Transcript Slide 1

The future of psychiatry:
evolution of integrative medicine
3rd Conference on Integrated Psychiatry
New Perspectives on Body and Mind
Groningen, Netherlands
3 December 2008
James Lake M.D.
www.IntegrativeMentalHealth.net
Clinical Assistant Professor, Stanford Psychiatry
Clinical 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, mindbody and energy-information modalities
including:
– Quality brands of herbals, amino acids, vitamins,
essential fatty acids and nutrient formulas
– Validated somatic and mind-body and energyinformation 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 doubleblinding 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 nonclassical 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 nonclassical 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, costcompetitiveness
• 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 nonpharmacological 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 nonclassical 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
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2. Shang, C. (2001) Emerging paradigms in mind-body
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Note: finish cites
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NOTE: finish cites
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[need complete reference)
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J.L.
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