Complementary and Alternative Medicine: Not Many Compliments but Lots of Alternatives

There has been growing interest in the use of complementary and alternative medicine (CAM) for the treatment of a variety of medical conditions, especially psychiatric disorders. Why should ‘‘good, evidence-based practitioners’’ worry about such interventions? After all, they do not actually involve ‘‘our patients’’ who are working closely with us and are so attentive to our wisdom and reassurance. Well, that conclusion may be unwarranted, and failure to consider CAM in the course of patient care may place patients in jeopardy because ‘‘good, evidence-based practitioners’’ may actually miss two important bits of evidence. First, some CAM treatments may actually be helpful for some patients so these treatments may represent missed therapeutic opportunities for our patients. Second, whether we like it or not, there is plenty of evidence to suggest that many patients use CAM treatments that, if undetected, may impair treatment responses or, even worse, lead to serious adverse events. There is a long history of specialized, nontraditional treatments being used for a variety of medical conditions, especially for child and adolescent psychiatric disorders. But, why focus on child psychiatric disorders? There are a number of suggestions as to why this is the case but four seem to be the most salient. First, there is a general lack of consensus as to the specific pathophysiology that can be the target of treatment for most psychiatric disorders. Second, relative to the rest of clinical medicine, there is purportedly a dearth of safe, effective medications; never mind the evidence suggesting that the psychiatric medication responses are comparable to those in other areas of medicine (Leucht et al. 2012). Third, there is concern about possible, undetected, medication side effects that will have an adverse impact on the developing brains or bodies of our youth. And fourth, many are fearful that using even wellstudied medications is not good for children and adolescents and certainly not as good as using more ‘‘natural’’ approaches to treatment, even if those ‘‘natural’’ treatments have not been studied at all. However reasonable or unreasonable one finds these concerns, clinicians must face the reality that these concerns open the door for both the responsible and not so responsible use of CAM treatments. And this door is often open quite wide as many of these treatments are unregulated and unsupervised and sometimes, though certainly not always, offered by various ‘‘therapists’’ who weigh on the anxiety and guilt of deeply concerned parents. So, where do fact and fallacy separate, and what is a responsible clinician to do when faced with CAM treatments? In general, ‘‘complementary and alternative’’ refers to various types of more ‘‘traditional,’’ ‘‘natural,’’ and/or noninvasive forms of healing. In some instances, CAM seems to focus on treatments that some ‘‘clinicians’’ have determined to have face validity and then maintain use, with only anecdotal evidence. Many CAM treatments have been around for a long time—decades to millennia—while others are new creations; whether new or old, most lack a solid, empirical base. To counter this, many CAM proponents argue that this lack of an evidence base is due to the lack of funding for proper clinical trials—an argument that can also be made for many, more mainstream or even ‘‘off-label’’ treatments. Of course, there are also some more-radical CAM proponents who argue that scientists (and their corporate sponsors) are so biased that they will not allow fair trials to be performed. In the presence of a limited or absent evidence base for CAM treatments, there are still strong CAM advocates who insist that CAM treatments are natural and safe so why not use them alongside (complementary) traditional treatments or even to replace (alternative) traditional treatments. A recent study by Gabbay and her colleagues (Gabbay et al. 2012), demonstrates all too well that there need be nothing alternative about the use of a natural compound in the treatment of a known disorder. In a study on the use of omega-3 fatty acids (O3Fas) (a component of often-suggested fish oils) for children and adolescents with Tourette syndrome (TS), Dr. Gabbay and her colleagues were able to conduct a proper, randomized, doubleblind, placebo-controlled trial. The logic behind the use of O3FAs was clear and with face validity including connections to the previously studied ability of O3FAs to affect central monoamine and immunomodulatory mechanisms, both of which have been implicated in the etiology of TS. While this small, initial trial failed to support the primary hypothesis related to reducing tics, there are still important lessons to be learned from this study. First of all, with careful design and planning, a CAM study can be successfully executed. Second, even though there was not a statistically significant reduction in tics in the treated patients, some children did have favorable outcomes. Equally importantly, there are now favorable safety data on the use of O3FAs in children and adolescents. Is this the end of the story? Hardly. Replication and careful assessment of other possible outcomes will be essential, but this is surely a demonstration that a CAM treatment can survive the rigors of standard empirical investigation. It seems quite clear that there are a wide variety of other treatments that are considered to be in the realm of CAM. And, they appear to be in very wide use. Indeed, some have estimated that as many as 75% of American adults use CAM treatments at some point with about 60% using such treatments in the past 12 months