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82 HEALTH VITAMINS MINERALS AND SUPPLEMENTS COMPLEMENTARY AND ALTERNATIVE MEDICINES FOR IMPROVING MENTAL HEALTH Pam Stone Pam is an accredited naturopath and medical herbalist with 35 years of experience in the complementary medicine industry. Her career has spanned senior roles covering development and delivery of evidence-informed education to pharmacists and other health professionals, with a focus on the clinical application of complementary medicine in pharmacy practice. LEARNING OBJECTIVES After completing this CPD activity, pharmacists should be able to: • List the common complementary medicines used for mental health conditions. • Decribe the evidence supporting complementary medicines for mental health conditions. • Identify the potential interactions between complementary medicines commonly used for mental health and prescription items. 2016 Competency Standards: 3.1, 3.2, 3.5, 3.6. Accreditation Number: A2105RP2 (exp: 30/04/2023) The World Health Organisation cites mental health as being more than just the absence of a mental disorder. It’s a positive state of balance, both within and with the environment and is the foundation for the wellbeing and effective functioning of an individual. Many interrelated factors create this balance, with inseparable links between mental and physical health.1 Mental health is commonly viewed as being a continuum, from ‘healthy’ at one end, to ‘unwell’ at the other. This continuum extends from a healthy and adaptive coping state towards a mild and reversible distress state, to more severe and persistent impairment, through to a clinically significant mental disorder.2 Where we sit on the continuum at any time can shift depending on a range of factors including life experiences, the cumulative effects of stress, our levels of resilience and levels of support. Modifiable lifestyle behaviours are known to impact mental health. These include alcohol, smoking, diet and exercise.3,4 A number of complementary medicines have evidence of benefit as supportive interventions, along with complementary therapies such as cognitive behavioural therapy (CBT) and self-help techniques such as yoga, meditation and tai chi. Used alongside lifestyle modifications, they can provide useful options as adjunctive therapy for maintenance of good mental health. They don’t replace the need for professional assessment and management of clinically significant mental disorders. People may not seek appropriate support for mental health issues for a number of reasons, including lack of awareness, stigma surrounding mental illness and limitations around some prescription medications due to possible side-effects. As trusted and accessible health professionals, pharmacists are well placed to provide evidence based advice to patients seeking complementary medicines and discuss the need to visit a GP. This can be particularly useful where early intervention can prevent stress becoming a chronic issue, with increased risk of more serious mental health issues. Stress and anxiety Anxiety is the most common mental health condition.4 Anxiety is a normal reaction to stress and can be beneficial in some situations. However, anxiety disorders differ from normal, occasional feelings of nervousness or anxiousness and involve excessive fear or anxiety, often about everyday situations. Specific anxiety disorders include generalised anxiety disorder, social phobia, panic disorder, PTSD and obsessive-compulsive disorder. The ability to cope with stress is integral to good mental health, with accumulative, ongoing stress often playing a part in development of anxiety and depression. Chronic stress and anxiety are also often accompanied by a range of somatic symptoms such as headaches, muscle tension, fatigue and exhaustion, sleep disturbance, panic attacks, palpitations, dizziness and digestive disturbances.5,6 A number of herbs are known to act as stress-response modifiers, increasing nonspecific resistance to stress and promoting adaptation. As such, they are known as adaptogens. The mechanism of adaptogens appears to involve the hypothalamic-pituitary-adrenal axis, one of the main stress-response pathways, with resultant decreases or normalising of nitric oxide and cortisol, which are increased during times of stress. Adaptogens are considered to be metabolic regulators that help protect against physiological stress-related damage.7,8 Ashwagandha (withania somnifera) Ashwagandha, also called withania, Indian ginseng and winter cherry, is one of the most valued botanicals in Indian Ayurvedic medicine, where its use dates back 3000-4000 years. It’s now classed as an adaptogen and is indicated for anxiety and nervous exhaustion and to reduce the negative physiological effects of stress. The plant contains a range of bioactive constituents, including alkaloids and the steroidal lactones withanolides, glycowithanolides, sitoindosides and withaferin A. Its GABAergic effects are believed to be responsible for its clinical benefits.9 A clinical picture for a patient that may benefit from ashwagandha would be one who is exhausted but can’t relax, or ‘tired and wired’. Evidence Studies consistently suggest that ashwagandha root extract reduces psychological and physiological markers of stress, improves mental wellbeing, reduces serum cortisol levels and improves stress- related eating behaviours. • A 2012 RCT (n=64) reported a significant reduction in stress-assessment scales after two months relative to placebo. Dosage used was a 300mg extract taken twice daily. Serum cortisol levels were substantially reduced, with findings suggesting that ashwagandha safely and effectively improves an individual’s resistance to stress and self-assessed quality of life.10 • A 2016 RCT (n=50) with a dose of 300mg twice daily measured serum cortisol, body weight and body mass index in chronically stressed subjects. After four and eight weeks, the ashwagandha root extract was more effective than placebo in achieving a statistically significant reduction in serum cortisol, body weight and body mass index. This was related to reductions in food cravings and better eating behaviour.11 • In a 2020 six-week RCT with 40 patients with generalised anxiety disorder, 1gm/day of the extract produced a significant amelioration of HAM-A scores versus placebo.12 RETAIL PHARMACY • MAY 2021 2 CPD CREDITS