Use of alternative remedies by psychiatric patients: illustrative vignettes and a discussion of the issues.

Abstract

This clinical conference, in the form of several vignettes, focuses on the increasing importance for clinicians to actively attend to their patients’ uses of herbal “alternative” or “complementary” therapies. First, the prevalence of alternative therapy use is remarkably high. According to data from a national follow-up survey (1), in 1997 the probability of visiting an alternative practitioner was 46.3%, up from the initial 1990 survey figure of 33.8%, and the total number of visits to alternative therapy practitioners increased from 427 million in 1990 to 629 million in 1997, representing primarily an increase in the numbers of individuals visiting alternative practitioners, not an increase in the number of visits per person. In 1997 the amount of out-of-pocket money spent for alternative medicine professional services and herbal products was conservatively estimated to be $27 billion, comparable with the projected 1997 out-of-pocket expenditures for all U.S. physician services; this represents an increase in expenditures of 45.2% between 1990 and 1997. Second, of particular concern to psychiatrists and other mental health professionals, fatigue, headaches, insomnia, depression, and anxiety are among the most common reasons cited for seeking treatment from alternative practitioners (1, 2). These patients often seek treatment from psychiatrists while still taking, and often still believing in, their alternative remedies. Finally, we are witnessing an explosive marketing push for the development of new “nutraceuticals” or “pharmafoods,” i.e., purportedly therapeutic foodstuffs, and the emergence and rapid growth of an industry of food-like herbs marketed as alternative therapies that do not require approval by the U.S. Food and Drug Administration (FDA) (3, 4). This rapidly evolving trend is most clearly seen in herb-laced beverages ranging from brand-named teas to upscale soft drinks, all increasingly available at the local supermarket, as well as at specialty health food emporiums, and we can expect major increases in the rates at which patients seeking psychiatric care will have already been taking herbal alternative remedies that may or may not be active and that may or may not have positive or deleterious interactions with conventional treatments. All of this suggests that clinicians need to routinely and nonjudgmentally ask patients about their use of herbal alternative and complementary treatments, know enough about the more common ones to assess patients for deleterious effects or interactions, and know where to find legitimate information about other treatments. This clinical conference will first present cases demonstrating use of two of the more commonly used herbal alternative medicine compounds, present a third case dealing with staffpatient interactions concerning the use of herbal remedies, and end with a discussion of perspectives and attitudes that contemporary clinicians may find useful concerning their patients’ use of herbal alternative treatments.