Advances in Integrative Medicine 2 (2015) 12

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Advances in Integrative Medicine

journal homepage: www.elsevier.com/locate/aimed

Editorial

Integrative mental health in 2015

Keywords:
Integrative mental health
Mindfulness
EMDR

In the US, The National Institute of Mental Health lists the

prevalence of mental illness among adults as 18.6% and for serious
mental Illness (SMI) at 4.1% [1]. Unfortunately, as with the
prevalence for heart disease, diabetes, and cancer, other countries
are catching up with the States, with the WHO identifying similar
or at times higher prevalence of mental health conditions
worldwide [2]. These disorders, particularly SMI, are at a high
personal and societal cost. Current treatments are lacking with
limited benet over placebo or control interventions [3,4]. We
know that theres a serious problem and traditional approaches
have signicant limitations. Will efforts in integrative mental
health ll this void? A full discussion on this topic, from leaders of
the International Network of Integrative Mental Health (INIMH),
is published in the Advances in Integrative Medicine as a White
Paper [5].
Why do patients seek out complementary and integrative
therapies? Some individuals have a holistic health orientation and
are motivated to seek out self-management strategies consistent
with their beliefs. Many more, it seems, seek treatment because
they are experiencing a disabling condition for which they have not
been able to nd appropriate relief through traditional approaches.
What do we bring to the mix that can help our patients?
Even before we put on our integrative hats, we have an
advantage. People who go into this eld are likely to practice selfcare, hopefully serving as a model for our patients. I have fond
memories of a heartfelt speech that my father, the scoutmaster,
gave to my Cub Scout troop about the evils of smoking. It might
have carried more weight had he not had a lit cigarette in his hand
at the time. Additionally, we have qualities that allow us to connect
with patients, convey optimism, and motivate change, even if its
only a change of perspective. In a reductionist model, these nonspecic factors are considered a pesky placebo effect, as opposed to
an essential part of the relationship that facilitates healing.
We can think of a holistic approach as involving a 3-legged
stool, with the legs being mind-body practice, exercise, and diet.
Mindfulness has received wide exposure in the media and has
come into our common parlance. Consequently, discussions with
http://dx.doi.org/10.1016/j.aimed.2015.02.002
2212-9588/ 2015 Elsevier Ltd. All rights reserved.

patients about meditation and mind-body approaches are less

likely to elicit blank stares or the accusation of being woo woo. As
with our colleagues in primary care medicine, we devote effort to
help patients step up their aerobic activity level and clean up their
diets. Using the Stages of Change model offers us a greater chance
of successfully engaging our patients [68]. This model works
especially well for what may be a 4th leg of our stool, helping
individuals affected by substance use disorders.
Each practitioner has his own toolkit. Hopefully, were not the
person with only a hammer. By the nature of our training, some
will be oriented to psychotherapeutic modalities. Increasingly,
approaches that incorporate a mind-body perspective are being
used in clinical practice and tested in a research setting. Among
these are: mindfulness-based cognitive therapy, dialectical behavioral therapy, and cardiac coherence training utilizing heart rate
variability biofeedback. A novel intervention was developed by a
group from the University of Calgary, showing dramatic reductions
in depressive symptoms with a program oriented to spirituality
[9]. Modules focus on areas such as connectedness, self-acceptance, compassion, and gratitude. While this program was
provided remotely through a web-based program, many holistic
practitioners incorporate these principles into their work with
clients.
For those in naturopathic medicine as well as traditionally
trained physicians and psychiatrists, there are things on the
biomedical horizons. Because of our openness to new ideas,
integrative practitioners may be the bellwethers for ideas that nd
their way into more traditional practice. Before Integrative
Medicine existed as a eld, there were isolated reports of
antibiotics being used to treat peptic ulcer disease. This was
dismissed as heretical, as before the discovery of H. Pylori, we
knew that nothing can survive in the acidic milieu of the
stomach. Abnormalities of folate metabolism and methylation in
general are a subject of study, with much interest in Methyltetrahydrofolate Reductase (MTHFR) polymorhisms [10]. CatehcholO-methyl Transferase (COMT) is another enzymatic pathway tied
in with mental health and general health problems. Single

Editorial / Advances in Integrative Medicine 2 (2015) 12

nucleotide polymorphisms (SNPs) may partially explain the

overlap seen between chronic pain and mental health conditions
[11,12]. Our traditionally oriented colleagues are watching the
literature on SNPs, but we may be 10 years away from EvidenceBased Medicine (EBM) pointing to specic treatments. We can use
our knowledge of cell metabolism and biochemical pathways
to point to nutritional treatments that may impact on the
manifestations of these SNPs [13,14]. The Institute for Functional
Medicine provides a nice model, which extends readily to
individuals experiencing mental health difculties https://www.
functionalmedicine.org/.
Our colleagues in Traditional Chinese Medicine, Ayurveda, and
Naturopathic Medicine have comfort and experience with the use
of dietary approaches, supplements, and herbal agents for the
treatment of mental health disorders. This body of knowledge is
slowly making its way into our journals with better designed
studies. Limitations include paucity of funding support, inherent
challenges with natural product research, and issues around the
complexity of studying multi-modal treatments. EBM favors
randomized placebo-controlled clinical trials (RCTs), typically of
the format: agent A vs. placebo for condition B. This bears little
resemblance to clinical practice, in which our patients are diverse
with comorbidities and our treatments often include a complex
mix of diet and lifestyle changes, mind-body interventions,
supplements, and possibly pharmacologics. One of the challenges
we face as an academic eld is coming up with the models for
testing complex interventions in a pragmatic fashion that will
highlight the salient benets of these treatments singly and in
combination [15,16].
An issue facing the mental health community is how to bridge
the gap between services available in Westernized countries vs.
areas with greater poverty, limitations to health care, and issues
such as wars, terrorism, natural disasters, and refugees. This
presents an opportunity for integrative approaches. Many developing countries have culturally based systems of healing, which
can be enhanced to make services more widely available. Under
the leadership of James Lake, MD, INIMH conducted its 1st
international educational mission trip to Cuba, providing collaborative education for both Cuban and the international team of
professionals. The easing of tensions between the US and Cuba may
allow for a follow-up conference to take place. We hope to lead a
future program in Nepal, to help widen knowledge of the
Traditional Tibetan Medicine system as it applies to mental health
issues. Eye Movement Desensitization and Reprocessing is a
psychotherapy modality found to be quite effective in the
treatment of post-traumatic stress disorders [17]. In the States,
EMDR Humanitarian Assistance Program has been providing low
cost training for psychotherapists from the non-prot and public
sectors [18]. They have responded to international crises and are
exploring expanding their mission to venues overseas. Medecins
Sans Frontie`res http://www.msf.org/has led the way for providing
assistance to individuals suffering from the effects or wars and
natural disasters has been. They literally put themselves in the line
of re.
Understandably, Integrative Medicine and Health has generated skepticism and at times antagonism from our allopathic
colleagues. More recently, there has been greater acceptance.
There are 61 academic health centers in North America that
comprise the Consortium of Academic Health Centers for Integrative Medicine, suggesting that we are no longer on the fringes
http://www.imconsortium.org/. The International Network of
Integrative Mental Health is a growing organization, which

provides collegial support, education, and mentorship through

web-based and other programming http://www.inimh.org. Under
the leadership of Rogier Hoenders, MD, PhD, the Netherlands hosts
a biannual Conference on Integrative Psychiatry, the last attended
by 600 psychiatrists. This years conference took place in March
2015 http://www.congresintegralepsychiatrie.nl/english/. Educational programs, such as at Saybrook University http://www.
saybrook.edu, are being developed to provide formal education in
an integrative model of care. Speaking collectively for practitioners
of integrative mental health, were not yet mainstream, but there is
an increasing chorus of young energetic people interested in
incorporating these approaches.
References
[1] Substance Abuse and Mental Health Services Administration. Results from the
2012 National Survey on Drug Use and Health: Mental Health Findings,
NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD:
Substance Abuse and Mental Health Services Administration; 2013.
[2] Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, et al. The
global burden of mental disorders: an update from the WHO World Mental
Health (WMH) surveys. Epidemiol Psichiatr Soc 2009;18:2333.
[3] Khan A, Faucett J, Lichtenberg P, Kirsch I, Brown WA. A systematic review of
comparative efcacy of treatments and controls for depression. PLoS ONE
2012;7:e41778.
[4] Kirsch I. Antidepressants and the placebo response. Epidemiol Psichiatr Soc
2009;18:31822.
[5] Sarris J, Glick R, Hoenders R, Duffy J, Lake J. Integrative mental healthcare
White Paper: establishing a new paradigm through research, education, and
clinical guidelines. Adv Integr Med 2014;1:916.
[6] Kong W, Langlois MF, Kamga-Ngande C, Gagnon C, Brown C, Baillargeon JP.
Predictors of success to weight-loss intervention program in individuals at
high risk for type 2 diabetes. Diabetes Res Clin Pract 2010;90:14753.
[7] Paschal AM, Lewis-Moss RK, Sly J, White BJ. Addressing health disparities
among African Americans: using the stages of change model to document
attitudes and decisions about nutrition and physical activity. J Community
Health 2010;35:107.
[8] Werch CE, Ames S, Moore MJ, Thombs D, Hart A. Health behavior insights: the
transtheoretical/stages of change model: Carlo C. DiClemente, PhD. Health
Promot Pract 2009;10:418.
[9] Rickhi B, Moritz S, Reesal R, Xu TJ, Paccagnan P, Urbanska B, et al. A spirituality
teaching program for depression: a randomized controlled trial. Int J Psychiatry Med 2011;42:31529.
[10] Nazki FH, Sameer AS, Ganaie BA. Folate: metabolism, genes, polymorphisms
and the associated diseases. Gene 2014;533:1120.
[11] Tammimaki A, Mannisto PT. Catechol-O-methyltransferase gene polymorphism and chronic human pain: a systematic review and meta-analysis.
Pharmacogenet Genomics 2012;22:67391.
[12] Witte AV, Floel A. Effects of COMT polymorphisms on brain function and
behavior in health and disease. Brain Res Bull 2012;88:41828.
[13] Morledge TJ. Introduction to Integrative Medicine. Cleveland Clinic Center for
Continuing Education; 2015.
[14] Lynch B. MTHFR.Net; 2015.
[15] Bland J. Does complementary and alternative medicine represent only placebo
therapies? Altern Ther Health Med 2008;14:168.
[16] Braun MM. Temporary practice pause then resumption (TPPR) study design:
an extension of the withdrawal study design to complementary and alternative medicine mind and body interventions (CAM-MABI). J Altern Complement
Med 2013;19:8337.
[17] Shapiro F. The role of eye movement desensitization and reprocessing (EMDR)
therapy in medicine: addressing the psychological and physical symptoms
stemming from adverse life experiences. Perm J 2014;18:717.
[18] EMDR Humanitarian Assistance Program. EMDR HAP; 2015.

Ronald M. Glick MD*

Departments of Psychiatry, Physical Medicine and Rehabilitation,
University of Pittsburgh School of Medicine,
United States
*Tel.: +1 4126233023; fax: +1 4126236414
E-mail address: glickrm@upmc.edu (R.M. Glick).