From the Editor
Kava. Ginkgo. St John’s wort.
These plant-based medicines (or phytoceuticals) have gained popularity in recent years. Patients ask about them; in some pharmacies, they are now sold prominently and side by side with other products; celebrities talk up their helpfulness. Plant-based medicines are having a moment.
But what’s the evidence? In the first selection, Jerome Sarris (of the Western Sydney University) and his co-authors consider phytoceuticals for psychiatric disorders in a new Canadian Journal of Psychiatry paper. They draw on meta-analyses of RCTs reporting on the efficacy and effectiveness of these medicines. What did they find? “This ‘meta-synthesis’ of the data from 9 meta-analyses showed positive findings for a variety of plant-based medicines in a range of psychiatric disorders, albeit limited by the quality of source data.” We consider the big paper and its clinical implications.
St. John’s wort – pretty flower, but evidenced?
In this week’s second selection, we look at wearables and new technologies. Dr. John Torous (of Harvard University) joins me for a Quick Takes podcast interview. We discuss their potential for mental health care including how data captured on devices (especially data related to sleep and exercise) can potentially improve care – and overall health. “Could we be using the step count on a patient’s phone for mental health? Could we transform GPS into something like studying green space to learn about its impact on mental health?” And, yes, we do talk about Star Wars.
Selection 1: “Plant-based Medicines (Phytoceuticals) in the Treatment of Psychiatric Disorders: A Meta-review of Meta-analyses of Randomized Controlled Trials”
Jerome Sarris, Wolfgang Marx, Melanie M. Ashton, et al.
The Canadian Journal of Psychiatry, October 2021
Data from the World Health Organization (WHO) reveal a continuing increase in the use of herbal and plant-based medicines, with an estimated 80% of the world population utilizing them as part of primary health care treatment for a range of physical ailments. In the United States, a national household survey has shown that herbal/natural medicines, along with dietary supplements, were the most commonly utilized complementary therapies for psychiatric disorders, with St John’s wort (Hypericum perforatum L.) and kava (Piper methysticum) as a treatment of mood disorders being the most used in this population…
Phytoceuticals have a range of psychoactive effects that include putative antidepressant, anxiolytic, nootropic (cognitive enhancing), sedative, hypnotic, and analgesic properties. The diverse mechanisms of action for these plant-based medicines primarily involve alteration of neurotransmitter synthesis and degradation, agonism and antagonism of neuroreceptors or inhibition of neurotransmitters reuptake proteins, or supporting the homeostatic function of the hypothalamic pituitary adrenal (HPA) axis. For example, kava, through its main active compounds, kavalactones, acts as a γ-aminobutyric acid pathway agonist, whereas St John’s is a known monoamine reuptake inhibitor, although its modulation of HPA activity is also evident (note that preclinical data may not directly translate into pharmacodynamic effects at relevant human doses). Further, phytoceuticals such as ginkgo (Ginkgo biloba) may exert antioxidant, anti-inflammatory, and antiplatelet activities, while increasing blood–brain barrier permeability, providing a potential adjunctive supportive treatment for brain disorders… Conventional mechanistic understandings of these agents in this context are, however, somewhat limited…
The aim of this meta-review was to aggregate and evaluate the top-tier evidence for the efficacy of plant-based medicines in the treatment of psychiatric disorders.
Here’s what they did:
- The authors used the search strategy and data synthesis in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.
- They searched several databases, including Cochrane Database of Systematic Reviews, and also did a Google search.
- They focused on “studies of individuals with common and severe mental disorders” – these included major depressive disorder, bipolar disorder, schizophrenia, and ADHD.
- Statistical analyses were done, including consideration of pooled effect sizes.
Here’s what they found:
- The search found 882 results; three reviewing academics identified 9 relevant meta-analyses of RCTs, with primary analyses including outcome data from 5,927 individuals.
- “Meta-analyses of RCTs with primary analyses including outcome data revealed 5 plant-based medicines focusing on 4 disorders.”
- Data source. “United States and Europe for St John’s wort, Europe and Australia for kava, Iran for saffron, China for ginkgo, and a range of countries for curcumin.”
- Best evidence.“The interventions with the strongest evidentiary support were for St John’s wort for MDD (supported also by pooled analysis of key European study data), curcumin, and saffron for MDD and depression symptoms, and ginkgo for total and negative symptoms.”
- Limited evidence. “Kava was not effective in treating diagnosed anxiety disorders, with an absence of statistical significance in GAD…”
- “These results in the main reflects the position held in the most recent Canadian Network for Mood and Anxiety Treatment guidelines.”
A few thoughts:
- This is a good study.
- The paper is highly relevant to practice. Our patients increasingly look to alternative medicines. The authors offer a thoughtful review of the evidence.
- A five-word summary: some evidence for some phytoceuticals.
- How do the findings compare to the literature? “The data concerning kava should also be further taken into context due to a recently published large RCT involving the phytoceutical in the treatment of GAD, which revealed a nonsignificant effect compared to placebo on the Hamilton Anxiety Rating Scale.”
- Like all studies, there are limitations. The authors note issues with data. “Some of the data from studies contained within the individual meta-analyses had poor reporting and weak methodological standards, small samples, or absence of constituent standardization, thus some degree of caution needs to be applied.”
- Many of our patients are using phytoceuticals. But there is a problem with quality – what’s on the label may not be what’s in the bottle given the light regulation of these medications. For the record, if a patient with depression is uninterested in a pharmaceutical, I do suggest that St. John’s wort may be an option, and discuss picking a reputable brand like Jamieson. (If you have better advice, please email me, and I’ll include it in a future Reading.)
- Past Readings have considered alternative and complementary medicines, including the use of aromatherapy for insomnia. See https://davidgratzer.com/reading-of-the-week/reading-of-the-week-aromatherapy-for-insomnia-also-ramadan-and-mental-health-and-responding-to-vaccine-history/
The full Canadian Journal of Psychiatry paper can be found here: https://journals.sagepub.com/doi/full/10.1177/0706743720979917
Selection 2: “What all physicians need to know about wearables (and tech) in mental health care”
Quick Takes, November 2021
In this episode of Quick Takes, I speak with Dr. John Torous, director of the Digital Psychiatry Division at the Department of Psychiatry at Beth Israel Deaconess Medical Centre. Dr. Torous (a returning guest) notes the potential of wearables.
I highlight from the discussion:
A wearable is anything you want to wear. In the context that we’re talking about: a wearable is a digital device – a sensor – that is able to capture electronic data related to behaviour or physiology. We could classically think of, say, a smartwatch or a pedometer as examples.
On future directions of wearables
Some wearables are a ring that you would put on your finger, or a patch you could put on your undergarments or on your skin. Soon, they could be necklaces or other types of jewelry. Smartwatches are the first generation of wearables. Maybe your shoe will have a wearable in it…
On the possible use in mental health care
As we do with all health care, we want to have a multimodal assessment of how people are doing. We ask our patients about things like diet, exercise, sleep – and wearables could be a useful tool to give us new insights and information into how patients are experiencing their life, how active and how sedentary are they, how good is their sleep. And again, these are important targets because these are things we can modify and help improve their behavioural health and physical health, too.
On the big potential
The technical term is “just in time adaptive intervention.” Somehow it gets abbreviated as JEDI (which I don’t quite see it as that from a Star Wars nerdy point).
The idea: if the phone could say, “Well, John, your mood is worse and we’ve noticed that you’re exercising less,” that would naturally lend itself to a recommendation to say, “Why don’t you try exercise?”
On virtual reality
Much research has been done around PTSD and exposure therapies for using virtual reality.
It’s much easier to handle a spider or to go up on a tall building in virtual reality than to do it in person. And those exposure therapies seem to have pretty strong evidence.
Of course, there’s also a concern for iatrogenic effects, right? What is the harm of doing unguided exposure therapy?
On social media
Peer support is very impactful. Peers are perhaps the future of mental health – a new workforce that could really embrace technology, and become the technology experts.
Using social media to connect with people – to help build positive experiences, to help share experiences, in some ways to crowd-source treatments – has tremendous potential too if used in the right way.
On the risk to privacy with digital mental health
It’s the number one thing I lose sleep over.
The above answers have been edited for length.
The podcast can be found here, and is just over 28 minutes long:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.