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David S. Sobel, MD, MPH
Regional Health Education, Kaiser Permanente Northern California, Oakland, Calif

JAMA. 2000;284:1705.

What if there was a new medical treatment that had been shown in clinical trials to improve health outcomes in a number of illnesses, speed postsurgical recovery, reduce unnecessary procedures, decrease medical costs, and improve patient satisfaction? And what if its major sequelae were that patients felt less isolated, more confident, satisfied, and happier, all without adverse effects? These benefits (and many others) result from a variety of nonpharmacologic mind/body and behavioral medicine treatments.

An increasing number of studies, including randomized clinical trials, point to safe and relatively inexpensive interventions that can improve health outcomes and reduce the need for more expensive medical treatments.¹ Consider the following mind/body prescriptions:

Heart Disease: A study of patients with heart disease found that psychosocial interventions can reduce the risk of further cardiac events by 75% compared to those given only usual medical care and medications.² A sample of 107 patients with heart disease was randomly divided into 3 groups (usual care, exercise, and stress management) and followed up to 5 years for the incidence of myocardial infarction, bypass surgery, and angioplasty. The stress management group showed a marked difference when compared with the other 2 groups: only 10% experienced these clinical endpoints, vs 21% in the exercise group and 30% in the usual-care group.

Chronic Illness: The Chronic Disease Self-management Program, developed jointly by Stanford University and Kaiser Permanente, includes educational group sessions for patients with chronic disease. The intervention consists of a patient handbook and 7 weekly 2-hour small group sessions that focus on developing practical skills to cope with common symptoms and emotions. In a randomized clinical trial of 952 patients, those participating in the course, when compared with wait-listed control subjects, demonstrated significant improvements at 6 months in weekly minutes of exercise, self-reported health, health distress, fatigue, and disability. They also had fewer hospitalizations and spent an average of 0.8 fewer nights in the hospital. Assuming that a day in the hospital costs $1000, the health care expenditure savings (savings in hospital visits minus program costs) approximated $750 per participant—more than 10 times the cost of the program.³

Surgical Preparation: An important component of psychological preparation for surgery involves giving patients positive physiological suggestions and imagery. In a randomized, placebo-controlled, double-blind clinical trial, 335 patients were given 1 of 4 different audiotapes to listen to before and during surgery. A placebo group listened to a tape with a neutral white noise. Only 1 of the experimental tapes produced statistically significant benefits. This tape contained guided imagery, music, and specific suggestions of diminished blood loss and rapid healing. Patients who listened to this tape experienced a 43% reduction in blood loss and were able to leave the hospital more than a day earlier than the other groups.⁴

Premature Infants: Certain types of pleasurable sensory stimulation are associated with positive health and cost outcomes. Pleasurable sensory stimulation can be used to improve mood, decrease recovery time, and foster healthy growth and development. Tactile stimulation appears to be vital to infant development. In 2 randomized trials premature infants who received comforting physical contact and massage 3 times a day for 10 days had 47% greater weight gain and were discharged from the hospital 5 to 6 days earlier, resulting in savings of more than $10,000 (adjusted for inflation) per infant.⁵

If the case for mind/body medicine seems so strong from both a clinical and cost viewpoint, why has there been little investment in such integration?⁶ One reason is that the data are incomplete. However, even when there are good data, providers of medical and mental health services are often unaware of them. Mind/body medical interventions are often held to a higher standard of evidence than are traditional, and must justify themselves not only by improved health outcomes and quality of care, but also on the basis of cost alone. Both medical and mind/body health interventions should be judged by a similar set of criteria, and the beliefs and biases that delay the use of psychosocial interventions need to be challenged.⁷

While the health care system cannot be expected to address patients' every psychosocial need, clinical interventions should better reflect the emerging evidence on the efficacy and cost-effectiveness of mind/body interventions. Mind/body medicine is not something separate or peripheral to the main tasks of medical care but should be an integral part of evidence-based, cost-effective, quality health care.

REFERENCES
1. Sobel D. The cost-effectiveness of mind-body medicine interventions. In: Mayer EA, Saber CB, eds. The Biological Basis for Mind Body Interactions, Progress in Brain Research. Amsterdam, the Netherlands: Elsevier Science. 2000;122:393-412. 2. Blumenthal JA, Jiang W, Babyak M, et al. Stress management and exercise training in cardiac patients with myocardial ischemia: effects on prognosis and evaluation of mechanisms. Arch Intern Med. 1997;157:2213-2223. FREE FULL TEXT 3. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37:5-14. FULL TEXT | WEB OF SCIENCE | PUBMED 4. Dreher H. Mind-body interventions for surgery: evidence and exigency. Adv Mind-Body Med. 1998;14:207-222. 5. Scafidi FA, Field TM, Schanberg SM, et al. Massage stimulates growth in preterm infants: a replication. Infant Behav Dev. 1990;13:167-188. 6. Friedman R, Sobel DS, Myers P, Caudill M, Benson H. Behavioral medicine, clinical health psychology, and cost offset. Health Psychol. 1995;14:509-518. FULL TEXT | WEB OF SCIENCE | PUBMED 7. Williamson P, Beitman BD, Katon W. Beliefs that foster physician avoidance of psychosocial aspects of health care. J Fam Pract. 1981;13:999-1003. WEB OF SCIENCE | PUBMED

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