Transcript PowerPoint Presentation - INTEGRATIVE PSYCHIATRY: HOLISTIC

INTEGRATIVE PSYCHIATRY:
HOLISTIC HEALING FOR THE MIND
Sudha Prathikanti, MD
University of California, San Francisco
THE PROCRUSTEAN BED
EVOLUTION OF MODERN
BIOMEDICINE
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European Enlightenment
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Germ Theory of Disease
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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
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Mandate of standardized, science-based curriculum
Stringent licensing and regulation of practice
THE BIOMEDICAL PARADIGM
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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
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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.
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Complementary: together with conventional practice
Alternative: in place of conventional practices
NIH CLASSIFICATION OF CAM
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Mind-Body Interventions
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Meditation
Biofeedback
Hypnosis and Guided Imagery
Energy Therapies
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Biologically-Based
Interventions
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Botanicals and Herbs
Diet and Nutritional Supplements
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Alternative Medical
Systems
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Manual Therapies
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Massage
Chiropractic
Reiki
Magnets
Chakras
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Ayurveda (India)
Traditional Chinese Medicine
Homeopathy
THE PARADIGM SHIFT WITH CAM
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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
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Historical Roots
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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
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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
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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
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India
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China
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Germany
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Clinical Teaching
Classroom Lectures
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UNIVERSITY-BASED
INTEGRATIVE MEDICINE CENTERS
IN THE U.S.
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Harvard
UCSF
Cornell
Columbia
University of Pittsburg
University of Miami
University of Arizona
INTEGRATIVE PSYCHIATRY
UCSF OSHER CENTER
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Protect
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Promote
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Partner
PROTECT AGAINST
REMEDIES WITH LIKELY HARM OR NO
DEMONSTRATED EFFECT
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St. John’s Wort in patients with AIDS or patients
undergoing organ transplant
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Rapid breathing techniques in patients with
known seizure history
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Acupuncture for weight loss or smoking
cessation in lieu of comprehensive behavioral
programs with clear benefit
PROMOTE
REMEDIES WITH LOW RISK AND
LIKELY BENEFIT
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Meditation techniques for decreasing stress
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Folic acid and omega-3 supplements in
appropriate doses
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Acupuncture for post-operative pain
PARTNER ON
EXPLORATION OF UNTESTED
REMEDIES
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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
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St. John’s Wort
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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
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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
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Kava
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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
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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
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Omega-3 Fatty Acids
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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
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Folate
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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)
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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
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Chronic anxiety (TM, MBSR)
Chronic pain (RR, MBSR)
Chronic insomnia (RR)
Recurrent Depression (MBSR)
Overall emotional well-being (RR, MBSR)
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Less anxiety and depression
Increased sense of control
Increased empathy
ACUPUNCTURE
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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