Why I Practice Integrative Psychiatry

My Parallel Education

Reason #1: I have more to offer my patients than just medications

Alongside my medical and scientific training, I completed what I like to call my parallel education in yoga therapy. This was a 3-year process that built on 10 years of experience as a yoga student, and was concurrent with my postdoctoral fellowship in neurobiology, while I was living in Switzerland.  What is most important is that this training, the time I spent as a student of yoga therapy practices, and my experience with teaching yoga and meditation to my colleagues, friends, and others, all occurred prior to my return to clinical work in psychiatry.  This allowed me to formulate a clinical approach to psychiatry that always included an integrative perspective on mental health treatment. It has also given me extra tools, beyond medications, that I can offer to my patients, as they chart their unique paths towards whole person well-being.

Things are Changing

Reason #2: The Evidence Base for Integrative Psychiatry is Growing

More and more evidence is accumulating demonstrating the efficacy of non-medication augmentation strategies for mental health.  What this means is that more researchers have become interested in studying the effects of combining nutritional and herbal supplements, life-style changes (such as diet, exercise, and other changes in habits), and mindfulness-based interventions with psychotropic medications for treatment of mental health diagnoses.  Since most academic clinicians, and any clinician keeping up with the evidence base, rely on researchers to conduct the studies that inform their treatment strategies, this is a really exciting time to be practicing integrative psychiatry, because we know more about which strategies are most likely to work.  There have also been innovations in the field of neuromodulation, which is just a fancy term for technology that involves activation (or inactivation) of regions of the brain that contribute to mental health symptoms.  These are newer and very effective non-medication treatments with an expanding number of applications across different age groups.  The evidence base for non-medication augmentation strategies continues to grow, making integrative medicine approaches more acceptable to the medical community, and more useful to patients.

Autonomy, Choice and Becoming Unnecessary

Reason #3: Integrative psychiatry relies on patient self-empowerment and autonomy

I don’t believe entering into a treatment relationship with a psychiatrist is meant to be a life-long commitment.  In fact, I believe our goal as physicians should be to become unnecessary. There is also something troubling to me about any treatment relationship that builds a feeling of dependency in a patient, rather than nurturing self-empowerment and autonomy. Integrative psychiatry places well-being in the hands of patients by offering medication augmentation strategies that are dependent on the patients daily choices, rather than relying on the psychiatrists prescribing privileges alone.  The role of the psychiatrist in integrative psychiatry is to provide knowledge, and to coach or guide, as it involves teaching, motivating, troubleshooting, and thoughtfully passing the responsibility for improvement from the psychiatrist to the patient, over time.

Your Brain on Exercise

Exercise Improves Mental Health

It is likely common knowledge by now that physical exercise is good for overall health and emotional well-being, however I think it’s worth taking a slightly deeper dive into this subject, as I find that more in depth knowledge can help people to feel motivated to create new habits. Hundreds of research studies have demonstrated that the benefits of regular exercise go far beyond physical health.  Positive effects have been shown for anxiety, depression, bipolar disorder, ADHD, psychotic symptoms, suicidal ideation, insomnia, and cognitive aging. 

For example, individuals with major depressive disorder who exercise regularly may need about half the dose of antidepressants compared to those who do not exercise; for me, this evidence creates a powerful argument for psychiatrists to “prescribe” physical exercise to augment medications in patients with depression.   Physical exercise can also improve attention and executive functioning in children with ADHD, reduce anxiety in individuals with anxiety disorders, improve symptoms of psychosis in adults with psychotic disorders, and reduce the risk of developing suicidal ideation.

In non-clinical populations (individuals who do not have a mental health diagnosis), exercise can reduce symptoms of anxiety and depression as well.

How Does it Work?

We don’t know with 100% certainty exactly why exercise improves mental health, but we have a pretty good idea of at least a few likely mechanisms in the brain.  We know that when people exercise, it leads to an increase in molecules in the brain that reduce neuroinflammation, protect neurons from dying, and promote and stabilize new connections between neurons in areas of the brain that are important for regulating mood and learning.  These molecules include irisin (released by skeletal muscles during exercise), BDNF (brain derived neurotrophic factor), the same molecule that scientists believe is responsible for the effects of some antidepressants, and dopamine, a neurotransmitter responsible for motivation, learning and memory, regulating attention, and reinforcing pleasure-seeking behaviors.

I can think of very few down sides to exercise, other than mild and temporary muscle soreness, provided you are exercising in a responsible way, with guidance when needed.  The way I like to describe this to my patients who may not feel motivated to exercise, is that it is kind of like taking a medication, but without the side effects.  And yes, I do “prescribe” exercise to my patients!

How Much Exercise is Enough?

There are a range of ideas about this, and the answer really depends on the specific research study that is being quoted.  In general, following physical activity guidelines from the American Heart Association and U.S. Department of Health and Human Services is a good starting place: 150 minutes of moderate intensity aerobic exercise, or 75 minutes of vigorous aerobic activity per week for adults, and 60 minutes of moderate to vigorous physical activity per day for children and teens. 

How Will you Know if it is Working?

I would suggest identifying the specific changes you want to see in your mood and/or symptoms, and keeping track of these over time. Some people start to notice benefits within 3 weeks, and most notice improvements in their target symptoms within 12 weeks.

Your Brain on Nature

Exposure to Green Spaces Changes Your Brain!

You may have experienced the calming effects of spending time in nature, but are you aware that there is a neurobiological basis for this calming experience?  Scientists who study the structure and activity of the brain have known for some time now that spending time in nature can change the brain. 

Specifically, the part of the brain that is associated with fear, anxiety, and trauma-related disorders is less active after spending time in nature.  Moreover, the overall structural integrity of the brain is improved by living in proximity to a forested area, presumably due to spending time in that same forested area.

These findings suggest that you can reduce feelings of stress and anxiety by spending time in green spaces, whether that is a park, a forest, a botanical garden, or your backyard. 

How Does Nature Impact Mental Health?

What do we know about access to green spaces and mental health?  Recently, the entire world experienced a major stressor in the form of a global pandemic that changed the way we work, play and relate to each other.  During the pandemic, those who spent more time in nature were less likely to experience depression and anxiety, possibly due to reduced experiences of stress. 

We also know that time in nature can improve memory, attention and impulse control, both for typically developing individuals, and those with attention and impulse control challenges, such as individuals with ADHD.

The benefits of time in nature go beyond mental health as well, and include improved academic performance, improved cognition, and improved physical well-being.

How Much Nature is Enough?

Well, the more the better, however the few research studies that have tried to answer this question have shown that the most benefit from indoor green spaces is achieved when 10-25% of the space is filled with plants. 

The benefits of time in outdoor green or blue spaces can be seen after just 5 minutes, however the more time you spend in nature, and the more frequently natural spaces are visited, the more likely you are to benefit. 

I hope this knowledge motivates you to go outside, find a green (or blue) space, and enjoy the calm and clarity that comes from your time in nature.

The Mindful Pause: A How-to Guide

Mindfulness Supports a Calm and Attentive Mind

Mindfulness-Based Stress Reduction (MBSR) is a program based on the principles of mindfulness meditation practices, which has been simplified and repurposed for Western lifestyles.  The goal of MBSR is to cultivate life-skills that are useful for reducing the stress response, and the mental health and physical health consequences that result from chronic stress.

The mindful pause is one of the mindfulness-based practices considered integral to MBSR, and is exactly what it sounds like -- a pause, in which you stop whatever you are doing, and take 3-5 min to engage in a mindfulness exercise.  This is one of my go-to introductory meditation practices, due to its simplicity, and because it is feasible for most people to make time for this brief practice in their daily lives.

In my experience, the most difficult part of this practice is remembering to use it on a regular basis.  To help with this, my recommendation is to pair this practice with something you are already doing on a regular basis.  For example, you can practice this every time you open the door to enter or leave your home, or when you enter or leave your place of work.  For physicians, maybe you use this practice every time you transition between patients.  Pick something that feels practical and feasible for you.

An easy way to remember the steps in the mindful pause, is by remembering the “STOPP” acronym:

Stop

Take several deep breaths

Observe your breathing

Purpose

Prepare

The Mindful Pause Step-by-Step Guide:

Step 1: Pause whatever you are doing.

Step 2: Take several intentionally deep breaths.

Step 3: Observe the quality of your breathing:

Is your breathing fast, or slow? How does it feel to breathe?  Does your breath feel open, easy and comfortable, or does it feel restricted, shallow or difficult? 

Just observe the quality of your breathing.  As you observe the quality of your breathing, try not to judge your breathing as good or bad, just observe the quality of your breathing

Step 4: Take a moment to reflect on what your purpose is right now:

What are you meant to be doing? For example, are you about to go to a meeting? Are you about to start driving?  Are you about to start writing?  Are you about to call a friend?  What exactly is your purpose, right now?

Once you have decided on your purpose, prepare; step by step, what exactly do you need to do in order to fulfil your purpose. For example, if you are about to call a friend, you would first pick up your phone, then you would unlock your phone, then you would search for your friends name, then you would hit the green dial button, then you would hear the phone ring, then your friend would answer the phone, and then you would say something like “Hi Anne”. 

Step by step, what exactly do you need to do, in order to fulfil your purpose, right now?

Step 5: Open your eyes.

Now you are ready to fulfil your purpose.

Audio recording:  

Self-Hypnosis for Sleep: A How-to Guide

All Hypnosis is Self-Hypnosis

Hypnosis is a state of deep absorption, in which individuals lose awareness of their surroundings, and become highly suggestible. All hypnosis is self-hypnosis, meaning that individuals allow themselves to enter this trance-like state, rather than being forced to do so by someone else. When used with wisdom, the power of suggestion can be an effective means of making positive changes in peoples lives.

Everyone has experienced the state of hypnosis, although not everyone is aware that they have been in a trance-like state, and not everyone uses the terminology of hypnosis.  Some common examples of trance-like states include watching television, daydreaming, and becoming absorbed by work or play.  As you attempt to intentionally use self-hypnosis in your life, try to remember that you have done this before, many times, so you can definitely do it again.

One way in which I apply self-hypnosis in my clinical practice is for challenges surrounding falling asleep and staying asleep.  I have taught this strategy to family members, friends and patients, and I use it myself. Many of us have found it very helpful for those restless nights when sleep does not come easily, for falling asleep on overnight flights, and any other situation in which you feel you need a little extra help with sleep.

Helpful Tips:

• Please do not use self-hypnosis for sleep in any scenario during which it would be dangerous for you to fall asleep (i.e. driving, operating machinery, etc).

• You can choose to memorize this script, and recite it to yourself in your mind, or you may prefer to use a recording of your own voice.

Step 1. Prepare to Sleep:

• Prepare to sleep by finding a comfortable position, laying in your usual location for sleep (for most people, this will be in their bed).

• If you are on an airplane or train, get as comfortable as you can while sitting up.

• Decide for yourself what you’d like your sleep to do for you – do you want your sleep to be restful? Restorative? Calming? Healing?  Choose three benefits you would like to experience while you sleep, and insert these into the following script where the letters are in bold.

Step 2. Self-Hypnosis for Sleep Script:

 1. Say to yourself (in your mind, not out loud): 

“I will count down from 10 to 1, and as I count down from 10 to 1, I will become progressively more relaxed, letting go of all of the tension in my body, letting go of all of the unnecessary thoughts in my mind….becoming so relaxed, and so tired, that by the time I reach the number 1, I will fall into a deep, restful, restorative sleep”.

2. Pause for several seconds.

3. Then say to yourself:

“10…starting to relax now, letting go of all of the tension in my body, letting go of all of the unnecessary thoughts in my mind…becoming so relaxed, and so tired, that by the time I reach the number 1, I will fall into a deep, restful, restorative sleep”

4. Pause for several seconds.

5. Then say to yourself:

“9… feeling more relaxed now, letting go of all of the unnecessary tension in my body, letting go of all of the unnecessary thoughts in my mind… …becoming so relaxed, and so tired, that by the time I reach the number 1, I will fall into a deep, restful, restorative sleep”

6. Pause.

7. Then say to yourself:

“8…. feeling even more relaxed now, more and more relaxed, letting go of all of the unnecessary tension in my body, letting go all of the unnecessary thoughts in my mind… …becoming so relaxed, and so tired, that by the time I reach the number 1, I will fall into a deep, restful, restorative sleep”

8. Continue to repeat this script for numbers 7 through 1… if you are still awake after you reach the number 1, then repeat the entire script.

In my experience, I usually fall asleep by the time I reach the number 6…

I hope you find this helpful, and may you enjoy your deep, restful, and restorative sleep…

What is Yoga Therapy?

Yoga therapy is a systematic and individualized approach to achieving well-being, by way of yoga.  The ultimate goal of yoga therapy is a healthy body and an integrated mind, which is achieved by correcting imbalances in the body and mind, through the practice of yoga.  

Correcting imbalances in the body usually involves the physical movement practice of yoga, also referred to as “postures” or “asanas”, and is what most people in the U.S. understand to be “yoga”.  Imbalances in the mind are usually corrected by regulation of the breath (pranayama) combined with meditation (focus).  From the perspective of yoga, the body and mind are very much influenced by our behaviors, such as our thoughts and actions.  Therefore, correcting imbalances in the body and mind also involves making changes to our behavior towards ourselves and others.

In other words, yoga therapy involves making intentional changes to the way individuals relate to themselves, and to others, to achieve mental and physical well-being. 

How is Yoga Therapy Applied to Mental Health?

The word “therapy” can be a bit confusing, particularly when yoga therapy is used in the context of mental health treatment.  Yoga therapy is not yoga plus psychotherapy; it is therapeutic through the transformative process of restoring balance to the body and mind, through the practice of yoga.    

In this context of yoga therapy for mental health, the purpose of the physical movement practice is to increase the quality of the breath, and to prepare the body to be in a state of meditation.  For most people, this requires correcting imbalances in the body that create discomfort, pain or restlessness in the body or mind when attempting to engage in breathing practices or meditation.   

From the perspective of yoga therapy, the state of the body, breath and mind are interdependent and always affecting each other, and they are always capable of changing.  Yoga therapy is a vehicle for change that works by addressing the imbalances in the body, breath, and mind that may result in illness, and offers a path towards long-lasting health and well-being.

Where Can You Learn More About Yoga Therapy?

Here are a few resources that I recommend to anyone who is interested in learning more about yoga therapy:

•  https://www.svastha.net

•  https://yogaknowledge.net

• “Yoga Therapy: A Guide to the Therapeutic use of Yoga and Ayurveda for Health and Fitness.” A.G.Mohan and Indra Mohan

• “Yoga for Body, Breath, and Mind: A Guide to Personal Reintegration.” A.G.Mohan

What is Integrative Psychiatry?

Integrative psychiatry is an approach to mental health treatment that combines psychotropic medications with non-medication alternatives.  These non-medication treatment options are numerous, and can include psychotherapy, nutritional or herbal supplementation, mindfulness-based interventions, meditation, yoga, lifestyle changes, hypnotherapy, acupuncture, etc.  The intention behind choosing an integrative approach may vary based on the psychiatrist, however, in my experience, most of us who identify as integrative are interested in prevention, understand both the usefulness and the limitations of medications, and want to offer our patients more choices on their path towards well-being.  Usually this requires additional education, training, and experience beyond our medical school and residency or fellowship training, in one or more complementary modality.   In my clinical practice, I rely heavily on experiential mind-body practices, based on the principles of classical hatha yoga, due to my training in yoga therapy, pranayama and meditation.  This is not instead of, but in addition to medications, the evidence-based use of nutritional supplements and life-style optimization strategies.

Why Integrative Psychiatry?

Medications play an important role in most moderate to severe mental health challenges, however not all patients respond to medications, some patients respond only partially, and others cannot tolerate medications due to their side effects.  Integrative modalities are used to augment medications, meaning that they can fill the gap in treatment that medications cannot achieve, helping patients to move closer towards their well-being goals.  The integrative psychiatry approach also offers patients something medication alone cannot, which is the opportunity to create long-lasting positive changes to their lives through building new habits, new ways of interacting with themselves and others, and a new relationship to their bodies and minds.  One way to think of this is that integrative approaches involve learning life skills that are free to use, do not have side effects, and do not depend on anyone except the individual, and their choices.   The goal of integrative psychiatry is whole-person well-being, and this usually requires more than medication alone.