Dr P Murali Doraiswamy, a psychiatrist teaching and practising medicine at Duke University and its medical center, in North Carolina, has earned acclaim for his straight talking on a variety of medical topics, but particularly on the possible side effects of the interaction of herbal medicines of alternative medicine with prescription drugs. In the first part of his interview, with Arthur J Pais, the physician and teacher provided rediff.com with his career background. In the concluding part of this interview Doraiswamy spoke at length on his views and beliefs on this subject.

What led you to investigate the interaction between holistic (alternative) medicine and conventional medicine?

As a doctor, I quickly discovered that one of the most neglected areas in all of medicine is the study of how different drugs interact in the human body. As the number of drugs developed grows so does the number of possible interactions.

Before the advent of palm pilots, it was almost impossible for a physician to check on a patient's risk for interactions quickly at the bedside. So, about five years ago, I and two colleagues published a pocket sized reference book that listed, in tables, many of the most common drug interactions.

Almost a hundred thousand copies were sold immediately since this could be carried, in a doctor's white coat, to the bedside. Nowadays, it is very common for an older person with chronic illnesses to be on five to 10 prescription drugs and a variety of nutritional or herbal supplements.

I remember one patient in particular who was on eight medications. To educate my students we did an exercise where we calculated all possible interactions these drugs could be having in his body. A total of more than 8,000 interactions were possible and of these at least six had already previously been reported to cause problems.

For example, this person was taking coumadin, a blood thinner given by his doctor, and on his own was taking ginkgo biloba and vitamin E for his memory. The patient had never told his regular doctor about his herbals because he was never asked about it. The patient was not aware that ginkgo, vitamin E and coumadin could interact to increase his risk for bleeding. In this case, we recommended he stopped using ginkgo and suggested some other alternative strategies for enhancing his memory that were less likely to adversely interact with his medications.

Not all interactions are as easy to spot since they can sometimes occur after a patient has stopped a medicine.

Here's an example: About a year ago, I saw a patient who was complaining of nausea and diarrhea. He had been taking fluoxetine (Prozac) for depression but had stopped it a few days before because his mood had improved. However, he had also started taking St John's wort on his own. His nausea and diarrhea resolved completely in a few days after I asked him to stop taking the St John's wort. This person had not realized that it normally took several weeks for fluoxetine and its byproducts to fully get out of one's system after stopping it.

My diagnosis was that an interaction between SJW and fluoxetine had resulted in a mild form of a condition called "serotonin syndrome". This is caused by too much build of the chemical serotonin. In his case, the likely explanation was that both SJW and fluoxetine may act in the body, to increase levels of this chemical, and that when both are given at the same time the levels, in susceptible subjects, may be too high. In many such cases, it is difficult to know exactly what happens but consumers should be aware that many drugs can linger on in the body for days or weeks after they are stopped.

Fortunately, we only rarely encounter serious herbal drug interactions. We reported on another very insightful case a couple of years ago -- this time it was caused by abrupt withdrawal of a herbal preparation after long use. This patient had been taking valerian (also referred to in the popular press as nature's Valium) for several years at very high doses to self medicate his anxiety and sleep problems.

When he came into the hospital for a minor procedure, he did not report the valerian. Since hospitals don't usually administer herbal medicines, he ended up not receiving any of his usual valerian for several days. His mental state deteriorated and he became confused and delirious. The doctors in the intensive care unit could not figure out what was wrong and ended up testing him for lots of other conditions.

When we discovered he had been taking valerian, we administered a short acting Valium like preparation that reversed his symptoms. The reasoning was simple -- valerian acts on the same chemicals in the brain as Valium and alcohol. When chronic drinkers develop withdrawal delirium we treat them with Valium like drugs. This illustrates how important it is for patients and health care professionals to have good communication, and also for someone trained in both herbal and conventional medicines to be able to recognize such interactions when they occur.

Medical doctors rarely keep up with the growing list of alternative treatments and most herbalists rarely know much about prescription drugs or their interactions. So we really need a breed of practitioners with expertise and interest in both conventional and alternative medicine to be able to really make sound judgments about such combinations and to recognize and treat interactions when they occur.

You grew up in India. Did you take alternative medicine? Do you still take them? What kind? And what kind of precaution do you take?

The word "alternative medicine" covers a lot of ground. Yes, I have taken alternative medicine (homeopathy, ayurveda) when growing up occasionally mostly for minor conditions. I do not currently buy any herbals from drug stores but believe that diet and exercise are the most potent natural medicines available.

They are the key to longevity and health. I make sure I get enough vitamins, especially folic acid and B complex vitamins, as well as antioxidants from my diet. Strict Indian vegetarians who avoid dairy products may be at risk for deficiencies of vitamin B12 and this vitamin is essential for the brain.

Since I am mostly a vegetarian, I take a B complex supplement regularly. We thought Linus Pauling (who won the Nobel Prize for discovering the links between vitamin C and scurvy) was a crackpot because he recommended that high doses of vitamins may protect against disease. We now know that vitamins A, C and E are powerful antioxidants and protect cells from age related accumulation of free radicals. In a very comprehensive review two years ago we suggested that high dose vitamin E was promising for fighting Alzheimer's disease. Fresh fruits and berries are good sources of antioxidants.

I avoid almost all meat products and products that are high in certain kinds of fats. For one thing, I never have to worry about mad cow disease! Second, my cholesterol is low and that means less of it blocks the arteries in my heart and brain. Many people do not realize that there is a very powerful connection between aging, loss of mental functions and blockage of arteries. I also try to exercise three times a week. Last year, in a careful scientific study of older adults, we showed that regular exercise training can improve mood and cognitive abilities.

You have said people are turning to alternative medicine partly because of conveyor-belt approach to medicine as practiced today. Is the conveyor belt approach changing?

Yes, I think the conveyor belt approach is slowly changing in the US as both doctors and consumers realize that mind body integrative medicine results in the best outcomes. Even managed care has begun to realize this.

Medical schools all over the US have started integrating alternative medicine teaching to medical students. There is even a Physician Desk Reference (PDR) for herbal remedies. Several top-notch institutions, such as Duke University, have established integrative medicine centers of excellence and started offering educational courses on alternative medicine for trainees and practicing doctors.

The NIH is funding large grants and alternative medicine centers to make sure scientific research into alternative medicines keeps pace with the demands of consumers. Although the funding of alternative medicine research is still far less than what it should be, I am very encouraged by these trends and what this means for the next generation of US doctors.

Unfortunately, I notice a reverse trend in India, where young doctors are shunning holistic approaches for the more lucrative model of running more and more tests/procedures. After being a leader in alternative medicine for centuries, it would be a shame if India ends up having to turn to other countries to relearn the benefits of mind body medicine.

You urge patients to tell their physicians about the alternative medicines they are taking. What could happen if the doctors do not show interest, if the doctors do not understand the alternative medicine. What practical advice would you give?

Lack of positive interest should be differentiated from lack of information or narrow-mindedness. A well-informed doctor who is aware of the literature and suggests that he/she is convinced that a particular herb does not work is doing their job correctly. I would also expect such a doctor to have a balanced discussion with the patient about the evidence and why he/she thinks the alternative remedy is not appropriate for this situation.

But there are also plenty of doctors who refuse to even talk about alternative treatments or feel it is a waste of time without ever bothering to read this literature. It may be possible to educate this doctor by bringing them information from the Internet or press but if the mind is closed this never works.

The best solution then may be to find another doctor who is more communicative and better informed. Before you blame a doctor keep in mind that this field is a Pandora's box. The reason many doctors don't ask is because they don't know how to deal with this issue. They were never trained in medical school about alternative remedies. So it's really up to the consumer to educate themselves about the alternative remedies they take and also find the best doctor.

It's baffling to me that we may spend more time shopping around for a $20 dress at a sale than we do for a doctor who is taking care of our health.

At many leading hospitals in America, many doctors are taking a serious interest in alternative medicine. Do you envisage a time when there will be an effective convergence between the two systems?

Yes, but it will not fully happen until the next generation of doctors is firmly in control and alternative medicine is fully reimbursed by third party payers. The research studies being done currently will set the stage for that to occur.

I envision that every medical school will require students take at least one alternative medicine course and that we will soon have the regulatory agencies overseeing licensure of alternative medicine practitioners to ensure the public does not get taken for a ride.

What are your recommendations to doctors and medical schools in dealing with alternative medicine and dealing with patients who take alternative medicine?

The emphasis will be on "treating the patient and not the lab test". There is an old saying "treat the patient and not the lab test". Doctors need to understand that consumers of alternative medicine in 2001 are not a fringe element but are mainstream health conscious individuals. Such consumers want a tailored, negotiated and shared responsibility in the healing process.

The word physician itself comes from nature and almost 25 per cent of all medicines in use today are derived from natural sources. Some of these natural therapies, like yoga, have been refined over thousands of years and one does not necessarily need to purify or isolate an active ingredient to obtain effective results. This may be particularly true for some complex herbal extracts where isolation of the active ingredient may actually result in greater risk for drug interactions.

Consumers are attracted by the perspective that natural treatments are safer and have fewer side effects. They are also aware that the risk of prescription medicines are often understated and the benefits overstated because of heavy pharmaceutical marketing. Doctors have to be skeptical since it is their job to protect patients safety and have to learn how to evaluate the literature on natural remedies.

They should make sure they do not hold such remedies to a higher standard than they would to a prescription product because of their biases.

At the same time they cannot be like an ostrich burying its head in the sand and ignore the entire field of alternative medicine since they will miss an opportunity to help their patients. There is overwhelming evidence that mental and emotional factors shape the outcome of all major physical illnesses. For example, depression is almost as big a predictor of survival after a heart attack as are abnormal heart rhythms and the two when present together pose the biggest risk.

In Germany, nearly 75 per cent of physicians prescribe phytomedicine (herbs) whereas this number is less than 5 per cent in the US. I am convinced that a doctor who has a knowledgeable and balanced view of integrative medicine, knows when to apply it and when not to, respects the intellect of the consumer, and establishes an open therapeutic alliance will get the best results.

Design: Lynette Menezes

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