In the first part of this column (Psychiatric Times, February 2007), I reviewed treatments whose beneficial effects are probably achieved through a discrete biological or pharmacological mechanism of action. These included dietary modifications; supplementation with specific vitamins, minerals, and amino acids; and medicinal herbs. In this part, I will review the evidence for approaches that reduce the risk of relapse, diminish craving, or mitigate withdrawal symptoms but for which there is no evidence for direct biological or pharmacological effect. These include exercise, mindfulness training, virtual reality graded exposure therapy (VRGET), cranio- electrotherapy stimulation (CES), dim light exposure,electroencephalogram (EEG) and electromyogram biofeedback, acupuncture, and qigong. Persons receiving conventional pharmacological treatments that seek to reduce the risk of relapse, diminish craving, and mitigate withdrawal symptoms may safely use these and other nonbiological therapies.
Exercise
Persons who chronically abuse alcohol(Drug information on alcohol) frequently experience depressed mood, which may trigger increased drinking. Those who exercised daily while hospitalized for medical monitoring during acute detoxification of alcohol reported significant improvements in general emotional well-being.1 Persons abstaining from alcohol use who were enrolled in outpatient recovery programs reported improved mood with regular strength training or aerobic exercise.2,3 Because of its demonstrated mental health benefits, regular exercise should be encouraged in all patients who abuse alcohol and drugs (assuming that there are no medical problems that would be aggravated by physical activity).
Mindfulness training is offered widely in drug and alcohol relapse prevention programs and may reduce the risk of relapse in persons with substance use disorders.4 Two studies suggest that transcendental meditation may be espe- cially effective in reducing the relapse rate in persons who abstain from alcohol.5,6 One study found that 12-step programs that emphasize a particular religious or spiritual philosophy may be more effective than "spiritually neutral" programs.7
Virtual reality graded exposureVRGET is a rapidly emerging technological intervention with a wide range of promising clinical applications for psychiatric disorders, including posttraumatic stress disorder, phobias, eating disorders, cognitive rehabilitation following stroke, and substance abuse and dependence. Most virtual reality tools are in the early stages of development and are not commercially available. VRGET protocols have been created with the goal of stimulating drug or alcohol craving in patients followed by response prevention and desensitization.
Regular VRGET sessions result in diminished nicotine(Drug information on nicotine) or illicit drug cravings in real-life situations that would be expected to trigger craving. In a small controlled trial, 20 nicotine-dependent adults who were not taking conventional anticraving medications were enrolled in a VRGET protocol.8 The patients were exposed to virtual smoking cues that resulted in increased nicotine craving and physiological indicators of craving, including elevated pulse and respiration rates. Subjects exposed to neutral virtual reality stimuli in the sham arm did not report symptoms of increased nicotine craving.
Other virtual reality environments are being developed to stimulate alcohol or marijuana craving, and future virtual reality tools will be combined with cognitive therapy strategies aimed at response prevention and desensitization to real-life situations that would be expected to stimulate craving or drug-seeking behavior. Future VRGET tools will couple cognitive therapy with increasingly realistic virtual cues to achieve the goal of desensitizing persons who abuse alcohol or drugs to environments that would be expected to stimulate craving or drug-using behavior. A significant emerging virtual reality tool is the "virtual crack house," which is currently under development at the University of Georgia.
