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| MANN KI BAAT - SPL. ISSUE - SECTION 2: SCIENCE & EVIDENCE |
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| Year : 2023 | Volume
: 7
| Issue : 5 | Page : 19-24 |
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Transforming Indian Healthcare: A Systemic Integrative Healthcare Model at NIMHANS for Advancing Evidence-Based Medicine as Envisioned in Prime Minister Modi’s Mann Ki Baat
Kishore Kumar Ramakrishna, Hemant Bhargav, Bharath Holla, Umesh Chikkanna, Nishita Jasti, Shiva Kumar, Shivarama Varambally, BN Gangadhar
Dept. of Integrative Medicine National Institute of Mental Health and Neuro-Sciences, Bengaluru, India
| Date of Submission | 17-Apr-2023 |
| Date of Acceptance | 18-Apr-2023 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Dr. Kishore Kumar Ramakrishna
Dept. of Integrative Medicine National Institute of Mental Health and Neuro-Sciences, Hosur Road/ Marigowda Road, (Lakkasandra, Wilson Garden) Bangalore – 560029
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jras.jras_105_23
How to cite this article:
Ramakrishna KK, Bhargav H, Holla B, Chikkanna U, Jasti N, Kumar S, Varambally S, Gangadhar B N. Transforming Indian Healthcare: A Systemic Integrative Healthcare Model at NIMHANS for Advancing Evidence-Based Medicine as Envisioned in Prime Minister Modi’s Mann Ki Baat. J Res Ayurvedic Sci 2023;7, Suppl S1:19-24 |
How to cite this URL:
Ramakrishna KK, Bhargav H, Holla B, Chikkanna U, Jasti N, Kumar S, Varambally S, Gangadhar B N. Transforming Indian Healthcare: A Systemic Integrative Healthcare Model at NIMHANS for Advancing Evidence-Based Medicine as Envisioned in Prime Minister Modi’s Mann Ki Baat. J Res Ayurvedic Sci [serial online] 2023 [cited 2023 Jun 8];7, Suppl S1:19-24. Available from: http://www.jrasccras.com/text.asp?2023/7/5/19/374501 |
| Background | |  |
Integrative medicine, as defined by the American Board of Integrative Medicine (ABOIM) and the Consortium of Academic Health Centres for Integrative Medicine, is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing.[1] Integrative medicine has gained popularity in the West, but in India, it is still in the initial stages.[2],[3]
In the 96th edition of Mann Ki Baat, on 25.12.2023, Honourable Prime Minister of India, Shri Narendra D. Modi, said: “Satyam kim pramanam, pratyaksham kim pramanam.” “Truth does not require proof,” in other words, “what is evident also does not require proof.” However, he cautioned that ‘Evidence’ is of the prime importance in the context of medical science. He commended the work of Tata Memorial Centre (TMC), pointing out how the institute’s research has proven the value of yoga for subjects with breast cancer.
Prime Minister also appreciated the Centre for Integrated Medicine and Research, established at Delhi AIIMS to develop traditional medicine. The institute has established a reputation for itself in research, innovation, and cancer care, he added. The Centre for Integrative Medicine and Research, which was established six years ago, has supported the use of traditional medicine for conditions like syncope, migraine, heart disease, depression, sleep disorders, and a number of issues that affect pregnant women. According to Prime Minister, the more evidence-based Indian medical systems are in the modern world, the more widely accepted they would be.
In India, many institutes have tried “integration” through different models. A commonly followed model is that of “co-location” of Ayush systems in the conventional care setups or vice versa (cafeteria approach). However, some institutions have adopted alternative models that concentrate on the step-by-step process of integration. One such integrative approach has been built by the National Institute of Mental Health and Neurosciences (NIMHANS), an Institute of National Importance and tertiary mental and neurological healthcare facility located in Bengaluru, India.[4] The current manuscript explores the methods and processes of “systemic integration” of medicine, which can assist in producing useful guidelines to develop the evidence-based Indian medical systems that the Hon. Prime Minister mentioned in his Mann ki Baat.
| 1. Department of integrative medicine at NIMHANS | | |
The Department of Integrative Medicine (IMD) was established in October 2019 at NIMHANS, Bengaluru. The Outpatient services began in October 2019. The 30-bed in-patient facility started in May 2021. IMD offer inclusive health care involving Yoga, Ayurveda and Modern Medicine in Mental Health and Neurosciences. It is a unique model of systemic integration rather than cafeteria approach (a Psychiatrist, an Ayurveda Expert and a Yoga Expert consult and optimize the treatment of a patient together simultaneously) and mere co-location of traditional and modern health systems. The IMD’s inclusive healthcare approach involves the integration of different healthcare systems, patient involvement in decision-making, and a focus on preventive care, all of which are critical components of the department’s efforts to provide holistic and patient-centered care.
The main highlights of the unique department in an Institute of National importance are:
1.1. Systemic Integration
At IMD NIMHANS, the sanctity of each system of medicine is maintained and integration is implemented at the level of concept, therapeutics, etiopathogenesis and outcome assessments.
This means that each system of medicine, including Yoga, Ayurveda, and modern medicine, is given due importance and is used in a complementary manner to achieve the best possible outcome for the patient. The approach is not limited to simply co-locating traditional and modern health systems or following a cafeteria approach where different experts provide independent treatments. Instead, the focus is on combining the strengths of each system of medicine to provide a comprehensive treatment plan.
This systemic integration approach ensures that the patient receives the most effective and comprehensive treatment plan that considers all aspects of their health and well-being. It also helps to bridge the gap between traditional and modern medicine and provides a platform for collaboration and communication between different systems of medicine. Overall, this approach promotes a patient-centered approach to healthcare and helps to improve the quality of care provided to patients.
1.2 Patient Choice and Voice
Patient involvement in decision making is a critical aspect of clinical care in IMD. We work closely with patients to develop treatment plans that are tailored to their individual needs and preferences. Patients are encouraged to be active participants in their treatment and are provided with comprehensive information about their conditions and the available treatment options. This patient-centered approach ensures that patients have a greater sense of control over their healthcare, and are more likely to follow-up with treatment plans.
Patients are also given the opportunity to provide feedback on their experience at IMD, and this feedback is taken into account when making decisions about how to improve the quality of care. Patient satisfaction surveys are regularly conducted to assess the quality of care and identify areas for improvement.
1.3 Focus on translational interdisciplinary research
The department focuses on translational interdisciplinary research to advance the field of integrative medicine. The department recognizes the need to bridge the gap between traditional and modern medicine and aims to contribute towards improving specific clinical outcomes through its research efforts. Another area of research for the department is to understand the biological mechanisms through which integrative therapies interact and produce their effects
| 2. Clear standard operating procedures (SoP's) for integrative clinical care | | |
At the first step, when the patient comes to NIMHANS OPD for seeking treatment for any neuro-psychiatric condition, he consults a resident medical officer (RMO) who is a MBBS doctor. RMO performs initial screening and then refers the patient to respective clinical departments based on the clinical presentation. Here, at the level of RMO, the patient is given a choice of either choosing conventional care or integrative medicine. Patient who chose conventional care are sent to the modern medicine departments and if the consultants in the modern medicine department feel that adding yoga or Ayurveda may help the patient, then they refer the patient to IMD OPD or to the department directly. If the patient opts for Integrative Medicine, then patient is initially evaluated through history taking and examination by the junior resident doctors (JRs) of the department of Integrative medicine (JR can be doctors from the field of modern medicine, Yoga or Ayurveda). Then, JRs discuss the case with senior resident doctors (SRs) from the field of modern medicine, Yoga and Ayurveda. SRs (from either modern medicine, Ayurveda, Yoga whichever field of medicine that would be playing a major role in patient care in that particular case) present the case to all the three consultants (Modern medicine, Yoga and Ayurveda) who sit in the OPD together in the same cabin. After initial evaluation of symptoms from modern medicine, Yoga and Ayurveda point of view, the patient is referred to the modern medicine department for confirmation of the diagnosis (if the diagnosis is not already confirmed by a consultant from the respective field) and opinion. Then, based on the modern diagnosis and understanding of aetiopathogenesis from Yoga and Ayurveda point of view an integrative treatment plan is made. The treatment plan is explained to the patient and his opinion and choice is taken into consideration before finalizing the plan.[4] Patients are taught Yoga sessions by MSc Yoga Therapy students in the OPD itself, those advised Ayurveda receive Ayurveda prescriptions from Ayurveda Physicians and undergo Ayurveda Panchakarma procedures on day care basis or as in-patients if they are willing to get admitted and there is an indication for the same. Modern medicine residents and consultant also write their prescription. Regular follow-ups are done using outcome assessments from each of the respective disciplines.
| 3. Research in the area of integrative medicine by NIMHANS | | |
3.1 Yoga Research
Over the last two decades, NIMHANS has conducted several clinical research projects in the area of application of Yoga as a therapy in neuropsychiatric disorders.[5],[6],[7] The NIMHANS Integrated Centre for Yoga has focused on developing generic Yoga modules for different mental and neurological disorders, validating them with experts, doing initial pilot studies, and finally testing them in patients through systematic controlled trials. This has been done for most of the common disorders such as Major Depressive Disorder, Schizophrenia, Mild Cognitive Impairment (MCI) & Dementia, Somatoform Disorders, Obsessive compulsive Disorder (OCD), Substance Use Disorder, Parkinson’s disease, Epilepsy, and Anxiety Disorder.
Initial randomized controlled clinical trials led by Prof. B N Gangadhar (Ex-Director of NIMHANS and currently Professor Emeritus Department of Integrative Medicine, NIMHANS and President of Medical Assessment and Rating Board, National Medical Commission, New Delhi) demonstrated that practicing yoga 5 days per week for 12 weeks could be as useful as taking anti-depressants in patients with mild to moderate depression.[8] Further studies demonstrated that 12-week Yoga practice led to enhancement in Brain derived neuro-trophic factors (BDNF, a marker of neuroplasticity) levels and reduction in serum cortisol (stress related hormone) levels in subjects who practiced Yoga along with medications as compared to those who took medication alone. [9] Recently, a funded randomized controlled trial in depression led by Dr K Muralidharan, Professor of Psychiatry and Medical Superintendent, NIMHANS that explored underlying biological mechanisms of action of Yoga, found that Yoga optimizes functions of the autonomic nervous system and enhances brain GABAergic tone (assessed using trans-magnetic stimulation technique). [10] Recently, a PhD dissertation by Dr. Aditi Devi under the guidance of Professor Shivarama Varambally, the Head of the Department of Integrative Medicine showed that patients with mild- moderate depression improved with yoga as a sole therapy.[11] It was also found that Yoga practice also enhanced the conversion of a precursor to mature BDNF, a process which is impaired in depression.[12] This supports the hypothesis that Yoga enhances neuroplasticity in patients with depression.
Another important area in which beneficial effects of yoga has been demonstrated at NIMHANS is in a severe mental illness, schizophrenia. It was believed initially that yoga may not be feasible treatment option for patients with psychosis. But, as demonstrated through systematic researches by Prof. BN Gangadhar and Prof. Shivarama Varambally, in-patient as well as out-patient settings, Yoga was not only found feasible but was observed to be significantly more effective than exercise in reducing negative symptoms such as social withdrawal and lack of motivation. [13] This research was instrumental in yoga being recognized as one of the complementary treatment modalities for schizophrenia as per the 2014 NICE guidelines in the UK. Further research by the team at NIMHANS has shown that yoga may be reducing negative symptoms by two mechanisms: 1) enhancing serum oxytocin levels[14] and 2) improving ability to recognize facial expression and emotions (probably mediated through mirror neuron activation) in patients with schizophrenia.[15] Recent mutli-centric study headed by NIMHANS replicated our previous findings of improvement in negative symptoms of patients with schizophrenia through yoga.[16]
Ph.D. studies at NIMHANS have also found interesting results through the application of Yoga in the area of anxiety disorders and obsessive-compulsive disorder (OCD).[17],[18] They have observed that 1-month of yoga practice along with lifestyle modifications can significantly reduce anxiety related and obsessive symptoms in this population.
Substance use disorders are another area where encouraging results have been found with Yoga intervention. A randomized controlled study by Vedamurthachar et al, demonstrated that 2 week of yoga practice could reduce stress levels (ACTH and Serum Cortisol levels) in patients with Alcohol dependence disorder.[19] Similarly, Bhargav et al, developed and validated a Yoga module for acute withdrawal phase and maintenance phase in patients with opioid use disorders (OUD). This module was also found to be useful in enhancing “endogenous opioids (plasma endorphin levels)” in patients with OUD. [20],[21] In another 6-month follow-up trial it was observed that yoga practice could enhance quality of life and reduce number of OUD patients who relapse.[22]
3.2 Ayurveda Research
Role of Ayurvedic medicine has also been explored in conjunction with biomedicine in NIMHANS. In a randomized controlled trial on 81 subjects with Major Depressive Disorder (MDD), beneficial effects of 2-month Ayurveda intervention that consisted of Virechana (Therapeutic purgation), Shirodhara (oil dripping) therapy and polyherbal medicine Ayushman – 15A and 15B was observed on psychopathology, autonomic functions and serum cortisol levels. [23] In another study on 72 subjects who had generalized anxiety disorders (GAD), it was observed that Ayurveda intervention consisting of Shirodhara (Oil dripping) therapy for first seven days and polyherbal-mineral preparation Tab. Manasamitra Vataka 100 mg BID for one month was useful in reducing anxiety symptoms and enhancing quality of life. [24] Patients also reported that their social anxiety reduced and they could socialize better. In this study, there was also an evidence for improvement in quality of night-time sleep and reduced day-time sleepiness in favor of the Ayurveda group (patients attributed this effect to Shirodhara practice, especially). In another study, integration of Yoga and Shirodhara was found useful in improving cognitive performance and sleep quality of patients with anxiety disorders. [25]
In another pilot study, fourteen patients suffering from Unmāda (Schizophrenia) with a chronicity period between 2 to 6 years were administered with polyherbal formulation consisting of Brahmi, Vacha, Kusta, Sarpagandha, Jatamamsi and Tagara with a dose of 8 to 16 grams for three months duration showed significant improvements in schizophrenia symptoms rating scale. [26]
3.2. Ayurveda Research in Neurology
In a study on fifty patients of Ischemic stroke (Middle cerebral artery territory) where patients received add-on Ayurveda treatments along with standard allopathic medications[27], it was observed that there was an improvement in cardiac autonomic parameters. Patients received external therapies such as Abhyanga (therapeutic massage) with Niramisha mahamasha taila and Bashpa svedana (steam therapy) from day 1 to day 14, Matra basti with 60 mL of Balaswagandhadi taila from day 8–14 and internal medication of Ashtavarga kashaya orally, 15 mL TID with 15 mL warm water and Ksheerabala 101 orally, 5 drops BD with 15 mL warm water.
Recently, a case study on GB Syndrome, post plasmapheresis administered with combination of Ayurveda therapies and oral medication showed significant improvement in motor and sensory deficits. [28] Improvements were noticed in activities of daily living and balance index showed reduction in fall risk and improvements in limits of stability.
Another case study on a patient with spinocerebellar ataxia treated with add on Ayurveda interventions showed significant improvement in scale for assessment and rating of ataxia, activities of daily living and balance index showed reduction in fall risk and improvements in limits of stability. [29]
In an interesting case study on anti-psychotic induced Tardive dyskinesia, it was observed that add on combination of Ayurveda therapies and oral medication for 28 weeks showed significant improvement in Abnormal Involuntary Movement Scale (AIMS) and symptoms. [30] These therapies and medications were administered to patient along with modern medication were noticed to be safe and did not produce any adverse effects.
3.3. Ongoing Integrative Research Projects: Exploring New Horizons in AYUSH-based Neuroscience Research
The IMD’s Centre of Excellence in AYUSH research, titled “Yoga and Ayurveda in Neuroscience: Translational Research Accelerator program (YANTRA)”, aims to evaluate the efficacy, safety, and proposed mechanism of an integrated Yoga and Ayurveda treatment approach in four carefully selected neuropsychiatric diagnosis, including Schizophrenia, Multiple Sclerosis, Alzheimer’s Dementia, and Mood Disorders. These disorders are chosen due to their prevalence and impact across the lifespan. The CoE’s primary goals are to conduct clinical trials and understand the integrative neurobiology of neuropsychiatric disorders using traditional concepts. To achieve this, the CoE will integrate modern deep-phenotyping approaches with traditional assessments of Prakriti/Vikriti and gunas, creating a unified digital database incorporating multi-parametric information. Furthermore, the CoE aims to develop clinician-scientists with niche skills-sets in examining brain-health from traditional and modern scientific approaches. Ultimately, this research will aid in patient stratification and treatment, thereby, improving the lives of individuals affected by neuropsychiatric disorders.
| 4. Conclusion | | |
In conclusion, integrative medicine has gained popularity in the West, but it is still in the initial stages in India. The Department of Integrative Medicine (IMD) at the National Institute of Mental Health and Neurosciences (NIMHANS) has established a unique model of systemic integration rather than a cafeteria approach, which involves the integration of Yoga, Ayurveda, and Modern Medicine in mental health and neurosciences. The IMD at NIMHANS follows clear standard operating procedures for integrative clinical care, which include patient choice and voice, and focuses on translational interdisciplinary research. The department has conducted several clinical research projects in the area of application of yoga and Ayurveda as therapy in neuropsychiatric disorders. NIMHANS has demonstrated the benefits of integrative therapies in different disorders such as depression, schizophrenia, anxiety disorders, substance use disorders, and neurological conditions such as stroke and spinocerebellar ataxia. Integrative medicine can play a significant role in producing useful guidelines to develop evidence-based Indian medical systems. Overall, the integrative healthcare model at NIMHANS is a pioneering effort in India to provide evidence-based, patient-centered care. It serves as a model for other healthcare institutions to follow and is a step towards achieving India’s goal of universal and integrative healthcare as envisioned in the Prime Minister Narendra Modi’s radio program “Mann Ki Baat” in September 2021.
5. Acknowledgements
We would like to express our gratitude to the following organizations and institutions for their valuable support in our work: the Ministry of Health and Family Welfare (MoHFW), the Ministry of Ayush, Central Council for Research in Ayurvedic Sciences (CCRAS), the Ayurswasthya Yojana, Centre of Excellence grant by Ministry of Ayush, Govt. of India, Central Council for Research in Yoga and Naturopathy (CCRYN), Morarji Desai National Institute of Yoga (MDNIY), Department of Science and Technology (DST-SATYAM and DST-SERB), DBT-Wellcome Trust India Alliance, Governing Body of NIMHANS, and S-VYASA Yoga University, Bengaluru, along with all other collaborating institutions. Their support has been instrumental in enabling us to pursue our research and innovation initiatives in integrative medicine, and we look forward to continuing our collaboration with them in the future.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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