Evidence-Based Reviews

CAM for your anxious patient: What the evidence says

Current Psychiatry. 2010 October;9(10):43-52

References

1. 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(2):289-294.

2. Wahlström M, Sihvo S, Haukkala A, et al. Use of mental health services and complementary and alternative medicine in persons with common mental disorders. Acta Psychiatr Scand. 2008;118(1):73-80.

3. Saeed SA, Bloch RM, Antonacci DJ, et al. CAM for your depressed patient: 6 recommended options. Current Psychiatry. 2009;8(10):39-47.

4. Pilkington K. Searching for CAM evidence: an evaluation of therapy-specific search strategies. J Altern Complement Med. 2007;13(4):451-459.

5. van der Watt G, Laugharne J, Janca A. Complementary and alternative medicine in the treatment of anxiety and depression. Curr Opin Psychiatry. 2008;21(1):37-42.

6. Kirkwood G, Rampes H, Tuffrey V, et al. Yoga for anxiety: a systematic review of the research evidence. Br J Sports Med. 2005;39(12):884-891.

7. Vahia NS, Doongaji DR, Jeste DV, et al. Psychophysiologic therapy based on the concepts of Patanjali. A new approach to the treatment of neurotic and psychosomatic disorders. Am J Psychother. 1973;27(4):557-565.

8. Vahia NS, Doongaji DR, Jeste DV, et al. Further experience with the therapy based upon concepts of Patanjali in the treatment of psychiatric disorders. Indian J Psychiatry. 1973;15(1):32-37.

9. Sahasi G, Mohan D, Kacker C. Effectiveness of yogic techniques in the management of anxiety. J Pers Clin Stud. 1989;5(1):51-55.

10. Sharma I, Azmi SA, Settiwar RM. Evaluation of the effect of pranayama in anxiety state. Alternative Medicine. 1991;3:227-235.

11. Shannahoff-Khalsa DS, Ray LE, Levine S, et al. Randomized controlled trial of yogic meditation techniques for patients with obsessive-compulsive disorder. CNS Spectr. 1999;4(12):34-47.

12. Gupta N, Khera S, Vempati RP, et al. Effect of yoga based lifestyle intervention on state and trait anxiety. Indian J Physiol Pharmacol. 2006;50(1):41-47.

13. Smith C, Hancock H, Blake-Mortimer J, et al. A randomised comparative trial of yoga and relaxation to reduce stress and anxiety. Complement Ther Med. 2007;15(2):77-83.

14. Descilo T, Vedamurtachar A, Gerbarg PL, et al. Effects of a yoga breath intervention alone and in combination with an exposure therapy for post-traumatic stress disorder and depression in survivors of the 2004 South-East Asia tsunami. Acta Psychiatr Scand. 2010;121(4):289-300.

15. Broocks A, Bandelow B, Pekrun G, et al. Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder. Am J Psychiatry. 1998;155(5):603-609.

16. Merom D, Phongsavan P, Wagner R, et al. Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders—a pilot group randomized trial. J Anxiety Disord. 2008;22(6):959-968.

17. Abrantes AM, Strong DR, Cohn A, et al. Acute changes in obsessions and compulsions following moderate-intensity aerobic exercise among patients with obsessive-compulsive disorder. J Anxiety Disord. 2009;23(7):923-927.

18. Lidren DM, Watkins PL, Gould RA, et al. A comparison of bibliotherapy and group therapy in the treatment of panic disorder. J Consult Clin Psychol. 1994;62(4):865-869.

19. Rapee RM, Abbott MJ, Lyneham HJ. Bibliotherapy for children with anxiety disorders using written materials for parents: a randomized controlled trial. J Consult Clin Psychol. 2006;74(3):436-444.

20. Abramowitz JS, Moore EL, Braddock AE, et al. Self-help cognitive-behavioral therapy with minimal therapist contact for social phobia: a controlled trial. J Behav Ther Exp Psychiatry. 2009;40(1):98-105.

21. Saeed SA, Bloch RM, Antonacci DJ. Herbal and dietary supplements for treatment of anxiety disorders. Am Fam Physician. 2007;76(4):549-556.

22. Pittler MH, Ernst E. Kava extract for treating anxiety. Cochrane Database Syst Rev. 2003;(1):CD003383.-

23. Witte S, Loew D, Gaus W. Meta-analysis of the efficacy of the acetonic kava-kava extract WS1490 in patients with non-psychotic anxiety disorders. Phytother Res. 2005;19(3):183-188.

24. Sarris J, Kavanagh DJ, Byrne G, et al. The Kava Anxiety Depression Spectrum Study (KADSS): a randomized, placebo-controlled crossover trial using an aqueous extract of piper methysticum. Psychopharmacology (Berl). 2009;205:399-407.

25. Benjamin J, Levine J, Fux M, et al. Double-blind, placebo-controlled, crossover trial of inositol treatment for panic disorder. Am J Psychiatry. 1995;152(7):1084-1086.

26. Fux M, Levine J, Aviv A, et al. Inositol treatment of obsessive-compulsive disorder. Am J Psychiatry. 1996;153(9):1219-1221.

27. Fux M, Benjamin J, Belmaker RH. Inositol versus placebo augmentation of serotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder: a double-blind cross-over study. Int J Neuropsychopharmcol. 1999;2(3):193-195.

28. Palatnik A, Frolov K, Fux M, et al. Double-blind, controlled, crossover trial of inositol versus fluvoxamine for the treatment of panic disorder. J Clin Psychopharmacol. 2001;21(3):335-339.

29. US Food and Drug Administration. Consumer advisory: kava-containing dietary supplements may be associated with severe injury. Available at: http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm085482.htm. Accessed August 25, 2010.

30. Dragull K, Yoshida WY, Tang CS. Piperidine alkaloids from piper methysticum. Phytochemistry. 2003;63(2):193-198.

31. Simkins A, Thurston D, Colyar M, et al. Nature’s wrath? A closer look at complications with five popular herbs. Adv Nurse Pract. 2005;13(6):55-56.

32. Teschke R, Genthner A, Wolff A. Kava hepatotoxicity: comparison of aqueous, ethanolic, acetonic kava extracts and kava-herbs mixtures. J Ethnopharmacol. 2009;123(3):378-384.

33. Christl SU, Seifert A, Seeler D. Toxic hepatitis after consumption of traditional kava preparation. J Travel Med. 2009;16(1):55-56.

Conclusion. Few controlled studies evaluated yoga for anxiety disorders, and all have significant methodologic limitations and/or poor methodology reporting. The diagnostic conditions treated and both yoga interventions and control conditions varied. However, these limited results are encouraging, particularly for treatment of obsessive-compulsive disorder (OCD). There is little information regarding safety or contraindications of yoga. Reported attrition rates were high in most studies, which may raise concerns about patient motivation and compliance.

Table 1

Evidence on the effectiveness of yoga for anxiety disorders

Study	Design	Results
Vahia et al, 1973⁷	36 patients with psychoneurosis randomly assigned to yoga (N=15) or a control intervention of relaxation, postures, breathing, and writing (N=12)	Significant difference between groups in TAS scores after but not before treatment. Reduction in mean TAS score for yoga group but not control group
Vahia et al,1973⁸	39 patients received 6 weeks of yoga (N=21) or medication (amitriptyline and chlordiazepoxide on a variable dosage schedule) (N=18)	Yoga showed significantly greater reductions in TAS in this non-randomized sample
Sahasi et al, 1989⁹	91 patients randomly assigned to yoga practiced daily for 40 minutes (N=38) or diazepam at unspecified frequency or doses (N=53) for 3 months	Mean reduction in IPAT with yoga (3.39, P < .05) vs control group (0.36, P > .05). Attrition rate was 21.1% in yoga group and 66% in controls
Sharma et al, 1991¹⁰	71 patients with anxiety neurosis randomly assigned to 1-week yoga training, then daily practice (N=41) or control (N=30, placebo capsule)	HAM-A measured at 3 weekly intervals for 12 weeks. Significant between group mean difference at 3 weeks (greater improvement in yoga group compared with controls). Significant improvement in yoga group between 3 and 6 weeks but not for controls
Shannahoff-Khalsa et al, 1999¹¹	21 OCD patients randomly assigned to kundalini yoga (N=11) or relaxation and mindfulness meditation (N=10). Multiple outcome measures; Y-BOCS was primary	Seven in each group completed 3 months; patients who practiced yoga demonstrated greater improvements on Y-BOCS. Intent-to-treat analysis (Y-BOCS) for the baseline and 3-month tests showed that only the yoga group improved. Groups were merged for an additional year of yoga; at 15 months, the final group (N=11) improved 71% on the Y-BOCS
HAM-A: Hamilton Anxiety Rating scale; IPAT: Institute for Personality and Ability Testing, Anxiety Scale; OCD: obsessive-compulsive disorder; TAS: Taylor’s Anxiety Scale; Y-BOCS: Yale-Brown Obsessive Compulsive Scale

Exercise

The literature examining the relationship between exercise and depression is extensive, but much less has been published about exercise in patients with anxiety disorders (Table 2).^15-17 In a 10-week trial, Broocks and colleagues compared clomipramine, exercise (running), and placebo in 46 outpatients with panic disorder.¹⁵ Both exercise and clomipramine, 112.5 mg/d, significantly reduced panic symptoms compared with placebo, but clomipramine was more effective and faster-acting.

A more recent RCT compared group cognitive-behavioral therapy (GCBT) plus a home-based walking program vs GCBT and in 21 patients with panic disorder, generalized anxiety disorder (GAD), or social phobia.¹⁶ Compared with GCBT plus educational sessions, GCBT plus walking had a significant effect on self-reported depression, anxiety, and stress. Results differed by diagnosis; the most marked effects occurred in individuals with social phobia, whereas benefits for those with panic disorder or GAD were questionable.

Clinical Point

Results from small trials suggest exercise may help improve anxiety symptoms

Fifteen patients with OCD were recruited to participate in a 12-week, moderate-intensity aerobic exercise program added to their standard behavioral and/or pharmacologic treatment.¹⁷ Subjects demonstrated improvement in negative mood, anxiety, obsessions, and compulsions after each exercise session. Changes after each session persisted over the 12-week intervention, although the magnitude attenuated over the duration of the intervention.

Conclusion. Although initial results from small trials suggest exercise may help improve anxiety symptoms, further studies are needed to determine how to best use exercise training to treat anxious patients, specifically regarding dose-response relationship, differences in effectiveness between aerobic and resistance training, and the mechanisms by which exercise improves psychiatric symptoms.

Table 2

Exercise for anxiety: More research is needed

Study	Design	Results
Broocks et al, 1999¹⁵	46 patients with panic disorder randomly assigned to 10 weeks of running, clomipramine, or wplacebo pills	Both exercise and clomipramine resulted in significant decreases in symptoms but clomipramine improved symptoms earlier and more effectively
Merom et al, 2008¹⁶	21 patients with panic disorder, GAD, or social phobia randomly assigned to GCBT and either a home-based walking program or educational sessions	GCBT plus walking had a significant effect on depression, anxiety, and stress compared with GCBT plus educational sessions
Abrantes et al, 2009¹⁷	15 patients with OCD assigned to a 12-week exercise intervention that was added to their standard behavioral and/or pharmacologic treatment	Subjects reported improved mood, anxiety, obsessions, and compulsions after each exercise session
GAD: generalized anxiety disorder; GCBT: group cognitive-behavioral therapy