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INTEGRATIVE PSYCHIATRY: HOLISTIC HEALING FOR THE MIND Sudha Prathikanti, MD University of California, San Francisco THE PROCRUSTEAN BED EVOLUTION OF MODERN BIOMEDICINE European Enlightenment Germ Theory of Disease Emphasis on rationality and mechanistic view of the physical universe Split of mind-body-spirit Illness caused by specific invasive microbe Diagnose invasive microbe with lab equipment Destroy invasive microbe thru antisepsis Flexner Report on Medical Education Mandate of standardized, science-based curriculum Stringent licensing and regulation of practice THE BIOMEDICAL PARADIGM Body, mind, spirit are discrete & independent Illness in one component can be addressed independently of the other two components Illness is caused by specific factor (or set of factors) that is important to isolate, identify, and eradicate. Physicians are specialized technicians who identify and eradicate causal factors using powerful technologies. Treatment is specific to the illness, not the person Treatment should pass objective, scientific tests Attitudes of physician and patient and their interpersonal relationship have little bearing on outcome as long as adherence to treatment prevails Biomedicine: The model that works for understanding and treating acute infections will work for every other ailment. DISSATISFACTION WITH BIOMEDICINE Poorer results when condition chronic, non-bacterial, autoimmune or of multifactorial /unknown etiology Adverse effects of biomedical therapies Less time with physician as techno-medicine rises Increasingly rigid treatment delivery systems with emphasis on cost-efficiency Increasing sense of de-humanization & compartmentalization LEAVING THE PROCRUSTEAN BED: THE RE-DISCOVERY OF “ALTERNATIVE” MEDICINE NIH DEFINITION OF COMPLEMENTARY & ALTERNATIVE MEDICINE Healthcare practices outside the realm of conventional medicine, which are not yet validated using scientific methods. Complementary: together with conventional practice Alternative: in place of conventional practices NIH CLASSIFICATION OF CAM Mind-Body Interventions Meditation Biofeedback Hypnosis and Guided Imagery Energy Therapies Biologically-Based Interventions Botanicals and Herbs Diet and Nutritional Supplements Alternative Medical Systems Manual Therapies Massage Chiropractic Reiki Magnets Chakras Ayurveda (India) Traditional Chinese Medicine Homeopathy THE PARADIGM SHIFT WITH CAM Inter-dependence of body, mind, spirit (and nature, community) Illness manifesting in one dimension necessitates attention to all dimensions Search for specific causal factor in illness less critical Physician’s goal is to activate the self-healing capacity of the patient Treatment is specific to the person, not the illness Okay if treatment less amenable to scientific tests The attitude of physician and patient, and their interpersonal relationship, may have major impact on outcome PSYCHIATRY AS BIOMEDICINE SPECIALITY Historical Roots Conventional medical school training Vocabulary (e.g. case history, prevalence, pathogenesis, cure) syntonic with biomedicine paradigm Freud: Biology is destiny Clear separation from realm of spirit Current Developments Information explosion about the brain and its function Discovery of biochemical etiologies for mental illness Creation of powerful psychotropic medications PSYCHIATRY AS DEPARTURE FROM BIOMEDICINE Conversion disorders and the affirmation of the mind-body connection Consultation Psychiatry & further elucidation of mind-body and body-mind syndromes Psychoanalysis as a self-healing process with physician as catalyst; Acceptance of psychoanalysis despite initial lack of usual scientific tests Recent landmark recognition of cultural & spiritual dimensions in diagnosis and treatment Psychiatry is uniquely situated to integrate healing paradigms. INTEGRATED PSYCHIATRIC CARE WORLDWIDE India China Germany Photo 1 Clinical Teaching Classroom Lectures Photo 3 Photo 4 Photo 5 Photo 6 UNIVERSITY-BASED INTEGRATIVE MEDICINE CENTERS IN THE U.S. Harvard UCSF Cornell Columbia University of Pittsburg University of Miami University of Arizona INTEGRATIVE PSYCHIATRY UCSF OSHER CENTER Protect Promote Partner PROTECT AGAINST REMEDIES WITH LIKELY HARM OR NO DEMONSTRATED EFFECT St. John’s Wort in patients with AIDS or patients undergoing organ transplant Rapid breathing techniques in patients with known seizure history Acupuncture for weight loss or smoking cessation in lieu of comprehensive behavioral programs with clear benefit PROMOTE REMEDIES WITH LOW RISK AND LIKELY BENEFIT Meditation techniques for decreasing stress Folic acid and omega-3 supplements in appropriate doses Acupuncture for post-operative pain PARTNER ON EXPLORATION OF UNTESTED REMEDIES Harm unknown per scientific studies Benefit unknown per scientific studies Conventional healing paradigm inadequate Competent practitioner / product available Symptoms fit CAM healing paradigm Optimistic patient/healer expectation Agreement to limited therapeutic trial with monitering HERBAL REMEDIES St. John’s Wort Equivalent to low-dose tricyclic in mild-mod depression Better than placebo-sometimes Typical dose 900-1800 mg/day (in three divided doses) Two large negative studies compared to SSRI’s Watch for photoxicity and herb-drug interactions NIH Minor Depression study pending Gingko Biloba More than 30 double-blind trials show promise in dementia symptoms Man delay Alzheimer progression by 6-12 months Full effect may require 1 yr at 120-240 mg/day Most effective in Alzheimer’s , not Vascular dementia No head-to-head comparison with anti-cholinesterases Some prelim positive results in young, healthy subjects Watch for seizure in epileptics, hemorrhage in patients on anti-coags HERBAL REMEDIES Kava Some initial hope for efficacy in anxiety disorders In meta-analysis, major methodolgical flaws in 3 placebo-controlled trials showing most promise One major negative study Pulled from US market last year due to reports of severe liver damage Valerian Used for hundreds of years for anxiety / insomnia Seven placebo-controlled trials (400-900 mg/day) 6 of 7 studies found statistically significant, related sedative effects Not benzodiazapine, so no abuse potential Avoid if liver dysfunction dose- DIETARY SUPPLEMENTS Omega-3 Fatty Acids Worldwide, lower serum omega-3 fatty acids significantly correlated with depression Double-blind, placebo-controlled studies showing efficacy of omega 3 (from fish oil) in unipolar and bipolar depression Eicosapentanoic acid (EPA) more critical omega-3 fatty acid than docosahexanoic acid (DHA) 2.5 gm/day of EPA is typical dose Flaxseed oil also source for omega-3 fatty acids, but no controlled studies to date on its use in psych conditions Food increases omega-3 absorption; do not heat fish oil! Vitamin E may help preserve potency of omega-3 in vivo Caution with anti-coagulants and hi-dose NSAIDS DIETARY SUPPLEMENTS Folate Folate deficiency appears significantly correlated with higher rates of depression Data suggest low serum folate may hinder antidepressant response Folate (0.5 mg/day) may be important adjuvant in treating women (but not men) with resistant depression Folate may help prevent relapse during and after depression treatment Watch for reduced efficacy of concurrent phenobarb/phenytoin S-Adenosyl-Methionine (SAMe) Several placebo-controlled trials for use in depression Meta-analysis shows SAMe (400mg IV or 1600mg by mouth) may be equivalent to tricyclics (400mg IV or 1600mg by mouth) No data on comparison to SSRI’s Risk of mania, serotonin syndrome MEDITATION Chronic anxiety (TM, MBSR) Chronic pain (RR, MBSR) Chronic insomnia (RR) Recurrent Depression (MBSR) Overall emotional well-being (RR, MBSR) Less anxiety and depression Increased sense of control Increased empathy ACUPUNCTURE Clear efficacy in post-op pain , acute musculoskeletal pain (even as first-line therapy) Good as adjuvant therapy in chronic musculoskeletal pain (repetitive stress, TMJ, osteoarthritis) Perhaps some efficacy in major depression Less data on use for anxiety disorders On meta-analysis of several clinical trials, no convincing data as yet re: efficacy in smoking cessation or drug rehab CONCLUSION “Nature alone cures… what [medicine] has to do is put the patient in the best condition for nature to act upon him.” Florence Nightingale