The quality of information on websites selling St. John's wort

Is YouTube a Reliable and Quality Source on Unilateral Biportal Endoscopic Spine Surgery? A Cross-Sectional Study

OBJECTIVE

This study aimed to evaluate the quality and reliability of YouTube videos focusing on unilateral biportal endoscopic spine surgery, a novel technique for spinal decompression in degenerative spinal disease.

METHODS

This cross-sectional study, conducted in February 2023, involved an online search on YouTube using the term "unilateral biportal endoscopic spine surgery". Video popularity was assessed using the Video Power Index. Video reliability and quality were measured using the Global Quality Scale, the Journal of the American Medical Association benchmark criteria, and the modified DISCERN instrument.

RESULTS

Ninety-three videos were included for evaluation. Uploader profiles were categorized by continent, with 61.3% from Asia, 35.5% from the United States, 2.2% from Africa, and 1.1% from Australia. When comparing 3 groups as South Korea, United States, and other countries, no significant differences were observed in the technical characteristics of the videos. However, the educational quality and reliability of the videos were higher in those uploaded from South Korea (P < 0.001).When the videos were divided into 2 groups according to their educational quality, significant difference were noted in video duration, loading time, video quality, and reliability (P < 0.001).

CONCLUSIONS

The YouTube videos on unilateral biportal endoscopic spine surgery showed high quality and reliability. However, videos from South Korea were found to have higher educational quality and reliability, while other specifications were similar for all videos. Furthermore, it was determined that videos uploaded more recently and with longer duration were of higher quality.

Prevalence of Complementary Medicine Use in Children and Adolescents: A Systematic Review

INTRODUCTION

The objective of this systematic review was to determine the global prevalence of complementary medicine (CM) use among children and adolescents.

METHOD

Seven databases and the reference lists of included studies were searched for pertinent observational studies. Studies were limited to those published in English from July 1, 2013. Included studies were appraised using the JBI checklist for prevalence studies.

RESULTS

Twenty studies were eligible for inclusion (385,527 participants). Most studies were assessed as having low risk of bias. Meta-analyses revealed a 23.0% (95% confidence interval, 0.226-0.234; 17 studies) short-term (≤ 12 month) prevalence and a 77.7% (95% confidence interval, 0.760-0.794; six studies) lifetime prevalence of CM use in children and adolescents. Differences in CM use were evident across countries and regions.

DISCUSSION

The findings of this review indicate that the use of CM in children and adolescents is high and widespread and may be increasing.

Health Literacy of Parents and Carers in a Regional Community: A Cross-Sectional Study

BACKGROUND

Supporting a child's healthy development is determined, in part, by a parent's ability to seek, access, interpret and effectively utilize health information. This aspect of parenting draws on a set of skills referred to as health literacy.

OBJECTIVE

To assess the level of health literacy among parents/carers in a regional South Australian community.

METHODS

Parents/carers of primary school-aged children, residing in Whyalla, South Australia, were invited to complete the 13-item All Aspects of Health Literacy Survey.

RESULTS

155 parents/carers completed the survey (79% mothers). Most participants were English-speaking (97%), employed (62%) and had 2-3 children (62%), with 52% completing tertiary education. Median total health literacy scores were mostly in the moderate-high range (median 27, IQR 26,27), as were critical health literacy scores (median 7, IQR 6,8). Higher scores were reported for functional health literacy (median 8, IQR 7,9), communicative health literacy (median 9, IQR 8,9) and empowerment health literacy (median 4, IQR 3,5).

CONCLUSIONS

Our findings reveal modest levels of health literacy among a sample of parents/carers of primary school-aged children in a regional South Australian community. Further work is needed to understand the differential effect of parental health literacy on child health outcomes, and the types of strategies that may mitigate the impact of these barriers on a child's healthy development.

How Internet Websites Portray Herbal Vitality Products Containing Eurycoma longifolia Jack: An Evaluation of the Quality and Risks of Online Information

BACKGROUND

Tongkat Ali (TA) or Eurycoma longifolia is a herbal medicine (HM) plant traditionally used to treat sexual dysfunction and enhance libido in men. Websites containing information about HM are abundant. However, studies have shown that in general the quality of websites containing information on HM is low. The present study aims to assess the quality and risks of websites containing information about TA supplements and to identify the health claims for TA.

METHODOLOGY

A cross-sectional study to evaluate the quality and risks of websites discussing TA supplements was conducted. Online marketing websites, research articles, news articles, personal opinions, and those restricted by password were excluded. The quality and risks of websites were assessed using a modified DISCERN tool and a set of risk assessment criteria, respectively. The health claims for TA were identified and analyzed using content analysis.

RESULTS

Overall, 321 websites met the inclusion criteria and were further evaluated. The overall rating of the quality of the websites was low, with a mean score ± standard deviation of 1.07 ± 0.51. Most websites lacked information that there may be more than one possible treatment choice and did not discuss areas of uncertainty. However, 67.9% (218/321) of the websites received a risk score of zero. A minority of websites (5/321, 1.6%) discouraged the use of conventional medicines. The most common health claims for TA included in the websites related to the enhancement of testosterone level (121/321, 37.7%), treatment of malaria (112/321, 34.9%), and improvement in libido (108/321, 33.6%).

CONCLUSIONS

Websites containing information about TA supplements generally have a low-quality rating based on a modified DISCERN tool despite having a low-risk score. Government agencies and healthcare professionals (HCPs) must be more proactive in the critique and dissemination of information relating to HM, and in ensuring the safe use of HM among the public and patients.

Why Did I Consult My Pharmacist about Herbal and Dietary Supplements? An Online Survey Amid the COVID-19 Pandemic in Malaysia

Herbal and dietary supplements (HDSs) are frequently obtained from community pharmacies, but community pharmacists (CPs) have been underutilized for information regarding them. This study aimed to determine the prevalence of, factors behind, and reasons for consultation with CPs among HDS consumers in Malaysia. A cross-sectional study using an online survey was conducted among conveniently sampled individuals in Malaysia. Reasons for consultation or non-consultation with CPs about HDSs were sought from the respondents. A logistic regression analysis was conducted to determine the predictors of consultation with CPs. Overall, 40.3% (239/593) of participants consulted CPs about the HDSs that they purchased. The participants were predominantly unmarried (362/588, 61.6%) and belonged to the 18-29 age group (332/593, 56%). The multivariate analysis showed that a suburban residential setting was the only significant predictor for consultation with CPs (adjusted odds ratio = 0.390, 95% CI = 0.260-0.583). Respondents who consulted CPs generally agreed that the CPs were the right people to consult on HDSs (mean = 4.37, SD = 0.73). However, their discussion with CPs regarding HDSs mostly revolved around the benefits and directions for use, but little on the potential risks. Meanwhile, most respondents who did not consult CPs agreed that they had never thought of consulting CPs about their HDS use (mean = 3.45, SD = 1.02). The majority of them referred to the Internet (61.3%, 217/354) and social media (59.9%, 212/354) for information about HDSs. The findings from this study show that more efforts are warranted in encouraging consumers to consult CPs about their HDS use and to enhance their awareness of the roles of CPs in ensuring the safe use of HDSs.

Evaluation of the quality of online patient information at the intersection of complementary and alternative medicine and hypertension

Background

Hypertension impacts 1.1 billion people globally; many patients seek complementary and alternative medicine (CAM), as a result of adverse side effects from antihypertensive medications or because they believe natural options are safer. The internet is increasingly playing a role in patient health information-seeking behavior, however, the variability of information quality across websites is unclear. Thus, the purpose of this study was to assess the quality of websites providing consumer health information at the intersection of hypertension and CAM.

Methods

Four unique terms were searched on Google, across Australia, Canada, the US, and the UK. The first 20 webpages resulting from each search were screened for eligibility, and were included if they contained consumer health information relating to CAM therapies for the treatment/management of hypertension. To assess the quality of health information on eligible websites, we used the DISCERN instrument, a standardized quality index of consumer health information.

Results

Of 90 unique webpages, 40 websites were deemed eligible and quality assessed. The 40 eligible websites were classified into seven categories: professional (n = 15), news (n = 11), non-profit (n = 5), health portal (n = 3), commercial (n = 2), government (n = 1), and other (n = 3). The mean summed DISCERN score was 52.34 (standard deviation [SD] = 10.69) out of 75 and the mean overall score was 3.49 (SD = 0.08) out of 5. A total of 10 websites had a total DISCERN score of 60.00 and above with an average rating of 4.33. Among these, Medicine Net (69.00) and WebMD (69.00) were determined to have the highest quality information. Websites generally scored well with respect to providing their aims, identifying treatment benefits and options, and discussing shared-decision making; websites generally lacked references and provided inadequate information surrounding treatment risks and impact on quality of life.

Conclusions

While some websites provided high-quality consumer health information, many others provided information of suboptimal quality. A need exists to better educate patients about identifying misinformation online. Healthcare providers should also inquire about their patients’ health information-seeking behavior, and provide them with the guidance necessary to identify high-quality resources which they can use to inform shared-decision making.

Evolutionary Overview of Consumer Health Informatics: Bibliometric Study on the Web of Science from 1999 to 2019

BACKGROUND

Consumer health informatics (CHI) originated in the 1990s. With the rapid development of computer and information technology for health decision making, an increasing number of consumers have obtained health-related information through the internet, and CHI has also attracted the attention of an increasing number of scholars.

OBJECTIVE

The aim of this study was to analyze the research themes and evolution characteristics of different study periods and to discuss the dynamic evolution path and research theme rules in a time-series framework from the perspective of a strategy map and a data flow in CHI.

METHODS

The Web of Science core collection database of the Institute for Scientific Information was used as the data source to retrieve relevant articles in the field of CHI. SciMAT was used to preprocess the literature data and construct the overlapping map, evolution map, strategic diagram, and cluster network characterized by keywords. Besides, a bibliometric analysis of the general characteristics, the evolutionary characteristics of the theme, and the evolutionary path of the theme was conducted.

RESULTS

A total of 986 articles were obtained after the retrieval, and 931 articles met the document-type requirement. In the past 21 years, the number of articles increased every year, with a remarkable growth after 2015. The research content in 4 different study periods formed the following 38 themes: patient education, medicine, needs, and bibliographic database in the 1999-2003 study period; world wide web, patient education, eHealth, patients, medication, terminology, behavior, technology, and disease in the 2004-2008 study period; websites, information seeking, physicians, attitudes, technology, risk, food labeling, patient, strategies, patient education, and eHealth in the 2009-2014 study period; and electronic medical records, health information seeking, attitudes, health communication, breast cancer, health literacy, technology, natural language processing, user-centered design, pharmacy, academic libraries, costs, internet utilization, and online health information in the 2015-2019 study period. Besides, these themes formed 10 evolution paths in 3 research directions: patient education and intervention, consumer demand attitude and behavior, and internet information technology application.

CONCLUSIONS

Averaging 93 publications every year since 2015, CHI research is in a rapid growth period. The research themes mainly focus on patient education, health information needs, health information search behavior, health behavior intervention, health literacy, health information technology, eHealth, and other aspects. Patient education and intervention research, consumer demand, attitude, and behavior research comprise the main theme evolution path, whose evolution process has been relatively stable. This evolution path will continue to become the research hotspot in this field. Research on the internet and information technology application is a secondary theme evolution path with development potential.

Cannabis for pain: a cross-sectional survey of the patient information quality on the Internet

BACKGROUND

Cannabis has increasingly become an alternative treatment for chronic pain, however, there is evidence of concomitant negative health effects with its long-term usage. Patients contemplating cannabis use for pain relief commonly see information online but may not be able to identify trustworthy and accurate sources, therefore, it is imperative that healthcare practitioners play a role in assisting them in discerning the quality of information. The present study assesses the quality of web-based consumer health information available at the intersection of cannabis and pain.

METHODS

A cross-sectional quality assessment of website information was conducted. Three countries were searched on Google: Canada, the Netherlands, and the USA. The first 3 pages of generated websites were used in each of the 9 searches. Eligible websites contained cannabis consumer health information for pain treatment. Only English-language websites were included. Encyclopedias (i.e. Wikipedia), forums, academic journals, general news websites, major e-commerce websites, websites not publicly available, books, and video platforms were excluded. Information presented on eligible websites were assessed using the DISCERN instrument. The DISCERN instrument consists of three sections, the first focusing on the reliability of the publication, the second investigating individual aspects of the publication, and the third providing an overall averaged score.

RESULTS

Of 270 websites identified across searches, 216 were duplicates, and 18 were excluded based on eligibility criteria, resulting in 36 eligible websites. The average summed DISCERN score was 48.85 out of 75.00 (SD = 8.13), and the average overall score (question 16) was 3.10 out of 5.00 (SD = 0.62). These overall scores were calculated from combining the scores for questions 1 through 15 in the DISCERN instrument for each website. Websites selling cannabis products/services scored the lowest, while health portals scored the highest.

CONCLUSION

These findings indicate that online cannabis consumer health information for the treatment/management of pain presents biases to readers. These biases included websites: (1) selectively citing studies that supported the benefits associated with cannabis use, while neglecting to mention those discussing its risks, and (2) promoting cannabis as "natural" with the implication that this equated to "safe". Healthcare providers should be involved in the guidance of patients' seeking and use of online information on this topic.

Evaluation of the quality of information available on the internet on vaginal meshes

OBJECTIVE

The objective of this study was to evaluate the quality of information on the internet about vaginal meshes available to the general population.

STUDY DESIGN

The terms "vaginal sling," "sling vagina," "vaginal mesh," "mesh vagina," "vaginal tape," and "tape vagina" were used every time on three major search engines, and the first 10 websites retrieved by each search engine were selected and evaluated using the DISCERN questionnaire. The websites were divided into four categories based on the type of agency that created the website. These included websites created by private health institutions, non-private health institutions, and non-health institutions and websites for encyclopedias, libraries, articles and scientific papers. They were compared in terms of the reliability, information quality, and total DISCERN score.

RESULTS

The survey yielded 98 different websites; after applying the exclusion criteria, 62 sites were selected. Websites for articles, magazines, libraries, and encyclopedias and those by non-private health services had significantly high scores for the reliability dimension of the DISCERN tool as compared to the other two website categories (p < 0.05). Regarding the quality of information, websites for non-specific health services and those for articles, magazines, libraries, and encyclopedias presented significantly lower scores as compared to the other two website categories. Websites for non-specific health services had significantly lower average total DISCERN points when compared to other website categories. The websites for private health services and those for articles, magazines, libraries, and encyclopedias had significantly lower DISCERN scores than the websites for non-private health services did.

CONCLUSION

Our findings showed that the quality of information regarding vaginal meshes on the first 10 websites on major search engines was moderate.

Dietary and herbal supplements for fatigue: A quality assessment of online consumer health information

Background

The Internet is increasingly utilized by patients to acquire information about dietary and herbal supplements (DHSs). Previously published studies assessing the quality of websites providing consumer health information about DHSs have been found to contain inaccuracies and misinformation that may compromise patient safety.. The present study assessed the quality of online DHSs consumer health information for fatigue.

Methods

Six unique search terms were searched on Google, each relating to fatigue and DHSs, across four countries. Across 480 websites identified, 48 were deemed eligible and were quality assessed using the DISCERN instrument, a standardized index of the quality of consumer health information.

Results

Across 48 eligible websites, the mean summed score was 47.64 (SD = 10.38) and the mean overall rating was 3.06 (SD = 0.90). Commercial sites were the most numerous in quantity, but contained information of the poorest quality. In general, websites lacked discussion surrounding uncertainty of information, describing what would happen if no treatment was used, and how treatment choices affect overall quality of life.

Conclusion

Physicians and other healthcare professionals should be aware of the high variability in the quality of online information regarding the use of DHSs for fatigue and facilitate open communication with patients to guide them towards reliable online sources.

Attitudes, Provider and Treatment Selection of Complementary and Integrative Health among Individuals with Pain-Related Conditions

Complementary and integrative therapies are used by people to address many conditions, including pain-related conditions. There has been concern about the quality of online health information, including information pertaining to complementary and integrative health (CIH). In this qualitative interview study, we sought to investigate how individuals interact with CIH-related information online and how this might affect their subsequent behavior. We conducted semi-structured interviews with 14 individuals with chronic pain conditions. We report findings based on three main themes: individuals' beliefs about CIH; approach to CIH, including how people view provider information and personalize their CIH use strategy; and factors that affect trust in the information encountered. Overall, study participants believed there was value in CIH therapies and that treatments were effective. Many described experiences that had influenced their views of complementary therapies over time. We also found that individuals form impressions of CIH providers based on structural and personal characteristics, particularly cost and proximity, that are conveyed in information to which they are exposed. These findings have various implications. First, over time individuals with chronic pain conditions develop their own beliefs and attitudes, which play a role in their selection of providers and modalities relating to CIH. Health care providers should consider how people view information relating to, and make decisions about, CIH therapies and work collaboratively with patients to develop effective health management strategies. Information services should also consider patients' perspectives in developing websites and other informational materials.

Understanding drug interactions with St John's wort (Hypericum perforatum L.): impact of hyperforin content

Objective

The aim of this study was to review herb–drug interaction studies with St John's wort (Hypericum perforatum L.) with a focus on the hyperforin content of the extracts used in these studies.

Methods

PUBMED was systematically searched to identify studies describing pharmacokinetic interactions involving St John's wort. Data on study design and the St John's wort extract or product were gathered to extract hyperforin content and daily dose used in interaction studies.

Key findings

This analysis demonstrates that significant herb–drug interactions (resulting in a substantial change in systemic exposure) with St John's wort products were associated with hyperforin daily dosage. Products that had a daily dose of &lt;1 mg hyperforin were less likely to be associated with major interaction for drugs that were CYP3A4 or p-glycoprotein substrates. Although a risk of interactions cannot be excluded even for low-dose hyperforin St. John's wort extracts, the use of products that result in a dose of not more than 1 mg hyperforin per day is recommended to minimise the risk of interactions.

Conclusions

This review highlights that the significance of herb–drug interactions with St John's wort is influenced by the nature of the herbal medicines product, particularly the hyperforin content.

What risks do herbal products pose to the Australian community?

Traditional herbal products are widely used in Australia to treat a broad range of conditions and diseases. It is popularly believed that these products are safer than prescribed drugs. While many may be safe, it is worrying that the specific effects and harmful interactions of a number of their components with prescription medications is not well understood. Some traditional herbal preparations contain heavy metals and toxic chemicals, as well as naturally occurring organic toxins. The effects of these substances can be dire, including acute hepatic and renal failure, exacerbation of pre-existing conditions and diseases, and even death. The content and quality of herbal preparations are not tightly controlled, with some ingredients either not listed or their concentrations recorded inaccurately on websites or labels. Herbal products may also include illegal ingredients, such as ephedra, Asarum europaeum (European wild ginger) and endangered animal species (eg, snow leopard). An additional problem is augmentation with prescription medications to enhance the apparent effectiveness of a preparation. Toxic substances may also be deliberately or inadvertently added: less expensive, more harmful plants may be substituted for more expensive ingredients, and processing may not be adequate. The lack of regulation and monitoring of traditional herbal preparations in Australia and other Western countries means that their contribution to illness and death is unknown. We need to raise awareness of these problems with health care practitioners and with the general public.

Identifying Complementary and Alternative Medicine Usage Information from Internet Resources. A Systematic Review

OBJECTIVES

Identify and highlight research issues and methods used in studying Complementary and Alternative Medicine (CAM) information needs, access, and exchange over the Internet.

METHODS

A literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines from PubMed to identify articles that have studied Internet use in the CAM context. Additional searches were conducted at Nature.com and Google Scholar.

RESULTS

The Internet provides a major medium for attaining CAM information and can also serve as an avenue for conducting CAM related surveys. Based on the literature analyzed in this review, there seems to be significant interest in developing methodologies for identifying CAM treatments, including the analysis of search query data and social media platform discussions. Several studies have also underscored the challenges in developing approaches for identifying the reliability of CAM-related information on the Internet, which may not be supported with reliable sources. The overall findings of this review suggest that there are opportunities for developing approaches for making available accurate information and developing ways to restrict the spread and sale of potentially harmful CAM products and information.

CONCLUSIONS

Advances in Internet research are yet to be used in context of understanding CAM prevalence and perspectives. Such approaches may provide valuable insights into the current trends and needs in context of CAM use and spread.

Assessment of the quality and content of website health information about herbal remedies for menopausal symptoms

OBJECTIVE

To assess the quality, readability and coverage of website information about herbal remedies for menopausal symptoms.

STUDY DESIGN

A purposive sample of commercial and non-commercial websites was assessed for quality (DISCERN), readability (SMOG) and information coverage.

MAIN OUTCOME MEASURES

Non-parametric and parametric tests were used to explain the variability of these factors across types of websites and to assess associations between website quality and information coverage.

RESULTS

39 sites were assessed. Median quality and information coverage scores were 44/80 and 11/30 respectively. The median readability score was 18.7, similar to UK broadsheets. Commercial websites scored significantly lower on quality (p=0.014), but there were no statistical differences for information coverage or readability. There was a significant positive correlation between information quality and coverage scores irrespective of website provider (r=0.69, p<0.001, n=39).

CONCLUSION

Overall website quality and information coverage are poor and the required reading level high.

Forensic problems with the composition and content of herbal medicines

A survey of herbal medicines available for internet and over-the-counter purchase in South Australia, Australia, was conducted looking specifically at those used for 'arthritis', 'cold and flu', 'gastrointestinal', 'stress' and 'premenstrual syndrome'. 121 products consisted of 29 in the 'arthritis' category, 33 in 'cold and flu', 19 in 'gastrointestinal' 30 in 'stress' and 10 in 'premenstrual syndrome'. Twenty two (18%) of 121 products were not registered with the Australian Register of Therapeutic Goods (ARTG), despite this being a legal requirement for their sale. Of the registered products 59 (60%) of 99 had differing ingredient concentrations on the website compared to their ARTG listing. Only three of the 15 purchased products had ingredient concentrations which were consistent between the website, ARTG listing and product packaging. These findings demonstrate that it may not be possible to determine what herbal substance an individual has been exposed to prior to death and in what concentration, based on packaging from medications seized at the scene, or from examination of website data and the ARTG listing. These discrepancies may increase the problems that exist in attempting to determine what role herbal medicines may play in the mechanism of death in certain forensic cases.

Assessment and revision of clinical pharmacy practice internet web sites

BACKGROUND

Health care professionals, trainees, and patients use the Internet extensively. Editable Web sites may contain inaccurate, incomplete, and/or outdated information that may mislead the public's perception of the topic.

OBJECTIVE

To evaluate the editable, online descriptions of clinical pharmacy and pharmacist and attempt to improve their accuracy.

METHODS

The authors identified key areas within clinical pharmacy to evaluate for accuracy and appropriateness on the Internet. Current descriptions that were reviewed on public domain Web sites included: (1) clinical pharmacy and the clinical pharmacist, (2) pharmacy education, (3) clinical pharmacy and development and provision for reimbursement, (4) clinical pharmacists and advanced specialty certifications/training opportunities, (5) pharmacists and advocacy, and (6) clinical pharmacists and interdisciplinary/interprofessional content. The authors assessed each content area to determine accuracy and prioritized the need for updating, when applicable, to achieve consistency in descriptions and relevancy. The authors found that Wikipedia, a public domain that allows users to update, was consistently the most common Web site produced in search results.

RESULTS

The authors' evaluation resulted in the creation or revision of 14 Wikipedia Web pages. However, rejection of 3 proposed newly created Web pages affected the authors' ability to address identified content areas with deficiencies and/or inaccuracies.

CONCLUSIONS

Through assessing and updating editable Web sites, the authors strengthened the online representation of clinical pharmacy in a clear, cohesive, and accurate manner. However, ongoing assessments of the Internet are continually needed to ensure accuracy and appropriateness.

Mood disorders and complementary and alternative medicine: a literature review

Mood disorders are a major public health problem and are associated with considerable burden of disease, suicides, physical comorbidities, high economic costs, and poor quality of life. Approximately 30%-40% of patients with major depression have only a partial response to available pharmacological and psychotherapeutic interventions. Complementary and alternative medicine (CAM) has been used either alone or in combination with conventional therapies in patients with mood disorders. This review of the literature examines evidence-based data on the use of CAM in mood disorders. A search of the PubMed, Medline, Google Scholar, and Quertile databases using keywords was conducted, and relevant articles published in the English language in the peer-reviewed journals over the past two decades were retrieved. Evidence-based data suggest that light therapy, St John's wort, Rhodiola rosea, omega-3 fatty acids, yoga, acupuncture, mindfulness therapies, exercise, sleep deprivation, and S-adenosylmethionine are effective in the treatment of mood disorders. Clinical trials of vitamin B complex, vitamin D, and methylfolate found that, while these were useful in physical illness, results were equivocal in patients with mood disorders. Studies support the adjunctive role of omega-3 fatty acids, eicosapentaenoic acid, and docosahexaenoic acid in unipolar and bipolar depression, although manic symptoms are not affected and higher doses are required in patients with resistant bipolar depression and rapid cycling. Omega-3 fatty acids are useful in pregnant women with major depression, and have no adverse effects on the fetus. Choline, inositol, 5-hydroxy-L-tryptophan, and N-acetylcysteine are effective adjuncts in bipolar patients. Dehydroepiandrosterone is effective both in bipolar depression and depression in the setting of comorbid physical disease, although doses should be titrated to avoid adverse effects. Ayurvedic and homeopathic therapies have the potential to improve symptoms of depression, although larger controlled trials are needed. Mind-body-spirit and integrative medicine approaches can be used effectively in mild to moderate depression and in treatment-resistant depression. Currently, although CAM therapies are not the primary treatment of mood disorders, level 1 evidence could emerge in the future showing that such treatments are effective.