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Psychosomatic Medicine 64:549-551 (2002)
© 2002 American Psychosomatic Society

THE GREAT DEBATE

Resolved: Psychosocial Interventions Can Improve Clinical Outcomes in Organic Disease—Moderator Introduction

Jerome H. Markovitz, MD, MPH

Associate Professor of Medicine University of Alabama at Birmingham Division of Preventive Medicine 1717 Eleventh Avenue South Room 733 Birmingham, AL 35205 Email: jmarkovitz@dopm.uab.edu

It is my pleasure to introduce this debate, with its many distinguished participants. You might wonder what was the source of this debate? I would say that it began in 1985, with an editorial by Dr. Angell in the New England Journal of Medicine (1) that stated, "It is time to acknowledge that our belief in disease as a direct reflection of mental state is largely folklore." Obviously, this editorial was a great source of controversy in our society. It is notable that there is still a lot of the lay interest and the press interest in our area, and this interest is also expressed in popular culture. I have some song lyrics that exemplify this notion.

Don’t rock;
They like jazz but in small doses,
No shock, Bop—
And you could cause thrombosis
—Richard Maltby, 1978, "Loungin’ at the Waldorf"

These lyrics are obviously favorites of mine because the topic is relevant to my area of research, but it is also the only song I know of that has the audacity to not only to put "thrombosis" in the lyrics, but to rhyme with it.

The second set of lyrics I think you are probably more familiar with:

The average unmarried female, basic’lly insecure
Due to some long frustration may react
With psychosomatic symptoms difficult to endure
Affecting the upper respiratory tract
In other words,
Just from waiting around
For that plain little band of gold
A person can develop a cold
—Frank Loesser, 1950, "Adelaide’s Lament"

These lyrics were given to me by Sheldon Cohen, who was an author of a New England Journal of Medicine paper in 1991, which actually gave us some objective evidence that favored that sentiment (2). In preparing for this occasion, I thought it would be interesting to create a list of the empiric articles addressing psychosocial factors in organic diseases that have been published in the New England Journal of Medicine from 1985 (when Dr. Angell’s editorial appeared) through the year 2000 (2–7). It is of note that most of these were published while Dr. Relman was editor through 1991, relative to the past 10 years. In contrast, JAMA, which was edited by Dr. Lundberg from 1982 to 1999, has published many more empiric studies in this area (8–21). Some of these studies have been prominent and have had a great deal of impact on the things that we hear at our APS annual meetings. I might point out that there are a couple of recent articles that actually address interventions and were randomized trials (18, 19).

Accompanying one of these JAMA articles on job strain, blood pressure, and left ventricular mass (10) was an editorial by Dr. Williams (21), which was in essence a rebuttal to Dr. Angell’s editorial from 5 years before. He stated, "There is still skepticism that mental states and, hence, the brain play an important role in physical illness, with some in positions of authority consigning such notion to the realm of folk lore. If these results are considered along with the growing contributions of neuroscience to our understanding of how the brain speaks to the body’s organs, perhaps the idea that the brain plays a role in physical disease will soon seem less revolutionary and more like normal science." So in a sense, the editorials by Drs. Angell and Williams were the opening salvos of today’s debate.

More recently, Dr. Relman has weighed in with a little bit of a different bent. He participated in a debate with Dr. Andrew Weil about alternative medicine (22), and in that debate he said, "Practitioners of alternative medicine believe in the power of mind and thought to change physical matter and heal organic disease, a concept which basically contradicts the laws of physics in the modern scientific view of nature." In response to subsequent letters that disagreed with him about mind-body effects (23), he said, "The abundant evidence for mind-body effects are really referring to brain-body effects, ie, the bodily reactions of brain neuropeptides and neural hormones. These are well known and I have never denied their existence. But can these effects, although measurable, cure or change the natural history of organic disease? There is no objective, credible evidence of that." This last statement is the source of the topic for the present debate.

Finally, Dr. Schneiderman recently made a statement pertaining to the debate topic (24). He said, "Psychosocial interventions have been shown to improve the quality of life of patients with established disease, and seem to influence biological processes thought to ameliorate disease progression. Small-scale studies are useful for specifying the conditions under which psychosocial factors impact quality of life, biological factors, and disease progression. Only large-scale clinical trials, however, can determine the extent to which these psychosocial interventions may impact morbidity and mortality."

These statements of the debate participants set the stage for the present debate. Before the debate, the participants and others participated in a conference call to establish the ground rules. It was decided that those arguing for the resolution would provide a list of studies supporting their position to their opponents; hence a total of 23 articles were selected by Drs. Williams and Schneiderman for this purpose (2, 13, 20, 25–42). Dr. Relman added an article to this list (43). These articles form the primary background for the debate, although other studies may be introduced by the speakers.

Finally, let me provide a brief introduction for each of the speakers. Dr. Neil Schneiderman is James L. Knight Professor of Psychology, Medicine, and Psychiatry at the University of Miami, and Director of the University’s Behavioral Medicine Research Center. He is a long-time PI of program projects from both NHLBI and NIMH, and he is the PI at the Miami Clinical Unit of the NHLBI Multicenter Trial entitled "Enhancing Recovery in CHD Patients," or ENRICHED.

Dr. Redford Williams is Professor of Psychiatry, Psychology, and Medicine at Duke University. He is Director of the Behavioral Medicine Research Center at Duke, and is a past president of this Society. His major contributions have been in the area of cardiovascular behavioral medicine, and he is also involved in the ENRICHED trial.

Dr. Arnold Relman is a nephrologist by training, and Professor Emeritus of Medicine and Social Medicine at Harvard Medical School. He served as Editor-in-Chief of New England Journal of Medicine from 1977 to 1991, and continues to be active in the areas of medical education and health policy.

Dr. Marcia Angell is a Senior Lecturer in Social Medicine at Harvard, was Editor-in-Chief of the New England Journal of Medicine from 1999 through 2000, and she was Executive Editor of the New England Journal of Medicine for 21 years before that. Many of her writings have been concerned with medical ethics, including her book entitled, "Science on Trial: The Clash of Medical Evidence and the Law in the Best Implant Case" (44). She has also written about health disparities based on socioeconomic status, which is a subject of great interest to this society.

Finally, our discussant, Dr. George Lundberg was Professor of Pathology at the University of Southern California and at University of California, Davis, before becoming editor of JAMA from 1982 to 1999. He is presently Editor-in-Chief of MedScape, which is a leading site for health and medical information on the Internet. I might point out that he grew up in rural Alabama and is an alumnus of the University of Alabama at Birmingham, where I am presently entrenched.

NOTES

1This debate was presented at the Annual Meeting of the American Psychosomatic Society, Monterey, California, March 9, 2001. Back

This work is dedicated to Jack Markovitz, MD.

REFERENCES

  1. Angell M. Disease as a reflection of the psyche [editorial]. N Engl J Med 1985; 312: 1570–2.[Medline]
  2. Cohen S, Tyrell DA, Smith AP. Psychological stress and susceptibility to the common cold. N Engl J Med 1991; 325: 606–12.[Abstract]
  3. Rozanski A, Bairey CN, Krantz DS, Friedman J, Resser KJ, Morell M, Hilton-Chalfen S, Hestrin L, Bietendorf J, Berman DS. Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. N Engl J Med 1988; 318: 1005–12.[Abstract]
  4. Ragland DR, Brand RJ. Type A behavior and mortality from coronary heart disease. N Engl J Med 1988; 318: 65–9.[Abstract]
  5. Yeung AC, Vekshtein VI, Krantz DS, Vita JA, Ryan TJ Jr, Ganz P, Selwyn AP. The effect of atherosclerosis on the vasomotor response of coronary arteries to mental stress. N Engl J Med 1991; 325: 1551–6.[Abstract]
  6. Leor J, Poole WK, Kloner RA. Sudden cardiac death triggered by an earthquake. N Engl J Med 1996; 334: 413–9.[Abstract/Free Full Text]
  7. O’Malley PG, Jones DL, Feuerstein IM, Taylor AJ. Lack of correlation between psychological factors and subclinical coronary artery disease. N Engl J Med 2000; 343: 1298–304.[Abstract/Free Full Text]
  8. Brodsky MA, Sato DA, Iseri LT, Wolff LJ, Allen BJ. Ventricular tachyarrhythmia associated with psychological stress. The role of the sympathetic nervous system. JAMA 1987; 257: 2064–7.[Abstract/Free Full Text]
  9. Zonderman AB, Costa PT Jr, McCrae RR. Depression as a risk for cancer morbidity and mortality in a nationally representative sample. JAMA 1989; 262: 1191–5.[Abstract/Free Full Text]
  10. Schnall PL, Pieper C, Schwartz JE, Karasek RA, Schlussel Y, Devereux RB, Ganau A, Alderman M, Warren K, Pickering TG. The relationship between "job strain," workplace diastolic blood pressure, and left ventricular mass index. Results of a case-control study. JAMA 1990; 263: 1929–35.[Abstract/Free Full Text]
  11. Williams RB, Barefoot JC, Califf RM, Haney TL, Saunders WB, Pryor DB, Hlatky MA, Siegler IC, Mark DB. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease JAMA 1992; 267: 520–4.[Abstract/Free Full Text]
  12. Markovitz JH, Matthews KA, Kannel WB, Cobb JL, D’Agostino RB. Psychological predictors of hypertension in the Framingham study: Is there tension in hypertension? JAMA 1993, 270: 2439–43.[Abstract/Free Full Text]
  13. Frasure-Smith N, Lésperance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival. JAMA 1993; 270: 1819–25.[Abstract/Free Full Text]
  14. Lyketsos CG, Hoover DR, Guccione M, Senterfitt W, Dew MA, Wesch J, VanRaden MJ, Treisman GJ, Morgenstern H. Depressive symptoms as predictors of medical outcomes in HIV infection. Multicenter AIDS Cohort Study. JAMA 1993; 270: 2563–7.[Abstract/Free Full Text]
  15. Burack JH, Barrett DC, Stall RD, Chesney MA, Ekstrand ML, Coates TJ. Depressive symptoms and CD4 lymphocyte decline among HIV-infected men. JAMA 1993; 270: 2568–73.[Abstract/Free Full Text]
  16. Kark JD, Goldman S, Epstein L. Iraqi missile attacks on Israel. The association of mortality with a life-threatening stressor. JAMA 1995; 273: 1208–10.[Abstract/Free Full Text]
  17. Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M, Candib D. Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998; 280: 1995–2000.[Abstract/Free Full Text]
  18. Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial. JAMA 1999; 281: 1304–9.[Abstract/Free Full Text]
  19. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA 1999; 282: 2215–9.[Abstract/Free Full Text]
  20. Irribarren C, Sidney S, Bild DE, Lui K, Markovitz JH, Roseman JM. Hostility: linked to early subclinical coronary disease? The CARDIA study. JAMA 2000; 283: 2546–51.[Abstract/Free Full Text]
  21. Williams RB. The role of the brain in physical disease. Folklore, normal science, or paradigm shift? JAMA 1990; 263: 1971–2.[Abstract/Free Full Text]
  22. Dalen JE. Is integrative medicine the medicine of the future: a debate between Arnold S. Relman, MD, and Andrew Weil, MD. Arch Intern Med 1999; 159: 2122–6.[Free Full Text]
  23. Relman AS. Integrative medicine: who needs it and why? [letter]. Arch Intern Med 2000; 160: 1205.[Free Full Text]
  24. Schneiderman N, Antoni MH, Saab PG, Ironson G. Psychosocial and biobehavioral aspects of chronic disease management. Ann Rev Psychol 2001; 52: 555–80.[CrossRef][Medline]
  25. Anda R, Williamson D, Jones D, Macera C, Eaker E, Glassman A, Marks J. Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of U.S. adults. Epidemiology 1993; 4: 285–94.[Medline]
  26. Antoni MH, Lehman JM, Kilbourn KM, Boyers AE, Culver JL, Alferi SM, Yount SE, McGregor BA, Arena PL, Harris SD, Price AA, Carver CS. Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol 2001; 20: 20–32.[CrossRef][Medline]
  27. Blumenthal JA, Jiang W, Babyak M, Krantz DS, Frid DJ, Coleman RE, Waugh R, Hanson M, Appelbaum M, O’Connor C, Morris JJ. Stress management and exercise training in cardiac patients with myocardial ischemia. Arch Intern Med 1997; 157: 2213–23.[Abstract/Free Full Text]
  28. Cruess DG, Antoni MH, McGregor BA, Kilbourn KM, Boyers AE, Alferi SM, Carver CS, Kumar M. Reductions in herpes simplex virus type 2 antibody titers after cognitive behavioral stress management and relationships with neuroendocrine function, relaxation skills, and social support in HIV positive men. Psychosom Med 2000; 62: 828–37.[Abstract/Free Full Text]
  29. Everson SA, Goldberg DE, Kaplan GA, Cohen RD, Pukkala E, Tuomilehto J, Salonen JT. Hopelessness and risk of mortality and incidence of myocardial infarction and cancer. Psychosom Med 1996; 58: 113–21.[Abstract/Free Full Text]
  30. Fawzy FI, Fawzy NW, Hyun CS, Elashoff R, Guthrie D, Fahey JL, Morton DL. Malignant melanoma: Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiat 1993; 50: 681–9.[Abstract/Free Full Text]
  31. Friedman M, Thoresen CE, Gill JJ, Ulmer D, Powell LH, Price VA, Brown B, Thompson L, Rabin DD, Breall WS, et al. Alteration of type A behavior and its effect on cardiac recurrences in postmyocardial infarction patients: Summary of the recurrent coronary prevention project. Am Heart J 1986; 112: 653–65.[CrossRef][Medline]
  32. Gidron Y, Davidson K, Bata I. The short-term effects of a hostility-reduction intervention in CHD patients. Health Psychol 1999; 18: 416–20.[CrossRef][Medline]
  33. Jonas BS, Franks P, Ingram DD. Are symptoms of anxiety and depression risk factors for hypertension?: Longitudinal evidence from the National Health and Nutrition Examination Survey I epidemiologic follow-up study. Arch Fam Med 1997; 6: 43–9.[Abstract/Free Full Text]
  34. Leserman J, Petitto JM, Golden RN, Gaynes BN, Gu H, Perkins DO, Silva SG, Folds JD, Evans DL. Impact of stressful life events, depression, social support, coping, and cortisol on progression to AIDS. Am J Psychiatry 2000; 157: 1221–8.[Abstract/Free Full Text]
  35. Lutgendorf SK, Antoni MH, Ironson G, Starr K, Costello N, Zuckerman M, Klimas N, Fletcher MA, Schneiderman N. Changes in cognitive coping skills and social support during cognitive behavioral stress management intervention and distress outcomes in somatic human immunodeficiency virus (HIV) seropositive gay men. Psychosom Med 1998; 60: 204–14.[Abstract/Free Full Text]
  36. Mayne TJ, Vittinghoff E, Chesney MA, Barrett DC, Coates TJ. Depressive affect and survival among gay and bisexual men infected with HIV. Arch Intern Med 1996; 156: 2233–8.[Abstract/Free Full Text]
  37. Schneider RH, Staggers F, Alexander CN, Sheppard W, Rainforth M, Kondwani K, Smith S, King CG. A randomized controlled trial of stress reduction for hypertension in older African Americans. Hypertension 1995; 26: 820–7.[Abstract/Free Full Text]
  38. Shekelle RB, Gale M, Ostfeld AM, Paul O. Hostility, risk of coronary disease, and mortality. Psychosom Med 1983; 45: 219–28.[Abstract/Free Full Text]
  39. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989; 2 (8668): 888–91.[CrossRef][Medline]
  40. Watson M, Haviland JS, Greer S, Davidson J, Bliss JM. Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet 1999; 354: 1331–36.[CrossRef][Medline]
  41. Williams JE, Paton CC, Siegler IC, Eigenbrodt ML, Nieto FJ, Tyroler HA. Anger proneness predicts coronary heart disease risk: prospective analysis from the Atherosclerosis Risk in Communities (ARIC) Study. Circulation 2000; 101: 2034–9.[Abstract/Free Full Text]
  42. Williams RB, Barefoot JC, Califf RM, Haney TL, Saunders WB, Pryor DB, Hlatky, Siegler IC, Mark DB. Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. JAMA 1992; 267: 520–4.
  43. Kabat-Zinn J, Wheeler E, Light T, Skillings A, Scharf MJ, Cropley TG, Hosmer D, Bernhard JD. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosom Med 1998; 60: 625–32.[Abstract/Free Full Text]
  44. Angell M. Science on trial: the clash of medical evidence and the law in the best implant case. New York: WW Norton, 1996.



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