Clinical article

Use of Mind-Body Therapies in Psychiatry and Family Medicine Faculty and Residents: Attitudes, Barriers, and Gender Differences

Victor Sierpina MD1, , , Ruth Levine MD1, John Astin PhD2 and Alai Tan MD, PhD3
1University of Texas Medical Branch, Galveston, TX
2California Pacific Medical Center, San Francisco, CA
3Office of Biostatistics, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX

Available online 13 March 2007.

Background

Mind-body medicine (MBM) approaches to many health problems have been well documented in the literature, including through multiple meta-analyses. Efficacy has been well demonstrated in conditions such as headache, irritable bowel syndrome, anxiety, fibromyalgia, hypertension, low back pain, depression, cancer symptoms, and postmyocardial infarction. However, an apparent disconnect (ie, translational block) prevents more widespread adoption of such therapies into practice. Biofeedback, relaxation therapy, hypnosis, guided imagery, cognitive behavioral therapy, and psychoeducational approaches are the domain of MBM we examined in assessing physician attitudes, beliefs, and practices.

Methods

Using a Web-based survey, we obtained responses from 74 faculty and resident physicians in the Department of Family Medicine and the Department of Psychiatry. Our response rate was 69%. We conducted descriptive statistics, bivariate analysis, and multivariate analysis using a logistic regression model. Various statistics were chosen depending on the nature of analyzed variables. Synoptic tables are presented.

Results

Comparing these cohorts, we found little difference between physicians in the two specialties, but substantial reports that barriers to the use of MBM were largely based on lack of training, inadequate expertise, and insufficient clinic time. Lack of expertise and insufficient clinic time were higher among family physicians than among psychiatrists. There was a high interest in both groups in learning relaxation techniques and meditation and lower interest in biofeedback and hypnosis. Female physicians were significantly more likely to use MBM, both with patients and for their own self-care, and were less likely to be concerned that recommending these therapies would make patients feel that their symptoms were being discounted. Female physicians also had significantly higher beliefs about the benefits of MBM on health disorders in several of the conditions examined, with a consistent though nonsignificant trend in others.

Key words: Mind-Body therapies; medical education; translational barriers

Complementary medicine treatments for fibromyalgia syndrome

Brian M. Berman MD, Director, Complementary Medicine Programf1 and James P. Swyers MA, Senior Science Writer, Complementary Medicine Program
University of Maryland School of Medicine, Third Floor, Kernan Mansion, James L. Kernan Hospital, 2200 Kernan Drive, Baltimore, MD 21207-6697, USA
Received 1999, Accepted 1999 Available online 6 April 2002.

Abstract

Fibromyalgia is a chronic-pain-related syndrome associated with high rates of complementary and alternative medicine (CAM) use. Among the many CAM therapies frequently used by fibromyalgia patients, empirical research data exist to support the use of only three: (1) mind–body, (2) acupuncture, and (3) manipulative therapies for treating fibromyalgia. The strongest data exist for the use of mind–body techniques (e.g. biofeedback, hypnosis, cognitive behavioural therapy), particularly when utilized as part of a multidisciplinary approach to treatment. The weakest data exist for manipulative techniques (e.g. chiropractic and massage). The data supporting the use of acupuncture for fibromyalgia are only moderately strong. Also, for some fibromyalgia patients, acupuncture can exacerbate symptoms, further complicating its application for this condition. Further research is needed not only in these three areas, but also for other treatments being frequently utilized by fibromyalgia patients.

Author Keywords: acupuncture; biofeedback; chiropractic; cognitive-behavioural therapy; complementary/alternative medicine; fibromyalgia; hypnotherapy/hypnosis; manipulation; massage

An recent article in the Journal of Musculoskeletal Pain (Geenen, 2009) points out that even though the number of studies on Fibromyalgia Syndrome (FMS) have increased six times over what existed 20 years ago, the struggle for validation of this condition is still ongoing. This search for validation is a very important issue for many who suffer with FMS and are reminded on a daily basis how real the pain is. The Dutch Fibromyalgia Association has made validation an important issue.

Source:

Geenen, R. (2009) Journal of Musculoskeletal Pain, Vol 17 Issue 1, p 80-85

Anne M. McCaffrey1, 2 , Guy F. Pugh1 and Bonnie B. O’Connor2, 3

(1) Marino Center for Progressive Health, 2500 Massachusetts Avenue, Cambridge, MA 02140, USA
(2) Division for Research and Education in Complementary and Integrative Medical Therapies, Harvard Medical School Osher Institute, Boston, MA, USA
(3) Department of Pediatrics, Brown Medical School, Providence, RI, USA
Received: 14 January 2007 Revised: 20 June 2007 Accepted: 3 July 2007 Published online: 11 September 2007

Abstract
Background Integrative medicine (IM), a combination of conventional and complementary and alternative medicine (CAM), has become a popular source of medical care, yet little is known about its use.
Objective To identify the motivations of people who choose IM for their primary care needs.
Design Qualitative study from focus group data of regular users of IM.
Participants Six focus groups that include a total of 37 regular users of IM who consented to participate in a study of IM use.
Approach Focus group meetings were audiotaped and transcribed verbatim. Qualitative analysis using grounded theory was used to derive the motivations for use of IM.
Results Participants beliefs include the following: the combination of CAM and conventional medicine is better than either alone; health is a combination of physical, emotional, and spiritual well being; nutrition and lifestyle play a role in wellness; and pharmaceuticals should be avoided except as a last resort. Participants suffer from health problems that are not well treated by conventional medicine. Participants want to discuss CAM with physicians and obtain guidance on its use. Participants want time with their providers, to feel listened to and to have the opportunity for shared decision-making.
Conclusion Much of what patients are seeking in integrative medical care is likely universally shared: a strong therapeutic relationship with providers who listen and provide time and knowledgeable advice. Users believe a combined approach of CAM and conventional medicine is better than either alone and want to be able to discuss CAM use with their providers.
KEY WORDS CAM – integrative medicine – patient satisfaction – therapeutic encounter

Anne M. McCaffrey
Email: amccaffrey@marinocenter.org

Understanding Patient Preference for Integrative Medical Care: Results from Patient Focus Groups
Journal Journal of General Internal Medicine
Publisher Springer New York
ISSN 0884-8734 (Print) 1525-1497 (Online)
Issue Volume 22, Number 11 / November, 2007
Category Original Article
DOI 10.1007/s11606-007-0302-5
Pages 1500-1505
Subject Collection Medicine
SpringerLink Date Tuesday, September 11, 2007

Here are excerpts from: Formulary; Feb2009, Vol. 44 Issue 2, p32-33, 3p about the newly FDA approved Milnacipran for fibromyalgia. Please note the safety precautions. There are some heavy duty concerns that should not be dismissed. Please choose wisely. Hope you are all doing as well as possible.

Selective noreplnephrine and serotonin
reuptal management of fibromyaigia

Milnacipran is a selective norepinephrine
and serotonin reuptake inhibitor that inhibits
norepinephrine uptake with greater
potency than serotonin uptake. The
precise mechanism by which this agent
inhibits pain and improves the symptoms
of fibromyaigia is unknown. Milnacipran
was approved on January 14, 2009, for
the management of fibromyaigia.

Milnacipran-treated patients
were also more likely to rate themselves
as much improved or very much improved
on the patient global assessment

Safety. Patients with depression or other
psychiatric disorders may experience worsening
of depression, suicidal ideation and
behavior, or unusual changes in behavior;
treatment with drugs that inhibit norepinephrine
and/or serotonin reuptake may play
a role in inducing these symptoms. Patients
treated with antidepressants should therefore
be monitored closely for changes in behavior,
especially early in treatment and at times of
dose changes. Treatment with drugs that
inhibit serotonin reuptake may lead to the development
of serotonin syndrome, especially
when these agents are used concomitantly
with serotonergic drugs and drugs that impair
the metabolism of serotonin. Inhibition
of norepinephrine and serotonin may lead to
cardiovascular effects, particularly increases
in blood pressure and heart rate. In clinical
trials, treatment with milnacipran was associated
with mild elevations of alanine aminotransferase
(ALT) or aspartate aminotransferase
(AST). Treatment with milnacipran
may lead to hyponatremia. Patients treated
with this agent may have an increased risk
of bleeding events. Milnacipran can affect
urethral resistance and micturition. Patients
treated with milnacipran have experienced
mydriasis; this agent should be used with
caution in patients with controlled narrowangle
glaucoma. The most common adverse
events associated with milnacipran treatment
include nausea, constipation, hot ñush, hyperhidrosis,
vomiting, palpitations, increased
heart rate, dry mouth, and hypertension.
Dosing. The recommended dose of mil

Here is an interesting study that supports the important role that the mind plays in fibromyalgia. An earlier study posted shows that the changed brain chemistry is similar to people who suffer from depression. Please note and read other posts about how hypnosis can clear up depression (and ultimately change brain chemistry?).

Pain In Fibromyalgia Is Linked To Changes In Brain Molecule

ScienceDaily (Mar. 13, 2008) — Researchers at the University of Michigan Health System have found a key linkage between pain and a specific brain molecule, a discovery that lends new insight into fibromyalgia, an often-baffling chronic pain condition.

In patients with fibromyalgia, researchers found, pain decreased when levels of the brain molecule called glutamate went down. The results of this study, which appears in the journal Arthritis and Rheumatism, could be useful to researchers looking for new drugs that treat fibromyalgia, the authors say.

“If these findings are replicated, investigators performing clinical treatment trials in fibromyalgia could potentially use glutamate as a ‘surrogate’ marker of disease response,” says lead author Richard E. Harris, Ph.D., research assistant professor in the Division of Rheumatology at the U-M Medical School’s Department of Internal Medicine and a researcher at the U-M Chronic Pain and Fatigue Research Center.

The molecule glutamate is a neurotransmitter, which means it conveys information between neurons in the nervous system. When glutamate is released from one neuron, it diffuses across the space between cells, and then binds to receptors on the next neuron in line and causes the cell to become excited, or to be more active.

This molecule was suspected to play a role in fibromyalgia because previous studies had shown that some brain regions in fibromyalgia patients appear to be highly excited. One such region is the insula.

In functional magnetic resonance imaging (fMRI) studies, researchers at U-M had previously shown that the insula displays augmented activity in fibromyalgia, which means neurons in these patients are more active in this part of the brain. The U-M team hypothesized, Harris notes, that more activity among these neurons might be related to the level of glutamate in this region.

To gauge the linkage between pain and glutamate, the researchers used a non-invasive brain imaging techinique called proton magnetic resonance spectroscopy (H-MRS). H-MRS was performed once before and once following a four-week course of acupuncture or “sham” acupuncture.

Researchers used either acupuncture or sham acupuncture to reduce pain symptoms. The sham procedure involved using a sharp device to prick the skin in order to mimic real acupuncture sensations.

Following the four weeks of treatment, both clinical and experimental pain reported were reduced significantly. More importantly the reduction in both pain outcomes was linked with reductions in glutamate levels in the insula: patients with greater reductions in pain showed greater reductions in glutamate. This suggests that glutamate may play a role in this disease and that it could potentially be used as a biomarker of disease severity.

Because of the small number of participants in this study, further research should be conducted to verify the role of glutamate in fibromyalgia, Harris says.

The senior author of the study was Daniel J. Clauw, M.D., director of the U-M Chronic Pain and Fatigue Research Center. Other authors were Richard H. Gracely, Ph.D., and Seong-Ho Kim, M.D., of the U-M Department of Internal Medicine; Pia C. Sundgren, M.D., Ph.D., Yuxi Pang, Ph.D., and Myria Petrou, M.D., of the U-M Department of Radiology; Michael Hsu, M.D., of the U-M Department of Physical Medicine and Rehabilitation; and Samuel A. McLean, M.D., of the U-M Department of Emergency Medicine.

Funding came from a Department of Army grant, the National Institutes of Health, and the NIH National Center for Complementary and Alternative Medicine.

Reference: Arthritis and Rheumatism, March 2008, Volume 58, Issue 3, “Dynamic Levels of Glutamate within the Insula are Associated with Improvements in Multiple Pain Domains in Fibromyalgia.”

Adapted from materials provided by University of Michigan Health System.

University of Michigan Health System (2008, March 13). Pain In Fibromyalgia Is Linked To Changes In Brain Molecule. ScienceDaily. Retrieved April 7, 2008, from www.sciencedaily.com­ style=”font-size: 1px;”> /releases/2008/03/080310112658.htm

A new study just reported in June’s Clinical Rheumatology states that , “There is a statistically significant correlation between self-reported and objective measurements of disability for the fibromyalgia patients” (p.711) and this highly correlates with the objective measurements of disability that is self reported by patients with Rheumatoid Arthritis. Those medical professionals who continue to dismiss an individual’s fibromyalgia complaints should pay heed to this study.

For more information check out the full article in this month’s journal:

Raftery, G., Bridges, M., Heslop, P., & Walker, D.J. (2009). Are fibromyalgia patients
as inactive as they say they are? Clinical Rheumatology, 28,
Retrieved June 7, 2009, from Academic Search Premiere database.