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