Complementary and alternative therapies

OCD is one of the most commonly occurring mental health disorders. It affects about 2% to 3% of people in Western general populations. It is characterised by recurring intrusive thoughts that are very hard to prevent or control (the obsessions).

These lead to irresistible and recurring behaviours (the compulsions or rituals). Compulsions are actions taken to negate or resolve the disruptive, anxiety provoking and disturbing thoughts. A familiar example are those individuals so fearful of “contamination” from everyday activities, such as using a keyboard, touching a doorknob, or handling a notebook, that they feel compelled to scrub their hands with soap and water or a disinfectant many dozens of times a day and despite raw skin from the cleansers.

Other unwanted obsessive thoughts can have more disturbing and aggressive themes. Intrusive thoughts/obsessions/compulsions may occur so frequently that they disrupt personal relationships, work, sleep and almost all other aspects of daily life.

Many people experience troubling, unwanted thoughts occasionally. However, in those without OCD, these thoughts are given little importance, do not necessarily compel any actions, and easily disappear. By comparison, in those with OCD, the thoughts or impulses are intense, relentless and can cause tremendous anxiety, guilt, and disgust.

The themes of the intrusive thoughts in people without OCD may be quite similar to those occurring in OCD. It is not necessarily the nature of the obsessive thought that defines OCD, but rather how that thought is interpreted and acted upon by the patient.

Regrettably, OCD is usually a lifelong condition that waxes and wanes in intensity and frequency. Treatment can help manage the obsessions and compulsions, so that they are less disruptive. However, existing treatments for OCD are often ineffective, which is why we are pushing for the development of new and better treatments for this devastating condition.

Plant-based medicines have been tested in anxiety disorders, but only a few have undergone a clinical trial for OCD.

Plant-based medicines have been tested in anxiety disorders, but only a few have undergone a clinical trial for OCD. These are St. John’s wort, milk thistle, borage, and valerian root. While there are several other plant-derived treatments used for OCD, information is far too scant to judge any effectiveness. These include Kava and Wisthania somnifera root extract. However, a number of plant-based remedies have been convincingly found to have a degree of effectiveness in primary depressive and anxiety disorders.

From a general safety standpoint, the majority of herbal remedies are exempt from regulatory oversight, and therefore at risk for poor manufacturing processes, including the presence of potentially harmful contaminants.

JOHNS WORT (HYPERICUM PERFORATUM)

St. John’s wort (SJW) appears to be useful for mild to moderate depression; in some studies the effect was similar to an SSRI.

St. John’s wort (SJW) appears to be useful for mild to moderate depression; in some studies the effect was similar to an SSRI. Several case reports and uncontrolled trials also suggest some efficacy in anxiety disorders, but this is not a firm finding. While its actions on neurotransmitters in the brain are incompletely understood, they include increased serotonin levels.

Although a small trial of SJW for OCD in 2000 was encouraging, this same group conducted a more recent 12-week controlled, double blind clinical study of SJW and placebo in 60 individuals with moderate to severe OCD. At the end of treatment, the SJW group had Y-BOCS and anxiety rating scores that were virtually the same as the placebo group and only minimally different from their baseline values. Side effects from SJW include anxiety, panic attacks, headaches, nausea, abrupt increases of blood pressure, dry mouth, and skin irritation associated with sun exposure.

It is important to recognise two additional potentially harmful effects. SJW can interfere with the effectiveness of a number of critical drugs by lowering their concentrations. Among these are birth control pills, blood thinners, heart disease drugs, and several drugs used to treat human immunodeficiency virus (HIV), cancer, and anti-rejection medications used in organ transplantation. There also is the risk of excessive and potentially dangerous levels of brain serotonin when SJW is combined with an SSRI or similarly acting drug.

There is little current evidence of a beneficial role for SJW in OCD. This observation, as well as its side effects and potentially harmful interactions with other drugs, should dissuade its use.

MILK THISTLE (SILYBUM MARIANUM)

This plant, a member of the same family as sunflowers and daisies, has been used over several millennia for a wide range of medicinal applications.

This plant, a member of the same family as sunflowers and daisies, has been used over several millennia for a wide range of medicinal applications. The authors of a recent study remarked that folklore in their particular region (Iran) has long considered milk thistle to be a remedy for obsessions and compulsions. Silimarin has been identified as a principal active compound in milk thistle. Among its several actions, silimarin acts on several brain neurotransmitters, including enhancement of serotonin activity. In what currently appears to be the only controlled study of a possible role for OCD, milk thistle was compared to the SSRI fluvoxamine in an eight-week trial. All study subjects had baseline Y-BOCS scores of ≥21 points and were off all psychopharmacological drugs for a minimum of six weeks. While the average Y-BOCS scores progressively decreased for both the SSRI and milk thistle groups, the fluvoxamine and milk thistle groups decreased by about 11 and 12.5 points respectively, with average outcome scores of 17 and 20 for fluvoxamine and milk thistle, respectively. Although these are highly significant improvements, the comparative outcomes of the two groups were essentially the same. Several aspects of this study, however, raise some questions. First is that authors do not make clear whether the baseline Y-BOCS scores were comparable to those obtained before drug therapy was stopped, particularly since the actual average score for the entire group was about 41. Also, this study was conducted over eight weeks, and given the longer period of time before SSRI effects are maximized it is not known whether a longer study period would have shown different outcomes. The types and frequency of side effects for both groups were essentially the same, and typical for those that occur with SSRIs. Milk thistle can also affect the metabolism of other drugs and thus should not be taken without professional guidance.

BORAGE (ECHIUM AMOENUM)

Borage is another herbal preparation that has been used as a remedy for numerous conditions over a period of time that extends, at least, back to its use by Romans several hundred years BC. Among its many cited properties are benefits for anxiety and mood disorders. Its anxiolytic and sedative properties have been demonstrated in humans with claims of comparability to diazepam (Valium). Its mechanisms of action are, as yet, unclear, and only one direct study of its use in OCD could be identified. A preparation from dried borage flowers was tested in a controlled, six week study (108). Both Y-BOCS scores, and Hamilton Anxiety Rating Scales (HAM-A), were tested repeatedly during the treatment period. At the conclusion of the trial, significantly lower Y-BOCS scores were observed in the treatment group compared to those given placebo. Overall, however, the amounts that the scores decreased were considered to convey little overall improvement of OCD symptoms. Consistent with previous observations, however, the HAM-A scores improved significantly for those receiving borage. The authors concluded that, although the OCD findings were disappointing, the effects on anxiety were of merit since generalised anxiety is common in patients with OCD. The uses of borage for OCD and in studies of other psychiatric disorders have reported little to no common side effects. However, borage may contain chemicals known as pyrrolizidine alkaloids that may cause liver injury or cancer if used in high doses over long time periods. For those taking borage, caution is advised to only use borage preparations that have been tested and deemed free of these potentially harmful compounds.

VALERIAN ROOT (VALERIANA OFFICINALIS L)

Valerian is a sweetly scented flowering plant, the root of which is dried and available as an herbal remedy.

Valerian is a sweetly scented flowering plant, the root of which is dried and available as an herbal remedy. It has long been used as a treatment for insomnia, particularly in the Middle East. Additional claims of effectiveness for other conditions such as anxiety, pain, and migraine headache have little scientific support. Compounds in Valerian root are believed to bind to the same GABA NT receptors as benzodiazepams. However, based on a single, small, controlled study of anxiety treatment, valerian was no better than placebo and inferior to diazepam. Given its effects on GABA, one small, but randomised and controlled eight week investigation of valerian root was carried out with OCD patients whose baseline Y-BOCS scores were at least 21. The patients were taking no other medications for at least two weeks before the study began and were not receiving CBT. The principal finding was that treatment with valerian root resulted in significantly superior reductions of Y-BOCS scores compared to controls. These differences first appeared after four weeks of treatment. Like the anxiety study, however, only this one small OCD investigation of OCD is reported, and there is insufficient evidence to draw any conclusions about the efficacy of valerian for OCD. Treatment with valerian root appears to be well tolerated, and side effects are minor, although it is not surprising that more than half of those treated with valerian experienced somnolence. The investigators also made the point that there is no reported sexual dysfunction that has been attributed.

Alternative medicine is developing a firm foothold in several niches of Western medicine, although skeptics are wary of these treatments and await the results of more conventional study methods in sufficient numbers of patients. As is also true for many of the nutrition and herbal remedies discussed previously, the assessments of acupuncture and psychosocial therapies for OCD are hampered because most of the data are based on case reports and/or studies of generally poor quality. Nonetheless, appropriately designed research studies are appearing. Most clinicians would agree that statistical proof of benefit is only a part of an assessment of effectiveness for a particular clinical intervention, and experience does matter a great deal. Also, even if not OCD specific, many acupuncture and psychosocial methods show promise for management of anxiety and depression, and are likely to be of interest to many OCD patients. It is strongly recommended that patients considering alternative or complementary treatments should first have an open discussion with their principal therapists. They often will offer opinions about which forms of these alternative therapies would be most complementary to the person’s treatment goals.