Monday, February 13, 2012

Can Integrative Psychiatry Save Psychiatry?

Integrative psychiatry involves incorporating complementary and alternative medicine (CAM) into clinical practice. I first came across the term in mid-2003 at a two-day conference, “Non-Pharmaceutical Approaches to Mental Disorders” staged in Pasadena by the nonprofit organization, Safe Harbor.

Two weeks earlier, I had attended the six-day American Psychiatric Association annual meeting in San Francisco. The main event there was Pharma-driven psychiatry, but the brain science on display signaled a new paradigm in the making. Only one session (to my knowledge) involved vitamins and supplements. This wasn’t going to change.

So, here we are, nearly nine years later. Psychiatry is facing a major identity crisis and Safe Harbor keeps soldiering on. Safe Harbor was founded by businessman Dan Stradford, who lost the dad he knew to mental illness. Medical treatment failed to return his father, at least the father he knew. There had to be a better way,

Several months after the conference - I ran into Dan at a NAMI national convention in Cincinnati. I was outside, taking a break, enjoying the sun. I greeted Dan walking past, and he sat down beside me. It looked like he needed a break, as well. One of the loneliest feelings in the world is being outside of your time zone when exhaustion overtakes you. I think Dan was having one of those moments.

In vulnerability lies strength.

Safe Harbor just released the 108-page “The Flying Publisher Guide to Complementary and Alternative Treatments in Psychiatry,” available as a free download. Dan is one of the four authors. The document gives a good run-down on lifestyle, nutrition, mindfulness, and other things we need to consider incorporating into our recovery. Of particular interest is a chapter co-authored by Hyla Cass (pictured here) entitled, “The Integrative Psychiatrist.”

Dr Cass is another person I met at the Safe Harbor conference. A former assistant professor at UCLA, she now runs her own private practice, appears regularly in the media, and markets her own line of supplements. Yes, this raises the same kind of concerns as MDs financially linked to Pharma, but let’s focus on what she says:

“During my residency at Cedars-Sinai/UCLA Medical Center,” she writes, “I eventually found that the standard ‘couch and Prozac’ combination of psychoanalytic and pharmacological treatments had their limitations.” This would lead her down the path of nutrition and lifestyle. Depressive or anxious or other symptoms, she found, could be related to such things as low blood sugar. viral and fungal infections, hormonal imbalances, allergies, toxins, and specific nutrient deficiencies.

The no-brainer approach to this is a generous order of lab tests. Dr Cass cites one instance of a 55-year-old woman arriving at her practice being treated for numerous physical complaints by her internist and depression and anxiety and insomnia by her psychiatrist. A lab test revealed a magnesium deficiency.

Dr Cass’ exams include a standard range of screenings that measure for anemia, thyroid, cholesterol, and so on. In addition, depending on the patient’s symptoms and information she has gathered, she will order additional labs that measure for nutritional deficiencies, toxic minerals, and allergies.

Every patient fills out an inventory checking for stress, depression, anxiety, and sleep, plus a far more involved questionnaire that screens for symptoms that suggest issues with lifestyle, brain chemistry, thyroid function, adrenal function, blood sugar, digestive imbalances, toxin overload, headaches, arthritis, and osteoporosis, plus men-only and women-only problems.

In addition, Dr Cass screens for personal and family histories. According to Dr Cass:

From the patient information, physical assessment, and labs, a picture begins to emerge. While the client could be primarily suffering from stress, where lifestyle changes or counseling would be in order, more often I find physical issues - commonly a number of them - impacting behavior, emotions, and cognitive function.

When these issues can be pinned down (such as hormonal imbalances) the solutions may present themselves. Various specific nutritional remedies tend to be her first choice, her credo being: “Apply a continuum of treatments, always beginning with the safest, most natural, and most benign.” Medications as needed are also part of her toolbox. Hence the “integrative” in integrative psychiatry.

In essence, what do we make of a depressed individual with a vitamin B deficiency? Is it depression? Or is the vitamin B deficiency the real issue? These are the very same type of questions brain scientists are asking, namely what is really going on? Sensitivity to certain substances? A glitch in the wiring? How about what is going on in the person’s life right now? How about family? On and on.

Our new understanding is screaming for new diagnostics. The kind of lab screens and surveys that Dr Cass employs, but also the type of gene scans and qEEGs that are coming on the scene. And - always, always, always - sitting down and listening to the patient. High tech with human touch. Integrative psychiatry - we are long overdue.


Anonymous said...

Minus the vitamins, I don't know if I'd consider what Dr. Cass does with her patients is complimentary. Ruling out physical causes sounds like something every doctor should do.

Unfortunately, this rarely happens. Primary care providers often see psych symptoms as merely psych symptoms and will prescribe a drug and/or shuffle you off to a psychiatrist (assuming you have access to one). The psychiatrist, who may work for an under-staffed and poorly-funded community mental health clinic, or perhaps a group practice where a quota needs to be met (Yes, I know of group practices that keep tabs on clients seen and sessions billed and have a "ranking system") and has a short amount of time to ask generic questions and prescribe a medication. For some, this system works fine. For others, not so much.

I've been left with the impression that many psychiatrists would prefer to spend more time with people - therapy, the opportunity to rule out physical causes, and do thorough medication reviews. I suspect massive student loans, the need for health insurance, providing for a family, and not feeling confident in the ability to run a private practice are some reasons that prevent psychiatrists from getting out of the 15 minute med review rut. I found out through the grapevine that my first psychiatrist saw around 32 people a day. (He somehow remembered me - he either kept thorough notes, had an amazing memory, or I left quite an impression) He ended up leaving the country for a different job.

Yeah, I don't doubt there are doctors who are content with short med reviews. Everyone has their interests and their strengths. But I do find it unfortunate that there are people out there who find they're perhaps not helping people as much as they thought they would when they did their residencies.

John McManamy said...

Great comments, Anonymous. I think this sums it up.