Quotes of the Month

Alternative Medicine
     Dr. Ed Furber, Fort Worth Psychiatrist, recently presented at our weekly Journal Club meeting. He reported on several articles dealing with alternative medicine, which is currently a popular subject in the medical literature. After listening to his presentation, I thought alternative medicine would make an interesting topic for the monthly Webletter. Its scope is enormous therefore I am only going to address the concept and discuss some common drugs used in mental problems.
     According to a report by Eisenberg, et. al., in JAMA (1998;280:1569-1575), Americans spend an estimated 27 billion dollars for alternative medicine, related professional services, and products per year. The popularity of these substances and over the counter medications derived from herbal sources is rapidly growing. Many herbal medications have potent pharmacological properties and have potential dangerous side effects. In addition, some of these preparations contain active ingredients that can adversely react with other medications, both over the counter and physician prescribed.
     These so called alternative medications are not regulated by The Food and Drug Administration (FDA), which is the only regulatory body available for this type of needed supervision. There is no organized research program that studies their potential beneficial or egregious properties. Many beneficial and potent medications such as digitalis, curare, and quinine are derived from plant sources, but these are controlled substances which are available to the public by prescription only. These alternative herbal medications may offer the same type medicinal benefits if they are properly analyzed so their active components can be synthesized and economically manufactured.
     I am going to list some of the more popular preparations Dr. Furber discussed and describe their use and potentially harmful side effects.

     1. Ginkgo Biloba and related Compounds in Alzheimer's Disease by Barbara R.Sommer, M.D. and Alan F. Schatzberg, M.D. (Dept of Psychiatry Stanford Univ. School of Medicine. Psychiatric Annals 31:11/Nov.2001) Ginkgo Biloba comes from the maiden hair tree and it's active ingredient is Egb which is in the fruit, nuts, and leaves. Egb contains many compounds and their relative concentrations and potency will vary in different brand preparations. The complexity of the extract makes purification into one molecule difficult and also potentially less effective.
     Ginkgo Biloba is commonly prescribed in Germany for the treatment of cognitive impairment. According to the authors listed above 1997 sales in the United States, as a dietary supplement amounted to $90 million.
     The authors conclude that Ginkgo Biloba may be helpful in cognitive clinical problems such as Alzheimer's Disease but an analysis of current studies is inconclusive to warrant a positive recommendation for treatment. Ginkgo Biloba also has a potential for blood coagulation abnormalities if patients are taking large amounts of Vitamin E or aspirin. The authors also recommend additional prospective studies especially those extending over a longer time period.
     Ed. This conclusion illustrates what I previously stated. The potential for effectiveness is there but it must be logically researched.

     2. Hypericum Perforatum Extract (St. John's Wort) for Depression. This is another article in the Nov.2001 issue of Psychiatric Annals by Ronald Brenner, M.D., et. al. These authors state that Depression is a chronic disorder and equates its morbidity to that of hypertension and diabetus melitus. This malady is widespread in the United States and is a costly burden to both old and young patients.
     There are many conventional treatments for depression such as electro-convulsive therapy, psychotherapy, and medications. In Germany hypericum or St. John's Wort is one of the most widely prescribed preparations for depression. There were 3.7 million prescriptions written in 1997 for it and this represented over 25% of all antidepressant prescribed drugs.
     The exact mode of action and the active ingredient of hypericum in depression has not been identified. St.John's Wort has had very few adverse events in studies which compared it to a placebo. Photo-toxicity has been rarely reported. It also has the potential of reacting and negating the effect of immunosuppressive drugs used in surgical transplant patients to prevent rejection.
     The authors state that depression will be an increasingly important problem in the United States especially as the population continues to age rapidly. They conclude that St. John's Wort could play a very important role in the treatment of mild to moderate depression in controlled situations.
     Ed. More detailed analysis of this preparation may discover the active ingredient which might lend itself to synthesis thus making it even more cost effective.

     Other preparations described in the Nov. 2001 issue of Psychiatric Annals are:

     1. S. Adenosylmethionine (SAMe) occurs naturally in all living cells and has been shown to be quite effective in treating depression. It has few side effects and a high level of safety. It can cause a manic state especially in those patients with a bi-polar disorder.
     Ed. This drug definitely needs more research so it can be available as a prescription medication in the U.S.

     2. Kava: This is an extract from the kava shrub and its use originated in the Polynesian Islands. The natives drink a kava beverage and claim it has a calming effect. It has become popular in the United States and is primarily used for anxiety states. Studies have shown that kava may be more effective than a placebo in the treatment of mild anxiety. It supposedly acts as a muscle relaxant. Toxic symptoms have been reported with high doses of the medication. There is a possibility that patients could become tolerant or dependent after long time usage.

     3. Valerian: The root of Valeriana officinalis has been used as a drug for more than a 1000 years according to Dr. David Mischoulon. It is used as a sedative and mild hypnotic. Studies have shown that toxic symptoms are rare and the drug may have the potential for treating insomnia with no adverse effects.
     Ed. Again,more scientific studies of the plant kingdom in regards to current medicinal usage and additional treatment potentials is certainly warranted but it must be done under some type of control and this means governmental supervision for the safety of the United States population. I realize I have been redundant and we don't need more governmental control but unfortunately the FDA is currently the only regulatory body that has any authority to enforce rules and regulations and insist on maintaining standards derived from scientific research.
     When patients go to their doctor they should volunteer that they take alternative medications just as they list all prescription drugs taken. When patients go in for surgery they should voluntarily stop all alternative medication 5 days prior to the procedure.
     All of this is necessary until the pharmacology of all of these alternative herbal medications is known as well as that of conventional regulated drugs.

"The art of medicine is my discovery. I am Help-Bringer
Throughout the world and all the potency of herbs
Is known to me."
     - Ovid (43BC - 17AD) Roman Poet spoken by Apollo

"Anything green that grew out of the mould
Was an excellent herb to our fathers of old."
     - Rudyard Kipling (1865 - 1936)
Take care until next time,
Richard J.Turner, III, M.D., F.A.C.S.

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