The APA Caucus on Integrative Psychiatry (http://www.intpsychiatry.com) was established in 2004 to represent psychiatrists practicing nonconventional therapies; to educate psychiatrists on safe, appropriate uses of nonconventional modalities; to facilitate complementary and alternative medicine (CAM)-related research; to liaise with allied mental health professionals and CAM practitioners; and to educate psychiatrists on ethical, legal, and regulatory issues that affect the practice of CAM/integrative mental health (IMH).
Several symposia on a range of CAM-related themes have been presented at annual APA meetings. Important accomplishments of the APA Caucus include a subcommittee on omega-3s (2005) that resulted in the publication of a peer-reviewed paper on the evidence for omega-3s in mental health care, and a special Task Force on CAM and mental health (2007) that resulted in publication of a peer-reviewed article that summarized research evidence for select CAM therapies in MDD.
The Consortium on Academic Health Centers for Integrative Medicine (CAHCIM; http://www.imconsortium.org) working group on integrative mental health was founded in March 2009. Membership is currently limited to academic faculty affiliated with Consortium member institutions worldwide, including North America, the European Union, and the Middle East. The major activity of the working group is a bimonthly conference call devoted to strategic planning and expert-hosted discussions on evidence-based integrative management of specific psychiatric disorders.
In 2010, the American Academy of Child and Adolescent Psychiatry (AACAP; http://www.aacap.org) established a committee on CAM and IMH that is concerned with research and education.
The International Network of Integrative Mental Health, Inc (INIMH; http://www.inimh.org) was established in March 2010, and a high-end Web site for mental health professionals was launched in June 2011; membership has been steadily growing. The INIMH is building collaborative relationships with other US and European initiatives to achieve important strategic goals. A 4-day strategic planning meeting was held in April 2011, at which the following priorities were set:
• Facilitating communication and collaboration among the INIMH, CAIM (Caucus on Alternative and Integrative Medicine), AACAP, European initiatives, and other entities on shared goals
• Expanding the network to include worldwide mental health professionals
• Ensuring that Web site includes expert forums, searchable library, world map showing member clinicians by specialty, links to Web-based resources, video library
• Developing curricula and training programs for mental health professionals and postgraduate trainees in medicine and allied mental health degree programs
• Publishing a White Paper establishing IMH as discipline and inviting interdisciplinary dialogue on the future of psychiatry
• Identifying key research priorities and facilitating research agenda at the National Center for Complementary and Alternative Medicine/NIH and at other private and public institutions
The Center for Integrative Psychiatry (www.congressintegratedpsychiatry.com/English/) in Groningen, the Netherlands, is the hub for a national Dutch network of integrative clinicians, including psychiatrists, psychologists, and family physicians. A research program at the Center is conducting studies on mindfulness, heart rate variability, and natural products (eg, inositol). Since 2006, the Center has organized a yearly major international conference on integrative psychiatry.
The European Consortium of Integrative Mental Health Centers (www.ecimh.com) was established in 2009 and shares the broad strategic goals of the INIMH and the CAHCIM working group.
Novel approaches for evaluating and treating serious mental illnesses are being shaped by advances in neuroscience and genetics as well as scientific validation of ancient healing traditions. In the coming decades, complementary and alternative medicine (CAM) will evolve from the use of “herbs and vitamins” to a sophisticated research-driven model of integrative medicine based on individualized treatments that incorporate biological, mind-body, informational, and energy therapies. This multidimensional approach will target complex multifactoral causes of mental illness.
Improvements in the pharmacological management of mental illness and advances in manufacturing and quality assurance of vitamins, herbal supplements, amino acids, and other natural products will result in more effective and safer conventional and alternative treatment choices for psychiatric disorders. Protocols that incorporate validated mind-body and energy therapies will become widely used as preventive and treatment modalities.
Rapid evolution in biomedical psychiatry and CAM
Rapid evolution is taking place in both conventional biomedical psychiatry and CAM. Novel assessment and treatment approaches in biomedical psychiatry will emerge from ongoing advances in the basic neurosciences, functional brain imaging, immunology, and genetics. Future models of mental illness causation will not depend exclusively on empirical verification of strictly biological processes and will postulate both classically described biological and biophysical causes (eg, genetic factors and neurotransmitter dysregulation) as well as nonclassical phenomena (eg, nonlinear brain dynamics and quantum-level processes).
Future studies will use advanced functional imaging technologies to examine the role of complex nonlinear dynamic relationships between neural circuits and the immune system and specific psychiatric disorders. These new technologies will be used to examine the postulated role of quantum “entanglement” associated with large-scale coherent macroscopic quantum field effects in both normal consciousness functioning and psychiatric symptom formation.
Ongoing advances in the neurosciences, psychopharmacology, and brain imaging research will soon yield novel assessment approaches and more effective and safer conventional treatments. Drugs based on novel mechanisms of action and new therapeutic uses of light, weak electrical current, and magnetic fields will provide new treatment modalities. Collectively, these advances will transform the theoretical foundations and clinical therapeutics of contemporary Western mental health care.
A revolution in psychiatric treatment
Novel theories in biomedical psychiatry promise significant advances in understanding the nature and causes of mental illness. For example, nonlinear dynamics (ie, chaos theory) may help explain the complex influences of hormones and neurotransmitters on mood changes during the menstrual cycle as well as social and psychological variables on mood.1 Substantiation of this model by research findings may eventually lead to effective preventive strategies that address hormone-mediated mood disturbances. There is significant emerging evidence that complex interactions between immune function, neurotransmitters, and hormones are important in depressed mood, anxiety, and other mental disorders.2
Improved understanding of genetic factors that mediate mental illness continues to accrue from analysis of the data from the Human Genome Project. Biomedical psychiatric research is increasingly taking into account the significance of genetic and biochemical variability in mental illness. For example, the high degree of individual variability in response to conventional drugs suggests poorly characterized differences in neurotransmitter deficiencies or imbalances associated with MDD, generalized anxiety disorder, and other psychiatric disorders.3
Studies on the effects of neurotransmitter depletion on mood are consistent with the view that changes in brain serotonin or norepinephrine activity levels alone do not fully explain the causes of depressed mood or observed differential responses to antidepressants. These differences are probably related to complex biological and social factors, such as genetic variability (and thus, ethnicity), diet, and culturally determined expectations.
Genetic, cultural, and social variability translates into differences in effective dosing strategies using conventional drugs and commensurate differences in susceptibility to adverse effects.4 The high degree of biological variability may be especially problematic for African or Asian patients and might cause safety issues or poor outcomes.5,6
The AmpliChip CYP450 test, recently introduced by Roche Pharmaceuticals, incorporates 2 DNA amplification and detection technologies that screen for genetic mutations. A polymerase chain reaction is used to amplify or make copies of genetic material followed by high-density microarray technology to capture and scan the amplified DNA. The device will enable physicians to determine when variations or mutations are present in the cytochrome P-450 (CYP450) system. The device provides information about individual differences in prescription drug metabolism. Psychiatrists will be able to routinely order outpatient laboratory tests to determine the most appropriate drugs and dosages for a given patient while minimizing the risk of adverse effects.7
A more open paradigm
Recently published systematic reviews fail to show strong efficacy for widely used conventional pharmacological therapies for common psychiatric disorders such as MDD, bipolar disorder, schizophrenia, and dementia.8-13 In addition to growing concerns about the lack of efficacy, psychopharmacological agents are plagued by serious safety issues. Moreover, concerns about the limitations of contemporary biomedical treatments have been raised by leading figures in academic psychiatry.14
In response to the limitations of conventional care, research and clinical practices are becoming progressively more open to the rigorous examination of novel perspectives. This growing intellectual openness is giving rise to an integrative model of mental health care that draws from the best evidence in both conventional biomedical psychiatry and alternative modalities. Novel theories are being embraced by psychiatry that more adequately explain both normal conscious functioning and the complex factors that contribute to mental illness. These emerging theories are at the heart of a rapidly evolving paradigm called “integrative mental health care.” This will lead to more effective and more compassionate “whole person” mental health care that takes into account the complex biological, psychological, social, cultural, and possibly also spiritual causes and meanings of mental illness.
Important technological innovations that will become more widely used treatments of mental illness in the first half of the 21st century include transcranial magnetic stimulation, electroencephalographic biofeedback, and virtual reality expo-sure therapy (VRET). Biofeedback based on real-time monitoring of galvanic skin resistance and electroencephalography is being used to treat phobias and other anxiety disorders. Emerging findings suggest that biofeedback training based on heart rate variability significantly reduces stress and improves general feelings of emotional well-being in individuals who are subjected to acute job-related stress.15
Cognitive-behavioral therapy (CBT) is effective for a range of anxiety symptoms whether done in conventional outpatient therapy settings or via broadband videoconferencing.16 An effective therapeutic alliance can be achieved between therapist and patient using video-conferencing.17,18 Patients who are chronically anxious, and especially those with panic disorder or agoraphobia, are frequently too impaired by their symptoms to seek professional care. Others are geographically isolated and cannot obtain conventional CBT or pharmacological treatment for severe anxiety syndromes. The rapid growth in broadband Internet access will result in widespread use of biofeedback techniques by patients with portable devices based on existing computer technology.
Broadband videoconferencing using Internet technology is a cost-effective alternative mode of treatment delivery to homebound patients. Videoconferencing allows the therapist to demonstrate behavioral exercises for the patient, and both the therapist and the patient are able to accurately observe nonverbal behaviors.
Controlled studies confirm that VRET is more effective than conventional imaginal exposure therapy and is comparable to in vivo exposure therapy for some anxiety disorders.19,20 Many VRET tools are available that allow patients to use computer-based advanced exposure protocols through real-time videoconferencing anywhere high-speed Internet access is available.21
Within the next few decades, treatment of phobias, panic attacks, and other severe anxiety disorders will combine VRET with biofeedback, CBT, or mind-body practices. Broadband Internet connections will allow real-time interactions between patients and therapists in separate settings.
An evolving trend is the increased use of synergistic combinations of synthetic drugs and select natural products.22 Greater antidepressant efficacy has been shown when antidepressants are combined with SAMe, folic acid, l-tryptophan, or omega-3 fatty acids.22 Sarris and colleagues23 showed that efficacy is increased when N-acetylcysteine, magnesium, folic acid, or amino acids are combined with conventional mood stabilizers in patients with bipolar disorder. The use of natural products, including nutrients or botanicals, in combination with pharmacotherapeutic agents holds the potential for improving outcomes while reducing adverse effects by permitting reductions in effective doses of psychotropics and commensurate reduction of adverse-effect risks.
Novel assessment approaches
Some assessment approaches rely on the accurate characterization of classically described biological, energetic, or informational processes that constitute the presumed causes of a particular symptom or symptom pattern. A more complete and accurate assessment may require a combination of techniques used in biomedicine and nonallopathic systems of medicine.
All living organisms emit ultraweak photons, and under certain conditions, such biophotons are emitted as highly ordered or “coherent” light.24,25 Research on biophoton emissions released from the human body has led to speculation about “light channels” that regulate energy and information transfer within the body, biological rhythms associated with the intensity and patterns of biophoton emissions, and diseases related to energetic “asymmetries” between the left and right sides of the body.26,27 Studies on biophoton emissions associated with acupoints suggest that subtle differences in count, wavelength, and coherence may correspond to energetic “imbalances” in yin and yang associated with neurological and psychiatric disorders.28
Future research studies of nonallopathic assessment approaches will validate some as clinically useful in mental health care, while others will become marginalized. The increasing use of novel assessment approaches in clinical psychiatry will gradually lead to more comprehensive and more cost-effective treatment planning. Promising emerging approaches in psychiatric assessment include use of the following:
• Urine and blood testing to reveal dysregulation at the level of neurotransmitters and immune factors associated with mental illness
• Quantitative electroencephalography (QEEG) to quantify differences in brain electrical activity for clarifying psychiatric diagnosis and predicting treatment response
• Microarray chips to analyze genetic differences in drug metabolism associated with individual differences in the CYP450 system
• Advanced semiconductor devices to measure ultraweak biophotons that provide clinically useful indicators of neurochemical and energetic causes of mental illness
• Pulse diagnosis as used in Chinese medicine, Ayurveda, and Tibetan medicine and scientific studies to validate energy assessment in the context of novel paradigms in physics (eg, quantum mechanics and quantum field theory)
Complex systems theory
Complex systems theory invites an increasingly integrative perspective in the social sciences, biology, and medicine. Complex systems theory argues that dynamic nonlinear energetic or informational states at multiple levels in the brain and body manifest as symptoms.29 This view implies that although a particular symptom may have an apparent primary or discrete cause, complex dynamic cause(s) can vary with each person’s unique biochemical, genetic, social, psychological, and energetic makeup. In contrast to the orthodox view, many traditional healing systems conceptualize illness, health, and healing in terms of subtle nonlinear processes at multiple hierarchical levels of body-mind-spirit within each unique human being and between humans and their environments.
Changing understandings of “energy” and future mental health care
Disparate systems of medicine postulate the existence and involvement of different forms of energy and information in health, illness, and healing. In biomedical psychiatry, classically described forms of energy are used as probes to provide information about brain activity associated with symptoms. Normal brain functioning is characterized by complex biomagnetic and electrical activity that is measured using functional brain imaging techniques (eg, positron emission tomography, single photon emission CT, functional MRI, magneto-/electroencephalography, and QEEG.
Advances in functional brain imaging permit studies on discrete neurotransmitter/receptor systems underlying normal conscious functioning as well as on neural and molecular processes involved in the pathogenesis of specific psychiatric disorders. This results in improved diagnostic accuracy of neurological and psychiatric disorders with commensurate improvements in the efficacy of treatments that target discrete neurotransmitter systems and neural circuits.30
Emerging evidence suggests that consistent relationships exist between specific patterns of electrical brain activity and discrete psychiatric disorders.31,32 However, it is often difficult to determine whether energetic abnormalities in the CNS are causes or effects of pathology. Electrical currents and pulsed electromagnetic fields are established conventional treatments in contemporary biomedical psychiatry. They probably have real-time effects on the biomagnetic properties of brain functioning as well as long-term effects on neurochemical and biomagnetic changes in the activity of brain circuits associated with the regulation of affect, cognition, and behavior.33
As with many therapies in biomedical psychiatry, select alternative treatments also use well-described forms of energy, such as electromagnetism and sound. Treatment approaches based on such classically described forms of energy and information may have specific or general beneficial effects at the level of neurotransmitter systems or brain circuits. In contrast, alternative therapies based on postulated nonclassical kinds of energy or information, including quantum mechanics and quantum field theory, may have both direct and subtle effects on brain function and mental health. Nonconventional modalities based on concepts that are presently outside the tenets of biomedicine include acupuncture, homeopathic remedies, Healing Touch, qigong, and Reiki. Ancient healing traditions and accumulating modern research suggest that prayer and other forms of directed intention may help alleviate symptoms of physical and mental illness. This is the domain of energy medicine.34
Novel ideas of energy and information are coming from recent theoretical developments in quantum physics. A fundamentally new direction in our understanding of consciousness—and by extension the causes of mental illness—comes from an emerging theory that regards brain functioning from the perspective of quantum mechanics and quantum field theory.35,36 Quantum brain dynamics attempts to explain subtle characteristics of brain functioning in terms of nonclassical forms of energy and information.37 Quantum brain dynamics may eventually help explain reports of therapeutic benefits achieved through nonlocal interactions between the consciousness of the clinician and that of the patient.38,39
Quantum brain dynamics is an example of a nonclassical model that invokes quantum field theory to explain certain dynamic characteristics of brain functioning that may include the influences of nonclassical forms of energy or information on mental health. It has been suggested that healing intention operates through nonlocal subtle energetic interactions between the consciousness of the clinician and the physical body or consciousness of the patient.40 In contrast, energy psychology assumes that highly developed energetic techniques (eg, acupuncture, acupressure, Healing Touch) are required to effect energetic balance and health. Mind energetics is a recently introduced conceptual model that postulates the exchange of energy through language and intention during therapeutic encounters, and it claims that energy transforms psychological defenses in beneficial ways.41 Research in these emerging paradigms will eventually yield testable hypotheses about the role of intention in health and healing and will help clarify therapeutic mechanisms associated with spiritual and mind-body practices, including meditation, yoga, prayer, and energy medicine.
Looking to the future
There are strong indications that in the coming decade mental health care will emerge as a more inclusive and more open paradigm in response to research advances in both conventional biomedicine and CAM. Congressionally mandated reforms will progressively restrict the influence of the pharmaceutical industry on research priorities in both academic psychiatry and the private sector. Quality manufacturers of select CAM modalities will become established players in an increasingly diversified health care marketplace in which private insurance and Medicare will cover select alternative therapies that will have parity with conventional biomedical treatments. Government, industry, and academic research centers will work in a more coordinated fashion to develop systematic research programs that will result in more effective and more cost-effective treatment choices. In parallel with these trends, increased collaboration between researchers and clinicians on a global scale will accelerate evolution toward integrative mental health care.
By mid-century a new paradigm will be solidly in place. New ways of thinking about and practicing medicine will lead to novel explanatory models of mental illness causation and a broad range of effective and safe clinical therapeutics in mental health care. Biomedical theory will be informed by complexity theory, by novel theories in physics and information science, and by accumulating research findings from the basic sciences and consciousness research. There will no longer be a rigid dichotomy between biomedicine and CAM.
Advances in the genetics and neurobiology of mental illness will yield more specific, more effective, and more individualized pharmacological, genetic, and energetic therapies. Ongoing advances in functional brain imaging will permit studies on postulated roles of magnetic fields, biophotons, and macroscopic highly coherent quantum field effects on normal brain functioning and mental illness. In this century, medicine will continue to evolve at an accelerating pace. Select biomedical and CAM modalities will be strongly validated by unequivocal findings, while others will be relegated to interesting historical footnotes because of safety concerns or lack of efficacy.
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