The future of psychiatry: - PowerPoint Presentation

Slide1

The future of psychiatry: evolution of integrative medicine 3rd Conference on Integrated PsychiatryNew Perspectives on Body and Mind Groningen, Netherlands3 December 2008

James Lake M.D.

www.IntegrativeMentalHealth.net

Clinical Assistant Professor, Stanford Psychiatry

Clinical Assistant Professor, University of Arizona Program in Integrative MedicineSlide2

Our future: challenging and promisingCAM and integrative mental health care—use trendsEmerging paradigms and implications for medicine and psychiatryPsychiatry as a paradigm—factors shaping evolutionForecasts—where we will be in 2020 and 2050Slide3

CAM and integrative mental health:defining our agendaApprox 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 RxThose who can afford and elect to use biomedical Rx are increasingly open to CAM Rx Slide4

Biomedical psychiatry will make significant advancesFunctional brain imaging including PET, SPECT and fMRI will permit quantitative analysis of neurotransmitter dysregulations resulting in more specific and more effective treatmentsResearch 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 Slide5

Limitations of conventional medical careContemporary biomedical theory and clinical therapeutics do not adequately address medical and psychiatric illness needs15% 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 careEfficacy and safety issuesIncreasing costs Slide6
Slide7

Limited efficacy of conventional Pharmacological RxFor 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). Slide8

CAM and integrative approaches in mental healthHistorical trends, how many people use CAM, and how mental health care is changingSlide9

Changing public and institutional attitudes towards CAMGerm 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. Slide10
Slide11

Growing Uses of CAM RxIncreasing % 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). Slide12

Increasing CAM use for mental healthAny 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)Slide13

CAM Rx—what can we say?Select CAM and integrative Rx: Consistently yield beneficial outcomesAre safe and cost-effective modalitiesAre based on highly evolved traditions of medical practice in their cultures of originAre becoming validated by Western style researchAre appropriate in Western countriesAre finding new Rx applications for medical and psychiatric disordersSlide14

CAM and integrative psychiatry will continue to evolveCAM Rx will evolve from “herbs and vitamins” to broad range of biological, somatic, mind-body and energy-information modalities including: Quality brands of herbals, amino acids, vitamins, essential fatty acids and nutrient formulas Validated somatic and mind-body and energy-information protocols for specific symptoms or psychiatric disordersSlide15

Emerging paradigmsImplications for the future of psychiatrySlide16

Contemporary Psychiatry—useful but limited insightsContemporary psychiatry based on diverse perspectives of “mind-body” problemNo consensus on most complete explanatory model of mind-body interactions.1 Biomedical psychiatry based on neurotransmitters and electromagnetic fieldsCause-effect relationships difficult to determineSlide17

Limitations of Conventional Medicine invite CAM and integrative medicine Shortcomings suggest inadequate model; invite consideration of CAM and integrative RxIncreasing openness of Western culture to non-Western healing traditionsGrowing demand for more meaningful and personal contact with medical practitioners, difficult to achieve in Western health care settingsSlide18

Western medicine already integrativeAcupuncture, other CAM Rx routinely used in Western medicineStudies examining mechanisms and benefitsTrans-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 integratedSlide19

Psychiatry is a paradigm—beliefs and practicesPsychiatry: evolving beliefs and practicesResearch advances determine and limit evolutionClinical use trends shaped by urgent unmet needsNovel theories of etiology and classificationTrend towards holismCost and cost-competitiveness Slide20

Research, social and economic trendsResearch advances in genetics and neurosciences will bring more effective conventional Rx and validate certain CAM RxPatients increasingly seeking effective, affordable and safe alternatives Values will embrace more “holistic” approachGlobal economic crisis will accelerate research progress, uses of CAM and integrative RxSlide21

Non-Western paradigmsNon-Western traditions posit different energy and information in health, illness, and healingIn conventional biomedicine chemistry and biology provide foundationsMore 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.3Slide22

Future research methodologies will examine quantitative and qualitative dataQualitative 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)Slide23

Alternatives to “blinding”Blinding controversial: impossible to “blind” patient and researcher. Absence of double-blinding can bias findingsDual-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)Slide24

Emerging research methodologiesSingle-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 effectsParticipant-centered analysis: complex relationships between treatments and outcomes (32). Aptitude x treatment interaction (ATI): match between patient “aptitudes” and Rx response (33).Slide25

Emerging research methodologiesSingle-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 effectsParticipant-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).Slide26

Range of evidence for CAM RxSome CAM Rx meet scientific criteria but not used for other reasonsMost CAM studies done on biological mechanismsMind-body Rx and postulated “energy” Rx not thoroughly evaluated Reiki, qigong, and homeopathy based on postulated “energies,” studies suggest beneficial effects.15-20 Slide27

Paradigm differencesBiomedicine only beginning to use new findings and theories from physics, biology, and information scienceBiomedicine assumes linear causality and discrete causal relationships can be characterized using current methodsComplex systems model rejects linear causality.26 Many non-Western traditions reject linear causality and understand illness, health, and healing in fundamentally different waysSlide28

Complex systems theory invites integrative perspectiveComplex 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.Slide29

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 processesSlide30

Functional medicineFunctional 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 levelsEffective Rx modify informational basis of psychiatric symptoms at level of complex interactions between mediators and brainSlide31

Future medicine will embrace non-classical paradigmsComplexity theory, quantum mechanics, and quantum field theory overlooked by biomedicineNon-classical paradigms may clarify informational or energetic basis of health, illness, and healingLegitimate phenomena in non-biomedical paradigms overlooked by Western medicine: intention and effects of “subtle energy” on healthSlide32

Some CAM Rx use classical and non-classical forms of energy EEG biofeedback, music and binaural sounds, bright light exposure, micro-current brain stimulation, and high-density negative ions probably have direct effectsCAM 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 effects32Slide33

QBD may help explain “energy” healingQuantum brain dynamics (QBD) uses quantum field theory to explain subtle characteristicsHealing 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.35Slide34

The future of psychiatric assessmentFuture assessment will address biological, informational and “energetic” causesQEEG will become widely used to assess neural fx and predict Rx responseSerologic and urinary assays will be increasingly usedSubtle energy assessment: pulse diagnosis; analysis of the VAS; ultra-weak bio-photonsSome approaches will be validated; others refuted. Novel assessment approaches will lead to more comprehensive and cost-effective treatment planningSlide35

ADD comments on economic trends and cost/cost-effectiveness, cost-competitivenessBorrow from intro chs. Thieme and check pubmed cites “CAM and cost”Slide36

Progress toward CAM and integrative psychiatryAmerican Psychiatric Association: CAM Caucus, Sub-committee on Omega-3 EFAs, Task force on CAM; full committee pendingProgram in Integrative Medicine, U. of A. College of Medicine: proposal to create specialty track in integrative psychiatry International Association for Integrative Psychiatry: planning meetingsSlide37

Forecasts10 years and at mid-centurySlide38

The future of psychiatry—21st centuryPsychiatrists will accept novel Dx and Rx based on both conventional and CAM research findingsFuture models more complete—considering established theories, emerging paradigms, and non-Western healing traditionsWestern psychiatry will become more integrative resulting in deeper understandings of psychological, biological, informational and “energetic” processes Slide39

Psychiatry in 2020Conservative and “Optimistic” ForecastsSlide40

2020—conservative forecastBiomedical paradigm still dominantPharmaceutical industry still entrenched, influencing FDA, congress, academic psychiatryMost CAM treatments still marginalizedSelect CAM treatments covered by insuranceAcademic centers still prioritize pharmacological researchFDA, APA, AMA still unengaged or opposed to systematic CAM research programSlide41

2020—optimistic forecastBiomedical paradigm evolving—open to non-pharmacological RxHegemony of pharmaceutical industry waningManufacturers of select CAM Rx are establishedSelect CAM Rx covered by mainstream insurances and offered in health plansAcademic centers research select CAM RxFDA, APA and AMA collaborate on CAM researchSlide42

Psychiatry in 2050Conservative and “optimistic”Slide43
Slide44

Psychiatry in 2050Conservative and “optimistic”Slide45

2050—conservative forecastBiomedical paradigm dominant but complexity theory, consciousness research, QFT, other theories now play roleWell-designed studies validate select CAM Rx in psychiatryNovel technologies permit studies on non-classical energy/information in health and illnessSlide46

2050--“optimistic” forecastBiomedical paradigm more flexible and openHealth care delivery more pluralisticSelect CAM Rx endorsed by biomedicineNo longer rigid biomedical/CAM dichotomyAssessment will permit more specific, effective RxSlide47

2050—optimistic forecastPreventive strategies addressing serious mental illnessesSome CAM Rx will be refuted as ineffective or unsafeResearch on-going on select biological CAM modalities at academic research centersFDA, APA, AMA, other institutions engaged in dialog on CAM research initiatives Slide48

The future of psychiatryWe are creating itSlide49

The future of psychiatry—how we are creating itThis conference—international association, collaboration and information exchangeU. of A. PIM fellowship track in integrative psychiatryCourses in med schools, residency training programsAPA—CAM Caucus, Task force, pending committeeSlide50

APA Caucus on Complementary, Alternative and Integrative Mental Health Carewww.APACAM.orgList-serve for announcements and networkingGrowing library and links to related sitesForums 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 curriculaSlide51
Slide52

Add cites from Paradigms ch and Explore paper; assessment paperSlide53

1. Kendler, K. (2001) A psychiatric dialogue on the mind-body problem. Am Jour Psychiatr, 158(7), 989-10002. Shang, C. (2001) Emerging paradigms in mind-body medicine. Jour Alt and Comp Medicine, 7(1), 83-91.  3. Curtis B, Hurtak J. Consciousness and quantum information processing: uncovering the foundation for a medicine of light.

J

Altern

Complement Med

. 2004;10:27-39.

4.

Starfield

B. Is U.S. health really the best in the world?

JAMA.

2000;284:483-485.

5.

Zhan C, Miller M. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.

JAMA.

2003;290:1868-1874.

 Slide54

6. Barnes P, Powell-Griner E, McFann K, Nahin R. Complementary and alternative medicine use among adults: United States, 2002. Semin Integrative Med. 2004;2:54-71. 7. Astin J. Why Patients use alternative medicine.

JAMA.

1998;279:1548-1553.

8.

Rees L. Integrated medicine: imbues orthodox medicine with the values of complementary medicine.

BMJ.

2001;322:19-120.

9.

Tindle

H, Davis R, Phillips R, Eisenberg D. Trends in use of complementary and alternative medicine by U.S. adults: 1997-2002.

Alt

Ther

Health Med.

2005;11:42-49.

10.

Unutzer

J,

Klap

R, Sturm R, et al. Mental disorders and the use of alternative medicine: results from a national survey.

Am J Psychiatry.

2000;157:1851-1857.Slide55

Note: finish cites11. Unutzer J, et al. [According to the journal’s Web site, the authors of this article are Sparber A and Wootton JC.] Surveys of complementary and alternative medicine: part V. Use of alternative and complementary therapies for psychiatric and neurologic diseases. J Altern Complement Med. 2002;8:93-96. (This cite covers the same territory as the one I suggested but also more recent. Mine was published in Am J. Psychiatry, 2000; Let’s stay with the one you found. J.L.)

12.

Kessler R,

Soukup

J, Davis R, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States.

Am J Psychiatry.

2001;158:289-294.

13.

Eisenberg D, Davis, R,

Ettner

S, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.

JAMA.

1998;280:1569-1575.

14.

Astin

J, Marie A, Pelletier K, et al. A review of the incorporation of complementary and alternative medicine by mainstream physicians.

Arch Intern Med.

1998;158:2303-2310.Slide56

NOTE: finish cites15. Allen J, Schnyer R, Hitt S. The efficacy of acupuncture in the treatment of major depression in women. Psychol Sci. 1998;9:397-401.16. Bradway. The Effects of Healing Touch on Depression, 1997. In: Healing Touch Research Summary, 2003. [need complete reference)

Weze

C

,

Leathard

HL

,

Grange J

,

Tiplady

P

,

Stevens G

. (2007) Healing by Gentle Touch Ameliorates Stress and Other Symptoms in People Suffering with Mental Health Disorders or Psychological Stress.

Evid

Based Complement

Alternat

Med.

4(1):115-123. Slide57

17. Davidson J, Morrison R, Shore J, et al. Homeopathic treatment of depression and anxiety. Alt Therapies. 1997;3:46-49.18. Gaik F. Merging east and west: A preliminary study applying spring forest qigong to depression as an alternative and complementary treatment. Adler School Of Professional Psychology, US Dissertation Abstracts International: Section B: The Sciences & Engineering. Vol 63(12-B) (2003): 6093 Additional Info: US; Univ Microfilms International ISSN: 0419-4217 (Print) English.19.

Kempson

D. Effects of intentional touch on complicated grief of bereaved mothers.

OMEGA.

42:4;341-353, 2000-2001.

20.

Shore A. Long-term effects of energetic healing on symptoms of psychological depression. and self-perceived stress.

Alt Therapies.

2004;10:42-48.Slide58

21. Dixon M, Sweeney K. The Human Effect in Medicine: Theory, Research And Practice. Oxford: Radcliffe Medical Press; 2000.22. Kirsch I, Moore T, Scoboria A, Nicholls S. The emperor’s new drugs: an analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention & Treatment 5:Article 23, 2002. [Could not find this article at this Web address.] Please delete the web address and leave cite as is. J.L.23. Thase M. Antidepressant effects: the suit may be small, but the fabric is real. Prevention & Treatment 5:Article 32, 2002. Available at:

[Could not find this article at this Web address.] Please delete web address and leave cite as is. J.L.Slide59

24. Sussman N. The “file-drawer” effect: assessing efficacy and safety of antidepressants. Prim Psychiatry. 2004 ;11:12. 25. Tangrea J, Adrianza E, Helsel W. Risk factors for the development of placebo adverse reactions in a multicenter clinical trial. Ann Epidemiol. 1994;4:327-331.

26.

Bell I,

Caspi

O, Schwartz G, et al. Integrative medicine and systemic outcomes research.

Arch Intern Med.

2002;162:133-140.

27.

Strogatz

S. Exploring complex networks.

Nature.

2001;410:268-276.

28.

Schuck

J, Chappell T, Kindness G. Causal modeling and alternative medicine.

Alt Therapies.

1997;3:40-47.Slide60

29. Mercier C, King S. A latent variable causal model of the quality of life and community tenure of psychotic patients. Acta Psychiatr Scand. 1994;89:72-77.30. Bland J. New functional medicine paradigm: dysfunctional intercellular communication. Int J Integrative Med. 1999;1:11-16.31. Hankey A. Are we close to a theory of energy medicine?

J

Altern

Complement Med

. 2004;10:83-86.

32.

Chen K. An analytic review of studies on measuring effects of external

Qi

in China. Review Article.

Alt Therapies.

2004;10:38-50.

33.

Zahourek

R. Intentionality forms the matrix of healing: a theory.

Alt Therapies.

2004;10:40-49.

34.

Abbot N. Healing as a therapy for human disease: a systematic review.

J

Altern

Complement Med.

2000;6:159-169.