1 / 134

The Ecology of Mental Health

The Ecology of Mental Health. scott shannon, md abihm. Agenda. Philosophy Concerns with psychiatry Assessment-Treatment format Depression Anxiety Addictions. What is Integrative Psychiatry?. It is the ecologically sound care of the whole person: body, mind and spirit*.

vlad
Télécharger la présentation

The Ecology of Mental Health

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related