Complementary Therapies for Schizophrenia: Expanding the Clinician’s Toolbox

Lake's synthesis of published research evidence has identified these nonconventional therapies as "provisional treatments for psychosis" (see page 3 for more detailed information):

• glycine
• EPA (eicosapentaenoic acid), an Omega-3 fatty acid
• DHEA (dehydroepiandrosterone)
• folate, niacin and thiamine
• spiritually oriented group therapy

• dietary changes (decreased intake of saturated fats and gluten; increased intake of Omega-3 fatty acids; improved glucose control)
• ginkgo biloba
• yoga practices
• mineral supplements (manganese, selenium, zinc)

Guidance for using complementary therapies

Leaders in complementary psychiatry have the following guidance for clinicians who are considering or starting to use the approach:

• Take a comprehensive patient history that includes
  -the patient's overall health history
  -previous mental-health problems
  -family history of psychiatric disorders
  -when symptoms of psychosis started
  -frequency and severity of psychotic episodes
  -which therapies the patient has tried (conventional and  complementary); how well they worked (or didn't); side effects they  produced
  -patient's daily activities, sleep/wake patterns, and sources of stress
  -patient's family situation, living situation and significant relationships
  -diet and exercise habits
  -spiritual/religious beliefs and activities
  
• Determine whether the patient poses a danger to himself or others. If so, make sure he gets immediate treatment in an emergency or inpatient setting, and emphasize to the patient the importance of staying on his prescribed medications.
• Ask about patients’ use of complementary therapies -- and don’t be judgmental of their response. A 2006 research review of complementary therapies in psychiatry found that, depending on the criteria used, between 8 and 57% of psychiatric patients use nonconventional therapies. A 2005 study from the Scott & White Memorial Hospital and Clinic found that among 82 psychiatric inpatients, 63% had used a complementary modality in the previous year, but most respondents had not discussed it with their psychiatrist. This may have dangerous repercussions, since some herbs and supplements can cause adverse reactions when taken with conventional medications.

  Many patients avoid mentioning complementary therapies because they fear their doctor’s disapproval, notes William M. Greenberg, MD, clinical associate professor of psychiatry at New York University, whose private practice incorporates complementary therapies including dietary supplements, meditation and spirituality.

  "I approach patients individually and broadly," Greenberg says. If a patient seeks to use natural remedies in place of medications, he usually advises against it. Still, he says, "I don't reject that attitude outright. I find that the clinician being open to it really strengthens the therapeutic alliance."

  Until recently, Greenberg was director of outpatient research at the Nathan Kline Institute for Psychiatric Research, where he led a randomized, placebo-controlled trial on the Effect of High-Dose B-Complex Vitamins on the Symptoms of Schizophrenia (results are not yet available).

• Determine whether psychosis is the patient's only primary symptom , or whether there are comorbid symptoms, such as anxiety or depression. Lake's Textbook of Integrative Mental Health Care includes tables and an algorithm that provide guidance on assessing and treating patients with comorbid symptoms in addition to psychosis, vs. psychosis alone.
• Try all substantiated conventional therapies before starting complementary therapies. "If the patient has tried all the antipsychotics except one, I'd try that one before going to [nonconventional] treatments," Lake says.
• Start slow. When introducing or changing therapies (conventional or nonconventional) for a patient, avoid making quick or drastic changes. Start with the lowest recommended dose, then increase it incrementally if it's not having the desired effect. Always aim for the lowest possible effective dose of any treatment, to minimize the risk of adverse effects while increasing compliance.
• Consider cost. Nonconventional treatments are rarely covered by insurance, and many schizophrenia patients have limited financial resources, making it difficult for them to pay for treatments out-of-pocket. While common dietary supplements typically cost $20 to $50 per month, other treatments -- such as Chinese herbal medicines or less-common supplements -- can cost several hundred dollars a month.
• Carefully explain to patients the rationale for the complementary therapies you’re recommending; the risks involved -- including potential herb-drug interactions -- and the importance of staying on the patient’s prescribed medication regimen. Document these discussions, and get the patient's written consent before beginning treatment.
• Refer patients to high-quality brands and suppliers of complementary remedies. Since the FDA does not regulate herbs or dietary supplements, there are no guarantees about the products’ contents or quality. One helpful guideline is to look for a certified “GMP” (Good Manufacturing Practices) certification (the GMP stamp will appear on the label), as well as products that have a “USP” (United States Pharmacopeia) stamp. Independent evaluations of the safety and efficacy of dozens of dietary supplements are available (for a modest fee) at ConsumerLab.com. Greenberg often suggests the Life Extension Foundation brand and Web site for herbs and supplements (he has no ties to the foundation).
• Listen. "Doctors can seem more interested in technology than in the patient's feelings. Patients miss having that emotional connection," Brown explains. "Just listening is very important." Effective listening, he notes, requires quieting the mind, eliminating distractions and focusing on the patient.

The following resources can help educate mental-health clinicians about the use of complementary therapies in psychiatry:

• Two books published last year -- the Textbook of Integrative Mental Health Care (Thieme Medical Publishers, October 2006, by James H. Lake) and Complementary and Alternative Treatments in Mental Health Care (American Psychiatric Publishing, December 2006, co-edited by Drs. James H. Lake and David Spiegel) -- identify what Lake and Spiegel regard as safe, effective complementary treatments for psychiatric disorders, and present evidence-based guidelines for their use.
• The American Psychiatric Association’s Caucus on Complementary, Alternative and Integrative Care offers an e-mail newsletter, information on meetings and events in complementary psychiatry, and an e-mail discussion group for clinicians. The group is building an online database of research evidence on complementary therapies in psychiatry.
• The American Psychiatric Association’s annual research meeting includes presentations and workshops on nonconventional treatments in psychiatry.
• The NIH’s National Center for Complementary and Alternative Medicine, known as NCCAM, lists on its Web site training resources for clinicians, including online CME courses, although these resources are not focused specifically on psychiatry.