These are my notes for a webinar presented through Great Plains Lab by Dr James Greenblatt MD about integrative medicine for mental health. You can see his website here, and the site of his practice here. I really liked this quote from his Comprehensive Resources for Psychiatry site:
"The most significant lesson I relearn with every patient is how complex
our uniqueness really is. This individuality defines our core metabolism
and biochemistry. Our unique metabolic puzzle supports our ability to
pay attention, inhibit unwanted behaviors, and regulate our moods."
The integrative medicine model is one which provides alternatives to the pharma-based approach of conventional psychiatry, in which medications are used to treat symptoms. It is an Orthomolecular approach, (orthomolecular means "right molecule"), which means that this approach strives to correct imbalances at the molecular level which lead to symptoms. Each person's symptom picture is unique. He says the mind is what the brain does, it's the biochemistry. This is a model not only of treatment, but of prevention. A model that looks at etiology, which is the "why", and not just the "what". Conventional psychiatric practice does not look at the "why" at all, only the "what" (the symptoms).
This talk uses depression as the example of what this model and approach look like. Medications have a place, but this model also identifies underlying cause. Nearly half of patients treated for depression respond to placebo. Pharmaceutical companies do less research into new meds for depression because the placebo effect is so strong, that it's hard to come up with meds that perform better than placebo. Pharma is choosing to put it's research money into other types of meds, which are more likely to generate a profit. Recently there have been many books that point out the problems with meds, but do not offer an alternative. Whether or not drugs are the answer, patients need help. Integrative medicine offers this alternative so that people can be treated and helped. The DSM is based on symptoms and patterns of symptoms, and medications are developed for symptom complexes with no sense of etiology (the "why") or objective measures, so psychiatry is just monitoring symptoms rather than treating cause. Integrative medicine looks for biological treatments for causes.
For example, if 10 patients with the same symptom complex called depression come into a doctor's office, some will have low vitamin D levels, some will have celiac disease, others will have low cholesterol levels (patients often have more than one cause). Nutritional deficiencies are one of these causes. Nutrition is not alternative health care. The name of the disorder is meaningless, what matters for treatment is what needs to be done to heal. Are there deficiencies? Is there something the patient needs? Is there something the patient needs to avoid? Are there toxicities? Bacterial overgrowth? Heavy metal toxicity? Food allergies?
Genetics
Genetics and epigenetics are very important, they set the stage. For all patients with major mental illnesses there are related issues in family members, there is an underlying genetic liability. Epigentics is not the specific genes that influence us, but the expression of our genes influenced by stress, nutrition, and environmental factors such as toxins and pathogens. Depression has a strong genetic liability, but the role of environmental factors is even stronger.
Neurotransmitters
All psychiatric medications influence neurotransmitter levels. There are hundreds of chemicals that act as neurotransmitters in the brain. Most are under precursor control, such as by levels of amino acids, which we get from our diet. Density of serotonin receptors influences risk of depression, so does neurotoxins and diet. To make neurotransmitters, it takes amino acids such as tryptophan and tyrosine, and many cofactors (B6, vitamin C, etc). A basic concept of integrative medicine is supping with whatever precursors and/or cofactors are deficient so that the body can produce what it needs on it's own. Physical exam may not tell us what the cause of the mental illness is, for example both low thyroid and low methylB12 levels can look alike, so testing is often required to identify which precursors are missing.
Nutrition
A perfect diet may not mean correct nutrition. How can people still have low levels of amino acids, a big risk factor for depression, even when they feel that they eat a good diet? Many vegetarians and vegans don't have adequate protein intake, resulting in not enough precursors. Dr Greenblatt does not suggest vegetarian diets for mental health. The kind of meat eaten can matter as well, grass fed meat has a much healthier profile of fats than grain-fed meat. Also, antacid use and other causes of low stomach acid can mean that the nutrients aren't being absorbed from the food eaten. Amino acid powders can be helpful, and are often customized via testing. These are not the same as protein powders. What we eat also influences our gut flora, which in turn can influence our mental health. Yeast and Clostridia overgrowth in the gut have both been associated with major mental health issues, including OCD and anxiety. Yeast is not well measured in stool samples, it is more accurate to measure metabolites present in the urine (an Organic Acid Test). Yeast can also cause problems with regulation of blod sugar levels, which can also contribute to mental health problems.
Folic acid is a very important nutrient for treating depression. Folic acid is the synthetic form, folate is the natural form found in food (L-methylfolate is the form the brain uses). A clear association has been found between low folate and depression, and poor response to anti-depressant medication and a higher relapse rate are also associated with low folate levels. New beginnings has a quality L-methylfolate supplement. Folate supplementation in this form, at about 500 mcg per day, has been found to increase the success of anti-depressant medications. An almost 40% difference in relapse rates for people with low folate levels vs normal levels has been found. There is evidence of folic acid, the synthetic form, having toxic effects so it is best to use the l-methylfolate form.
B12 is one of most misunderstood, neglected nutrients. B12 deficiency
can present as hallucinations, dementia, even paranoid schizophrenia.
Also fatigue, panic attacks, OCD, depression, and paranoia. Many labs
set the normal level way to low; the level should be above 500 units not
200. MMA (methylmalonic Acid) is a very accurate marker for B12
levels, if it's elevated it means that levels of B12 are low (serum B12
levels are often not accurate). The vitamin cofactors B6 and B12 have been found in research to reduce depression in elderly. Homocysteine levels can be an indication of methyl-folate problems. Homocysteine levels increase as B6 , folate, and B12 levels drop. SAM-e is necessary to make neurotransmitters, and is helpful in treating depression. When SAM-e is taken (800-1600 mg/day) it improves the response in people who are not responding to meds. Avoid SAM-e for people with bipolar, as it can cause mania.
Dietary fat is critical for mental health. The popularity of low fat diets has been very bad for mood disorders. The brain is made mostly of fat. EFAs are involved at every level of neurotransmission, as is cholesterol. Fish oil not a quick fix for many people, it can take up to 3 months to see a noticeable change. Skin disorders, dandruff, and keratosis pilaris (chicken skin bumps on the upper arms or legs) can be an indicator of low EFAs. Patients who avoid fish or fats are at risk for low levels of EFAs. Lack of bile acid can also mean poor fat absorption. Research performed in Australia that involved 81 adolescents and adults with sub-clinical psychosis, for those given 1.2 grams of omega3s daily, for 12 weeks, only 5% developed psychosis, as opposed to 28% in the control group. Testing for this is critical.
"Right food may be the wrong food", food allergies and reactions are important to consider. Celiac is one example, because it can result in patients not absorbing all the nutrients they need from their food. People with celiac are at least twice as likely to b depressed as those who don't have it. Also test for allergies and neuropeptides, especially if there is binge eating, autism, OCD, etc. Casein breaks down into casomorphine, a morphine analog. Gluten also breaks down into a morphine analog called gliadomorphine. (when this reaction is present, it indicates both a low level of the enzyme DPP-IV which brekas these peptides down into smaller harmless pieces, as well as leaky gut which allows the morphine-like peptides to cross over out of the gut and into the bloodstream. This enzyme can be supplemented, but often complete removal of gluten, dairy and soy are necessary to eliminate the symptoms).
Exercise and the Mind-Body Connection
Exercise is also very effective in treating depression, but is often hard to do for people who are depressed. Other treatments may be needed first, such as supplements and dietary changes, to give a person the energy to create good exercise habits. Begin by nourishing the brain, focus on nutrient deficiencies critical for brain function. Once the foundation is laid, it is important to nurture the mind, and to include mind-body approaches such as mediation and yoga. It is often necessary to address a person's state of mind to heal. Spirituality and faith can be protective against mood disorders and depression.
Inflammation
Depression is the result of inflammation, essentially the brain is on fire. Depression is associated with many chronic illnesses, those that involve a high degree of inflammation. Depression is "sick behavior", the signs of depression are ways that our bodies react to being sick. They are the result of having elevated inflammatory cytokines in our systems. We have all had the flu, and experienced first-hand how being sick can lead to loss of appetite, loss of interest in things we previously found pleasurable, low sex drive, and avoidance of social interaction (in the case of the flu, these symptoms are the result of inflammation caused by a virus). Another example of the connection between mental illness and inflammation is the fact that many people with schizophrenia have celiac disease.
The treatments for depression listed above (exercise, proper diet including adequate fats, eliminating allergies) decrease inflammation in the brain. One of the mechanisms for the connection between inflammation and depression is that inflammatory cytokines produce an enzyme called IDO that breaks down tryptophan and serotonin. Additionally, lower levels of serotonin means less melatonin is produced, resulting in sleep problems. Also, quinolinic acid is a toxin that results from inflammation and which destroys neurons in the brain. Tests can be run for both quinolinic acid and c-reactive protein to give an indication of how much inflammation is present. The causes of inflammation include the standard American diet (SAD), pathogens such as Lyme and strep, allergies, sleep deprivation, stress, lifestyle, environmental toxins, and chronic dysbiosis in the gut. Identifying the cause of the inflammation is a major part of understanding and treating a patient's depression.
In Conclusion
Medications for depression have not generally been very effective, how many of those medications work has yet to be identified, and inflammation is a model that can explain the pathology of depression and leads to effective treatments. This talk has focused on depression, but what has been said applies to mental illness in general. Integrative medicine also focuses on increasing a person's nutrient reserves for long term health rather than focusing on managing symptoms. Research has shown that even simple interventions can lead to major changes, for example research in England found that when prisoners were supplemented with EFAs and multivitamins, there was a more than 25% reduction in episodes of violence and serious behavior problems. Imagine the impact on society as a whole if these changes were implemented on a large scale.
There are many relevant lessons from history in regards to mental illness. For example, the disease Pellagra which mimics symptoms of schizophrenia is caused by a deficiency in vitamin B3. At one point in the early half of the 20th century, nearly half of the people hospitalized with schizophrenia in the southern US actually had Pellagra. This is a case in which a major illness can have a simple solution. Abram Hoffer's books are a great source for more information on this topic. Integrative medicine is preventative, predictive, personalized, and puts the individual patient at the center. Mental illness is the reflection of multiple errors of physiology; if we can find the cause we can find the cure. Many patients have both toxic elements and nutritional deficiencies at the root of their illness. Medications still have a place, but they don't heal people.
There has been an epidemic of diagnosing even very young kids with major mental illness, such as bipolar, and the tragedy is the psychotropic meds that are being given to these children. Especially for kids under the age of 6 or 7, it is a tragedy to jump to medications first without even considering looking at the child's metabolism. These young patients can be treated in the integrative medicine model. As their illness progresses, interventions become more challenging. Addressing the underlying causes of children's mental health challenges when they are young can prevent mental health problems in the future. In the case of young children on the autism spectrum, early treatment based on the integrative medicine model can significantly improve their long-term quality of life and even result in recovery.
