Integrative Medicine in Psychiatry

[drwatson]

As I am a lowly MS III and my interests tilt a little toward CAM and integrative medicine, I was wondering if anyone uses these treatment modalities in their psychiatric practice. I know that Family Medicine is generally the jumping off point for these treatment practices but I was wondering what, if any, of these treatments are utilized in psychiatry. Guided imagery, herbs, etc.

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[Anasazi23]

The use of herbs in most, but not all cases, can be dangerous in psychiatry.

Unless you have empirically-validated treatments, you'll likely suffer on the witness stand should someone hurt themselves or someone else because you didn't follow the psychiatric practice standard of care.

This isn't to say there is no place for it, and there is a large patient population that is looking for this, but it does run that risk.

 

[OldPsychDoc]

There was an earlier thread here re: acupuncture. I worked in one hospital that used it to calm borderlines.

 

[lloyd braun]

I have certainly seen guided imagery in use, and many patients seem to appreciate its effects. Herbs, in addition to the standard psychopharmacology, may be appropriate supplements, though you have to be careful of herb-drug interactions. Furthermore, there is little evidence as to the efficacy of herbal supplements.

 

[nitemagi]

I'm a trained hypnotherapist, and fully plan to integrate that into my psych practice.

 

[whopper]

There's been a lot of things considered integrative that are scientifically backed for psychiatry.

Fish oil has been found to have benefit in treatment of mood and anxiety disorders.

1 g a day is where the maximum benefit has been attained. Higher doses will not yield more benefit.

Also sunlight exposure, excercise, proper sleep hygiene all improve mood disorder.

Studies show a diet free from refined and simple sugars reduces sx of ADHD.

People with an anxiety d.o.--tell them to avoid caffeine or any other stimulant that's not needed.

 

[nitemagi]

Also, Meditation (mindfulness), is a core part of dialectical behavioral therapy, the main psychotherapeutic approach to Borderline Patients.

 

[OldPsychDoc]

What about psychoanalysis?
Some might consider it a bit, um, "integrative"*



*(where integrative carries connotations of unproven, non-empirical, speculative, out-of-the-mainstream...etc.)

 

[littlepurplepil]

What about psychoanalysis?
Some might consider it a bit, um, "integrative"*



*(where integrative carries connotations of unproven, non-empirical, speculative, out-of-the-mainstream...etc.)

Careful who you say that to, OPD...they might smother you with their couch-cushions!

 

[watto]

Also, Meditation (mindfulness), is a core part of dialectical behavioral therapy, the main psychotherapeutic approach to Borderline Patients.

Hear, hear. And there are attempts being made to quantify the effects of mindfulness-based stress reduction in things such as sleep disorders - I know of research going on in this particular area that is being performed by pretty hardcore investigators in sleep in cooperation with the Center for Spirituality and Healing at the U of MN.

And hey, I had the chance to meditate in a group led by Jon Kabat-Zinn this year, and found mindfulness to be a much more rigorous, effective practice than I had previously thought. Don't knock it 'til you try it!

 

[nitemagi]

Nice Watto.

The study I work on is actually studying the effects of MBSR on the immune system of the elderly, while also testing other parallel changes, including mood d/o, and baseline brain wave changes via EEG.

I met Jon Kabat-Zinn once. He's pretty remarkable.

 

[bgabes]

Hi,

I know of a psychiatrist who has an extremely lucrative practice utilizing alot on integrative/CAM techniques. Actually his approach is a mixture of "functional medicine," endocrinology, and nutrition just to name a few. But in any event, he's faculty and actually usually receives award for best lecturer at our school but I know he does extremely well financially utilizing a rather unorthodox approach to psychiatry

 

[DrWuStar]

I'm actually doing a rotation in Integrative Medicine right now, and also went to a conference a couple weeks ago that wasn't specifically related to psych or integrative medicine, but heard a great talk on integrative medicine that focused a lot on psych issues.

My impression at this point is that for disorders like mild depression and anxiety, integrative or "alternative" techniques can be as effective as medication - things ranging from St. Jonh's Wort to guided visualization to relaxation techniques to healing touch to light box therapy. A lot of it is probably placebo, but then, more and more evidence seems to point to SSRIs being largely placebo in mildly depressed patients as well. The mind is a powerful thing.

For more serious mood disorders, there is evidence of some integrative techniques working well as an adjunct to conventional therapies. Omega-3 and vitamin D supplementation have both been shown to augment SSRIs in patients who only partially respond to SSRIs. If I have time, I will try to post some references, since I know there are a lot of nay-sayers out there when it comes to non-pharmaceuticals. In any case, these 2 supplements don't really have any risk associated (obviously, you would monitor vitamin D so pts don't get toxic), so why not try?

St. John's Wort, on the other hand, does have risk associated (P450 interactions affecting levels of other drugs, including OCPs), so one has to be more careful when recommending that. I would use similar caution with any other botanicals since there are so many active compounds in them.

 

[whopper]

Fish oil may also prevent Alzheimer's dementia. This is currently being investigated at Columbia.

as for its benefits in mood disorders...
http://www.ncbi.nlm.nih.gov/sites/entrez

http://abcnews.go.com/WNT/MedicineCuttingEdge/story?id=129498&page=1

Plenty of hits. Overall there are some studies not showing efficacy, but several that do. IMHO its enough to justify suggesting to a patient to consider the use of fish oil as an adjunctve treatment in addition to an FDA approved antidepressant, not a replacement for such, and if you suggest its use, do tell the patient that more research needs to be done. I personally suggest it because many of my patients have problems that fish oil may help such as high blood pressure & hyperlipidemia, and is well tolerated & cheap. If I got the time I also suggest a well balanced diet. I also am mindeful that fish oil is an anti-platelet agent just like SSRIs are. While they are not very strong antiplatelet agents, consider this and consider that patients may be on other anti-platelet/anti-coagulant agents.

Also from the MGH Psychiatry Update & Board Prep book...
One Carbon Cycle Metabolism Abnormalities-S-adenosyl methionine, folate, Vit B12 & homocysteine are linked with depression. High homocysteine, low folate, low Vit B12 & low SAM-E are linked to depression.

I would reccomend against the use of St. John's Wort. For the reasons mentioned above but also becuase it has more side effects than conventional meds & has less efficacy. In fact some studies show no effect at all. Lots of people have an erroneous idea that just because something is "natural" its safer & better. True in some cases, not true in others. This is a case where its not true.

 

[DrWuStar]

Fish oil may also prevent Alzheimer's dementia. This is currently being investigated at Columbia.

as for its benefits in mood disorders...
http://www.ncbi.nlm.nih.gov/sites/entrez

http://abcnews.go.com/WNT/MedicineCuttingEdge/story?id=129498&page=1

Plenty of hits. Overall there are some studies not showing efficacy, but several that do. IMHO its enough to justify suggesting to a patient to consider the use of fish oil as an adjunctve treatment in addition to an FDA approved antidepressant, not a replacement for such, and if you suggest its use, do tell the patient that more research needs to be done. I personally suggest it because many of my patients have problems that fish oil may help such as high blood pressure & hyperlipidemia, and is well tolerated & cheap. If I got the time I also suggest a well balanced diet. I also am mindeful that fish oil is an anti-platelet agent just like SSRIs are. While they are not very strong antiplatelet agents, consider this and consider that patients may be on other anti-platelet/anti-coagulant agents.

Also from the MGH Psychiatry Update & Board Prep book...
One Carbon Cycle Metabolism Abnormalities-S-adenosyl methionine, folate, Vit B12 & homocysteine are linked with depression. High homocysteine, low folate, low Vit B12 & low SAM-E are linked to depression.

I would reccomend against the use of St. John's Wort. For the reasons mentioned above but also becuase it has more side effects than conventional meds & has less efficacy. In fact some studies show no effect at all. Lots of people have an erroneous idea that just because something is "natural" its safer & better. True in some cases, not true in others. This is a case where its not true.

Most studies that show St. John's Wort has not effect were done in more severely depressed patients, and SSRIs weren't effective alone either. In studies of patients with mild to moderate depression, I think the evidence is pretty solid that St. John's Wort is effective. I believe there is a Cochrane review that supports it's efficacy. I'm still hesitant about it though because of the safety issues mentioned above. I seriously wonder how many unplanned pregnancies have been caused by women taking St. John's Wort without realizing it interferes with OCPs.

Also of interest, SAMe can flip people into mania the same way SSRIs can.

 

[sideshow bob]

I graduated from a US west-coast medical school with an MD about 10 years ago - never did internship or residency. I have been practicing Acupuncture and Traditional Chinese Medicine all these years, and am very impressed with the role of acupuncture and herbs in many situations. One of the common things I treat is withdrawal symptoms from anti-depressants. To be clear, I think often anti depressants (SSRIs, etc) are appropriate and effective interventions. But when the patient feels strong enough to stand on their own, the come-down from these medications can be a bitch, with feelings of extreme frustration, rage, insomnia, muscle-tension, etc.
I have found that a combination of acupuncture and chinese herbs can be very helpful in calming down these symptoms, transitioning the patient off of their medications.
To be clear, I have also treated some cases of mild depression with only acupuncture and herbs, often successfully; but some cases have proven too difficult, and I have referred patients to psychiatrists and other MDs to be evaluated, the result often being that the patient is started on medication. This is a good thing.
My pitch would be for complementary roles - clearly medication is warranted in some cases. And just as clearly for me, some patients can make great strides using alternative modalities. In my work, an important part of what I do (or hope that I do) is empower patients to learn coping skills and appropriate methods to learn how to manage their own condition. I am sure that good psychiatrists do this too, whenever they can.

Peace,
Sideshow

 

[Anasazi23]

Do you tell them about alterante nostril breathing?

 

[sideshow bob]

Not sure if that is meant to be serious, (given your posts above) but yeah, I teach breathing techniques in my practice - they can be enormously helpful. I don't teach alternate nostril breathing, like is often done in yoga class during pranayama...But I often have patients get a relaxation CD put together by emmett miller MD - kind of new-agey sounding and maybe a little out of date for that reason, but he includes a "three-part breathing technique" in the four relaxation techniques on the CD - takes just 15 minutes and can be a very useful tool.
Sometimes I think the alternative/complementary techniques I teach and offer my patients are a little like giving someone a free pass to use a really good gym. The potential is enormous, IF the patient actually uses these ideas and techniques, incorporates them into their life. I think acupuncture is actually similar - it offers the patient a whole new way of patterning the way they habitually hold "energy" or qi.But it doesn't DO it for them (the way that an SSRI actually changes brain chemistry) Explains why you can get such enthusiastic supporters of something like acupuncture, and then others will say "It didn't do much for me"
Just some ideas.
Sideshow.

 

[whopper]

IF someone wanted to use complementary/integrative medicine, I got no problem with it so long as the scientific data is spelled out to the patient, & some of these methods need more data. Omega/Essential Fatty Acids, sunlight exposure, excercise, music & art therapy, balanced diets, SAM-E all have data to support it--though in many of these cases more data is needed, and/or their benefits are not as much as FDA approved treatments.

But there's the other aspects of these types of approaches--alternative approaches that have no data backing them up. Some of these for all I know may work, but if it did, it could've been pure placebo effect. Someone in our profession has no business suggesting methods that have no data to back it up. There is an argument (that I support) that such methods should be investigated, but we should not as medical doctors endorse unstudied methods to patient. Research them? Yes, but not endorse them to patients.

As for breathing--there is data backing up the use of controlled breathing to counter effects of stress & anxiety.

 

[Anasazi23]

Not sure if that is meant to be serious, (given your posts above) but yeah, I teach breathing techniques in my practice - they can be enormously helpful. I don't teach alternate nostril breathing, like is often done in yoga class during pranayama...But I often have patients get a relaxation CD put together by emmett miller MD - kind of new-agey sounding and maybe a little out of date for that reason, but he includes a "three-part breathing technique" in the four relaxation techniques on the CD - takes just 15 minutes and can be a very useful tool.
Sometimes I think the alternative/complementary techniques I teach and offer my patients are a little like giving someone a free pass to use a really good gym. The potential is enormous, IF the patient actually uses these ideas and techniques, incorporates them into their life. I think acupuncture is actually similar - it offers the patient a whole new way of patterning the way they habitually hold "energy" or qi.But it doesn't DO it for them (the way that an SSRI actually changes brain chemistry) Explains why you can get such enthusiastic supporters of something like acupuncture, and then others will say "It didn't do much for me"
Just some ideas.
Sideshow.

I was actually being serious. I get on weird kicks sometimes and am looking for ways to steer my dozens of benzo-dependent patients to an alternative way of chilling out.

 

[nitemagi]

I was actually being serious. I get on weird kicks sometimes and am looking for ways to steer my dozens of benzo-dependent patients to an alternative way of chilling out.

I teach relaxation techniques to patients all the time, even in the E.R.
There's a good meta-analysis looking at a bunch of RCT's showing it's equal in efficacy to CBT for anxiety disorders.