James Lake, MD
Clinical Assistant professor, Center for Integrative Medicine, University of Arizona School of Medicine, Chair emeritus, International Network of Integrative Mental Health
Dr. Lake has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: Dr. Lake, please tell us what integrative medicine is. Dr. Lake: In the broadest sense, integrative medicine encompasses methods and research findings from both mainstream biomedicine and the range of so-called complementary and alternative (CAM) specialties including, for example, acupuncture, naturopathic medicine, and homeopathy. Integrative medicine acknowledges the advantages and limitations of the dominant biomedical model while recognizing the strengths and weaknesses of other ways of understanding illness and alleviating suffering. The goal is to find the optimal blend of biomedical and alternative approaches when assessing or treating a particular condition in each unique patient. A core concept in integrative medicine is emphasis on person-centered, rather than treatment-centered, care. Prevention and maintaining optimal wellness are important values of integrative medicine.
TCPR: Why does there seem to be a discrepancy between the integrative mental health model and what seems to be practiced in mainstream psychiatry? Dr. Lake: As practiced in most developed countries today, psychiatry places enormous emphasis on psychopharmacology almost to the exclusion of many other valid therapies. In order to be reimbursed by insurance companies psychiatrists are often limited to brief sessions focused on “managing” medications. Meaningful relationships with patients and important cultural and spiritual issues related to a mental health are seldom explored. It is well known that the pharmaceutical industry strongly influences research priorities and practices in academic medicine and the way psychiatry is practiced in both private and public healthcare settings. In contrast to conventional mental health care, integrative mental health care starts from the perspective of the bio-psychosocial model while honoring spiritual and cultural beliefs and values that influence how mental health problems are experienced by unique patients. This is what we are trained to do and ideally this is how mental health professionals should approach mental illness.
TCPR: But that’s often not the way mental health care is actually practiced, despite the fact that research shows doctors and patients wish it was. Dr. Lake: When you survey physicians about their attitudes and patients about their preferences, both sides consistently remark that they want more opportunities for individualized attention and more time for discussion about values and spiritual beliefs (MacLean CD et al, J Gen Int Med2003;18(1):38–43). Patients frequently use complementary and alternative medicine (CAM) approaches without first disclosing this to their psychiatrists or family physicians because they assume that conventionally trained healthcare providers will have negative attitudes toward CAM therapies or simply dismiss approaches that are not part of the biomedical model. For example, roughly two-thirds of people diagnosed with major depressive disorder use at least one CAM treatment together with a prescription medication yet few disclose this fact to the physician prescribing their medication (Kessler RC et al, Am J Psychiatry 2001;158(2):289–294; Elkins GR et al, J Psychotherapy: Theory, Res, Prac Train 2005;42(2)232–235). This is an important issue because while select natural products have beneficial adjunctive effects when in combination with pharmaceuticals, some natural products may be unsafe when used with prescription drugs.
TCPR: How do psychiatrists and CAM practitioners work together? Dr. Lake: There are growing numbers of integrative clinics with an MD who focuses mainly on prescribing medications, and one or more CAM practitioners who work collaboratively. For example, many integrative clinics or centers employ Chinese medical practitioners who offer patients acupuncture, compound herbal formulas, moxibustion, and energetic massage. Integrative clinics often include energy therapists with training in Reiki or medical qigong. Naturopathic physicians and specialists trained in Western herbal medicine or homeopathy consult with patients before or after the MD sees them. Ideally, clinicians work together to teach patients about appropriate, safe, evidence-based uses of the various CAM modalities when used alone or in combination with conventional pharmaceuticals.
TCPR: Are integrative mental health and CAM approaches being embraced by mainstream organizations like the APA and by payors like insurance companies? Dr. Lake: Within the American Psychiatric Association a strong Caucus on integrative psychiatry has been active for many years. The Caucus convened last May in San Francisco during the APA Annual Meeting and discussed strategic initiatives aimed at bringing the dialog on integrative mental health care into the consciousness of APA members, patients, and the general public. Every year the APA Caucus on Integrative Psychiatry organizes several symposia and courses during the annual APA meeting on a broad range of CAM and integrative approaches in mental health care and these are always very well attended. (Learn more about this group at www.intpsychiatry.com) The International Network of Integrative Mental Health (learn more about this initiative at www.INIMH.org) is a recently formed non-profit organization dedicated to transforming mental health care through training, research, education and advocacy. INIMH and the APA Caucus are starting to collaborate on various projects including educational programs for psychiatrists and planning a major conference on integrative mental health care.
TCPR: What are the differences between Chinese medicine and Western medicine? Dr. Lake: These two systems of medicine approach illness and treatment in essentially different ways, though in my view they are complementary approaches that can be safely used together with benefit. Chinese medicine is one of the most evolved and widely practiced systems of medicine in the world. Increasing numbers of patients with medical and mental health problems see Chinese medical practitioners in addition to their conventionally trained healthcare provider. Chinese medicine’s herbal approaches and acupuncture provide a more graded or gradual way for the body to readjust to internal or external factors underlying illness and achieve a new equilibrium that corresponds to improved health. Research findings suggest that certain Chinese therapies may be more effective for mild to moderate symptoms than severe symptoms (Lake J, Integrative Med2004;3:4). In contrast, the conventional biomedical approach provides a more rapid and dramatic response when more severe symptoms may be difficult to manage adequately using Chinese medical treatments alone.
TCPR: How different are the diagnostic approaches among Eastern and Western medicine? Dr. Lake: Chinese medicine uses an approach called pattern discrimination that has the goal of capturing diagnostically useful information about the energetic status of the individual through history, pulse diagnosis and examination of the eyes and the tongue. Of course in conventional biomedicine we are also trained to take a detailed history, examine the pulse, eyes, tongue, and other parts of the body; however these things are done in the context of a very different conceptual framework founded on different philosophical assumptions about the nature of reality, the body, and by extension the causes and conditions of health and illness. Western physicians check the pulse to make inferences about pathophysiology and the concept of ‘energetic’ balance is completely outside our worldview. It is interesting that different diagnostic approaches used in biomedicine and Chinese medicine may lead to different treatments that effectively address the same medical or mental health problem. The difference is that in Chinese medicine ‘treatment’ of causes or conditions underlying a problem translates into correcting putative energetic imbalances. In contrast, in Western biomedicine ‘treatment’ translates into correcting a presumed underlying physiological dysregulation, in the case of mental health problems, dysregulation at the level of neurotransmitters, the immune system or endocrine system. My view is that both perspectives provide useful, culturally distinct metaphors when trying to understand and alleviate the causes and conditions of suffering.
TCPR: How are complementary medicine and integrative mental health being incorporated into research and what are some of the positive results that have been found? Dr. Lake: The research methodologies used in biomedicine are sometimes quite different than the methodologies used to evaluate particular CAM or integrative approaches. The standard Western research methodology places primacy on randomized placebo-controlled study designs and there is an assumption that pooled data from large studies can be validly generalized to all individuals who have the same ‘disorder.’ As I mentioned earlier, many non-Western systems of medicine, including Chinese medicine and Ayurveda, rest on fundamentally different assumptions about the nature of the body and the causes and conditions of health and illness. These conceptual differences translate into different research methodologies and outcomes. At this point there is no consensus among researchers about the best methodologies to rigorously investigate CAM.
TCPR: One thing about evidence-based medicine is that it offers protocols that we can apply to large numbers of people and have some measurable objective quality outcome measures. But this is in contrast to the whole-person individualized philosophy of integrative medicine, right? Dr. Lake: Yes, one problem you often run into when trying to compare so-called evidence based medicine with methods and outcomes in CAM studies is that the majority of CAM research studies don’t meet the often arbitrary criteria required by Western researchers. In my view the methodologies used in evidence-based medical research are inherently biased against many CAM approaches. This is an important issue because it has resulted in negative judgments by many researchers and conventionally trained healthcare providers about CAM approaches before they are fairly evaluated.
TCPR: Thank you, Dr. Lake.
Dr. Lake is the author or co-author of a number of books on alternative medicine, including Chinese Medical Psychiatry: A Clinical Manual (Blue Poppy Press, 2000), Textbook of Integrative Mental Health Care (Thieme, 2006), Complementary and Alternative Treatments in Mental Health Care(American Psychiatric Press, 2007), and Integrative Mental Health Care: A Therapist’s Handbook(Norton, 2009).