Abstracts: Complementary and Integrative Medicine
A Systematic Review of St. John's Wort for Major Depressive Disorder
Syst Rev 2016; 5:148
Background: This systematic review evaluated St. John’s wort (SJW) for the treatment of Major Depressive Disorder (MDD). The objectives of this review are to (1) evaluate the efficacy and safety of SJW in adults with MDD compared with placebo and active comparator and (2) evaluate whether the effects vary by severity of MDD.
Methods: We searched PubMed, CINAHL, PsycINFO, CENTRAL, Embase, AMED, MANTIS, Web of Science, and ICTRP and existing reviews to November 2014. Two independent reviewers screened the citations, abstracted the data, and assessed the risk of bias. We included randomized controlled trials (RCTs) examining the effect of at least a 4-week administration of SJW on depression outcomes against placebo or active comparator in adults with MDD. Risk of bias was assessed using the Cochrane Risk of Bias tool and USPSTF criteria. Quality of evidence (QoE) was assessed using the GRADE approach.
Results: Thirty-five studies examining 6993 patients met inclusion criteria; eight studies evaluated a hypericum extract that combined 0.3% hypericin and 1%−4% hyperforin. The herb SJW was associated with more treatment responders than placebo (relative risk [RR] 1.53; 95% confidence interval [CI] 1.19, 1.97; I2 79%; 18 RCTs; Nc=c2922, moderate QoE; standardized mean differences [SMD] 0.49; CI 0.23, 0.74; 16 RCTs; I2 89%, Nc=c2888, moderate QoE). Compared with antidepressants, SJW participants were less likely to experience adverse events (OR 0.67; CI 0.56, 0.81; 11 RCTs; moderate QoE) with no difference in treatment effectiveness (RR 1.01; CI 0.90, 1.14; 17 RCTs, I2 52%, moderate QoE; SMD −0.03; CI −0.21, 0.15; 14 RCTs; I2 74%; Nc=c2248, moderate QoE) in mild and moderate depression
Conclusions: SJW monotherapy for mild and moderate depression is superior to placebo in improving depression symptoms and not significantly different from antidepressant medication. However, evidence of heterogeneity and a lack of research on severe depression reduce the quality of the evidence. Adverse events reported in RCTs were comparable to placebo and fewer compared with antidepressants. However, assessments were limited due to poor reporting of adverse events and studies were not designed to assess rare events. Consequently, the findings should be interpreted with caution.
© The Author(s). 2016
Inflammation as a Predictive Biomarker for Response to Omega-3 Fatty Acids in Major Depressive Disorder: A Proof-of-Concept Study
Mol Psychiatry 2016; 21:71–79
This study explores whether inflammatory biomarkers act as moderators of clinical response to omega−3 (n-3) fatty acids in subjects with major depressive disorder (MDD). One hundred fifty-five subjects with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) MDD, a baseline 17-item Hamilton Depression Rating Scale (HAM-D-17) score greater than or equal to 15 and baseline biomarker data (interleukin (IL)-1ra, IL-6, high-sensitivity C-reactive protein (hs-CRP), leptin and adiponectin) were randomized between May 18, 2006 and June 30, 2011 to 8 weeks of double-blind treatment with eicosapentaenoic acid (EPA)-enriched n-3 1060cmgcday−1, docosahexaenoic acid (DHA)-enriched n-3 900cmgcday−1 or placebo. Outcomes were determined using mixed model repeated measures analysis for ‘high’ and ‘low’ inflammation groups based on individual and combined biomarkers. Results are presented in terms of standardized treatment effect size (ES) for change in HAM-D-17 from baseline to treatment week 8. Although overall treatment group differences were negligible (ES=−0.13 to+0.04), subjects with any ‘high’ inflammation improved more on EPA than placebo (ES=−0.39) or DHA (ES=−0.60) and less on DHA than placebo (ES=+0.21); furthermore, EPA-placebo separation increased with increasing numbers of markers of high inflammation. Subjects randomized to EPA with ‘high’ IL-1ra or hs-CRP or low adiponectin (‘high’ inflammation) had medium ES decreases in HAM-D-17 scores versus subjects ‘low’ on these biomarkers. Subjects with ‘high’ hs-CRP, IL-6 or leptin were less placebo-responsive than subjects with low levels of these biomarkers (medium to large ES differences). Employing multiple markers of inflammation facilitated identification of a more homogeneous cohort of subjects with MDD responding to EPA versus placebo in our cohort. Studies are needed to replicate and extend this proof-of-concept work.
Reprinted by permission from Macmillan Publishers Ltd: Molecular Psychiatry (21:71–79), copyright 2016.
Meta-Analysis of the Efficacy and Safety of Ginkgo Biloba Extract for the Treatment of Dementia
J Pharm Health Care Sci 2015; 1:14
Background: The benefit of Ginkgo biloba for the treatment of dementia remains controversial. The aim of this study was to evaluate the efficacy and safety of Ginkgo biloba in patients with dementia in whom administration effects were reported using meta-analysis.
Methods: We searched MEDLINE, Embase, the Cochrane databases, and Ichushi for controlled trials of Ginkgo biloba for the treatment dementia. Clinical characteristics and outcomes were extracted. Meta-analysis results were expressed as standard mean differences (SMDs) in scores of the Syndrome Kurztest (SKT), Alzheimer’s Disease Assessment Scale Cognitive Subscale (ADAS-Cog) for cognition efficacy, or odds ratios (ORs) for dropouts and adverse drug reactions.
Results: Thirteen studies using the extract EGb761 met our inclusion criteria, which were duration of 12 to 52 weeks and daily dose of more than 120 mg, and included a total of 2381 patients. Meta-analysis was performed by using 9 of 13 studies, 7 of which used the SKT and 2 ADAS-Cog (dose 120 mg, 26 weeks) scores as efficacy parameters. In meta-analysis of all patients, SMDs (95% confidence interval [CI]) in the change in SKT scores (7 studies) were in favor of Ginkgo biloba over placebo (SMD=−0.90 [−1.46, −0.34]), but 2 studies that used ADAS-Cog did not show a statistically significant difference from placebo for ADAS-Cog (−0.06 [−0.41, 0.30]). For Alzheimer’s disease (AD) and vascular dementia (VaD) subgroups, SMDs [95% CI] in SKT in the combined AD and VaD subgroup (−1.07 [−1.66, −0.47]) and AD subgroup (−1.36 [−2.27, −0.46]) were in favor of Ginkgo biloba over placebo. In terms of daily dose of Ginkgo biloba in the combined AD and VaD subgroup, SMD in SKT score in 240-mg daily dose groups was significantly greater than with placebo (−0.71 [−1.28, −0.14]). Dropout rates for any reason did not differ between two groups, but dropout rates due to side effects were significantly lower in Ginkgo biloba groups compared with placebo groups (OR=1.72 [1.06, 2.80]).
Conclusions: Taking a 240-mg daily dose of Ginkgo biloba extract is effective and safe in the treatment of dementia.
© The Author(s). 2014
How Do Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction Improve Mental Health and Wellbeing? A Systematic Review and Meta-Analysis of Mediation Studies
Clin Psychol Review 2015; 37:1–12.
Given the extensive evidence base for the efficacy of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), researchers have started to explore the mechanisms underlying their therapeutic effects on psychological outcomes, using methods of mediation analysis. No known studies have systematically reviewed and statistically integrated mediation studies in this field. The present study aimed to systematically review mediation studies in the literature on mindfulness-based interventions (MBIs), to identify potential psychological mechanisms underlying MBCT and MBSR's effects on psychological functioning and wellbeing, and evaluate the strength and consistency of evidence for each mechanism. For the identified mechanisms with sufficient evidence, quantitative synthesis using two-stage meta-analytic structural equation modeling (TSSEM) was used to examine whether these mechanisms mediate the impact of MBIs on clinical outcomes. This review identified strong, consistent evidence for cognitive and emotional reactivity, moderate and consistent evidence for mindfulness, rumination, and worry, and preliminary but insufficient evidence for self-compassion and psychological flexibility as mechanisms underlying MBIs. TSSEM demonstrated evidence for mindfulness, rumination and worry as significant mediators of the effects of MBIs on mental health outcomes. Most reviewed mediation studies have several key methodological shortcomings which preclude robust conclusions regarding mediation. However, they provide important groundwork on which future studies could build.
Copyright 2015. Reprinted with permission from Elsevier.
The Neuroscience of Mindfulness Meditation
Nat Rev Neurosci 2015 Apr;16(4):213–225
Research over the past two decades broadly supports the claim that mindfulness meditation — practiced widely for the reduction of stress and promotion of health — exerts beneficial effects on physical and mental health, and cognitive performance. Recent neuroimaging studies have begun to uncover the brain areas and networks that mediate these positive effects. However, the underlying neural mechanisms remain unclear, and it is apparent that more methodologically rigorous studies are required if we are to gain a full understanding of the neuronal and molecular bases of the changes in the brain that accompany mindfulness meditation.
Reprinted by permission from Macmillan Publishers Ltd: Nature Reviews Neuroscience 16(4):213–225, copyright 2015.
Complementary and Alternative Medicine Therapies for Perinatal Depression
Best Pract Res Clin Obstet Gynaecol 2014; 28(1):85–95
Complementary and alternative medicine therapies are increasingly sought out by people with psychiatric disorders. In this chapter, we review the evidence for several commonly used CAM therapies (i.e. omega−3 fatty acids, folate, S-adenosyl-methionine, St John's Wort, bright light therapy, exercise, massage, and acupuncture) in the treatment of perinatal depression. A number of these treatments may be reasonable to consider for women during pregnancy or postpartum, but the safety and efficacy of these relative to standard treatments must still be systematically determined. Evidence-based use of complementary and alternative medicine therapies treatments for perinatal depression is discussed. Adequately powered systematic studies are necessary to determine the role of complementary and alternative medicine therapies in the treatment of perinatal depression.
Copyright 2014. Reprinted with permission from Elsevier.
The Use of Complementary and Alternative Medicine in Adults With Depressive Disorders: A Critical Integrative Review
J Affect Disord 2015; 197:101–113
Background: Depression has been identified as one of the most frequent indications for CAM use and is a strong predictor of CAM use. The present article provides a critical review of CAM use for depressive disorders including bipolar depression by addressing prevalence of CAM use and CAM users׳ characteristics, motivation, decision-making and communication with healthcare providers.
Methods: A comprehensive search of 2003–2014 international literature in the Medline, CINAHL, AMED, and SCOPUS databases was conducted. The search was confined to peer-reviewed articles published in English with abstracts and reporting new empirical research findings regarding CAM use and depressive disorders.
Results: A considerable level of CAM use was observed among both general and clinical populations of people suffering from depressive disorders, many of whom use CAM concurrently with their conventional medicine. In particular, high rates of CAM use were found among those with bipolar disorder, an illness known to cause substantial impairments in health-related quality of life. Concomitant prescription medication use ranged from 0.52% to as high as 100%.
Limitations: Study design such as the inclusion of bipolar and depression in the same diagnostic category hamper the differentiation and attribution of CAM usage for symptoms.
Conclusion: Findings of our review show that enduring impairments in function and persistence of symptoms (as reflected by increased CAM use proportional to severity of illness and comorbidity) are the impetus for sufferers of depressive illness to seek out CAM. The psychosocial factors associated with CAM use in depressive illnesses and severe mental illness are yet to be established. Subsequent research among those with depressive disorders would be informative in clarifying the range of motivations associated with mental illness.
Copyright 2015. Reprinted with permission from Elsevier.
Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States
Mayo Clinic Proceedings 2016; 91(9):1292–1306
Although most pain is acute and resolves within a few days or weeks, millions of Americans have persistent or recurring pain that may become chronic and debilitating. Medications may provide only partial relief from this chronic pain and can be associated with unwanted effects. As a result, many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches—acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga—as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.
Copyright 2016. Reprinted with permission from Mayo Foundation for Medical Education and Research.
