INTEGRATIVE PSYCHIATRY: HOLISTIC HEALING FOR THE MIND

Sudha Prathikanti, MDSudha Prathikanti, MDUniversity of California, San FranciscoUniversity of California, San Francisco

THE PROCRUSTEAN BEDTHE PROCRUSTEAN BED

EVOLUTION OF MODERN EVOLUTION OF MODERN BIOMEDICINEBIOMEDICINE

European Enlightenment European Enlightenment Emphasis on rationality and mechanistic view of the physical universeEmphasis on rationality and mechanistic view of the physical universe Split of mind-body-spiritSplit of mind-body-spirit

Germ Theory of DiseaseGerm Theory of Disease Illness caused by specific invasive microbeIllness caused by specific invasive microbe Diagnose invasive microbe with lab equipmentDiagnose invasive microbe with lab equipment Destroy invasive microbe thru antisepsisDestroy invasive microbe thru antisepsis

Flexner Report on Medical EducationFlexner Report on Medical Education Mandate of standardized, science-based curriculumMandate of standardized, science-based curriculum Stringent licensing and regulation of practiceStringent licensing and regulation of practice

THE BIOMEDICAL PARADIGMTHE BIOMEDICAL PARADIGM

Body, mind, spirit are discrete & independentBody, mind, spirit are discrete & independent Illness in one component can be addressed Illness in one component can be addressed

independently of the other two componentsindependently of the other two components Illness is caused by specific factor (or set of factors) Illness is caused by specific factor (or set of factors)

that is important to isolate, identify, and eradicate.that is important to isolate, identify, and eradicate. Physicians are specialized technicians who identify and Physicians are specialized technicians who identify and

eradicate causal factors using powerful technologies. eradicate causal factors using powerful technologies. Treatment is specific to the illness, not the personTreatment is specific to the illness, not the person Treatment should pass objective, scientific testsTreatment should pass objective, scientific tests Attitudes of physician and patient and their interpersonal Attitudes of physician and patient and their interpersonal

relationship have little bearing on outcome as long as relationship have little bearing on outcome as long as adherence to treatment prevailsadherence to treatment prevails

Biomedicine:Biomedicine:The model that works for The model that works for

understanding and treating understanding and treating acute infections will work for every acute infections will work for every

other ailment.other ailment.

DISSATISFACTION WITH DISSATISFACTION WITH BIOMEDICINEBIOMEDICINE

Poorer results when condition chronic, non-Poorer results when condition chronic, non-bacterial, autoimmune or of multifactorial /unknown bacterial, autoimmune or of multifactorial /unknown etiologyetiology

Adverse effects of biomedical therapiesAdverse effects of biomedical therapies Less time with physician as techno-medicine risesLess time with physician as techno-medicine rises Increasingly rigid treatment delivery systems with Increasingly rigid treatment delivery systems with

emphasis on cost-efficiencyemphasis on cost-efficiency Increasing sense of de-humanization & Increasing sense of de-humanization &

compartmentalizationcompartmentalization

LEAVING THE PROCRUSTEAN BED: LEAVING THE PROCRUSTEAN BED:

THE RE-DISCOVERY OF THE RE-DISCOVERY OF “ALTERNATIVE” MEDICINE“ALTERNATIVE” MEDICINE

NIH DEFINITION OFNIH DEFINITION OF COMPLEMENTARY & ALTERNATIVE COMPLEMENTARY & ALTERNATIVE

MEDICINEMEDICINE

Healthcare practices outside the realm of Healthcare practices outside the realm of conventional medicine, which are not yet conventional medicine, which are not yet validated using scientific methods.validated using scientific methods.

Complementary: together with conventional practiceComplementary: together with conventional practice Alternative: in place of conventional practicesAlternative: in place of conventional practices

NIH CLASSIFICATION OF CAMNIH CLASSIFICATION OF CAM

Mind-Body InterventionsMind-Body Interventions MeditationMeditation BiofeedbackBiofeedback Hypnosis and Guided ImageryHypnosis and Guided Imagery

Biologically-Based Biologically-Based InterventionsInterventions

Botanicals and HerbsBotanicals and Herbs Diet and Nutritional SupplementsDiet and Nutritional Supplements

Manual TherapiesManual Therapies MassageMassage ChiropracticChiropractic

Energy TherapiesEnergy Therapies ReikiReiki MagnetsMagnets ChakrasChakras

Alternative Medical Alternative Medical SystemsSystems Ayurveda (India)Ayurveda (India) Traditional Chinese MedicineTraditional Chinese Medicine HomeopathyHomeopathy

THE PARADIGM SHIFT WITH CAM THE PARADIGM SHIFT WITH CAM

Inter-dependence of body, mind, spirit Inter-dependence of body, mind, spirit (and nature, community)(and nature, community)

Illness manifesting in one dimension necessitates Illness manifesting in one dimension necessitates attention to all dimensionsattention to all dimensions

Search for specific causal factor in illness less critical Search for specific causal factor in illness less critical Physician’s goal is to activate the self-healing Physician’s goal is to activate the self-healing

capacity of the patientcapacity of the patient Treatment is specific to the person, not the illnessTreatment is specific to the person, not the illness Okay if treatment less amenable to scientific testsOkay if treatment less amenable to scientific tests The attitude of physician and patient, and their The attitude of physician and patient, and their

interpersonal relationship, may have major impact on interpersonal relationship, may have major impact on outcomeoutcome

PSYCHIATRY AS PSYCHIATRY AS BIOMEDICINE SPECIALITYBIOMEDICINE SPECIALITY

Historical RootsHistorical Roots Conventional medical school training Conventional medical school training Vocabulary (e.g. case history, prevalence, pathogenesis, cure) Vocabulary (e.g. case history, prevalence, pathogenesis, cure)

syntonic with biomedicine paradigmsyntonic with biomedicine paradigm Freud: Biology is destinyFreud: Biology is destiny Clear separation from realm of spiritClear separation from realm of spirit

Current DevelopmentsCurrent Developments Information explosion about the brain and its functionInformation explosion about the brain and its function Discovery of biochemical etiologies for mental illnessDiscovery of biochemical etiologies for mental illness Creation of powerful psychotropic medicationsCreation of powerful psychotropic medications

PSYCHIATRY AS PSYCHIATRY AS DEPARTURE FROM BIOMEDICINEDEPARTURE FROM BIOMEDICINE Conversion disorders and the affirmation of the Conversion disorders and the affirmation of the

mind-body connectionmind-body connection Consultation Psychiatry & further elucidation of Consultation Psychiatry & further elucidation of

mind-body and body-mind syndromesmind-body and body-mind syndromes Psychoanalysis as a self-healing process with Psychoanalysis as a self-healing process with

physician as catalyst; physician as catalyst; Acceptance of psychoanalysis despite initial lack of Acceptance of psychoanalysis despite initial lack of

usual scientific testsusual scientific tests Recent landmark recognition of cultural & spiritual Recent landmark recognition of cultural & spiritual

dimensions in diagnosis and treatmentdimensions in diagnosis and treatment

Psychiatry Psychiatry is uniquely situated to integrate is uniquely situated to integrate

healing paradigms.healing paradigms.

INTEGRATED PSYCHIATRIC CAREINTEGRATED PSYCHIATRIC CARE WORLDWIDE WORLDWIDE

IndiaIndia

ChinaChina

GermanyGermany

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Clinical Teaching

Classroom Lectures

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UNIVERSITY-BASEDUNIVERSITY-BASEDINTEGRATIVE MEDICINE CENTERSINTEGRATIVE MEDICINE CENTERS

IN THE U.S. IN THE U.S.

HarvardHarvard UCSFUCSF CornellCornell ColumbiaColumbia University of PittsburgUniversity of Pittsburg University of MiamiUniversity of Miami University of ArizonaUniversity of Arizona

INTEGRATIVE PSYCHIATRY INTEGRATIVE PSYCHIATRY UCSF OSHER CENTER UCSF OSHER CENTER

ProtectProtect

PromotePromote

PartnerPartner

PROTECT AGAINSTPROTECT AGAINSTREMEDIES WITH LIKELY HARM OR REMEDIES WITH LIKELY HARM OR

NO DEMONSTRATED EFFECTNO DEMONSTRATED EFFECT St. John’s Wort in patients with AIDS or patients St. John’s Wort in patients with AIDS or patients

undergoing organ transplantundergoing organ transplant

Rapid breathing techniques in patients with Rapid breathing techniques in patients with known seizure historyknown seizure history

Acupuncture for weight loss or smoking Acupuncture for weight loss or smoking cessation in lieu of comprehensive behavioral cessation in lieu of comprehensive behavioral programs with clear benefitprograms with clear benefit

PROMOTE PROMOTE REMEDIES WITH LOW RISK AND REMEDIES WITH LOW RISK AND

LIKELY BENEFITLIKELY BENEFIT

Meditation techniques for decreasing stressMeditation techniques for decreasing stress

Folic acid and omega-3 supplements in Folic acid and omega-3 supplements in appropriate dosesappropriate doses

Acupuncture for post-operative painAcupuncture for post-operative pain

PARTNER ON PARTNER ON EXPLORATION OF UNTESTED EXPLORATION OF UNTESTED

REMEDIESREMEDIES

Harm unknown per scientific studiesHarm unknown per scientific studies Benefit unknown per scientific studiesBenefit unknown per scientific studies Conventional healing paradigm inadequateConventional healing paradigm inadequate Competent practitioner / product availableCompetent practitioner / product available Symptoms fit CAM healing paradigmSymptoms fit CAM healing paradigm Optimistic patient/healer expectation Optimistic patient/healer expectation Agreement to limited therapeutic trial with moniteringAgreement to limited therapeutic trial with monitering

HERBAL REMEDIESHERBAL REMEDIES

St. John’s WortSt. John’s Wort Equivalent to low-dose tricyclic in mild-mod depressionEquivalent to low-dose tricyclic in mild-mod depression Better than placebo-sometimesBetter than placebo-sometimes Typical dose 900-1800 mg/day (in three divided doses)Typical dose 900-1800 mg/day (in three divided doses) Two large negative studies compared to SSRI’sTwo large negative studies compared to SSRI’s Watch for photoxicity and herb-drug interactionsWatch for photoxicity and herb-drug interactions NIH Minor Depression study pendingNIH Minor Depression study pending

Gingko BilobaGingko Biloba More than 30 double-blind trials show promise in dementia symptomsMore than 30 double-blind trials show promise in dementia symptoms Man delay Alzheimer progression by 6-12 monthsMan delay Alzheimer progression by 6-12 months Full effect may require 1 yr at 120-240 mg/dayFull effect may require 1 yr at 120-240 mg/day Most effective in Alzheimer’s , not Vascular dementiaMost effective in Alzheimer’s , not Vascular dementia No head-to-head comparison with anti-cholinesterasesNo head-to-head comparison with anti-cholinesterases Some prelim positive results in young, healthy subjectsSome prelim positive results in young, healthy subjects Watch for seizure in epileptics, hemorrhage in patients on anti-coagsWatch for seizure in epileptics, hemorrhage in patients on anti-coags

HERBAL REMEDIESHERBAL REMEDIES KavaKava

Some initial hope for efficacy in anxiety disordersSome initial hope for efficacy in anxiety disorders In meta-analysis, major methodolgical flaws in In meta-analysis, major methodolgical flaws in

3 placebo-controlled trials showing most promise3 placebo-controlled trials showing most promise One major negative study One major negative study Pulled from US market last year due to reports of Pulled from US market last year due to reports of

severe liver damagesevere liver damage

ValerianValerian Used for hundreds of years for anxiety / insomniaUsed for hundreds of years for anxiety / insomnia Seven placebo-controlled trials (400-900 mg/day)Seven placebo-controlled trials (400-900 mg/day) 6 of 7 studies found statistically significant, 6 of 7 studies found statistically significant,

dose-related sedative effectsdose-related sedative effects Not benzodiazapine, so no abuse potentialNot benzodiazapine, so no abuse potential Avoid if liver dysfunctionAvoid if liver dysfunction

DIETARY SUPPLEMENTSDIETARY SUPPLEMENTS

Omega-3 Fatty AcidsOmega-3 Fatty Acids Worldwide, lower serum omega-3 fatty acids significantly Worldwide, lower serum omega-3 fatty acids significantly

correlated with depression correlated with depression Double-blind, placebo-controlled studies showing efficacy of Double-blind, placebo-controlled studies showing efficacy of

omega 3 (from fish oil) in unipolar and bipolar depressionomega 3 (from fish oil) in unipolar and bipolar depression Eicosapentanoic acid (EPA) more critical omega-3 fatty acid than Eicosapentanoic acid (EPA) more critical omega-3 fatty acid than

docosahexanoic acid (DHA)docosahexanoic acid (DHA) 2.5 gm/day of EPA is typical dose 2.5 gm/day of EPA is typical dose Flaxseed oil also source for omega-3 fatty acids, but no Flaxseed oil also source for omega-3 fatty acids, but no

controlled studies to date on its use in psych conditionscontrolled studies to date on its use in psych conditions Food increases omega-3 absorption; do not heat fish oil!Food increases omega-3 absorption; do not heat fish oil! Vitamin E may help preserve potency of omega-3 in vivoVitamin E may help preserve potency of omega-3 in vivo Caution with anti-coagulants and hi-dose NSAIDSCaution with anti-coagulants and hi-dose NSAIDS

DIETARY SUPPLEMENTSDIETARY SUPPLEMENTS

Folate Folate Folate deficiency appears significantly correlated with higher Folate deficiency appears significantly correlated with higher

rates of depression rates of depression Data suggest low serum folate may hinder antidepressant responseData suggest low serum folate may hinder antidepressant response Folate (0.5 mg/day) may be important adjuvant in treating women (but not men) Folate (0.5 mg/day) may be important adjuvant in treating women (but not men)

with resistant depression with resistant depression Folate may help prevent relapse during and after depression treatmentFolate may help prevent relapse during and after depression treatment Watch for reduced efficacy of concurrent phenobarb/phenytoinWatch for reduced efficacy of concurrent phenobarb/phenytoin

S-Adenosyl-Methionine (SAMe)S-Adenosyl-Methionine (SAMe) Several placebo-controlled trials for use in depressionSeveral placebo-controlled trials for use in depression Meta-analysis shows SAMe (400mg IV or 1600mg by mouth) may Meta-analysis shows SAMe (400mg IV or 1600mg by mouth) may

be equivalent to tricyclics (400mg IV or 1600mg by mouth)be equivalent to tricyclics (400mg IV or 1600mg by mouth) No data on comparison to SSRI’s No data on comparison to SSRI’s Risk of mania, serotonin syndromeRisk of mania, serotonin syndrome

MEDITATIONMEDITATION

Chronic anxiety (TM, MBSR)Chronic anxiety (TM, MBSR) Chronic pain (RR, MBSR)Chronic pain (RR, MBSR) Chronic insomnia (RR)Chronic insomnia (RR) Recurrent Depression (MBSR)Recurrent Depression (MBSR) Overall emotional well-being (RR, MBSR)Overall emotional well-being (RR, MBSR)

Less anxiety and depressionLess anxiety and depression Increased sense of controlIncreased sense of control Increased empathy Increased empathy

ACUPUNCTUREACUPUNCTURE

Clear efficacy in post-op pain , acute musculo-Clear efficacy in post-op pain , acute musculo-skeletal pain (even as first-line therapy)skeletal pain (even as first-line therapy)

Good as adjuvant therapy in chronic musculo-Good as adjuvant therapy in chronic musculo-skeletal pain (repetitive stress, TMJ, osteoarthritis)skeletal pain (repetitive stress, TMJ, osteoarthritis)

Perhaps some efficacy in major depressionPerhaps some efficacy in major depression Less data on use for anxiety disordersLess data on use for anxiety disorders On meta-analysis of several clinical trials, On meta-analysis of several clinical trials,

no convincing data as yet re: efficacy in smoking no convincing data as yet re: efficacy in smoking cessation or drug rehabcessation or drug rehab

CONCLUSIONCONCLUSION

““Nature alone cures… Nature alone cures…

what [medicine] has to do is what [medicine] has to do is

put the patient in the best condition put the patient in the best condition

for nature to act upon him.”for nature to act upon him.”

Florence NightingaleFlorence Nightingale