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.

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

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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.

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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.

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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.

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Bibliotherapy

Investigation of bibliotherapy for treatment of anxiety disorders has been limited (Table 3).^18-20 A 2009 RCT demonstrated that for 21 patients with mild-to-moderate social phobia, bibliotherapy—in the form of an 8-week self-directed CBT program with minimal therapist involvement—was superior to a wait-list control and induced clinically significant change in approximately one-third of patients.²⁰

Rapee et al randomly assigned 267 children age 6 to 12 with anxiety disorders to bibliotherapy that consisted of parents treating their children in the home with written materials, 9 sessions of GCBT, or a wait-list control condition.¹⁹ Bibliotherapy provided by parents demonstrated benefit compared with wait-listing but was not as efficacious as GCBT at post-treatment and 3-month follow-up.

Clinical Point

Preliminary evidence supports bibliotherapy for social anxiety disorder, childhood anxiety disorders, and panic disorder

Lidren and colleagues randomly assigned 36 adult patients with panic disorder to bibliotherapy, group therapy combined with bibliotherapy, or a waitlist.¹⁸ Both treatments were more effective than wait-listing in reducing the frequency of panic attacks, severity of physical panic symptoms, catastrophic cognitions, agoraphobic avoidance, and depression. Both interventions maintained their effects at 3-and 6-month follow-up and produced clinically significant change in most patients.

Conclusion. Some preliminary evidence supports the effectiveness of bibliotherapy for social anxiety disorder, childhood anxiety disorders, and panic disorder.

Table 3

Preliminary evidence supports bibliotherapy for select anxiety disorders

Study	Design	Results
Lidren et al, 1994¹⁸	36 adults with panic disorder randomly assigned to bibliotherapy, bibliotherapy plus group therapy, or wait-list control	Both bibliotherapy and bibliotherapy plus group therapy were more effective than wait-listing in reducing the frequency of panic attacks and severity of physical panic symptoms
Rapee et al, 2006¹⁹	267 children with anxiety disorders randomly assigned to bibliotherapy (parents treating their children in the home with written materials with no therapist contact), 9 sessions of group CBT, or wait-list control	Parent-delivered bibliotherapy was beneficial compared with wait-listing but was not as efficacious as group CBT
Abramowitz et al, 2009²⁰	21 patients with mild-to-moderate social phobia underwent an 8-week self-directed CBT program with minimal therapist involvement	Bibliotherapy was superior to wait-listing. One-third of patients experienced clinically significant change
CBT: cognitive-behavioral therapy

Dietary supplements

Many dietary and herbal supplements are purported to have therapeutic efficacy for anxiety symptoms. Because of inadequate FDA regulation of manufacturing and marketing of these agents, most of these supplements have not been tested on patients with anxiety disorders.²¹ Limited evidence supports the use of kava for GAD and inositol for panic disorder (Table 4).^22-28

Clinical Point

Multiple RCTs show kava is effective for treating anxiety but case reports of liver toxicity warrant concern

Kava. Multiple double-blind RCTs found kava (Piper methysticum)—a plant indigenous to South Pacific islands—has effects greater than placebo and comparable to standard treatments for mild to moderately severe GAD. A Cochrane meta-analysis²² of 11 trials with 645 participants concluded that kava is effective for reducing GAD symptoms, with risks comparable to standard treatments for up to 6 months of use.

Case reports of kava-associated liver toxicity led to a marketing ban in Canada in 2000, followed shortly by Germany, Australia, and the United Kingdom. In 2002 the FDA issued a Consumer Advisory²⁹ discouraging kava use. Since then a flurry of research has looked for sources of possible toxicity, including individual sensitivities,²⁹ excessive dosing, use of toxic parts of the kava plant instead of the roots,^30,31 interactions with other hepatoactive substances, and non-water based extraction methods. RCTs demonstrating kava’s efficacy and safety were characterized by careful dosing supervision, use of standardized kava extracts, and avoidance of interactions with other hepatoactive medications or CAM treatments. Doses ≤300 mg/d are recommended.²²

RCTs that used the standardized acetone extract WS1490²³ found that women and younger adults show more positive effects from kava, and showed no liver toxicity when used for 1 to 24 weeks. A recent RCT that used kava extracts obtained via water-based methods showed kava had significant anxiolytic effects.²⁴ However, a study of liver toxicity reports found that water-based extractions, acetonic extractions, and ethanol extractions all have been associated with toxic hepatic reactions.³² Aqueous extraction does not guarantee safety, and the extraction solvent does not cause toxicity. A recent report of a severe liver reaction to the native drink by a tourist in Samoa³³ suggests that aqueous extractions from the root stock— the type of kava used by South Pacific islanders—also can be unsafe.

Conclusion. Multiple RCTs have found kava relatively safe and effective for treating anxiety symptoms. Caution is necessary, however, because of reports of liver toxicity associated with its use. Physician oversight and monitoring of kava use are appropriate.