Mind-Body Research Calls For Evidence

One measure of the rising interest in mind-body medicine is the increasing entry of young physicians into specialties that focus on the interface between mental and physical disorders. Yet there is a dire need for controlled, clinical trials of treatments that address this interface in a variety of complex disorders. Such evidence-based support is especially important to doctors who specialize in psychosomatic medicine, because they face a cost-cutting threat from managed care groups. These were the themes and warnings of the 46th annual meeting of the Academy of Psychosomatic Medicine (APM), Nov. 18-21, 1999, in New Orleans. The Chicago-based APM is the organization for consultation and liaison (C/L) psychiatry, which is concerned with the interactions between medical and psychiatric illnesses in patients. "We're the commandos of the SWAT team in psychiatry," declared Thomas N. Wise, a psychiatry professor at both Georgetown University School of Medicine and Johns Hopkins University School of Medicine. He gave the Thomas P. Hackett Memorial Lecture, in which he acknowledged that biological psychiatry is currently in a favored position as a subspecialty, although C/L is gaining ground, particularly with the help of scientific research. "We're the commandos of the SWAT team in psychiatry." --Thomas N. Wise He said that although C/L is based on the biopsychosocial model developed by George L. Engel, professor emeritus of behavioral and psychosocial medicine at University of Rochester Medical Center, this theory was expanded into four perspectives with which the subspecialty is concerned: a disease model, life stories of the patients, their individual behaviors, and the dimen-sions of their illness. Of the four, Wise identified behavioral applications (such as goal-directed activities that reduce tension, pain, sexual and eating disorders, or substance abuse) as the least used. "We need to increase and integrate the behavioral perspective in our work." Robert G. Robinson, head of psychiatry at University of Iowa College of Medicine, who has done groundbreaking investigations into poststroke psychiatric disorders, won the group's annual research award. He cited American Psychiatric Association (APA) statistics showing that a substantial increase in residents entering specialties in the medical/psychiatric interface over recent years (for example, in geriatric psychiatry) has been accompanied by a significant decline in general psychiatry entries. He added that this change is reflected in increased publication of research papers concerned with the interface. However, physical/mental interfaces are numerous and often have not been well studied. Even in areas that have been researched, results sometimes differ. "My take-home message is that what we need in our field more than anything are treatment studies," he said. "Speculating doesn't get you very far. What really [affects] our practice is data." Outcomes data is useful, he added--even though it often is open label and anecdotal--but double-blind, randomized trials remain the gold standard. Robinson, who also won the 1999 APA award for research, published a monograph in 1998 that includes studies by his team of more than 700 patients with stroke over the past two decades. 1 He said many psychiatric disorders may follow stroke, and can interact with a variety of comorbidites. For example, such "catastrophic reactions" can occur as the sudden onset of anxiety, tearfulness, swearing, or refusal to engage with others. In those cases, which have been found to be associated with basal ganglia lesions, more than three-quarters of patients also experience depression. Parkinson's disease, myocardial infarction, spinal cord injury, and traumatic brain injury are other physical disorders that can spark psychiatric troubles. Robinson gave an example of conflicting research findings that stemmed from his own group's work. They showed that left brain hemisphere lesions are associated with poststroke depression; but rather than prompting studies of pathology or treatment, these findings were replicated in Sweden, Germany, and Australia. Similar studies by other groups found no correlation. He explained why the results varied. "When you get out to three to six months [poststroke], you lose this lateralized phenomenon." Neuronal sprouting and regeneration occurs, he said, "leading to compensatory neuronal process that will, I think, lead to shorter duration of the disorder ... This is a temporal phenomenon. So patients need to be studied longitudinally, to see which patients hold up over time and which do not." Promising new researchers were showcased at the meeting when fellowship grant recipients made presentations. Linda Mah, a neuropsychiatry fellow at the University of Massachusetts Medical School, discussed her retrospective study to determine the frequency and clinical variables of HIV mania. The charts of 434 HIV-positive patients referred for psychiatric consultation over six years at McGill University Hospital in Canada were examined. Mah found eight patients (1.8 percent) with mania and no family history of mood disorder. The median survival time after mania onset was six months, similar to that of AIDS-related dementia. A possible mechanism, she said, was basal ganglia and temporal-limbic structure lesions, given that those areas are rich in CD4+ T-cell receptors. Despite an absence of MRI data for the eight patients, they showed evidence of cerebral atrophy on CT scans. "Mania related to AIDS is probably due to disruption in the orbital-frontal-subcortical circuit," she concluded. Gregory L. Fricchione, director of medical psychiatry services at Brigham and Women's Hospital in Boston, concurred. Calling the study "wonderful," he observed, "We have learned a lot about how our brain works because of this plague of HIV." Ati Yates, a provider in the psychiatric clinic and the internal medicine residency clinic at Michigan State University, talked about her involvement in developing evidence-based medicine (EBM) there. Her definition of EBM came from a book by David L. Sackett and colleagues, who created the system in the mid-1980s at McMasters University in Ontario: "The conscious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients."2 Yates said EBM burgeoned after Sackett accepted a chair in clinical epidemiology at Oxford University in 1994, and more than 65 countries were represented at a 1997 EBM meeting she attended. Internists have increasingly employed it in recent years, she said, adding, "EBM is just in the beginning, I think, and it's going to need continued evaluation and improvement." She commented that her nonphysician friends have been surprised to learn that not all medical practice is based on such investigations. Eventually, she believes, even surgeons will adopt the system. Aided by the Internet, databases for EBM use have grown rapidly, as has global networking, Yates observed. "There's an amazing consensus on what's considered important, and on critical appraisal." Steve Bunk (sbunk@uswest.net) is a contributing editor for The Scientist. References 1. R.G. Robinson, The Clinical Neuropsychiatry of Stroke, Cambridge, U.K., Cambridge University Press, 1998. 2. D.L. Sackett et al., Evidence-Based Medicine: How to Practice and Teach EBM, London, Churchill-Livingston, 1997. For More Information Center for Evidence-Based Medicine cebm.jr2.ox.ac.uk

Mind-Body Research Calls For Evidence

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January 2000

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