Complementary and Alternative therapies in Psychiatry

This is a seminar which i had presented as a part of academic activity in my department. Please comment on the seminar, so that i can make any future changes... Thank you.

1. Complementary and Alternative
Therapies in Psychiatry
Presenter- Dr.D.Raj Kiran
Chairperson- Dr.Keshava Pai
“He's the best physician that knows the worthlessness
of the most medicines“ - Benjamin Franklin

2. National Centre for Complementary and
Alternative Medicine (NCCAM)
•It is the US Government's agency for scientific
research on complementary and alternative
medicine (CAM).
•Mission: - Is to define, through scientific
investigation, the usefulness and safety of
CAM interventions and their roles in improving
health and health care.
•In India, it is Indian Board for Alternative
Medicine (IBAM).
•IBAM- A Internationally Recognized
Government Institution of CAM providing
world-wide research in the field of
complementary and alternative medicines.

3. •1. CAM: - Group of diverse medical and
healthcare systems, practices, and
products that are not presently
considered to be part of conventional
medicine.
•2. Complementary medicine: - It is used
together with conventional medicine.
•3. Alternative medicine: - It is used in
place of conventional medicine.
•4. Integrative medicine: - It combines
mainstream medical therapies and CAM
therapies for which there is some high-
quality scientific evidence of safety and
effectiveness.

4. National Health Interview Survey by CDC
in USA in 2007
•In adults- 4 /10 use CAM, most
commonly used are non-vitamin, non-
mineral, natural products (17.7%) and
deep breathing exercises (12.7%).
•In children- 1/ 9 use CAM, most
commonly used are non-vitamin, non-
mineral, natural products (3.9%) and
chiropractic or osteopathic
manipulation (2.8%).
•Children whose parent used CAM were
almost 5x as likely (23.9%) to use CAM.
•When worry about cost delayed
receipt of conventional care,
individuals were more likely to use CAM.

5. NCCAM classifies CAM therapies into:
•Alternative Medical Systems: – Built upon complete systems of
theory and practice. Examples- Ayurveda, Homeopathy,
Acupuncture and Chinese medicine.
•Mind-Body Interventions: - Techniques designed to enhance the
mind’s capacity to affect bodily function and symptoms. Examples
- Meditation, Spirituality, Creative therapies.
•Biologically Based Therapies: - Substances found in nature are
used. Examples- Dietary supplements, Herbal products, vitamins.
•Manipulative and Body based methods: - Based on manipulation
and/or movement of one or more parts of the body. Examples-
Yoga, Massage.
•Energy Therapies: - Involves the use of energy fields. Two types:
–a)Bio field therapies: - Qigong, Reiki, Therapeutic Touch.
–b)Bio electromagnetic therapies- pulsed fields, magnetic fields, or
alternating-current or direct-current fields.

6. •5000 year old Indian system of healing.
•Derived from Vedic concepts of health and
healing .
•Charaka Samhita is important compilation.
•Focuses on prevention of illness rather than
treatment.
•Causes-
–Improper diet,
–Actions committed in this birth,
–Bad deeds done in the last birth,
–Physical illnesses and overindulgence,
–Severe mental or physical stress,
–Un favourable -personal, familial and social
environment

7. •Mental Disorders described in Ayurveda-
–Unmada - Insanity,
–Apasmara- Epilepsy,
–Avasada- Depression,
–Citto Udvega- Anxiety neurosis,
–Manasa Mandata- Mental Retardation,
–Atatva abhinevisha- Obsessive Disorders,
–Madatyaya - Intoxication.
•Describes three ‘guna’ of Mind (manas) ->
Satwa , Raja &Tama.
•Disease is due to imbalance of the ‘tamas’ or
‘rajas’ in the mind.
•Rajas and Tamas are termed as ‘Doshas of
mind’.

8. •Tridosha- Vata, Pitta and Kapha.
•They literally mean the darkness and
brightness of the mind or negative
thoughts in the mind.
•These impurities or imbalances are
called ‘doshas’.
•It concentrates on the aspect of mind,
body and soul and thus moulds the
treating process combining both mind
and body.
•It declares that health is the result of
pure body, happy soul and selfless
mind.

9. •Methods of healing-
•1. Daivavyaprashya Chikitsa-
–Mantra- Chanting of Hymns,
–Gems- Auspicious Stones,
–Mangala- Auspicious offerings,
–Homa- Yajna,
–Niyama- Regulations,
–Prayaschita-Atonement,
–Upavasa-Fasting.
•2. Yukti Vyapashraya (Medicines)-
•a. Antah Parimarjana
–(a) Shodhana: Cleansing (Panchkarma & Mild purgation ,
therapeutic Emesis & Purgation in Pitta & Kaphja type).
–(b) Shamana: Palliative (Medhya Rasayanas, Diet etc.)

10. •2. Yukti Vyapashraya (Medicines)-
•b. Bahir Parimarjnana- Murdha Taila,
Ahyanga, Shirodhara.
•3. Satvavajaya Cikitsa (Psychotherapy)-
–Aim is to augment the sattva guna in order
to correct the imbalance in state of rajas
(passion) and tamas (inertia).”
•NCCAM research- Most clinical trials were
small, problems with research designs, or
lacked control groups. Researchers have
studied Ayurvedic approaches for
schizophrenia; however, scientific
evidence for its effectiveness is
inconclusive.

11. •Developed in Germany by Samuel Hahnemann at
the end of the 18th century.
•Three unconventional theories:
–"Like cures like“- disease can be cured by a
substance that produces similar symptoms in healthy
people.
–"Law of minimum dose“- lower dose of medication,
has greater effectiveness.
–Remedies are effective when they are selected on
the “total” characteristic set of symptoms, not just
those of the disease.
•Remedies are derived from plants, minerals, or
animals, such as red onion, arnica, crushed whole
bees, white arsenic, poison ivy, belladonna.
•Formulated as sugar pellets.

12. •Widely used to self-treat generalized anxiety and
other anxiety symptoms.
•Case reports of homeopathic remedies in PTSD,
social phobia, panic disorder, and OCD were
published. However, findings of placebo-controlled
studies were negative or equivocal.
•NCCAM research on Homeopathy-
–Little evidence to support homeopathy as an effective
treatment for any specific condition.
–Key concepts are not consistent with fundamental
concepts of chemistry and physics. For example, it is
not possible to explain how a remedy containing little
or no active ingredient can have any effect.
–There is no uniform prescribing standard for
practitioners.

13. •It is an ancient Chinese treatment & central to Traditional
Chinese Medicine (TCM).
•TCM promotes a holistic, energy-based approach to well-
being, as opposed to the disease-oriented approach of
Western medicine.
•Acupuncture incorporates use of ultra-fine needles, inserted
into specific points on the skin (acupoints).
•Concept- The body’s energy/ Qi, flows along series of points
called meridians. Each of the internal organs has a
corresponding meridian, and applying pressure, heat or
needles to relevant acupoints is believed to influence each
of the internal organs and harmonize the body’s Qi.

14. •Exact mechanism is unclear.
•Research shows that it results in local and systemic
effects, such as an increased release of pituitary beta-
endorphins and ACTH.
•Endorphins- Analgesic property, ACTH→ ↑Cortisol→ Anti
inflammatory effects.
•It also leads to accelerated synthesis & release of 5-HT &
NA in CNS.

15. •Luo et al (1998) & Yang et al (1994) found
electro-acupuncture to be as effective as
amitriptyline for depressive symptoms.
•Acupuncture is also a promising treatment for
depression during pregnancy.
•Wang et al (2001) found that pts treated with
acupuncture reported significantly lower levels
of anxiety than did controls.
•Reports from the Chinese literature suggest that
different acupuncture protocols are beneficial
in the management of anxiety disorders.
•Inconclusive evidence in treatment of
Psychotic disorders and Substance use
disorders.

16. •“It is a psychological state of active
passivity and creative quiescence”.
• Meditator purposefully and
nonjudgmentally pays attention to the
present moment.
•Focus is on the process, or flow of psychic
content, rather than on the content itself.
•There are many types of meditation, most
have originated in ancient religious and
spiritual traditions.
•Meditator generally uses certain
techniques, such as a specific posture,
focused attention, and an open attitude
toward distractions.

17. •Two common forms- Mindfulness
meditation and Transcendental
meditation (TM).
•Mindfulness- essential component of
Buddhism.
•The meditator is taught to bring attention
to the sensation of the flow of the breath
in and out of the body.
•Helps the meditator learn to experience
thoughts and emotions in normal life with
greater balance and acceptance.
•TM- derived from Hindu traditions.
•Uses a mantra to prevent distracting
thoughts from entering the mind. The goal
of TM is to achieve a state of relaxed
awareness.

18. •Davidson et al (2000)- meditation increases left-sided anterior
activation → reductions in anxiety and negative affect and
increases in positive affect.
•Other physiological effects include
–↓ Oxygen consumption,
–↓ Respiratory rate,
–↓ BP,
–EEG changes associated with decreased autonomic arousal.
•RCTs- consistent practice of mindfulness meditation significantly
reduces generalized anxiety and other anxiety symptoms.
•NCCAM finds the common use of meditation in health problems
like anxiety, pain, depression, stress, insomnia, physical symptoms
associated with chronic illnesses.

19. •Religion: - Organized system of beliefs, practices, rituals, and
symbols designed to facilitate closeness to the sacred or
transcendent.
•Spirituality: - Personal quest for understanding answers to the
ultimate questions about life.
•In medieval ages most mental disorders were considered as
witchcraft or demonic possession, when natural causes was not
considered to mental disorders.
•Most of the Physicians like Charcot, Maudslay, Sigmond Freud,
Albert Ellis had anti religious stance based on their personal
experiences.
•David Larson, Jeffrey Levin, Harold Koenig have conducted a
series of studies looking at the relationship between religious
involvement and mental health.

20. •Levin & Chatters (1998) stated that “the existing research has
shown that religious involvement has protective effects over
psychological well-being related outcomes”.
•Koenig et al (1998) found out that intrinsic religious motivation
was associated with faster remission from depression.
•Kendler et al (2003) found a strong association between religion
and lower prevalence rates of nicotine, alcohol and drug abuse
or dependence.
•Koenig et al (2001) found lower rates of suicide or more
objections to suicide among the more religious subjects
•Koenig et al (2001) “Research has shown that medical patients
have religious and spiritual needs that are intimately related to
their physical health conditions, and that religious and spiritual
beliefs and practices can often be important for emotional
healing”

21. •Reasons ???
–Feelings of social connectedness,
–Messages of healthy living,
–Reduced drug-seeking behaviour,
–Beliefs that justice prevails at the end,
–Belief that adverse events always have a
message and a meaning,
–That there is a caring ever-present God.
•Faith and Religion play important roles in
the lives of many patients and
physicians, but such concepts are yet to
be incorporated into routine clinical
care.

22. •Def: - It is based on the premise that when someone
works creatively under the guidance of a qualified
therapist, they become more expressive and
communicative.
•Music therapy: - It is use of music to accomplish
individualized goals within a therapeutic relationship
by a professional.
•Art therapy: - It is a mental health profession who uses
the creative process of art making to improve and
enhance the physical, mental, and emotional
wellbeing of individual.
•Drama therapy: - It is the intentional use of drama
and/or theatre processes to achieve therapeutic
goals.
•Dance therapy: - The psychotherapeutic use of
movement to further the emotional, cognitive,
physical and social integration of the individual.

23. •Others- Poetry therapy, Play therapy, Sand-play
therapy, Multi-modal therapy.
•Compared to others they have-
–Self expression,
–Active participation,
–Imagination,
–Mind body connections.
•Music therapy is the most widely researched
modality, because physiological and
behavioural reactions to music can be
quantified.

24. •Beneficial effects- effects on endorphins and
other neurotransmitters that mediate
improvements in depressed mood.
•A Cochrane review (2005)- concluded that Music
therapy as an adjunct in schizophrenia was
found to improve their global state and may also
improve mental state and functioning.
•A meta-analysis in dementia concluded that
regular singing, engaging in dance therapy,
listening to music, and participating in musical
games improve cognitive and behavioural
functioning in individuals with severe dementia.
•They also experienced reduced agitation,
irritability & wandering, enhanced social
interaction mood & cooperative behaviour.

25. modifications
•↓ refined sugar and caffeine→ improves mood in
some depressed patients.
•Caffeine→ ↑ serum Adr, NA, and cortisol→
general feelings of “nervousness” / ↑ risk of panic
attacks in predisposed individuals.
•Consumption of high fat & calorie diet→ ↑
developing Alzheimer's disease compared to
those who take moderate fat & calories.
•Excess caloric & fat intake→ promote formation
of damaging free radicals→ diffuse neuro-
pathological changes in the brain.
•Moderate but not heavy consumption of wine→
↓ risk of Alzheimer's disease.

26. •Deficiencies:
–Causative role in mental illness and exacerbate
symptoms.
–Symptoms can result in poor nutrition.
–May compromise patient recovery.
•B1 (Thiamine)-
–Chronic Alcoholism, Eating disorders.
–Wernick’s encephalopathy, Korsakoff’s psychosis.
•B2 (Riboflavin)-
–Excess Alcohol
–Depression (Glutathione def)
•B6 (Pyridoxine)-
–Hemodialysis, OCP’s.
–Depression

27. •B9 (folate)-
–Required for synthesis of 5 HT, NA, DA.
–Mood disorders, Depression, Psychosis.
–Augmentation with L-Methylfolate in antidepressant rx.
•B12 (Cobalamin)-
–Associated with ↑ Homocysteine.
–Depression, Irritability, Agitation, Psychosis, Obsessive
symptoms, Cognitive decline, Alzheimer’s dis.
–Compromises antidepressant efficacy.
•C (Ascorbic acid)-
–Drug/ Alcohol abuse, Eating disorders.
–Depression, Schizophrenia.
•A-
–Excess- Aggression, Depression, Psychosis, Suicide.

28. •D-
–Role in brain function and development.
–Depression, Cognitive dysfunction, Seasonal Affective
disorder.
•Supplementation of Folate (1 to 15mg), Thiamine
(50mg), Inositol (up to 20gm/ d)→ ↑ Efficacy of
conventional antidepressants.
•↑ Serum Homocysteine is a marker for folate, B6, and
B12 deficiencies→ risk factor for Alzheimer's disease
and other neurodegenerative diseases.
•Supplementation of Folate, Choline,
Phosphatidylcholine → ↑ efficacy of lithium in acute
mania.
•In Schizophrenia, daily Folate & Niacin +
antipsychotic→ fewer +ve & -ve symptoms and
respond more rapidly.

29. •Mg
–Rapid recovery from severe depressed mood,
–Ameliorate symptoms of anxiety, irritability,
insomnia, postpartum depression and short-term
memory,
–Improve neuropsychological deficits,
–Low in ADHD and supplementation can help
inattention.
•Studies→ high copper levels may be a causative
factor in the pathogenesis of Alzheimer's
disease.
•Deficiencies in Zinc, Manganese and Iron are
common in alcoholics and worsen with chronic
heavy use.

30. •In psychiatric symptoms→ SAMe (S Adenosyl l
Methionine), L-tryptophan, 5-hydroxytryptophan,
L-taurine, tyrosine, acetyl-L-carnitine & glycine.
•SAMe-
–Efficacy in treatment of depression along with
antidepressants.
–↓ SAMe→ may lead to depression in Alcoholics.
•L-tryptophan
–Effective in treatment of moderate depression and
as adjuvant in treatment resistant depression.
–Combined with antidepressant→ rapid response in
insomnia.
–↓ levels → BPAD in genetic predisposed.

31. •Acetyl L Carnitine-
–Treat cognitive impairments related to dementia
and other neurodegenerative disorders.
–May improve mood in depression.
•L-Theanine-
–Found in green tea
–Treat symptoms of anxiety and depressed mood.
–↑ brain 5-HT, DA and GABA levels and may have
neuro-protective effects.
•Glycine-
–Some efficacy in treatment of -ve symptoms of
schizophrenia in addition to antipsychotics.

32. • 2 main omega-3 FA - Eicosapentaenoic acid
(EPA) & docosahexaenoic acid (DHA).
•Studies suggest that PUFA’s- EPA and DHA-
Ameliorate symptoms associated with many
psychiatric disorders.
•Studies→ Association b/n depression and low
omega-3 FA.
•Studies → Therapeutic benefit when EPA is
added on to existing psychotropic medication
in depression & schizophrenia.
•Individual trials→ Benefits of EPA treatment in
BPD
•Trails→ combined omega-3 and omega-6 fatty
acid treatment for ADHD showed some
evidence.

33. •EPA supplementation→ effective
augmentation strategy for the
management of MDD.
•No definitive conclusions about the
preventive or therapeutic role as a stand-
alone treatment of MDD, BPAD,
schizophrenia, ADHD, borderline personality
disorder and other psychiatric disorders.
•MOA- antidepressant efficacy include
–↑ CNS serotonin activity,
–Anti-inflammatory effects,
–Suppression of PIP second messenger activity,
–↑ Heart rate variability.

34. •Hypericum perforatum aka St John's wort, is a flowering plant.
•Called so because traditional flowering and harvesting takes
place on St John's day, 24 June.
•Constituents (Hyperforin) function as
–SRIs,
–↓ binding to BZD receptors,
–Weakly inhibit MAO,
–Possibly bind to NMDA receptors.
•Current evidence→ treatment of mild to moderate depression
and Somatisation disorder with tentative support in Seasonal
affective disorder.
•Studies were conducted to explore its use in other psychiatric
disorders like ADHD, Dysthymia, OCD, GAD, Social phobia etc..,
but the evidence is not conclusive.

35. •The ginkgo is a living fossil, with fossils recognisably
dating back 270 million years.
•It is one of the most frequently prescribed herbal
preparation in Germany and over the counter herbal
preparation in US.
•MOA- Antioxidant and Anti PAF activity
•Induces→ Modulatory effects on Cerebro-
Vasculature tone, receptor activity and EEG activity.
•Indications- Alzheimer’s age associated dementia,
Traumatic brain injury, Multi infarct dementia,
Cerebral edema etc..,
•Lack of evidence- autism, ADHD, addiction, GAD,
and tardive dyskinesia.
•Adverse effects- Bleeding tendencies.

36. •Yoga is a Sanskrit word, meaning “to join”.
•Mahabharata- The experience of uniting the
individual “Ātman” with the universal “Brahman”
that pervades all things.
•Early indications of yogic postures are seen in
remains of Indus valley civilisation.
•Early texts such as Patanjali’s yoga sutras
describe the basic principles of yoga.
•Sub-types and incorporates physical postures
(asanas), controlled breathing (pranayama),
deep relaxation and meditation.
•Effects in mental illness- Calming effects,
increasing awareness, increasing the attention
span, Acceptance and adaptability and a
sense of security.

37. •Sivakumar et al (2013)- following yoga significant
improvement in cognitive function, QOL, sleep
quality in elderly.
•Gangadhar et al (2013)- in depression yoga had
better efficacy than pharmacotherapy and
devoid of side-effects.
•Manjunath et al (2013)- found yoga with
pharmacotherapy better than physical exercise
in-patients with psychosis.
•Varambally et al & Thirthalli et al (2013)-
demonstrated increase in serum BDNF & ↓ Cortisol
following yoga in depression.
•Good evidence as an adjunct treatment in
depression, schizophrenia and ADHD.
•Fair evidence in treatment of sleep disorders and
eating disorders.

38. •Def- “The manipulation of the soft tissue of the
body to bring about generalised improvements
in health”.
•Variety of strokes- effleurage, petrissage and
kneading.
•Touch- thought to be therapeutic in those with
less physical contact like those without intimate
friends or family or who have painful physical
conditions.
•Different ways- Lower stress, Increase immune
function, Boost mental health and wellness,
Manage pain and Improve physical fitness.
•Increasingly being used as supplement to
pharmacotherapy to counteract anxiety,
agitated behaviour, and depression.
•Its efficacy however, is contested.

39. Energy therapies
•Believes healer can channel healing energy into the person
seeking help by different methods.
•Edzard Ernst (Prof of CAM)- "healing continues to be
promoted despite the absence of biological plausibility or
convincing clinical evidence ... that these methods work
therapeutically and plenty to demonstrate that they do not."
•These are controversial to conventional health care
providers and policymakers for two main reasons:
–The dearth of rigorous scientific data that support or refute their
efficacy.
–Because bio-fields currently cannot be measured, so their
scientific method of action remains questionable.

40. •Provides healing energy to recharge and rebalance
the human energy fields, creating optimal conditions
needed by the body’s natural healing system.
•Japanese term for ‘‘universal life energy,’’.
•Originated thousands of years ago in Tibet and re-
established in the 1800s.
•Administered through a gentle lying of hands.
•Practitioner maintains a meditative presence and
allows the Reiki energy to flow to where the patient
needs it.
•Studies- reduces anxiety and depression and
increases relaxation and comfort.
•Widely used outside of mainstream medicine, to
relieve pain, especially postoperative pain and to
facilitate patient recovery.

41. •Traditional Chinese exercises widely practised
for health benefits.
•Involves sequences of flowing movements
coupled with changes in mental focus,
breathing coordination and relaxation.
•Relatively safe, non-pharmacological practices
which can be used for treatment and proven
benefit for psychosomatic diseases with few
adverse events reported.
•Showed improvement in immune function,
vaccine response, increased endorphins and
baroreceptor sensitivity, decreased
inflammatory markers, ACTH and cortisol.
•Most logical clinical application is for stress
reduction.

42. Why people use Complementary and
Alternative therapies?
•Three theories have been proposed to explain the use of CAM
•1.Dissatisfaction: - Dissatisfied with conventional treatment
because it has been ineffective, has produced adverse effects,
or too costly.
•2.Need for personal contact: - They see them less authoritarian,
more empowering, offering them offer personal autonomy over
their health care decisions.
•3.Philosophical congruence: - More attractable because they
are seen as more compatible with patients’ values, spiritual/
religious philosophy, or beliefs.

43. Take Home Message…
•Whenever required using an alternative therapy may be helpful.
•Usage of alternative therapies based on patients religious
background.
•To discourage the use of non evidence based therapies.

44. Refercences
• 1.http://nccam.nih.gov/health/whatiscam.
• 2.Barnes PM, Bloom B. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. National health statistics report. Number 12, December 10, 2008.
• 3.Venkoba rao A. Mind in Ayurveda. Indian Journal of Psychiatry, 2002, 44(3)201-2.
• 4.Ramu MG, Venkataram BS. Manovikara (Mental disorders) in Ayurveda. Ancient sci of life. Vol. IV, No.3 January 1985, Page 165-173.
• 5.Ernat E. A systematic review of systematic reviews of homeopathy. Br J Clin Pharmacol, 54, 577–582.
• 6.Acupuncture Research Resource Centre, British Acupuncture Council: Depression and anxiety: The evidence for effectiveness. Briefing paper No. 9. February 2002.Available at:
http://www.acupuncture.org.uk/content/Library/doc/anxiety_bp9.pdf.
• 7.McGee M. Meditation and psychiatry. Psychiatry 2008. Jan, pg 28-41.
• 8.http://www.amtamassage.org/articles/1/News/detail/2885.
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• 10.Murali SR. Spirituality in psychiatry, Letters to the editor. Psychiatry 2005, sept, pg 20-3.
• 11.http://www.musictherapy.org/
• 12.http://www.arttherapy.org/
• 13.http://www.adta.org/
• 14.http://www.nadta.org/
• 15.Herrmann W, Lorenzl S, Obeid R: Review of the role of hyperhomocysteinemia and B-vitamin deficiency in neurological and psychiatric disorders—Current evidence and preliminary
recommendations. Fortschr Neurol Psychiatr. 2007;75(9):515.
• 16.Kaplan BJ, Crawford SG, Field CJ, Simpson JS: Vitamins, minerals, and mood. Psychol Bull. 2007;133(5):747.
• 17.Lakhan SE, Vieira KF: Nutritional therapies for mental disorders. Nutr J. 2008;7:2.
• 18.Ross BM, Seguin J, Sieswerda LE: Omega-3 fatty acids as treatments for mental illness: Which disorder and which fatty acid? Lipids Health Dis. 2007;18(6):21.
• 19.Sarris J: Herbal medicines in the treatment of psychiatric disorders: A systematic review. Phytother Res. 2007;21(8):703.
• 20.Cavaye J. Does Therapeutic Massage Support Mental Well-Being?. Medical Sociology online. Volume 6, Issue 2, May 2012, pg 43- 50.
• 21.Vander vaart S, Gijsen VMGJ, Wiidt SN, Koren G. A Systematic Review of the Therapeutic Effects of Reiki. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE. Volume 15,
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• 22.Abbott R & Lavretsky H. Tai chi and Qigong for the treatment and prevention of mental disorders. In Sec 3: mind- body of Complemantary and integrative therapies for psychiatric
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45. THANK YOU