Post-Traumatic Stress Disorder

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Vergleich: Siehe: Gulf War Syndrom + Depression + Stress

4 main types of Post-Traumatic Stress Disorder.

All involve the same symptoms and are only differentiated by the length of time the symptoms have been manifested. Acute Stress Disorder: Acute Stress Disorder

is diagnosed when symptoms occur within four weeks of the traumatic event and last for more than two days but less than four weeks. Acute Post-Traumatic Stress Disorder: Acute post-traumatic stress disorder is diagnosed when symptoms last for more than four weeks.

Delayed Onset Post-Traumatic Stress Disorder: This form of the disorder may not appear until years after the initial traumatic experience. Chronic Post-Traumatic Stress Disorder: This form of PTSD is diagnosed when symptoms last for more than 90 days. The patient will likely experience lapses in symptoms for a number of days or weeks in a row, but the symptoms will always return. 5 Examples of traumas that can lead to PTSDor Acute Stress Disorder

• military combat

• violent personal assault (physical attack, mugging, robbery)

• being kidnapped or taken hostage

• torture

• incarceration as a prisoner of war or in a concentration camp

• natural disaster (earthquake, fire, tornado, hurricane)

• terrorist attack

• serious automobile accident

• serious accident at work or in the home

• sexual abuse during childhood

• sexual assault or abuse

• being diagnosed with a life-threatening illness

• unexpectedly observing the serious injury or unnatural death of another person

It has also been my experience that young children may develop PTSD as a result of parents having loud and/or violent arguments in front of their children. Unfortunately, I have seen many cases of this. As a matter of fact, while I am writing this chapter, one of my young patients is recovering from such a terrifying experience. In these cases family therapy is essential. In some cases, individual homeopathic prescribing for one or both parents might also be indicated as there may

be some significant psychological pathology, including PTSD, undiagnosed in one of the parents.

Conventional treatments for PTSD and Acute Stress Disorder

Most of the treatment guidelines suggest psychotropic medications (psychopharmacology) +/o. various types of psychotherapy. While certain types of psychotherapy have been consistently shown to be effective in treatment of PTSD, evidence for the effectiveness of psychotropic medications has been at best inconclusive. Remarkably, one of the most frequently used prophylactic psychological tools, a brief psychological intervention (debriefing), which is conducted immediately after exposure to a stressful event, has also been reported as ineffective in preventing the development of PTSD. A large proportion of female PTSD victims opt for psychotherapy over medication. The reasons most frequently cited are the effectiveness (or lack there of) of a treatment, including potential masking of symptoms with the medication and, more logical, long-lasting effects with the psychotherapy. There is also evidence suggesting that, in depressed patients with a history of early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect), psychotherapy alone was superior to antidepressant monotherapy. Various ethical issues that exist around the research, production, and marketing of anti-depressants and other psychotropic medications also make the efficacy and safety of psychophar-macology highly questionable. Amazingly, some allopathic physicians have suggested that there is no evidence that conventional medication, including psychotropic medications, "are likely to do more good than harm in the long term" and that "although several drug classes (and possibly some antidepressants) are known to induce psychic indifference, the utility and desirability of this effect is doubtful". As a matter of fact, the authors cited above represent a group of physicians

who question the so-called "drug-centered approach;" at the core of their objections is the fact that conventional drugs, instead of treating the target problem, create

a different state in the brain or the body (sedation) that simply suppresses symptoms of the illness rather that treating them. Dr. Hahnemann would be very happy to

read such a statement coming from the "old school!"

Homeopathic approach to PTSD

While there is ample evidence characterizing the risks and benefits of conventional treatment of PTSD, there are no controlled studies that I was able to identify on the efficacy (or lack of thereof) of homeopathy for this fairly prevalent disease. This comes as no surprise to anyone involved with homeopathy. The need for well-funded, well-designed studies of homeopathy has been acknowledged on numerous occasions by the homeopathic community. The problem is that no one with significant funds wants to finance such studies. The only attempt to conduct such a study was undertaken in 2006 by Dr. Iris Bell, who received funding from the Samueli Institute for

a pilot study on PTSD. The writer of this chapter was one of the homeopaths contracted to conduct the study. Unfortunately, this very well designed study had an early termination owing to one of the most common phenomena of PTSD described above: most of the subjects refused or were unable to participate in the study.

A cursory search of the literature within the National Library of Medicine (http://www. ncbi. nlm. nih. gov/) gives us a very rough estimate of the research basis in CAM and mental health care: when doing a search with the keywords "Complementary Medicine" (as a Mesh heading) the library returns 130,098 references. Only 0.3% (N=362) of these references deal with the Mesh heading "Mental Health" whereas another 9.8% (N=12,700) cover the Mesh heading "mental disorder". When doing

the same with "Homeopathy" as a keyword (not as a Mesh heading) we end up with 3,832 references in total. Of these 0.3% (N=l) have to do with "Mental Health" (Mesh Heading) and 2.8% (N=108) cover the topic of "Mental disorders" (Mesh heading). This shows us that mental disorders play only a marginal role in CAM and mental health is covered even less. It also shows us that the evidence base of homeopathy and mental health care is even more limited. Some authors claim the right question to ask here would be "Are homeopathic dilutions any more than placebo?" whereas others state that there are many more pertinent questions to answer when researching homeopathy. For example two authors who have more than 20 years of expertise behind them propose:

Our suggestion would be that we should be asking different questions than whether homeopathy is different from placebo. These questions include: How effective is homeopathy compared with other treatments? What is the baseline chance of patients improving or being healed under homeopathic treatment-

How stable are treatment effects?

What are good prognostic indicators for success in homeopathic treatment?

How much does success with homeopathy cost compared to conventional treatment?

What are the risks of side effects in homeopathy weighed against the odds of improvement?

In terms of promising and useful research designs the authors continue to "suggest that some of the following studies could be a main focus of any research agenda

in homeopathy":

• Observational and cohort studies to determine the general effects of homeopathy.

• Combined with an analysis of large sets of prognostic factors on doctors and patients, among them personality traits, measures of expectancy, hope, self-involvement, sympathy.

• Randomized comparison studies to determine effectiveness compared with alternative treatments.

• Quasi-experimental comparison studies in natural, self-selected groups to find out about the importance of self-selection.

• Combined with measures of cost and safety.

• Studies of biological activity of Serially Agitated High Solutions or the question of whether homeopathic dilutions are placebos should be delegated to stable, basic research models.

• Those who still believe in the superiority of homeopathy over placebo in clinical trials should try to replicate one of the promising positive results reported so far

and book a therapist for the time after the trial.

After setting the agenda for homeopathy research and beginning to map results from homeopathy and mental health care to research designs and questions, we feel that a serious warning is in place.

The authors of the lists above correctly stated that until 2002 there was no research whatsoever which can answer the pertinent questions and there is a significant lack

of trials and studies reporting results from the latter research designs. Bearing this in mind we have to expect a lot less research in mental health care. This is in fact what we found even today in 2009, and thus we cannot provide definite answers under the following subheadings.

2.1 Research in homeopathy and mental health care

In order to provide a comprehensive picture of research that links homeopathy with mental health issues, we would like to present results from basic research as well as from large and small quantitative and qualitative studies.

2.7.7 Basic research

Basic research in homeopathy is rather scarce compared to clinical studies. Thus, as we would ex-pect, studies exploring homeopathy in cells, plants or animals which model situations applicable to the mental health context are even rarer. Additionally, the general notion is that results are difficult to repeat, effects are seen then and again, but no generic rule exists about what test systems, which dilutions or what remedies yield consistently positive results.

One study from Brazil reports two experiments in Swiss mice and the application of Chamomilla (6 C). The data suggests that mice getting Chamomilla per os recover more quickly after stressful conditions compared to controls. Regarding the antidepressive effect of Chamomilla in mice, the results show that Chamomilla is less effective than amitryptilin, but definitely alters behaviour (swimming test) compared to baseline. The conclusion from this behaviour test model is that mice are less susceptible to depression after application of Chamomilla. For all who would like to embark on basic research of homeopathy and mental health models we would like

to share the advice this author had to give. He points out that, particularly in testing basic research models for mental health context, it is important to control for the effect of ethanol (mostly part of the manufacturing process of homeopathic remedies) as ethanol clearly has anxiolytic and antidepressive effects.

2. 7. 2 Systematic reviews and randomized controlled studies

Prominent research results from conventional depression treatment set the stage for what effect sizes could be expected in mental health research involving placebo controls, more specifically in depression research. A meta-analysis done by Kirsch et al. on published and unpublished data showed that people got better on medication, but they also got better on placebo, and the difference between the two was small, namely roughly a third of a standard deviation [18]. Clinical sig-nificance was only found in (a few relatively small) studies conducted on patients with very severe levels of depression. These results were based on data from all clinical trials conducted for marketing approval of the six most widely prescribed antidepressants approved in recent years in USA, which represent all but one of the selective serotonin reuptake inhibitors (SSRIs) approved during the study period. This result is virtually identical to one published in parallel pointing out the relative lack of effectiveness of SSRIs compared to placebo, mainly due to the strong placebo effect [19]. 267

Apart from the small effect size which has to be expected in depression care, there is a significant lack of large and well-conducted randomized controlled studies (RCTs) in homeopathy and mental health problems. Thus, to date it is not possible to draw any definite conclusion with respect to the effectiveness of homeopathy over placebo or even over conventional care in the areas of psychiatric diseases [20]. Bearing in mind what was said at the beginning of this chapter that researchers and clinicians are often openly against the idea of applying homeopathy in psychiatric care, there is virtually no room (or money) for doing randomized controlled studies. Moreover, with small effect sizes large numbers of study participants are needed, complicated by the fact that patients seeking CAM are often unwilling to be randomly assigned to treatments. A feasibility study of an RCT of homeopathy for depression in general practice showed tellingly: In this three-armed study (comparing individualized homeopathy vs. Prozac vs. placebo) the recruit-ment total over nine months was 31 patients who were potentially eligible out of 230 patients who were seen for depression. Of these, 23 met the inclusion criteria using DSM-IV and Hamilton Ra-ting Scale for Depression (HAM-D), 11 could be randomized and 6 completed the study. The major reason for not entering the study was the preference for homeopathic treatment. Thus, patients were not prepared to take the risk of getting either Prozac or placebo, but were prepared to embrace homeopathy. Apart from the latter study which was too small to report results in terms of effects, there is one controlled study in the field of depression and anxiety; see below. A study of individualized homeopathy versus placebo in fibromyalgia patients reported less depression in homeopathically treated patients. Other RCTs studied the effectiveness of homeopathy in generalized Anxiety Disorder, in Chronic Fatigue Syndrome or in Attention Deficit Hyperactivity Disorder in a juvenile sample. These studies will be described in detail below. One two-armed pilot study comparing homeopathy with placebo in Pre-Menstrual Syndrome suffered also from recruitment problems, nonetheless results are available and will be presented below.

2.1 Randomized controlled trial in depression and anxiety

There is one published RCT comparing a homeopathic complex therapy (L 72) with the use of Diazepam in mixed states of anxiety and depression.

Although the initial report states that L 72 is as effective as Diazepam with a slight trend in favour of homeopathy, subsequent systematic re-views pointed out major flaws. These were: inappropriate use of Diazepam as this is an anxiolytic drug, but not useful in treating depressive symptoms. Also, missing information on the randomization process, as well as on blinding, compliance and co-interventions led to quality scores below the threshold for including trials in a systematic review. Another RCT compared the results of a placebo group of 22 patients with the psychiatrically con-firmed diagnosis of generalized anxiety disorder to a drug group of 22 patients which were treated with individually assigned homeopathic remedies [26]. Initially patients got one single dose of the homeopathic drug in 1M or 200C potency (or placebo), but were re-evaluated after six weeks and the remedy could be changed if necessary. Results were the score on the Hamilton Rating Scale for Anxiety (HAM-A) as primary outcome with the Hamilton Rating Scale for Depression (HAM-D) and other scales measuring depression, anxiety, wellbeing and subjective distress as secondary out-comes. In terms of effectiveness of homeopathy over placebo, no difference whatsoever could be detected, either at five weeks or at ten weeks after the initial dose. However, all measures except trait anxiety showed highly significant improvements in both groups over time.

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