Adolescent Psychiatry - Volume 5, Issue 2, 2015

Background: Complementary and alternative medicine (CAM) has become increasingly popular over the past 20 years and is used by many adolescents and their families. CAM includes a host of integrative approaches whose difference from traditional medicine center around its holistic rather than compartmentalized approach to the patient, in which evaluation of health and well-being considers the mind, body, and spirit. Methods: This article provides an overview of both pharmacologic and non-pharmacologic approaches, with a focus on 1) how CAM can be used in clinical practice; 2) how to best choose amongst available approaches guided by research findings that provide information to maximize safety and efficacy. Two hypothetical cases illustrate how to apply the research base of evidence to patients and thus avoid diagnostic pitfalls and safety concerns. Results: Current research points to the efficacy of CAM in adult and adolescent populations and the efficacy of interventions that include attention to good nutrition, regular exercise, sunlight, and hygiene, especially as these interventions may prevent or reduce the incidence of conduct disorder. Recent studies suggest that CAM treatments can improve overall functioning and reduce difficulties such as insomnia, depression and aggression that occur due to anxiety, attentional deficits, and mood disorders. Conclusions: It is important to acknowledge the current public perception that CAM treatments are less likely to cause serious adverse effects as compared to conventional treatments. More studies of adolescent populations critical to confirm which complementary and alternative medicine treatments are both safe and efficacious. An informed open-minded attitude to non-conventional approaches has the potential to improve outcomes and trust amongst parents, adolescents and mainstream medical and behavioral health staff.

Background: Complementary and alternative medicine (CAM) in psychiatry or integrative psychiatry covers a wide range of biological, psychological and mind-body treatments that enhance standard medical practices and patient outcomes. While CAM approaches are popular among patients, health professionals have received limited education in these interventions and they are often unaware of their patients’ use of CAM treatments. Method: This overview highlights evidence-based CAM treatments for attention deficit hyperactivity disorder (ADHD) including dietary interventions, phytomedicines, mind-body practices and neurofeedback. Results: While conventional treatments are the mainstays for ADHD, there are a large number of available treatments that can be used to enhance treatment response. Conclusion: With improved education and further scientific and clinical research, validated integrative treatments will provide more effective, lower risk and lower cost care for patients with ADHD.

Background: Adolescents are at elevated risk for using and experimenting with substances such as alcohol, nicotine and marijuana. Research has demonstrated not only the harmful effects of these drugs on the developing brain, but that individuals with early use have a higher risk for substance use disorders (SUD’s) later in life. Given the current prevalence of substance use among youth, resources are needed to study, develop, and implement safe and effective treatment modalities. Because of the dearth of conventional medications for SUD’s, alternative methods of treatment must be explored. Complementary and alternative medicine (CAM) is a growing field with an ever-increasing evidence base. Method: This paper presents a qualitative review of the present-day use of CAM within adolescents, and creates a conceptualization for its potential in treating substance use disorders. Results: Mindfulness and yoga were found to have the largest evidence base, with limited current support for the use of acupuncture and supplements such as melatonin and St. John’s Wort. Further research is warranted to determine the true efficacy of these treatments in the adolescent population. Conclusions: With the favorable safety profile of many of these forms of treatment, their use should be considered despite the limited evidence, especially in those who have failed other options.

Background: Sleep disturbance, including insomnia, is a major health issue among both adults and adolescents. Mindfulness-based interventions (MBIs) have recently received increased attention as a non-pharmacological treatment option for patients with insomnia. Objectives: This meta-analysis assesses the effects of MBIs on sleep disturbance in the general population. Methods: A literature search was conducted using PubMed, Medline, PsychInfo, Google Scholar, and Cochrane library. The search terms were “mindfulness therapy”, “mindfulness based cognitive therapy”, “mindfulness based stress reduction”, “acceptance and commitment therapy”, and “yoga” crossed by “insomnia”, “adults”, “adolescents”, or “children”. All studies in English-language were examined through October 2013. Sixteen studies from different age groups were included in this meta-analysis. Sleep measurements were evaluated before and after MBIs, using both subjective as well as objective methods. Long-term effects were also examined. Results: The meta-analysis included 575 individuals across 16 studies. Ages ranged from 8-87 years and 82.09% of participants were female (472/575). MBIs were associated with increased sleep efficiency (SE; ES = 0.88; p & 0.0001) and total sleep time (TST; ES = 0.47; p = 0.003) as assessed by sleep log. Additionally, wake after sleep onset and sleep onset latency decreased (WASO; ES = -0.84; p & 0.0001; SOL; ES = -0.55; p & 0.00001). Changes in sleep when measured by polysomnography and actigraphy, however, were not statistically significant. Sleep improvements as assessed by sleep log continued 2-6 months following treatment initiation. Interpretation is limited by the small number of studies on MBIs for insomnia, especially in adolescent populations. Conclusion: This meta-analysis suggests efficacy of mindfulness-based interventions for improving sleep, as assessed by subjective sleep logs but not by objective measures, and this continued several months after treatment initiation. More research is needed to explore this promising treatment option for adults and adolescents with insomnia.

Background: Mind-Body practices constitute a large and diverse group of practices that can substantially affect neurophysiology in both healthy individuals and those with various psychiatric disorders. In spite of the growing literature on the clinical and physiological effects of mind-body practices, very little is known about their impact on central nervous system (CNS) structure and function in adolescents with psychiatric disorders. Method: This overview highlights findings in a select group of mind-body practices including yoga postures, yoga breathing techniques and meditation practices. Results: Mind-body practices offer novel therapeutic approaches for adolescents with psychiatric disorders. Findings from these studies provide insights into the design and implementation of neuroimaging studies for adolescents with psychiatric disorders. Conclusions: Clinical neuroimaging studies will be critical in understanding how different practices affect disease pathogenesis and symptomatology in adolescents. Neuroimaging of mind-body practices on adolescents with psychiatric disorders will certainly be an open and exciting area of investigation.

Objective: Despite recent advancements in treatments, prognosis for PTSD is still poor and there are limited therapeutic options. Because of feasibility and acceptability issues with many existing treatment options, this challenge is even more pronounced in adolescents with PTSD. The extinction-only based treatments including prolonged exposure therapy (PE) have significant limitations in terms of tolerability and efficacy. Method: This paper presents an overview of Trauma Interventions using Mindfulness Based Extinction/Reconsolidation (TIMBER), a translational mindfulness based psychotherapy for PTSD, which was developed by the first author, and preliminary results of this treatment in four adolescent patients. The methodology of TIMBER integrates principles of mindfulness based graded exposure therapy with neurobiological understanding of trauma memories including the interplay between the memory extinction and memory reconsolidation mechanisms that lead to formation and maintenance of the trauma memories in a dynamic way. TIMBER uses combined extinction and reconsolidation approaches, whereby reappraisal and modification of the trauma experiences are done via cognitive-emotive restructuring. The technique employs cognitive-behavioral and standardized Yoga and meditation interventions to induce new learning. This combined and targeted approach prevents restoration or re-expression of the trauma memories and the associated reactivity that lie at the core of the dysfunctions in PTSD. TIMBER has been tested in adults, either alone or in combination with medications. Results: All four patients remitted with respect to the symptoms of PTSD and associated dysfunction as measured clinically as well as based on their scores on PTSD specific rating scale. This improvement was maintained during follow-up of up to 8 months. Conclusion: Efficacy of TIMBER is currently being evaluated in a double blind randomized controlled trial in adult patients with PTSD. In this paper, we present the version of the TIMBER applicable to adolescents suffering from PTSD. Although further replication in future studies is necessary before drawing definite conclusions, preliminary data on efficacy of TIMBER for treatment of PTSD are encouraging. Further study in larger samples is necessary to confirm its usefulness in adolescent patients with PTSD.

Objective: Mental health treatment today incorporates neurobiology, genetics, neuro-imaging, and pharmacologic mechanisms, offering more options to patients. For some, these modern approaches are not viable choices due to reasons such as limited access to care, cost, intolerable side effects, and, in the pediatric population, fears of potential long-term effects. With the growing prevalence of chronic health conditions, concerns for age of onset, (McGorry, Purcell, Goldstone, & Amminger, 2011) and a growing population of mental health patients, cost-effective and evidencebased treatment options should be evaluated. Integrative treatments, also known as complementary and alternative medicine (CAM), may offer interventions that meet today’s clinical needs. Method: To evaluate evidence-based treatment options, we initiated the school-based integrative health program (IHP) in January 2011 at three high schools located in Massachusetts. Our goal was two-fold: first, to design a holistic treatment program and evaluate several integrative modalities, and; second, to determine the feasibility of providing a CAM health program through school clinics. Our protocol utilized three integrative treatments that addressed stress and anxiety conditions. Anxiety disorders are the most common mental illness affecting over 40 million adults in the US (Anxiety and Depression Association of America). Results: The program has been successfully implemented. Preliminary results indicate that this intervention decreased anxiety in these youth. Conclusion: Providing integrative techniques to students in the school setting has the potential to decrease barriers to accessing care, lowering treatment costs and decreasing school absenteeism by instituting care on-site. Offering a holistic approach to treatment in schools is feasible. Because utilizing these approaches involves their active participation, adolescents can acquire life-long skills that improve their ability to cope and confront inevitable life stressors.