Evidence-Based Reviews

CAM for your anxious patient: What the evidence says

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Dr. Antonacci discusses when CAM might be appropriate for your patient with anxiety

The number of people with psychiatric disorders who use complementary and alternative medicine (CAM) is on the rise. In surveys of patients seeking psychiatric care, estimates of CAM use range from 8% to 57%; the most frequent uses are for depression and anxiety disorders. A population-based study in the United States found that 9% of respondents had anxiety attacks and 57% of these individuals had used CAM.1 Similarly, in a Finnish population-based study (N=5,987) 35% of subjects reported some form of CAM use in the previous year; those with comorbid anxiety and depressive disorders used CAM most frequently.2

Unfortunately, a MEDLINE search shows that the number of studies examining psychotropic medications dwarfs the number of studies on even the most common CAM treatments used for psychiatric disorders. Far more patients with diagnosed mental disorders are studied in trials of standard treatments than CAM treatments. Because very few studies evaluate the cost-effectiveness of CAM treatments for psychiatric disorders, the risk-to-benefit ratio is difficult to calculate. Although several CAM treatments for depressive disorders have enough support to be considered options,3 CAM options for anxiety disorders are fewer and have less evidence of efficacy.

For these reasons, it is hard to recommend any CAM treatment as first line. Despite the relative lack of high quality research on CAM treatment outcomes, high rates of CAM use make it critical for clinicians to understand what treatments are available—or at least which treatments should be favored if patients are intent on trying them. We review the current research for yoga, exercise, bibliotherapy, and the dietary supplements kava and inositol for treating anxiety disorders and suggest those that warrant consideration for patients who do not respond, respond partially, or suffer from side effects from selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines.

Limitations of CAM research

There are several limitations to the research literature on CAM approaches for anxiety disorders.4 First, there is a wide diversity of practices considered alternative or complementary and various ways in which these methods are applied across cultures. Some authors consider complementary medicines to be only herbal remedies, whereas others include individual therapies such as acupuncture, aromatherapy, herbal therapy, homeopathy, iridology, naturopathy, and reflexology.5 This article defines “alternative” treatments as those other than a form of psychotherapy or an FDA-approved medication that substitute for standard psychiatric treatment, and “complementary” approaches as those used to augment standard psychiatric treatments.

Anxiety and stress are ubiquitous, perhaps motivating interest in CAM options and prompting research on heterogeneous groups of individuals with poorly defined clinical syndromes or with isolated symptoms of anxiety or subjective distress. Few studies examine well-defined patient groups with diagnosed anxiety disorders. There are also multiple research design problems, including poorly specified treatments, poorly chosen placebos, and interpreting nonsignificant differences from established treatments as equivalence in underpowered studies.

The CAM treatments reviewed in this article have ≥2 randomized controlled trials (RCTs) that support their use for patients with diagnosed anxiety disorders, and ≥1 study that shows that the treatment can induce remission.

Yoga

In 2005 Kirkwood et al carried out the first systematic review of research evidence for the effectiveness of yoga in anxiety treatment.6 Of 19 studies identified, 4 RCTs and 1 nonrandomized trial met their inclusion criteria, which were an anxiety disorder diagnosis, use of yoga or yoga-based exercises alone, and anxiety rating scales used as outcome measures. Most found significant improvement in anxiety symptoms with yoga compared with placebo. Details of the 5 trials evaluated in Kirkwood’s review are summarized in Table 1.7-11

Since the 2005 review, 3 additional studies of yoga and anxiety have been published, but none would meet Kirkwood’s inclusion criteria. One that evaluated a heterogeneous group of patients using an intervention with multiple components—only 1 of which was yoga—found the intervention significantly reduced anxiety scores.12 A second study comparing yoga with relaxation in 131 patients with mild-to-moderate stress but no anxiety disorder diagnosis showed yoga was as effective as relaxation in improving anxiety symptoms as measured by the anxiety subscale of the State Trait Personality Inventory.13 In a study of 183 nonrandomized survivors of the 2004 southeast Asia tsunami with posttraumatic stress disorder (PTSD) symptoms, yoga-based breathing either alone or paired with trauma reduction exposure techniques significantly reduced PTSD symptoms compared with wait-list controls.14

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