a psychiatrist named Richard Brown, who specializes in alternative treatments for psychiatric issues and illnesses. To this day, I periodically meet with him to discuss clinical challenges and to learn about new methodologies, and on several occasions, I have brought him to the Vineyard to give lectures and teach classes on subjects ranging from yoga breathing to drug interactions. Last year, along with his wife, Dr. Pat Gerbarg (the primary author), and colleague, Dr. Phil Muskin, Dr. Brown co-edited a comprehensive review of alternative psychiatric treatments called “Complementary and Integrative Treatments in Psychiatric Practice,” published by the American Psychiatric Association Publishing. The three editor/authors are all traditionally trained academic psychiatrists, and this is the latest of several books that they have written on out-of-the-box treatments in psychiatry.
While traditional psychopharmacology is often effective, only about a third of individuals treated for depression reach full remission. For those who do not, medicine alone just isn’t enough. And while numerous new medications have been developed, rates of response haven’t budged in 30 years. In my decades of practice, I have learned that patients are far more likely to reach full remission if, in addition to taking medication, they follow recommendations regarding nutrition, light therapy, cardiovascular exercise, various kinds of psychotherapy, sleep hygiene, and yoga breathing. While these complementary treatments aren’t always effective, I am often astounded at how transformative some patients find them to be.
There is abundant evidence that alternative treatments work for many people, but the strength of the evidence varies. Unfortunately, while traditional pharmacologic treatments are studied with large, well-executed research funded by the pharmaceutical industry, there is little incentive to fund research on treatments that are not on patentable. Nonetheless, given that medications alone frequently fail to achieve optimal results, it makes sense to augment medicinal treatments with safe alternatives and adjuncts, especially when credible research exists to support their use. “Complementary and Integrative Treatments in Psychiatric Practice” explores these options with scientific rigor.
As Gerbarg, Muskin, and Brown point out, “Mind-body practices… that were on the fringe of health care for decades are now embraced by clinics, hospitals, schools and even the military.” During training, Dr. Brown was regarded as a maverick. Now, many of the practices that he has espoused for years have become mainstream.
Even with all of the scientific evidence that is presented in “Complementary and Integrative Treatments in Psychiatric Practice,” it is hard to know which treatments to turn to first. There are rarely head-to-head comparison studies. As with traditional psychopharmacology, there are few long-term studies, and there are virtually no studies of the combination of treatments that any given person is likely to be on at the same time. Consequently, it is best — especially when symptoms are not severe — to try one treatment at a time so as to determine what works and what doesn’t.
A unique feature of this book is a set of decision trees that guide where to begin and how to combine treatments for best effects for each condition. It is advisable to start with low risk, common sense interventions like meditation, yoga breathing, exercise, light therapy, and low sugar and carb diets — all things that are part of a healthy lifestyle for anyone. Complementary treatments can have side effects, but overall they are fewer and less severe than prescription pharmaceuticals. But if symptoms are severe, it usually makes sense to start with traditional medications that are better studied for such symptoms.
“Complementary and Integrative Treatments in Psychiatric Practice” is divided into six sections and includes chapters by multiple academicians. The sections include an overview of complementary and integrative medicines (CAIM), what they are, how they are studied and how widespread their use now is. Subsequent sections address nutrients, plant based medicines, neurohormones, mind body practices, and other technologies. Here is an example from each these sections:
An example of “Nutrients in Psychiatric Care” is SAMe — S-adenosylmethionine. Similar to an amino acid and found in every cell in the body, SAMe catalyzes the formation of a range of neurotransmitters and hormones and contributes to cell membrane fluidity. There are good studies of its efficacy in treating depression and arthritis, and it may also help cognitive function. The hitch, as with so many nutritional and herbal medicines, is that different brands have different contents. The authors suggest that the 1-4 butanedisulfonate formula (found in the Azendus brand) is most effective, and my experience backs this up. Of note, Vitamins B12 and folic acid in themselves promote the body’s production of SAMe. In my experience, this can have a powerful antidepressant effect.
The longest section is entitled “Plant Based Medicines.” Brown and Gerbarg wrote a separate book entitled “The Rhodiola Revolution,” about the plant, Rhodiola rosea. Along with multiple other plants, it is classified as an adaptogen. Adaptogens, which in some cases have been used for thousands of years, “normalize physiological states and mitigate the effects of environmental or emotional stress.” In studies and clinical experience, Rhodiola rosea promotes physical and mental energy, exercise tolerance, alertness, and focus. It is not so much an “antidepressant” as a promoter of well-being, especially for people who find themselves sweating the small stuff, struggling to pay attention, and experiencing low energy. Several people have reported that Rhodiola rosea profoundly reduced symptoms of chronic Lyme.
Gerbarg and Brown are well known for their books, articles, and lectures on yoga breathing. Their section on this technique, “Mind Body Practices” states that “breathing slowly and gently through the nose with eyes closed for a few minutes, particularly coherent breathing at four to six breaths a minute with equal time for inhalation and exhalation, reduces acute stress, worry, frustration, anger, and rumination. Practicing coherent breathing for 20 minutes at least five days a week balances and strengthens the stress response system, lowers blood pressure, and may reduce inflammation.” Apparently, this kind of breathing stimulates the vagus nerve that slows heart rate, lowers blood pressure, and enhances well being. I have used this breathing technique myself, and when I do, my blood pressure declines measurably, and I feel a sense of calm.
The section entitled, “Neurohormones” focuses on melatonin, which is available in every pharmacy and most supermarkets as a sleep aid. Melatonin is a brain hormone, produced by the pineal gland, that is released following a circadian rhythm. Bright light during the day increases its night-time release. Its production is turned off by light and turned on by darkness. Immediate-release melatonin helps people get to sleep, and the sustained release formula helps people stay asleep. Melatonin is also a powerful antioxidant, regulates energy metabolism, and modulates immune function. It is useful in a wide range of neurological conditions as well as in cancer and some metabolic disorders. There are also studies that suggest its use for some kinds of anxiety, for treating late day confusion or “sundowning” in dementia, and for the treatment of a range of side effects from antipsychotic medication.
The final section of the book is on the “technologies” that interact with brainwaves to induce calm, balance, and well-being. A variety of machines are available for home and office use that for some people are remarkably helpful. Neurofeedback is an emerging technology, a form of “biofeedback” that measures brain waves and teaches people how to induce healing patterns of brain function. There are good studies of its use in treating anxiety, mood, addictions, PTSD, traumatic brain injury and chronic pain. It can also be used to enhance peak performance in sporting activities. On Martha’s Vineyard, Paul Farrington has a therapeutic practice using neurofeedback. Alternately, there is “The Muse” — a home neurofeedback device that enhances meditation.
Though a dense read from cover to cover, “Complementary and Integrative Treatments in Psychiatric Practice” is an indispensable resource for anyone who is trying to understand mechanisms, underlying research, and alternatives for mental and physical health.
Dr. Charles Silberstein is a psychiatrist at Martha’s Vineyard Hospital and Island Counseling Center. He is board-certified in general, addiction, and geriatric psychiatry. He writes regularly about issues Islanders have with mental health.