An integrative integrative psychiatrist provides practical guidance for incorporating complementary and alternative medicine into psychiatric practice in the treatment of severe mental illness.
Asian healing traditions are emerging as increasingly accepted alternative approaches to diagnosis and treatment in the US and other Western countries, while biomedicine is becoming increasingly used in Asia. The confluence of disparate modalities in both Western countries and Asia presents complex problems and opportunities. What are the limitations and advantages of biomedicine and Asian medicine in mental health care? An integrative integrative psychiatrist provides practical guidance for incorporating complementary and alternative medicine (CAM) into traditional medicine in the treatment of severe mental illness.
Conventional biomedicine is appropriate and often necessary for the treatment of severe mental illness. In cases of threatened suicide or homicide, safety is paramount and it is imperative that the patient receive urgent attention at the nearest emergency department or urgent care facility. Biomedical psychiatry contends that mental illness can sometimes be explained by dysregulation of neurochemical processes and expands the medical paradigm to take into account the influences of culture and religion on symptoms. Asian systems of medicine such as traditional Chinese medicine (TCM), Ayurveda, and Tibetan medicine, rest on fundamentally different assumptions about the nature of the human body; the role of consciousness in healing; and the influences of biological, psychological, or postulated “energetic” factors on health and illness.
When symptoms are not severe or life-threatening, the first step in determining which treatment to recommend-biomedical, Asian, or other CAM modalities-is a thorough review of the evidence on efficacy and safety. In cases research findings show equivalent safety and efficacy, cost and patient preference play an important role in decision-making. After decades of widespread use of traditional Chinese medicine in Western countries, there is still a paucity of reliable information about which herbal formulations and prescription medications can be safely combined. Chinese medical practitioners and Western trained providers acknowledge the risks associated with combining Chinese herbal formulas and prescription medications, and the need for carefully weighing risks and benefits of a combined regimen on a case by case basis. For example, ma huang (which contains ephedrine) taken with antidepressants or blood pressure medications can have serious, potentially fatal consequences. Even less is known about potential risks of combining prescription medications with herbal treatments used in other Asian healing traditions, including Ayurveda, Tibetan medicine, and Japanese traditional medicine (Kampo).
In cases where there is comparable evidence for a particular Asian medical treatment and a particular biomedical treatment, the former often represents a more holistic first treatment choice. Biomedical treatments are generally more costly and are frequently associated with a greater risk of potentially serious adverse effects. Many widely used Asian medical modalities and CAM therapies are likewise limited by efficacy and safety problems, availability, and cost issues. Integrative medicine is emerging in response to the limitations of biomedicine and CAM. This new paradigm utilizes evidence-based interventions while emphasizing person-centered care and actively engaging each patient in the process of changing his or her lifestyle to achieve improved health.
Because pharmacologic treatments are generally more potent and in most cases work faster, it is appropriate to initially recommend prescription medications to patients who have severe psychiatric symptoms. When a patient reports symptoms and a history that suggest a severe, chronic, or life-threatening illness, it is appropriate to refer the patient for urgent medical evaluation by a conventionally trained Western physician. When the patient does not respond to conventional treatment response or reports severe adverse effects, he or she may benefit from a referral to a CAM practitioner for further evaluation and consideration of appropriate CAM treatment options. Any questions regarding prescription medications should be referred to the patient’s physician. By the same token, questions that pertain to Asian herbal formulations or other CAM treatments should be referred to the patient’s CAM practitioner.
With a poor treatment response to either biomedicine or Asian medicine, consultation between the Asian medical practitioner and the biomedical practitioner is warranted to explore promising diagnostic and treatment directions that have not previously been tried. Integrative medicine takes into account the strengths and limitations of all systems of medicine in the context of each patient’s unique needs and preferences. The result is an evidence-based plan centered on a biomedical treatment, Asian medicine, or a particular combination of biomedical and CAM modalities. Depending on the case, it may be both reasonable and prudent to recommend a particular Asian medical treatment that is established as safe and effective for a particular mental health problem-assuming the patient is not impaired by severe psychiatric symptoms or at risk for suicide.
When recommending any treatment strategy that is not supported by solid evidence in the peer-reviewed medical literature, it is important to obtain informed consent from the patient and to carefully document this in the chart. Patients should know the risks and benefits of any treatment before starting any new Asian, biomedical, or combined treatment regimen. Nondisclosure of pertinent safety information pertaining to treatment has many potential risks, including misdiagnosis, inappropriate treatment, and adverse effects or toxic interactions.
For more on this topic, see Integrating Biomedicine and Asian Medicine: Challenges and Opportunities, on which this slideshow is based.