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Considerations for CAM use

Vol. 8, No. 12 / December 2009

I thoroughly enjoyed the article on complementary and alternative medicine (CAM) for depression (“CAM for your depressed patient: 6 recommended options,” Current Psychiatry, October 2009) and have seen patients benefit from these treatments. I wish the authors had included information about the use of valerian root for anxiety, as this is common among some CAM users.

I think our use or discussion of CAM can show our patients we are flexible and will consider various treatments. I believe if you dismiss all CAM treatments as not as effective as prescription medications—which may be true—you will lose patients. We know how popular CAM is with the American public, despite lack of evidence and poor oversight.

In depression treatment, exercise is as effective as sertraline in some studies,1,2 but I would think the high dropout rate for exercise would make sertraline more likely to be effective in the long run. In 1 study, participants received a phone call if they missed an exercise session. This doesn’t mimic real life at all. Also St. John’s wort is administered 300 mg tid, while many antidepressants are once a day. Efficacy aside, we can guess that compliance with a medication taken 3 times a day will be less than 1 taken once daily.

I believe we need to examine our patients’ thoughts about CAM vs traditional treatment. Do they feel CAM is safer because it is natural? Do they feel less stigma if they use CAM? What are their “automatic thoughts” about this?

I disagree with the conclusion that bibliotherapy can’t hurt. Bibliotherapy does have a cost: the cost of the book, the time spent reading it, and minimal benefit. There are people making millions of dollars on self-help books that may be having little, if any, impact on our patients’ lives.

Corey Yilmaz, MD
Southwest Behavioral Health Rural Services
Tolleson, AZ


1. Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Arch Intern Med. 1999;159(19):2349-2356.

2. Babyak M, Blumenthal JA, Herman S, et al. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med. 2000;62(5):633-638.

Dr. Saeed responds

Despite the common belief that valerian root is effective in reducing stress and anxiety, it has not been tested for depressive disorders and is not supported by studies on anxiety disorders. Our paper did not review CAM treatments for anxiety disorders, so we did not point out that a recent Cochrane review1 of valerian for anxiety disorders included only 1 randomized controlled trial2 and found no differences between valerian and placebo.

We also agree that treatment discontinuation is a serious problem, but this is a universal concern for treating many chronic disorders. There is evidence that patient reports of treatment adherence can be unreliable. Research has shown that periodic monitoring,3 even by automated systems, can maintain compliance longer.

We disagree with Dr. Yilmaz’ comments about bibliotherapy. A meta-analysis of 29 bibliotherapy studies found bibliotherapy using cognitive and behavioral techniques superior to wait-list comparison groups.4 We feel there is ample evidence supporting bibliotherapy as a low-risk, low-cost alternative or complementary treatment for mild-to-moderate depressive disorder.

Sy Atezaz Saeed, MD
Department of psychiatric medicine
Brody School of Medicine at
East Carolina University


1. Miyasaka LS, Atallah AN, Soares BG. Valerian for anxiety disorders. Cochrane Database Syst Rev. 2006;(4):CD004515.-

2. Andreatini R, Sartori VA, Seabra ML, et al. Effect of valepotriates (valerian extract) in generalized anxiety disorder: a randomized placebo-controlled pilot study. Phytother Res. 2002;16(7):650-654.

3. Gensichen J, von Korff M, Peitz M, et al. Case management for depression by health care assistants in small primary care practices: a cluster randomized trial. Ann Intern Med. 2009;151(6):369-378.

4. Gregory RJ, Schwer Canning S, Lee TW, et al. Cognitive bibliotherapy for depression: a meta-analysis. Professional Psychology: Research and Practice. 2004;35(3):275-280.

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