Alternatives to Psychopharmacology

From Mental Health 2009, presented by the College of Medical Education, Pierce County Medical Society, Tacoma, WA

Educational Objectives

The goal of this program is to explore alternatives to psychopharmacology in the treatment of mental health disorders and addictions. After hearing and assimilating this program, the clinician will be better able to:

1.   Explain briefly the difference between transcendental meditation and Vipassana meditation.

2.   Discuss the literature supporting the use of meditation in treating substance abuse disorders.

3.   Describe the Mindfulness-Based Relapse Prevention program.

4.   Enumerate the benefits of exercise to neurologic function.

5.   List some of the neurologic and psychiatric disorders for which there is evidence of improvement with exer­cise.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgements

Drs. Marlatt and Hogan were recorded at Mental Health 2009, held February 6, 2009, in Tacoma, WA, and sponsored by the College of Medical Education, Pierce County Medical Society. The Audio-Digest Foundation thanks the speakers and the College of Medical Education for their cooperation in the production of this program.

Mindfulness Meditation and Recovery from Addiction

G. Alan Marlatt, PhD, Professor, Department of Psychology, University of Washington, Seattle

Project Choices: study designed to provide alternatives to 12-step programs for addictions; program involved having prison inmates voluntarily attend “pretty rigorous” 10-day Vipassana meditation retreat; Vipassana meditation used with good results in Indian prisons; US prison officials wished to test efficacy for treatment of inmates with alcohol and drug addictions

Meditation: 2 of many styles of meditation evaluated as treatments for substance abuse; transcendental meditation (TM)  —  rooted in Hindu teachings; requires meditation on assigned mantra (usually, Sanskrit word) for 20 min twice daily; study of heavy social drinkers found that, compared to control group, amount of alcohol consumed in TM group was significantly reduced during treatment and follow-up period; another study of binge-drinking col­lege students found that alcohol consumption dropped by »50% in meditation group; also, students in meditation group showed interest in continuing meditation practice after study ended; Vipassana meditation  —  rooted in tradi­tional Buddhist teachings; speaker finds its principles, which emphasize focus on thoughts and behaviors, very sim­ilar to those of cognitive behavioral therapy

First study of Vipassana in North America: conducted in North Rehabilitation Facility (NRF) near Seattle in 1997; 244 men and 61 women agreed to participate in study while incarcerated at NRF; participants completed baseline assessment and chose to attend Vipassana course or to have treatment as usual (TAU); 173 completed assessment at end of course, and 87 completed follow-up assessment 3 mo after release from prison; outcomes  —  participants in both groups did better in terms of alcohol and drug use, but individuals in Vipassana group showed significantly greater improvement on most outcome variables; some participants from each group dis­continued drinking and using drugs; reduced consumption observed in higher proportion of subjects; Drinking-Related Internal/External Locus of Control (DRIE) showed significant shift from external locus of control (blam­ing substance use on external factors beyond patient’s control) at incarceration to internal locus (patient’s accep­tance of responsibility for his or her actions) in Vipassana group; much smaller shift in TAU group; Vipassana group also showed more increase in optimism than TAU group; best outcomes seen in depression (significantly decreased in Vipassana group)

Doctrine of impermanence: people in Vipassana courses taught that whatever they are feeling now (including crav­ing) will change without  any action to cause change

Posttraumatic stress disorder (PTSD): in study of women in prison with PTSD, subjects reported that with Vipas­sana meditation, they still experienced rumination about trauma but were better able to deal with it (“I don’t have to keep thinking about it; I can let it go”)

Buddhist perspective on addiction: alcohol and drug addiction described in Buddhist literature as problems related to ego-attachment, with emphasis on craving as major process underlying motivational dynamic

Mindfulness-Based Relapse Prevention (MBRP): participants randomized to Vipassana meditation or TAU; speaker and colleagues modified 10-day Vipassana retreat into 8-session program, with each session lasting »2 hr; first hour devoted to meditation, second to discussion; principles of delivery  —  2 therapists per group of 8 to 10 participants; therapists adopt person-centered Rogerian approach; used motivational interview style; thera­pists have own ongoing mindfulness-meditation practice similar to that taught to group; treatment manual avail­able, but therapists strive for spontaneity and creativity within MBRP parameters; program characterized by qualities of authenticity, unconditional acceptance, empathy, humor, and present-moment experience through which teacher and student experience group process and associated changes; preliminary outcomes for MBRP group (compared to TAU group)  —  76% reported weekly meditation practice at midcourse, 80% postcourse, and 65% at 2-mo follow-up; meditation averaged 5.4 days/wk and 28.9 min/day across all time points; subjects re­ported increases in mindfulness skills, and decreases in experiential avoidance, self-medication to deal with neg­ative emotions, and thought suppression; at 3-mo follow-up, 1 lapse in MBRP group, 6 in TAU group; in addition, those who did lapse were able to discontinue using substance more quickly, and showed significant im­provements in emotional-regulation skills, fewer cravings, and significant increases in mindfulness overall; if de­pression increased, craving did not increase proportionally; midcourse scores on “nonjudgment” subscale of Five Factor Model of Personality and on “nonacceptance” subscale of Difficulties of Emotion Regulation scale medi­ated the relation between treatment and craving

Conclusions: preliminary evidence suggests potential of MBRP for decreasing rates and/or severity of substance use, reducing effects of relapse risk factors, increasing acceptance and nonjudgment, and decreasing strength of relation between negative affect and craving and between negative affect and problematic substance-related be­haviors

Mindfulness meditation: physical effects  —  lowers heart rate and blood pressure; activates relaxation response of parasympathetic nervous system; settles fight-or-flight stress response of sympathetic nervous system; activates sensory awareness and control of attention; long-term effects  —  dampens reactivity to stress; increases positive emotions through left frontal lobe activation; enhances neural integration and self-regulation from increased activ­ity in middle prefrontal cortex; monitors and inhibits limbic firing; produces greater response reflexivity for paus­ing before acting; enhances empathetic resonance; increases insight and self-awareness; modulates fear through release of g-aminobutyric acid (GABA) into lower limbic areas; modulates morality; primes brain to enter states of coherent neutral activity across broad regions of brain

Bottom line: “it is on the very ground of suffering that we can contemplate well-being; it is exactly in the muddy wa­ter that the lotus grows and blooms” (Thich Nhat Hanh)

Physical Exercise as Medicine

Patrick J. Hogan, D.O., Director, Puget Sound Neurology Movement and Motility Disorders Clinic; Director, Tacoma Neu­rological Headache Center, Tacoma, WA

Benefits of exercise training on brain: promotes neuroplasticity; facilitates neuroregenerative, neuroadaptive, and neuroprotective processes in nervous system; fitness results from conditioning of brain, with secondary effects on muscles and cardiovascular system

Mechanisms by which exercise improves brain health: increased growth factors (eg, brain-derived neurotrophic factor [BDNF], insulin-like growth factor [ILGF], and vascular endothelial growth factor [VEGF]) that form new brain cells, synapses, and blood vessels; control of oxidative-stress damage by free radicals; attenuation of adverse effect of life stress on brain (through neurochemical enhancement and principle of hormesis)

Growth factors induced by exercise: BDNF  —  increased in brain by fitness conditioning; plays central role in form­ing new neurons and increasing synaptic plasticity; when released due to exercise, may be key mechanism for en­hancing neuronal activity lost due to neurologic degenerative disease, brain injury, and/or normal aging process and for preventing brain deterioration; ILGF  —  involved in improving learning and memory; aids formation of myelin; works with BDNF to improve brain function; VEGF  —  triggered by exercise to form new blood vessels and deliver more oxygen and nutrition to brain

Neurologic disorders shown to improve with exercise: brain injury due to stroke or trauma; Parkinson’s disease; multiple sclerosis; Alzheimer’s disease; migraine; cognitive decline with normal aging; pain disorders; depres­sive disorders; anxiety and panic disorders; attention-deficit disorders; others

Parkinson’s disease: exercise increases BDNF by 40% in animal studies; exercise provides neuroprotection against severity and rate of progression; increased synaptic connections (seen in studies of animals with Parkinson’s dis­ease); increased dopamine production and dopamine receptors (may require exercise of sufficient frequency and intensity to challenge brain); exercise that requires skilled coordination (eg, treadmill, dancing, tai chi) provides greater stimulation of brain; studies show that people with Parkinson’s disease who exercise regularly do better than those who do not

Alzheimer’s disease: epidemiologic studies demonstrate that exercise slows onset and progression of Alzheimer’s disease; 5-mo animal study showed reduction in amyloid plaques and preservation of learning ability in animals that exercised, compared to controls; long-term exercise enhances neuronal metabolism and affects amyloid pro­tein processing in manner that may delay or prevent onset of dementia; recent study showed 30% less dementia in older people who exercise at least 3 days/week; people who engage in ³4 physical activities have half the risk for developing Alzheimer’s disease, especially if activities started in midlife; obesity (especially abdominal) dou­bles rate of Alzheimer’s disease; exercise is both preventive and regenerative

Cognitive preservation in normal aging: exercise induces neurogenesis in hippocampus, stimulates synaptic plastic­ity and neuronal networks, and enhances neurotransmitters; increases cerebral blood flow, helping prevent stroke; stimulates cognition; enhances serotonin to improve moods and decrease stress; contributes to preventing loss of balance, strength, dexterity, stamina, and flexibility, and enhances zest for life

Depression: exercise shown to improve control of major depression and to decrease relapse rates; regulates levels of all neurotransmitters targeted by antidepressant medication; studies have shown equal benefit for exercise and antidepressant, but exercise provides more rapid benefit; greatest benefit seen with combination of exercise and antidepressant; exercise especially effective in patients with no response to medication; even single bout of exer­cise improves mood; regulation of dopamine enhances sense of well-being and self-esteem in all age groups

Anxiety: exercise enhances GABA (major anxiety-inhibiting neurotransmitter); atrial natriuretic peptide (ANP) produced by heart during exercise inhibits hyperarousal state; BDNF promotes rewiring of memories so unrealis­tic fears related to anxiety replaced by healthy memories and responses; anxiety and stress reactions to daily life reduced by hormesis

Attention-deficit disorders (ADD, including attention-deficit/hyperactivity disorder [ADHD]): exercise helps regu­late amygdala, which assigns emotional intensity to incoming stimuli; helps suppress overreaction to stimuli (eg, road rage, panic attacks); enhances dopamine to engage prefrontal cortex reward system (necessary for maintain­ing attention); maintains function in prefrontal cortex; triggers growth of prefrontal cortex and cerebellum through release of BDNF; release of dopamine and norepinephrine regulate attention system and temper ADHD; complex skilled exercise, such as martial arts, gymnastics, dancing, or swimming, most effective in treating ADHD; exercise early in day benefits attention throughout day; speaker recommends  ³30 min aerobic exercise per day

Addictions: involve stimulation of brain reward circuit served by dopamine; exercise helps suppress cravings by ac­tivating that circuit and enhancing endorphins; rates of smoking cessation and drug abstinence higher if exercise substituted for tobacco or drug

Conclusions: advise patients that exercise is medicine for their brain and body; “fitness” forestalls effects of aging and enhances memory, sense of well-being, and zest for life; make exercise ritual; do it consistently (no excuses); concentrate on diversity and fun

Suggested Reading

Beitel M et al: Reflections by inner-city drug users on a Buddhist-based spirituality-focused therapy: a qualitative study. Am J Orthopsychiatry 77:1, 2007; Bowen S et al: Mindfulness meditation and substance use in an incarcerated popula­tion. Psychol Addict Behav 20:343, 2006; Brach T: Radical Acceptance: Embracing Your Life with the Heart of a Bud­dha. New York: Bantam, 2004; Exercise may slow or reverse brain decline. Aerobic exercise benefits executive-control brain function, and may enable the brain to continue to grow and develop. Health News 15:3, 2009; Farb NA et al: At­tending to the present: mindfulness meditation reveals distinct neural modes of self-reference. Soc Cogn Affect Neurosci 2:313, 2007; Galanter M: The concept of spirituality in relation to addiction recovery and general psychiatry. Recent Dev Alcohol 18:125, 2008; Glasser W: Positive Addiction. New York: Harper Paperbacks, 1985; Griffin K: One Breath at a Time: Buddhism and the Twelve Steps. Emmaus, PA and New York, NY: Rodale Books, 2004; Heinrich B: Racing the Antelope: What Animals Can Teach Us About Running and Life. New York City: Ecco Publishing, 2001; Hsu SH, Grow J, Marlatt GA: Mindfulness and addiction. Recent Dev Alcohol 18:229, 2008; King LA, Horak FB: Delaying mobility disability in people with Parkinson disease using a sensorimotor agility exercise program. Phys Ther 89:384, 2009; Kripke C: Aerobic activity for cognitive function. Am Fam Physician 79:562, 2009; Maddigan B et al: The ef­fects of massage therapy and exercise therapy on children/adolescents with attention-deficit/hyperactivity disorder. Can Child Adolesc Psychiatr Rev 12:40, 2003; Menahemi A, Ariel E: Doing Time, Doing Vipassana [video]. Karuna Films; 1997; Ratey JJ, Hagerman E: SPARK: The Revolutionary New Science of Exercise and the Brain. New York: Little, Brown and Company, 2008; Simpson TL et al: PTSD symptoms, substance use, and Vipassana meditation among in­carcerated individuals. J Trauma Stress 20:239, 2007; Tetlie T et al: Using exercise to treat patients with severe mental illness: how and why? J Psychosoc Nurs Ment Health Serv 47:32, 2009; Toneatto T, Nguyen L: Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry 52:260, 2007; Trungpa C: Meditation in Action. Boston MA: Shambhala Publications, 1996; Whitney K: Sitting Inside: Buddhist Practice in America’s Prisons. Boulder CO: Prison Dharma Network, 2002.