chronic diseases case studies & im research update 2011 · depression - exercise •28 trials...
TRANSCRIPT
Chronic diseases ndash case studies amp
IM research update 2011copy Dr Vicki Kotsirilos
Abbreviations
bull MA Meta-analysis
bull SR Systematic Review
bull RCT Randomised Control
Trial
bull P Placebo
bull DB Double Blind
Cochrane reviews
ndash RCTs for SRs MAs
ndash gt 725 reviews on CM
httpwwwcompmedummeducochrane_abo
utasp
Evidence for CMs - growing
bull Many trials have methodological problems
bull Variability quality from 1 trial to another
bull Mixed results and conclusions ndashesp MA
bull Level 1 evidence exists for CMs but with
mixed results amp some with no efficacy
bull Need better quality trials
bull Well-planned large-scale studies
NHMRC level of evidence
bull Level I ndash SR of RCTs MA Cochrane‟s
bull Level II - gt1 RCT
bull Level IIIa ndash well designed pseudo-RCT
bull Level IIIb ndash comparative studies with
cohort or concurrent amp case controls
bull Level IIIc ndash comparative studies
bull Level IV ndash opinions of respected
authorities reports of expert committees
bull Level V ndashminimal evidence - testimonials
Management of chronic diseases-Lifestyle amp preventative advice
bull Diet
bull Sleep
bull Exercise
bull Sunshine
bull Restrelaxationstress management
bull CBT counsellinghellip
bull Support groups religion spiritualhellip
bull Environment ndash avoiding chemicals amp pollutants
ndash eg smoking drugs traffic pollutionhellip
CHRONIC DISEASES
bull OSTEOARTHRITIS
bull DEPRESSION
bull ANXIETY
bull ASTHMA
bull HYPERTENSION
bull HEADACHES MIGRAINES
Osteoarthritis
bull Ruth 72 years of age
bull Sx‟s bdquoaches amp pains jts‟ esp knees amp neck
bull Years gradually getting worse
bull Difficulty sleeping due to pain
bull Morning stiffness
bull Walks are restricted by pain
bull Pain worse when more active during the day
bull Difficulty coping with pain
bull PHx gastritis unable to tolerate NSAIDs
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Abbreviations
bull MA Meta-analysis
bull SR Systematic Review
bull RCT Randomised Control
Trial
bull P Placebo
bull DB Double Blind
Cochrane reviews
ndash RCTs for SRs MAs
ndash gt 725 reviews on CM
httpwwwcompmedummeducochrane_abo
utasp
Evidence for CMs - growing
bull Many trials have methodological problems
bull Variability quality from 1 trial to another
bull Mixed results and conclusions ndashesp MA
bull Level 1 evidence exists for CMs but with
mixed results amp some with no efficacy
bull Need better quality trials
bull Well-planned large-scale studies
NHMRC level of evidence
bull Level I ndash SR of RCTs MA Cochrane‟s
bull Level II - gt1 RCT
bull Level IIIa ndash well designed pseudo-RCT
bull Level IIIb ndash comparative studies with
cohort or concurrent amp case controls
bull Level IIIc ndash comparative studies
bull Level IV ndash opinions of respected
authorities reports of expert committees
bull Level V ndashminimal evidence - testimonials
Management of chronic diseases-Lifestyle amp preventative advice
bull Diet
bull Sleep
bull Exercise
bull Sunshine
bull Restrelaxationstress management
bull CBT counsellinghellip
bull Support groups religion spiritualhellip
bull Environment ndash avoiding chemicals amp pollutants
ndash eg smoking drugs traffic pollutionhellip
CHRONIC DISEASES
bull OSTEOARTHRITIS
bull DEPRESSION
bull ANXIETY
bull ASTHMA
bull HYPERTENSION
bull HEADACHES MIGRAINES
Osteoarthritis
bull Ruth 72 years of age
bull Sx‟s bdquoaches amp pains jts‟ esp knees amp neck
bull Years gradually getting worse
bull Difficulty sleeping due to pain
bull Morning stiffness
bull Walks are restricted by pain
bull Pain worse when more active during the day
bull Difficulty coping with pain
bull PHx gastritis unable to tolerate NSAIDs
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Cochrane reviews
ndash RCTs for SRs MAs
ndash gt 725 reviews on CM
httpwwwcompmedummeducochrane_abo
utasp
Evidence for CMs - growing
bull Many trials have methodological problems
bull Variability quality from 1 trial to another
bull Mixed results and conclusions ndashesp MA
bull Level 1 evidence exists for CMs but with
mixed results amp some with no efficacy
bull Need better quality trials
bull Well-planned large-scale studies
NHMRC level of evidence
bull Level I ndash SR of RCTs MA Cochrane‟s
bull Level II - gt1 RCT
bull Level IIIa ndash well designed pseudo-RCT
bull Level IIIb ndash comparative studies with
cohort or concurrent amp case controls
bull Level IIIc ndash comparative studies
bull Level IV ndash opinions of respected
authorities reports of expert committees
bull Level V ndashminimal evidence - testimonials
Management of chronic diseases-Lifestyle amp preventative advice
bull Diet
bull Sleep
bull Exercise
bull Sunshine
bull Restrelaxationstress management
bull CBT counsellinghellip
bull Support groups religion spiritualhellip
bull Environment ndash avoiding chemicals amp pollutants
ndash eg smoking drugs traffic pollutionhellip
CHRONIC DISEASES
bull OSTEOARTHRITIS
bull DEPRESSION
bull ANXIETY
bull ASTHMA
bull HYPERTENSION
bull HEADACHES MIGRAINES
Osteoarthritis
bull Ruth 72 years of age
bull Sx‟s bdquoaches amp pains jts‟ esp knees amp neck
bull Years gradually getting worse
bull Difficulty sleeping due to pain
bull Morning stiffness
bull Walks are restricted by pain
bull Pain worse when more active during the day
bull Difficulty coping with pain
bull PHx gastritis unable to tolerate NSAIDs
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Evidence for CMs - growing
bull Many trials have methodological problems
bull Variability quality from 1 trial to another
bull Mixed results and conclusions ndashesp MA
bull Level 1 evidence exists for CMs but with
mixed results amp some with no efficacy
bull Need better quality trials
bull Well-planned large-scale studies
NHMRC level of evidence
bull Level I ndash SR of RCTs MA Cochrane‟s
bull Level II - gt1 RCT
bull Level IIIa ndash well designed pseudo-RCT
bull Level IIIb ndash comparative studies with
cohort or concurrent amp case controls
bull Level IIIc ndash comparative studies
bull Level IV ndash opinions of respected
authorities reports of expert committees
bull Level V ndashminimal evidence - testimonials
Management of chronic diseases-Lifestyle amp preventative advice
bull Diet
bull Sleep
bull Exercise
bull Sunshine
bull Restrelaxationstress management
bull CBT counsellinghellip
bull Support groups religion spiritualhellip
bull Environment ndash avoiding chemicals amp pollutants
ndash eg smoking drugs traffic pollutionhellip
CHRONIC DISEASES
bull OSTEOARTHRITIS
bull DEPRESSION
bull ANXIETY
bull ASTHMA
bull HYPERTENSION
bull HEADACHES MIGRAINES
Osteoarthritis
bull Ruth 72 years of age
bull Sx‟s bdquoaches amp pains jts‟ esp knees amp neck
bull Years gradually getting worse
bull Difficulty sleeping due to pain
bull Morning stiffness
bull Walks are restricted by pain
bull Pain worse when more active during the day
bull Difficulty coping with pain
bull PHx gastritis unable to tolerate NSAIDs
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
NHMRC level of evidence
bull Level I ndash SR of RCTs MA Cochrane‟s
bull Level II - gt1 RCT
bull Level IIIa ndash well designed pseudo-RCT
bull Level IIIb ndash comparative studies with
cohort or concurrent amp case controls
bull Level IIIc ndash comparative studies
bull Level IV ndash opinions of respected
authorities reports of expert committees
bull Level V ndashminimal evidence - testimonials
Management of chronic diseases-Lifestyle amp preventative advice
bull Diet
bull Sleep
bull Exercise
bull Sunshine
bull Restrelaxationstress management
bull CBT counsellinghellip
bull Support groups religion spiritualhellip
bull Environment ndash avoiding chemicals amp pollutants
ndash eg smoking drugs traffic pollutionhellip
CHRONIC DISEASES
bull OSTEOARTHRITIS
bull DEPRESSION
bull ANXIETY
bull ASTHMA
bull HYPERTENSION
bull HEADACHES MIGRAINES
Osteoarthritis
bull Ruth 72 years of age
bull Sx‟s bdquoaches amp pains jts‟ esp knees amp neck
bull Years gradually getting worse
bull Difficulty sleeping due to pain
bull Morning stiffness
bull Walks are restricted by pain
bull Pain worse when more active during the day
bull Difficulty coping with pain
bull PHx gastritis unable to tolerate NSAIDs
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Management of chronic diseases-Lifestyle amp preventative advice
bull Diet
bull Sleep
bull Exercise
bull Sunshine
bull Restrelaxationstress management
bull CBT counsellinghellip
bull Support groups religion spiritualhellip
bull Environment ndash avoiding chemicals amp pollutants
ndash eg smoking drugs traffic pollutionhellip
CHRONIC DISEASES
bull OSTEOARTHRITIS
bull DEPRESSION
bull ANXIETY
bull ASTHMA
bull HYPERTENSION
bull HEADACHES MIGRAINES
Osteoarthritis
bull Ruth 72 years of age
bull Sx‟s bdquoaches amp pains jts‟ esp knees amp neck
bull Years gradually getting worse
bull Difficulty sleeping due to pain
bull Morning stiffness
bull Walks are restricted by pain
bull Pain worse when more active during the day
bull Difficulty coping with pain
bull PHx gastritis unable to tolerate NSAIDs
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
CHRONIC DISEASES
bull OSTEOARTHRITIS
bull DEPRESSION
bull ANXIETY
bull ASTHMA
bull HYPERTENSION
bull HEADACHES MIGRAINES
Osteoarthritis
bull Ruth 72 years of age
bull Sx‟s bdquoaches amp pains jts‟ esp knees amp neck
bull Years gradually getting worse
bull Difficulty sleeping due to pain
bull Morning stiffness
bull Walks are restricted by pain
bull Pain worse when more active during the day
bull Difficulty coping with pain
bull PHx gastritis unable to tolerate NSAIDs
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Osteoarthritis
bull Ruth 72 years of age
bull Sx‟s bdquoaches amp pains jts‟ esp knees amp neck
bull Years gradually getting worse
bull Difficulty sleeping due to pain
bull Morning stiffness
bull Walks are restricted by pain
bull Pain worse when more active during the day
bull Difficulty coping with pain
bull PHx gastritis unable to tolerate NSAIDs
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Osteoarthritis
bull Paracetamol - not strong enough
OE overweight BMI 30 Normotensive
Knees mild restriction in the ROM
pronounced crepitus some tenderness
medially worse on flexion No effusion
Rx options
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Osteoarthritis
Lifestyle therapy
bull Lifestyle ndashdietBMI darr
bull CBT ndashpt education self Mx
bull Exercise ndashlow intensity
bull Tai chi
bull Hydrotherapy
bull Cold packs
bull Electromagnetic fields
bull Avocadosoybean unsaponifiables
bull Rosehip (Rose haw)
bull Glucosaminechondroitin sulfate
bull SAMe
bull Acupuncture
Level of evidence
bull IIIc
bull I
bull I
bull II
bull I
bull I
bull I
bull I
bull I
bull I
bull I
bull II
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
OA ndash thermotherapy (ice packs vs heat packs)
bull 3 RCTs 179 patients
Authors conclusions
ldquoIce massage compared to control had a statistically
beneficial effect on ROM function and knee
strength Cold packs decreased swelling Hot
packs had no beneficial effect on edema compared
with placebo or cold application Ice packs did not
affect pain significantly compared to control in
patients with OArdquoBrosseau L Yonge K Welch V Marchand S Judd M Wells GA
Tugwell P Thermotherapy for treatment of osteoarthritis Cochrane
Database of Systematic Reviews 2003 Issue 4 Art No CD004522
DOI 10100214651858CD004522
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
OA knee-acupuncture
bull RCT multi-site trial
bull 570 patients with OA knee
Randomised
bull 23 true or sham acupuncture sessions over
26 weeks
bull or Controls 6 two-hour group education
sessions over 12 weeks
bull Medication PRN
Berman BM et al Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee a randomized controlled trial
Ann Intern Med 2004 Dec 21141(12)901-10
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
OA knee-acupuncture
bull True acupuncture group
experienced greater improvement in
function scores cf sham acupuncture gp
at 8 weeks esp at 26 weeks
bull However at 26 weeks
ndash 43 of the participants in the education gp amp
ndash 25 in each of the true amp sham acupuncture
gps not available for follow-up analysis
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
OA of knee-acupuncture
bull 97 pts with OA of knee
bull RCT acupuncture or sham acupuncture
bull gt 12 weeks
bull All were taking 50mgs diclofenac
bull Acupuncture plus diclofenac significant
in pain rigidity use of medication
improvements in physical function amp QOL
bull cf sham treatment plus diclofenac
Vas J et al BMJ 20043291216-1219
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
OA - Electromagnetic fields
bull 3 studies 259 OA patients
bull Authors conclusions
ldquoCurrent evidence suggests that electrical
stimulation therapy may provide significant
improvements for knee OA but further studies are
required to confirm whether the statistically
significant results shown in these trials confer to
important benefitsrdquo
Hulme JM Welch V de Bie R Judd M Tugwell P Electromagnetic
fields for the treatment of osteoarthritis Cochrane Database of
Systematic Reviews 2002 Issue 1 Art No CD003523 DOI
10100214651858CD003523
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Cochrane ndashOA
-glucosamine sulphatebull 25 RCT 4963 patients
ldquoCollectively the 25 RCTs favoured
glucosamine with a 22 (change from
baseline) improvement in pain (SMD -047
95 CI -072 to -023) and a 11 (change
from baseline) improvement in function
using the Lequesne index (SMD -047 95 CI
-082 to -012)rdquoTowheed T Maxwell L Anastassiades TP Shea B Houpt J Welch V Hochberg
MC Wells GA Glucosamine therapy for treating osteoarthritis Cochrane
Database of Systematic Reviews 2005 Issue 2 Art No CD002946 DOI
10100214651858CD002946pub2
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
OA - glucosamine sulphate
Rotta
ldquoPooled results from studies using a non-
Rotta preparation or adequate allocation
concealment failed to show benefit in pain
and WOMAC function while those studies
evaluating the Rotta preparation showed
that glucosamine was superior to placebo in
the treatment of pain and functional
impairment resulting from symptomatic
OArdquo
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Glucosamine sulfateA major constituent of glycosaminoglycans in
CTs
Derived from shellfish bovine cartilage corn
starch
bull Dosage1500-2000 mgday for at least 2
months
bull orally or topically to the joint
bull SE minimal -GIT upset RASH allergic
reactions
bull Avoid if seafood allergy Warning on label
Cohen et al Journal of Rheumatology 200330(3)523-28
Review article Medicine Today April 2003(4)487-91
ndash (of 17 RCTrsquos)
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Chondroitin sulfate
bull Forms part of proteoglycan matrix of cartilage
derived from bovine cartilage
bull Multi-centre DBRCT 146 OA patients
bull chondroitin sulfate vs diclofenac vs placebo
bull diclofenac immediate pain relief but reappeared
after stopping it
bull chondroitin pain relief later but more sustained
after stopping it
bull 800-1200 mgsday
Journal of Rheumatology 199623(8)1385-91
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Cochrane OA-Herbal therapy
bull 5 studies (4 different herbs) met criteria
bull 2 studies of avocadosoybean extracts
beneficial effects on function pain
NSAIDs drugs amp global evaluation
bull No serious SEs reported
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
OA-Herbal therapy
ldquoThe evidence for avocado-soybean
unsaponifiables in the treatment of OA is
convincing but evidence for the other herbal
interventions is insufficient to either
recommend or discourage their userdquo
Little CV Parsons T Logan S Herbal therapy for treating osteoarthritis
Cochrane Database of Systematic Reviews 2001 Issue 1 Art No
CD002947 DOI 10100214651858CD002947
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Depression
bull Paul 48 year old mechanic with 3 children
bull Smoker 25 cigarettes per day
bull Severe traumatic event 10 years ago
bull Suffered Major depression following
incident several years of anti-depressants
bull Free counselling several sessions
bull Sx‟s several months difficulty coping at
work dealing with his adolescent 16 year
old boy who was ldquopushing the boundariesrdquo
feeling down
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Depression
bull Depressed no of years recently moreso
bull Amotivated missing days at work poor
concentration easily losing temper at times
displaying aggressive behaviour such as
punching the walls amp doors
bull Binge drinking alcohol
bull Sleeps late ndashmost nights 1am
bull Lacking energy
bull Feeling ldquohopeless and no good to anyonerdquo
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Depression
bull Work absenteeism-further strain on his
relationships with workmates and family
bull Friends not visiting
bull Denies any suicidal thoughts
bull Not happy with the way life is
bull Not keen on anti-depressants as he suffered
SEs from the medication
ndash low libido difficulty with ejaculation some
dizziness amp ldquofoggy headrdquo
Rx options
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Depression
Lifestyle Therapy
bull Physical activityexercise
bull CBT
bull Meditation Relaxation
bull Music therapy
bull Yoga
bull Bright light therapy
bull Sleep therapy
bull St Johnrsquos wort
bull SAMe
bull Fish oils
bull Folate Tryptophan
bull Multivitamin vit B‟s
Level of evidence
bull I
bull I
bull II I
bull I
bull II
bull I
bull II
bull I
bull II
bull I
bull I
bull II
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Relaxation therapy
bull 11 trials included
Authors conclusions
bull ldquoRelaxation techniques were more effective
at reducing self-rated depressive symptoms
than no or minimal treatmentrdquo
Jorm AF Morgan AJ Hetrick SE Relaxation for depression Cochrane
Database of Systematic Reviews 2008 Issue 4 Art No CD007142
DOI 10100214651858CD007142pub2
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Depression - Exercise
bull 28 trials included
Authors conclusions
bull ldquoExercise seems to improve depressive
symptoms in people with a diagnosis of
depression but when only methodologically
robust trials are included the effect sizes
are only moderate and not statistically
significantrdquoMead GE Morley W Campbell P Greig CA McMurdo M Lawlor DA
Exercise for depression Cochrane Database of Systematic Reviews
2009 Issue 3 Art No CD004366 DOI
10100214651858CD004366pub4
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Music therapyhellip for depression
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
helliphelliphellipyes
ldquo4 of the 5 studies individually
reported greater reduction in Sx‟s
of depression among those
randomised to music therapy than
to those in standard care
conditionsrdquo
Maratos A Gold C Wang X Crawford M Music therapy for depression
Cochrane Database of Systematic Reviews 2008 Issue 1
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Music therapy
bull 5th study no benefit
bull Dropout rates from music therapy low in all
studies
bull low methodological quality of studies
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Depression
ndash Bright Light Therapybull 20 studies (49 reports) included
ndash Results mainly based on studies lt 8 days of Rx
Authors conclusions
bull ldquoFor patients suffering from non-seasonal
depression light therapy offers modest though
promising antidepressive efficacy especially when
administered during the first week of treatment in
the morning and as an adjunctive treatment to
sleep deprivation respondersrdquo
Tuunainen A Kripke DF Endo T Light therapy for non-seasonal
depression Cochrane Database of Systematic Reviews 2004 Issue 2
Art No CD004050 DOI 10100214651858CD004050pub2
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
St John‟s wort
bull 29 trials (5489 patients)
bull 18 cf placebo 17 cf synthetic
bull Results of PCT rarr marked heterogeneity
Authors conclusions
ldquoThe available evidence suggests that the hypericum extracts
tested in the included trials
a) superior to placebo in patients with major depression
b) similarly effective as standard antidepressants
c) fewer SEs than standard antidepressants The association
of country of origin and precision with effects sizes
complicates the interpretationrdquo
Linde K Berner MM Kriston L St Johns wort for major depression
Cochrane Database of Systematic Reviews 2008 Issue 4
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Adverse effects of STJW
bull SE‟s 26 cf 45 with antidepressants
ndash photosensitivity rash nausea headache
dizzy fatigue dry mouth
ndash induces hepatic CYT P450 enzyme
[drugs] eg OCP BTB
warfarin rarr darr INR
ndash Beware Serotonin syndrome ndashantideps
SSRI‟s amp tramadol
Australian Adverse Drug Reactions Bull 200524( 1)2 and Oct 2009
Voiles KM and Kelly WN Potential Interactions Between Oral Contraceptives and Other
Medication and Natural Substances US Pharmacist 200429(01)
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Folate
bull 3 trials of 247 patients
bull ldquoThe limited available evidence suggests folate may have a potential role as a supplement to other treatment for depression It is currently unclear if this is the case both for people with normal folatelevels and for those with folate deficiencyrdquo
Taylor MJ Carney SM Geddes J Goodwin G Folate for depressive disorders Cochrane Database of Systematic Reviews 2003 Issue 2
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Depression - Tryptophan
bull 111 trials were located
bull Only 2 trials (64 patients) sufficient quality
to meet inclusion criteria
bull AA rarrserotonin manufacture nicotinic acid
(vitamin B3)
bull ldquoThe available evidence suggests these
substances were better than placebo at
alleviating depressionrdquo ndash SLEEP
ndash No firm conclusion more studies neededShaw KA Turner J Del Mar C Tryptophan and 5-Hydroxytryptophan for
depression Cochrane Database of Systematic Reviews 2002 Issue 1
Art No CD003198 DOI 10100214651858CD003198
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Anxiety
bull Mandy 32 year old single woman
bull Anxious feelings panic attacks
bull Reacts easily sensitive tearful
bull Fear driving on freeways ndashfear of MCA
bull Multiple Sx‟s GIT upset bloating HA‟s
bull Difficulty sleeping
bull Fears she has cancer ndash multiple Ix‟s
bull Drinks 6 cups of coffee daily
bull No exercise
Rx options
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
AnxietyLifestyle Therapy bull Exercise CBT
bull Bibliotherapy
bull Dance therapy
bull Hypnosis
bull Music therapy
bull Relaxation therapy
bull Reiki
bull Acupuncture
bull Aromatherapy massage
bull Yoga
bull Kava sage
bull Passiflora valerian
bull Fish oils Mg Melatonin
Level of evidencebull I
bull I
bull I
bull IIIa
bull III
bull I
bull I
bull I
bull II
bull II
bull I
bull I +- II
bull II
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Cognitive behaviour therapy
- anxiety amp phobia
bull CBT self help techniques relaxation
Parslow R Morgan AJ Allen NB Jorm AF ODonnell CP Purcell R
Effectiveness of complementary and self-help treatments for anxiety in
children and adolescents Med J Aust 2008 Mar 17188(6)355-9
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Panic Disorder and Agoraphobia Australian and New
Zealand Journal of Psychiatry 2003 37641ndash656
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Meditation for anxiety
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
hellipno
Cochrane review could not conclude from 2x
small studies if meditation alone is effective
for anxiety
T Krisanaprakornkit et al Meditation therapy for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 3
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Music therapy ndash anxiety
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
hellipyesbull Bradt J Dileo C Music for stress and anxiety reduction in coronary
heart disease patients Cochrane Database of Systematic Reviews
2009 Issue 2 Art No CD006577 DOI
10100214651858CD006577pub2
bull Cooke M Chaboyer W Sculter P Hiratos M The effect of music on
preoperative anxiety in day surgery Journal Advanced Nursing 2005
Oct52(1)47-55
bull Sendelbach SE Halm MA Doran KA et al Effects of music therapy
on physiological and psychological outcomes for patients undergoing
cardiac surgery J Cardiovasc Nurs 2006 May-Jun21(3)194-200
bull Gallagher LM Lagman R Walsh D et al The clinical effects of music
therapy in palliative medicine Support Care Cancer 2006
Aug14(8)859-66
bull Whitehead-Pleaux AM Baryza MJ Sheridan RL The effects of music
therapy on pediatric patients pain and anxiety during donor site
dressing change J Music Ther 2006 Summer43(2)136-53
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Exercise ndash anxiety
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
hellipyes
MA of RCTs
Wipfli BM Rethorst CD Landers DM The
anxiolytic effects of exercise a meta-analysis of
randomized trials and dose-response analysis J
Sport Exerc Psychol 2008 Aug30(4)392-410
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Anxiety ndash fish oilsbull RDBPCT students
bull omega-3 fish oils (25 gd 2085 mg eicosapentaenoic acid
and 348 mg docosahexanoic acid) or placebo capsules
bull rarr 14 darr in lipopolysaccharide (LPS)
stimulated interleukin 6 (IL-6) production
(inflammatory marker) amp
bull a 20 darr in anxiety Sx‟s
ndash No change in depressive Sx‟sJanice K Kiecolt-Glaser Martha A Belury Rebecca Andridge William B
Malarkey and Ronald Glaser Omega-3 supplementation lowers inflammation
and anxiety in medical students A randomized controlled trial Brain
Behavior and Immunity In Press Corrected Proof Available online 19 July
2011
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Kava
Useful for anxiety
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
hellipyesnohellippossibly
bull 12 DB RCTs (n=700) included
ndash 5 poor quality studies
ndash Hamilton Anxiety (HAM-A) scale
bull ldquoThe result suggests a significant effect towards a
reduction of the HAM-A total score in Pts
receiving kava extract cf Pts receiving placebordquo
ldquoFrom data available kava is relatively safe for
short-term treatmentrdquo (1 to 24 weeks)rdquoPittler MH Ernst E Kava extract versus placebo for treating anxiety
Cochrane Database of Systematic Reviews 2003 Issue 1 Art No
CD003383 DOI 10100214651858CD003383
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Kava
buthellipCochrane conclusion
ldquoCompared with placebo kava extract is an
effective Sxrsquoatic Rx for anxiety although at
present the size of the effect seems small
The effect lacks robustness and is based on
a relatively small samplehelliphellip
Also long-term safety studies of kava are
requiredrdquo
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
TGA safety review of KAVA
bull cases of hepatotoxicity in Australia amp
Oseas
bull RARE but serious
bull alcoholic extract
bull lt 250 mg of active kavalactones day
bull tablet or capsule lt 125 mg KL dose
bull tea bag ndash the amount of dried whole
or peeled rhizome lt 3 g tea bag
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Anxiety - Valerian nobull 1 RCT 36 patients GAD
bull 4 week pilot study
bull valerian diazepam amp placebo
bull No significant differences between the
valerian amp placebo groups in HAM-A total
scores
bull ldquo there is insufficient evidence to draw any
conclusions about the efficacy or safety of valerian
compared with placebo or diazepam for anxiety
disordersrdquoMiyasaka LS Atallah AacuteN Soares B Valerian for anxiety disorders
Cochrane Database of Systematic Reviews 2006 Issue 4 Art No
CD004515 DOI 10100214651858CD004515pub2
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Anxiety ndash passiflora
bull 2 studies (198 participants)
bull 1 study demonstrated ldquolack of difference in
the efficacy of benzodiazepines amp
passifloradropout rates were similar between
the 2 interventionsfindings from 1 study
suggested an improvement in job performance in
favour of passiflora and 1 study showed a lower
rate of drowsiness as a SE with passiflora as
compared with mexazolam neither of these
findings reached statistical significancerdquoMiyasaka LS Atallah AacuteN Soares B Passiflora for anxiety disorder
Cochrane Database of Systematic Reviews 2007 Issue 1 Art No
CD004518 DOI 10100214651858CD004518pub2
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
Anxiety ndash passiflora
Authors conclusions
bull ldquoRCTs examining the effectiveness of
passiflora for anxiety are too few in number
to permit any conclusions to be drawnrdquo
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc
AIMA
wwwaimanetau
03 8699 0582
bull Not-for-profit charity
bull Journals amp e-newsletters
bull peer body referral service
bull annual conference OCT 14-16th in Sydney
bull database of IM protocols
bull RACGP-AIMA jwp AMA etc