Interdisciplinary Collaboration

1
Interdisciplinary Collaboration

• - Obstacles and some probable solutions

Uriel Halbreich, MD Chair, WPA Section on
Interdisciplinary Collaboration
U.H. 2005
2
The Issues

• A. Forces of Change in Mental Health
• I. The Intellectual Field
• The knowledge
• The concepts
• The understanding
• II. The individual skills
• III. The economic, administrative and social
  environment
• IV. Required adaptation to change

U.H. 2005
3
The Issues (cont)
B. Mental Health Organization(s) The
professional organizations and journals The
centrifugal fragmentary force C. Other Medical
and Scientific Organizations D. Advocacy Groups
and the Public E. The Ideal Solution Integration
Interdisciplinary operational collaboration F.
Problems Can they be overcome?
U.H. 2005
4
Forces of Changein Mental HealthI. Explosion of
Knowledge

• Broad spectrum of advancement of investigational
  techniques
• e.g. Molecular biology, genetics, brain
  circuitry, in-vivo processes
• New Insights on the pathophysiology of Mental
  Disorders
• World wide epidemiologic data, evidence-based
• psycho-social information

U.H. 2002
5
New Knowledge Eventually leads to

• Development of physical diagnostic procedures
• (e.g. functional brain imaging, biochemistry)
• Elucidation of Mechanisms of Interrelationships
  between
• psycho-social, cultural, economic, and
  environmental inputs, physical inputs and
  brain processes
• Development of preventive
  Bio-Psycho-Social interventions
• Development of comprehensive treatment
  modalities
• Clarification of the bidirectional relationship
• Between peripheral body organs and the brain

U.H. 2005
6

• During the last 50 years
• there is an exponentially
• accelerated expansion
• of in-depth knowledge
• of Neurosciences
• and Psycho-Social processes.
• It is predicted that acceleration
• will continue

U.H. 2005
7
The magnitude of change in Brain and Behavior
knowledge is no longer quantitative it is
qualitative Adaptation should be substantial
U.H. 2005
8
The adaptation is on two levels

• Conceptual Shift
• Practical Consequences

U.H. 2005
9
The Conceptual Shift

• The brain as
• The main organ of mood, cognition and behavior
• The coordinator of peripheral body functions
• The mediator between environment and Man
• The embodiment of Mind

U.H. 2005
10
Mind and body

• Homeostasis
• Dynamic balance between brain and body
• and
• between multiple organs and systems
• Adaptation
• - to changing environment
• - to stressors and assaults
• - to malfunction of a body system

U.H. 2005
11
GeneticsEnvironmental-Cultural inputsDynamic
evolvement of positive as well as negative life
experiences and their perceptionsBrain
functioning and its homeostatic circuitryBrain
and body adaptation mechanisms, resiliency
and efficiencyMental Disorder may depend on any
of the processes, their interactions and
imbalances(definition of mental disorder may
still be debatable)
Mental State at a Given Point at Timeis a
Manifestation of
U.H. 2005
12
Multiple Processes Leading to Same Disordered
State
Neurostructural Disorders
Hormonal Changes
Peripheral Diseases
Neurotransmitter Abnormalities
Psycho-Social Processes
?
U.H. 2005
13
Science is built of facts the way a house
is built of bricksbut accumulation of facts
is no more science
than a pile of bricks
is a house
Jules-Henri Poincare, 1854-1916
UH 2005
14
The Understanding

• Accumulation of data may, but not necessarily
• lead to understanding
• We are moving towards knowledge of the processes
  underlying Mood, Cognition, and Behavior
• This is leading to development of
  efficient treatments
• even without the essential understanding
  of Mind and its intricacies

U.H. 2005
15

• We need to know
• what we dont know
• More importantly
• we need to know
• what we believe that we know
• but actually do not

UH 2005
16
On a knowledge level
A single individual or a single
professioncannot master the knowledge and
skillsneeded for a comprehensive understanding
of mind, brain and behavior - Interdisciplinary
collaboration is essential
UH 2005
17
The multifaceted complexity of brain and
behavior call for a multidisciplinary
collaboration toward better understanding and
implementation of knowledge in clinical practice.
Did you hear about the Psychiatrist and
Proctologist who opened an office together and
called it Odds and Ends?
U.H. 2005
18
Forces of Change in Mental Health II- The
Economic, Administrative and Social Environment

• A significant change in economic milieu of
  medicine
• Health care has become an industry
• Financial considerations determine the quality
  and quantity of care
• Managed care administrators impose structured,
  corporate, cost-effective practices
• Change in functioning of many physicians
• -from an independent practitioner to
  employee/health
• engineer
• -from decision maker to a restricted
  tightly-regulated
• accessory

U.H. 2005
19

• Almost any socioeconomic processIs globalized.

• Economic and information globalization are
  happening simultaneously with re-emphasison
  National and Tribal fragmentation.

U.H. 2005
20
Forces leading to multi-intertwining dependence
have to be balanced with forces of
independence and conservation of distinct
identities.
U.H. 2005
21

• The Simultaneous Rapidly-Changing Processes of
• Accumulation of new knowledge base
• Industrialization and commercialization of health
  delivery systems
• Globalization of information flow, technology,
  corporations and agencies
• -Require new operational and
• administrative arrangements

U.H. 2005
22

• Operational Necessities
• Redefinition of the relevant clinical fields
• -Psychiatry, Neurology, Psychology, etc
• Reorganization of Institutes, Organizations
• and administrative processes

U.H. 2005
23
Increased numbers of specialized
organizations
So far The explosion in knowledge Results in
fragmentation

• Increased number of specialized Journals

U.H. 2005
24
Organizations Of and For Neuropsychiatry and
Mental Health(Total 1280)
U.H. 2002
From Encyclopedia of Associations, 38th Edition,
probably only a partial list
25
NeuroPsychiatry JournalsIndexed by Index
Medicus 1990, 2002
New Journals not indexed as of end of 2001 are
not included
U.H. 2002
26
Mission of Organizations in the Field of Mental
Health
Common Denominators

• To improve well-being of people with Mental
  Disorders
• To promote Mental Health
• To increase (disseminate) knowledge

U.H. 2005
27

• Most groups officially state that establishment
  of cooperation is essential for the benefit of
  all.
• Reality might be different
• Administrative and professional organizations
• may represent different, sometimes
• competing interests

U.H. 2005
28
Organizations are
Created by PeopleRun by People

• Are they Operating

For people?
U.H. 2005
29
People in Organizations Leadership
Have

• Personal interests
• Positive as well as Negative personality
  characteristics
• Personal connections, friendships and animosities
• Personal overlap with other organizations
• Ties with pharmaceutical companies

U.H. 2005
30
Pharmaceutical Corporations Interests
Money
In order to make more money a corporation is
interested in

• Public image
• Connections with opinion leaders
• Limited non-profitable activities
• Collaborative Applied Research
• Global Common denominators
• Global networks
• Culture specific treatment-response and sales

U.H. 2005
31
The Ideal
Goal Oriented Interdisciplinary
Comprehensive Integrative Factual Diversity
Sensitive Efficient
Operational collaboration
Does and can it exist? How can we attempt to get
closer?
U.H. 2005
32
The need for partnership is undisputed
But the mechanisms to achieve multi-agreeable and
productive arrangements are still Not completely
established
U.H. 2005
33
The Obstacles

• Individual
• Local Level

• Psychiatrists adaptation
• Conflicting interests
• and competition
• Perceived interests
• at a given time
• Competition
• Turf

Organizational
U.H. 2005
34
Incentives for Interdisciplinary Collaboration

• Common Mission
• Overlap of knowledge and procedures
• Common clients
• Complementary knowledge and/or services
• Strength and efficiency
• Increased clout and recognition
• Money

U.H. 2005
35
Operational arrangements of cooperation Require

• Multi-parity
• Multi-accommodating

coalition

• Multiple mutually beneficial compromises

U.H. 2005
36
The main obstacle for change is comfort with and
vested interest in
maintaining the status quo
U.H. 2005
37
The Status Quocannot be maintainedChange is
inevitable and may be painful There is a need
to spearhead the organizational adaptation
U.H. 2005
38
The Mathematics of Interdisciplinary Integration

• Duplicating and multiplying a one (1x1) is still
  oneEven for infinity (12, 13, 14 18)
• Adding one to one (11) is still the same sum of
  the two with no added value
• But when the two start multiplying (22, 23, 24
  ) The sky is the limit

UH 2005
39
Developmental Model of Pregnancy
UH 2005
40
A Bio-Psycho-Socio-Cultural Model of the
Processes Leading to Post Partum Disorders
I. Genetic Predisposition
A. Predisposition to Reproductive-Related
Disorders
Hypersensitivity to hormonal changes
Vulnerability to CNS and multiple systems
dysregulation
Impaired adaptation mechanisms
B. Phenotype Predisposition
Specific CNS systems, locations and processes
Interactional circuitries
Peripheral systems
Cumulative Psychosocial Inputs Early life
experiences Past episodes of disorders Adverse
socio-economic events Immediate support
(Positive events ?)
Cumulative Hormonal Inputs Past hormonal
destabilizing situationse.g. specific
OCs, Pregnancies (peripartum), PMS, other
hormonal withdrawals
II. Dynamically Evolving Vulnerability
III. Peripartum Biological and Social Trigger(s)
CRF withdrawal, Gonadal hormones withdrawal
Symptoms and Disorders
Abrupt psycho-social change(?)
IV. Peripartum and Post Partum Environment
Family support system cultural aspects
V. Perception and Coping Mechanisms
Normalization Homeostatic mechanisms
UH 2005
41
Organizational Chart Mental Health of Women
During Pregnancy and Post Partum
PI U. Halbreich
WPA A. Okasha
Management (SCG) T.D. Zweifel Y. Wurmser
Urban Planning H. L. Taylor
Government M. Weiner
WFMH P. Franciosi
Gyn/Ob J. Yeh
WHO (Broker) J. Bertolote
DEVO Lisa Stephens
Nursing E. Perese
Scientific Advisory Boards/ Task Forces
Epidemiology R. Kessler
Clinical Sites
Data Management B-E Pennell
Stress-early Development C. Nemeroff
Brazil (3) G. Valdares F. Kerr-Correa J. Renno Jr
Cross Cultural V. Patel J. Mezzich
Argentina R. Fahrer
Genetics J. Cowell
Psychometrics M. O'Hara J. Cox
China (2) Yu X Xiao Z-P
Endocrinology of Pregnancy P. Wadhwa
Chile E. Jadresic
Gonadal Hormones A. Genazzani
Mind-Body D. Hellhammer
EU Sites
Hungary P. Gaszner
India S. Karat
OB/GYN F. Naftolin
Statistics P. Rogerson
U.K. D. Phillips
France N. Glangeaud
Israel M. Bloch
Korea Min SK
Hormones, Brain Behavior U. Halbreich
Morocco D. Moussaoui
Romania M. Coculescu
Treatment Modalities U. Halbreich
Biological Markers F. Holsboer
Slovak Rep. E. Palova
Italy A. Genazzani
South Africa M. Tomlinson
Tunisia S. Douki
USA U. Halbreich
Iraq N. Ali
UH 2005