What is in scope, and what is not
A grading framework, and the methods that fall outside it.
In short
A method belongs in integrative psychiatric practice when there is evidence that it improves a patient’s functioning or quality of life at acceptable risk and burden. That standard admits several methods most psychiatric training covers lightly. It also excludes a good deal of what is currently sold under the integrative label.
Most published descriptions of integrative psychiatry answer the scope question with a list of modalities. Lists date quickly, and they invite reasoning by category: a method gets admitted for being natural, or excluded for being unfamiliar. This project uses a standard instead of a list.
The standard follows directly from the formal definition. Once functioning and quality of life are named as the endpoints, membership stops being a question about a method’s philosophical lineage and becomes a question about what has been measured. The tiers below record the current state of that measurement.
The four tiers
| Tier | Criterion | Clinical posture |
|---|---|---|
| A | Recommended in a current clinical practice guideline from a major body. | Offer it. Document if the patient declines. |
| B | Supported by meta-analysis or multiple adequately powered trials, without a guideline recommendation yet. | Reasonable to offer alongside guideline treatment, with the evidence described honestly. |
| C | Small trials, heterogeneous results, or evidence that has not been tested against functional endpoints. | Discuss as uncertain. Do not present as established. Track the outcome in the individual patient. |
| D | Tested and not shown to work, or resting on a mechanism that has failed testing, or never assessed against any patient-relevant outcome. | Outside the scope of the term as defined here. |
Tier A and Tier B: what the standard admits
These are the methods a psychiatrist practising under this definition is expected to be able to assess and to prescribe, in the same way and to the same standard as a medication.
| Method | Tier | Evidence anchor |
|---|---|---|
| Cognitive behavioural therapy for insomnia, as first-line treatment of chronic insomnia | A | American College of Physicians clinical practice guideline, 20161 |
| Structured exercise as a treatment for depression | B | Network meta-analysis of 218 trials, 14,170 participants, 20242; earlier randomised comparison against sertraline, 19993 |
| Dietary improvement as an adjunct in moderate to severe depression | B | SMILES randomised controlled trial, 20174 |
| Selected nutraceuticals for specified indications, at specified doses | B to C, agent by agent | WFSBP and CANMAT taskforce clinician guidelines, 20225 |
The nutraceutical row is the one most often misread. A taskforce of the World Federation of Societies of Biological Psychiatry and the Canadian Network for Mood and Anxiety Treatments graded these agents individually, and the grades vary widely across the class.5 Citing the guideline as blanket support for supplementation inverts its finding. Detail by agent is on the nutraceuticals page.
Tier D: what falls outside
Publishing this tier is unusual, and it is the reason the framework is worth having. A definition that admits everything offered under its name describes a market rather than a field.
Methods that have failed testing or were never tested against outcomes
| Method | Why it sits in Tier D |
|---|---|
| Energy-field and biofield therapies presented as treatments for psychiatric disorders | The proposed mechanism has failed testing, and trials against patient-relevant outcomes do not support a specific effect. |
| Broad “functional” laboratory panels ordered without an indication | Panel results have not been shown to change functioning or quality of life when used to direct psychiatric treatment. Untargeted testing also generates false positives that produce further testing and treatment. |
| Supplement regimens directed by MTHFR genotype | Genotype-directed supplementation has not demonstrated improvement in functional outcomes in psychiatric populations. |
| Hair, saliva, or urine panels used to diagnose psychiatric illness or nutrient causation | These assays lack validation for the psychiatric purposes they are marketed for. |
The structural test, which the modality lists miss
Grading methods one at a time leaves out the feature that most reliably separates careful integrative practice from its commercial imitation, which is how the practice is paid.
Three arrangements sit in Tier D on their own, whatever methods accompany them:
- Dispensary revenue. A clinician who earns a margin on the supplements prescribed has a financial interest in the prescription. Retail dispensing platforms have made this arrangement the default in a large part of the field.
- Diagnostic testing sold by the prescriber. The same conflict, applied to the assessment side of the work, where it also drives the treatment that follows.
- Fee structures that require a testing package before clinical assessment. Initial evaluations advertised between roughly $300 and $975 commonly bundle panels selected before the patient has been assessed, which reverses the order of clinical reasoning.
None of these is illegal, and disclosure improves them. They belong in Tier D because each one predictably distorts the measurement that the definition depends on. A method whose adoption is driven by its margin has not earned its place by evidence.
Where integrative methods are the wrong starting point
Breadth of method carries a specific hazard, which is that an adjunct is offered while indicated treatment is deferred. The sequencing rule from the integrative mental health literature is that additional methods follow guideline treatment, or at minimum follow its documented recommendation.6
Presentations where standard psychiatric care comes first, without exception: mania, psychosis, catatonia, severe depression with suicidal ideation, eating disorders at medical risk, delirium, and withdrawal states. In the United States, anyone in crisis can reach the Suicide and Crisis Lifeline by calling or texting 988.
How a method changes tier
Tier assignments on this site carry the date they were set and the evidence they rest on. A method moves up when adequately powered trials report improvement in functioning or quality of life, and down when replication fails. Movement in either direction is recorded in the page history rather than applied silently, so that a citation to an earlier assessment remains checkable.
Corrections are welcome and are handled under the editorial policy.
References
- Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125–133. PMID 27136449. doi:10.7326/M15-2175
- Noetel M, Sanders T, Gallardo-Gómez D, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2024;384:e075847. PMID 38355154. doi:10.1136/bmj-2023-075847
- Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Arch Intern Med. 1999;159(19):2349–2356. PMID 10547175. doi:10.1001/archinte.159.19.2349
- Jacka FN, O’Neil A, Opie R, et al. A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’ trial). BMC Med. 2017;15:23. doi:10.1186/s12916-017-0791-y
- Sarris J, Ravindran A, Yatham LN, et al. Clinician guidelines for the treatment of psychiatric disorders with nutraceuticals and phytoceuticals: the World Federation of Societies of Biological Psychiatry (WFSBP) and Canadian Network for Mood and Anxiety Treatments (CANMAT) taskforce. World J Biol Psychiatry. 2022;23(6):424–455. PMID 35311615. doi:10.1080/15622975.2021.2013041
- Hoenders HJR, Appelo MT, van den Brink EH, Hartogs BMA, de Jong JTVM. The Dutch Complementary and Alternative Medicine (CAM) Protocol. J Altern Complement Med. 2011;17(12):1197–1201. doi:10.1089/acm.2010.0762