Table 3 summarizes other contraindications that psychiatrists should know about when working with patients who are interested in CAMs.14,15 Advise patients to avoid combinations of a specific herbal or other natural product and a specific medication when there is a reasonable basis to assume that the combination is potentially unsafe. Phenothiazines or other drugs that potentially cause photosensitivity reactions should never be used in conjunction with herbals known to cause photosensitivity, including kava and St John’s wort.
Kava and valerian potentiate the sedating effects of benzodiazepines, and therefore should not be used in combination with this drug class. Reasonable exceptions to this caveat can be made for:
• The patient who uses a benzodiazepine at bedtime only for sleep may be able to take kava during the day.
• The patient who is being closely monitored during a gradual tapering of a daytime benzodiazepine regimen while titrating kava to manage withdrawal effects or recurring anxiety.
Psychiatrists who recommend herbals and other natural products should always provide patients with information about specific products that are approved by the United States Pharmacopeia for the disorder that is being treated and that are highly rated by third-party reviewers. It is prudent to document informed consent in the patient’s chart whenever herbals or other natural products are recommended. Reputable third-party reviewers—such as ConsumerLab, the National Nutritional Foods Association (NSF), and NSF International—have Web sites that provide safety reviews, product quality ratings, and reports of product recalls and warnings.
Somatic, mind-body, and energy modalities
In addition to herbals and other biological CAM modalities, acupuncture, yoga, qigong, and other somatic, mind-body, or energetic modalities are widely used to treat or self-treat psychiatric disorders in North America and Western Europe. Alternative somatic, mind-body, and energetic modalities have good safety profiles and relatively few contraindications or serious complications—especially when administered by a qualified CAM practitioner.
Massage can result in transient exacerbation of pain syndromes if too forceful. Massage of the abdomen, legs, and feet should be avoided during the first trimester of pregnancy. Chiropractic manipulation is generally safe; however, minor uncommon adverse effects can include transient local discomfort after therapy, headache, and fatigue.
Acupuncture is generally safe when performed by a trained Chinese medical practitioner. Infrequent adverse effects of acupuncture include transient pain, tiredness, bruising, fainting, and vomiting. Rare serious complications include pneumothorax and nerve damage. Infection from contaminated needles is extremely rare in the United States.
EEG biofeedback (or “neurotherapy”) and other forms of biofeedback involve weak electrical currents. Exercise caution when using this approach in patients who have heart conditions, pacemakers, or implanted defibrillators or electrical devices.
Homeopathic remedies contain extremely diluted amounts of active biological agents and as such are extremely safe. There are rare case reports of brief “healing crises” associated with transient worsening of symptoms with homeopathic remedies. Rare cases of transient psychosis or agitation have been reported during qigong practice by patients who have personality disorders or schizophrenia. Although yoga is generally safe, some advanced postures may result in injury to inexperienced practitioners.
It is important to be prudent when referring patients to CAM practitioners. Identifying a qualified CAM practitioner can pose challenges, especially for CAM specialty areas for which there are few or no requirements for minimum standards of professional training or credentialing.3,16 While most CAM practitioners are competent and caring professionals, some are poorly trained or do not have the specialized skills necessary to work with serious psychiatric disorders, and there is often little or no oversight of their clinical work.3,16 Herbalists, naturopaths, and homeopaths, for example, have widely varying training backgrounds and clinical experience ranging from no formal training to rigorous training programs followed by years of required supervision and credentialing by a professional board. Completion of a rigorous training program and verification of credentials and licensure are important steps in this process. CAM practitioners should be chosen after careful deliberation. Finally, even when qualified CAM practitioners are available, many patients elect to self-treat with 1 or more CAM therapies in the absence of appropriate professional consultation.17
1. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med. 2005;11:42-49.
2. Ernst E, Barnes J. Methodological approaches to investigating the safety of complementary medicine. Complement Ther Med. 1998;6:115-121.
3. Ernst E. Evaluation of complementary/alternative medicine. Z Arztl Fortbild Qualitatssich. 2007;
4. Druss BG, Rosenheck RA. Use of practitioner-based complementary therapies by persons reporting mental conditions in the United States. Arch Gen Psychiatry. 2000;57:708-714.
5. Elkins G, Rajab MH, Marcus J. Complementary and alternative medicine use by psychiatric inpatients. Psychol Rep. 2005;96:163-166.
6. Unutzer J, Klap R, Sturm R, et al. Mental disorders and the use of alternative medicine: results from a national survey. Am J Psychiatry. 2000;157:1851-1857.
7. Kessler RC, Soukup J, Davis RB, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry. 2001;158:289-294.
8. Gurley BJ, Gardner SF, Hubbard MA. Content versus label claims in ephedra-containing dietary supplements. Am J Health Syst Pharm. 2000;57:1-7.
9. Huggett D. Organochlorine pesticides and metals in select botanical dietary supplements. Bull Environ Contam Toxicol. 2001;66:150-155.
10. Huang W, Wen K, Hsiao M. Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan. J Clin Pharmacol. 1997;37:334-350.
11. Jacobs K, Hirsch K. Psychiatric complications of Ma-huang. Psychosomatics. 2000;41:58-62.
12. Spollen JJ, Spollen SM, Markowitz JS. Psychiatric side effects of herbal medicinals. J Pharm Practice. 1999;12:196-207.
13. Brown RP, Gerbarg PL, Muskin PR. Alternative treatments in psychiatry. In: Tasman A, Kay J, Lieberman JA, eds. Psychiatry. 2nd ed. London: Wiley; 2003:2147-2183.
14. Miller LG. Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med. 1998;158:2200-2211.
15. Lake J, Spiegel D. Complementary and Alternative Treatments in Mental Health Care. Washington, DC: American Psychiatric Publishing, Inc; 2007.
16. Ernst E, Siev-Ner I, Gamus D. Complementary medicine—a critical review. Isr J Med Sci. 1997;
17. Ernst E, Armstrong N. Lay books on complementary/alternative medicine: a risk factor for good health? Int J Risk Safety Med. 1998;11:209-215.
•Bratman S, Girman AM. Mosby’s Handbook of Herbs and Supplements and Their Therapeutic Uses. St Louis: Mosby; 2002.
•Chen J. Recognition and prevention of herb-drug interactions. Medical Acupuncture. 1998/1999;10: 9-13.
•ConsumerLab. http://www.ConsumerLab.com. Accessed June 17, 2009.
•Harkness R, Bratman S. Mosby’s Handbook of Drug- Herb and Drug-Supplement Interactions. St Louis: Mosby; 2002.
•Lake J. The integration of traditional Chinese Medicine (TCM) and Western biomedicine, with emphasis on treatment of psychiatric disorders. Integrative Medicine. Aug/Sept 2004.
•Natural Medicines Comprehensive Database. 1995- 2009. http://www.naturaldatabase.com. Accessed June 17, 2009.
•Stargrove MB,Treasure J, McKee DL. Herb, Nutrient, and Drug Interactions: Clinical Implications and Therapeutic Strategies. St Louis: Mosby; 2007.