What are the recommendations for a patient with anxiety or depression considering Complementary and Alternative Medicine Services (CAMS) therapy, particularly those with a history of medical conditions such as cancer?

Complementary and Alternative Medicine (CAM) for Anxiety and Depression in Cancer Patients

For patients with cancer experiencing anxiety or depression, healthcare providers should proactively initiate conversations about CAM use at multiple timepoints throughout the cancer journey, using a structured assessment approach to ensure safe integration with conventional treatments. 1

Opening the Conversation About CAM

Initiate CAM discussions frequently and at critical timepoints rather than waiting for patients to bring it up, as most patients will not voluntarily disclose CAM use unless directly asked. 1 The essential timepoints include:

• Initial consultation following diagnosis 1
• When making treatment decisions 1
• During changes in disease status or progression 1
• When experiencing severe side effects from conventional treatment 1
• At transition points such as completion of treatment 1

Avoid medical jargon entirely - do not use terms like "complementary medicine" or "alternative therapies" as patients often don't recognize their practices under these labels. 1 Instead, ask specifically about:

• Natural products, vitamins, minerals (vitamin E, D, calcium), or herbal therapies (turmeric, ginseng, St. John's wort) 1
• Visits to other practitioners such as naturopaths, acupuncturists, or massage therapists 1
• Mind-body practices like yoga, meditation, or tai chi 1

Structured Assessment Framework

Use the SCOPED framework to systematically evaluate CAM use: 1

• Situation: Document past medical history, current cancer treatment, and any past/present/future CAM use 1
• Choices: Assess understanding of conventional treatment plan and other therapies under consideration 1
• Objectives: Identify specific goals for CAM use (symptom management, quality of life improvement, sense of control) 1
• People: Determine who is involved in CAM decisions and whether social pressure exists 1
• Evaluate: Assess knowledge about specific CAM products/therapies including risks and benefits 1
• Decision: Determine where the patient is in their decision-making process 1

For each CAM therapy identified, document: 1

• Type, dose, and frequency of use 1
• Cost and financial burden 1
• Perceived benefits and any side effects experienced 1
• Whether CAM use has affected decisions about conventional cancer treatment 1

Evidence-Based CAM Recommendations for Anxiety and Depression

For Anxiety Symptoms

Offer mindfulness-based interventions as first-line integrative therapy for anxiety during active treatment and post-treatment, supported by the strongest evidence base. 1

Recommend music therapy or music-based interventions during active treatment for anxiety reduction. 1

Consider yoga specifically for breast cancer patients with anxiety, as this population has the most robust evidence. 1

Hypnosis, including self-hypnosis with training, is recommended for anxiety during cancer-related diagnostic and treatment procedures, with moderate strength evidence from 9 RCTs. 2

Massage therapy significantly reduces anxiety levels with the strongest evidence supporting this benefit compared to other psychological outcomes, though effects may be short-term. 3

For Depression Symptoms

Offer mindfulness-based interventions for depression during both active treatment and post-treatment phases. 1

Recommend yoga for breast cancer patients with depression symptoms, as evidence is strongest in this population. 1

Consider tai chi/qigong specifically for post-treatment depression symptoms. 1

Music therapy or music-based interventions can be offered during active treatment for depression. 1

Note that massage therapy has weaker evidence for depression compared to anxiety, with most trials showing no statistically significant results for depressive symptoms. 3

Integration with Conventional Mental Health Treatment

Prioritize referral to licensed mental health professionals for moderate to severe symptoms of anxiety or depression, as CAM should complement rather than replace evidence-based psychological interventions. 4

When both anxiety and depression are present, prioritize treatment of depressive symptoms first, or use a unified protocol combining cognitive behavioral therapy approaches for both conditions. 1

Psychological interventions should derive from manualized, empirically supported treatments delivered by licensed mental health professionals, with CAM serving as adjunctive therapy. 1

Regularly assess treatment response at pretreatment, 4 weeks, 8 weeks, and end of treatment for both conventional and CAM interventions. 1, 4

Critical Safety Considerations

Document all CAM use, including dose, frequency, potential interactions, and the discussion of evidence to ensure comprehensive care coordination. 1

Screen for contraindications before recommending specific CAM therapies: 2

• History of dissociation or substantial trauma requires qualified mental health practitioner involvement before hypnotherapy 2
• Patients with multiple chronic conditions require careful evaluation of drug-CAM interactions 1

Monitor for adverse events and report them to appropriate regulatory bodies such as the FDA Safety Reporting Portal or Health Canada's MedEffects program. 1

Serious adverse events from CAM are extremely rare when performed by trained professionals, making most modalities low-risk interventions. 3

Common Pitfalls to Avoid

Never assume patients will volunteer CAM use - studies show most patients will not disclose unless directly asked in a nonjudgmental manner. 1

Do not dismiss or use pejorative labels (such as "quackery") when discussing CAM, as this shuts down communication and prevents safety monitoring. 1

Avoid treating CAM as standalone therapy for moderate to severe anxiety or depression - it should be adjunctive to evidence-based psychological or pharmacological treatment. 4, 3

Do not neglect follow-up on CAM decisions - patients with anxiety often avoid follow-through on referrals, so confirming attendance and addressing barriers is essential. 4

After 8 weeks of treatment, if symptoms show little improvement despite good adherence, adjust the regimen by adding interventions, changing approaches, or referring from group to individual therapy. 1, 4

Practical Implementation

Normalize the patient's interest in CAM by acknowledging that it is common for individuals with cancer to consider these therapies for symptom management, stress reduction, or sense of control. 1

Provide education about specific CAM therapies the patient is considering, helping them locate and evaluate credible sources of information. 1

Make referrals to appropriately trained CAM practitioners when indicated, ensuring they are licensed and qualified to provide the specific therapy. 2

Address cost barriers proactively - out-of-pocket costs for CAM can be substantial, and comprehensive cancer centers should consider prioritizing access to evidence-based integrative therapies without significant financial barriers. 1