Early Osteopathic Thought on Serious Mental Illness and How Osteopathic Medicine Fits Into Psychiatry Today

Osteopathic medical students spend considerable time learning the history, philosophy, and theories of osteopathic manipulative medicine (OMM) and skills of osteopathic manipulative treatment (OMT), all of which are tested on licensing exams. Data from the National Resident Matching Program show that 17.4% of fourth-year osteopathic medical students matched into psychiatry postgraduate year-1 positions in 2021, compared with 6.5% in 2019. However, very few osteopathic psychiatrists utilize OMT.

Since its inception, osteopathic medicine has theorized about and proposed treatments for serious mental illness, such as mood disorders and schizophrenia. However, there has been minimal mention in osteopathic textbooks of the treatment of these conditions with OMT (1), limited studies investigating use of OMT for serious mental illness, and no official OMT clinical guidelines for psychiatric conditions. Furthermore, application of OMT requires physical touch—a controversial and ethically charged topic within psychiatry. The goal of this article is to contextualize early osteopathic thought about the treatment of serious mental illness, propose reasons for the decline in OMT utilization in psychiatry, and briefly discuss current literature on using OMT in psychiatry.

Dr. A. T. Still and Osteopathic Psychiatry

Dr. A. T. Still established osteopathic medicine in 1874 as a holistic approach to medical care. The osteopathic philosophy emphasizes a person as a unit of body, mind, and spirit that is capable of self-regulation, self-healing, and health maintenance. Still believed that structure and function of the body are interrelated and that there is a musculoskeletal component to disease. He developed a set of hands-on techniques (i.e., OMT) to restore function of the body, enhance wellness, and assist in recovery from disease and injury. Today, osteopathic physicians utilize this philosophy and OMT to treat a wide range of physical ailments. Yet, modern evidence for the utility of OMT in the treatment of mental illness is lacking, despite increasing knowledge about brain-body connections (e.g., the links between chronic pain and depression and between the brain and gut).

In his 1910 book, Osteopathic Research and Practice, Still wrote about treatment of multiple conditions that fall under the umbrella of psychiatry or neurology (2). Among other conditions, he specifically mentioned “insanity and feebleness of mind,” “mental shortage or overplus,” and “hysteria” (2). Furthermore, Still encouraged his two sons to establish what became known as the Still-Hildreth Sanatorium (3). Open from 1914 to 1968, it was the first osteopathic medical institution committed solely to the treatment of mental disorders (3).

Still believed that the “majority of the insane patients could be treated successfully by osteopathy” (3). He was among the earliest physicians to argue for a link between physical and mental illnesses. He considered the possibility that psychiatric disorders were caused by changes in “bony variations from their normal articulation” that resulted in “shortage or overplus” of one or more of the five senses (2). Furthermore, he attributed many cases of mental illness to functional abnormalities in the vascular or nervous system. He argued against physical means of treatment (i.e., mechanical restraint, physical punishment, and bloodletting) and for methods that involved compassion, kindness, and dignity (4). He was critical of medical leaders in his time, stating that they had “philosophized and experimented with drugs, physical punishment, using the whip and other instruments of cruelty upon the unfortunate with abnormal minds, without restoring them to normal mentality” (2). From his writing, we see that Still was sympathetic toward those with mental illness but dissatisfied with the treatment of serious mental illness. He wrote, “I will ask, will we still dope, dose, torture and confine the insane and say, verily, verily, the grave is the only asylum that will cure such diseases?” (2).

OMT in Psychiatry After A. T. Still

A series of historical articles from as early as 1917, reprinted in 2000 in the Journal of the American Osteopathic Association, serve to document the early stages of treatment of mental illness by osteopathic physicians (5–9). These articles demonstrate an osteopathy-centered approach to illness—that physical bodily changes possibly contribute to psychiatric illness. In 1917, Gerdine (6) suggested that “slight injuries causing no marked gross changes in the spine” could produce mental disorders and that these seemingly slight injuries were generally overlooked by doctors at the time. In the 1930s, comparisons were made between osteopathic and allopathic physicians treating mental disorders, with claims that Still-Hildreth Sanatorium had higher recovery rates than those of allopathic institutions (5, 7). In addition, we see discussion by early osteopathic physicians about the classification of mental disorders and other treatments regularly used at that time, such as insulin shock and electroshock therapies for schizophrenia (5, 8, 9).

Even after Still’s death in 1917, mid-20th century osteopathic physicians contributed to the discussion about the role of OMM in the treatment of serious mental illness (5). In the 1940s, Floyd Dunn highlighted the benefit of a physician’s touch and attention on a patient’s body image (5). He also emphasized that decreased musculoskeletal tension and improved visceral functioning can decrease emotional tension and improve mental processes. In the 1950s, William Sutherland and Harold Magoun Jr. pioneered cranial osteopathy, an OMT technique that focuses on the movement of cranial bones (5). Magoun described a patient’s improvement in learning and social functioning following cranial OMT (5). In 1965, Spencer Bradford (10) discussed the connection between primary skeletal disorders and emotional disorders through proprioceptive or pain impulses. Bradford proposed that reductions in skeletal muscle tension reduce the degree of cerebral activation and that removal of these contributing factors had potential benefits in alleviating emotional disturbances.

Others reported specific patterns of physical findings in certain mental illnesses, but little replicated empirical data are available to support these associations. A study by Woods and Woods (11), published in 1961, noted structural patterns in specific psychiatric illness, such as changes in the average number of cranial impulses per minute. Another study, published in 1997, found that psychotic disorders are associated with increased musculoskeletal dysfunction in the lower extremities, while affective disorders are associated with increased cervical and thoracic dysfunction (12). It appears that this line of theorizing and study of OMT ended shortly after this period because few articles have been published in the scientific literature since 1997.

Decline of OMT in Psychiatry

Still inspired many osteopathic physicians to theorize about the causes of mental illness and engage in the treatment of such illnesses from the perspective of osteopathy, although these ideas did not seem to take further root. It is difficult to determine the specific reasons that these theories did not flourish within American psychiatry. Of note, the decline of osteopathic research in psychiatry coincided with the growth of Freudian theory and the new psychopharmacology of the mid-20th century. These two approaches dominated psychiatric thinking and practice during that time, possibly overshadowing the relatively few authors publishing articles about osteopathic psychiatry (3). Ethical concerns regarding potential boundary violations in the doctor-patient relationship also create barriers to the use of OMT in psychiatry today. These factors likely explain why a robust modern literature investigating the utility of OMT in psychiatry does not exist.

Evidence for Use of Osteopathic Techniques in Treatment of Mental Illness

To date, few studies have investigated the benefit of OMT in the treatment of mental disorders. Most of these clinical studies have been small experimental studies examining use of OMT in depression (13–15), attention-deficit hyperactivity disorder (ADHD) (16), anxiety (17, 18), and pain (19, 20). An 8-week pilot study explored osteopathic treatment as an adjunct to psychotropic medications among adults with depression or anxiety (13). Participants were assigned to either a control group (N=10) or a treatment group (OMT) (N=6), and symptoms of anxiety and depression were recorded weekly with a modified version of the seven-item Generalized Anxiety Disorder scale and with the Harvard National Depression Screening Day scale. All patients in the treatment group showed statistically significant improvements in their anxiety and depression symptoms, whereas those in the control group had symptoms that worsened by week 8 (13). In another randomized study (N=28), OMT was investigated as an adjunct to conventional care (i.e., pharmacotherapy and psychosocial intervention) in the treatment of ADHD, and significant improvements in selective and sustained attention, measured with the Biancardi-Stroppa Test, were observed (16). Although there may be some promise for OMT as adjunct treatment for these conditions, little recent data exist to guide its use in psychiatry. It seems that more research into the utility of OMT is required if it is ever to be fully incorporated into the treatment of mental illness.

Conclusions

Starting with A. T. Still and the foundations of osteopathic medicine, efforts have been made to understand and incorporate osteopathic techniques into the treatment of psychiatric disorders. Still’s influence provided the framework for osteopathic physicians in the early 1900s. However, the research and evidence needed to support OMT in psychiatry never emerged. Current clinical investigations of osteopathic techniques for serious mental illness have continued to fall short of providing the evidence to support the routine use of these techniques. To find a place for OMT within modern clinical psychiatric practice, future research efforts should be directed at examining use of OMT across a variety of psychiatric conditions.