Rebecca Erwin Wells

To tell the truth, the whole truth, may do patients harm: the problem of the nocebo effect for informed consent.

The principle of informed consent obligates physicians to explain possible side effects when prescribing medications. This disclosure may itself induce adverse effects through expectancy mechanisms known as nocebo effects, contradicting the principle of nonmaleficence. Rigorous research suggests that providing patients with a detailed enumeration of every possible adverse event—especially subjective self-appraised symptoms—can actually increase side effects. Describing one version of what might happen (clinical “facts”) may actually create outcomes that are different from what would have happened without this information (another version of “facts”). This essay argues that the perceived tension between balancing informed consent with nonmaleficence might be resolved by recognizing that adverse effects have no clear black or white “truth.” This essay suggests a pragmatic approach for providers to minimize nocebo responses while still maintaining patient autonomy through “contextualized informed consent,” which takes into account possible side effects, the patient being treated, and the particular diagnosis involved.

Complementary and alternative medicine use among adults with migraines/severe headaches.

(Headache 2011;51:1087‐1097)

Meditation for Adults with Mild Cognitive Impairment: A Pilot Randomized Trial

To the Editor High levels of chronic stress are associated with an increased incidence of Mild Cognitive Impairment (MCI) and Alzheimers disease (AD) (1, 2) and negatively impact the hippocampus, a key AD brain region. Mindfulness Based Stress Reduction (MBSR), a standardized mindfulness meditation/yoga intervention, may decrease stress/cortisol, improve well-being, and increase hippocampal gray matter density in healthy adults. (3, 4) Studies also demonstrate that meditation selectively activates the hippocampus,(5) and experienced meditators have larger hippocampal volumes and gray matter compared to controls. (6) Within this context, our objectives were to: 1) test the safety/feasibility of MBSR in adults with MCI; 2) explore the effects of MBSR on cognition and well-being through standardized instruments, neuropsychological evaluations, and interviews.

Use of relaxation techniques and complementary and alternative medicine by American adults with insomnia symptoms: results from a national survey.

INTRODUCTION Though relaxation training is recommended for insomnia, national patterns of use remain unknown. Similarly, rates of complementary and alternative medicine (CAM) use by adults with insomnia are not well established. We sought to elucidate the patterns and reasons for use of relaxation techniques and CAM use by adults with insomnia symptoms. METHODS We used the 2007 National Health Interview Survey (n = 23,358) to estimate prevalence of use among adults by self-reported insomnia symptom status. Among adults reporting insomnia symptoms (n = 4,415), we examined reasons for use and disclosure to medical professionals. We employed logistic regression to determine the adjusted associations between relaxation techniques use, CAM use, and insomnia symptoms. RESULTS Among adults with insomnia symptoms, 23% used relaxation techniques and 45% used CAM annually. After adjustment, adults with insomnia symptoms had higher likelihood of using relaxation techniques (aOR 1.48, 95% CI 1.32, 1.66) and CAM (aOR 1.29, 95% CI 1.15, 1.44) compared with adults without insomnia. Deep breathing exercise was the most commonly used relaxation technique. Fewer than 2% of adults with insomnia used CAM specifically for insomnia. Only 26% of adults with insomnia symptoms disclosed their relaxation techniques use to medical professionals. Being male, lower educational and physical activity levels, income <

Mind/Body and Behavioral Treatments: The Evidence and Approach

20,000, living in South, and hypertension were associated with lower likelihood of relaxation techniques use among adults with insomnia symptoms. CONCLUSION While adults with insomnia symptoms commonly use relaxation techniques and CAM, few are using for their insomnia. Facilitating discussions about relaxation techniques may foster targeted use for insomnia.

Neuropsychiatric Symptoms and the Use of Complementary and Alternative Medicine

Nonpharmacological treatments may help many patients with headaches. This review addresses the most common questions about nondrug treatment options from the perspective of patients by (1) defining behavioral and mind/body treatments, (2) discussing the research evidence supporting their use, and (3) describing their role in the management of headaches. Research suggests that mind/body and behavioral treatments may decrease the frequency of migraine or tension‐type headaches by 35‐50%, an effect size comparable with those observed in medication trials but with fewer side effects than drugs. Most benefit seems to occur in those who combine medications with nonpharmacological treatments. Despite the fact that research evidence for behavioral treatment of headaches is stronger than that for specific mind/body treatments, research shows that adults with headache in the general population are more likely to use mind/body treatments. Nondrug treatments may have a longer time to onset of benefits than drugs, but their effect may be broader and more durable because they may improve stress, coping, and self‐efficacy. Additional research is needed to address other questions that patients and their physicians may have about these interventions.

Patterns of mind-body therapies in adults with common neurological conditions.

To assess the prevalence of complementary and alternative medicine (CAM) use by U.S. adults reporting neuropsychiatric symptoms and whether this prevalence changes based on the number of symptoms reported. Additional objectives include identifying patterns of CAM use, reasons for use, and disclosure of use with conventional providers in U.S. adults with neuropsychiatric symptoms.

Neuropsychiatric Symptoms and the Use of Mind-Body Therapies

Background: Over 40% of adults with common neurological conditions use complementary and alternative medicine, and mind-body therapies are the most commonly used form. Our objective was to describe mind-body use in adults with common neurological conditions. Methods: We compared mind-body use between adults with and without common neurological conditions (regular headaches, migraines, back pain with sciatica, strokes, dementia, seizures or memory loss) using the 2007 National Health Interview Survey of 23,393 sampled American adults. Results: Adults with common neurological conditions used mind-body therapies more frequently than those without (24.5 vs. 16.6%, p < 0.0001); differences persisted after adjustment. Deep breathing exercises, meditation and yoga were used most frequently. Nearly 70% of the adults with common neurological conditions did not discuss their mind-body use with their health care provider. Those with neurological conditions used mind-body therapies more than those without these conditions because of provider recommendation (26 vs. 13%) or because conventional treatments were perceived ineffective (12 vs. 4%) or too costly (7 vs. 2%), respectively. Conclusions: Mind-body therapies are used more frequently among adults with common neurological conditions, more often when conventional treatments were perceived ineffective. More research is warranted on the efficacy of mind-body use for common neurological conditions.

P02.146. Mindfulness Based Stress Reduction in Adults with Mild Cognitive Impairment: A Pilot Study Using fMRI

OBJECTIVE Neuropsychiatric symptoms affect 37% of US adults and present in many important diagnoses including posttraumatic stress disorder, traumatic brain injury, and chronic pain. However, these symptoms are difficult to treat with standard treatments, and patients may seek alternative options. In this study, we examined the use of mind-body therapies by adults with neuropsychiatric symptoms. METHOD We compared mind-body therapy use (biofeedback, energy healing, meditation, guided imagery, yoga, deep-breathing exercises, hypnosis, progressive relaxation therapy, qigong, and tai chi) between adults with and without neuropsychiatric symptoms (anxiety, depression, insomnia, headaches, memory deficits, attention deficits, and excessive daytime sleepiness) in the 2007 National Health Interview Survey (N = 23,393). Use of ≥ 1 of these therapies in the prior 12 months was the primary outcome of interest. We also examined prevalence and reasons for mind-body therapy use in adults with neuropsychiatric symptoms. We performed logistic regression to examine the association between neuropsychiatric symptoms and mind-body therapy use to adjust for sociodemographic and clinical factors. RESULTS Adults with ≥ 1 neuropsychiatric symptom used mind-body therapies more than adults without symptoms (25.3% vs 15.0%, P < .001). Prevalence increased with increasing number of symptoms (21.5% for 1 symptom, 32.4% for ≥ 3 symptoms, P < .001); differences persisted after adjustment for potential confounders (odds ratios, 1.39 [95% CI, 1.26-1.53] and 2.48 [95% CI, 2.18-2.82]). Reasons for mind-body therapy use among adults with ≥ 1 symptom included the ineffectiveness or expense of conventional medicine (30.2%). Most adults (nearly 70%) with ≥ 1 symptom did not discuss their mind-body therapy use with a conventional provider. CONCLUSIONS Adults with ≥ 1 neuropsychiatric symptom use mind-body therapies frequently; more symptoms are associated with increased use. Future research is needed to understand the efficacy of these therapies.

P04.74. Use of mind-body therapies among adults with neuropsychiatric symptoms common to mild traumatic brain injury

Purpose Fifty percent of adults with mild cognitive impairment (MCI) develop Alzheimer’s disease (AD) within 5 years. Preliminary data suggest that mindfulness-based stress reduction (MBSR) increases gray matter density of the hippocampus, which atrophies in AD. We studied the safety, feasibility, and impact of MBSR on brain function, memory, and quality of life (QOL) among adults with MCI.