Holistic strategies for treating mental disorders

Article 1:

Mental health and mental disorders

The brain is one of the most complex structures in the universe. The 86 billion nerve cells of the brain communicate by various chemical messengers, known as neurotransmitters, in trillions of nerve cell connections, called synapses (Herculano-Houzel, 2012). Even if we know many parts of this complex brain machinery and its interaction with the rest of the body, our understanding of exactly how everything works is rather limited. That makes it difficult to know precisely what is malfunctioning in various mental illnesses.

The complex biological machinery of the brain produces the psychological mind. Just as the heart pumps blood, the gut digests food, and the muscles move the body, the mind is a bodily function of the brain. As with any organ of the body, when the brain does not develop properly, when it’s not nurtured, cared for, stimulated, and exercised appropriately, or when it is hurt, harmed, and injured in some way, it may malfunction. The mind is impacted, and the dysfunctions may manifest as mental illnesses.

The mind is where we experience and reflect on ourselves, our relationships, our environment, and the world. It is comprised of thoughts and feelings that direct our behaviors. Memory, sensation, interpretation, imagination, desire, intention, willpower, planning, and execution are essential mental faculties that constitute the mind. In mental disorders, our ability to exercise these faculties may be impaired. This in turn impacts how we function and relate to ourselves, others, and the social context we live in.

The historic conceptualizations of mental disorders have tended to focus either on causes related to the supernatural, the biology of the human body (somatogenic), or the psychology of the mind (psychogenic). “Supernatural theories attribute mental illness to possession by evil or demonic spirits, displeasure of gods, eclipses, planetary gravitation, curses, and sin. Somatogenic theories identify disturbances in physical functioning resulting from either illness, genetic inheritance, or brain damage or imbalance. Psychogenic theories focus on traumatic or stressful experiences, maladaptive learned associations and cognitions, or distorted perceptions (Farreras, 2022).” While supernatural theories have dominated the understanding of mental illnesses throughout much of history, and still are commonly held beliefs in various cultures and faith traditions, contemporary psychology and psychiatry predominantly focus on somatogenic and psychogenic theories, and consequently biological and/or psychological treatment strategies.

In its constitution adopted in 1948, mental health was defined by the World Health Organization (WHO) as; “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”(World Health Organization, 1948). Rather than focusing on one dimension of health, often to the exclusion of others, this definition of health seeks to reflect a more holistic model and perspective of health. The more holistic ‘biopsychosocial model’ of health and illness (Engel, 1977) has since gained widespread acceptance in healthcare, though clinical practice often fails to be truly holistic and often predominantly focuses on one aspect or another of health.

What is missing from WHO’s and Engel’s definitions and models, is the supernatural, or spiritual aspects of existence. Materialistic worldviews dominate medical and psychological sciences and may leave little or no room for a spiritual dimension of existence. There has been some reluctance to move toward an even more holistic ‘biopsychosocial-spiritual model’. In 1999, at the 52^nd Assembly of WHO, it was proposed to revise the definition of health and insert “spiritual”, so it would state that: “Health is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1999). The proposed amendment failed, but the WHO has still emphasized the importance of the spiritual dimension in the prevention and treatment of illness.

The term ‘spiritual’ may have different meanings for different people. A broad and comprehensive definition is “the search for ultimate meaning, purpose and significance, in relation to oneself, family, others, community, nature, and the sacred, expressed through beliefs, values, traditions and practices” (Puchalski et al., 2014). Another term for the study of mental disorders is “psychopathology”. It is a derivative of three Greek words: ψυχή (psychē), πάθος (pathos) and λόγος (logos)—which literally translated would be something like “soul suffering study” (McRay et al., 2016). Many people experience that sooner or later in life, issues of meaning, purpose, and significance become of utmost importance. In mental illness, many people also experience existential and spiritual questions and suffering. Meaning, purpose, and significance are matters of the soul, and spirituality should therefore be included in concepts of mental illness and our strategies for treating them.

A holistic perspective on mental disorders adopts a biopsychosocial-spiritual framework for understanding and treatment strategies. This allows care and treatment to address all dimensions of human existence through the many and varied interventions available in order to minimize the duration and extent of suffering. When interventions are complementary, one should not exclude another. Such a holistic strategy for treating mental disorders increases the likelihood of achieving remission or optimal management of a chronic mental disorder.

Article 2:

A holistic treatment strategy

Sometimes, because of the preferences and beliefs of the patient, family, peers, and even healthcare professionals, some may avoid and reject a holistic strategy for management and treatment. They may, for example, be unwilling to try out lifestyle interventions, medication, or counseling and psychotherapy. Despite these being well-proven strategies for treatment and recovery, some may only be willing to accept certain kinds of treatment or none at all. It is important to respect the convictions and wishes of a patient, yet when the patient has the mental capacity and ability to make informed decisions and provide informed consent, one may seek through empathetic dialog to convey information and understanding that may encourage them to accept appropriate interventions and treatments. Unfortunately, estimates suggest that only half of the people with mental illnesses receive treatment (National Institute of Mental Health, 2022d). A further problem is that the quality of care people with mental disorders receive too often is insufficient (World Health Organization, 2021). Whether due to insufficient availability and quality of care or choices of the patient, many who could be helped do not receive appropriate and sufficient care, and thus their suffering is needlessly prolonged and the chance of recovery diminished.

If we seek to apply a truly holistic approach to managing and treating mental disorders, we ought to adopt a biopsychosocial-spiritual model that takes an interest in and seeks to optimize every dimension of human existence; physical, mental, social, and spiritual. Appropriate healthcare providers should be consulted, and appropriate interventions initiated in a timely manner, and not delayed unnecessarily. Unfortunately, many suffer from mental disorders for months and years before seeking treatment. The course of the illness and the effect of the interventions should be properly monitored and evaluated, and adjustments made when indicated. The goal of the treatment may be full recovery, or optimal management of the illness if it is of a more chronic nature. When the treatment goals have been achieved, appropriate measures should be taken to prevent relapse or deterioration.

A key principle in any treatment plan is to assure, optimize, and expedite the desired effects of the treatment, meanwhile minimizing the risk of undesirable side effects and potential harm. Treatment plans for moderate to severe mental disorders require the expertise of competent mental health professionals, and in complex and/or severe cases, often multi-disciplinary teams.

The chosen strategy depends on the nature, severity, and duration of the illness. A common approach to treating mild to moderate mental disorders may be a stepwise strategy where one level builds on the preceding ones, as illustrated in figure 1, and each step increasingly requires more professionalized, sophisticated, and comprehensive care and interventions. Treatment may start with the basics of self-care, optimizing lifestyle, and relational and spiritual support. These “steps” may be supported by primary care providers, family, friends, and spiritual care providers. When this is not sufficient, counseling or psychotherapy will often be recommended. For this, trained mental health professionals are required. When this isn't sufficient, or the illness already is moderate to severe, then we'll go on to trying out medication, and possibly hospitalization. If we still haven't achieved recovery, then various brain stimulation therapies may be indicated.

Figure 1: 

 In moderate to severe mental disorders, and especially when there is a risk of harm to the patient by suicide or self-harm, or harm to others by violence, a treatment plan will often follow a different sequence of interventional “steps”. Hospitalization may be the first “step”, followed by other “steps”, like medication, depending on what is considered to be necessary and what the patient is considered to be able to benefit from. Again, determining and designing a treatment plan for such patients requires the expertise of competent mental health professionals.

Article 3:

Lifestyle optimization

Lifestyle impacts the risk of developing mental disorders, as well as recovery and management of mental disorders. It is well-documented that the following lifestyle factors may play a significant role in the trajectory of mental well-being:

Sleep

Almost all adults need somewhere between seven to nine hours of quality sleep every night. That means seven to nine hours of actual sleep time, not simply that many hours in bed. Kids and teenagers need more. Unfortunately, many fail to get adequate amounts of sleep (Bergland, 2019). Sleep deprivation destabilizes the brain, impairs memory function, and makes us more likely to swing between extremes of emotions. When the brain is underslept, the frontal lobe’s ability to control the centers of the brain that drive emotion, impulsivity, and reward-seeking is significantly impaired. Thus, the risk of negative mood, irrational actions and decisions, aggression, behavioral problems, and addictions is significantly increased. Sleep disruption is a symptom of most mental illnesses; but beyond being a symptom, insufficient sleep in itself may lead to mental illness (Walker, 2017). 

Exercise

Physical activity is one of the quickest ways to boost our brains. Within a few minutes of just about any activity, we may be reaping benefits. Many who exercise regularly say that the positive effects it has on the mind are as important to them as the beneficial physical effects. But there’s more to exercise than instant, desirable, short-term effects. The long-term benefits of exercise are well-proven. People who exercise report significantly fewer days of poor mental health than people who don’t exercise (Chekroud et al., 2018). Exercise releases endorphins that relieve physical and emotional pain and make you feel better. Exercise also boosts the neurotransmitter networks of serotonin, noradrenaline, and dopamine. It can actually be as potent as antidepressant medication, though that does not mean it is a substitute for medication. Exercise improves blood flow to the brain, reduces inflammation, promotes growth and healthy functioning of the nerve cells, and reduces stress (Korb & Siegel, 2015). Exercise may have preventative as well as therapeutic benefits on various mental disorders, such as depression, anxiety, and others, as well as Alzheimer’s and Parkinson’s diseases (Walsh, 2011).

Nutrition

The foods we eat and the fluids we drink become the bodies we are. For optimal functioning of the brain in a healthy body, the raw materials matter. “Diets higher in whole foods, such as vegetables, fruits, whole-grain cereals, beans and legumes, nuts and seeds, fish and olive oil, are consistently associated with a reduced risk of depression” (Jacka, 2019). On the other side, “diets higher in ‘junk’ foods, such as sugar-sweetened drinks, fried foods, pastries, doughnuts, packaged snacks, and processed and refined breads and cereals are consistently linked to a higher risk of depression” (Jacka, 2019). Similar results for anxiety and other mental disorders have been found.

Nature

Many of us live and spend most of our time in man-made urban environments with little access to nature experiences. This may contribute to mental distress, meanwhile, exposure to nature may be beneficial to mental well-being. Research “links nature experience with increased positive affect; happiness and subjective wellbeing; positive social interactions, cohesion, and engagement; a sense of meaning and purpose in life; improved manageability of life tasks; and decreases in mental distress, such as negative affect. In addition, with longitudinal studies, as well as natural and controlled experiments, nature experience has been shown to positively affect various aspects of cognitive function, memory and attention, impulse inhibition, and children’s school performance, as well as imagination and creativity” (Bratman et al., 2019).

Rest and relaxation

Many mental disorders are characterized by chronic stress. It is well-proven that strategies for rest and relaxation may be beneficial in prevention and treatment. Research indicates that “many important mental processes seem to require what we call downtime and other forms of rest during the day. Downtime replenishes the brain’s stores of attention and motivation, encourages productivity and creativity, and is essential to both achieve our highest levels of performance and simply form stable memories in everyday life. A wandering mind unsticks us in time so that we can learn from the past and plan for the future. Moments of respite may even be necessary to keep one’s moral compass in working order and maintain a sense of self” (Jabr, 2013). Daily, weekly, and annual rest through downtime and vacation should be intentionally planned and enjoyed.

Relational and spiritual support

Relationships are foundational for mental well-being. Most people sense a need for connection with others. We are social beings in need of fellowship and community. We need intimate emotional bonds in nurturing relationships. Yet, mental disorders may make it more challenging to successfully satisfy these relational needs. The patient may struggle with fears, worries, negativity, avoidance, isolation, a sense of worthlessness, misinterpretation, aggression, and even delusions. Such symptoms may interfere with the relational ability of the patient, yet the need and desire for connection may be even greater because of the suffering. 

“Social connection (or disconnection) can affect health through biological pathways such as immune function or the regulation of stress hormones. Relationship quality can affect health by influencing psychosocial factors such as mood, motivation and coping skills. Friends and family members can also influence a person’s health-related behaviors such as eating and exercise habits. Together, those pathways can have long-term outcomes for physical and psychological health” (Weir, 2018).

Beyond providing practical help, assistance, and encouragement, quality relationships may contribute to maintaining a sense of hope, meaning, purpose, and significance. Thus, they may also be foundational for maintaining spiritual well-being. It is also recognized that faith leaders often are the first point of contact when individuals and families face mental health problems or traumatic events. In times of crisis, many will turn to trusted leaders in their communities before they turn to mental health professionals. When spiritual leaders and the community respond appropriately, they become significant assets in supporting the patient (U.S. Department of Health & Human Services, 2022).

Article 4:

Therapy

Another term for counseling and psychotherapy is 'talk therapy'. In counseling and psychotherapy, a therapist will guide the patient in processing what happens in the present, maybe what happened in the past, and strategize about the future. Therapy takes place with a licensed, trained mental health professional and a patient meeting one-on-one or with other patients in a group setting.

The goal of therapy may be to become aware of thoughts, feelings, and behaviors, identify ways to cope with stress, develop specific problem-solving strategies, examine a person’s interactions with others, develop social and communication skills, learn to tolerate the distress, and create a safety plan to help someone who has thoughts of self-harm or suicide, recognize warning signs and use coping strategies such as contacting friends, family, or emergency personnel. There are many different types of therapy, and one type should not be considered to be generally superior to others. For many therapies, research has provided evidence that specific therapies are effective for specific disorders and specific patients. These "evidence-based therapies" have been shown to reduce symptoms of depression, anxiety, and other disorders (National Institute of Mental Health, 2022c).

Some may be reluctant to seek therapy out of fear that a therapist may not share their worldview or faith and therefore be critical and disrespectful. Though this may happen, it is considered to be a breach of professionalism. The role of a therapist is to provide a safe, non-judgmental environment where the patient may explore all their thoughts, feelings, and behaviors. The relationship between the patient and their therapist is based on confidentiality, benevolence, and trust, and a good relationship is essential to working together effectively and benefiting from therapy. If the relationship between the patient and therapist over time proves to be unsatisfactory, it may be advisable and necessary for the patient to end the therapy and start a new one with a different therapist. 

Article 5:

Medication

Medications may be beneficial and necessary in treating mental disorders. They are often used in combination with other treatment approaches such as psychotherapies and brain stimulation therapies. Medications may affect people in different ways, and it is difficult to predict how a particular medication will affect a specific individual. It may take some trial and error to find the medication that is most effective with the fewest side effects. The goal is that the positive effects of any medication will far outweigh any negative effects (National Institute of Mental Health, 2022b). Starting and stopping medication should only be done in collaboration with and as supervised by a qualified health professional.

Antidepressants

Antidepressants are medications used to treat depression, but they may also be effective for anxiety, pain, and insomnia. Antidepressants take time to work - often 4 to 8 weeks. It is therefore important to take the medication for sufficient time before deciding whether or not it works. Antidepressants are not addictive (National Institute of Mental Health, 2022b).

Anti-anxiety medications

Various anti-anxiety medications help reduce symptoms of anxiety, such as panic attacks and extreme fear and worry. Antidepressants are commonly used to treat anxiety. Benzodiazepines are used to treat the short-term symptoms of anxiety, but taking benzodiazepines over long periods may lead to drug tolerance or even dependence. Beta-blockers may help manage anxiety symptoms such as rapid heart rate, sweating, and tremors (National Institute of Mental Health, 2022b).

Stimulants

Stimulant medications may markedly improve daily functioning for people with significant focus problems, such as people with ADHD. Some worry that stimulant medications may lead to misuse or dependence, but evidence shows this is unlikely when the medications are used as prescribed (National Institute of Mental Health, 2022b).

Antipsychotics

Antipsychotic medications are typically used to treat psychosis, a condition that involves some loss of contact with reality. Psychosis can be related to drug use or a mental disorder such as schizophrenia, bipolar disorder, or severe depression. Healthcare providers may also prescribe antipsychotic medications to relieve symptoms associated with delirium, dementia, bipolar disorder, depression, or other mental health conditions (National Institute of Mental Health, 2022b). Antipsychotics are not considered to be addictive.

Mood stabilizers

Mood stabilizers are typically used to treat bipolar disorder and mood changes associated with other mental disorders, such as depression, and schizoaffective disorder. Commonly used mood stabilizers are lithium and some anticonvulsant medications (National Institute of Mental Health, 2022b). Mood stabilizers are not considered to be addictive.

When medication is indicated, there are many options. Many medications for mental disorders may be prescribed by physicians who are not psychiatrists. If the desired effect of medication is not achieved, or if there are unexpected or excessive side effects, it may be time to consult with a psychiatrist, if the prescription hasn’t been initiated or monitored by a psychiatrist.

Article 6:

Hospitalization

When sufficient care and safety cannot be achieved as an outpatient, it may be appropriate to admit a patient into a hospital or some other institution where they may receive the appropriate care and treatment. Admission to a hospital may be elective or urgent, voluntary or involuntary, for shorter or longer stays. In most countries, there are comprehensive laws and regulations for hospital admissions that define the rights of the patient and the duties of the healthcare institution. When a patient is involuntarily admitted because they refuse voluntary admission, or because they are deemed incapable of making informed decisions and providing informed consent, they will usually be represented by a lawyer or some other advocate that is designated to protect the patient's rights. Being an inpatient allows for thorough observation of the patient, intensive treatment and monitoring, and measures to keep the patient safe from suicide and self-harm, or inflicting harm to others by violence.

Article 7:

Brain stimulation therapies

Brain stimulation therapies involve activating or inhibiting the brain directly with electricity. The electricity can be given directly by electrodes implanted in the brain, or noninvasively through electrodes placed on the scalp. Electroconvulsive therapy is the best-studied brain stimulation therapy and has the longest history of use. The electricity can also be induced by using magnetic fields applied to the head. While these types of therapies are less frequently used than medication and psychotherapies, they hold promise for treating certain mental disorders that do not respond to other treatments (National Institute of Mental Health, 2022a).

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