Chair’s Column November 2012

Developing Clinical Guidelines for Integrative Mental Health Care

J. Lake

The practice of integrative medicine, including integrative mental health care, is highly variable and idiosyncratic. The absence of standard practices in integrative mental health care reflects different philosophies, values and clinical perspectives of practitioners, and diverse goals of training programs, clinics and hospitals where integrative treatment approaches are taught or implemented. In the face of this diversity a recent survey (Horrigan et al 2012) suggests that integrative medicine is beginning to “mature” into a coherent set of values, a standard model of care delivery, and widely employed clinical therapeutics. According to the same survey, the most widely used model of integrative medicine in the U.S. is consultative care in which integrative clinicians work closely with the patient’s primary care physician to develop individualized treatment plans. The next most frequently used integrative care model is comprehensive care in which an expert clinician manages a specific medical condition throughout the course of treatment. Increasing numbers of integrative centers are also using a primary care model in which family physicians, internists and nurses provide medical and mental health care as needed throughout the patient’s life span. All of these care models employ flexible patient-centered approaches for both medical and mental health care. Rigorous clinical assessment of each unique patient’s complaints is the crucial first step needed to elucidate the causes or meanings of symptoms. Assessment findings point to therapeutic interventions from a variety of medical traditions in light of research evidence taking into account risks of adverse effects, cost and availability.

It is likely that the clinical practice of integrative mental healthcare will rapidly evolve to a very high standard following establishment of consensus-driven clinical guidelines. These will provide a template for deriving safe and effective assessment and treatment approaches on an individualized basis in relationship to the best available research evidence on efficacy and safety for both conventional and CAM therapies. Future guidelines in integrative mental health care will establish:
• Standardized methods for clinical integrative assessment and treatment planning
• Evidence-based treatment protocols that address efficacy and safety
• Multi-modal therapeutic interventions addressing specific symptoms and disorders
• Standardized outcome measures for evaluating treatment response
• Person-centered approaches in clinician-patient relationships

While diagnostic formulations based upon the Diagnostic and Statistical Manual (DSM) approach have serious limitations when approaching patient care from an integrative perspective, clinical practice guidelines based on DSM diagnostic categories provide a practical template for establishing well coordinated inter-disciplinary collaborative methods in assessment and treatment planning. Clinical guidelines in integrative mental health care will emerge from the DSM nosology to provide a framework for developing economic models that can be used to evaluate the cost-effectiveness of integrative approaches. However individual manifestations of mental illness occur along a spectrum [31], and disparate symptoms frequently overlap in a single patient [32]. The development of clinical assessment guidelines in integrative mental health care will take into account both the DSM nosology of discrete disorders, and more recent approaches that regard symptoms along a continuum of severity.