Chair’s Column August 2012

The Need for New Methods and Research Priorities in Integrative Mental Health

Psychiatric research in the past several decades has focused primarily on mechanisms of psychotropic drugs and a few kinds of psychotherapy. Recent studies have examined the effects of life style changes on mental health in addition to mind-body therapies, and select natural products. Few studies have been done on truly integrative approaches in medicine and psychiatry (ie, approaches that combine two or more discrete therapies), and most studies use randomized control trial (RCT) designs to examine single interventions. Important advances in research and the clinical practice of psychiatry will take place when formal research methodologies permit the rigorous evaluation of combinations of two or more therapeutic modalities used to treat real-world clinical populations. A truly integrative research methodology will elucidate the relative contributions of social, psychological, biological and spiritual factors in each unique patient’s response to combined treatment modalities while clarifying the roles of genetic and biochemical individuality, ethnicity, family history and culture in the pathogenesis of mental illness.

Recent findings from economic modelling research suggest that significant cost savings can be achieved when integrative strategies yield positive long-term outcomes in patients diagnosed with chronic medical and psychiatric disorders. Emerging findings of economic modelling studies on comparative cost-effectiveness of conventional vs CAM or integrative treatments of common psychiatric disorders including major depressive disorder, bipolar disorder and schizophrenia suggest that higher up-front costs of many CAM or integrative treatments may be offset by improved work productivity and increased quality of life.

An important future research challenge will entail targeting specific integrative treatment strategies to discrete psychiatric disorders in the context of a broad-based biopsychosocial model of care. This could involve studying both quantitative outcome measures using laboratory tests and validated psychometric scales, as well as qualitative reports of patient experiences including subjective perceptions of improved functioning in response to individually tailored multiple-component interventions. Along these lines a future study could compare outcomes following conventional treatment vs a complex intervention using specific evidence-based combinations of treatments in patients diagnosed with a specific DSM-V disorder. Such studies would use accepted protocols including comparisons of conventional therapies like cognitive therapy or drugs, established research methodologies including random allocation of matched patients to treatment arms, use of placebos or “sham” treatment in a “control” arm, validated symptom rating scales, blinded raters, and validated statistical methods. Studies employing non-conventional treatments such as natural products and mind-body practices would use standardized formulations of natural products prepared using good manufacturing practices (GMP), or other therapies for which there is extensive data on both safety and efficacy with respect to mental health problems, such as mindfulness-based stress reduction (MBSR), yoga, bright light exposure and biofeedback.

Priority areas that need to be emphasized in future IMH research include:
Studies on recently characterized botanical medicines and their synergistic or adjuvant properties when combined with conventional pharmaceuticals
Use of pharmacogenomic, epigenetic, and neuroimaging technologies to elucidate mechanisms of action
Exploration of the impact of lifestyle changes such as diet, exercise and stress management in both prevention and treatment of specific mental health problems
The systematic study of interactions between specific pharmaceuticals and neutraceuticals, especially with respect to potentially beneficial synergistic effects or potential adverse effects or toxic interactions