Being a month removed from my last medical school clinical rotation
(Psychiatry), I can safely say for as much as I enjoyed my time exploring
mental illness, I was more than a little dismayed at Western medicine’s approach
to healing when it comes to the disturbed mind.
As this post could easily explode into a rant, I want to start off by providing
a solid foundation for a health discussion and acknowledge the inspiration
behind this post: the pioneering work of one of my idols in functional medicine
(specifically functional neuropsychiatry): Dr. Kelly Brogan. Dr. Brogan has
just released her widely acclaimed book A Mind of Your Own that seeks to
question much of we are doing with modern psychopharmacology- SSRI’s for
pediatric obsessive-compulsive disorder, anti-psychotics for sleep deprived,
stress outs Type A’s, and benzodiazepines (BZD’s) for anything else causing you
a little anxiety. We’ve reached a scary point where drugs have taken over our
treatment plans, yet interestingly enough, data continues to emerge showing the
research for SSRI’s for mild/moderate depression, stimulants for ADHD and BZD’s
for anxiety is rather weak and biased- some evidence actually shows potential harm for these drugs over the long term! But as I mentioned before, this is not about bashing drugs, but about
promoting holistic and functional approaches to disease. So no better place to
start than with a whole foods diet, a mindfulness practice, a little sun
exposure, some energizing exercise, and time spent with loved ones. Taken together, regardless of one’s current
symptoms or physiologic disturbance, these five things will get you towards
your goals of obtaining and sustaining optimal health; it also just so happens
that the data behind these specific lifestyle practices for the treatment and
prevention of mental illness is quite encouraging.
Just in the
past 3 years, studies focused on sun exposure (and not
just Vitamin D levels,) quality/quantity
of social relationships, adherence to a Mediterranean style diet,
aerobic exercise, mindfulness meditation,
and combining mindfulness
meditation and aerobic exercise have all shown to be helpful in multiple
areas related to mental health including: 1)improving negative mood symptoms,
2)preventing depression, 3)decreasing anxiety/social anxiety and 4)decreasing
the likelihood of relapse after one’s initial presentation with a mental
illness. As we continue to explore the biologic and pathophysiology behind
specific mental disorders, we are discovering that disturbances in the body that
lead to a state of chronic, low level inflammation can actually affect the
integrity the blood/brain barrier that essentially allows inflammatory
cytokines free access into the intricate structures of the brain, leading to a
cascade of microglial activation and disrupted neuronal cell function. Coupled
to a disturbance in one’s gut microbiota (responsible for the production of
many neurotransmitters- including nearly 80-90% of all the serotonin in our
body), you can quickly see that a neurotransmitter deficiency in one region of
the brain isn’t exactly the whole story when it comes to depression. The
inflammatory cytokine model of depression as described above as well as the relatively
unknown effect of chronic environmental toxin exposure, are together, providing
more truth to the story of mental illness. I will be the first to admit that in
regards our current pharmaceutical approach to depression, there is supporting evidence
that in moderate
to severe depression there is a short term and substantial benefit for SSRI’s,
however, when it comes to mild-moderate depression, placebo and the wonders of
time are just as good- or perhaps better when you consider the lack of side
effects. That being said, just because we observe some benefit for the most
severely depressed, does not mean we completely understand the mechanism by
which this may occur (for example: start from a worse/ the worst place
imaginable and go forward in time, can things really get that much worse?), or
that we should see the same effect on those less impaired at baseline are both
rationalizations that simply cannot be made and truthfully hold little
validity. So why do we still see so much suffering when it comes to depression
for thousands of Americans? Well guess what, it just so happens that most
people diagnosed or treated for depression fall within the mild to moderate
range based on verified depression severity scales and what to this point have
we been primarily offering them for treatment?- exactly, something no better
and possibly more harmful than a placebo.
But the problem with prescribing SSRI’s is not
simply one of “Big Pharma” perpetuating their products, but of the way we
practice family medicine- prescribing drugs because you only have fifteen
minutes to talk to a patient presenting with mental illness. As Dr. Brogan
points out in her book, we are not here to attack “Western Medicine” and demand
the cessation of inappropriate pharmaceutical use, we are here to have a voice
and hold a space saying there is another way to address mental illness, and it’s
actually it’s a space that may be much more “medical” than “psychological.” Through
careful evaluation of one’s gut health including intestinal permeability, food
allergies, gluten sensitivity, SIBO, the presence of parasites or other
infections, and fungal overgrowth, to an overall assessment of one’s current
state of inflammation, blood sugar regulation, sleep patterns, social and work
environments, exercise and movement patterns, hormonal imbalances and autonomic
(in)stability, we see that mental illness does not exist in a silo where
medical intervention is reserved for extreme cases. Adding even more fuel to
the fire there’s our burgeoning understanding of the effects of our genetics
(SNP’s) and the epigenetic inheritance from our parents/grandparents on our
risk for developing mental illness. Did you know that if your grandmother was
in a relative state of stress/anxiety/famine when she gave birth to your
mother, regardless of your mother’s living conditions and environment, you may
be at a greater risk for developing obesity, metabolic syndrome or a mental
illness as it relates to your personal experiences of stress and/or traumatic
life events?
Brogan is
opening “Pandora’s Box” so everyone can see the truth behind our current
(flawed) approach to psychiatric care and I can only hope her message spreads
like wildfire to family practice clinics and psychotherapy groups across the
nation. Unfortunately, after seeing the relative lack of acknowledgement for
underlying physiologic “medical” disturbance in an inpatient psychiatry unit
(IV’s were not allowed on the unit- some would say for obvious reasons, and
blood work was virtually limited to drug levels of anti-psychotics and mood
stabilizers) I am not overly optimistic. Perhaps, most disturbing of all with regards to the observed inpatient
psychiatry care, was the approach to diet whereby all patients were given
double portions, and there was no such thing as a diabetic or heart healthy
diet. I can only speculate on the perceptions of other health care workers in
charge of hospital care/policy, but perhaps it was seen that being on the psychiatry
unit wasn’t exactly “pleasant” so why not just let the patients choose what
they wanted to eat and give them double of everything (of course your loved ones
could also bring in all the soda and candy you might want as well). As I saw
it, by providing this substantial amount of processed food without a context
for nutritional education and in complete disregard to the research behind a
whole food or Mediterranean style diet for the treatment/prevention of
depression, anxiety and psychosis, we were inadvertently sabotaging any realized
gains from the treatments we could and did provide simply by adopting a “caring”
approach to food for our patients.
So I end with
three final questions, (coming from someone who really does not like drugs) 1)
Is there possibly, just maybe, a role or actual benefit for SSRI’s as a
treatment for depression when we remove the overt antagonists- poor diet,
substance abuse, minimal movement, no natural light exposure, and toxic
relationships? Or (coming from someone who sees all those antagonists on the
extreme end of poor choices) 2) If we actually choose to push beyond simply NOT
doing something so BAD and choose, instead to shoot for DOING something
relatively GOOD we would find a path to true healing for those suffering from
mental illness? And finally (coming from someone with an open and gracious
heart) 3) If you are to remember one thing from this post, can you remember to
acknowledge those things that are directly harmful to the well-being of your
patients, and choose to not to put your energy to attacking those things you
may perceive as “bad” but choose instead with your complete consciousness to
hold a space for the relief of suffering? For in the end, for those in the
health care field, we may be (feel) obliged to “care” for all the patients we
encounter, but do we actually believe in the choice to be compassionate, and
perhaps, question if my belief and duty in the obligation to “care” is actually
really caring at all?
