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interviews
Complementary Therapies

Jacques Bradwejn, MD, FRCPC
Chairman of the Department of Psychiatry
Psychiatrist-in-Chief Royal
Ottawa Hospital

q How did you become interested in complementary therapies and their potential use in psychiatry?

a It's a long story. During residency I was very interested in what one might call explanatory models of the functioning of the mind. Many of these explanatory models - original ones could be found in non-Western systems of psychiatry and psychology such as in Eastern systems, which have Zen, Hinduism, yoga, where they have systems of mind and explanations of how the mind should function, and how health is maintained and how illness comes about. So it's purely on the psychological models of mind. That was during residency. And then I just kept it as a personal interest during my psychiatry career, which I spent many years doing what could be called hard science (i.e.. science done in a very classical and orthodox way, doing hypothesis research, using the very structured ways of doing research here in the West). And then doing this kind of research, I came upon a finding, on the neurobiology of the brain, so really what could be the biological underpinnings of some illnesses, psychiatric illnesses, such as panic disorder. And just to cut it short, about 15 years ago I discovered a brain protein called CCK which can induce panic attacks in patients who suffer from panic disorder; also in healthy volunteers. A few years ago I noticed a publication from the National Institute of Mental Health in Washington which described the effect of different herbal compounds used in Eastern systems of medicine on brain systems. So basically what they looked at is what effects these herbal compounds had on some of the neurotransmitter systems in the brain. And some of these herbal compounds would act on the CCK system which is a system found to have a role to play in panic attacks and panic disorder. So that is where I started, it led me to look at these herbal compounds from alternative medicine and to do research in complementary and alternative medicine.
   
q Was there a specific type of herbal compound you were interested in?

a There were 4 of them, and we focused on one in particular because it was easier to do research with this compound than the other ones, and the one we focused on is called Centella asiatica also known under the name of (gotucloa) So we looked at the effect of this compound on the stress response and anxiety. So my interest in explanatory models of the mind from way back plus the concrete finding that these herbal compounds had an effect on this brain peptide is what led me to do research in alternative medicine.
   
q So can you describe your research and perhaps what your findings have been with this compound, among others?

a The idea was then to take some treatments from alternative medicine and bring science to it - use the scientific method that has been used in Western systems - and test this idea from alternative medicine. So we've brought research techniques to looking at the effect of Centella asiatica to see what kind of activity it might have in a structured scientific way. So the first step was to look at its effect on animal behavior in rats. And the study was done in collaboration with Dr Franco Vaccarino and by a research fellow who was working with us, Dr Yueping Zhou, and this project was to look at the effects of Centella asiatica on models of stress or anxiety in rats. And it showed some effect on the stress response in rats. The next step was to do research on a model of stress and anxiety in healthy volunteers (that is people who had never had a mental illness) and test what Centella asiatica would do to the stress response in these people. We did this in a structured scientific way so we used a double-blind design, and our results showed that Centella asiatica does have an effect on the stress response - a stress-reducing effect. So now the third step was the carry out a study in patients suffering from anxiety, and we are now planning for this now.
   
q Would you be able to equate the sedating effects in this particular compound to some comparable effect from a benzodiazepine?

a No. Not at this point, we can't call it at this point a "sedative" effect, but we know that it does act on the biological stress system in animals and in healthy volunteers. So therefore it has a good potential for study in patients.
   
q Are you using it in practice yet or is it still under clinical investigation?
a It is under clinical investigation.
   
q Do you use any other herbal compounds in your clinical practice in any type of mood disorder?

a It's not only using herbal compounds, it's dealing with the issue of integration of alternative systems of medicine and treatment in clinical practice.
   
q And how do you integrate these alternative and mainstream medicine therapies?

a It's really a whole process, and I think it has to be built into the relationship with the patient. First, I think it would be very useful for most physicians to learn about these systems of medicine or at least be informed about these systems of medicine because not only could [alternative] treatments be useful in themselves, but what is also very useful to know about are the explanatory models; the reasons given as to why these treatments should work; the reasons given on what is wrong with a particular patient; the explanations of illness and well being that these systems offer. And I think the first step is to try to be as well informed as possible (not become an expert because it's impossible to be an expert in everything) but at least become well informed so that there could be some possibility of integration with evidence-based medicine that are our present systems of medicine. So that's the first, very important step. And knowing enough about these systems then also enables the practitioner to establish a dialogue with patients because statistics would show us that in Canada and in the US. at least 25 to 30% of patients looking for psychiatric care also use treatments that are derived from alternative systems of medicine. So it's important to be at least informed enough to be on the same wave length as the patient and to even be able to counsel and advise these patients on the use of these systems of medicine and at least also integrate them [with mainstream medicine].
   
q Do these explanatory models say for example in a certain philosophy specify a biological etiology or is it a philosophical orientation that's helping patients understand their mood disorder?

a They have explanatory models and these explanatory models also will incorporate systems of evaluation a bit like the diagnostic systems we use, and then propose treatment. But in the treatment that they propose, they often also propose fairly well defined changes in lifestyle.
   
q Could you be specific? For example what kinds of changes in lifestyle?
a For example, they will propose changes in one's diet (and very specific changes in the diet to make it healthier and also more adapted to one's body type or one's emotional type. They would propose changes in life pattern, life habits, life rhythms, as well as methods of exercise that may be suitable for a particular individual. And they also propose mind practices such as meditation or various types of concentration methods. And then, they will propose specific treatments, whether it be treatment based on herbology or based on techniques of acupuncture or massage, and so on. So it's quite important as a psychiatrist to know of these systems and that when patients are interested in them, to make sure that these systems are based on essential changes in lifestyle and at least advise on the incorporation of these lifestyle changes in the overall psychiatric treatment, and make sure it doesn't clash [with mainstream treatment but rather] be coordinated to enhance success.
   
q While the patients may be very open to these different practices, what about your colleagues? Do you run into resistance from people who can't really believe that they are all that useful in treating psychiatric illness?

a Yes of course, many of my colleagues don't believe they are useful and also regulatory bodies at this point, I'm not sure where they stand in terms of approving the use of these techniques but we are not really at that step. What I'm saying is that my colleagues should or could learn about these systems because a lot of them don't even know they exist and they don't know what they are all about. Even before they might say they show efficacy or not, just having information and being informed about these systems will enhance their way of treatment and their relationship with their patient.
   
q So you're saying that patients are going to ask about these alternative therapies anyway, so it's up to the physician to be well informed about them so that at least they can inform patients accurately about their efficacy?

a That's right but even before they deal with the issue of efficacy, it's just being informed about that their patient might already be using and they're not telling them because they may not feel there is enough openness to discuss it. So simply being informed about these [alternative therapies], having an idea about the explanatory model and having an idea of the treatments which are prescribed I think could be very useful with patients in terms of discussing whether or not patients are using them already, or if they have a strong intention to use them and to see if they can't propose any integration with evidence-based techniques.
   
q Have you found that if you are open and understand what the patient would rather do other than follow mainstream medicine treatment, have you found that to be particularly helpful in the clinical setting of anxiety or depression?

a Yes extremely useful. Because then, patients feel that they are coming to a specialist who can inform them about evidence-based (mainstream) medicine and who can thus inform them about treatments that have been shown to work in clinical trials but they are also open and informed about alternative and complementary medicine and they are willing to discuss all approaches.
   
q So you're not saying that you don't use mainstream medicine but rather that you may be able to convince patients more successfully that these treatments could be more useful for them in addition to perhaps alternative practices which they prefer to follow?

a I do use mainstream medicine because that is what I'm trained for. But I also try to be as informed as possible so I can put all treatment approaches in context and also explanatory models in context.
   
q Why do you think there has been a relatively recent but growing interest on the part of patients to use alternative medicines and in particular botanicals for depression? (St. John's Wort for example.) Have you a sense of why patients are so keen on not just taking traditional antidepressant medication but would rather try a herbal product instead?

a There are many different reasons. One of them is that there are myths about herbal compounds. For example, the notion that "natural" is better for me. So that has always been a driving force. I say it's a myth, because there is often a misunderstanding about what the herb is. A plant extract will work because there is a pharmacological compound - it comes from nature but there's a pharmacological compound in the product that gives the activity. In mainstream medicine, a good percentage of the medicines we have now have been developed from herbal compounds way back, even from the beginning of the century. So that mainstream medicine in a way is using some compounds derived from plants. So patients are not often acquainted with this knowledge. There's also the notion that if it's from nature, it must be better and they do not understand that it could also be toxic if it comes from nature -- Arsenic is natural. So it's that notion, it's a plant, it's natural therefore it's better for me, it's a misconception. But often a very driving force behind wanting to use natural compounds.
   
q So do you try and dissuade patients from using these compounds?

a No I put it into perspective and into context so that they understand better. There is the effect of stigma. Sometimes the mainstream approach (doing a diagnosis, saying you have depression, and that therefore you need to take an antidepressant) could add to the stigma of mental illness. Sometimes patients prefer to hear that they have a disturbance of their energy balance and that nature can take care of it, if they just do this type of exercise or they take a few plants, so they don't feel so stigmatized by the notion of mental illness. They may also sometimes be in denial that they have mental illness. And they find an explanatory model about their depression and anxiety that is offered by a system of alternative medicine more attractive than mainstream psychiatry. So they might identify more with it, or agree more with it, it might be more user-friendly to be told that there is an imbalance of energy or of Chi or of a certain way that their body energy is being managed which leads to fatigue and depression rather than hear about neurotransmitter, for example. And at the point at which we are now, the neurotransmitter hypothesis (even though there's a lot of science behind it) is also an explanatory model and in 20 years, that explanatory model will change drastically so there's a bit of arbitrariness to the neurotransmitter hypothesis right now.
   
q So if a physician is interested in finding out more about these explanatory systems or models, is there any one reference book that you've found particularly helpful as an overview, perhaps as a place to begin?
a Well, before that, there is another factor which I feel is very important [in terms of explaining why patients seek out alternative medicine] and that is the relationship between practitioners and patients. In our present system of healthcare, mainstream clinicians (psychological as well) are often overworked, and burdened and often don't have that much time to spend with patients. So sometimes the quality of the relationship is hurt by that, and it sometimes it also gets dehumanized. Therefore patients sometimes who are looking for a better relationship or re-establishment of a previously good relationship often find it with practitioners of alternative medicine who have more time, and who are often paid for services directly and therefore relate better, and who are able to better sustain the human aspect of the relationship - and that is a big driving force as well for this system of alternative medicine.
   
q Yes, I've often heard that homeopathic medicine is perhaps successful because of the length and nature of the therapeutic alliance.

a Yes, they can spend two hours on the first interview, and that's very important.
   
q So getting back to the reference for physicians who may be interested in finding out more about this on their own.

a There is an Encyclopedia of Alternative Medicine but I don't have the specifics. I think what's most important is that they learn about the explanatory models,3 because going to the specifics [is difficult]. At least, [they should learn to] counsel patients not to use these [alternative] treatments out of context. Very often, especially with herbal compounds, patients go to the drug store, grab something and use it themselves. They might not actually be doing themselves a good service, for several reasons. First, they may be denying themselves an efficacious treatment from mainstream medicine and they should know about it and at least weigh the pros and cons of using a mainstream, proven treatment versus a herbal treatment that may not have shown proven efficacy as yet. That's one point. The other point is that they often use [herbal treatments] out of context of the alternative medicine model. And they might therefore not maximize their chances to get a good use out of it and even harm themselves. Ginseng is known as a herbal- derived medicine that can help energy. So some patients say "It could help when I have low energy, or when I'm tired or depressed." And they might say "I'm going to use ginseng to help with my depressed symptoms or my depressed feelings." So they feel that it's an energy-activating type of plant: "I have no energy, I'm going to use it." However, when they just use it on its own and don't take into account the explanatory model and have a proper evaluation by a practitioner of Chinese medicine, they basically get either no effect from the medicine or they may harm themselves. Why? Because if they have some symptoms of depression, Chinese medicine would say that symptoms may be due to their energy being too low or their energy being too high (so in a way it's stuck in one organ so energy doesn't flow properly) So after an evaluation, and the disturbance of energy they have is identified, they would recommend a mixture or herbs or acupuncture which could either enhance or decrease energy. But if a patient runs to the store and takes ginseng because they have low energy, it might do the opposite of what they need. They may also not be able to nuance the different types of ginseng, some decrease energy , the others increase it, so if you are going to go with a system of alternative medicine, you might as well go with the whole process of evaluation and recommendation by a practitioner.
   
q Of course, there is the whole issue of quality controls in our herbal products isn't there.


a Yes that's the whole issue of standardization.
   
q Anything else you would like to add, Dr Bradwejn for your colleagues who may be interested in this area?

a Well there is the whole issue of integration. My approach will favor any evidence-based approach, therefore mainstream medications or psychological techniques would be my preferred recommendations. I try to have a dialogue and a process of eventually deciding on a medication by supporting an informed choice from patients and take it from there.
   
   


Over one million Canadians suffer from some form of depressive illness.