Article by Dr Vladimir Gurevich - Senior Clinical Advisor at Health Point Physiotherapy

Depression, anxiety, panic attacks and other mental health disorders are very common. Epidemiological prevalence of mental health disorders varies significantly among different demographic groups and geographic regions (1, 2). These conditions impact various aspects of lifestyle. They could affect emotional and physical wellbeing, family relationships, social interactions, sports performance, learning capacity, ability to work and many other most important values hence depriving people of joy and happiness. These disorders often interfere with adherence to an appropriately balanced diet, engagement in physical activity which, in turn, aggravates the conditions. Implementation of effective treatment and prophylactic measures are necessary to manage these disorders.

There are many factors such as inflammation, stress, chronic pain, adrenal hormones such as catecholamines and cortisol, neurotrophins, endogenous opioids, redox homeostasis and others involved in the aetiology and pathogenesis of mental disorders. These disorders are often associated with comorbidities and could also lead to psychosomatic conditions. Diseases with complex multifactorial pathogenesis are often difficult to manage and might require combination therapy to achieve better treatment outcomes.

Pharmacotherapy utilising antidepressants, tranquillisers, anxiolytic and other psychotropic medications is usually prescribed as the first-line treatment (3). These treatments however might not be suitable or effective for some people for a variety of reasons (4). These reasons could include cases of treatment-resistant conditions due to individual tolerance to the effect of the pharmacotherapy, severe side effects, contraindications, interactions with other medications or supplements and others. Some people decide to discontinue pharmacotherapy due to pregnancy or lactation, aggravation of comorbidities or are reluctant to take medications because of their personal views. In such cases people might require alternative treatment options to manage their conditions without pharmacotherapy or in addition to it.

Complementary and alternative medicine modalities could be used as monotherapy or as an adjunct to medications. Alternative treatment options comprise a variety of approaches such as exercises, phytotherapy, electroacupuncture, dietary and other lifestyle modifications, massage therapy and other modalities. These treatment modalities work through different pathways leading, depending on their properties, to reduction of pro-inflammatory cytokines, increased secretion of neurotrophic factors, release of endogenous opioids, improved gut microbiota and other therapeutic effects impacting different pathogenetic factors and hence allowing to alleviate symptoms of depression, anxiety and other mental disorders and psychosomatic conditions. Their effectiveness was evident from various clinical studies.

The aim of this article is to briefly review some of these complementary and alternative to pharmacotherapy treatment modalities. Each of these modalities embraces a wide range of treatment approaches. To achieve better therapeutic outcomes these approaches could be used in combinations to work through different pathways. In the following sections some representative methods from various treatment modalities would be discussed.

Physiotherapy and exercise

The role of physiotherapy and exercise in treatment of mental disorders was extensively described in a variety of research and clinical studies. Physiotherapy and exercises reduce the severity of the conditions through various pathways. A combination of physiotherapy and exercise modalities is particularly effective in treatment of inflammatory processes. Inflammation is an established factor involved in the aetiology and pathogenesis of different mental disorders (5). It leads to release of pro-inflammatory cytokines and other mediators and is associated with pain aggravating mental disorders.

Physiotherapy modalities are very efficient in treatment of acute inflammation. This has a dual role in management of mental disorders. Reduction of inflammation limits the impact of cytokines and other inflammatory mediators implicated in the pathogenesis of mental disorders. Another aspect is that pain resulting from acute inflammation often interferes with exercise activities. Hence implementation of exercise programs is restricted. Physiotherapy treatment of the acute inflammation enables patients to start prescription exercises. Pain also might cause mood imbalances hence aggravating depression and anxiety. Physiotherapy helps to release endogenous opioids improving the mood conditions.

Exercises help to maintain the effect achieved using physiotherapy modalities and prevent recurrencies and are important in management chronic inflammatory conditions. These treatment modalities increase secretion of neurotrophic factors, accelerate release of endogenous opioids, reduce the levels of pro=inflammatory cytokines, enhance the sensitivity of opioid and neurotrophin receptors and affect many other parameters associated with pathogenesis of psychological disorders. The levels of brain-derived neurotrophic factor (BDNF) were significantly elevated following a 4-hour rowing bout as compared to the pre-exercise parameters (6). A study showed that a high intensity aerobic exercise significantly increased the levels of BDNF and insulin-like growth factor-1 (IGF-1) and the working memory score while reduced cortisol secretion (7). A randomised clinical trial investigated the effect of aquatic exercises on mental health using both the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) parameters (8). The trial demonstrated that both the BDI and BAI scores of patients suffering from depression were significantly reduced after a 12-week the exercise program while no changes were observed for nondepressed participants. Another study examined the effect of exercise on mood parameters for patients with post-traumatic stress disorder (9). The study indicated that the mood symptoms were significantly improved following the exercise program as compared to the control group. It was demonstrated that exercise is a very useful modality to treat inflammation and reduce depression and anxiety scores (10). It is important to realise however that the type, intensity and frequency of exercise have specific effects on treatment of psychological conditions and should be taken into consideration. Appropriately designed and carefully controlled exercise programs conducted in clinical environment of a physiotherapy practice could effectively contribute to the success of treatment of depression, anxiety and other mental disorders.

Electroacupuncture

This modality involves applications of the electrical current to specific acupuncture points. The mechanisms of action of electroacupuncture in treatment of mental disorders incorporate different pathways. These might involve changes in synaptic plasticity, endocrine regulation through the hypothalamic-pituitary-adrenal (HPA) axis, impact on inflammatory processes and influence specific gene expression associated with the condition (11). A randomised controlled trial was performed to investigate the effect of electroacupuncture on treatment of depression-related insomnia (12). The results of the trial were assessed using the Hamilton Rating Scale for Depression, Self-Rating Depression Scale, Hamilton Rating Scale for Anxiety, Pittsburgh Sleep Quality Index and some other parameters. The trial demonstrated a significant improvement of the parameters in the treatment group as compared to the control subjects. This and other studies (13, 14) indicated that electroacupuncture could be an effective treatment modality for depression and anxiety.

Phytotherapy and other nutritional supplements

Phytotherapy utilises extracts from plants possessing specific medicinal properties. These plant extracts could be used as formulated nutraceuticals or as nutritional supplements. The use of phytotherapy for treatment of mental disorders could be a potential alternative approach. Plants such as saffron, St John’s wort, Ginkgo biloba and some others were shown to exhibit antidepressant and anxiolytic effects (15, 16). A study utilising saffron for treatment of depression showed an effect comparable to imipramine (17). The use of saffron was associated with lower level of side effects as compared to a tricyclic antidepressant imipramine and hence could be considered as a potential alternative treatment approach.

Nutritional supplements such as s-adenosylmethionine, tryptophan, 5-hydroxytryptophan and some other products showed promising results for treatment of depression and other mental disorders (18, 19). There are different potential mechanisms of action of phytotherapy and various nutritional supplements for treatment of mental disorders. These could embrace their role in redox homeostasis, anti-inflammatory processes, inhibition of monoamine oxidase, increased synthesis of neurotransmitters, activation of serotonin receptors and regulation of other pathways involved in the pathogenesis of mental disorders.

Dietary modifications

Diet has immediate implications in the aetiology and pathogenesis of mental disorders. It works through different pathways comprising its role in inflammation, mitochondrial dysfunction, oxidative stress, HPA axis endocrine regulation, gut microbiota and others (20). The bioactive components contained in vegetables, fruits, whole grains, nuts, fish and other anti-inflammatory foods could significantly improve depression and other mental disorders. A study was performed to assess the impact of polyphenols on depression (21). The study showed that higher consumption of phenolic acid, flavanones and anthocyanins resulted in a significant reduction of depressive symptoms.

A randomised controlled trial was conducted to investigate the effectiveness of dietary interventions for patients with major depression (22). The trial demonstrated a significant improvement in the depression scores obtained using the Montgomery-Åsberg Depression Rating Scale (MADRS) over the course of the trial.

Reviews summarising the results of various research and clinical studies clearly elucidated the role of dietary modifications in improving depression, anxiety and other psychological disorders (23, 24). They demonstrated the impact of nutritional compounds on cortisol levels, release of BDNF and IGF-1, pro-inflammatory cytokines and other biomarkers associated with depression and anxiety and indicated that dietary changes improved clinical manifestations of depression.

Nutritional psychiatry becomes an emerging field (25, 26) although more studies including randomised controlled trials should be warranted to support the clinical evidence of the role of diet in treatment of mental disorders. Dietary interventions might provide alternative options for treatment of mental disorders and certainly should not be ignored. Various food could have different impact on the conditions. A review investigating the antidepressant properties of specific foods (27) indicated that they vary significantly in their capacity to improve the conditions. The antidepressant food score (AFS) of different groups of products ranged from 3% for dairy to 48% for vegetables. Use of the AFS could be a helpful approach for designing nutritional interventions.

Summary

Implementation of alternative treatment and prophylactic approaches could offer significant benefits for managing depression, anxiety and other mental disorders. The use of these approaches is particularly important for cases of treatment-resistant conditions or for people who are unable to use pharmacotherapy due to severe side effects or other reasons. The modalities could be used as monotherapy or in combination or as an adjunct to medications.

These alternative treatment and prophylactic modalities are usually associated with less side effects as compared to pharmacotherapy. Nevertheless the alternative treatment and prophylactic approaches should be appropriately designed and carefully monitored to achieve the best results. Some of these modalities could be suitable for use as home-based while some treatments should be performed in clinical environment.

The available clinical evidence supports the effectiveness of specific alternative modalities for prevention and treatment of mental disorders. In many cases a wholistic approach utilising a combination of different modalities is necessary for the treatment success. In our physiotherapy practice we have established a specialised Anti-Depression and Anti-Anxiety Physiotherapy (ADAAPT) program. The program is based on the use of integrative physiotherapy combining a range of different modalities and collaboration with specialists from other clinical disciplines. The treatment protocols designed for the ADAAPT program include only evidence-based approaches. We would describe the ADAAPT program in more details in subsequent blogs so stay tuned for new articles.

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