Urgent Need for Transforming Mental Health Care

Existing models of care and conventional therapies are limited

Existing models of care and available conventional treatment approaches fail to adequately address the global crisis of mental health care. Mental illness accounts for about one-third of the world’s disability caused by all adult health problems, resulting in enormous personal suffering and socioeconomic costs. Severe mental health problems including major depressive disorder, bipolar disorder, schizophrenia, and substance use disorders affect all age groups and occur in all countries, including the US, Canada, the European Union countries, and other developed and developing countries. Mental illness is the pandemic of the 21st century and will be the next major global health challenge. There is a large and growing gap between mental health care needs of the population and available resources.

Weak evidence and safety problems affect many psychotropic medications

Many individuals diagnosed with bipolar disorder, major depressive disorder, and schizophrenia depend on medications to function and be productive members of society. However, after decades of research and billions of dollars of industry funding, the evidence supporting pharmacologic treatments of major depressive disorder, bipolar disorder, and other psychiatric disorders is not compelling. Many commonly prescribed psychotropic medications including antidepressants and antipsychotics are associated with serious adverse effects, including weight gain, increased risk of diabetes and heart disease, neurologic disorders, and sudden cardiac death. Metabolic syndrome associated with weight gain and increased risk of diabetes and coronary artery disease is a well-documented adverse effect of antipsychotics and other psychotropic agents. Poor treatment outcomes owing to limited efficacy of antidepressants, mood stabilizers, antipsychotics, and other psychotropic medications result in long-term impaired functioning, work absenteeism, and losses in productivity.

CAM therapies can help improve outcomes

In the context of the limitations of available conventional biomedical treatments, accumulating research findings are providing evidence for both safety and efficacy of select complementary and alternative (CAM) treatments of depressed mood, anxiety, and other mental health problems, including select pharmaceutical-grade natural products, lifestyle modifications (Lifestyle Medicine), mind-body approaches, and nonallopathic whole-system approaches such as traditional Chinese medicine and Ayurveda. Examples of natural supplements being investigated as nonpharmacologic therapies include S-adenosyl methionine for depressed mood; the adjunctive use of nutraceuticals (ie, botanicals and other natural product supplements) as stand-alone therapies or in combination with psychotropics such as omega-3 fatty acids, folic acid (especially its active form l-methyl-folinic acid), 5-hydroxytryptophan, and n-acetyl cysteine for mood disorders; a standardized extract of the herbal kava; and the amino acid l-theanine.

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Increasing Use of Alternative Therapies for Mental Health

Persons diagnosed with a major psychiatric disorder are significantly more likely to use CAM treatments than the general population, and the majority of people who use CAM to self-treat a mental health problem take prescription medications concurrently. Almost one-half of persons diagnosed with major depressive disorder or panic disorder use at least one CAM treatment, compared to less than one-third of the general adult population. Roughly two-thirds of severely depressed or anxious persons who use CAM therapies consult with a mental health professional and 90 percent of the time this is a psychiatrist. The majority of persons who use CAM therapies for a mental health problem do not disclose this to their mental health care provider. This trend is alarming in view of potentially serious safety problems that can result when combining certain herbals or other natural products with pharmaceuticals. More than one-half of persons who self-treat severe depression or anxiety using CAM while concurrently taking a pharmaceutical believe that CAM treatments and conventional medications are equally efficacious.

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Steady Growth in Use of Complementary and Alternative Medicine

In the North America, Europe, and other industrialized world regions, an increasing percentage of the population is using complementary, alternative, and integrative approaches to treat or selftreat medical and mental health problems. A large patient survey (N = 7,503) found that females, college graduates, and persons who believed that they received poor health care were more likely to use CAM, and only one-half of individuals who used CAM notified their health care providers. The majority of CAM users are well educated, committed to personal growth, satisfied with the conventional care provided by their physician or other health care provider, and use both prescription medications and CAM approaches for the same problem. An increasing number of medical schools, nursing schools, and psychology graduate programs offer courses on CAM. Symposia on CAM modalities are included in the annual meetings of the American Medical Association (AMA), the American Psychiatric Association (APA), and other professional medical associations. Approximately half of US physicians—and the majority of European physicians—believe that acupuncture, chiropractic, and homeopathy are valid therapeutic modalities and refer patients to practitioners of these therapies. Increasing numbers of primary care physicians are becoming certified to practice massage, acupuncture, herbal medicine, homeopathy, and other nonallopathic modalities.

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Limitations of conventional approaches used to evaluate depressed mood

Approaches used in biomedical psychiatry to evaluate depressed mood provide ambiguous information about possible underlying biological or other causes. Conventionally trained psychiatrists rely on structured interviews to obtain salient information about medical, psychiatric, family and social history that may be related to a patient’s complaint of depressed mood. The Mini-mental state exam, Beck Depression Inventory, and Hamilton Depression Inventory are structured interview tools commonly used to assess the relative severity of symptoms as well as social and psychodynamic factors associated with depressed mood. In addition to the clinical interview, laboratory screening studies are sometimes used to assess possible endocrinological, infectious, or metabolic causes of depressed mood. Bioassays that identify underlying medical causes of depressed mood include thyroid studies (FT4 and TSH), fasting blood glucose, liver enzymes, complete blood count (CBC), serum iron levels, serum electrolytes, BUN, and urinary creatinine. When an underlying medical problem, substance abuse or medication side effects contribute to mood changes, these problems are treated directly. When depressed mood does not resolve after a suspected medical cause has been treated, assessment continues until underlying psychological or medical causes are adequately addressed.

Conventional biomedical psychiatric assessment is limited by flawed standardized symptom rating instruments and poorly defined criteria for “response,” “remission,” and “recovery” when describing treatment outcomes in depression. For example a meta-analysis of 70 studies on the Hamilton depression scale suggests that this standardized instrument is conceptually flawed and does not reliably measure treatment outcomes. The response rates of most patients to conventional antidepressants are not well defined because most studies do not quantify treatment outcomes using formal criteria. Furthermore, relatively few psychiatrists are aware of, or regularly employ stringent research criteria to assess clinical outcomes when treating depressed patients.

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Depression causes an enormous economic and social burden

Depression is one of the most serious and costly health problems facing the world today. Because of the high incidence of suicide and other medical or mental illness in depressed individuals, depression is regarded as the leading cause of death and disability from adolescence through middle age. Approximately 15% of adults will experience severe depressed mood during their lifetimes and approximately 15% of these will eventually commit suicide. Available conventional treatment approaches do not adequately address depressed mood. In the medical community and the public at large there is growing debate over the efficacy and safety of antidepressants. It has been argued that many antidepressants are probably no more effective than placebo. This becomes even more concerning when high placebo response rates of most large controlled studies on antidepressants are taken into account.

In the context of widely shared concerns over the effectiveness and safety of prescription antidepressants research evidence is accumulating for many complementary and alternative treatments of depressed mood. To learn about safe and effective CAM treatments of depressed mood read “Depressed Mood: The Integrative Mental Health Solution,” by James Lake M.D.

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Complementary and alternative treatments of bipolar disorder

A large percentage of individuals diagnosed with bipolar disorder use complementary and alternative approaches together with prescription medications however there is little evidence for the safety and efficacy of many CAM therapies. The most appropriate and effective treatment approach should be determined by the type and severity of symptoms—including depressed mood, mania or states involving ‘mixed’ depression and mania, psychotic symptoms, insomnia and agitation—the presence of other medical or psychiatric disorders, response to previous mainstream and CAM treatments, patient preferences and constraints on cost and availability of different treatments.

When prominent symptoms of anxiety, psychosis or agitation are present, effective integrative strategies should prioritize the treatment of those symptoms. For example, reasonable integrative approaches when managing an acutely manic patient who is agitated and extremely anxious include an initial loading dose of valproic acid or another conventional mood stabilizer, high potency benzodiazepines, an antipsychotic that is sedating at bedtime—preferably a newer second generation antipsychotic—and possibly also amino acids known to have calming or sedating effects, such as L-tryptophan, 5-HTP or L-theanine. In general, CAM therapies have limited effectiveness against the hypomanic or manic phase of bipolar disorder however select CAM therapies are beneficial for the depressive phase of the disorder, either alone or when used in combination with antidepressant medications.

To read more about safe and effective uses of natural supplements and other complementary and alternative treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake M.D.

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Limitations of conventional medications used to treat bipolar disorder

Different medications are used to treat bipolar disorder including mood stabilizers (e.g. lithium carbonate and valproate), antidepressants, antipsychotics and sedative-hypnotics. Mood stabilizers do what the name implies, that is they keep the mood from going up and down between episodes of depressed mood and mania. Antidepressants are often used to treat the depressed phase of bipolar disorder though they also risk causing or ‘inducing’ mania. Antipsychotics are used to treat symptoms of agitation and psychosis which occur frequently in acute mania. Sedative-hypnotics such as lorazepam are used to treat insomnia and agitation.
Antipsychotics, specifically newer second generation antipsychotics (also called ‘atypical antipsychotics’) are currently regarded as the treatments of first choice for bipolar mania with or without psychosis. The therapeutic benefits of antipsychotics and other medications used to treat bipolar disorder are limited by frequent and potentially serious adverse effects. Earlier so-called ‘first generation’ antipsychotics were associated with frequent neurologic adverse effects (e.g. akathisia) in contrast to the newer second generation antipsychotics which cause weight gain and metabolic adverse effects but less often cause neurologic side effects.

After decades of research there is still no consensus on which particular medication should be tried first. Efforts to identify the most effective medication treatments have been hampered by problems in recent systematic reviews of studies on medications used to treat bipolar disorder including, for example, the use of non-representative patient samples, short trial duration, and experimental design flaws that make it difficult to generalize findings between studies.

Determining which medication may be most efficacious for bipolar mania is not at a simple or straight forward process because of large variations in response and tolerance in individuals with the same symptoms treated with the same medication. Diverse genetic and neurobiological causes of bipolar disorder mean that treatment with the same medication results in a wide range of responses and differences in adverse effects. For example the average weight gain seen in individuals taking second generation antipsychotics (the so-called ‘atypical agents’) is a few kilograms however metabolic differences between individuals can increase that amount 10 to 20 fold. A recent systematic review and meta-analysis of drug trials in acute mania included 68 studies on all drug classes and over 16,000 patients. All drugs were found to be moderately superior to placebo and antipsychotics were found to be more effective than other mood stabilizers in general.

In the context of the limitations of available pharmacologic treatments emerging research findings support the use of select natural products in the treatment of bipolar disorder. To read more about safe and effective uses of natural supplements and other complementary and alternative treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake M.D.

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Poor sleep habits increase the risk of relapse in persons with bipolar disorder

Abnormal sleep is known to increase the risk of developing cardiovascular disease. Sleeping too little or too long, as well as chronic insomnia significantly increase the risk of illness and death related to cardiovascular disease. This is probably related to the fact that chronically disturbed sleep increases the risk of obesity, hypertension, and diabetes, known risk factors for cardiovascular disease. Irregular sleep patterns and insomnia increase relapse risk and predict poor response in individuals diagnosed with bipolar disorder.

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Serious medical problems frequently accompany bipolar disorder

Many individuals diagnosed with bipolar disorder have serious medical problems including diabetes and cardiovascular disease which significantly increase their risk of dying. In fact cardiovascular disease is the leading cause of death in individuals diagnosed with bipolar disorder resulting in an average life expectancy that is 10 to 25 years shorter than the population at large. Bipolar patients are diagnosed with cardiovascular disease 14 years earlier on average compared to individuals who do not have mood disorders. Furthermore, bipolar individuals with cardiovascular disease have more frequent and more severe mood symptoms compared to medically healthy bipolar individuals. The association between increased risk of cardiovascular disease and bipolar disorder has not been adequately explained and may be due to chronic unhealthy lifestyle choices, the psychological stress of dealing with bipolar mood swings, or genetic and biological factors.

In addition to the above factors adverse effects of medications also significantly increase cardiovascular risk by causing weight gain. It is estimated that approximately two thirds of individuals diagnosed with bipolar disorder are overweight and one third are obese. In general individuals diagnosed with bipolar disorder exercise less and are more sedentary compared to individuals who are not diagnosed with serious psychiatric disorders. High rates of obesity, smoking, drug and alcohol use in bipolar patients lead to high rates of diabetes, hypertension, and heart disease resulting in increased overall mortality compared to the general population.

Available pharmacologic approaches used to treat bipolar disorder are limited because of safety problems and efficacy problems. Several emerging non-pharmacologic treatments are supported by research evidence. To read about safe and effective uses of natural supplements and other complementary and alternative treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake M.D.

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Many individuals diagnosed with bipolar disorder do not respond to treatment

It is estimated that fewer than one half of individuals who take prescription medications following a first manic episode have good long-term control of their symptoms. To make matters more complicated, as many as 40% of bipolar patients who are taking one or more medications at recommended doses continue to have manic or depressive mood swings. As many as 1 in 4 of individuals who have the more severe form of bipolar disorder (so-called ‘bipolar I’) attempt suicide, and a significant percent eventually succeed. Stressful work, family or relationship situations, changes in the season, not getting enough sleep and the use or abuse of stimulants or recreational drugs significantly increase the risk of a manic episode. Regular exercise, good nutrition, a strong social support network and a predictable, low-stress environment help reduce relapse risk.

In the context of widely shared concerns about the effectiveness of conventional pharmacologic treatments of bipolar disorder emerging research findings suggest that select natural supplements may help alleviate symptoms of bipolar disorder and other mood disorders. To read more about safe and effective uses of natural supplements and other complementary and alternative treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake M.D.

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