Bridging the Divide Between Specialties to Treat the Whole Patient

NEW YORK CITY—Immune-mediated inflammatory diseases (IMIDs) and mental health conditions have many common elements, and clinicians must work together across specialties to properly treat the whole patient, a pair of speakers said at the Interdisciplinary Autoimmune Summit.

“This dividing business we’ve been doing since we went to medical school, or nursing school, or [physician assistant] school, is incredibly damaging,” Psych Congress co-chair psychiatrist Rakesh Jain, MD, MPH, said. “Divide no more. The differences between our specialties are almost negligible.”

Psychotherapist and Psych Congress Steering Committee member Saundra Jain, MA, PsyD, LPC, said clinicians undergoing training develop a badge of honor and pride about their specialties, no matter what they are.

“I say keep that, hold on to that pride, because we should be proud of our accomplishments.

But when it gets down to where the rubber meets the road, in practice, face-to-face with patients, we need to push that aside because we are all taking care of the same patients,” she said.

Research has shown high associations between various psychiatric disorders and IMIDs, including rheumatoid arthritis, ankylosing spondylitis, psoriasis, psoriatic arthritis, inflammatory bowel disease, and hidradenitis suppurativa, Dr. Rakesh Jain, Clinical Professor, Department of Psychiatry, Texas Tech University School of Medicine, Midland, Texas, explained in his presentation. However, he said, mental health conditions are often not detected or treated by specialists from other fields.

Dr. Rakesh Jain was himself diagnosed with rheumatoid arthritis in 2011. He said he has been treated by 4 rheumatologists and 4 rheumatology nurses, in various types of settings, and taken many different types of medications. Yet none of the doctors or nurses ever asked about his sleep, mood, anxiety, nutritional health, or mental wellness.

“You cannot, you cannot walk away from issues above the neck, because they directly will impact everything you are touching,” Dr. Rakesh Jain told the attendees at the meeting, designed for rheumatologists, dermatologists, immunologists, gastroenterologists, and allied health care professionals. “You have to be interested in the patients’ mental health. It’s not optional.”

He explained the various neurobiological ways in which inflammation overlaps with stress and mental health disorders, and how each condition can affect the other.  For example, abnormalities in T and B lymphocyte cells are seen in both inflammatory disorders and psychiatric disorders

He said there are 3 major threads which tie inflammation, pain, and mental health together—the hypothalamic-pituitary axis, inflammatory cytokines, and the autonomic nervous system— and problems with each can be addressed through nonpharmacological interventions. Such techniques can not only reduce symptoms, but also improve the pathologies involved in IMIDs, he said.

“Nonpharmacological does not mean nonbiological. You can be incredibly biological by being nonpharmacological,” Dr. Rakesh Jain said. “If you have any interest in inflammatory disorders … you must embrace them and embrace them hard. The evidence for that is, I think, quite clear.”

Dr. Saundra Jain, Adjunct Clinical Affiliate, University of Texas at Austin, School of Nursing, presented details on a 30-day, 5-part intervention program she and Dr. Rakesh Jain have developed, called Wellness Interventions for Life’s Demands, or WILD 5. About 250 people have used the program over the last 4 years. Its 5 elements—exercise, nutrition, sleep, social connectedness and meditation/mindfulness—are all clearly supported as anti-inflammatory strategies, she said.

“We’re very interested in reduction of symptoms, improved functionality. But even in mental health, we overlook and miss the boat quite often in this other arena of wellness,” she said. “We still want symptom reduction, but we’ve got to add this missing ingredient if you will, which is wellness.”

A group of 51 people with chronic pain, including patients with rheumatoid arthritis or fibromyalgia, followed the program and saw improvements in their depression, anxiety, sleep quality, and overall well-being, Dr. Saundra Jain explained in her talk. What’s more, they reported less pain and more happiness, enthusiasm, resilience, and optimism.

The program is meant to cover all the bases by giving patients one simple, prescriptive, and trackable program to follow. When physicians recommend one of the strategies individually, follow-through is often low, she said.

Dr. Rakesh Jain urged clinicians to encourage patients to follow the whole program, not just 1 or 2 elements. “There’s a power in the fist that the individual fingers don’t have,” he said.

IAS co-chair Leonard H. Calabrese, DO, said he has been seeing more interest in wellness and immunologic health among clinicians who treat IMIDs in the last year. “It’s now becoming far more scientific and it’s not a peripheral subject.”

“I've been surprised and impressed that people here are equally interested in immunologic health, not just taking care of disease,” added Dr. Calabrese, Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland Ohio. “I think it's going to be a turning point in this conference, moving towards incorporating this.”

Another pair of IAS presenters spoke about how they work together in popular clinic to deliver dermatology and rheumatology care simultaneously.

“One of the major complaints patients have is their doctors don’t speak to each other. Here they see their doctors speaking to each other right on front of them,” said rheumatologist Elinor Anne Mody, MD, Director, Women’s Orthopedic and Joint Disease Program, and Assistant Professor, Brigham and Women’s Hospital and Harvard Medical School in Boston, Massachusetts. “I think that most of our patients are really quite satisfied.”

Other IAS sessions covered the practical implications of delivering gastroenterology and rheumatology care together, and delivering gastroenterology and dermatology care together.

—Terri Airov

References

“Divide No More: Understanding and Capitalizing on the Overlap Between Inflammatory Disorders and Mental Health.” Presented at the Interdisciplinary Autoimmune Summit; March 26, 2017; New York, NY.