Integrative Psychiatry

Findings of a recent large population survey suggest that 1 in 3 adults in this country (approximately 72 million people) uses 1 or more complementary and alternative medicine (CAM) modalities during any given year.1 Many CAMs are widely regarded as safe on the basis of their established uses in traditional systems of medicine over centuries or longer and their current widespread use in the United States and other Western countries. Unfortunately, there is limited reliable information on potential risks associated with the majority of these approaches.

Acupuncture is associated with an increase in the level of neurobiologically active substances, such as endorphins and enkephalins. There are also data indicating that acupuncture induces the release of norepinephrine, serotonin, and dopamine.

This review provides an overview of the efficacy, safety, and mechanisms of action in the treatment of depression.

Everyone is unique at the level of social, cultural, psychological, biological, and possibly "energetic" functioning. By extension, in every person, the complex causes or meanings of symptoms are uniquely determined. The diversity and complexity of factors that contribute to mental illness often make it difficult to accurately assess the underlying causes of symptoms and to identify treatments that most effectively address them.

Although there is evidence in the research literature from as far back as 40 years showing that the symptoms of attention-deficit/hyperactivity disorder (ADHD) often persist into adulthood, it has been only in the past decade or so that integrative treatment models designed specifically for adult ADHD have been developed.

In part 1 of this column, I reviewed research findings of the most substantiated nonpharmacological and integrative treatments for anxiety, such as kava-kava, L-theanine, applied relaxation, yoga, meditation and mindfulness training, virtual reality graded exposure therapy, and biofeedback training.

Virtual games, such as World of Warcraft, The Sims, and Second Life, are played by thousands every day, allowing people, worldwide, to connect and share information. In fact, the virtual "worlds" that can be created in these games are now being used to make money (through buying and selling virtual objects), to form partnerships and friendships, and even to conduct business; it is easy to see how many become engrossed in this alternative life.

Almost one third of US mental health care costs (approximately $50 billion) go toward the treatment of anxiety disorders. Conventional pharmacological treatments for anxiety are often beneficial but have limited efficacy.

In the first part of this column (Psychiatric Times, February 2007), I reviewed treatments whose beneficial effects are probably achieved through a discrete biological or pharmacological mechanism of action. These included dietary modifications; supplementation with specific vitamins, minerals, and amino acids; and medicinal herbs. In this part, I will review the evidence for approaches that reduce the risk of relapse, diminish craving, or mitigate withdrawal symptoms but for which there is no evidence for direct biological or pharmacological effect.

Dr Stark's article, "Neurotransmitters, Pharmacologic Synergy, and Clinical Strategies" ( Psychiatric Times , October 2006 Special Edition, page 1) offered a refreshing and sober discussion about the difficulties in treating psychiatric illnesses with the therapies that are currently available. The point regarding the error of adopting a "too-narrow focus on imbalanced neurotransmitter levels" without considering the "contributions of other biochemical and physiologic factors to the overall picture" was especially relevant. However, despite the inherent appeal of the holistic model of treatment, the practical adoption of its principles in the treatment of psychiatric patients may remain a guessing game for some time.

Psychiatry is the go-to specialty for determining whether a patient in need of inpatient hospitalization or has an alternative motivation?

Nonconventional and Integrative Treatments of Alcohol and Substance Abuse (Part 1)

Many physicians, including psychiatrists, may shy away from seeing elderly patients with symptoms of dementia because they imagine that there are a large number of alternative diagnoses and that differential diagnosis is complicated. In fact, however, the number of possible diagnoses in most situations is relatively small and the diagnosis of dementia in older patients is certainly feasible in primary care psychiatry.

In 1931, Gananath Sen and Kartick Chandra Bose reported on the use of an alkaloid extract from the Rauwolfia serpentina plant in the treatment of hypertension and "insanity with violent maniacal symptoms." They noted that dosages "of 20 to 30 grains of the powder twice daily produce not only a hypnotic effect but also a reduction of blood pressure and violent symptoms

Depression has long been recognized as a primary concern for health care providers. Many approaches to treating depression have been developed, ranging from medications, to long-term psychotherapy, to shorter, more structured cognitive-behavioral treatments--all of which help some of the patients, some of the time, to some extent.

While social anxiety disorder (SAD) may cause observable signs of anxiety and social awkwardness in some, many others suffer silently. Cognitive-behavioral therapy can be helpful for most patients with SAD, with alternative therapies such as psychodynamic therapy and interpersonal therapy filling the gaps.

The authors discuss gender differences found in patients with schizophrenia. Their group is the first to explore the possibility that gender differences in schizophrenia are mediated by differences in integrative network activity, reflected in a synchronous phase of high frequency (40 Hz) gamma activity.

Patients with Alzheimer's disease may suffer the same age- and disease-related changes to sleep as their age-matched peers. However, as the dementia progresses, even more severe disturbances develop, with impairments in both nighttime sleep continuity and daytime alertness. This article focuses on long-term, holistic approaches to treatment, including environmental and behavioral interventions to augment sleep medications.

Seasonal affective disorder affects 1% to 3% of the North American population. Evidence exists for the efficacy of high-intensity bright, fluorescent light. Pharmacological management with SSRIs has shown equivalent efficacy to light therapy. How can these two therapies be combined? What other therapies are available?

complementary medicine, alternative medicine, acupuncture, and integrative medicine

Obsessive-compulsive disorder is a prevalent, disabling and chronic illness. Serotonin reuptake inhibitors are the first-line of treatment; however a large proportion of patients will have either a partial or nonresponse. This review outlines the strategies for treatment-resistant OCD, including augmentation agents, alternative monotherapies, intravenous strategies and newer nonpharmacologic somatic treatments under development.

Even as data mount in support of rasagiline (Agilect) as an alternative therapy for the motor symptoms of Parkinson disease (PD), additional research on the next generation of dopamine agonists suggests that this class of drugs will not be dispensed with any time soon. Findings presented in April at the annual meeting of the American Academy of Neurology (AAN) linked symptom improvement not only to the monoamine oxidase type B inhibitor but also to several nonergoline agonists, including 2 that target receptors other than D1 and D2 and are delivered transdermally.

Long before the term "neurology" was coined and the brain was wholly mapped and labeled in illustrations by Thomas Willis (English anatomist and physician) in the mid-1600s, healers were trying to understand the cause of headaches and bring relief to sufferers. Willow bark, the "natural aspirin," has been in continual use for headache relief for more than 2000 years by Native Americans and Europeans. Once a contemporary of such therapies as the application of an electric catfish to an aching head (Egypt), and cutting a hole in the skull and inserting a clove of garlic for 15 hours (Arabia), it has withstood the test of time.

The use of alternative treatments--like acupuncture, homeopathy, herbs, dietary supplements--for postpartum depression is becoming widespread. Dr. Hendrick discusses the benefits and risks of these alternative treatments and research that is being done to ensure their safety for new mothers

Literature invites readers to see the world from another viewpoint, which can, in turn, lead to an increased capacity for empathy. In working with difficult-to-treat children, Alexandra Helper, MD, has found that the use of literature that focuses on alternative viewpoints helps such patients develop empathy and improve their functioning in the "real world."

Jose R. Maldonado, M.D., assistant professor of psychiatry and behavioral sciences at Stanford University, was named the 2001 recipient of the Psychiatric Times Teacher of the Year award. The award was presented to Maldonado at the 14th Annual U.S. Psychiatric & Mental Health Congress in honor of his outstanding achievements in and steadfast dedication to psychiatry. For his work with geriatric psychiatry, Dilip V. Jeste, M.D., has been appointed to the endowed Estelle and Edgar Levi Memorial Chair in Aging at University of California, San Diego (UCSD). Jeste is founder and chief of UCSD's division of geriatric psychiatry and Founding President of the International College of Geriatric Psychoneuropharmacology. He focuses his research on schizophrenia and other psychotic disorders in late life and their successful treatment with the use of safer and more effective drug and psychosocial treatments.Helping people of all ages with schizophrenia to reintegrate into society is the focus of the Eli Lilly and Company-sponsored Reintegration Awards. Recognizing both patient advocates and mental health care professionals, these awards provide grants for their recipients' respective reintegration programs. In the Honorary category, the 2001 "Public Eye Recipient" is Elizabeth Baxter, M.D., a Tennessee-based psychiatrist who, while suffering from psychosis herself, is a mental health advocate on the national level. The 2001 Reintegration Awards were also given in the categories of Advocacy (New Jersey Association for Mental Health Agencies Inc. in Manasquan, N.J.), Clinical Medicine (The Whole Person Family Medicine Clinic in Torrance, Calif.), Education (The Guidance Center Supported Education Program in New Rochelle, N.Y.), Housing (Fred Geilfuss, Scott Reithel, Jack Rosenberg in Milwaukee), Occupational (Restoration Project in Acton, Mass.) and Social Support/Rehabilitation (Fountain House in New York City).

Evidence is accumulating that untreated depression can impede comorbid medical treatment and increase mortality. The author reports on the latest research and treatment recommendations for depression that accompanies cardiovascular disease, stroke and Parkinson's disease.

A physician asks, via the Internet, for help in locating a resource to evaluate possible interactions between herbal remedies and Western medications. A Stanford researcher surveys 1,035 randomly selected people and reports that 40% of them have used such alternative health care as chiropractic, acupuncture or homeopathy during the past year (Astin, 1998). A survey of U.S. medical schools indicates nearly two-thirds of those responding (64%) now offer courses that include alternative medicine (Wetzel et al., 1998).

Alternative medicine was the theme of this issue of JAMA and in each of the other nine American Medical Association journals published in November. The editors of these scientific journals made an effort to provide physicians and other health care professionals with clinically relevant, reliable, fresh scientific information on alternative therapies.

There is a substantial constituency for alternative medicine. Worldwide, 70% to 90% of all health care "ranges from self-care according to folk principles, to care given in an organized health care system based on an alternative tradition or practice." As many as one-third of all Americans are reported to have some belief in alternative medicine or to be actively using nonmainstream remedies.