Integrating Biomedicine and Asian Medicine: Challenges and Opportunities

Premiere Date: December 20, 2016
Expiration Date: June 20, 2018

This activity offers CE credits for:

1. Physicians (CME)
2. Other

ACTIVITY GOAL

To understand the conceptual framework for integrating biomedicine and Asian medicine.

LEARNING OBJECTIVES

At the end of this CE activity, participants should be able to:

• Discuss the limitations and advantages of biomedicine and Asian medicine

• Assess when it is more beneficial to use biomedicine and when Asian medicine

• Describe the practical guidelines for combining biomedicine and Asian medicine

TARGET AUDIENCE

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

CREDIT INFORMATION

CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit™.

DISCLOSURE DECLARATION

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

James Lake, MD, has no disclosures to report.

David Mischoulon, MD (peer/content reviewer), reports that he has received research support from Fisher Wallace, Nordic Naturals, Methylation Sciences Inc, and PharmoRX Therapeutics; he has received honoraria from the Massachusetts General Hospital Psychiatry Academy; and he has received royalties from Lippincott Williams & Wilkins for the book, Natural Medications for Psychiatric Disorders: Considering the Alternatives.

Applicable Psychiatric Times staff and CME Outfitters staff have no disclosures to report.

UNLABELED USE DISCLOSURE

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

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Asian healing traditions are emerging as increasingly accepted alternative approaches to diagnosis and treatment in the US and other Western countries, while biomedicine is becoming increasingly used in Asia. The confluence of disparate modalities in both Western countries and Asia presents complex problems and opportunities.

Biomedicine is the dominant model of health and illness in Western culture. Disorders are constructed from symptom patterns that are attributed to underlying physical or psychological causes, and diagnosis entails the confirmation of a particular pattern of symptoms. Biomedicine equates health and illness with biological functioning and assumes that symptoms reflect dysregulation in biological processes in the human body.

Biomedical psychiatry contends that mental illness can sometimes be explained by dysregulation of elemental neurochemical processes and expands the medical paradigm to take into account the influences of culture and religion on symptoms. Many highly evolved systems of medicine that originated in non-Western cultures reject this assumption as spurious.

Asian medicine rests on fundamentally different assumptions about the nature of the human body; the role of consciousness in healing; and the influences of biological, psychological, or postulated “energetic” factors on health and illness. According to Chinese medical history, vital energy “qi” circulates through the body in “energy channels” or meridians. Internal and external influences affect the flow of qi, potentially creating imbalances that manifest as physical or emotional symptoms. This philosophical difference has resulted in important problems for biomedical researchers who attempt to objectively evaluate modalities used in Asian healing traditions and other non-Western systems of medicine.

Biomedicine evaluates its theories and methods based on findings in physics and the life sciences that call into question some of the core tenets of contemporary science. Scientific theories, including quantum field theory, complexity theory, and the theory of dissipative structures, are yielding novel conceptual frameworks that may eventually explain mechanisms that underlie non-conventional medical treatments such as “energy” medicine. Advances in functional brain imaging, such as functional MRI, quantitative EEG, and positron emission tomography, will eventually permit researchers to empirically test claims of “energy” healing in Asian healing traditions.

Advantages and limitations of biomedicine

In spite of impressive advances in biomedicine, broad sociocultural and economic issues limit its ability to provide adequate health care in many regions of the world. These include the high cost of many pharmacologic therapies, insurance company or managed-care restrictions, and limited or no insurance coverage for drugs or other biomedical treatments. Widespread dissatisfaction with the quality of conventional biomedical care has arisen out of concerns over cost, safety, and effectiveness. Moreover, managed-care constraints on physicians’ practices often result in short and impersonal contact with patients.

The growing public dissatisfaction with conventional biomedicine and the increasing costs and complexity associated with obtaining adequate care have led to a rapid increase in the use of complementary and alternative medicine (CAM) approaches to treat or self-treat a range of medical and mental health problems.¹ Continued growth in medical pluralism may lead to increased use of CAM while gradually slowing the use of psychotropic medications that have limited efficacy and safety risks.²

Many widely used CAM therapies are likewise limited by efficacy and safety, availability, and cost issues. Integrative medicine is emerging in response to the limitations of biomedicine and CAM therapies. This new paradigm utilizes evidence-based interventions while emphasizing person-centered care and actively engaging each patient in the process of changing his or her lifestyle to achieve improved health.³

Millions of people with serious mental illnesses rely on psychotropic medications for day-to-day functioning. As many as 1 out of 10 adults in the US and other post-industrial countries take prescription drugs for a serious mental health problem, including depressed mood, bipolar disorder, anxiety, and schizophrenia.⁴ Although there are many benefits to modern drug therapy, concerns are growing over the safety and efficacy of many psychotropic medications. In fact, safety risks associated with some prescription antidepressants may outweigh their beneficial effects.⁵

In this conservative medical landscape, real change is starting to take place in medical education, research, and popular attitudes toward CAM. Core competencies in integrative medicine are now being taught in many US medical schools and residency training programs, which should increase openness to CAM among physicians.⁶

Approximately half of US physicians endorse acupuncture, chiropractic, and homeopathy as valid medical principles and frequently refer patients for these therapies.⁷ And more physicians are becoming certified in one or more areas of CAM (eg, acupuncture, herbal medicine, homeopathy).⁸ In parallel with these changes, the National Center for Complementary and Integrative Health of the National Institutes of Health is funding research on promising CAM therapies, including herbal medicines, acupuncture, mind-body therapies (eg, meditation, yoga), and “energy” medicine.

The increasing use of CAM in developed countries may reflect an increasingly consumer-driven health care environment in the context of increasing medical diversity.⁹ One-third of individuals who experience generalized anxiety, mood swings, or psychotic symptoms use CAM.¹⁰

Integrating biomedicine and Asian medicine

In the US and other developed countries, the majority of persons who seek treatment from a practitioner of Asian medicine have received a diagnosis from a physician or other conventionally trained medical practitioner. Many are concurrently taking prescription medications for one or more disorders. Individuals who are being treated by a practitioner of Asian medicine typically do not disclose this information to their Western-trained medical practitioner who is treating them for the same problem, and vice versa.¹¹ Nondisclosure of information pertaining to treatment has many potential risks, including misdiagnosis, inappropriate treatment, and adverse effects or toxic interactions.

After decades of widespread use of traditional Chinese medicine in Western countries, there is still a paucity of reliable information about which herbal formulations and prescription medications can be safely combined. Trained practitioners acknowledge the unacceptable risks associated with combining select Chinese and prescription medications. For example, ma huang (which contains ephedrine) taken with antidepressants or blood pressure medications can have serious, potentially fatal consequences. Even less is known about potential risks of combining prescription medications with herbal treatments used in other Asian healing traditions, including Ayurveda, Tibetan medicine, and Japanese traditional medicine (Kampo).

Western psychopharmacology and traditional Chinese herbal formulations used to treat mental illness rest on mechanisms of action involving the same neurotransmitters, including serotonin, norepinephrine, and GABA.¹² Such findings provide a strong empirical basis for further integration of Asian medicine and biomedical psychiatry by identifying select herbal formulations that are safe and effective treatments of particular psychiatric disorders when used alone or in combination with psychotropic medications.

Practitioners of biomedicine and Asian medicine should carefully review the research literature on efficacy and safety when considering integrative approaches. Clinicians are urged to err on the side of caution to avoid combinations that can potentially result in serious adverse effects. When recommending a treatment strategy that is not supported by good evidence in the published medical literature, it is important to obtain informed consent from the patient and to carefully document this in the record.

Biomedicine and Asian medicine: strengths, weaknesses, and challenges

When the relative benefits and shortcomings of different treatments are compared, important considerations include the evidence for a particular treatment with respect to the patient’s current symptoms, history of treatment response, cost issues, and personal preferences. With both Asian medicine and biomedicine, patients choose treatments based on perceptions of comparative effectiveness, convenience, cost, and adverse effects.¹³

When a patient has a severe mental illness, it is prudent to treat with potent prescription medications or, when there is a question of suicide risk, to urgently refer the patient to the nearest emergency department. After a patient with a severe mental illness responds to prescription medications, it may be appropriate to try an Asian medical treatment (eg, herbal formulations, acupuncture) that has evidence of efficacy and safety for the illness. Herbal formulations used in traditional Chinese medicine and Ayurveda have shown efficacy for the treatment of neuropsychiatric disorders such as depressed mood, schizophrenia, and neurodegenerative disorders.¹⁴

Traditional Asian therapies result in responses that range from subtle effects with few or no adverse effects, to marked physiological or energetic changes with more potent therapies that may have more frequent or more serious adverse effects. The same general principle is at the heart of conventional Western biomedicine, which has the goal of achieving an adequate therapeutic response with the safest available interventions.

Although psychotropic medications have revolutionized mental health care and provided hope to millions of people with severe mental illness, many such medications are associated with serious adverse effects. In some cases the risks associated with typical and atypical antipsychotic medications may outweigh their potential benefits. The long-term use of antipsychotics may result in debilitating permanent movement disorders, life-threatening cardiac arrhythmias, and toxic metabolic syndromes that increase the risk of obesity and diabetes.

The belief that good health is a reflection of harmony is embedded in many healing traditions and is an easy concept for non-Asians to grasp. Based on the concept that the body is an integrated whole and that the core causes of illness can be eliminated only when the entire organism is restored to a healthy state of harmony with nature, Asian medicine treats the whole person not a particular symptom, organ, or illness.

In contrast to biomedicine, which uses highly technical language to convey information to patients, Asian medicine relies on simple metaphors that are easy to understand-illness is a manifestation of loss of energetic harmony between oneself and the world. According to this metaphor, curing illness entails making changes in lifestyle or taking treatments that restore life to its natural state of harmony with the universe. “Wind” is an important metaphor used to describe the energetic principle of rlung, which in Tibetan medical theory is related to balance or harmony. According to the Rgyud bzhi (Four Tantras), disorders of “wind” can manifest as a wide range of neuromuscular and psychosomatic disorders including “life-wind illnesses”-syndromes that resemble depressed mood, panic disorder, and generalized anxiety.

All Asian healing traditions are patient-centered. When practiced according to traditional principles, treatments address each patient’s unique imbalances that manifest as physical or mental symptoms. The highly individualized approaches ensure a close match between the underlying causes and the effects of treatments at various body and mind levels. The match between the energetic pattern of symptoms and treatments ideally results in few or no adverse effects.

A comprehensive analysis of the 2 major Asian medicine groups as they relate to mental health care is beyond the scope of this article; for more information, see Millard,¹⁵ Aung et al,¹⁶ and Pratikanti.¹⁷

When skillfully administered, external therapies such as acupuncture, energetic massage, and somatic therapies are seldom associated with adverse effects. On the other hand, herbal formulations may have adverse effects. However, Asian herbal formulations are typically prescribed on an individual basis that reflects each patient’s unique constitutional pattern and, when prescribed by skilled medical practitioners, pose little risk of adverse effects.

Asian medicine rests on a pattern-based prescriptive methodology in which a particular disease is a reflection of the energetic pattern of the body as a whole. A practical consequence of this concept is that good treatments are associated with few or no adverse effects. Applying the general concept to diagnosis in biomedicine may result in improved responses to prescription antidepressants and antipsychotics and a reduced incidence of adverse effects.

Strategies for integration

Opportunities for integrating biomedicine and Asian medicine take place at the level of outcomes assessment. For example, standardized symptom rating scales and biomedical tests such as blood chemistries and urinalysis are often useful when monitoring responses to Asian medical therapies. By the same token, pulse diagnosis in traditional Chinese medicine, Tibetan medicine, and Ayurveda may provide a valuable adjunctive lens when added to conventional biomedical assessment.¹⁸

Most Asian medicine interventions are less potent and less expensive than prescription medications used in biomedicine. When selecting the most appropriate treatment, different considerations apply depending on the type and severity of symptoms being addressed. The highest priority is on patient safety and well-being; other important considerations include the patient’s history of treatment response or lack thereof, cost, and personal or cultural preferences.

Patients with severe depression, bipolar disorder, schizophrenia, or other mental health problems are at significant risk for self-harm or suicide. Many aspects of contemporary biomedicine can be used with benefit by individuals who are being treated with Asian medicine. An important advantage of biomedicine is its systematic approach to diagnosis and prognosis, whereas Asian medicine relies largely on highly subjective reports that reflect energetic balance. This difference translates into greater diagnostic accuracy in biomedicine, which in turn leads to more appropriate treatment recommendations and better outcomes.

Because pharmacologic treatments are generally more potent and in most cases work faster, it is appropriate to initially recommend prescription medications to patients who have severe psychiatric symptoms. When a patient reports symptoms and a history that suggest a severe, chronic, or life-threatening illness, it is appropriate to refer the patient for urgent medical evaluation by a conventionally trained Western physician, including a thorough examination to rule out possible unrecognized medical problems. In cases of no treatment response or severe adverse effects, the patient may be referred to a CAM practitioner for further evaluation and consideration of appropriate non-pharmacologic treatment options. Any questions regarding prescription medications should be referred to the patient’s physician. By the same token, questions that pertain to Asian herbal formulations or other treatments should be referred to the patient’s Asian medical practitioner.

If a patient does not have a severe, life-threatening, or chronic condition, it is reasonable and appropriate to refer him or her to a qualified Asian medical practitioner if the patient agrees. If there are problems with the prescribed course of Asian treatment, a consultation between the Asian medical practitioner and conventionally trained physician involved in the patient’s care may yield valuable insights about further diagnostic and treatment considerations. While open communication between practitioners of biomedicine and Asian medicine is desirable, it is frequently difficult to achieve because of language barriers, the conceptual divide that separates Western and Asian medicine, and ingrained prejudices on both sides.

Integrative medicine takes into account the strengths and limitations of all systems of medicine in the context of each patient’s needs and preferences. The result is an evidence-based treatment plan centered on a biomedical treatment, Asian medicine, or a range of biomedicine and CAM. It is both reasonable and prudent to recommend Asian medicine that is established as safe and effective for a particular mental health problem-assuming the patient is not impaired by severe psychiatric symptoms or at risk for suicide. The choice of traditional Asian treatment over a biomedical treatment that is equally safe and effective makes sense when the latter is expensive or there is an increased risk of adverse effects. By the same token, switching therapy to conventional biomedicine is wise when there is poor response with Asian medicine.

Select Asian medical diagnostic approaches and therapies can be safely combined with conventional biomedical approaches to yield greater diagnostic clarity and beneficial synergistic effects. For example, energetic pattern diagnosis, acupuncture, and qigong can be safely used in conjunction with conventional psychiatric assessment, prescription medications, and hypnotherapy in the management of generalized anxiety disorder.¹⁶ Because of their different mechanisms of action, acupuncture, moxibustion, and energetic massage (tui na) will likely not interact with Western prescription medications.

When the safety and efficacy of a particular combination have not been clearly established, it is incumbent on the physician or Asian medical practitioner to avoid combining an Asian herbal formulation with a prescription medication. Recommending a combination of a prescription medication and an Asian herbal formulation is prudent only when there is strong evidence that the particular combination has beneficial synergistic effects and poses little or no risk of serious interactions.

Conclusions

The limitations and advantages of biomedicine and CAM approaches, including Asian medical therapies, are stimulating rapid growth in integrative medicine. Ayurveda, Tibetan medicine, and traditional Chinese medicine are highly evolved, coherent Asian practices that have been empirically validated and refined over millennia, are widely used in their parent cultures for maintaining wellness and treating illness, and are increasingly used in Western countries.

Asian diagnostic methods can complement biomedical diagnostic methods by providing useful information that can clarify underlying pathology and aid in treatment planning. Although more research is needed, emerging findings support the effectiveness and safety of treatments such as acupuncture and herbal formulations. Select herbal formulations used in Asian medicine can improve symptoms of depressed mood, anxiety, and schizophrenia.

CME POST-TEST

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Disclosures:

Dr. Lake is in private practice in Monterey, CA; he has studied acupuncture and traditional Tibetan medicine, and is the co-author of Chinese Medical Psychiatry: A Textbook and Clinical Manual.

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