Abstract
With the advent and acceptance of biological medicine, now called as modern biomedicine (or allopathy), the older regional medical systems were categorized as complementary and alternative medicine (CAM). Recently, the term CAM has been replaced with “integrative medicine.” This viewpoint manuscript focuses on the essential connotation of such terms and clarifies the debates on the several confusing terminologies hampering its actual conceptualization and leading to the “othering” phenomenon in health care approaches. Integrative medicine, in its essence, is a form of holistic and evidence-based health care approach that includes but is not limited to medical treatment. A closer look at the current management protocols of most noncommunicable diseases, such as diabetes mellitus, hypertension, obesity, pain syndromes, and psychiatric illnesses reveals that it incorporates relevant evidence-based management of all health care domains, along with mainstream pharmacologic and surgical treatment options. These management approaches point toward an already existing integration in the mainstream medical practice. Simultaneous management of all the dimensions of health and illness by expanding the current sphere of integration will ultimately result in comprehensive patient care. Therefore, we conclude that integrative medicine is essentially an application of different “culturally sensitive” health care approaches, optimally tailored to a given patient's needs and difficulties. Efforts are needed at the clinical, research, and administrative levels to reduce the “othering” phenomenon seen in health care approaches that are often detrimental to efficient patient care. There is a need to promote collaboration between different disciplines and generate evidence base to optimize integrative medical practice further. Establishing interdisciplinary departments of integrative medicine at mainstream medical institutions may be the first step in this direction.
Preamble
History of medical care can be traced back to ancient times all over the world. 1 Historically, there was an era when diseases were considered to be caused by evil spirits entering the body. Witchcraft, black magic, trepanation, mummy powder therapy, and so on were tried as treatments for the same. 2 Later, medical systems based on concepts of health and illnesses evolved. Ancient medical practices considered human bodily structure and functions and their abnormalities in a holistic way. Ancient India, Greece, Egypt, Rome, Arabia, Persia (now Iran), China, Africa, Australia, and South America all practiced their own forms of traditional medicines as evidenced from several inscriptions. 3
Gradually modifications and sophistication were introduced in the previously chronicled methods of medical management; surgical treatment being an example. With improvement in the knowledge of human anatomy, germ theory of infectious diseases, trauma management and the like, medical practice was constantly updated and improved. The 19th and 20th centuries saw the advent of specific biologic treatments, radiologic imaging techniques, development of chemical, molecular, and genetic laboratory investigation techniques, and further novel areas for scientific research, including both technology and medicine. 1
The current mainstream medical practice (allopathy) is often denoted as biomedicine, and the other existing medical practices as complementary and alternative medicine (CAM). 4 The use of CAM has been on the rise in the past few decades all over the world, with hospitals and care facilities often incorporating it into their management plans. 4 The National Center for Complementary and Alternative Medicine (NCCAM) was established in 1998 under the National Institute of Health, United States in view of the wide use of CAM, which was unregulated until then. 5 Recently its name has been changed to the National Center for Complementary and Integrative Health (NCCIH). 6 This denotes a change in the conceptualization of CAM as a comprehensive integrative health care practice.
In this article, we shall delve deeper into the concept of integrative medicine and try to answer a pertinent but yet-unanswered question, “What is, and what is not, integrated medical care?”
Nomenclature: Clarification of Concept and debates
Integrative medicine has been known by several names, including CAM, holistic medicine, traditional medicine, and region-specific names such as oriental medicine or Indian systems of medicine, mind–body medicine, functional medicine, to name a few. The definition of CAM as given by the former NCCAM is that it refers to “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”4,7 Ernst et al. defined CAM as “diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine.” 8
These descriptive definitions have been criticized due to their inability to clearly explain the concept and attributes of CAM. Rees and Weil suggested that integrative medicine is not just a synonym for CAM, and that the connotation it has is much more extensive; integrative medicine focusses on overall health and healing rather than just disease and treatment. 9 NCCIH also emphasizes on the concept of integrative health as a holistic approach to health and well-being, achieved by coordinated conjoint use of conventional and complementary medicines. 10 It brings natural products (e.g., herbs, vitamins, minerals, and probiotics), mind and body practices (e.g., yoga including meditation, chiropractic manipulation, Tai Chi, qigong, and massage), and other health approaches (Ayurveda, Traditional Chinese Medicine [TCM], homeopathy, and naturopathy) under the rubric of complementary health approaches. 10
The debate regarding the terminology is discussed in a qualitative study by Holmberg et al. from four perspectives, namely medical practice, research, public relations, and health care delivery. This study found integrative medicine to be a term well agreed-upon, conveying its role in medicine and health care. 11 While an appropriate term plays an important role in elucidating the underlying concept, excessive focus on it may actually be counterproductive by narrowing the repertoire. Thus, it is important that we discard the technicalities of naming and stick to the core concept of integrative medicine as it stands now, as per the NCCIH.
It is pertinent to mention in this study the salient points of the continued debate and conflict regarding integration of different medical systems and health approaches. They include safety concerns, lack of well-designed efficacy studies, insufficient knowledge about drug–product interactions, lack of stringency in regulatory control over products leading to misuse, statistically significant bias in mainstream medicine journals against CAM, and conflict between research- and clinical-based practice. 12 In contrast, research in complementary health care approaches has increased and significant data exist on the benefit of certain practices in some illnesses.13–15 In the next section, we discuss the current evidence-based management protocols in some common physical and psychiatric illnesses.
Evidence of Integration in Mainstream Medical Practice Across Categories and Dimensions
Dimensions of health and wellness include physical, intellectual, emotional, social, vocational, financial, and environmental ones.
16
A holistic health care management comprises management of all the dimensions, medical being one of them. An effective interdisciplinary collaboration is required for comprehensive health care provision.
17
We argue that the current approach followed by mainstream medicine is also integrative in its essence. This can be illustrated in the current evidence-based management protocols of some important noncommunicable diseases discussed hereunder:
Nutritional recommendations and exercise are well evidenced in the literature as effective primordial and primary prevention as well as management modalities for borderline to mild clinical illness. The American Diabetes Association (ADA) has given evidence-based recommendations for lifestyle management, including nutrition and physical activity.
19
Broadly, they focus on timely evidence-based patient-centered management, both pharmacologic and nonpharmacologic. The 2021 revision of the ADA guidelines on standards of medical care in diabetes includes social and cost domains, with a focus of care improvement and health promotion in DM rather than only clinical management. Comorbidity (e.g., obesity, cardiovascular illnesses, and dyslipidemia) management has been emphasized. Behavior change and well-being have also been recognized as important predictors of outcome.
20
Lifestyle modification is considered as first-line treatment along with antihypertensives, whose effects are often enhanced with lifestyle modification. They include in the assessment the psychosocial history, history of depression, physical activity, diet, tobacco and alcohol consumption, in addition to the clinical history, examination, and laboratory investigations of hypertension and associated cardiovascular and other medical morbidities.
22
Thus, careful examination of existing clinical recommnedations for management of most of the non-communicable diseases reveal that management is essentially integrative and holistic (includes all the dimensions of the healthcare).
23
Metabolic syndrome consists of the clinical parameters of insulin resistance (impaired glucose tolerance, increased fasting plasma glucose, type 2 DM, and lowered insulin sensitivity), increased body weight (waist-to-hip ratio >0.90 in men and 0.85 in women), dyslipidemia (triglycerides >150 mg/dL and/or high-density lipoprotein <35 mg/dL in men or <39 mg/dL in women), and deranged blood pressure (>140/90 mmHg). Although the etiopathology can be multiple (genetic factors, immune-metabolic dysregulations, lifestyle factors, psychiatric illness and care, and medical illness and care), metabolic syndrome is indicative of increased risk of cardiovascular morbidities and DM.22,25 The American Heart Association treatment goals encompass management of lifestyle risk factors, elevated blood pressure and plasma glucose, and prothrombotic state. In lifestyle modification, weight reduction, physical activities, and dietary management are considered beneficial in prevention in high-risk individuals, for example, those on second-generation antipsychotics.25,26 Limited evidence exists for drugs such as nebivolol, bisoprolol, carbamazepine, gabapentin, fluoxetine, nicardipine, verapamil, nimodipine, and nifedipine. In addition to the pharmacotherapy, there is grade-B evidence for nonpharmacologic managements such as relaxation training, thermal biofeedback, and cognitive behavioral therapy (CBT) in prophylaxis. Acupuncture has a grade-A evidence as a useful adjunct in migraine prophylaxis.28,29 Identification and management of environmental, behavioral, and dietary triggers of migraine are also recommended by the American Association of Family Physicians in preventive treatment.
28
Massage, yoga, and aerobic exercises are also advocated as adjuncts to first-line treatments.
30
LBP is a common musculoskeletal condition, with an age-standardized point prevalence of 7.5% as of 2017, causing significant disability.
31
The management requires assessing for red flag signs such as cancer, immunosuppression, intravenous drug use, fever, incontinence, unexplained weight loss in history, and saddle anesthesia, motor weakness in lower extremity, reduction in anal sphincter tone, and neurologic deficits on physical examination.
32
A careful evaluation of the causes and treatments thereof are recommended. Medical and psychiatric assessments are to be done simultaneously. For the various attributes of LBP, CBT, self-exercise, patient education, physical therapies such as ultrasound, heal/cold therapy, transcutaneous electrical nerve stimulation, spinal manipulative therapy, bracing, acupuncture, massage, yoga, interlaminar injections, annuloplasty, and pain-relieving medications are recommended with various degrees of evidence.
32
The American College of Physicians also advised noninvasive options such as acupuncture, massage, superficial heat, NSAID, skeletal muscle relaxant as first line for acute or subacute LBP. Multidisciplinary rehabilitation, exercise, Tai Chi, yoga, mindfulness-based stress reduction, relaxation, biofeedback (thermal and electromyography), CBT, and acupuncture are recommended for chronic cases. Yoga is among the options that the American College of Physicians recommends for first-line treatment of chronic LBP.
33
In patients with chronic LBP not responding to nonpharmacologic management, NSAID can be given as first-line medicine, and tramadol or duloxetine as second line. Opioids are advocated for use only in very limited cases with insufficient response to other treatments, after weighing for risk and benefit.
34
Role of appropriate psychosocial interventions is also emphasized in these guidelines. Among the psychotherapies, good evidence exists for self-help, CBT, behavioral activation, interpersonal therapy, and others such as problem-solving therapy, psychodynamic psychotherapy, behavioral couples therapy, marital therapy, and family therapy. Physical activities are also mentioned in cases of mild to moderate depression.36,37 The American Psychiatric Association (APA) guidelines for management of major depression mention acupuncture, folate, S-adenosyl methionine (SAMe), St. John's wort, and light therapy as potential treatment options.
37
Both National Institute for Health and Care Excellence (NICE) and APA guidelines incorporate assessment and management of psychosocial factors and comorbidities along with the primary treatment of depression.36,37 However, the management does not stop at reduction of the positive symptoms. Patients may often have deficits in general and social cognition, general well-being, quality of life, and may have persistent negative symptoms, leading to disability.
41
Comorbidities are high in schizophrenia patients. These comorbidities may be due to the illness itself or medications. Lifestyle modifications and drug therapy are recommended to manage them.39,40 A successful rehabilitation plan is needed for a comprehensive management of schizophrenia. The Schizophrenia Patient Outcomes Research Team found benefits of psychotherapeutic techniques such as social skill therapy, supported employment, CBT, assertive community treatment, token economy, family therapy, and psychosocial interventions for substance use and weight reduction.
42
The NICE guidelines in 2014 included yoga as one of the complementary approaches in schizophrenia due to its demonstrated benefit in reducing negative symptoms and improving social cognition.
43
Thus, although the acute treatment of schizophrenia is essentially pharmacologic, long-term management includes psychosocial, environmental, and physical domains. Some of the major noncommunicable disorders causing significant global disease burden are mentioned in this study. The list, however, is not exhaustive. There are other conditions, such as Parkinson's disease, dementias, motor neuron disease, multiple sclerosis, and cardiovascular and cerebrovascular illnesses that contribute to considerable morbidity and mortality. In the standard treatment guidelines of these illnesses, the management approach recommended is patient-centered and holistic, catering to all the dimensions of health, including medical care.
Where Does Integration Lie?
From the aforementioned discussion, it is noticeable that integration of different health care approaches is carried out all over the world without giving it a particular name. Lifestyle management in form of diet and physical exercise forms an integral part of almost all the preventive and treating mainstream medicine protocols, as mentioned earlier. Yoga, Tai Chi, qigong, acupuncture, and other mind–body practices are often recommended as add-on to medical treatment. In psychiatry, the role of comprehensive management is widely seen in chronic SMIs, wherein medical, psychiatric, psychological, occupational, social, environmental, financial domains are included in the long-term plan.
Thus, careful examination of existing clinical recommnedations for management of most of the non-communicable diseases reveal that management is essentially integrative and holistic (includes all the dimensions of the healthcare).
Other Systems of Medicine and Integrative Approach: Expanding the Scope
Physical exercise, dietary regulation, and to some extent yoga have already been incorporated in standard medical practice at present. However, these are not the only forms of treatment available across the world. TCMs include acupuncture, cupping, moxibustion, massage, herbal medicines, and mind–body practices such as Tai Chi and qigong. The therapeutic goal of TCM is to correct the disease-causing imbalance of the opposing life forces (Yin and Yang) and enhance vitality. 44 Similarly, traditional Indian medicines such as Ayurveda, Siddha, and Unani focus on the treatment of a disease and promotion of well-being in a holistic manner, taking into account the personal attributes of each patient.
The therapeutic goals include enhancing longevity and rejuvenating the body, besides treatment of the disease. 45 Many other forms of treatment are available worldwide, such as herbal remedies from different geographical areas, reflexology, chiropractic, spinal manipulation, massage, and relaxation techniques. 46
Yoga is known to improve depression, anxiety, autonomic hyperactivity, and promote mindfulness and acceptance, and scientific studies on yoga have been on the rise. 47 Similarly, there are Ayurvedic herbal formulations such as ashwagandha (Withania somnifera), brahmi (Bacopa monnieri), which are shown to have beneficial effects in cognitive impairment and dementia, depression, anxiety, schizophrenia, Parkinson's disease, ataxia, amyotrophic lateral sclerosis, attention-deficit/hyperactivity disorder, and so on.48,49 The active phytoconstituents of these herbs have been analyzed. Mechanistic pathways for action have also been proposed and that includes inflammatory, immune, oxidative, and endocrine, causing adaptogenic effects.50,51
TCM has also been demonstrated to act at molecular, biochemical network, tissue, and organ levels. 52 Nutritional supplements such as folic acid, SAMe, curcumin, St. John's wort, omega-3 fatty acids, vitamin E, and vitamin B are well studied in terms of effects, side effects, contraindications, and dosage, and are prescribed in conventional clinical settings. Essentially, all the traditional systems of medicine follow an inclusive approach in diagnosing and managing medical conditions.
The concept of holism is evident in the ancient texts, including Charaka Samhita (Shareera Sthana, 1st Chapter, 86th Shloka) and Sushruta Samhita (Sutra Sthana, 4th Chapter, 7th Shloka) from India. There is evidence of holistic practices all across the world with similar basic principles modified by indigenous properties. 53
Thus, there is a vast scope of expanding the current medical practices to incorporate the evidence-based traditional medicines. For example, an integrated system of health care exists in Cameroon, Central Africa, in collaboration with WHO, and is considered to have some role in improving health care access and treatment gap in the face of poverty and other socioenvironmental disadvantages. 54
Stumbling Blocks in Conceptualization and Application
The conceptualization of all the current medical practices as essentially integrative practices stumbles on the confusion regarding the nomenclature. Owing to the varied, inconsistent, and stigmatized naming of the other modes of treatment, the fundamental understanding is often lost. This next problem is the lack of knowledge among professionals. Owing to strict separation of medical and paramedical training, a professional trained in one form of health care often has minimal or no understanding of the other forms. This invariably leads to disapproval of the other management approaches as well as narrowing the range of health care delivery.
Belief systems of both the practitioners and patients may be responsible for creating the dichotomy and poor acceptance of an integrative medical care. Another pertinent issue is the lack of well-designed studies to establish the efficacy and safety of several CAM modalities. Although there is an increase in research work in yoga, Ayurveda, and Siddha in the past few decades, the evidence is still not robust for all clinical conditions. Wholesome integration gets jeopardized because of lack of methodologically sound data on mechanisms of action, safety, and drug–product interactions.
TCM also encounters similar problems, although research is being carried out on toxicologic analysis, dose–toxicity relationships, and drug interactions. Similar large-scale research is required for the other traditional therapies as well. Other obstacles to realization of integration include unethical practices and unscientific propagation by untrained professionals, thereby reducing acceptance in the scientific community and raising doubt regarding their validity.
What Is Not Integrative Medicine?
As noted in the earlier discussion, integrative medicine is the inclusive medical practice of all modalities of evidence-based treatment. However, there are several treatment practices that, although globally followed, do not have sufficient evidence for efficacy and safety. Reiki is one such example whose efficacy is not established for the conditions studied such as depression, anxiety, and pain. 55 Another instance may be herbs such as Yohimbe, cinnamon, Cat's claw, dandelion, to name a few. 46 Yohimbe is widely used in the Central and Western Africa for erectile dysfunction, but it has a significant number of adverse effects such as seizure, tachycardia, and other cardiovascular morbidities.
In view of the possible benefit but definitive risk, Yohimbe is not recommended as a dietary supplement. Cinnamon, although investigated for DM and irritable bowel syndrome, has not been found unequivocally effective. Besides these examples, it is pertinent to mention that not all treatment modalities among the traditional systems are thoroughly investigated for safety and efficacy. Thus, it is important to emphasize that integrative medicine, as it should be practiced and conceived, involves the amalgamation of only the treatment procedures whose safety and efficacy are acceptable.
Conclusion and Future Directions
To summarize the discussion, we can say that health care, practiced properly, is integrative medicine, integrating more than one principle of treatment. As emphasized in this article, patient-centered health care is the call of the hour across disciplines. A holistic health care management includes management of all the dimensions of health and well-being, including but not limited to medical treatment. Integrative medicine is essentially an application of different health care approaches, optimally tailored to a given patient's needs and difficulties. All the modalities may not be needed in every patient and thus, customizing the health care to the individual profile will make the health care delivery truly patient centered.
From the current scenario of working in silos, there is a need to incorporate approaches that are more inclusive. To achieve the same, the stumbling blocks need to be removed by strengthening scientific research-based evidence for all forms of management, improving awareness in the population regarding benefits and adverse effects of all medical practices. Educating the professionals of different disciplines on the fundamentals of different systems of medicine, mind–body practices, nutritional supplements, and advocating collaborative treatment practice by bringing all the professionals together and encouraging interdisciplinary dialogue will be conducive to the proper evolution of integrative medicine.
Efforts at institutional, national, regional, and international levels in this direction will establish a comprehensive health care beyond the puzzling, inconsistent, and meaningless trivia of nomenclature, and will pave the way toward establishing the integrative health care approach as the mainstream management offered by the state or national health systems. Establishing such interdisciplinary departments of integrative medicine at mainstream medical institutions may be the first step in this direction.
Footnotes
Acknowledgments
Authors thank the Ministry of AYUSH, Government of India for funding the Center of Excellence in AYUSH Research at the National Institute of Mental Health Neurosciences, Bengaluru, India. The Wellcome Trust/Department of Biotechnology (DBT) India Alliance supports H.B. and S.V., respectively, with early and intermediate career fellowships for research in integrative medicine.
Author Disclosure Statement
H.B. is on the editorial board of Integrative Medicine Reports journal. Other authors have no competing financial interests.
Funding Information
No funding was received for this article.