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{"project":"2_test","denotations":[{"id":"23700366-15538595-76000756","span":{"begin":1297,"end":1298},"obj":"15538595"},{"id":"23700366-21901717-76000756","span":{"begin":1297,"end":1298},"obj":"21901717"},{"id":"23700366-21407167-76000756","span":{"begin":1297,"end":1298},"obj":"21407167"},{"id":"23700366-22654508-76000757","span":{"begin":1521,"end":1523},"obj":"22654508"},{"id":"23700366-23152710-76000758","span":{"begin":1524,"end":1526},"obj":"23152710"},{"id":"23700366-22654508-76000759","span":{"begin":1601,"end":1603},"obj":"22654508"},{"id":"23700366-23152710-76000760","span":{"begin":1604,"end":1606},"obj":"23152710"},{"id":"23700366-20573326-76000761","span":{"begin":2073,"end":2075},"obj":"20573326"},{"id":"23700366-19666194-76000762","span":{"begin":2621,"end":2623},"obj":"19666194"},{"id":"23700366-15750381-76000763","span":{"begin":2627,"end":2630},"obj":"15750381"},{"id":"23700366-16131297-76000764","span":{"begin":2631,"end":2634},"obj":"16131297"},{"id":"23700366-19632969-76000765","span":{"begin":2764,"end":2767},"obj":"19632969"},{"id":"23700366-19033149-76000765","span":{"begin":2764,"end":2767},"obj":"19033149"},{"id":"23700366-15998607-76000765","span":{"begin":2764,"end":2767},"obj":"15998607"},{"id":"23700366-19821984-76000765","span":{"begin":2764,"end":2767},"obj":"19821984"},{"id":"23700366-22370502-76000766","span":{"begin":2822,"end":2825},"obj":"22370502"},{"id":"23700366-12418493-76000767","span":{"begin":5365,"end":5367},"obj":"12418493"},{"id":"23700366-9155210-76000768","span":{"begin":5371,"end":5374},"obj":"9155210"},{"id":"23700366-7686459-76000769","span":{"begin":5375,"end":5378},"obj":"7686459"}],"text":"Discussion\nCAM is not a primary treatment for mood or other psychiatric disorders. However, level 1 evidence is beginning to emerge. There are a variety of clinical scenarios in which a clinician might recommend CAM for a mood disorder, including:\npatients who do not respond to antidepressant treatment development of intolerable side effects to first-line antidepressants a condition for which there are no effective treatments patients who are resistant to standard treatments and augmentation strategies patients on medications which are necessary but causing side effects that could be alleviated by CAM mitigate effects of risk factors those who want to explore the full range of services and options a situation in which there is no access to standard treatment when the patient is uncomfortable with modern medications when the patient is more comfortable with CAM therapies the patient cannot afford the cost of modern medication multiple, complex comorbid medical conditions associated with depression. Mood disorders present in many different ways and are associated with a variety of biological, psychological, social, and environmental factors that contribute to their pathogenesis. Co-occurring psychiatric and physical conditions further complicate the treatment of mood disorders.8–11 Standard pharmacological and psychotherapies used in patients with depression have resulted in the following outcomes: 30% of patients remit, another 30% show a partial response, and the rest are resistant to treatment.12,13 Overall, 30%–40% of patients with major depression would benefit from CAM.12,13 Open-label clinical trials of CAM are more abundant than randomized controlled trials. The American Psychiatric Association Task Force report on CAM in major depressive disorder recommends more rigorous and larger studies in major depression. Further, each type of CAM must be evaluated separately in adequately powered controlled trials. This report also suggests that several CAM treatments presently appear promising in major depression and deserve further study.38 There are more than 120 CAM therapies used worldwide, yet their role in the treatment of mood disorders is limited because they have not all been studied scientifically.\nGuidelines have been developed for using CAM in clinical practice. These emphasize the taking of a full patient history, conducting a complete physical examination, laboratory investigations, and a review of medications in order to make an accurate diagnosis and develop a treatment plan. All information gathered from the patient needs to be documented in the medical notes.37,39,187,188 Web-based CAM programs may help to meet the increasing demand for such treatments by patients with depression and mood disorders.214–218 Whether or not integrative medicine and CAM57,209,213 can shift the therapeutic paradigm from conventional treatments to traditional therapies in the management of mood disorders is debatable.\n\nLimitations\nThis narrative review of the literature has some limitations. For example, limiting the literature search to papers published in the English language could have missed many relevant publications. Other relevant articles could also have been missed because not all full articles and abstracts were available. The inclusion of small open-label studies among the references that provide “evidence-based data” is problematic because of the risk for over-interpretation of results collected with limited scientific rigor. Lack of replication studies further limits the interpretation of individual studies. The strength of this narrative review is that it has smoothly organized widely scattered data on the therapeutic effects of CAM in mood disorders.\n\nRecommendations\nCAM therapies are expanding in number and being tested with increasing scientific rigor, similar to the clinical trials that evaluate modern drugs for depression and other mood disorders. Solid evidence is emerging about the efficacy of several types of CAM in these conditions. There is even some evidence that nutraceuticals, botanicals, and nutrients could be used alone as first-line treatments in mild-to-moderate mood disorders. However, severe depression, including psychotic depression, bipolar disorder with rapid cycling, and treatment-resistant depression require antidepressants, mood stabilizers, and atypical antipsychotics. CAM may be useful as an adjunct to conventional therapies for both acute treatment and prevention of recurrence of these disorders, perhaps with a reduction in adverse effects. Patients suffering depression comorbid with liver disease can benefit from S-adenosylmethionine, which not only improves depression but also protects the liver and restores liver function. Levodopa is a well known treatment for Parkinson’s disease, and is known to deplete S-adenosylmethionine in the central nervous system, resulting in depression that can be improved by S-adenosylmethionine supplementation. Increased production of homocysteine due to genetic polymorphism of the methyltetrahydrofolate reductase gene (C/T and T/T instead of C/C) is associated with a greater risk of cardiovascular disease. Reduction in levels of both S-adenosylmethionine and folate may result in depression that responds poorly to antidepressants yet robustly to supplementation with S-adenosylmethionine and folate.41,42,102,103\nAlthough St John’s wort alleviates depression in both men and women, it is particularly useful in women who cannot tolerate antidepressants. In addition to enhancing well-being, Rhodiola rosea is recommended for the treatment of mild-to-moderate depression, but needs to be used cautiously in women with a family or personal history of estrogen-sensitive breast cancer. Pregnant women are at higher risk for developing major depression, and all available antidepressants tend to cause adverse effects on the fetus or newborn, but omega-3 fatty acids are useful alternatives, and with no adverse effects. Further, adjunctive use of omega-3 fatty acids at 2–3 g/day with an EPA to DHA ratio of 2:1 is also recommended in bipolar disorder, given that it augments the response to antidepressants and mood stabilizers. Similarly, choline, inositol, 5-hydroxy-L-tryptophan, N-acetylcysteine, and DHEA are all reported to be more or less effective in bipolar depression. Ayurveda and homeopathic medicine need large-scale, randomized controlled trials to establish or refute their value in the treatment of mood disorders. Mind-body-spirit therapies, especially regular and long-term yoga practices, are critical for patients with moderate to-severe depression to sustain their benefits. A number of studies also support the effectiveness of meditation, exercise, and acupuncture in major depression. Integrative medicine with an underlying philosophy that involves a holistic approach to health care uses a combination of therapies to enhance the treatment of mood disorders. Randomized controlled trials continue to be needed to provide evidence for or against the use of CAM for mood disorders in the future. "}

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