Introduction

High prevalence rates and unmet treatment needs of individuals who struggle with major depressive disorder, bipolar disorder and other serious mental health problems underscore the inadequacies of both conventional treatments and complementary and alternative (CAM) treatments and the limitations of the current model of mental health care. In this post I briefly review the limitations of conventional treatment approaches and CAM treatments of mental health problems. I describe how integrative mental health care will more adequately address mental health care needs through safer, more effective treatment strategies incorporating evidence-based conventional treatments and CAM approaches in the context of a truly integrated model of mental health care delivery in which medical and mental health problems are addressed in outpatient clinic settings.

Limitations of conventional mental health care

Systematic reviews of placebo-controlled studies on widely used psychotropic medications have found marginal effectiveness of many pharmacologic treatments of major depressive disorder, bipolar disorder, and other psychiatric disorders (Kelly 2010; Stafford et al 2011; Hartling et al 2012; Fournier et al 2009; Thase 2007; Velligan et al 2009; Herrmann 2011; Kirsch et al 2008). In addition to concerns about efficacy, many commonly prescribed psychotropic medications including several antidepressants and antipsychotics are associated with serious adverse effects such as weight gain, increased risk of diabetes and heart disease, neurologic disorders, and sudden cardiac death (Henderson 2008). Metabolic syndrome associated with weight gain and increased risk of diabetes and coronary artery disease is a well-documented adverse effect of antipsychotics. Poor treatment outcomes owing to limited efficacy of psychotropic medications result in long-term impairments in functioning, work absenteeism, and losses in productivity (John Eisenberg Center 2016; Barnes 2008; Beck et al 2011; Laxman et al 2008; Barbato 1998).

In addition to the above concerns, the current mainstream model of mental health care is limited by disparities in the delivery of mental health services to different socioeconomic classes and the lack of integration of mental health services into primary care and other medical subspecialties (Cunningham 2009). Numerous studies show that collaborative care models reduce health care disparities in patients from different socioeconomic and ethnic backgrounds (Arean et al 2005; Ell et al 2009; Ell et al 2010; Ell et al) and are more effective than conventional care models for treatment of depressed mood, anxiety disorders, bipolar disorder, and schizophrenia (Unutzer et al 2002; Gilbody 2006; Simon 2009, Reilly et al 2013; Woltmann et al 2012). Both clinician and patients report high levels of satisfaction with the management of depressed mood in collaborative care settings (Levine et al 2005; Unutzer et al 2002). Finally, collaborative care is more cost-effective than usual care in all categories measured, including medication costs and inpatient, outpatient, and mental health specialty care (Unutzer et al 2008), as well as for the management of depressed patients with comorbid medical disorders (Katon et al 2011), severe anxiety disorders (Katon et al 2002), and serious chronic mental illness (Druss et al 2011; Grypma 2005; Reiss-Brennan et al 2010).

The growing relevance of complementary and alternative medicine (CAM) in mental health care

In the context of the limitations of available pharmacologic treatments research is ongoing to identify safe and effective complementary and alternative (CAM) treatments of depressed mood, anxiety, and other mental health problems. Accumulating research findings support that select natural supplements, lifestyle modification such as exercise and maintaining a healthy diet, mind-body and mindfulness approaches such as meditation and yoga have beneficial effects on different mental health problems. Examples include S-adenosyl methionine (SAMe) for depressed mood; omega-3 fatty acids, folic acid (especially its active form l-methyl-folinic acid) as add-ons to antidepressants, the amino acids 5-hydroxytryptophan, and n-acetyl cysteine for mood disorders; a standardized extract of the herbal kava for anxiety disorders; and the amino acid l-theanine also for anxiety disorders (Lake 2017). In addition to natural supplements research findings support the use of acupuncture for generalized anxiety and depressed mood, and mindfulness training for improving anxiety, mood disorders as well as cognitive symptoms that often accompany schizophrenia (Lake 2006).

In addition to discrete treatments that target a specific disorder or symptom pattern, lifestyle modifications such as regular exercise, healthy diet, sufficient sleep, and reducing alcohol and nicotine use also enhance mental and emotional well-being while reducing the relapse risk for many psychiatric disorders (Sarris 2011). CAM approaches are already widely used to treat or self-treat mental health problems. Survey findings show that roughly 1/2 of individuals with an anxiety disorder (Bystritsky et al 2012) or depressed mood (Wu et al 2007) use 1 or more CAM treatments. It is significant that individuals with severe mental illnesses such as major depressive disorder and bipolar disorder who use CAM therapies to treat their symptoms feel strongly that such nonpharmacologic treatments improve their physical, emotional, cognitive, social, and spiritual functioning; reduce the severity of their symptoms; and enhance overall wellness (Sirois 1008). Increasing acceptance of CAM therapies in the US and other economically developed world regions is the result of scientific advances, social trends, and the availability of safe, affordable nonpharmacologic treatments.

Widespread use of CAM by individuals who are concurrently receiving psychotropic medications is driving a trend toward increasingly integrative mental health care in North America, Europe, Australia, and other world regions. Findings of a recent survey (Horrigan 2012) support that integrative treatment strategies incorporating medications and evidence-based CAM therapies are often beneficial for both medical and mental health problems. The same survey pointed to depressed mood and anxiety as among the top 5 health concerns for which CAM and integrative approaches are most beneficial.

The limitations of CAM in mental health care

Although growing acceptance of evidence-based CAM in mental health care is an improvement over available conventional treatments, CAM treatments are not without problems. For example, it is estimated that more than 50% of all individuals with a diagnosis of a mood or anxiety disorder use CAM therapies to manage their symptoms but few disclose CAM use to their psychiatrist, family physician, or other conventional health care practitioners (Thomson 2012). To further complicate matters, many widely used CAM therapies are supported by limited research evidence. In fact, relatively few CAM therapies have been substantiated by consistent positive findings of large, well-designed, placebo-controlled studies. Furthermore, many CAM therapies are limited by incomplete knowledge of their mechanisms of action, small study sizes, inconsistent research findings, and – in some cases – safety concerns. The result is that individuals who use supplements or other CAM therapies not supported by strong research place themselves at risk of disappointing outcomes or potentially serious safety problems (Ernst 2003) when such therapies are used in combination with conventional pharmacologic agents.

The emerging role of integrative mental health care

High prevalence rates and unmet treatment needs of individuals with major depressive disorder, bipolar disorder, schizophrenia and other severe mental illnesses in both developed and less developed countries underscore the inadequacies of both conventional pharmacologic treatments and CAM modalities and the limitations of current models of mental health care. The lack of compelling evidence for many conventional and CAM modalities poses complex challenges for psychiatrists and therapists as well as individuals seeking ‘evidence-based’ treatment(s) for their mental health problem. These circumstances define an urgent agenda for developing effective, safe, and affordable integrative treatment strategies incorporating evidence-based pharmacologic treatments and psychotherapies, and substantiated CAM modalities including select natural supplements, mind-body and mindfulness approaches and others. In equal measure, there is an urgent need to establish a more integrated model of mental health care delivery in which medical and mental health problems are addressed in a single clinic.

The paradigm of integrative medicine has emerged in response both to patients’ needs, providers’ changing perspectives, and the limitations of the current model of care. Integrative medicine affirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by research evidence, and goes beyond the limitations of biomedicine or CAM by incorporating diverse treatment approaches with the goals of achieving optimal wellness, preventing relapse, and improving outcomes (Academic Consortium for Integrative Medicine 2017). Integrative mental health care is an important offshoot of integrative medicine that focuses on the whole person rather than a particular disorder. Like integrative medicine, integrative mental health care emphasizes wellness and healthy lifestyle choices while addressing complex biological, psychological, cultural, economic and spiritual or religious factors that affect general well-being and mental health. As such, integrative mental health care is an evidence-based, research-driven paradigm that acknowledges the legitimacy of conventional and CAM treatments and recommends specific treatment combinations supported by research findings. The reader is referred to Lake et al 2012 (Lake et al 2012) for a more detailed discussion of the foundations and methods of integrative mental health care. A model of care that incorporates evidence-based conventional and CAM modalities into existing models used in outpatient settings will address the limitations of conventional and CAM treatments, resulting in improved outcomes, increased patient satisfaction, and reduced costs.