The Use of Herbal Medications and Dietary Supplements
by People with Mental Illness
Noosha Niv Æ Æ Jess P. Shatkin Æ Æ Alison B. Hamilton Æ Æ
Ju ¨rgen Unu ¨tzer Æ Æ Ruth Klap Æ Æ Alexander S. Young
Received: 27 October 2008/Accepted: 3 August 2009/Published online: 18 August 2009
? The Author(s) 2009. This article is published with open access at Springerlink.com
herbal medication and dietary supplement (HMDS) use and
mental health characteristics. Data are drawn from a
national household survey of the United States’ civilian,
non-institutionalized population (N = 9,585). Psychiatric
medication and HMDS use, psychiatric diagnoses and
treatment needs, utilization and satisfaction were assessed.
Compared to non-users, HMDS users were more likely to
perceive themselves as having mental health needs, to have
received mental health and primary care treatment, and to
be dissatisfied with their overall healthcare. Psychiatric
medication use was not related to HMDS use, and in
multivariate analyses, HMDS use was associated with
perceived mental health needs. Differences in use of
This study examined the relationship between
specific HMDS between those with and without a psychi-
atric disorder were also examined. The use of HMDS
warrants particular attention in persons with perceived
mental health problems as these individuals may be turning
to HMDS use for treatment of their symptoms.
Herbal medication ? Dietary supplement ? Mental illness
Complementary and alternative medicine ?
Use of complementary and alternative medicine (CAM) in
the US population increased from 34% in 1990 to 42% in
1997 (Eisenberg et al. 1998). More recent data from the
2002 National Health Interview Survey reported that 36%
of US adults used some type of CAM, excluding prayer, in
the past 12 months (Barnes et al. 2004). Use of herbal
medicines and dietary supplements (HMDS) has been no
exception to this rising trend. However, little is known
about the relationship between use of specific HMDS and
mental health characteristics. It is becoming increasingly
important to clarify these relationships as there is ample
data indicating that a number of HMDS can cause signif-
icant drug interactions (Cott 2001) and that most patients
do not discuss their use of CAM modalities with their
mental healthcare specialist (Elkins et al. 2005). Also, it is
important to understand the extent to which mental health
needs are driving use of HDMS.
Rates of psychiatric disorders among CAM users are
high. A national survey found that of the 14.5% of
respondents who had used CAM in the past year, 21% met
diagnostic criteria for one or more psychiatric disorders
compared to 12.8% of respondents who did not report
CAM use (Unu ¨tzer et al. 2000). Druss and Rosenheck
N. Niv ? A. B. Hamilton ? A. S. Young
Department of Veterans Affairs, Desert Pacific Mental Illness
Research, Education and Clinical Center (MIRECC),
Los Angeles, CA, USA
N. Niv ? A. B. Hamilton ? A. S. Young
Department of Psychiatry and Biobehavioral Sciences,
University of California Los Angeles, Los Angeles, CA, USA
J. P. Shatkin
School of Medicine, New York University, New York, NY, USA
J. Unu ¨tzer
Department of Psychiatry, University of Washington, Seattle,
Health Services Research Center, University of California
Los Angeles, Los Angeles, CA, USA
N. Niv (&)
West Los Angeles VA, MIRECC, 11301 Wilshire Boulevard,
210A, Los Angeles, CA 90073, USA
Community Ment Health J (2010) 46:563–569
(2000) found that 9.8% of those with a psychiatric condi-
tion reported using CAM, and approximately half of those
individuals (4.5%) reported visiting a CAM provider spe-
cifically to treat their mental health condition. One study
found that 4.5% of respondents reported using CAM to
treat anxiety or depression (Barnes et al. 2004), and indi-
viduals reporting these disorders used CAM more than
those reporting any other condition other than back and
neck pain (Eisenberg et al. 1998). In fact, those who cited
anxiety as one of their three most serious health problems
were much more likely to use CAM compared to those
without anxiety (67 vs. 39%) (Astin 1998). A national
survey found that of the 7% of individuals who reported
severe depression and of the 9% of individuals who
reported anxiety attacks, CAM use in the past year was 54
and 57%, respectively (Kessler et al. 2001). These findings
have been replicated among older adults as well (Grzywacz
et al. 2006). In persons 65 years old and older, those with
anxiety or depression (35%) were significantly more likely
to use any CAM excluding prayer compared to those that
were not anxious or depressed (27%).
Herbal medicines and dietary supplements (HMDS) are
types of CAM whose use has also increased from 2.5% in
1990 to 12% in 1997 to 14% in 1998/99 to 19% in 2002
according to community surveys (Eisenberg et al. 1998;
Kaufman et al. 2002; Kelly et al. 2005). HMDS use was
among the most widely used CAM modalities in adults
with psychiatric problems (Kessler et al. 2001; Knaudt
et al. 1999), and chronic psychiatric disorders such as
major depression are predictive of dietary supplement use
(Druss et al. 1998). One study showed that 4.3% of
depressed individuals and 3.3% of those with panic disor-
der used herbal medication (Kessler et al. 2001). Studies of
outpatient psychiatric patients have shown even higher
rates of HMDS use ranging from 15 to 24% (Knaudt et al.
1999; Matthews et al. 2003). HMDS use was 11% in a
sample of 682 primary care patients that was weighted
toward those with anxiety symptoms (Roy-Byrne et al.
2005). The most commonly used HMDS in this study were
St. John’s wort, ginseng, ginko biloba, kava kava, mela-
tonin, and valerian root.
Using a nationally representative sample, the goals of
this study are: (1) to examine differences between HMDS
users and non-users in regard to demographic variables,
mental health characteristics and treatment utilization, (2)
to determine if rates of use of specific HMDS differ
between individuals with and without psychiatric prob-
lems, or between individuals who use psychiatric medica-
tions and those who do not, (3) to examine rates of
psychiatric problems and psychiatric medication use
between those who use different HMDSs and those who do
not, and (4) to determine if mental health characteristics are
associated with HMDS use after controlling for covariates.
The data for this study is drawn from Healthcare for
Communities (HCC), a national household telephone sur-
vey funded by the Robert Wood Johnson Foundation and
completed from 1997 to 1998. The HCC respondents rep-
resent a stratified probability sample of participants from
the Community Tracking Study (CTS), a nationally rep-
resentative study of the United States’ civilian, non-insti-
tutionalized population (Kemper et al. 1996). The CTS
sample was stratified by psychological distress [distressed
vs. not distressed as determined on the basis of subjects’
responses to two mental health items from the 12-item
Short Form Health Questionnaire (Ware et al. 1996)] and
use of mental health specialty services in the past
12 months (use vs. no use). HCC sampled all adults who
had reported psychological distress or mental health ser-
vice use (n = 7,164) plus a random sample of non-dis-
tressed, non-mental health service users (n = 7,821). Of
the 14,985 individuals selected for the sample, 9,585
completed the HCC interview for a response rate of 64%.
Verbal informed consent was obtained from all subjects.
Sampling weights were derived based on the inverse of the
probability of selection and included adjustments for par-
ticipant non-response and for the exclusion of households
without telephones. The design of the HCC is described in
more complete detail elsewhere (Sturm et al. 1999).
All data originate from the HCC survey with the exception
of some demographic data from the CTS survey. The HCC
survey can be found at www.hsrcenter.ucla.edu/research/
Psychiatric Medication and HMDS Use
To assess medication use, participants were asked ‘‘In the
past 12 months, did you take any medications or drugs at
least several times a week for at least 1 month?’’ and
prompted to ‘‘include vitamins and herbs.’’ They were then
asked for the name of each medication. Medication codes
allowed for identification of psychiatric medication and
HMDS use. Herbal medications were defined as any
product commonly known to be an herbal treatment or
defined as such by the survey participant. The definition of
dietary supplements was based on the Dietary Supplement
Health and Education Act (DSHEA) of 1994 and included
amino acids, tissue extracts, and botanical products. Vita-
mins and minerals were not included. In addition to
examining the use of any HMDS and specific HMDS, we
564Community Ment Health J (2010) 46:563–569
also examined the use of psychoactive HMDS, defined as
the use of Saint John’s Wort, ginkgo, ginseng, valerian,
kava, melatonin, or fish oil.
Mental Health and Substance Abuse Problems
Depression, dysthymia, and panic disorder were assessed
using short-form versions of the Composite International
Diagnostic Interview (CIDI-SF: Kessler et al. 1998) and
are based on DSM-III-R criteria. Kessler et al. (1998)
reported that the sensitivity and specificity of the CIDI
short-form relative to full CIDI diagnosis is excellent, with
concordance ranging from 90 to 100%. Lifetime mania was
screened for by asking, ‘‘Has there ever been a period of at
least 4 days when you were so happy or excited that you
got into trouble, or your family or friends worried about it,
or a doctor said you were manic?’’ Psychosis was also
screened for by asking, ‘‘Has a doctor ever said that you
had schizophrenia or schizoaffective disorder?’’ Substance
use disorders were also assessed. The Alcohol Use Disor-
ders Identification Test (AUDIT: WHO 1992) was used to
assess for alcohol use and abuse, and drug abuse was
assessed with a screener described by Rost et al. (1993).
Study participants were considered to have a psychiatric
problem if they met criteria for depression, dysthymia, or
panic disorder, or they screened positive for mania or
psychosis. Individuals who had a substance use problem
alone were not included in this group.
Treatment Need, Utilization, and Satisfaction
Perceived need for mental healthcare and service utiliza-
tion were assessed by self report. Participants were asked if
they thought they needed help for emotional or mental
health problems in the past year. They were also asked if
they had seen a mental health provider, a substance abuse
specialist or their primary care physician in the past year.
Counseling from a primary care provider was assessed by
asking whether medical visits included at least 5 min of
counseling about an ‘‘emotional, mental health, alcohol or
drug problem.’’ Lastly, participants were asked how satis-
fied or dissatisfied they were with their overall health care.
Data were weighted and analyzed with SUDAAN software
(Research Triangle Institute 2002), which applies a Taylor
series linearization method to account for the study’s
complex survey design. Chi-square tests and t-tests were
used to compare HMDS users to non-users on demographic
variables, mental health characteristics, and treatment uti-
lization. We next examined the relationship between
HMDS use and psychiatric problems and psychiatric
medication use using chi-square analyses. All results are
reported as unweighted n’s and weighted means and per-
centages reflecting weighted US population estimates. To
control for Type I error due to multiple tests, the signifi-
cance level of these tests was set at P\.01 to be conser-
vative. Lastly, we developed a series of logistic regression
models to predict the use of HMDS for which both P\.05
and P\.01 are provided accordingly. Institutional review
and approval for the project was obtained. The authors
certify responsibility for this study and have no known
conflicts of interest.
Demographics, Mental Health Characteristics and
Treatment Utilization of HMDS Users and Non-Users
HMDS users (50.1 ± 15.9) were significantly older than
non-users (46.6 ± 17.4) (t = 3.9, P\.001) and more
likely to be White than non-users (78.5 vs. 72.0%;
v2= 11.8, P\.01). Compared to non-users, HMDS users
were significantly more educated (v2= 35.2, P\.001)
and less likely to be unemployed (2.1 vs. 4.6%; v2= 15.6,
P\.001). Those who used HMDS were more likely to live
in the Western region of the US than non-users (36.9 vs.
22.4%), whereas non-users were more likely to live in the
South than HMDS users (36.9 vs. 25.9%) (v2= 27.3,
P\.001). There were no significant gender differences
between the two groups.
HMDS users and non-users did not significantly differ in
their rates of psychiatric disorders, alcohol and substance
use disorders, or use of psychiatric medication. HMDS
users, however, were more likely to perceive themselves as
having mental health needs (16.0 vs. 9.7%; v2= 21.4,
P\.001), to have seen a mental health provider in the past
year (8.2 vs. 4.4%; v2= 11.4, P\.001), and to have seen
a primary care physician in the past year (80.4 vs. 73.7%;
v2= 9.4, P\.01). HMDS users were less satisfied with
their overall healthcare compared to non-users (v2= 9.3,
HMDS Use Among Individuals with Psychiatric
Problems and Those Using Psychiatric Medication
The weighted prevalence of HMDS use was 10.6% with
HMDS users using an average of 1.9 ± 1.5 different
medications/supplements (range 1–13), and the weighted
prevalence of use of HMDS with psychoactive properties
was 2.9%. The most frequently used HMDS in this
sample along with their weighted population estimates of
use were garlic (1.8%), ginkgo (1.5%), St. John’s Wort
Community Ment Health J (2010) 46:563–569565
(1.2%), zinc (1.2%), ginseng (1.1%), echinacea (1.0%),
chromium picolinate (0.9%), saw palmetto (0.5%), and
DHEA (0.4%). Co-enzyme Q10, omega-3 fatty acids,
bilberry, evening primrose oil, glucosamine sulfate, and
melatonin were all used by an estimated 0.3% of the
Rates of use of any of these HMDS did not differ
between individuals with and without psychiatric problems
(11.9 vs. 10.4%; v2= 1.9, P[.01). However, those with
psychiatric problems were more likely to use an HMDS
that has psychoactive properties compared to those without
a psychiatric problem (4.7 vs. 2.6%) (v2= 7.9, P\.01).
In regard to specific HMDS, those with a psychiatric
problem were more likely to use St. John’s Wort than those
without a psychiatric problem (3.3 vs. 0.8%; v2= 14.0,
P\.001). Individuals with a psychiatric disorder were
also more likely to use melatonin than those without a
psychiatric disorder (1.0 vs. 0.2%; v2= 7.8, P\.01).
Compared to those without a psychiatric disorder, those
with a psychiatric disorder were less likely to use garlic
(0.9 vs. 2.0%; v2= 9.2, P\.01) and bilberry (0.02 vs.
0.3%; v2= 6.9, P\.01). Rates of other HMDS use did
not differ between individuals with and without psychiatric
problems. Rates of HMDS use also did not differ between
those who used psychiatric medications and those who did
not (P[.01 for all HMDS).
Psychiatric Problems and Medication Use of HMDS
Users and Non-Users
Rates of psychiatric problems and psychiatric medication
use among individuals who used different HMDS were
examined. Those who used an HMDS with psychoactive
properties, St. John’s Wort and melatonin were more likely
to have a psychiatric problem than those who did not use
these HMDS. Specifically, 22% of those who used an
HMDS with psychoactive properties met criteria for at
least one psychiatric diagnosis compared to 13.4% among
those who did not use an HMDS with psychoactive prop-
erties (v2= 7.9, P\.01). Rates of psychiatric problems
were significantly higher among those who used St. John’s
Wort (38.5%) compared to those who did not use St. John’s
Wort (13.4%) (v2= 14.0, P\.001). Rates of psychiatric
problems were also higher among those who used mela-
tonin (49.5%) compared to those who did not use melato-
nin (13.6%). In contrast, rates of psychiatric disorders were
significantly lower among those who used garlic (6.6%)
compared to those who did not use garlic (13.8%)
(v2= 9.2, P\.01). They were also lower among those
who used bilberry (0.8%) than those who did not use bil-
berry (13.7%) (v2= 6.9, P\.01). Rates of psychiatric
medication use did not differ for HMDS users and non-
users (P[.01 for all HMDS).
Multivariate Analyses Examining the Associations
Between Mental Health Characteristics and HMDS Use
Bivariate analyses had indicated a relationship between the
presence of a psychiatric problem and the use of HMDS
that had psychoactive properties as well as several specific
HMDS (i.e., St. John’s Wort, melatonin, garlic, and bil-
berry). Logistic regression models were developed to
determine if mental health characteristics were associated
with the use of these HMDS in multivariate analyses.
Mental health characteristics included in the model were
presence of a psychiatric problem, perceived mental health
needs, use of psychiatric medication, and receipt of mental
health treatment. Covariates included demographic char-
acteristics (i.e., age, gender, ethnicity, education, employ-
ment, income, and census region) and other important
health characteristics (i.e., visited a primary care physician
and satisfaction with overall health).
Perceived mental health need was the only mental health
characteristic significantly associated with using any
HMDS with use of HDMS higher among respondents
reporting perceived need (OR = 1.7; P\.01). The use of
any HMDS significantly increased as age, education, and
dissatisfaction with healthcare increased (P\.01 for all).
Unemployed individuals were half as likely to use any
HMDS relative to employed persons (P\.01), and living
in the Western region was significantly associated with
HMDS use as well (P\.01).
Mental health characteristics significantly associated
with the use of any psychoactive HMDS included per-
ceived mental health needs (OR = 2.4; P\.01) and
receipt of mental health services (OR = 1.6; P\.05). The
use of any psychoactive HMDS significantly increased as
age, family income, and dissatisfaction with healthcare
increased (P\.01 for all). Living in the Western region
was also significantly associated with psychoactive HMDS
The use of St. John’s Wort increased with the presence
of a psychiatric disorder (OR = 1.9; P\.05) and
increased perceived mental health needs (OR = 3.3;
P\.01). Other independent variables associated with the
use of St. John’s Wort included being female (P\.05),
having a greater family income (P\.01), and living in the
Western region of the US (P\.05). African-Americans
were significantly less likely to use St. John’s Wort than
Whites (OR = 0.2; P\.05). The presence of a psychiatric
disorder (OR = 3.3; P\.01), perceived mental health
needs (OR = 2.9; P\.01), and having seen a mental
health provider (OR = 3.1; P\.05) were significantly
associated with melatonin use. Other independent variables
associated with melatonin use included being male, greater
family income, and living in the Western region of the US
(P\.05 for all).
566 Community Ment Health J (2010) 46:563–569
The use of garlic decreased with the presence of a
psychiatric disorder (OR = 0.4; P\.01); however, it
increased with greater perceived mental health needs
(OR = 2.1; P\.05). Other variables significantly associ-
ated with garlic use included greater age and living in the
Western region of the US (P\.01 for both). Additionally,
Hispanics were significantly less likely to use garlic than
Whites (OR = 0.2; P\.01). The use of bilberry signifi-
cantly decreased when a psychiatric disorder was present
(OR = 0.1; P\.05) or if an individual had seen a mental
health provider (OR = 0.01; P\.01). Use of bilberry
increased with age, employment, income, and Western
living and decreased with lower satisfaction with health-
care (P\.05 for all).
This study enhances our understanding of the use of CAM
by focusing on HMDS use, and specifically, the relation-
ship between HMDS use and mental health. Although use
of HMDS in general was not associated with psychiatric
illness, bivariate analyses showed that the use of any psy-
choactive HMDS, St. John’s Wort, and melatonin was
associated with the presence of psychiatric problems, and
the use of garlic and bilberry was associated with the
absence of psychiatric illness. However, the relationship
between psychiatric illness and use of psychoactive HMDS
in general was no longer significant in multivariate analy-
ses, suggesting that multiple individual characteristics
affect HDMS use.
Consistent with prior research (Roy-Byrne et al. 2005),
HMDS users and non-users did not differ in their rates of
psychiatric medication use. Similar to that study, utilization
of mental health services was not associated with HMDS
use in general. It was, however, associated with the use of
any psychoactive HMDS, melatonin, and bilberry. Fur-
thermore, regardless of the presence or absence of a psy-
chiatric diagnosis, one’s perceived need for mental health
care and dissatisfaction with health care were strongly
associated with HMDS use. These findings could be
attributed to the possibility that individuals with greater
perceived health needs tend to make greater use of all
available health care services, both conventional and
alternative, a finding also suggested by earlier research on
the use of CAM from this survey (Unu ¨tzer et al. 2000) as
well as other studies (Druss and Rosenheck 1999).
The data indicate that 14% of those who use HMDS also
use a psychiatric medication, and of those taking a psy-
chiatric medication, 12% also use an HMDS. The
increasing use of herbal remedies has generated the need
for healthcare providers to familiarize themselves with the
risks,side effects,and contraindicationsof more
commonly used HMDS. However, not enough is known
about the interactions between HMDS and conventional
medication treatment (Ernst and Schmidt 2004; Yager et al.
1999). Although there is sufficient data to suggest signifi-
cant drug–drug interactions involving HMDS (Cott 2001),
more research is needed to better understand these inter-
actions. To compound the issue, a number of studies have
shown that patients do not typically inform their physicians
of their use of HMDS or other CAM modalities and such
treatments are not consistently documented in the medical
records (Druss and Rosenheck 1999; Eisenberg et al. 1998;
Elkins et al. 2005; Kessler et al. 2001; Knaudt et al. 1999).
These findings underscore the need for clinicians to
directly ask their patients about HMDS use (Mamtani and
Cimino 2002). Information about such use would also
allow clinicians to explore potentially unmet mental health
The findings indicate that individuals with a psychiatric
disorder were significantly more likely to utilize St. John’s
Wort and melatonin. However, the effectiveness of these
compounds on outcomes is uncertain. The effectiveness of
St. John’s wort for depression is still questionable because
clinical trials have reported contradictory results. Past
reviews and meta-analysis of the effectiveness of St. John’s
wort concluded that it was more effective than placebo and
as effective as standard antidepressants in treating depres-
sion (Gaster and Holroyd 2000; Kim et al. 1999). These
studies, however, had several limitations including small
sample sizes, inclusion of individuals with minor to mod-
erate symptom severity, absence of an active antidepressant
arm, and lack of data regarding long-term use. Since then,
large, well-designed studies of St. John’s wort in major
depression have found the herb to be no more effective
than placebo (Hypericum Depression Trial Study Group
2002). A more recent meta-analysis concluded that the
evidence is inconsistent with older and smaller trials that
were not restricted to major depression showing St. John’s
wort to have a large effect on depression compared to
placebo while larger trials that included major depression
showed little to no effect (Linde et al. 2005).
In regard to melatonin, clinical studies suggest that
melatonin may be more effective than placebo in
decreasing the amount of time required to fall asleep,
increasing the number of sleeping hours, and boosting
daytime alertness. There is some evidence that melatonin
may improve depressive symptoms in seasonal affective
disorder (Lewy et al. 1998). Melatonin has also been
shown to decrease insomnia in individuals with depression
(Dalton et al. 2000) and improve sleep latency and quality
in schizophrenia (Sharmir et al. 2000). However, these
were small trials with a number of design limitations.
Although research on specific HDMS has increased over
the past decade, there is a clear need for further research on
Community Ment Health J (2010) 46:563–569 567
the effectiveness of varying HMDS on mental health out-
comes. Well-designed, controlled trials in select patient
populations are needed before a clear conclusion can be
reached about the effectiveness of any HMDS in mental
health disorders. Randomized, controlled trials that com-
pare specific compounds to both placebo and effective
prescription medication are needed. The utility of HMDS
as adjunctive therapies should also be examined.
Though the use of HMDS in the US has increased in the
past decade, the precise reasons for this increase remain
ambiguous. Self-treatment through the use of HMDS could
represent an appealing option for those who fear stigma-
tization due to their perceived and/or diagnosed psychiatric
disorder(s) (Charlton 2005), who have not received
appropriate mental health treatments (Young et al. 2001) or
who have experienced limited or no response to prescrip-
tion psychiatric medication. The finding that HMDS users
were more likely to be dissatisfied with their healthcare
lends support to these explanations. HMDS may also be
appealing in that they represent a relatively inexpensive
alternative to conventional medicine in that the physician
and associated fees can be by-passed. The increase in the
use of HMDS may also be attributable to the increase in
direct-to-consumer advertising, particularly the increase in
Internet marketing of herbal medicines and dietary sup-
plements. A 2002 study reported that 62% of Internet users
sought health information online, and approximately half
of these individuals sought information on alternative and
complementary treatments (Fox and Rainie 2002). These
hypotheses are provided as potential explanations for the
increased use of HMDS, however, there is little research
addressing this issue. Further research is needed to under-
stand the reasons for increased use of specific HMDS.
The study data was collected from 1997 to 1998 and
may not reflect current trends in HMDS use. Given the rise
in HMDS use over the last decade (Eisenberg et al. 1998;
Kaufman et al. 2002; Kelly et al. 2005), the data likely
underestimate current use. The methodology likely under-
estimates use as well since participants were asked about
medication they had taken at least several times a week for
at least 1 month. The findings remain important, however,
as even recent CAM studies do not focus specifically on
HMDS use and mental health (Grzywacz et al. 2006;
Rossler et al. 2007). We also cannot determine if use of
particular HMDS represented an individual’s personal
decision or a recommendation by a traditional or alterna-
tive health care provider.
The use of complementary and alternative medicine,
including herbal medicines and dietary supplements, is
widespread in American society. The use of HMDS war-
rants particular attention in persons with mental health
problems or even perceived mental health problems as
these individuals may be turning to HMDS use for
treatment of their symptoms, though not to the exclusion of
traditional treatments. However, those who seek both
conventional and alternative care may not communicate
their efforts to all of their providers. Considering the
potential interactions between some HMDS and traditional
medications, providers should talk with their patients about
their use of HMDS (Werneke et al. 2006). Why individuals
who use HMDS seek such alternative treatments, how they
get information about the vast variety of HMDS, and what
the interactions are between HMDS and conventional
treatments are all important questions that need to be
addressed in order to better meet the needs of those who
use HMDS and experience psychiatric problems.
Wood Johnson Foundation, the NIMH UCLA-RAND Center for
Research on Quality in Managed Care (MH 068639), the NIMH
UCLA-RAND Partnered Research Center for Quality Care (MH
082760), and the Department of Veterans Affairs Desert Pacific
Mental Illness Research, Education and Clinical Center (MIRECC).
We are grateful to Lily Zhang, Jiaye Liu, and Diana Liao for assis-
tance with data analysis, and to Kenneth B. Wells, M.D., M.P.H. for
his leadership of the HCC project. Any opinions expressed are those
of the authors and not necessarily the views of affiliated institutions.
This research was supported by the Robert
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
This article is distributed under the terms of the
Astin, J. A. (1998). Why patients use alternative medicine: Results of
a national study. Journal of the American Medical Association,
Barnes, P. M., Powell-Griner, E., McFann, K., & Nahin, R. L. (2004).
Complementary and alternative medicine use among adults:
United States, 2002. Advance Data, 343, 1–19.
Charlton, B. G. (2005). Self-management of psychiatric symptoms
using over-the-counter (OTC) psychopharmacology: The S-DTM
Medical Hypotheses, 65, 823–828.
Cott, J. M. (2001). Herb-drug interactions: Focus on pharmacokinet-
ics. CNS Spectrums, 6, 827–832.
Dalton, E. J., Rotondi, D., Levitan, R. D., Kennedy, S. H., & Brown,
G. M. (2000). Use of slow-release melatonin in treatment-
resistant depression. Journal of Psychiatry and Neuroscience,
Druss, B. G., Rohrbaugh, R., Kosten, T., Hoff, R., & Rosenheck,
R. A. (1998). Use of alternative medicine in major depression.
Psychiatric Services, 49, 1397.
Druss, B. G., & Rosenheck, R. A. (1999). Association between use of
unconventional therapies and conventional medical services.
Journal of the American Medical Association, 282, 651–656.
Druss, B. G., & Rosenheck, R. A. (2000). Use of practitioner-based
complementary therapies by persons reporting mental conditions
in the United States. Archives of General Psychiatry, 57, 708–
Eisenberg, D. M., Davis, R. B., Ettner, S. L., Appel, S., Wilkey, S.,
Van Rompay, M., et al. (1998). Trends in alternative medicine
568 Community Ment Health J (2010) 46:563–569
use in the United States, 1990–1997: Results of a follow-up Download full-text
national survey. Journal of the American Medical Association,
Elkins, G., Rajab, M. H., & Marcus, J. (2005). Complementary and
alternative medicine use by psychiatric inpatients. Psychological
Reports, 96, 163–166.
Ernst, E., & Schmidt, K. (2004). ‘Alternative’ cures for depression—
How safe are web sites? Psychiatry Research, 129, 297–301.
Fox, S., & Rainie, L. (2002). Vital decisions: How internet users
decide what information to trust when they or their loved ones
are sick. Washington, DC: Pew Internet & American Life
Gaster, B., & Holroyd, J. (2000). St. John’s wort for depression: A
systematic review. Archives of Internal Medicine, 160, 152–156.
Grzywacz, J. G., Suerken, C. K., Quandt, S. A., Bell, R. A., Lang, W.,
& Arcury, T. A. (2006). Older adults’ use of complementary and
alternative medicine for mental health: Findings from the 2002
National Health Interview Survey. Journal of Alternative and
Complementary Medicine (New York, NY), 12, 467–473.
Hypericum Depression Trial Study Group. (2002). Effect of Hyper-
icum perforatum (St. John’s wort) in major depressive disorder:
A randomized controlled trial. Journal of the American Medical
Association, 287, 1807–1814.
Kaufman, D. W., Kelly, J. P., Rosenberg, L., Anderson, T. E., &
Mitchell, A. A. (2002). Recent patterns of medication use in the
ambulatory adult population of the United States: The Slone
survey. Journal of the American Medical Association, 287, 337–
Kelly, J. P., Kaufman, D. W., Kelley, K., Rosenberg, L., Anderson, T.
E., & Mitchell, A. A. (2005). Recent trends in use of herbal and
other natural products. Archives of Internal Medicine, 165, 281–
Kemper, P., Blumenthal, D., Corrigan, J. M., Cunningham, P. J., Felt,
S. M., Grossman, J. M., et al. (1996). The design of the
community tracking study: A longitudinal study of health system
change and its effects on people. Inquiry, 33, 195–206.
Kessler, R. C., Andrews, G., Mroczek, D., Ustun, B., & Wittchen, H.
U. (1998). The world health organization composite interna-
tional diagnostic interview short-form (CIDI-SF). World Health
Kessler, R. C., Soukup, J., Davis, R. B., Foster, D. F., Wilkey, S. A.,
Van Rompay, M. M., et al. (2001). The use of complementary
and alternative therapies to treat anxiety and depression in the
United States. American Journal of Psychiatry, 158, 289–294.
Kim, H. L., Streltzer, J., & Goebert, D. (1999). St. John’s wort for
depression: A meta-analysis of well-defined clinical trials.
Journal of Nervous and Mental Diseases, 187, 532–538.
Knaudt, P. R., Connor, K. M., Weisler, R. H., Churchill, L. E., &
Davidson, J. R. (1999). Alternative therapy use by psychiatric
outpatients. Journal of Nervous and Mental Disease, 187, 692–
Lewy, A. J., Bauer, V. K., Cutler, N. L., & Sack, R. L. (1998).
Melatonin treatment of winter depression: A pilot study.
Psychiatry Research, 77, 57–61.
Linde, K., Berner, M., Egger, M., & Mulrow, C. (2005). St. John’s
wort for depression: Meta-analysis of randomised controlled
trials. British Journal of Psychiatry, 186, 99–107.
Mamtani, R., & Cimino, A. (2002). A primer of complementary and
alternative medicine and its relevance in the treatment of mental
health problems. Psychiatric Quarterly, 73, 367–381.
Matthews, S. C., Camacho, A., Lawson, K., & Dimsdale, J. E. (2003).
Use of herbal medications among 200 psychiatric outpatients:
Prevalence, patterns of use, and potential dangers. General
Hospital Psychiatry, 25, 24–26.
Rossler, W., Lauber, C., Angst, J., Haker, H., Gamma, A., Eich, D.,
et al. (2007). The use of complementary and alternative medicine
in the general population: Results from a longitudinal commu-
nity study. Psychological Medicine, 37, 73–84.
Rost, K., Burnam, M. A., & Smith, G. R. (1993). Development of
screeners for depressive disorders and substance disorder history.
Medical Care, 31, 189–200.
Roy-Byrne, P. P., Bystritsky, A., Russo, J., Craske, M. G.,
Sherbourne, C. D., & Stein, M. B. (2005). Use of herbal
medicine in primary care patients with mood and anxiety
disorders. Psychosomatics, 46, 117–122.
Sharmir, E., Laudon, M., Barak, Y., Anis, Y., Rotenberg, V., Elizur,
A., et al. (2000). Melatonin improves sleep quality of patients
with chronic schizophrenia. Journal of Clinical Psychiatry, 61,
Sturm, R., Gresenz, C., Sherbourne, C., Minnium, K., Klap, R.,
Bhattacharya, J., et al. (1999). The design of healthcare for
communities: A study of health care delivery for alcohol, drug
abuse, and mental health conditions. Inquiry, 36, 221–233.
SUDAAN. (2002). Professional software for survey data analysis,
Version 8.0.1. Research Triangle Park, NC: Research Triangle
Unu ¨tzer, J., Klap, R., Sturm, R., Young, A. S., Marmon, T., Shatkin,
J., et al. (2000). Mental disorders and the use of alternative
medicine: Results from a national survey. American Journal of
Psychiatry, 157, 1851–1857.
Ware, J., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form
health survey: Construction of scales and preliminary tests of
reliability and validity. Medical Care, 34, 220–233.
Werneke, U., Turner, T., & Priebe, S. (2006). Complementary
medicines in psychiatry: Review of effectiveness and safety.
British Journal of Psychiatry, 188, 109–121.
World Health Organization. (1992). The alcohol use disorders
identification test (AUDIT). Guidelines for use in primary health
care. Geneva, Switzerland: World Health Organization.
Yager, J., Siegfreid, S. L., & DiMatteo, T. L. (1999). Use of
alternative remedies by psychiatric patients: Illustrative vignettes
and a discussion of the issues. American Journal of Psychiatry,
Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K. B. (2001).
The quality of care for depressive and anxiety disorders in the
United States. Archives of General Psychiatry, 58, 55–61.
Community Ment Health J (2010) 46:563–569569