1. www.thelancet.com/psychiatry Published online May 18, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30025-6 1
Series
Lancet Psychiatry 2016
Published Online
May 18, 2016
http://dx.doi.org/10.1016/
S2215-0366(16)30025-6
*Joint first authors
This paper forms part of the
China–India Mental Health
Alliance Series. Other papers in
the series are available at
http://www.thelancet.com/
series/china-india-mental-health
National Institute of Mental
Health and Neurosciences
(NIMHANS), Bangalore, India
(JThirthalli MD,
B N Gangadhar MD); Xiangya
School of Public Health, Central
South University, Changsha,
China (L Zhou MD, H Liu PhD,
GWang MS); National Ayurveda
Dietetics Research Institute
(NADRI), Bangalore, India
(K Kumar MD); Guangzhou
University of Chinese Medicine,
Guangzhou, China (J Gao MD);
Public Health Foundation of
India, New Delhi, India
(HVaid MA); Swami
VivekanandaYoga
Anusandhana Samsthana,
Bangalore, India
(A Hankey PhD); Bioethics
Centre, University of Otago,
Dunedin, New Zealand
(J-B Nie PhD); and School of
Anthropology, University of
Arizona,Tucson, AZ, USA
(M Nichter PhD)
Correspondence to:
Dr Liang Zhou, Xiangya School of
Public Health, Central South
University, Changsha 410011,
China
liangzhou_csu@vip.163.com
China–India Mental Health Alliance
Traditional, complementary, and alternative medicine
approaches to mental health care and psychological
wellbeing in India and China
JagadishaThirthalli*, Liang Zhou*, Kishore Kumar, Jie Gao, HennaVaid, Huiming Liu, Alex Hankey, GuojunWang, Bangalore N Gangadhar,
Jing-Bao Nie, Mark Nichter
India and China face the same challenge of having too few trained psychiatric personnel to manage effectively the
substantial burden of mental illness within their population. At the same time, both countries have many practitioners
of traditional, complementary, and alternative medicine who are a potential resource for delivery of mental health
care. In our paper, part of The Lancet and Lancet Psychiatry’s Series about the China–India Mental Health Alliance, we
describe and compare types of traditional, complementary, and alternative medicine in India and China. Further, we
provide a systematic overview of evidence assessing the effectiveness of these alternative approaches for mental
illness and discuss challenges in research. We suggest how practitioners of traditional, complementary, and alternative
medicine and mental health professionals might forge collaborative relationships to provide more accessible,
affordable, and acceptable mental health care in India and China. A substantial proportion of individuals with mental
illness use traditional, complementary, and alternative medicine, either exclusively or with biomedicine, for reasons
ranging from faith and cultural congruence to accessibility, cost, and belief that these approaches are safe. Systematic
reviews of the effectiveness of traditional, complementary, and alternative medicine find several approaches to be
promising for treatment of mental illness, but most clinical trials included in these systematic reviews have
methodological limitations. Contemporary methods to establish efficacy and safety—typically through randomised
controlled trials—need to be complemented by other means. The community of practice built on collaborative
relationships between practitioners of traditional, complementary, and alternative medicine and providers of mental
health care holds promise in bridging the treatment gap in mental health care in India and China.
Introduction
The burden of disease attributable to mental illness in
India and China is substantial.1
Trained manpower to
provide biomedical care for such disorders in these highly
populous countries is insufficient.2
Both nations have
many systems of medicine that are either indigenous or
have been adapted from elsewhere at different points in
each country’s history. Up to 80% of individuals with
different health conditions consult practitioners of
traditional, alternative, and complementary medicine at
one time or another, although this proportion varies by
region.3
People with mental illness consider traditional,
alternative, and complementary medicine either before or
after they have visited a biomedicine provider.4
In this
paper, part of The Lancet’s Series about the China–India
Mental Health Alliance, we describe and compare types
of traditional, alternative, and complementary medicine
in India and China and provide a systematic overview of
existing evidence assessing the effectiveness of these
approaches for mental illness. Furthermore, we discuss
the challenges in developing evidence for effectiveness of
traditional, alternative, and complementary medicine for
the treatment of mental illnesses. Finally, we suggest how
practitioners of these alternative methods and public
mental health professionals might forge collaborative
relationships to provide accessible, affordable, and
acceptable mental health care in India and China.
Systems of traditional, alternative, and
complementary medicine
Panel 1 describes the most popular types of traditional,
alternative, and complementary medicine in China, and
panel 2 shows those in India; a discussion of the myriad
forms of these approaches in these countries is beyond
the scope of our paper. The terms allopathic and
biomedical practitioners are used interchangeably to
refer to individuals trained in modern biomedicine.
Traditional, alternative, and complementary medicine
resources should be considered according to the form of
training needed, the method of treatment, and the focus
of therapy when explanatory models of mental illness
could affect the mode of treatment.
Form of training
In both India and China, some systems of traditional,
alternative, and complementary medicine have formal
course-based institutional training, whereas others
have training through apprenticeship, which we refer
to as informal training in the sense that it is not codified
and subject to a formal examination. Formal or
institutional systems are in place for training in
Ayurveda, yoga, naturopathy, Unani, Siddha, homoeo-
pathy, Sowa-Rigpa, and traditional Chinese medicine
(panels 1, 2). We include in the informal therapy group
popular forms of faith-based healing and folk therapies

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(broadly conceived) and forms of self-care based on a
set of learned practices.
Method of treatment
Traditional, alternative, and complementary medicine
practices can be classified in several ways. The first
category encompasses approaches that use herbal and
other natural substances—eg, Ayurveda, homoeopathy,
and traditional Chinese medicine. Next are methods
that entail physical therapy, such as acupuncture and
traditional Chinese massage, and others that target
the mind–body relationship—eg, yoga, Qigong, and
tai chi. The final classification comprises methods
that incorporate faith-based healing practices, including
temple-healing rituals and folk therapy.
Many practitioners who use herbs or natural substances
as primary methods of treatment receive formal training,
but others do not and have learned their vocation
through apprenticeship or self-study.6
Among individuals
who are not trained institutionally are those who adhere
closely to medical traditions passed down through
generations, practitioners who have ad-hoc knowledge of
herbal remedies but do not practise any systematic
form of diagnosis, and people who practise hybrid forms
of therapy using the resources of many systems,
including biomedicine. Registered medical practitioners
Panel 1: Systems of traditional, complementary, and alternative medicine in China
Traditional Chinese medicine
Of the many different medical systems that have existed in
China’s long history, what is today called traditional Chinese
medicine constitutes the most prominent and influential. Its
concepts—eg, qi (or chi), yin and yang, and the five phrases or
elements are embedded deeply in Chinese cultures and
philosophies. The basic theories of traditional Chinese
medicine include: five yin (Zang) organs and six yang (Fu)
organs; the Meridians; and six pathological factors. These
theories were established in the Yellow Emperor’s Classic of
Medicine, which appeared around the 2nd century BCE.
Diagnosis in traditional Chinese medicine takes the whole
body into consideration: systemic pathological changes
resulting from local pathologies are considered, and both
systemic and local pathophysiology are supposed to be treated
simultaneously. The four principal diagnostic methods of
traditional Chinese medicine are observing or looking,
listening and smelling, asking, and touching, with observing
the tongue and taking the pulse the two pillars of
examination. The predominant therapeutic device of
traditional Chinese medicine is medication (herbal and animal
substances). Other approaches include massage, acupuncture,
and moxibustion.
Acupuncture and moxibustion
Acupuncture has a tradition of more than 2000years in China. It
is an art of healing based on the idea of treating internal diseases
externally.Through the conduction of qi along channels known
as meridians and acupoints, acupuncture provides treatment
throughout the body by inserting needles into the skin to
stimulate specific points of the body (acupoints). Moxibustion is
a natural treatment using smoking plant products (eg, Artemisia
argyi) to stimulate specific acupoints.
Massage
Massage therapy is used widely in many countries, but massage
of traditional Chinese medicine is different. Besides body parts
such as the head, neck, and back, which are involved in
common massage therapy, traditional Chinese medicine
massage also includes massage on acupoints to treat specific
conditions.
Self-practice
Qigong and tai chi are closely related to traditional Chinese
medicine and religious beliefs such as Buddhism and Daoism,
but these are mainly self-practice approaches aimed at health
promotion and disease prevention.
Qigong
Qigong has its origins in the Jin Dynasty (266–420 CE) and is a
practice of coordinating body, breath, and mind, based on
Chinese philosophy. It comprises a diverse set of activities that
can be characterised primarily as dynamic and static. Dynamic
practice entails fluid movement, whereas static practice
involves self-control of mind and breath with holding gestures.
Most activities are carried on by using a combination of
dynamic and static practices.
Tai chi
Tai chi is atraditionalChinese martial art in accordance withyin
andyang and changes inthe five elements. It can meet both
physiological and psychological requirements ofthe human body
through specific exercises for Yi (mind), Qi (breath), Xing (body
gesture and movements), and Shen (spirit). In additionto having
general physiological and psychological health benefits,tai chi is
helpful for improving relationships between human groups.
Faith-based therapies
Folk therapy in China developed in the context of a mixture of
Buddhism, Daoism, animistic belief, superstitious ideas, and
other cultural beliefs.The main types of folk therapy include:
calling back a lost soul; getting rid of a ghost or evil supernatural
being that is believed to cause an illness; getting help from
deities to avoid disasters or treat illnesses through rituals;
feeding patients with specific substances (eg, sacred water);
rituals such as avoiding specific people, locations, or food; and
hypnosis. Folk therapy is generally practised by witch doctors,
shamans, and religious personnel (eg, monks and Daoist
priests).5
These folk therapies are regarded as superstitious and
were forbidden before the 1970s CE. After the reform and
opening-up policies in 1978 CE, ideological repressions have
loosened and folk therapy has become popular again.

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(appendix p 1) provide a mix of herbal and biomedical
treatments and are immensely popular among poor
populations in both rural and urban India. In China,
practitioners of traditional Chinese medicine who have
not been trained institutionally are allowed to take the
medical licensing examination if they can meet specific
requirements (eg, they have received continuous
apprentice education from a qualified master in
traditional Chinese medicine for at least 3 years). Reliable
estimates of the number of such practitioners and their
clientele are unavailable.
Focus of treatment based on perceived cause
Systems of traditional, complementary, and alternative
medicine can also be classified according to the
presumed cause of ill health.7
Practices based on
internal causes of mental illness assume that the
primary cause of the disorder is a humoral imbalance
See Online for appendix
Panel 2: Systems of traditional, complementary, and alternative medicine in India
AYUSH systems
Seven systems of medicine are recognised by the Government
of India Ministry of AYUSH: Ayurveda, yoga and naturopathy,
Unani, Siddha, Sowa-Rigpa, and homoeopathy.
Ayurveda
Ayurveda is a health-care science with origins from the Vedas
(Indian and Hindu scriptures) reported more than 5000 years
ago.The system is based predominantly on the humoral theory
of Tridosha (ie, three bioforces, vata, pitta, and kapha). It is the
most popular system of traditional, complementary, and
alternative medicine in India. Medicinal natural substances,
special diets, purifying rituals, and surgeries form the important
therapeutic procedures in Ayurveda.
Yoga
The Sanskrit word yoga literally means the union of a person’s
consciousness with a universal one, which is considered to be an
ideal state of health.This system is based entirely on
non-pharmacological interventional regimens, including
different postures (Asanas), breath control (Pranayama), and
meditation (Dhyana).
Naturopathy
Although the naturopathic system traces its origins from
different parts of the world, in India, naturopathic principles are
rooted in Indian systems of medicine. Accordingly, the
principles involve judicious therapeutic use of five basic material
forms—earth, water, fire, air, and ether (space)—externally and
internally, and changes in lifestyle and diet. Pharmacological
interventions are not used and spirituality is encouraged.
Unani
Unani is a Greco-Arabic (Unan means Greece) system of
medicine based on the teachings of Hippocrates and Galen. It
evolved in the Middle Ages under Arabian and Persian doctors
and was patronised through the Mughal period in India from
the 12th century CE onwards. Unani is based on the idea of
humours: blood, phlegm, yellow bile, and black bile.Treatment
modalities include regimental therapy, special diets, herbal
medicines, and surgery.
Siddha
The Siddha system of medicine is believed to have originated as
a contemporary of Ayurveda in south India (mainlyTamil
Nadu).The Siddha literature is inTamil. Its diagnostics and
treatment modalities are similar to those of Ayurveda.
Sowa-Rigpa
Sowa-Rigpa means science of healing and is also called Amchi
medicine. It hasTibetan and Indian origins and is practised by
tribal and Bhot people living in parts of the Himalayan region.
The principles of diagnostics and treatment are similar to
Ayurveda. Sowa-Rigpa predominantly uses pharmacological
(herbal) interventions.
Homoeopathy
The homoeopathic system of medicine was systematised by
Samuel Hahnemann, a German doctor. It was introduced in
India around 1810 CE.The treatment approach is based on the
principles of Similia Similibus Curentur (like cures like). Remedies
include animal, plant, mineral, and synthetic substances.
Self-practice
Yoga is practised by many people as a method of treating
common mental disorders and for promotion of mental
wellbeing and health.
Faith-based therapies
Several faith-based rituals and procedures are done for
individuals with mental health problems. The rituals differ
based on the religious faith of the practitioner, but it is
common for people from one faith to consult practitioners of
another. Hindu practices include: incantations of sacred
sounds imbued with power (mantra); wearing sanctified gems
(mani dharana) or herbs (aushadha dharana) on the body or
placing them at the entrance of the house; auspicious rituals
(mangala); ritual offerings through sacrificial fire (bali); fasting
on religious days (upavasa); measures adopted to overcome
sins of this birth or the previous one (prayashchitta); and
following a set of religious codes (niyama) giving
endowments (dana). Muslim practices include: inculcating
positive behaviours (tarbiyah); Sufi practices, such as nafs and
ruh (soul) through dhikr (remembrance of Allah); spiritual
exercises (shughl) and restraining the desires (riyadah);
recitation of the Quran to ward off afflictions due to evil eye
(ruqyah); invoking blessings of the prophet; and seeking
forgiveness from Allah. Healers of other religious faiths,
including Christianity and Sikhism, also have specific practices
related to their religions.

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in the body or some obstruction of flow that interferes
with an essential bodily process, such as digestion,
defecation, or menstruation. Practitioners of Ayurveda,
Unani, and Siddha largely focus on treating internal
causes of illness, although they recognise that other
factors might have rendered an individual vulnerable to
illness. Their therapies are generally ingested, applied
to, or inserted in the body. Therapeutic practices based
on external causes of mental illness assume that the
primary cause of an affliction lies outside the body—eg,
stars or celestial bodies, misalignment with directional
forces, malevolent spirits, debts to ancestors, sorcery, or
land embedded with negative forces. The patient might
be treated locally or travel great distances to healing
centres. Although associated with particular religions,
these healing centres are visited by people who are
more interested in the power of the place rather than
the ethnic or religious group maintaining the centre.
Examples of healing centres for mental disorders and
problems associated with psychosis are Chottanikkara
Hindu temple, Vettucaud Catholic church, and
Beemapalli mosque in Kerala.8,9
Traditional, complementary, and alternative medicine
in formal settings
India and China both have well established systems of
training and service provision in traditional, comple-
mentary, and alternative medicine. In 2014, the
Government of India formed a separate ministry for
administration of traditional, complementary, and
alternative medicine, referred to as AYUSH systems
(Ayurveda, yoga and naturopathy, Unani, Siddha, Sowa-
Rigpa, and homoeopathy; panel 2). The Central Council
for Indian Medicine (CCIM) sets uniform syllabi and
examinations for training in AYUSH systems in India.
Trainees who undergo 4·5 years of training and 1 year of
internship in institutes recognised by CCIM are eligible
to be included in state-level and central-level registries.
AYUSH hospitals that maintain specific standards are
accredited by CCIM and the National Accreditation
Board for Hospitals and Health care Providers (NABH).
In 2013, 516 institutes of AYUSH were accredited, of
which 127 offered postgraduate courses (table 1). Every
year, about 28300 practitioners are trained at these
institutes. However, only a small proportion go on to
practise. Some students pursue degrees to improve
marriage prospects, for prestige, or as a stepping stone
into other professions. Table 1 also shows the number of
registered practitioners and government-run hospitals
and dispensaries of AYUSH systems. The distribution of
India’s 686319 registered AYUSH practitioners varies
widely by region (appendix pp 4, 5): in some northeastern
states, no AYUSH practitioners are registered, whereas
nearly 20% of all AYUSH practitioners are registered in
Bihar alone. The numbers of services and trainees in
AYUSH systems have risen considerably over the past
20 years (table 1).
In China, 256 institutions provide medical training, of
which 42 are solely universities of traditional Chinese
medicine or Chinese herbology; a further 99 universities
of modern medicine also provide degree training in
traditional Chinese medicine or Chinese herbology.
About 408871 on-campus students are currently enrolled
at the 42 institutions that provide training in traditional
Chinese medicine; a bachelor degree takes 5 years to
achieve, and associate college education takes 3 years.
The licensing procedures for modern medicine and
traditional Chinese medicine are similar: all graduates
with a degree in traditional Chinese medicine must pass
the national medical licensing examination to practise
legally. In 2012, 356779 practitioners of traditional
Chinese medicine were licensed, accounting for 14% of
all licensed doctors (including doctors of modern
medicine, dentists, public health clinicians, and
practitioners of traditional Chinese medicine). Most
licensed practitioners of traditional Chinese medicine
work in hospitals in China. In 2012, 2889 hospitals
specialised in traditional Chinese medicine, accounting
for around 13% of all hospitals: 15% of all outpatient and
emergency services and 12% of all inpatient services were
provided by hospitals of traditional Chinese medicine.
Although the clinical practice, research, and industry
of traditional Chinese medicine is supported by the
Chinese Government, it is facing challenges.11
Growth in
numbers of doctors and hospitals specialising in
traditional Chinese medicine was much slower than that
for doctors and hospitals of modern medicine in the past
decade. The relative decline in services for traditional
Chinese medicine might be accounted for by economic,
cultural, and historical evolutions in China.12
Overall, traditional, complementary, and alternative
medicine in India and China shares similarities in terms
of forms of training and government sponsorship,
methods of treatment, and the focus of treatment in
keeping with bodily disturbances (ie, humoral and flow
based) and models of illness. The greater diversity in
traditional, complementary, and alternative medicine
practices in India, compared with in China, might be
indicative of the sociocultural, ethnic, and religious
diversity in India.
Mental illnesses treated by practitioners of
traditional, complementary, and alternative
medicine
The Government of India Department of AYUSH
maintains a database on disorders treated by practitioners
of AYUSH in government hospitals and dispensaries
(appendix pp 6–8). In 2013–14, only 1911 (<1%) of
28749613 consultations were categorised as being for a
mental illness. However, AYUSH systems typically regard
symptoms that a psychiatrist might identify as mental
illness as signs of deeper humoral disorders. Furthermore,
many patients with mental illness experience and
communicate their distress in terms of bodily complaints

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(eg, indigestion, aches and pains, palpitations, or
giddiness),6,8,13–16
because somatic disorders do not carry
the stigma associated with psychiatric problems.15
As
such, the actual proportion of patients with mental illness
who consulted AYUSH practitioners in these settings is
probably much higher than reported.
Few studies have used modern systems to diagnose
patients seeking help from traditional, complementary,
and alternative medicine systems. In India, some studies
have been done to assess people who seek help by visiting
religious healing centres,17–20
and in China, a study has
investigated outpatients at a hospital in Shenyang
specialising in traditional Chinese medicine.21
In the
Indian studies, most individuals who sought treatment
by religious healing had psychoses manifesting as trance
or possession disorders. By contrast, the most prevalent
mental illnesses among outpatients who visited the
traditional Chinese medicine clinic were mood and
anxiety disorders. The prevalence of mental illness
among outpatients of the traditional Chinese medicine
clinic was 21·5%, whereas for outpatients of internal
medicine clinics at the same hospital, the prevalence of
mental illness was 18·2%.
The pathways to psychiatric care have been studied in
psychiatric or tertiary care hospitals located in urban
areas of India (table 2).22–28
In most studies, researchers
used different versions of WHO’s encounter form.24
Patients were either predominantly or exclusively
suffering from severe mental illness. The proportion of
patients who visited either magico-religious systems
(10–69%) or formal AYUSH systems (1–6%) varied
widely. In Taiwan, 9% of patients with schizophrenia and
40% of individuals with depression had used traditional
Chinese medicine services.29,30
Folk therapy is also used
frequently in China; in a study of 387 patients with
psychiatric disorders living in rural areas, 286 (74%) had
consulted exorcists or diviners.31
Few epidemiological surveys have been done of help-
seeking behaviours of individuals with mental illness.
Findings from Shenzhen City in China indicated that 6%
of participants had sought help from traditional,
complementary, and alternative medicine because of
mental health issues, whereas 3% had used mental
health services.32
In the World Mental Health Survey
done in Beijing and Shanghai, of people seeking help
from medical professionals, 14% had used traditional
Chinese medicine services, and use of these services was
ranked third after other allopathic doctors and mental
health professionals.33
Findings of a community-based
survey in rural Hunan province showed that folk therapy
was the first choice for 147 (67%) of 220 patients with
schizophrenia.34
No studies from India were identified that investigated
systematically the proportion of people with mental
illness in the community who sought the services of
traditional, complementary, and alternative medicine.
However, individuals with behavioural afflictions—
ranging from common mental illnesses such as anxiety,
unwanted possession attacks, and dissociative states, to
severe mental illnesses such as psychoses—are more
likely to seek help from practitioners who treat disorders
with an external cause, whereas those with bodily
complaints (eg, somatisation associated with depression)
are more likely to seek treatment from practitioners who
treat conditions with an internal cause.6,8,9,15–17,35–37
For
example, in south India, exorcists (Mantravadis) are
consulted frequently for psychosocial stress manifesting
as anxiety states, fear, and social isolation, and for
antisocial behaviour, dissociative states, psychosis, and
unwanted possession states (possession states not tied to
planned religious activities). Ayurvedic practitioners
(Vaidyas), on the other hand, more commonly treat
disorders encompassing depression and anxiety neurosis
and involving somatic idioms of distress, which entail
complaints such as chronic indigestion and gastritis,
body aches, sexual problems, or weakness.6,38
Individuals with mental health problems in India and
China not only frequently use the services of traditional,
Total Ayurveda Yoga Naturopathy Unani Siddha Homoeopathy Sowa-Rigpa
Manpower training
Undergraduate institutions 516 (3·6%) 261 (4·2%) NA 17 (8·6%) 41 (2·2%) 9 (7·4%) 188 (2·8%) NA
Undergraduate admission capacities 25507 (5·0%) 10472 (4·3%) NA 850 (12·6%) 1591 (3·1%) 398 (4·8%) 12196 (5·7%) NA
Postgraduate institutions 127 (5·6%) 76 (4·6%) NA NA 8 (7·2%) 3 (5·6%) 40 (7·7%) NA
Postgraduate admission capacities 2776 (8·6%) 1709 (7·1%) NA NA 112 (5·3%) 124 (9·6%) 831 (15·7%) NA
Registered manpower and government infrastructure
AYUSH practitioners* 686319 (0·9%) 387976 (0·5%) NA 1620 (0·2%) 50475 (1·2%) 7600 (–2·3%) 238648 (1·9%) NA
Hospitals 3167 (0·8%) 2408 (0·6%) 7 (NA) 29 (NA) 255 (1·9%) 267 (4·5%) 201 (–1·9%) NA
Number of beds 57056 (2·4%) 42830 (2·8%) 87 (NA) 984 (2·2%) 3489 (1%) 2285 (3·1%) 7381 (0·5%) NA
Dispensaries 26107 (1·1%) 15927 (0·9%) 140 (6·6%) 120 (6·6%) 1483 (2·2%) 830 (4·9%) 7585 (0·9%) 22 (–4·9%)*
Drug manufacturing units 8896 (0·1%) 7744 (0·5%) NA NA 485 (0·7%) 344 (–0·7%) 323 (–4·5%) NA
% represents annual growth during the period 1993–2013.10
Negative % represents a decline in growth. NA=data not available. *In period 2001–13. As of 2013 there are 5502 AYUSH doctors per 10 million
population.
Table 1:Training, manpower, and infrastructure of AYUSH practitioners in the government sector in 2013

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complementary, and alternative medicine but also show
similar patterns in doing so. Patients with common
mental illnesses (eg, mood and anxiety disorders) are
most likely to consult AYUSH practitioners or doctors of
traditional Chinese medicine, whereas individuals with
behavioural afflictions are most likely to seek help
from practitioners who treat conditions with an external
cause, faith healing centres, or folk therapists. Accurate
estimation of the proportion of individuals with mental
illness who consult practitioners of traditional, comple-
mentary, and alternative medicine is difficult. People who
use these services do so for several reasons: their easy
approachability; the perception that the methods are less
expensive; because of stigma associated with psychiatric
centres; as an explanation for the individual’s abnormal
behaviour (ie, to be due to an external cause rather than
blamed on their own self); because of belief that these
treatments have fewer adverse effects; dissatisfaction with
allopathic treatment, either because of slow or no
improvement or adverse effects; perception that non-
allopathic systems are less authoritarian and give personal
autonomy and control over health-care decisions; and a
shared ethos between healers and their patients.17,39
Studies on the pathways to psychiatric care reflect these
ideas (table 2); however, systematic research attempting to
profile patients who use the services of traditional,
complementary, and alternative medicine is sparse.
Evidence for usefulness of traditional,
complementary, and alternative medicine in
psychiatric disorders
Systematic reviews and randomised controlled trials
Randomised controlled trials have been done of
traditional, complementary, and alternative medicine
practices in different health conditions, including
psychiatric disorders, and systematic reviews and meta-
analyses based on such trials have been published.
We did a systematic overview of these reviews to
evaluate current evidence on the effectiveness of
traditional, complementary, and alternative medicine in
treating major mental illnesses (panel 3). We included
94 systematic reviews published in English and 19 in
Chinese in our analysis (figure). The characteristics of
these 113 reviews are listed in the appendix (pp 9–77).
Table 3 summarises the results of 79 reviews that
focused on one traditional, complementary, and
Setting Methodsused Diagnostic categories (n) ProportionusingTCAM practitioners
before psychiatric consultation
Comments
Campion and
Bhugra (1998)22
Private clinic in atown
inTamil Nadu, south
India
Semi-structured
proforma, checked
only for religious
healing
All psychiatricdisorders (198) 50% consulted religious healers Lower income and belief in supernatural
causation, but notdiagnostic categories,were
associatedwith higher likelihoodof religious
consultation
Chadda et al
(2001)23
Instituteof Human
Behaviour andAllied
Sciences, Delhi
Semi-structured
proforma
All psychiatricdisorders (78) 30% consulted faith healers, 1% consulted
alternative systemof medicine
Accessibility, belief inthe systemof care,
attributionof supernatural causationof illness,
recommendation by friendsor relatives, and
perceptionof less expensivetreatment
determinedthe choiceof systemof care; no
differencewas noted acrossdiagnoseswith
respecttowho patients contacted first
Gater et al
(1991)24
Rural community in
Karnataka, south India
Encounter form Psychosis (4),other psychiatric
disorders (75)
13% consulted nativeor religious healers,of
whom 61%were prescribed religious
treatment and 31%were prescribed herbal
or native medicine
Factors associatedwithTCAMuse not studied
Mishra et al
(2011)25
All India Instituteof
Medical Sciences,
New Delhi
Semi-structured
questionnaire
Neuroticdisorders (86 [43%]),
mooddisorder (36 [18%]),
schizophrenia (22 [11%]),other
(56 [28%])
8% consulted faith healers, 3% consulted
practitionersof alternative medicine as
their first consultation, 51% met faith
healers and 8% met practitionersof
alternative medicine at sometimeduring
their illness
Accessibility, belief inthe systemof care,
attributionof supernatural causationof illness,
recommendation by friendsor relatives, and
perceptionof less expensivetreatment
determinedthe choiceof systemof care
Pradhan et al
(2001)26
Five centres across
India
Modified encounter
form
Diagnosticdetails not provided
(384)
7% consulted practitionersof alternative
medicine, 26% consulted faith healers
Thosewith somatic symptoms preferred
psychiatrists andthosewith psychotic symptoms
preferredotherdoctors astheir first contact;
factors associatedwithTCAMusewere not
analysed
Lahariya et al
(2010)27
Gwalior Psychiatric
Institute
Encounter form Psychosis (128 [43%]), bipolar
disorder (126 [43%]),depression
(29 [10%]),other (12 [4%])
69% consulted faith healers, 4% consulted
practitionersof alternative medicine
Low education and low incomewere associated
withuseof alternative healing systems
Thirthalli et al
(2009)28
National Instituteof
Mental Health and
Neurosciences,
Bangalore
Encounter form Schizophrenia (556) 41% consulted religiousor faith healers,
6% consulted practitionersof alternative
medicine
Factors associatedwithTCAMusewere not
analysed
TCAM=traditional, complementary, and alternative medicine.
Table 2: Studies on pathways to psychiatric care in India

7. www.thelancet.com/psychiatry Published online May 18, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30025-6 7
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alternative medicine approach (eg, needle acupuncture,
electro-acupuncture, and auricular acupuncture) and one
category of mental illness (appendix pp 78–80). Our
analysis was done according to result type (ie, positive,
mixed, or negative) and quality of evidence (ie, high or
low). Positive results were defined as either consistent
positive results for traditional, complementary, and
alternative medicine across individual clinical trials or
pooled estimates that showed at least one of the following:
traditional, complementary, and alternative medicine
was as good as or superior to a previously established
treatment; traditional, complementary, and alternative
medicine was superior to placebo, wait-list control, or no
treatment; or a combination of traditional, comple-
mentary, and alternative medicine and an established
treatment was better than the established treatment
alone. Mixed results were defined as either inconsistent
results for traditional, complementary, and alternative
medicine across individual clinical trials, with no pooled
estimates provided, or pooled estimates showing
inconsistent findings for different outcome measures,
for various comparisons (ie, traditional, complementary,
and alternative medicine superior to placebo but not as
good as an established treatment), or at alternate
timepoints. Systematic reviews were judged high quality
if the individual clinical trials, based on the final
conclusions reached, were of high quality (ie, had a Jadad
score ≥3). One of the 79 studies did two comparisons:
one was based on randomised controlled trials
irrespective of quality; the other was based on high-
quality trials only. Therefore, 80 results based on
79 reviews are summarised in table 3.
More than half the reviews (n=53) yielded positive
findings, whereas seven reported negative results.
However, most reviews (n=75) included low-quality
clinical trials (table 3). Hence, no firm conclusion can be
drawn about the effectiveness of any category of
traditional, complementary, and alternative medicine for
treatment of any specific mental illness. The most
frequently investigated traditional, complementary, and
alternative medicine approach was acupuncture (n=41)
and the disorder studied most often was depression
(n=33). 16 reviews assessed the efficacy of acupuncture to
treat depressive disorders: two positive results were
based on high-quality studies; nine positive and
five mixed results were based on low-quality studies.
Of ten reviews on the use of Chinese herbs to treat
depression, positive findings were reported in nine;
one review was based on high-quality data and
eight included low-quality studies. Four reviews on yoga
to treat depression consistently showed positive findings
based on low-quality studies. Thus, potentially, the most
effective traditional, complementary, and alternative
medicine approaches are acupuncture, Chinese herbs,
and yoga, for treatment of depression.
Scientifically rigorous clinical trials assessing the efficacy
of traditional, complementary, and alternative medicine
practices for treatment of mental illnesses are scarce.
Several reasons could account for this shortage. First,
researchers of traditional, complementary, and alternative
medicine approaches might not have been trained in the
conduct of methodologically rigorous randomised
controlled trials. Second, impetus to do randomised
controlled trials is low because government regulation of
drugs and practices is confined to new products, not those
deemed traditional or classical. Third, the major driver for
pharmaceutical companies to do randomised controlled
trials is to achieve state approval for drugs as safe and
Panel 3: Search strategy and selection criteria
We did a search for systematic reviews and meta-analyses published in English or Chinese
between Jan 1, 1995, and Dec 31, 2014.We searched PubMed, EBSCO, the Cochrane
Library, PsycINFO,Web of Science—core collection, CINAHL, and Embase for papers
published in English, with the following terms: (“systematic review” OR “meta-analysis”)
AND (“non-allopathic” OR “non-traditional” OR “traditional medicine” OR
“complementary medicine” OR “alternative medicine” OR “CAM” OR “T-CAM” OR
“TCAM” OR “Ayur*” OR “Yog*” OR “unan*” OR “homeopath*” OR “naturopath*” OR
“meditati*” OR “traditional Chinese Medicine” OR “acupuncture” OR “Chinese herbs” OR
“Tai Ji” OR “Tai chi” OR “Qi Gong”) AND (“mental” OR “psychia*” OR “schizoph*” OR
“depres*” OR “anxi*” OR “somati*” OR “dement*” OR “alcohol use” OR “alcohol abuse” OR
“alcohol dependence” OR “alcoholism” OR “drug use” OR “drug abuse” OR “drug
dependence” OR “addiction” OR “conversion*” OR “dissoci*”).We searched the China
National Knowledge Infrastructure Project (CNKI), China BioMedical literature Database
(CBM), and the digital journal ofWanfang Data (Wanfang) for papers published in
Chinese, with the same search terms.
We included systematic reviews and meta-analyses that had a comprehensive search
strategy and explicit inclusion and exclusion criteria; at least one study in the review had
to focus on the effectiveness of one or more Indian or Chinese traditional,
complementary, and alternative medicine approach for treatment of either anxiety
disorder, mood disorder, schizophrenia, substance use disorder (including nicotine), or
dementia and cognitive impairment disease, or a combination of these mental illnesses.
We excluded reviews if they were overviews of systematic reviews or meta-analyses (ie,
they did not review original research papers); if diagnosis of mental illness was not done
or mentioned in all included individual studies; if no trial was included in the systematic
review; if trials of only one herb were included; if the included studies were solely of
childhood mental illnesses and behavioural problems; or if an updated systematic review
was available at a later date.
HL and HV decided independently on the eligibility of systematic reviews and
meta-analyses, based on titles and abstracts.Those rated as relevant or possibly relevant
by either HL or HV were included in full-text analyses. HL and HV assessed the full text of
all included papers and used inclusion and exclusion criteria to evaluate eligibility.
Systematic reviews and meta-analyses published in Chinese were checked by HL and GW.
Disagreements were resolved through discussion and final decisions were made by LZ.
JT and GW assessed independently the quality of systematic reviews and meta-analyses
published in English using AMSTAR (A MeasurementTool to Assess Systematic
Reviews).40
Systematic reviews and meta-analyses published in Chinese were evaluated by
HL and GW. Reviews with an AMSTAR score of 3 or lower were classified as low quality and
were excluded. Disagreements were resolved through discussion. Data from systematic
reviews and meta-analyses published in English were extracted by JT and LZ using a
predesigned table. Data from systematic reviews and meta-analyses published in Chinese
were extracted by HL and LZ.

8. 8 www.thelancet.com/psychiatry Published online May 18, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30025-6
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effective, for the indications they are marketed. Because
most traditional, complementary, and alternative medicine
methods are already on the market and highly popular, the
need to convince the public or health professionals about
their effectiveness is diminished. Furthermore, evidence
to support insurance coverage is not needed, because the
costs of outpatient medicine in India and China are not
covered by most insurance schemes and, particularly in
India, only a very small proportion of the population has
health insurance. Fourth, with respect to out-of-pocket
expenditure, the high popularity and level of user
satisfaction for traditional, complementary, and alternative
medicine reduces public demand for proof of
effectiveness.17
Therefore, the results of clinical trials might
have little effect on real-world behaviour.
What types of studies are needed and which methods
are applicable?
The assumption that randomised controlled trials are the
gold standard of treatment effectiveness is disputed by
providers of traditional, complementary, and alternative
medicine, who point out that many characteristics of
their practice challenge the appropriateness of
randomised controlled trials to assess treatment
effectiveness.41
First, practitioners of traditional, comple-
mentary, and alternative medicine frequently use a
combination of treatments rather than one therapy alone.
Second, providers of traditional, complementary, and
alternative medicine use different diagnostic categories
to classify patients with mental illnesses,42
so studies
need to use dual diagnostic systems. Third, traditional,
Figure: Identification and selection of papers published in English andChinese
AMSTAR=A MeasurementTool to Assess Systematic Reviews. CBM=China BioMedical literature Database. CNKI=China National Knowledge Infrastructure Project.
Wanfang=the digital journal ofWanfang Data.
4640 publications identified
717 PsycINFO
41 Embase
2223 PubMed
131 Cochrane Library
388Web of Science—core collection
827 EBSCO
313 CINAHL
2684 records screened
250 full-text articles assessed for eligibility
116 studies included in quality evaluation
94 English language studies included in
overview
1956 duplicate records removed
2434 articles excluded
• overviews of systematic reviews
• no diagnosis of mental illness
• no trial was included
• childhood mental illnesses and behavioural
problems
• updated later
• duplicated
• language other than English
134 full-text articles excluded
• withdrawn
• only single herbs included
• overviews of systematic reviews
• no diagnosis of mental illness
22 full-text articles excluded (AMSTAR score ≤3)
A English language publications
2100 publications identified
718 Wanfang
471 CNKI
911 CBM
1038 records screened
120 full-text articles assessed for eligibility
40 studies included in quality evaluation
19 Chinese language studies included in
overview
1062 duplicate records removed
918 articles excluded
• no diagnosis of mental illness
• no trial was included
• childhood mental illnesses and behavioural
problems
• updated later
• duplicated
• also published in English
80 full-text articles excluded
• only single herbs included
• overviews of systematic reviews
• no diagnosis of mental illness
21 full-text articles excluded (AMSTAR score ≤3)
B Chinese language publications
For Wanfang Data see
http://www.wanfangdata.com

9. www.thelancet.com/psychiatry Published online May 18, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30025-6 9
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complementary, and alternative medicine approaches are
highly individualised and tailored based on patient’s
feedback. Finally, some treatments are presumed to
depend on the unique characteristics of the healer and
healer–patient relationship. Alternatives to randomised
controlled trials suggested by an Institute of Medicine
taskforce, which was convened to investigate methods for
assessing the effectiveness of traditional, complementary,
and alternative medicine, include pragmatic studies,
factorial designs, preference trials, n-of-1 trials, and
Systematic
reviews
Positive results
from high-quality
evidence
Positive results
from low-quality
evidence
Negative results
from high-quality
evidence
Negative results
from low-quality
evidence
Mixed results from
high-quality
evidence
Mixed results
from low-quality
evidence
Acupuncture
Dementia and cognitive deficits .. .. .. .. .. .. ..
Alzheimer’s disease 2 0 1 0 1 0 0
Vascular dementia 1 0 0 0 0 0 1
Dementia 1 0 1 0 0 0 0
Mild cognitive impairment 1 0 1 0 0 0 0
Addiction .. .. .. .. .. .. ..
Nicotine 5 0 3 1 0 0 1
Alcohol dependence 1 0 0 0 0 0 1
Cocaine 3 0 0 0 2 1 0
Heroin 3 0 1 0 0 0 2
Depressive disorders .. .. .. .. .. .. ..
Perimenopausal depression 1 0 1 0 0 0 0
Post-stroke depression 5 1 4 0 0 0 0
Depressive neurosis 1 0 1 0 0 0 0
Depressive disorders 9 1 3 0 0 0 5
Insomnia 2 0 2 0 0 0 0
Schizophrenia 3 0 2 0 0 0 1
Anxiety disorders 3 0 3 0 0 0 0
Chinese herbs
Depression 10 1 8 0 0 0 1
Dementia and cognitive deficits .. .. .. .. .. .. ..
Alzheimer’s disease 2 0 2 0 0 0 0
Vascular dementia 3 0 3 0 0 0 0
Dementia 3 0 2 0 0 0 1
Mild cognitive impairment 1 0 1 0 0 0 0
Schizophrenia 1 0 1 0 0 0 0
Anxiety disorders 1 0 1 0 0 0 0
Heroin addiction 1 0 0 0 0 0 1
Qigong and tai chi
Depression 2 0 1 0 0 0 1
Cognitive impairment 2 0 1 0 0 0 1
Ayurvedic medicine
Schizophrenia 1 0 0 0 1 0 0
Homoeopathy
Insomnia 1 0 0 0 1 0 0
Depression 1 0 1 0 0 0 0
Anxiety disorders 1 0 0 0 0 0 1
Yoga
Depression 4 0 4 0 0 0 0
Schizophrenia 2 0 1 0 1 0 0
Anxiety disorders 2 0 1 0 0 0 1
Addiction 1 0 0 0 0 0 1
Data are number of systematic reviews.TCAM=traditional, complementary, and alternative medicine.
Table 3: Data from systematic reviews of the effect ofTCAM approaches for treatment of mental illness in India and China

10. 10 www.thelancet.com/psychiatry Published online May 18, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30025-6
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observational trials.41
Moreover, outcome measures used
in studies of biomedicine might not accord with the
expectations and perceptions of effectiveness of
traditional, complementary, and alternative medicine.
Verhoef and colleagues43
suggest use of qualitative
methods not only to better understand the meaning of
intervention to patients but also to ascertain their
expectations from the intervention, and then to develop
different outcome measures. In a US study, a method to
measure patient-reported outcomes, which could be
adapted culturally to ascertain outcomes of traditional,
complementary, and alternative medicine approaches,
was developed based on analysis of the patient’s
narrative.44,45
Such studies complement the set of Good
Clinical Practice guidelines for randomised controlled
trials that the department of AYUSH in India published
in 2013 to guide trials for Ayurveda, Siddha, and Unani.46
This development is likely to spur more research into
AYUSH systems in India.
Harm avoidance
Although traditional, complementary, and alternative
medicine systems are widely believed to be free of adverse
effects, this notion is not always correct. Direct harm has
been reported from heavy metals, impurities, and possible
adulteration of Ayurvedic preparations47,48
and Chinese
herbs.49
Although controversial, some mental health
experts have identified a disorder induced by the practice of
Qigong and have included this culture-related psychiatric
syndrome in the third version of the Chinese Classification
of Mental Disorders.50
Consistent evidence shows that a
delay in starting effective treatment is associated with a
poorer outcome for patients with severe mental illnesses
such as schizophrenia.51,52
Because evidence is scant for the
effectiveness of traditional, complementary, and alternative
medicine practices, particularly in individuals with severe
mental illness, potential indirect harm because of either a
delay in beginning or denial of evidence-based treatment
cannot be ignored. Another form of harm results from
serious human rights violations and cruelty towards people
with psychiatric problems at some faith-healing centres.53
Finally, contrary to the popular belief that traditional,
complementary, and alternative medicine services are
inexpensive, anecdotal evidence suggests some patients
and families have incurred substantial expenses,
sometimes having to sell their assets or even being
indebted, in pursuit of relief through traditional,
complementary, and alternative medicine.
Encouraging interprofessional collaboration
between biomedicine and traditional,
complementary, and alternative medicine
In view of the popularity of traditional, complementary,
and alternative medicine, it is likely that even if sufficient
biomedical mental health services were available, people
would continue to access other therapeutic systems.17,20
In India, outreach efforts by the National Mental Health
Programme, which have focused almost exclusively on
biomedical care, have proven largely unsuccessful.2,54,55
Thus, investigating ways of encouraging collaboration
and triage between biomedicine and traditional,
complementary, and alternative medicine, to reduce the
gap in mental health care, seems a prudent course of
action.
Communication and collaboration between systems
Collaboration between traditional Chinese medicine and
biomedicine is well established in China. Biomedical
doctors receive about 6 months of training in traditional
Chinese medicine in medical schools and prescribe
Chinese medicine in their routine practice. General
hospitals hire doctors of traditional Chinese medicine and
provide outpatient and inpatient services in this area.
Similarly, in most schools of traditional Chinese medicine,
about 40% of the curriculum focuses on biomedicine,
including basic sciences and clinical medicine. Biomedical
approaches in diagnosis and treatment are common in
hospitals of traditional Chinese medicine. Although few
historical documents are available on emotional therapies
and talking cures, the approaches to treat patients with
mental illnesses have not been developed fully in the
history of traditional Chinese medicine.56
Thus, efforts to
integrate traditional Chinese medicine and biomedicine
in mental health care are sparse compared with other
disciplines of medicine.
In India, biomedical doctors do not get any training in
AYUSH. Undergraduates of AYUSH courses are trained
in the basics of biomedicine, particularly anatomy,
physiology, pathology, surgery, and obstetrics, but receive
very little training in biomedical approaches to mental
health.57
Under the National Rural Health Mission, steps
have been taken to integrate AYUSH and biomedicine,58
which include involving practitioners in national health
programmes, incorporation of AYUSH modalities into
primary health care, and providing infrastructural support
for AYUSH. However, little has been done about the
treatment of mental illnesses. A few non-governmental
organisations and innovative practitioners have piloted
the feasibility of offering biomedical mental health care at
faith-healing centres.59
One such programme is at a
Muslim healing shrine in Gujarat attended by people of all
religious denominations (appendix p 2).
In both China and India, practitioners of biomedicine
are restricted in their use of traditional, complementary,
and alternative medicine systems, and vice versa. In
China, the Mental Health Law, which came into effect in
May, 2013,60
precludes the biomedical diagnosis and
treatment of mental health disorders by professionals
other than trained psychiatrists. Although, by law,
practitioners of traditional Chinese medicine cannot
prescribe allopathic drugs, they are legally allowed to
treat patients with mental disorders with their own
diagnostic and therapeutic methods. By contrast,
although no published data are available, observations

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indicate that many psychiatrists prescribe traditional
Chinese proprietary herbal drugs that are available in the
market in their daily practice. In India, allopathic doctors
are not permitted to prescribe AYUSH treatments, but
the decision whether to authorise use of allopathic drugs
by AYUSH practitioners is at the discretion of different
state governments.61
In practice, doctors trained in one
system of medicine commonly prescribe treatments of
the other.62,63
How would the general public in both India and China
respond to referral and collaborative efforts to treat
mental health problems? People in these countries do
not view healers, doctors, and healing spaces as mutually
exclusive but rather as alternatives.8
Individual
practitioners—irrespective of the therapeutic system—
are regarded as having the power to treat specific types of
ailments.64
Pragmatism over-rides cognitive dissonance.
For example, at healing temples, where doctors hand out
medicines to devotees, people commonly believe that the
medicine will be effective only with the deity’s blessing.65
Treatment is not seen as integrated, but rather
complementary, with biomedical practitioners treating
and managing symptoms with drugs and the temple
offering spiritual protection and divine intervention.
Creating a mental health community of practice
Little systematic research has been done on what type
of working relationship might be forged between
doctors of biomedicine and practitioners of traditional,
complementary, and alternative medicine, towards the
common goal of better management of mental health
disorders in India and China. Establishing a loosely
structured mental health community of practice is a
productive first step for investigation of collaborative
relationships between types of practitioners who do
not ordinarily interact or problem solve together.66
A
community is formed through engaging in joint
activities, discussion, information sharing, referral,
and mutual assistance. Even though collaborative
relationships can be formed around weak ties,67
mutual
respect is established when each individual recognises
what other members contribute to a common agenda.
For example, practitioners in traditional, comple-
mentary, and alternative medicine can be trained to
recognise the benefit of managing some patients with
drugs and to advise patients taking these drugs not to
stop taking them abruptly when they consult them.
Mental health experts can be trained to better
appreciate the work of culture underlying healing
rituals,68–70
the psychosocial effect of local forms of
treatment, and the potential benefits of specific
herbal medicines or yoga.
Institutionally trained practitioners in traditional
Chinese medicine and AYUSH might be more willing to
participate in this community of practice initially than
might religious and faith healers who work outside of
formal settings. However, role models from these healing
traditions could be invited to participate in the community
of practice and become exemplars for others once the
benefits of collaboration and mutual respect can be shown.
Professional bodies of biomedical doctors and practitioners
of traditional, complementary, and alternative medicine,
and the participation of a few esteemed religious institutes,
could help build such collaborations. It is worth noting
that cross healing tradition partnerships have long existed
in parts of India between Ayurvedic practitioners,
astrologers, and exorcists. Successful communities of
practice involving practitioners of biomedicine, systems of
complementary and alternative medicine, and traditional
healers have already been established and proven
successful in both North America and Africa. For example,
findings of a study funded by the US National Institutes of
Health showed that addiction specialists, practitioners of
Chinese medicine, chiropractors, and massage therapists
could form a community of practice to address smoking
cessation.71
In Cameroon, a community of practice
involving traditional healers, community health workers,
and hospital staff has been established and is proving
effective in managing the neglected tropical disease
Buruli ulcer.72
Limitations and concluding remarks
Our review has several limitations. First, we did not
include relatively infrequently used practices of
traditional, complementary, and alternative medicine
(eg, Pranic healing, Marma therapy). Second, child
psychiatric conditions—eg, attention-deficit hyperactivity
disorder—were excluded from the systematic overview.
Finally, a large part of our review was narrative rather
than systematic.
A substantial proportion of individuals with general
medical and mental health disorders seek treatment from
various traditional, complementary, and alternative
medicine practices in India and China. Some of these
treatment methods have gained formal recognition by the
Indian and Chinese Governments. Religious practices,
self-practices, and folk therapies are also widely used by
individuals with mental health disorders. Evidence
suggests the effectiveness of acupuncture, traditional
Chinese medicine, and yoga therapy for the treatment of
depression. Although extensive research has investigated
the usefulness of traditional, complementary, and
alternative medicine for other psychiatric disorders, the
quality of much of this work is poor. The contemporary,
evidence-based standard of using randomised controlled
trials to assess efficacy of drugs and treatment strategies
does not seem to be appropriate in the setting of traditional,
complementary, and alternative medicine. Other study
choices have been proposed and need to be used
systematically. Because the biomedical system alone is
inadequate in filling the wide mental health gap in India
and China, there is a need to investigate public health
approaches involving collaboration between biomedicine
and traditional, complementary, and alternative medicine.

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Contributors
JT and LZ planned and prepared the review. KK, MN, J-BN, JG, AH, and
BNG contributed to writing from the perspectives of yoga, Ayurveda,
traditional Chinese medicine, psychiatry, and anthropology. HL, GW,
MN, HV, LZ, and JT did the literature search, assessed the quality of
retrieved articles, and extracted and analysed data (panel 3). HL, GW, LZ,
and JT prepared the figure and tables.
Declaration of interests
We declare no competing interests.
Acknowledgments
The China–India Mental Health Alliance, which is coordinated jointly by
the Shanghai Jiao Tong University and the Public Health Foundation of
India, supported the multinational collaboration that made this paper
possible. The activities of the Alliance have been supported by a grant
from the China Medical Board and by technical assistance from WHO,
Emory University, the London School of Hygiene & Tropical Medicine,
and Harvard University.
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