Basic Principles of Integrative Mental Health Care

Integrative mental health care encompasses the whole person (body, mind,).It emphasizes the therapeutic relationship and makes use of all appropriate therapies, including conventional, alternative, and complementary. Adapted from the definition of integrative medicine byThe Program in Integrative Medicine, University of Arizona.
             
Whether you are a general practitioner, psychiatrist, neurologist, internist, or another medical specialist, a psychologist, nurse, social worker, counselor, physician’s assistant, chiropractor, physical therapist, acupuncturist, mind–body therapist, nutritionist, homeopathic practitioner, dentist, or other health care provider, you already know the basic principles of good clinical practice in your field. We offer a few suggestions regarding how to apply what you know to improve your practice of complementary and alternative medicine (CAM) and to seamlessly integrate it into your work.
             
A study of information-seeking behavior among the health sciences faculty at the University of California, San Francisco concluded that the majority of health professionals are unable to locate the CAM information they need for research, teaching, and practice (Owen & Fang, 2003). While 41% of respondents got useful information from the Web and 40% from journals, 46% relied on their colleagues for advice. Reliable information is the foundation of clinical work. In Appendix B, you will find useful resources for CAM information. In each chapter, you will find treatments that we have found beneficial in clinical practice and in Appendix A information on where to obtain products of good quality.
             
The quality and quantity of scientific information on CAM treatments vary greatly. This can add to the clinician’s uncertainty about using such treatments. In addition to indicating the extent and validity of the scientific research for each treatment, we will put this information in the context of clinical decision making. Keep in mind that a lack of research often has little to do with the potential benefits of a herb and more to do with whether a company would profit enough from sales to offset the costs of doing a double-blind, placebo-controlled study (approximately $500,000 to $2,000,000). Unlike synthetic drugs, patents usually cannot protect the sale of natural herbs, so no single company would profit enough from exclusive sales to pay the cost of research. Many companies obtain patents for herbal combinations with “proprietary blends.” While we prefer to see large-scale controlled studies, these are available for only a few CAM treatments. In most cases, there is preliminary or pilot data. Each clinician must decide how long to wait for positive preliminary results to be validated by further studies before using these treatments.
             
 While most health care professionals agree that double-blind randomized placebo-controlled trials are the gold standard of research, in many cases such studies are no guarantee of efficacy or safety. This may be due to the fact that most studies use carefully selected subjects without comorbid conditions who do not represent the range of patients in clinical practice. Furthermore, few studies run for more than six weeks and therefore yield little information on long-term effects.
             
We have a lower threshold for trying CAM treatments based on preliminary data than for synthetic drugs for several reasons. First, synthetic pharmaceuticals are new to biological systems. Because most CAM treatments have been used by large groups of people of all ages and stages of health for hundreds if not thousands of years, we have much more information about their safety and potential side effects than we could possibly have for drugs that are often tested for six weeks in a carefully selected group of physically healthy subjects. Second, in general, CAM treatments have far fewer and far milder side effects than prescription medications or surgery. The relatively high safety profile of most CAM treatments weighs in favor of trying them even if the scientific research is limited.
             
The context and options are also important in deciding whether to offer complementary treatments. If a patient is suffering and has not responded to standard treatments or cannot tolerate side effects, then it makes sense to offer low-risk alternatives with few adverse effects. The level of evidence for medical treatments is an assessment of the amount and the quality of research available to support the use of each treatment. For example, if there are six well-documented double-blind randomized placebo-controlled studies of a substantial number of patients that all report significant positive benefits, the level of evidence is rated as high. In contrast, if there is only one study or if there are only a few small open, uncontrolled studies, then the level is lower. Rather than dismissing all but those treatments with the highest levels of evidence, we suggest that different clinical situations warrant different levels of evidence for treatment. Here are several scenarios in which the clinician might accept a lower level of evidence in recommending CAM treatments:
 
1.The patient has tried and failed to respond to standard treatments.
2. The patient is unable to tolerate side effects of standard treatments.
3. The patient has a condition for which there is no effective standard treatment.
4. Standard treatments and augmentation strategies partially relieve symptoms, but the patient is             still symptomatic.
5. The patient is taking necessary medications and those medications are causing side effects that             could be alleviated by CAM treatments.
6. The patient wants to reduce or mitigate the effects of risk factors, for example, a family history           of Alzheimer’s disease, a personal history of cigarette smoking, or head trauma.
7. The patient wants to explore the full range of preventive, antiaging, or function-enhancing (e.g.,           cognitive or sexual) options.
8. The patient is in a situation in which there is no access to standard treatments, for example, a             mass disaster or war zone.
9. The patient is uncomfortable with traditional pharmaceuticals and is more comfortable starting             with CAM.
10. The patient cannot afford traditional pharmaceuticals and wants to start with lower cost                     alternatives.
 
It is best to start by focusing on a small number of CAM treatments to develop in-depth knowledge as you gain experience. Clinicians add to their repertoire of CAM treatments over time. As is true in all areas of health care, it is important to know one’s limits and when to refer to other providers in order to do no harm. The same principles of good clinical judgment used in standard practice apply to CAM, including objectively weighing risks versus benefits, evaluating the evidence base for each treatment, flexibility in adapting treatments to the individual patient’s needs, and risk reduction. Along the way you will discover through clinical work which experts provide information that really helps your patients do well. Once you identify such experts, you can attend their lectures or contact them for advice or supervision if needed. Reading their articles can offer an opportunity to dig for diamonds in their reference lists.
 
It is essential to learn how each CAM treatment works. Simplistic tables that say use herb X for symptom Y are of limited use. Knowledge of the underlying mechanisms of action for each treatment allows better understanding of all the ways it may affect the patient, including interactions with medications. Look for CAM lectures and courses sponsored by reputable organizations such as professional societies and academic institutions.
 
The quality of products used in CAM varies greatly. Not knowing which brands are of high quality is a major obstacle for practitioners. Stable supplements that are easy to produce, such as vitamin C, can be purchased from any large reliable company. However, the purity and potency of herbal preparations may depend on where they were grown, when they were harvested, and the specific extraction techniques. Certain nutrients, such as S-adenosylmethionine, are highly unstable and require great care not only in production, but also in the manufacturing and packaging of the tablet. For those supplements that require special attention for processing and manufacturing, we provide a list of products believed to be of good quality in the tables in Appendix A. The intention is to help practitioners identify reliable products that they can begin to use while gaining experience. These lists do not cover all available products. Exclusion from a list does not mean that we have assessed other products to be inferior. In developing the list of quality herbal products, we took into consideration the following sources of information:
 
1. Some companies were asked to supply detailed information about the source of their materials, the methods of extraction and manufacture, documents such as high-pressure liquid chromatography as proof of purity, reports of all tests and clinical studies done on their products, and evidence of testing for shelf life (how long the product retains full potency while sitting on the shelf). If a company was unable or unwilling to supply adequate documentation, they were not included on our list.

2. Specific products that demonstrated efficacy in controlled studies published in peer-reviewed journals were considered of high quality.

3. Information gathered from independent testers such as ConsumerLab and SupplementWatch was also used.

4. Observations over many years of clinical practice provided us with valuable information about the efficacy and tolerability of products.
 
The information about quality products is not intended to promote any company. We have attempted to provide several options in each category. Some companies specialize in combination products tailored to specific clinical problems. In such cases, the choices may be limited to one or two product lines.



Ethical Practices: We recommend avoiding the temptation to profit from the sale of CAM products. Practitioners are often approached by herbal companies offering financial incentives to prescribe or sell their products. One can promote ethical practices by just saying no. Even if you believe that a product is of good quality, as soon as you start to sell it in your office, you are on the slippery slope of allowing money to influence clinical judgment. Although many CAM experts believe in the quality of their name brand products, they have opened the door for conflict of interest to erode trust. However, there are exceptions. For example, some CAM products and medications used in other countries can only be purchased by a licensed physician. In such cases, the physician may have to purchase and resell the product to patients. To prevent any compromise of ethics, we advice selling such products at cost without profit. This may seem a bit austere, but the unconscious is a greedy beast that can subvert clinical judgment. Even when the practitioner’s decision to prescribe a CAM product is not influenced by profit, if the practitioner benefits financially from the sale of that product, the patient’s trust may be undermined by the appearance of a conflict of interest. Accepting customary lecture fees is also within the bounds of ethical practice. It is best to apply the same ethical standards to CAM that you would use with prescription medications.