The future of psychiatry: evolution of integrative medicine

3rd Conference on Integrated PsychiatryNew Perspectives on Body and Mind

Groningen, Netherlands3 December 2008

James Lake M.D.www.IntegrativeMentalHealth.net

Clinical Assistant Professor, Stanford PsychiatryClinical Assistant Professor, University of Arizona Program

in Integrative Medicine

Our future: challenging and promising

• CAM and integrative mental health care—use trends

• Emerging paradigms and implications for medicine and psychiatry

• Psychiatry as a paradigm—factors shaping evolution

• Forecasts—where we will be in 2020 and 2050

CAM and integrative mental health:defining our agenda

• Approx 12% of world’s population will experience mental illness in any given year (2008 report, World Federation for Mental Health).

• Most do not have access or cannot afford conventional pharmacological Rx

• Those who can afford and elect to use biomedical Rx are increasingly open to CAM Rx

Biomedical psychiatry will make significant advances

• Functional brain imaging including PET, SPECT and fMRI will permit quantitative analysis of neurotransmitter dysregulations resulting in more specific and more effective treatments

• Research progress in genetics of mental illness will come from Human Genome Project

• Biomedical psychiatry will continue to make important advances in its theories and practices

Limitations of conventional medical care

• Contemporary biomedical theory and clinical therapeutics do not adequately address medical and psychiatric illness needs

• 15% of U.S. GDP ($1.6 trillion) spent on healthcare, but drug reactions, infections, surgical errors among leading causes of death and morbidity.4,5

• Factors that limit or interfere with conventional care (7):– Restrictions on covered Rx – Dissatisfaction with quality of care– Efficacy and safety issues– Increasing costs

Limited efficacy of conventional Pharmacological Rx

• For major depressive disorder (Kirsch 2008; Thase 2008).

• For bipolar D.O. (Boschert 2004).• For GAD, OCD, phobias and PTSD (Westen

2001). • For schizophrenia only clozapine yielded

better outcomes than first generation antipsychotics (Davis 2003).

CAM and integrative approaches in mental health

Historical trends, how many people use CAM, and how mental health

care is changing

Changing public and institutional attitudes towards CAM

• Germ Theory (1870’s) and demand for more scientific medicine

• Reaction to “scientific” medicine (1890 through 1900) osteopathy, chiropractic and naturopathy offer “drugless healing”

• Flexner Report (1910) repressed diversity of medical training in U.S.

• “Counter culture” rejected orthodox model; increased in 70s and 80s. OAM established in ‘92, NCCAM established (1998)—improved funding and research quality.

Growing Uses of CAM Rx

• Increasing % of patients who see physicians seek treatment from CAM practitioners (eg, Chinese medical practitioners, herbalists, homeopathic physicians, and energy healers).6

• People critical of Western biomedicine increasingly using CAM Rx for medical and mental health7,8

• 72 million US adults use CAM Rx (approx 1 in 3 adults).9 • Half of US physicians believe acupuncture, chiropractic,

and homeopathy are valid refer to CAM practitioners (14).

Increasing CAM use for mental health

• Any psychiatric Dx increases rate of CAM use.10,11 • One third patients dx’d GAD, bipolar DO, schizophrenia

use CAM Rx.10 • Two thirds severely depressed or anxious use both

conventional and CAM Rx.12 • Most mental health patients use conventional and CAM

Rx together.10,13 • Half of M.D.s refer patients to CAM practitioners (14)• Few patients disclose CAM use to physician: treatment

failures, delays and safety issues (Eisenberg et al., 1998)

CAM Rx—what can we say?

• Select CAM and integrative Rx: – Consistently yield beneficial outcomes– Are safe and cost-effective modalities– Are based on highly evolved traditions of medical practice

in their cultures of origin– Are becoming validated by Western style research– Are appropriate in Western countries– Are finding new Rx applications for medical and psychiatric

disorders

CAM and integrative psychiatry will continue to evolve

• CAM Rx will evolve from “herbs and vitamins” to broad range of biological, somatic, mind-body and energy-information modalities including: – Quality brands of herbals, amino acids, vitamins,

essential fatty acids and nutrient formulas – Validated somatic and mind-body and energy-

information protocols for specific symptoms or psychiatric disorders

Emerging paradigms

Implications for the future of psychiatry

Contemporary Psychiatry—useful but limited insights

• Contemporary psychiatry based on diverse perspectives of “mind-body” problem

• No consensus on most complete explanatory model of mind-body interactions.1

• Biomedical psychiatry based on neurotransmitters and electromagnetic fields

• Cause-effect relationships difficult to determine

Limitations of Conventional Medicine invite CAM and integrative medicine

• Shortcomings suggest inadequate model; invite consideration of CAM and integrative Rx

• Increasing openness of Western culture to non-Western healing traditions

• Growing demand for more meaningful and personal contact with medical practitioners, difficult to achieve in Western health care settings

Western medicine already integrative

• Acupuncture, other CAM Rx routinely used in Western medicine

• Studies examining mechanisms and benefits• Trans-paradigm validation led to acceptance of

concepts initially rejected by Western medicine (Eg. denatured viruses in immunization; antisepsis for surgery; x-rays).

• Western medicine has evolved into eclectic theories and practices, already integrated

Psychiatry is a paradigm—beliefs and practices

• Psychiatry: evolving beliefs and practices• Research advances determine and limit

evolution• Clinical use trends shaped by urgent unmet

needs• Novel theories of etiology and classification• Trend towards holism• Cost and cost-competitiveness

Research, social and economic trends

• Research advances in genetics and neurosciences will bring more effective conventional Rx and validate certain CAM Rx

• Patients increasingly seeking effective, affordable and safe alternatives

• Values will embrace more “holistic” approach• Global economic crisis will accelerate research

progress, uses of CAM and integrative Rx

Non-Western paradigms

• Non-Western traditions posit different energy and information in health, illness, and healing

• In conventional biomedicine chemistry and biology provide foundations

• More complete understanding of mind-body may require classical and non-classical paradigms.2

• Light exposure therapy affects melatonin and neurotransmitter activity; possibly c/w quantum mechanics or quantum brain dynamics.3

Future research methodologies will examine quantitative and qualitative data• Qualitative criteria: training and duration;

historical and current uses; safety; coherence of theory

• Future CAM research will combine methodologies to more adequately address complex factors (25)

• Probability of finding useful information increases when RCT designs combined with observational studies, case series analysis, design-adaptive allocations, participant-centered research, and “N of 1” trials (26) . (NOTE: cites in Paradigms paper)

Alternatives to “blinding”

• Blinding controversial: impossible to “blind” patient and researcher. Absence of double-blinding can bias findings

• Dual-blinding: patient blinded, researcher not blinded, second investigator blinded. May improve research integrity (27).

• Design-adaptive allocations: alternative to RCT; better “balance” between treatment groups; analyzing findings in small studies (28)

Emerging research methodologies

• Single-case (“N=1”) study yields individualized outcomes; but can’t generalize (29, 30, 31).

• Case series estimate Rx benefits but can’t account for placebo or non-specific effects

• Participant-centered analysis: complex relationships between treatments and outcomes (32).

• Aptitude x treatment interaction (ATI): match between patient “aptitudes” and Rx response (33).

Emerging research methodologies

• Single-case (“N=1”) study assesses benefit and safety; yields definitive, individualized outcomes; can’t generalize, doesn’t apply to “unstable” illnesses (29, 30, 31).

• Case series estimate Rx benefits but can’t account for placebo or non-specific Rx effects

• Participant-centered analysis uses measures of single variable for analysis of complex relationships between treatments and outcomes at the individual level (32).

• Aptitude x treatment interaction (ATI): outcomes depend on match between patient “aptitudes” and Rx response (33).

Range of evidence for CAM Rx

• Some CAM Rx meet scientific criteria but not used for other reasons

• Most CAM studies done on biological mechanisms

• Mind-body Rx and postulated “energy” Rx not thoroughly evaluated

• Reiki, qigong, and homeopathy based on postulated “energies,” studies suggest beneficial effects.15-20

Paradigm differences

• Biomedicine only beginning to use new findings and theories from physics, biology, and information science

• Biomedicine assumes linear causality and discrete causal relationships can be characterized using current methods

• Complex systems model rejects linear causality.26 • Many non-Western traditions reject linear causality

and understand illness, health, and healing in fundamentally different ways

Complex systems theory invites integrative perspective

• Complex systems theory—dynamic non-linear relationships between multiple causes manifest as emergent properties of the brain-mind-body experienced as symptoms.27

• Corollary: one symptom has single apparent “primary” cause, and underlying complex cause(s) vary between individuals due to unique biochemical, genetic, social, psychological, and possibly energetic constitution.

Complexity theory and Functional medicine

• Non-linear causal relationships described in complex systems theory may provide more adequate explanatory model of mental illness than contemporary linear models

• Functional medicine sees health and illness in relationship to informational changes in complex intercellular communication processes

Functional medicine

• Functional medicine assumes conventional biomedical model of pathophysiology but biochemical and genetic individuality.30

• Different molecules function as cellular mediators (eg. neuropeptides, steroids, inflammatory mediators, and neurotransmitters) and influence brain functioning at several levels

• Effective Rx modify informational basis of psychiatric symptoms at level of complex interactions between mediators and brain

Future medicine will embrace non-classical paradigms

• Complexity theory, quantum mechanics, and quantum field theory overlooked by biomedicine

• Non-classical paradigms may clarify informational or energetic basis of health, illness, and healing

• Legitimate phenomena in non-biomedical paradigms overlooked by Western medicine: intention and effects of “subtle energy” on health

Some CAM Rx use classical and non-classical forms of energy

• EEG biofeedback, music and binaural sounds, bright light exposure, micro-current brain stimulation, and high-density negative ions probably have direct effects

• CAM Rx based on non-classical models may have direct and subtle effects3,3

• Acupuncture, homeopathy, Healing Touch, qigong, not described by Western science, may employ classical and non-classical effects32

QBD may help explain “energy” healing

• Quantum brain dynamics (QBD) uses quantum field theory to explain subtle characteristics

• Healing intention: non-local interactions between consciousness and patient.33

• Science: outcomes of “energy” Rx are placebo; can’t falsify non-classical effects

• “Energy” medicine may be consistent with quantum field theory.35

The future of psychiatric assessment

• Future assessment will address biological, informational and “energetic” causes

• QEEG will become widely used to assess neural fx and predict Rx response

• Serologic and urinary assays will be increasingly used• Subtle energy assessment: pulse diagnosis; analysis of

the VAS; ultra-weak bio-photons• Some approaches will be validated; others refuted. • Novel assessment approaches will lead to more

comprehensive and cost-effective treatment planning

ADD comments on economic trends and cost/cost-effectiveness, cost-competitiveness

• Borrow from intro chs. Thieme and check pubmed cites “CAM and cost”

Progress toward CAM and integrative psychiatry

• American Psychiatric Association: CAM Caucus, Sub-committee on Omega-3 EFAs, Task force on CAM; full committee pending

• Program in Integrative Medicine, U. of A. College of Medicine: proposal to create specialty track in integrative psychiatry

• International Association for Integrative Psychiatry: planning meetings

Forecasts

10 years and at mid-century

The future of psychiatry—21st century

• Psychiatrists will accept novel Dx and Rx based on both conventional and CAM research findings

• Future models more complete—considering established theories, emerging paradigms, and non-Western healing traditions

• Western psychiatry will become more integrative resulting in deeper understandings of psychological, biological, informational and “energetic” processes

Psychiatry in 2020

Conservative and “Optimistic” Forecasts

2020—conservative forecast

• Biomedical paradigm still dominant• Pharmaceutical industry still entrenched,

influencing FDA, congress, academic psychiatry• Most CAM treatments still marginalized• Select CAM treatments covered by insurance• Academic centers still prioritize pharmacological

research• FDA, APA, AMA still unengaged or opposed to

systematic CAM research program

2020—optimistic forecast

• Biomedical paradigm evolving—open to non-pharmacological Rx

• Hegemony of pharmaceutical industry waning• Manufacturers of select CAM Rx are established• Select CAM Rx covered by mainstream

insurances and offered in health plans• Academic centers research select CAM Rx• FDA, APA and AMA collaborate on CAM research

Psychiatry in 2050

Conservative and “optimistic”

Psychiatry in 2050

Conservative and “optimistic”

2050—conservative forecast

• Biomedical paradigm dominant but complexity theory, consciousness research, QFT, other theories now play role

• Well-designed studies validate select CAM Rx in psychiatry

• Novel technologies permit studies on non-classical energy/information in health and illness

2050--“optimistic” forecast

• Biomedical paradigm more flexible and open

• Health care delivery more pluralistic• Select CAM Rx endorsed by biomedicine• No longer rigid biomedical/CAM

dichotomy• Assessment will permit more specific,

effective Rx

2050—optimistic forecast

• Preventive strategies addressing serious mental illnesses

• Some CAM Rx will be refuted as ineffective or unsafe

• Research on-going on select biological CAM modalities at academic research centers

• FDA, APA, AMA, other institutions engaged in dialog on CAM research initiatives

The future of psychiatry

We are creating it

The future of psychiatry—how we are creating it

• This conference—international association, collaboration and information exchange

• U. of A. PIM fellowship track in integrative psychiatry

• Courses in med schools, residency training programs

• APA—CAM Caucus, Task force, pending committee

APA Caucus on Complementary, Alternative and Integrative Mental Health Care

• www.APACAM.org– List-serve for announcements and networking– Growing library and links to related sites– Forums in major CAM areas (need hosts)

• Task Force (work completed 9/08)• Standing Committee on CAM (pending)– Expert resources for clinicians and patients– CME-sponsored conferences– Med school and residency curricula

Add cites from Paradigms ch and Explore paper; assessment paper

1. Kendler, K. (2001) A psychiatric dialogue on the mind-body problem. Am Jour Psychiatr, 158(7), 989-1000

2. Shang, C. (2001) Emerging paradigms in mind-body medicine. Jour Alt and Comp Medicine, 7(1), 83-91.

3. Curtis B, Hurtak J. Consciousness and quantum information processing: uncovering the foundation for a medicine of light. J Altern Complement Med. 2004;10:27-39.

4. Starfield B. Is U.S. health really the best in the world? JAMA. 2000;284:483-485.

5. Zhan C, Miller M. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-1874.

 

6. Barnes P, Powell-Griner E, McFann K, Nahin R. Complementary and alternative medicine use among adults: United States, 2002. Semin Integrative Med. 2004;2:54-71.

7. Astin J. Why Patients use alternative medicine. JAMA. 1998;279:1548-1553.

8. Rees L. Integrated medicine: imbues orthodox medicine with the values of complementary medicine. BMJ. 2001;322:19-120.

9. Tindle H, Davis R, Phillips R, Eisenberg D. Trends in use of complementary and alternative medicine by U.S. adults: 1997-2002. Alt Ther Health Med. 2005;11:42-49.

10. Unutzer J, Klap R, Sturm R, et al. Mental disorders and the use of alternative medicine: results from a national survey. Am J Psychiatry. 2000;157:1851-1857.

Note: finish cites11. Unutzer J, et al. [According to the journal’s Web site, the authors of this article

are Sparber A and Wootton JC.] Surveys of complementary and alternative medicine: part V. Use of alternative and complementary therapies for psychiatric and neurologic diseases. J Altern Complement Med. 2002;8:93-96. (This cite covers the same territory as the one I suggested but also more recent. Mine was published in Am J. Psychiatry, 2000; Let’s stay with the one you found. J.L.)

12. Kessler R, Soukup J, Davis R, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry. 2001;158:289-294.

13. Eisenberg D, Davis, R, Ettner S, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569-1575.

14. Astin J, Marie A, Pelletier K, et al. A review of the incorporation of complementary and alternative medicine by mainstream physicians. Arch Intern Med. 1998;158:2303-2310.

NOTE: finish cites

15. Allen J, Schnyer R, Hitt S. The efficacy of acupuncture in the treatment of major depression in women. Psychol Sci. 1998;9:397-401.

16. Bradway. The Effects of Healing Touch on Depression, 1997. In: Healing Touch Research Summary, 2003. [need complete reference)

Weze C, Leathard HL, Grange J, Tiplady P, Stevens G. (2007) Healing by Gentle Touch Ameliorates Stress and Other Symptoms in People Suffering with Mental Health Disorders or Psychological Stress. Evid Based Complement Alternat Med. 4(1):115-123.

17. Davidson J, Morrison R, Shore J, et al. Homeopathic treatment of depression and anxiety. Alt Therapies. 1997;3:46-49.

18. Gaik F. Merging east and west: A preliminary study applying spring forest qigong to depression as an alternative and complementary treatment. Adler School Of Professional Psychology, US Dissertation Abstracts International: Section B: The Sciences & Engineering. Vol 63(12-B) (2003): 6093 Additional Info: US; Univ Microfilms International ISSN: 0419-4217 (Print) English.

19. Kempson D. Effects of intentional touch on complicated grief of bereaved mothers. OMEGA. 42:4;341-353, 2000-2001.

20. Shore A. Long-term effects of energetic healing on symptoms of psychological depression. and self-perceived stress. Alt Therapies. 2004;10:42-48.

21. Dixon M, Sweeney K. The Human Effect in Medicine: Theory, Research And Practice. Oxford: Radcliffe Medical Press; 2000.

22. Kirsch I, Moore T, Scoboria A, Nicholls S. The emperor’s new drugs: an analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention & Treatment 5:Article 23, 2002. [Could not find this article at this Web address.] Please delete the web address and leave cite as is. J.L.

23. Thase M. Antidepressant effects: the suit may be small, but the fabric is real. Prevention & Treatment 5:Article 32, 2002. Available at: [Could not find this article at this Web address.] Please delete web address and leave cite as is. J.L.

• 24. Sussman N. The “file-drawer” effect: assessing efficacy and safety of antidepressants. Prim Psychiatry. 2004 ;11:12.

• 25. Tangrea J, Adrianza E, Helsel W. Risk factors for the development of placebo adverse reactions in a multicenter clinical trial. Ann Epidemiol. 1994;4:327-331.

• 26. Bell I, Caspi O, Schwartz G, et al. Integrative medicine and systemic outcomes research. Arch Intern Med. 2002;162:133-140.

• 27. Strogatz S. Exploring complex networks. Nature. 2001;410:268-276.

• 28. Schuck J, Chappell T, Kindness G. Causal modeling and alternative medicine. Alt Therapies. 1997;3:40-47.

29. Mercier C, King S. A latent variable causal model of the quality of life and community tenure of psychotic patients. Acta Psychiatr Scand. 1994;89:72-77.

30. Bland J. New functional medicine paradigm: dysfunctional intercellular communication. Int J Integrative Med. 1999;1:11-16.

31. Hankey A. Are we close to a theory of energy medicine? J Altern Complement Med. 2004;10:83-86.

32. Chen K. An analytic review of studies on measuring effects of external Qi in China. Review Article. Alt Therapies. 2004;10:38-50.

33. Zahourek R. Intentionality forms the matrix of healing: a theory. Alt Therapies. 2004;10:40-49.

34. Abbot N. Healing as a therapy for human disease: a systematic review. J Altern Complement Med. 2000;6:159-169.