Objective: The study examined the relationship between mental
disorders and the use of complementary and alternative medicine.

Method: Data from a national household telephone survey
conducted in 1997-1998 (N=9,585) were used to examine the relationships
between use of complementary and alternative medicine during the past
12 months and several demographic variables and indicators of mental
disorders. Structured diagnostic screening interviews were used to
establish diagnoses of probable mental disorders.

Results: Use of complementary and alternative medicine during
the past 12 months was reported by 16.5% of the respondents. Of those
respondents, 21.3% met diagnostic criteria for one or more mental
disorders, compared to 12.8% of respondents who did not report use of
alternative medicine. Individuals with panic

disorder and major depression were significantly more likely to
use alternative medicine than those without those disorders.
Respondents with mental disorders who reported use of alternative
medicine were as likely to use conventional mental health services as
respondents with mental disorders who did not use alternative medicine.

Conclusions: We found relatively high rates of use of
complementary and alternative medicine among respondents who met
criteria for common mental disorders. Practitioners of alternative
medicine should look for these disorders in their patients, and
conventional medical providers should ask their depressed and anxious
patients about the use of alternative medicine.. More research is needed
to determine if individuals with mental disorders use alternative
medicine because conventional medical care does not meet their health
care needs.

(Am J Psychiatry 2000; 157:1851-1857)

The Surgeon General's recent report on mental health (1)
emphasized the high rates of mental disorders in the United States and
pointed out that many who suffer from these disorders do not receive
mental health treatments that have been shown to be efficacious. It has
been well established that persons with common mental disorders such as
depression or anxiety are frequent users of general medical services
(2, 3), but little is known about their use of alternative medical
services. If a substantial unmet need for mental health care exists,
then persons with mental illness might be expected to turn for help to
alternative providers or therapies outside the formal health care
system. The study reported here examined the use of complementary and
alternative medicine among survey respondents who met criteria for a
number of common mental disorders. The study used data from a large
national survey of 9,585 adults.

Typical problems for which persons see alternative providers
include back problems, anxiety, headaches, insomnia, depression,
arthritis, and allergies (4, 5). Several recent studies have suggested
high rates of depression or anxiety among users of alternative medicine
(4, 6-10). Eisenberg et al. (7) found that 40.9% of the adults who
reported severe depression and 42.7% of those who reported anxiety
attacks had used alternative therapies in the past 12 months, compared
with 28.2% of adults in the overall sample. Druss et al. (11) found
that major depression was a significant predictor of use of both
antidepressants and nonprescription dietary supplements. Burstein et
al. (12) examined use of alternative medicine among women with
early-stage breast cancer and found relatively high rates of depression
among women who were new users of alternative medicine. Davidson et al.
(13) administered structured diagnostic interviews (Structured Clinical
Interview for DSM-III-R) to 83 users of complementary and alternative
medicine services in the United States and the United Kingdom. The
majority (69%) met lifetime criteria for an axis I disorder, and 40%
met criteria for a current axis I disorder, most frequently an anxiety
or depressive disorder. The authors concluded that individuals with
depression or anxiety disorders may be particularly interested in
pursuing alternative medicine services and called for greater awareness
of the possibility of psychiatric illness in persons who seek help from
the complementary medicine sector.

Most studies of the relationship between mental disorders and
use of alternative medicine have used small and nonrepresentative
samples or have used simple self-reports of the presence or absence of
mental disorders, rather than more standardized interviews. In the
study reported here, we used a household sample and included
standardized screening measures for specific psychiatric disorders to
examine the association between mental disorders and the use of
alternative medicine, while controlling for potentially confounding
demographic and health status factors. We hypothesized that respondents
with common mental disorders such as depression or anxiety would have
higher rates of complementary and alternative medicine use.

Method

Data Source and Sample

We analyzed data from a pre-release version of Healthcare for
Communities, a national household telephone survey funded by the Robert
Wood Johnson Foundation and fielded in 1997-1998 (14). Healthcare for
Communities researchers reinterviewed adults who had participated in an
earlier telephone survey, the Community Tracking Study, an average of
15 months after the earlier study. The Community Tracking Study sample
was representative of the U.S. civilian, noninstitutionalized
population (15) and included individuals clustered within 60 randomly
selected U.S. communities, as well as a geographically dispersed
subsample. In 12 communities that were considered primary sites, a
larger sample size allowed for site-specific estimates. The remaining
48 communities were considered secondary sites. Community Tracking
Study researchers interviewed all adults and one randomly selected
child within each participating household. In the primary sites, the
study included a small field sample, so that households with little or
no chance of being selected in a telephone survey could be represented.
A sample of 14,985 individuals was selected for the Healthcare for
Communities survey from a random sample of 30,375 adult respondents to
the Community Tracking Study telephone interview. To allow for more
power for national estimates with the reduced sample size, Healthcare
for Communities oversampled individuals from the geographically
dispersed sample and from the secondary sites in the Community Tracking
Study. To obtain more precise national estimates of mental health care
needs, Healthcare for Communities also oversampled individuals from the
previous study who had reported low income, high levels of
psychological distress, and use of mental health specialty services.
The sample was stratified by family income (<=$20,000 versus >$20,000),
psychological distress (distressed versus nondistressed, determined on
the basis of subjects' responses to two mental health items in the
12-Item Short-Form Health Survey [ 161), and use of mental health
specialty services in the past 12 months (use versus no use).
Healthcare for Communities selected everyone who reported psychological
distress or mental health service use (N=7,164). We sampled among the
nondistressed nonusers of mental health services to obtain a group of
4,305 nonpoor, nondistressed nonusers of services and a group of 3,516
poor, nondistressed nonusers. Of the 14,985 respondents selected for
the sample, 9,585 completed the Healthcare for Communities interview,
for a response rate of 64.0%. The study was approved by the
institutional review boards at RAND and UCLA. After complete
description of the study to the subjects, informed consent was obtained
from all subjects. Sampling weights based on the inverse of the
probability of selection were derived. The weights included adjustments
for nonresponse and for the exclusion of households without telephones.

Measures

The Healthcare for Communities telephone survey included
questions on demographic characteristics, health and daily activities,
mental health, alcohol and drug use, insurance coverage, and the use of
medications and health services. Specifically, we asked whether
respondents had made any primary care visits, made any primary care
visits that addressed mental health problems, used specialty mental
health care, or used psychotropic medications. We used an indicator
developed in earlier work to assess appropriate use of psychotropic
medication or counseling for respondents with probable depressive or
anxiety disorders (17). To assess the use of complementary and
alternative medicine, we asked participants the following question: "In
the past 12 months, did you use any alternative or folk medicine,
either from a practitioner or on your own?" We included the following
statement to give examples of alternative medicine therapies:
"Alternative medicine includes therapies like homeopathic medicine,
acupuncture, massage therapy, herbal medici157, no. 11 (Nov 2000): p.
1851-1857ne, and spiritual healing." Individuals who reported the use
of alternative medicine were asked if they used alternative medicine to
help with emotional, mental health, alcohol, or drug abuse problems.

Other studies have used somewhat different methods to assess
the use of alternative medicine. For example, Eisenberg et al. (4) used
a relatively broad definition of "unconventional medicine" that
included such treatments as relaxation techniques, herbal medicine,
massage, chiropractic, spiritual healing by others, megavitamins,
self-help groups, imagery, commercial diets, folk remedies, lifestyle
diets, energy healing, homeopathy, hypnosis, biofeedback, and
acupuncture. In recent years, it has become harder to make clear
distinctions between conventional and alternative medicine. As medical
schools have developed courses in alternative and complementary
medicine, insurers have started to cover many treatments previously
considered "alternative" (i.e., chiropractic and acupuncture) and
prominent hospitals have started centers for "alternative,"
"complementary," or "integrative" medicine. We asked respondents to use
their own judgment about whether the services they reported were
considered "alternative," given the definition reported above.

We assessed the presence of mental disorders by using a
structured diagnostic interview. Questions on generalized anxiety
disorder and major depression were based on the World Health
Organization (WHO) Composite International Diagnostic Interview Short
Form (18). Questions on dysthymia, panic disorder, and mania were
derived from items in the WHO Composite International Diagnostic
Interview (19). Alcohol use/abuse was assessed by using the Alcohol Use
Disorders Identification Test (20). Drug abuse was assessed by using a
screening instrument described by Rost and colleagues (21). We also
included a question about lifetime history of having been hospitalized
for schizophrenia or symptoms of psychosis.

Analysis

We used t tests and chi-square tests to examine the association
of use of complementary and alternative medicine with several
demographic variables, several indicators of mental disorders
(depression, dysthymia, panic disorder, generalized anxiety disorder,
and severe mental illness such as bipolar disorder or psychosis), and
an indicator of probable alcohol or drug abuse. We also used chi-square
tests to examine whether respondents with mental disorders who did and
did not report use of alternative medicine differed in their use of and
satisfaction with conventional mental health services.

We then developed a series of logistic regression models to
predict the use of alternative medicine. Because substantial overlap
exists among the specific mental disorders we studied, we first
developed a model containing all of the indicators for mental disorders
and then a full model containing all of the diagnoses and a number of
demographic and health status factors such as gender, geographic area,
level of education, age, marital status, ethnic minority status,
employment status, insurance status, and overall satisfaction with
health care.

Our analyses were weighted to account for the disproportionate
sampling of respondents from the Community Tracking Study and to be
nationally representative (14). We used SUDAAN statistical software
(22) to adjust our analyses for the clustering.

Results

Of the total of 9,585 respondents who agreed to participate in
the telephone survey for this study, 19 answered "don't know" or
refused to answer the question about use of complementary and
alternative medicine. Of the remaining 9,566 respondents, 1,576
reported use of alternative medicine in the past 12 months, resulting
in an unweighted proportion of 16.5%. After weighting, we estimated the
prevalence of the use of alternative medicine to be 14.5%. From this
point on, we present only weighted proportions.

Among those who reported using alternative medicine, 15.0%
reported that they had used it to treat mental or emotional problems,
45.4% reported at least one visit to an alternative medicine
practitioner, and 54.6% either self-administered alternative treatments
or received treatments from a traditional health care provider (we do
not have data to distinguish these two possibilities).

Table 1 shows the characteristics of the study participants and
the differences between study participants who did and did not report
use of alternative medicine in the 12 months before the study.
Individuals who reported use of alternative medicine were significantly
more likely to meet diagnostic criteria for at least one of the mental
disorders we assessed.

Table 2 shows the association between use of alternative
medicine and each of the mental disorders we assessed. Use of
alternative medicine was significantly more likely among respondents
who met criteria for any of the disorders except for dysthymia.
Respondents who met criteria for major depression and panic disorder
were particularly likely to report the use of alternative medicine.

TABLE 1.

Respondents with more than one mental disorder were not
significantly more likely to use alternative medicine than those who
met criteria for just one disorder (22.4% versus 21.5%) (X^sup 2^=0.10,
df=l, p=0.76). Use of alternative medicine was significantly higher
among respondents who reported that they needed help with emotional or
substance abuse problems in the past 12 months than among those who did
not report needing such help (30.1% versus 12.7%) (X^sup 2^=86.31,
df=l, p<0.001).

After controlling for all mental disorders in our logistic
regression model (Table 3, model 1), we found that major depression and
panic disorder remained significantly associated with the use of
alternative medicine. In addition, in the model that controlled for the
other disorders, a significant association between dysthymia and use of
alternative medicine emerged. In the full model that included all
mental disorder diagnoses and demographic and clinical covariates
(Table 3, model 2), major depression, dysthymia, panic disorder,
gender, age, level of education, geographic area, severity of chronic
medical illness, type of insurance, and general satisfaction with
health care were significantly associated with use of alternative
medicine. When all other factors were controlled, participants with
generalized anxiety disorder and with severe mental disorders (probable
bipolar disorder or schizophrenia) did not have significantly higher
rates of alternative medicine use than those without those disorders.
Participants who met criteria for dysthymia were significantly less
likely to report use of alternative medicine than those who did not
meet those criteria.

Table 4 shows the association between the use of alternative
medicine, the use of conventional mental health treatments, and
satisfaction with available mental health services among the 1,787
respondents who met criteria for at least one mental disorder and used
any health services (primary, specialty, or alternative care) in the
year before the survey. In this subgroup, respondents who used
alternative medicine were as likely as those who did not to report
having made primary care visits, having received mental health
treatments in primary care, having used specialty mental health care,
and having used psychotropic medications. All of the users of
alternative medicine in this group also used at least one of the
conventional mental health treatments we asked about (mental health
treatment in primary care, a psychotropic medication, or specialty
mental health care).

When we examined participants' ratings of "health care
available for personal or emotional problems during the past 12
months," we found that 20.3% of those who used alternative medicine
reported being dissatisfied, compared with 12.6% of those who did not
use alternative medicine (X^sup 2^=2.86, df=1, p<0.10).

Among the 1,762 respondents who met diagnostic criteria for
common mental disorders (anxiety or depressive disorders), those who
used alternative medicine were more likely to have received appropriate
treatment with psychotropic medications or counseling than those who
did not use alternative medicine (50.1% versus 30.2%) (X^sup 2^= 23.14,
df=1, p<0.001).

Discussion

In our sample, about 21% of complementary and alternative
medicine users met diagnostic criteria for at least one probable mental
disorder (compared to about 13% of nonusers). About 15% of those who
reported using alternative medicine said that they were using these
services to help with emotional, mental, or substance abuse problems.
This rate is consistent with the rates of 13% reported by Elder et al.
(23) and 11% reported by Kelner and Wellman (24) but lower than the
rates reported by Eisenberg (4), who found that users of alternative
medicine considered anxiety and depression some of the most common
indications for the use of those services (for 28% and 20% of users,
respectively). The discrepancy may be due to differences in the
populations sampled, in the way we defined and elicited information
about alternative medicine use, or in the way we elicited the reason
for alternative medicine use.

TABLE 2.

Our findings suggest that practitioners of alternative medicine
should be aware that a considerable number of their patients may be
suffering from common mental disorders such as major depression or
panic disorder. For these patients, consultation and collaboration with
a specialty mental health practitioner should be strongly considered if
they do not respond to alternative medicine treatments as expected. We
also encourage all primary care providers and mental health specialists
who are treating patients with major depression and anxiety disorders
to inquire about the use of alternative treatments. Clinicians'
knowledge of such treatments and, when indicated, coordination with
providers of alternative medicine might improve overall health care for
these patients and prevent potentially harmful interactions between
conventional and alternative treatments (25, 26).

When we examined use of alternative medicine among individuals
with specific mental disorders, we found relatively high rates of use
among individuals with major depression and panic disorder, even after
the analysis adjusted for comorbid mental disorders and demographic and
health status variables. In addition, after this adjustment, the
associations between use of alternative medicine, generalized anxiety
disorder, and severe mental disorders were no longer significant, and
individuals with dysthymia were actually significantly less likely to
report use of alternative medicine. However, these results may be due
to relatively high rates of comorbidity between these disorders.

Our research also confirmed previously identified associations
between use of alternative medicine and number of factors, such as
female gender, middle age, a higher level of education, a higher level
of medical illness, and residence in the Western part of the United
States (7, 24, 27, 28).

Our overall estimates of alternative medicine use are lower
than those previously reported (4, 7, 20, 27, 29, 30) but higher than
the rate reported by Druss and Rosenheck (31). The discrepancy may be
due to differences in the populations studied and the definitions of
complementary and alternative medicine used. For example, we did not
include chiropractic medicine in our definition of alternative
medicine, as this treatment is now covered by a large number of health
insurers and most states have health insurance mandates to cover
chiropractic care (28).

Our study sampled a larger population than most previously
reported surveys about alternative medicine, but the data we collected
have some limitations. We relied on respondents' recall of services
used over a 12-month period, and this long recall period may have
resulted in some underreporting of alternative medicine use. We
provided a definition of alternative medicine, but we relied on
respondents to classify treatments they were reporting as
"alternative." We did not collect detailed information on why
respondents used alternative medicine except for asking if the services
had been used to treat mental or emotional problems. A number of
theories for the use of alternative medicine have been advanced in
earlier studies (5, 24, 29, 30, 32-35), and we cannot add to this
discussion.

TABLE 3.

We did not collect detailed information about what specific
types of alternative medicine treatments were used. We did collect
information about medications taken several times a week for at least 1
month in the past year, and we found that 3.7% of the respondents with
probable depression or dysthymia reported the use for at least 1 month
of St. John's wort (hypericum), an over-the-counter herbal product for
which there is some empirical evidence of efficacy (36-38). We cannot
determine from our data if the use of this compound represented
self-use or was recommended by a traditional or alternative health care
provider. Additional research should examine the nature of the
alternative medicine treatments used by individuals with mental
disorders in greater detail. It would, for example, be important to
know whether people are using alternative treatments for which there is
some evidence of efficacy.

Most users of alternative medicine also use conventional
medical treatments, and some researchers (31) have suggested that
alternative medicine is used as a complementary treatment to
conventional health care rather than as a substitute. In our study,
users of alternative medicine who met criteria for mental disorders
were as likely to use primary care or conventional mental health
treatments as those who did not use alternative medicine. All
respondents who met probable diagnostic criteria for mental disorders
and reported using alternative medicine also reported using at least
one of the conventional mental health services we asked about,
suggesting that, in this sample, use of alternative medicine was indeed
complementary to conventional treatments. Persons with high levels of
psychological distress may be more likely to use a range of available
treatments, including conventional mental health and alternative
medicine treatments.

Alternative medicine users with probable depressive or anxiety
disorders were somewhat more likely to receive conventional mental
health care that met criteria for appropriate care than were those who
did not use alternative medicine. On the other hand, respondents with
probable mental disorders who used alternative medicine reported a
somewhat lower level of satisfaction with available mental health
services than those who did not, although the difference was not
statistically significant. It is possible that patients with mental
disorders attempt to get help in the conventional medical sector and
then turn to alternative medicine if they feel that they have not been
helped by conventional medicine. However, our cross-sectional data do
not allow us to adequately test this hypothesis.

In summary, we found relatively high rates of use of
complementary and alternative medicine in individuals with common
mental disorders, particularly major depression and panic disorder.
Further research is needed to examine the nature and quality of
alternative medicine treatments used by persons with mental disorders
and to determine whether these individuals use alternative medicine
treatments because conventional medical and mental health care does not
properly address their health care needs. Such research may help us
improve conventional medical services for these persons and may suggest
ways of coordinating services across the conventional and alternative
health care sectors to provide better care to patients.

TABLE 4.

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Received March 14, 2000; revision received June 12, 2000;
accepted July 6, 2000. From UCLA Neuropsychiatric Institute, and RAND,
Santa Monica, Calif. Address reprint requests to Dr. Unutzer, Center
for Health Services Research, UCLA Neuropsychiatric Institute, 10920
Wilshire Blvd., Suite 300, Los Angeles, CA 90024





 

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