INTEGRATIVE%20PSYCHIATRY:%20%20HOLISTIC%20HEALING%20FOR%20THE%20MIND

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INTEGRATIVE PSYCHIATRY HOLISTIC HEALING FOR
THE MIND

• Sudha Prathikanti, MD
• University of California, San Francisco

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THE PROCRUSTEAN BED
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EVOLUTION OF MODERN BIOMEDICINE

• European Enlightenment
• Emphasis on rationality and mechanistic view of
  the physical universe
• Split of mind-body-spirit
• Germ Theory of Disease
• 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

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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

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BiomedicineThe model that works for
understanding and treating acute infections will
work for every other ailment.
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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

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LEAVING THE PROCRUSTEAN BED THE RE-DISCOVERY
OF ALTERNATIVE MEDICINE
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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

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NIH CLASSIFICATION OF CAM

• Mind-Body Interventions
• Meditation
• Biofeedback
• Hypnosis and Guided Imagery
• Biologically-Based Interventions
• Botanicals and Herbs
• Diet and Nutritional Supplements
• Manual Therapies
• Massage
• Chiropractic

• Energy Therapies
• Reiki
• Magnets
• Chakras
• Alternative Medical Systems
• Ayurveda (India)
• Traditional Chinese Medicine
• Homeopathy

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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
• Physicians 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

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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

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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

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Psychiatry is uniquely situated to integrate
healing paradigms.
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INTEGRATED PSYCHIATRIC CARE WORLDWIDE

• India
• China
• Germany

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Photo 1
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Clinical Teaching
Classroom Lectures
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UNIVERSITY-BASEDINTEGRATIVE MEDICINE CENTERSIN
THE U.S.

• Harvard
• UCSF
• Cornell
• Columbia
• University of Pittsburg
• University of Miami
• University of Arizona

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INTEGRATIVE PSYCHIATRY UCSF OSHER CENTER

• Protect
• Promote
• Partner

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PROTECT AGAINSTREMEDIES WITH LIKELY HARM OR NO
DEMONSTRATED EFFECT

• St. Johns 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

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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

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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

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HERBAL REMEDIES

• St. Johns 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 SSRIs
• 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 Alzheimers , 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

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

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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

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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 SSRIs
• Risk of mania, serotonin syndrome

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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

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ACUPUNCTURE

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

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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