I am a bit naïve. Yes, I am a psychiatrist, a Clinical Professor of Psychiatry, and the founder of the National Center for Whole Psychiatry. Given my experience, I should, you would think, know better. Yet I was in practice for probably 20 or more years before I realized that some times my patients lie to me about how they are doing, and whether they are following our jointly agreed upon recommendations. I am prompted to write about this, because a week ago I had an experience where a patient told me that she was lying to her other doctor.

Now, using the word ‘lying’ seems a bit strong, but I use it to get the point across. In fact, it is more like hiding the truth, not wanting to disappoint the doctor, avoiding shame, judgment, criticism, or the doctor’s expected anger.  Any reason that might inspire a child or adolescent to lie to their parent can probably be operative here because, understandably, being a patient is a vulnerable state for many.

My patient’s name is Joan.  Joan is a 58-year old married accountant who has, for the past 15 months, been having odd symptoms—feeling like the walls are closing in on her, feeling unsteady on her feet all the time, as if she just got off a boat, seeing faces “melting”. A thorough medical and psychiatric work has revealed some underlying hormonal, nutritional, and immunological dysfunctions, which are contributing to the symptoms.  As part of the medical work-up I referred her to a neurologist (Dr. Blandt), who prescribed a medication for Joan.  When I next met with Joan, I asked her if the medication worked and discovered her lie.  Our conversation went like this:

“Joan, what did Dr. Blandt say when you saw her last week?”

“ Well not that much, she had given me the Scopolamine, but I didn’t like it.”

“Did you tell her that?”

“Yes.”

“What did Dr. Blandt say?”

“She said I should try different drug.”

“How long did you take the Scopolamine for?”

“Not very long, I took it once or twice.”

“Did you tell Dr. Blandt that?”

“No.”

“Why not?”

“I didn’t want her to be upset with me.  I don’t want more drugs.”

“Joan, you have a right to not take a medicine, but you need to tell Dr. Blandt the whole truth and your concerns.  Dr. Blandt may well conclude that the Scopolamine didn’t help you, and so it’s not helpful for the type of symptoms you have and other patients like you have.  She will be less likely to prescribe it for other patients, based on the experience she believes you had.  Dr. Blandt’s ability to help people is somewhat diminished by such erroneous information.  When this happens enough a doctor’s ability to help their patients is compromised.  You need to be more direct.”

I explained to Joan how her inaccurate reporting to Dr. Blandt could easily effect her ability to get relief through proper diagnosis and treatment her problem.  A patient’s reaction to medication tells the physician something about the patient’s biology and clarifies the diagnosis.  

Inaccurate reporting leads to inaccurate treatment not just for you, but for others with similar conditions or symptoms. If you fear telling your doctor the whole truth when you are face to face, consider writing her a note before you see her telling the doctor ALL the facts of your situation – whatever they are.  You can certainly tell the doctor in the note that you have some fear or concern about telling him the whole truth. An understanding physician will appreciate your concerns and your honesty.

Antidepressants have a role in clinical practice but they are grossly over-utilized.  As a certified psychopharmacologist, practitioner of Whole Psychiatry (Functional Medicine and traditional psychiatry) and Clinical Professor of Psychiatry at Georgetown School of Medicine, I prescribe antidepressants, but  only after a thorough multi-faceted  evaluation of the patient.

We rely on drugs as a solution rather than deal with root causes of illness, and the pills generally are not as effective as we would be led to believe by the pharmaceutical companies (publically acknowledged as distorted in peer reviewed journals such as New England Journal of Medicine, Eric Turner, 2008). Nor are these drugs without financial costs and side effects.  I suggest that the solution is to develop better assessments of the metabolic factors leading to the syndrome of depression. The psycho-social-spiritual risk factors are reasonably well spelled out, and we have excellent targeted psychotherapeutic techniques available now.

The fact that the head and brain are connected to the body by something called the neck may be relevant.  In fact, there is a great deal of basic science and a good deal of clinical science indicating the very significant role played in subjective and objective mental health by at least six metabolic systems: nutrition, gastrointestinal physiology, immune/inflammatory/infectious processes, methylation processes, oxidative stress, and all hormonal systems.  This list excludes other factors such as circulatory problems, physical-structural problems, age, gender, and lifestyle factors.

Assessing these metabolic systems, and their mediators in a careful comprehensive manner, and re-establishing multi-system reserves not only helps depression with less medication, but at the same time reduces the side effect burden imposed by medication, and reduces the incidence of known co-morbidities such as diabetes, cardiovascular disease, osteoporosis, sexual dysfunction.  Psychopharmacology is only one small tool in our toolbox.  As Confucius once said, “To do good work, one must first have good tools.”  Anti-depressants are somewhat useful tools; they are just not the best or the only ones.  We have other tools at our disposal.  Why not use them?

Vitamin B12 deficiency and its detection have been in the news lately from the New York Times and The Dr. Oz Show.

B12 Deficiency Effects Widespread
The effects of vitamin B12 deficiency are widespread.  Vitamin B12 has a major influence on the function of neurons and also on the ability of the bone marrow to make red blood cells.

B12 Causes Psychiatric Symptoms
B12 deficiency can cause almost any psychiatric symptom—from anxiety, and panic to depression and hallucinations.  This is because B12 deficiencies trigger symptoms in the nervous system and red blood cells.

Diagnosing B12 Deficiency
While it is not possible to go into the details of the diagnosis and how to interpret these tests, it is important to understand that assessing vitamin B status involves understanding A DYNAMIC (moving & interacting changes in these parameters) not static assessment of the metabolic systems involved.  And because it is a dynamic system, a static measurement (e.g., B12 level) does not suffice.

As an example of the interactive dynamics, a low iron level makes red blood cells smaller; and, low vitamin B12 makes red blood cells larger. Thus, normal red blood cell size can present a false normal because low iron and low b12 counterbalance each other. If one assesses the size of the red blood cells alone once would miss this fact. However if one also looks at the iron and homocysteine, one would not miss it.  Similarly, a homocysteine level is the result of B12, folate, and mercury levels and therefore a normal homocysteine does not necessarily mean an absence of of B12 or folic acid deficiency.  In turn, all must be assessed to understand the homocysteine.

Early Detection Is Critical
It is critical that a vitamin B12 deficiency be detected as early as possible in order to prevent permanent damage to the nervous system.

The Best Way to Assess for B12 Deficiency
Unfortunately a simple B12 blood level is NOT a sensitive test for detection of B12 deficiency.  A variety of studies have shown that a simple B12 blood level misses vitamin B12 deficiency over 80% of time.  There is no one perfect test for the diagnosis of vitamin B12 deficiency.  Therefore, to determine a vitamin B12 deficiency a thorough assessment involves the following tests and other factors:

Tests

1.    Homocysteine level

2.    Red blood cell count

3.    MCV which (mean corpuscular volume)

4.    Iron & ferritin

5.   MTHFR - a genetic test

Other Factors

1.         One’s age and dietary history (the elderly and vegetarians most often have B 12 deficiencies)

2.        Medications used (people on Glucophage/Metformin, and proton pump inhibitors are often deficient)  

3.        Findings from a physical examination

(Methylmalonic acid testing is commonly thought to be useful, however a little known fact is that less than 20% of the variation in the blood or urine level is accounted for by B12 metabolism, so this test is not useful.)

If you think you have a B12 deficiency, get yourself assessed and treated right away.  

Yes!  Over the last 20 years, ample evidence has accumulated to prove that inflammation in the body causes changes in the brain that lead to depression, anxiety, sleep problems, and memory problems. Inflammation comes from the Latin  ‘inflammare’ -- to set on fire.  Our brain is ‘on fire’ when it is inflamed, or when our body is inflamed.

What sets your brain on fire?

Your body experiences inflammation the way your skin reacts to a cut:  The area becomes swollen, warmer, and it may hurt.  (This happens because there is increased blood flow, increased immune activity, and a change in the chemistry in the area.)

When there is inflammation any where in the body, signals are sent to the brain via various cytokines. The cytokines send signals to the brain via the vagus nerve and other pathways.  These cytokine signals then block the brain from making serotonin.

What does the fire do to your brain?

Inflammation affects hormones and other neurotransmitters in your brain. Inflammation drives down the level of serotonin, which can lead to feelings of depression or anxiety, and problems with memory.  It prevents melatonin from being produced, which causes insomnia.  It causes dopamine levels to rise, which contributes to insomnia, and feelings of anxiety and agitation.  The excitatory neurotransmitter, glutamate, goes up. Over time or with excessive levels of glutamate, anxiety can result. In extreme amounts, glutamate can be toxic to brain cells.

In fact, in depression, a certain type of brain cell-called an astrocyte, actually deteriorates under these circumstance, which permits the inflammation to continue. Now you have a brain that is, if not on fire, at least smoldering.

You too can prevent brain fires!

It’s not as complicated as you might think!  Try these suggestions (with your doctors approval of course.)

A) Clean up your diet by eliminating food common allergies –

¨    breads

¨    gluten

¨    milk and dairy products

¨    eggs 

¨    sugar

B) Balance your diet

¨    Try the Barry Sear’s “Zone” diet, or one of the diets in my book-“The Anti-depressant Survival Guide”

C) Keep exercise moderate,

D) Make sure your air is clean

¨    No mold, or things you are allergic to-such as dust mites

E) Reduce your stress so your adrenal glands can recover their anti-inflammatory function

F) Clear up all gut issues

¨    70% of inflammation comes from the gut-such as bloating, gassiness, diarrhea, constipation and reflux.

G) Be sure you do not have any hidden infections.

H) Drink lots of water

I) Eat lots of anti-oxidant rich foods

¨    Lots of organic colorful veggies, with a bit of fruit

Many people would be surprised that the immune system, the gastro-intestinal tract and stress interact, but that is what the most recent of a number of studies shows. In this study on mice, (Brain, Behavior, and Immunity Volume 25, Issue 3, March 2011, Pages 397-407. http://www.ncbi.nlm.nih.gov/pubmed/21040780)  researchers demonstrated that  psychological stress causes almost immediate changes to the gut bacterial population, and that some of these affected sub-populations strongly influence the effect that stress has on immunity. In the study, the researchers exposed mice to social disruption, which is known to cause increases in circulating cytokines ('hormones of the immune system), which themselves induce enhanced reactivity in the immune system.  The researchers found that social disruption altered bacterial counts of some gut bacteria sub-populations, particularly when the bacteria were assessed immediately after stress exposure. Stress exposure  increased the relative abundance of bacteria in the genus Clostridium, which often causes prolonged and severe diarrhea (generally after antibiotc use). The stressor also increased circulating levels of IL-6  which was significantly correlated with stressor-induced changes to certain other sub-populations. In a second experiment, these researchers found that a combination of antbiotics prevented the stress induced increase IL-6. This means that certain gut bacteria are necessary for stressor-induced increases in circulating cytokines.So, not only does stress affect the gut bacterial population, but these organisms are also required for  activation of the immune system.

This information becomes even more relevant for psychiatric disorders such as OCD, and depression, as activation of IL-6 has clearly been associated with depression. In fact blockers of IL-6 (eg etanercept) have been shown to reduce depression scores. Furthermore, we can now see, that stress, via its effect on gut bacteria, and hence the immune system (IL-6) can change brain function. We know this because IL-6 activates a certain enzyme (IDO), which actually 'steals' or syphons-off  tryptophan from its normal metabolic pathway ( ie conversion into serotonin and then melatonin) and instead converts it into chemicals that increase activity of glutamate (in depression) at an excitatory-and some times toxic- receptor (NMDA) in the brain. The result of all of this is increased depression, anxiety, and reduced memory. In mice this effect can take moths to reverse. The upshot of all of this, is that stress, the gut, the brain and the immune system are really intimately linked, and inseparable. While this might be news to most psychiatrists, it is not news when one understands the Whole Psychiatry model.

Nutrition, Neuronal Protection and Depression
Neuronal protection (protection against cognitive decline) requires glutathione peroxidase (a crucial enzyme which requires selenium, cysteine, carotenoids, zinc,  and vitamin E) is an important aspect of the treatment of mood disorders both because they tend to be recurrent over one’s life, and because they are associated with neuronal loss in specific parts of the brain, such as the hippocampus. R-lipoic acid, vitamin C and omega 3 fatty acids are also critical to neuronal protection.

Omega 3 Fatty Acids, Vitamin D, and Depression

There are numerous studies of the efficacy of omega 3 EFA’s in depression.  A recent large-scale (33,000) cohort of Swedish women (12) found that “a frequent consumption of fish, omega-3 and omega-6 fatty acids appears to reduce the risk of positive psychotic-like symptoms. Interestingly, they found a lower rate of psychotic-like symptoms with increasing vitamin D intake.”  It is unclear what the optimal dose of Omega 3’s is, and while it is thought that EPA is better for mood disorders, this is not clear yet.

In a cross-sectional study (13) of older adults (N=80), vitamin D deficiency was associated with low mood and with impairment on two of four measures of cognitive performance.  After adjusting for age, race, gender, and season of vitamin D determination, vitamin D deficiency was associated with presence of an active mood disorder (p = 0.022).

References:
1) Rush, AJ. STAR-D: What have we learned? Am J Psychiatry. 2007;164-201
2) Pigott, et al. Efficacy and Effectiveness of Antidepressants: Current Status:Psychother Psychosom. 2010;79(5):267-79.
3) Bourre, JM: J. Nutrition, Health & Aging: Vol 10(5) 2006: 377-385. Effects of nutrients (in food) on the structure and function of the nervous system: update on dietary requirements for brain: Part 1: micronutrients.
4)Miller HL :et al.: Clinical and biochemical effects of catecholamine depletion on antidepressant-induced remission of depression. Arch Gen Psychiatry. Vol.53( 2):117-128.
5) Spillmann MK. Et.al.; Tryptophan depletion in SSRI recovered depressed outpatients. Psychopharmacology (Berl)2001, May;155 (2):123-127
6) Maes M.,et al.:Hypozincemia in depression. J Affective Disorders; 31(2):13Maes M.: “Lower serum zinc in major depression is a sensitive marker of treatment resistance and of the immune/inflammatory response in that illness” Biol Psychiatry: 42(5):349-358 (1997).5-140 (1994)
7)Maes M.Et.al.: Lower serum zinc in major depression in relation to changes in serum acute phase proteins. J. Affect Disord 1999:56(2-3):189-194
8) Methylenetetrahydrofolate Reductase (MTHFR) Genetic Polymorphisms (C677T variant) and Psychiatric Disorders: A HuGE Review: Am J Epidemiol 2007;165:1–13
9) Coppen A, et al.: Enhancement of antidepressant action of fluoxetine by folic acid: a randomized, placebo controlled trial. J Affect Disord: 2000:60(Nov.):121-130
10)Rutten: Epigenetic Mediation of  Environmental influences in Major Psychotic Disorders Schizophrenia Bulletin; 2009: Vol 35 (6):1045-1056
11)McGowan: the epigenetics of social adversity in early life: Implications for mental health outcomes. Neurobiology of Disease (2010): In Press
12)Hedelin, M. Dietary Intake of Fish, Omega 3’s, Omega 6 PUFA’s and Vitamin D and the pPrevalence of Psychotic Symptoms in a Cohort of 33,000 Women from the General Population. BMC  Psychiatry 2010 (10): 38; 1-13
13)Wilkins CH., et al.: Vitamin D deficiency is associated with low mood and worse cognitive performance in older adults. Am J Geriatric Psychiatry, 2006 Dec;14(12):1032-40
14)Van Praag: Depression, glucose tolerance, peripheral glucose uptake and their alterations under the influence of anti-depressive drugs of the hydrazine type. Psychopharmacologia (Berlin) 1965;8:67-78.)
15)Cassidy, F. et.al.: Elevated Frequency of Diabetes Mellitus in Hospitalized Manic-Depressive Patients. Am J Psychiatry 1999;156 1417-1420.
16)Weiss JH., et.al.: Zn(+2): a novel ionic mediator of neural injury in brain disease. Trends Pharmacol Sci 2001: 21(12):112-3
17)Lindenbaum J. et.al.: Neuropsychiatric disorders caused by cobalamin deficiency in the absence of anemia or macrocytois. N Engl J Med 1988;318:1720-1728.
18)Vogiatzoglou, A. Determinants of Methylmalonic Acid in a Large Population: Implications for Assessment of Vitamin B12 Status. Clinical Chemistry (55)12: 2198-2206 (2009)

Being on the faculty of the Institute of Functional Medicine is a rewarding part of my professional life. On Sunday, I returned from an intense weeklong meeting with other members of the faculty and leadership of the Institute for Functional Medicine.  I’m excited to report that we brought the Functional Medicine Health Matrix (for diagnosis and treatment) protocol to a new level. One of the things that is so exciting about this is that this proceeds from the same structural premise found in THE age-old Eastern approaches to health.  Thus, the Matrix is a marriage of the old and the new and has significant treatment implications. While the new Matrix will not be rolled out for a year to new practitioners, faculty physicians, such as myself, will be using the new Matrix immediately. We anticipate lowering health care costs and improving health outcomes to our patients using this new Matrix.
 
In addition to the faculty and leadership meeting, I attended a Functional Medicine Detoxification Education Module, which featured the latest data regarding chemical and environmental toxicity [we are all facing increased levels of toxicity], and various protocols to detoxify ourselves.

Let me start by acknowledging what is well known: Manic Depression or Bipolar disorder can be a devastating illness. Affecting at least 1% of the population, it can, untreated, result in suicide, ruined careers and devastated families. Bipolar disorder is often accompanied by alcohol and drug abuse and addiction, criminal and even violent behavior. I acknowledge this, because I do not want to make light of the burden this illness places on people’s lives, their families and communities.

On the other hand, the history of the world has been influenced very significantly by people with manic depression (see my website www.wholepsychiatry.com for details)-from actors and actresses (Patty Duke, Jim Carey and Robin Williams) to Politicians (Winston Churchill, Theodore Roosevelt) to astronauts (Buzz Aldren), media mogels (Ted Turner) and perhaps even well known religious figures.

It seems clear that for at least some people with Bipolar disorder, there is an increased sense of spirituality, creativity, and accomplishment. It may be that having bipolar disorder holds great potential, if one is able to master or effectively channel the energies, which are periodically available, to some higher task. This would of course presume the ability to abstain from harmful drugs and alcohol, to have good character, and at least some supportive relationships and community networks.

It might be helpful to consider a reconceptualization. Perhaps instead of it being a disorder, we can think of people with bipolarity as having access to unusual potency. This potency will find a way to be outstanding-either in a destructive way, or in a constructive way. If such a choice is presented to the person, perhaps it can open some doors.

I will be discussing this and other aspects of bipolar disorder on Wednesday, August 4th @ 12PM Eastern time in my free virtual teleconference.

In a previous blog, I talked about how many doctors and patients do not know the full story about their drugs or medical treatments because of a widespread problem involving unpublished or biased clinical trials. Here is an update on what is happening.

As I mentioned, frequently, medical journals or pharmaceutical companies that sponsor research will report only positive results, leaving out the non-findings or negative findings where a new drug or procedure may have proved more harmful than helpful.

“A new review of research about this problem points to hidden or misleading studies for all sorts of conditions, including depression, Alzheimer's disease, type 2 diabetes, menopausal symptoms and cancer”, said Beate Wieseler, deputy head of the Institute for Quality and Efficiency in Health Care (IQWiG) Drug Assessment Departmentresearchers at in Germany.

Much of that problem arises from financial conflicts of interest when pharmaceutical or medical device companies fund the studies, according to Wieseler and her colleagues.  They pointed to past research showing an association between industry sponsorship and positive outcomes or conclusions in studies.  The FDA currently does not disclose much of the information it receives from companies when deciding what drugs or devices to approve for market. Now Wieseler and her colleagues want a global system to register trials and make public all research results for drugs or other medical interventions.  They detailed their findings in the April issue of the journal Trials.

"It's been shown that reporting bias is associated with all sorts of funding – government funding, department funding, industry funding – but the worst source of bias is industry-funded," said Kay Dickersin, an epidemiologist at Johns Hopkins University in Baltimore.

The FDA's European counterpart, the European Medicines Agency, has also considered its own steps toward more disclosure. "The agencies understand that there's a need for more transparency," Wieseler said. "There is increasing understanding that the public should have access [to clinical trial data]."
But regulatory agencies still have not decided how to balance the need for public access against the desire by companies to keep commercial information or trade secrets confidential, Wieseler noted.

As a post script…

In the above we see the overlapping territory of medicine, government, and politics. I encourage people to be proactive in improving and protecting their health. Here is an opportunity to do so.

There are over 900 'new to nature' chemicals in our environments, in our blood, and many are even in the blood of unborn children. Now, following the heightened concern regarding bisphenol A (in clear plastics, such as baby bottles), the FDA is beginning to set its sights on Triclosan. Triclosan is an antibacterial preservative used in "76% of liquid soaps and 29% of bar soaps". Aside from soaps, triclosan is also used in toothpastes, cosmetics, shoes, socks, workout clothes, and many personal care products. Triclosan has been detected in the urine of 75% of Americans, 60% of US streams, and persists in the environment for at least 40 years.

"Animal studies have shown that triclosan alters hormone regulation" according to the FDA, and there is no benefit to using soaps containing this chemical. Despite the fact that the European Union will prohibit its use in products that come into contact with food beginning next year, the FDA states that it "does not have sufficient safety evidence to recommend changing consumer use of products that contain triclosan at this time." The last time I checked, we were part of the animal kingdom. It seems reasonable to conclude that there is a possibility that this chemical is part of the cause of the national epidemic of hormonal dysfunction (e.g, hypothyroidism). While the FDA is advising no change in regulation or consumer behavior until there is evidence that triclosan is harmful to humans, such studies could take years. Additionally, studies which can determine the synergistic effect of this chemical in combination with other new-to-nature concoctions will, in all likelihood, never be done.

Given the facts that a) animal studies show an effect of triclosan on thyroid function (reduction in thyroxine, testosterone and sperm counts in rats), b) triclosan is toxic to aquatic animals and plants and c) there is no benefit to using the product , I advise you to seek out products that are free of triclosan.

These products can be found at IKEA, the Body Shop, Whole Foods and Trader Joes (read the labels!).  Brands that do not use triclosan include Ivory, Tom's of Maine, Listerine Essential Care, Peelu, Weleda, Toxic Free Basics, Aveda, Clean Well, LUSH, Nature's Gate, Vermont Country, Paul's Organic, Dr Bronner's Magic Soaps, MiEssence, The Natural Dentist.

For more information, visit http://www.fda.gov/forconsumers/consumerupdates/ucm205999.htm

Yours in health,
Dr. Robert Hedaya