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The Ecology of Mental Health

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  1. The Ecology of Mental Health scott shannon, md abihm

  2. Agenda • Philosophy • Concerns with psychiatry • Assessment-Treatment format • Depression • Anxiety • Addictions

  3. What is Integrative Psychiatry? It is the ecologically sound care of the whole person: body, mind and spirit*. *mental, emotional, social or spiritual issues may predominate as presenting complaints

  4. Integrative Psychiatry • Ecological in scope • Intuitive in cognitive style • Scientific in framework • Humanistic in approach to the patient • Developmental in concept • Collaborative in practice

  5. Ecological in scope • Person as ecosystem • Interconnected and interdependent • The myth of narrow treatments • Precautionary principle • Homeostasis and stability

  6. Intuitive in style • Intuition vs Logical thought • Pattern recognition • Non-linear and non-algorithmic • Looking for imbalances • Can’t be forced • Mindfullness and receptivity

  7. Scientific in Framework • Use of evidenced based approaches • Safety vs efficacy • The limitations of RCTs • Commercial bias • Level of Risk should determine caution • Power of placebo

  8. Humanistic in approach • Caring • Respectful • Supportive • Inspiration and motivation • Empowerment as crucial concept

  9. Developmental in concept • We grow from one cell, we reach an incredible level of complexity • We are neuro-plastic and ever changing-the cns rewires as we go • Epigenetics can make change last • Integration as frontal lobe capacity • Nutrition, environment, family • Illness? or deficit of nutrient, skill or nurturing

  10. Collaborative in practice • The need to listen and listen some more • Need vs want • Decision making as real partners • Provide choices • “The Empowered Patient”

  11. Psychiatric Disorders • Complex Pattern • Multi-faceted cause • Power of Mind and Spirit • Relational Foundation • Self-correcting Power • Mental/Emotional/Spiritual Homeostasis

  12. Mechanistic Assumptions in Psychiatry • Complex triggers often ignored • Narrow measures of efficacy and success • Assumes isolation of effect • Mind has no effect on brain • Treatment is often narrowly focused • Ignores self-correcting capacity • Assumes static/non-plastic CNS • Ignores epigenetics

  13. The Power of Epigenetics • The Human Genome Project has disappointed • Affected 1 to 2% of psychiatric care at most • Epigenetic changes from diet, trauma, environment, can last years to generations-the Agouti Mice • Swedish farmers and harvest

  14. Challenged Assumptions • Psychiatric illnesses represent fundamental imbalances of brain biochemistry • Our current psychiatric diagnostic system is valid or reliable • Over the long term psychiatric medications are safe and effective treatments • Psychiatric treatments other than psychopharmacology represent second tier options

  15. Low Reliability • Large meta-analysis • 38 studies • 16,000 patients • Low correlation between clinical evaluations and standardized diagnostic interviews (SDIs) • K value: 0.27 overall (poor) Rettew, DC et al Int Methods Psych Res 2009, 18:169-184

  16. STEP-BD Study of Bipolar Relapse • 1,469 patients with Bipolar Disorder • 48.5% relapse within two years • Depression more common than mania • Lamotrigine better than antidepressants • “Recurrence common and highlights the need for more treatment options” Perlis, R, American Journal of Psychiatry 2006, 163:217-24

  17. CATIE Study of Anti-Psychotics • Largest and longest study of its kind • Over 1,400 patients with schizophrenia • 18 months: Tolerability and Efficacy • Efficacy and Tolerability: poor • 74% stopped meds for any reason • Substantial side effects: 64% to 70% • FGA fared as well as Atypicals Stroup, T and McEvoy, J. American Journal of Psychiatry 2006, 163: 600-622.

  18. STAR*D Study of Major Depression • Largest US study of Major Depression. • 3,671 patients over one year. • No medication better than another. • 37% remission after 1 trial, 67% after 4. • Massive drop out rates= 21, 30 and 42% • More than one med= more likely to relapse • “The 67% rate is almost certainly an over estimate of what would happen in the real world” Rush, J, American Journal of Psychiatry 2006, 163:1905-17

  19. Common Themes • Research not sponsored by pharmaceutical industry • Looks at long term results • Designed to mimic clinical practice • Offers much more pessimistic view of meds • Humbles us in psychiatry

  20. Is Psychiatry Evidenced Based? • Does the current clinical practice of psychiatry follow evidence? • The trend towards polypharmacy grows • 13,079 psychiatric visits monitored:1996-2006 • Visits with 2 or more psychiatric medications-increased from 42% to 60% • Very little evidence to support this • 1.2 million children on 2 or more psych meds: even less evidence Mojabai, R Arch Gen Psych 2010; 67: 26-36

  21. Anti-Depressants and Depression Severity • Meta-analysis of RCTs from 1980 to 2009 • Effect size for mild to moderate depression : non-significant • Separation increases as depression severity increases • Reaches significance at HDRS of 25 (very severe= 13% of depressed patients) • Reinforces Kirsch’s prior articles Fournier, JC et al JAMA2010 303 (1): 47-53 Kirsch, I et al PLoS Med 2008 5(2): 45

  22. Kirsch meta-analysis 2008

  23. Publication Bias in Psychiatry 12,564 patients and 74 FDA registered studies reviewed • 31% not published • 94% of published trials positive (51% positive by FDA) • 37 positive published, 1 positive not • Vast majority of unpublished: negative • Compared FDA effect size to published: increase ranged from 11 to 69%, average distortion = 32% Turner, E NEJM 2008, 17;358(3):252-60

  24. Questions Long-Term Efficacy Robert Whitaker-Anatomy of an Epidemic 2010

  25. Safety, Efficacy and the Patient • RCTs highlighted as gold standard, highly scrutinized • Safety appears to be less severely scrutinized • Safety vs Effectiveness: a paradigmatic split----CAM vs Conventional • Patient preference should help to determine direction • True informed consent rarely provided Shannon, Weil, Kaplan Alternative and Complementary Therapies 2011,17 (2):84-91

  26. Depression as a Model • Ecosystem: Environmental, physical, emotional, mental, social, or spiritual triggers • Final common pathway • Lack of core pathophysiology • Very broad assessment needed

  27. Depression—Overview • What is it? What heals it? • Mood disorder spectrum • Current treatment trends • Vulnerability and resilience

  28. The Six Realms • Environmental • Physical • Mental • Emotional • Social • Spiritual

  29. Depression—Holistic Assessment • History (also collateral) • Physical • Mental/Emotional • Spiritual

  30. Depression—History • First onset—age, situation • Chronicity/severity • Response to treatment • History of trauma • Relational history • Specific quality of experience

  31. Assessment: Environmental • Time outside and sunlight • Chaotic settings • Commute • Heavy metals • Pesticides • Air quality

  32. Assessment: Physical • Exercise • Energy/vitality/sexuality • Appetite/diet/food allergy • Weight • Sleep (also rule out sleep apnea) • Physical illness/symptoms

  33. Assessment: Lab • Thyroid: TSH, T3, T4 (antibodies?) • Adrenal: DHEA-s, cortisol pattern • Blood: CBC/ferritin • GI/dysbiosis and elimination diet • Vitamin D level • Cholesterol • High Sens CRP • Homocysteine/MTHFR

  34. Assessment: Emotional • Emotional regulation • Affective expression • History of trauma • Family of origin

  35. Assessment: Mental • Recreational/relaxation • Work • Hobbies • Addictions/patterns • Creative outlet

  36. Assessment: Social • Primary relationships • Family time/play • Family relationships/dynamics • Friends-type and variety • Community connection • Neighbors

  37. Assessment: Spiritual • Worship/path • Prayer • Centering • Love

  38. Depression Treatments: Physical–1Overview • Exercise • Nutrition/oils • Herbs and supplements • Energy medicine • Acupuncture • Somatic • Pharmacology • Hormonal

  39. Depression Treatments: Physical–2Aerobic Exercise: increases BDNF • 15-20 minutes • 4 times per week • Lots of supportive/encouragement needed • Prescribe it • SMILE study: 10 months later 70% response vs. 48%. Relapse 8%v38% Babyak, D Psychosomatic Medicine 2000 (62): 633-38

  40. Depression Treatments: Physical–3Nutrition • High protein • Food allergy concerns • Caffeine free • Low sugar • Omega 3 oils—1,000 mg of EPA/day minimum (EPA/DHA better than flax)

  41. Food Allergy • Colic or reflux as infant • Eczema • Chronic otitis media; lots of anti-bx • Insomnia • IBS or chronic constipation • Mood issues/irritibility • Narrow food interest

  42. Cookbook from the1940’s

  43. EFA and Psychosis • Randomized, placebo controlled, DB 12 wk trial • High risk group (sub-threshold psychosis) 13-25 years old-81 patients • 1.2 gm/d of omega 3 EFA for 12 weeks • Progression to psychosis monitored over next 40 wks. • Active: 4.9% vs 27.5% placebo Amminger, GP et al, Arch Gen Psych 2010 67(2): 146-154

  44. EFA in Pregnancy • Randomized placebo controlled DB trial • EFAs in Pregnancy with MDD • One month washout, 8 week trial • 33 subjects (all female) • 3.4 grams Omega-3 EFAs • Significantly higher response rate (p=.03) and lower HAM-D (p=.001) Su, KP et al, J Clinical Psychiatry, 2008 69(4): 644-51

  45. Depression Treatments: Physical–4Herbs and Supplements • St. John’s Wort (0.3%)—600mg a.m./300mg p.m. (mild to moderate depression) • 5-HTP—50-400 mg/day–sedating • Ginkgo Biloba—80-120 mg BID–stimulating • Tonics (Ginseng/Ginger) • B-6 and B-12- (B complex 50mg best)

  46. Depression Treatments: Physical–5SAMé • S–adenosyl methionine (crucial methyl donor) • Enhances methylation in body • Profound, effective and synergistic antidepressant • Stimulating, works quickly (2 weeks) • Headache, insomnia, nausea • 200-800 mg twice daily, start low, give on empty stomach • Can induce mania