1	Psychiatry in the Light of Holism Scott Shannon, MD Northern Colorado Center for Holistic Medicine Fort Collins, Colorado
2	Benito Martinez Abrogan
3	Benito: 1887-2006 Oldest living human: 119 years old Smoked until 108 years old Favorite food: sweet potatoes fried in pork fat Did not see a doctor until 115 years old No hospital care until time of death Cuba: health care: $251/pp vs $6,000 US The Economist, October 21st, 2006
4	Challenged Assumptions Psychiatric illnesses represent fundamental imbalances of brain biochemistry Our current psychiatric diagnostic system is both valid and reliable Over the long term psychiatric medications are safe and effective treatments Psychiatric treatments other than psychopharmacology represent second tier options
5	STAR*D Study of Major Depression Largest US study of Major Depression. 3,671 patients over one year. No medication better than another. 37% remission after 1 trial, 67% after 4. Massive drop out rates= 21, 30 and 42% More than one med= more likely to relapse “The 67% rate is almost certainly an over estimate of what would happen in the real world” Rush, J, American Journal of Psychiatry 2006, 163:1905-17
6	STEP-BD Study of Bipolar Relapse 1,469 patients with Bipolar Disorder 48.5% relapse within two years Depression more common than mania Lamotrigine better than antidepressants “Recurrence common and highlights the need for more treatment options”
7	CATIE Study of anti-psychotics Largest and longest study of its kind Over 1,400 patients with schizophrenia 18 months: Tolerability and Efficacy Efficacy and Tolerability: poor 74% stopped meds for any reason Substantial side effects: 64% to 70% FGA fared as well as Atypicals Stroup, T and McEvoy, J. American Journal of Psychiatry 2006, 163: 600-622.
8	Common Themes Research not sponsored by pharmaceutical industry Looks at long term results Designed to mimic clinical practice Offers very pessimistic view of meds Humbles us in psychiatry
9	Overview Philosophy Approach Depression Anxiety Addictions
10	Psychiatry and Holism Body—Mind—Spirit Systems Perspective Physical Contribution Mental/Emotional Contribution Spiritual Contribution
11	Body—Mind—Spirit We exist and function on many levels simultaneously Imbalance on any (or multiple) level(s) can trigger psychiatric illness Focus treatments on the level(s) most out of balance Biology is typically over represented in our thinking and treatment Biological treatments have limited effectiveness for non-biological balances
12	Psychiatric Disorders Complex Pattern Over-determined-cause Power of Mind and Spirit Relational Foundation Self-correcting Power Mental/Emotional/Spiritual Homeostasis
13	The Inherent Error of Simple Solutions Most useful to practitioner Chronically stable dyshomeostasis Superficial re-equilibration True re-equilibration and homeostasis
14	Psychiatric Disorders as Final Common Pathway Diffuse non-specific indicator of distress/disorder (think fever) Multi-dimensional interactive system Potential causes/treatments unlimited Breadth of assessment critical
15	Final Common Pathway Causes not labels Search for root(s) of imbalance Understanding triggers and predispositions crucial No one has a monopoly on cures
16	Depression as a Model Environmental, physical, emotional, mental, social, or spiritual triggers Final common pathway Lack of core pathophysiology Very broad assessment needed
17	Depression—Overview What is it? What heals it? Mood disorder spectrum Current treatment trends Vulnerability and resilience
18	Depression—Holistic Assessment History (also collateral) Physical Mental/Emotional Spiritual
19	Depression—History First onset—age, situation Chronicity/severity Response to treatment History of trauma Relational history Specific quality of experience
20	Assessment: Body Exercise Energy/vitality/sexuality Appetite/diet Weight Sleep (also rule out sleep apnea) Physical illness/symptoms
21	Assessment: Lab Thyroid Adrenal Blood GI/dysbiosis Elimination diet
22	Assessment: Mind Mood/affect Recreational/relaxation Work Hobbies Addictions/patterns Creative outlet Sexuality Relationships
23	Assessment: Spirit Worship/path Prayer Centering Love
24	Assessment: Family/Community Family time/play Family relationships/dynamics Community connection/service Neighbors/friends
25	Depression Treatments: Body–1 Overview Exercise Nutrition/oils Herbs and supplements Energy medicine Acupuncture Somatic Pharmacology Hormonal
26	Depression Treatments: Body–2 Aerobic Exercise 15-20 minutes 4 times per week Lots of supportive/encouragement needed Prescribe it
27	Depression Treatments: Body–3 Nutrition High protein Food allergy concerns Caffeine free Low sugar Omega 3 oils—2,000 mg/day minimum (EPA/DHA better than flax)
28	Depression Treatments: Body–4 Herbs and Supplements St. John’s Wort (0.3%)—600mg a.m./300mg p.m. (mild to moderate depression) 5-HTP—50-400 mg/day–sedating Ginkgo Biloba—80-120 mg BID–stimulating Tonics (Ginseng/Ginger) B-6 and B-12- (B complex 50mg)
29	Depression Treatments: Body–5 SAMé S–adenosyl methionine (crucial methyl donor) Enhances methylation in body Profound, effective and synergistic antidepressant Stimulating, works quickly (2 weeks) Headache, insomnia, nausea 200-800 mg twice daily, start low, give on empty stomach Can induce mania
30	Depression Treatments: Body–6 Energy Medicine Light—10,000 lux, 18 inches, 30 minutes in the a.m. Cranial electrical stimulation Negative ions Homeopathy–individualized
31	Depression Treatment: Body–7 Acupuncture Electro-stimulation Chinese herbs Auricular points Cumulative effect
32	Depression Treatments: Body–8 Hormonal Augmentation Desiccated thyroid (1-2 grains in the a.m.) Cytomel (10-25 mg twice daily) DHEA Check DHEA sulphate blood level first Estrogen/Testosterone Arch Gen Psych. 2005;62:154-162 (90mg and 450 mg of DHEA for 6 weeks)
33	Depression Treatments: Body–9 Medications SSRIs Buproprion Venlafaxine Stimulants Iatrogenic Cause Other
34	Depression Treatments: Body—10 Somatic Massage/Rolfing Qi Gong Cranial Manipulation (head injury, headaches) Reiki
35	Depression Treatments: Mind Psychotherapy Recreation Social/Relationships Work Hobbies Education
36	Depression Treatments: Mind–Therapies Cognitive–Behavioral Solution Oriented DBT (Dialectical Behavior Therapy) Hakomi Process Work Psychosynthesis Meridian Therapies Groups
37	Depression Treatments: Spirit Retreat Spiritual Counseling Dream Work Service Existential Exploration Prayer Love, Joy, Hope
38	Anxiety What is it? What heals it? Anxiety Disorder Spectrum Developmental Context Vulnerability and Trauma
39	Anxiety Treatments: Body Supplements and Herbs St. John’s Wort (0.3%)—900 mg/day Calcium/Magnesium (Citrate) 200-400 mg of Mag.; 500-1,000 mg of Calcium Inositol—1,000-6,000 mg/day Kava Kava—100-400 mg/day (on hold–issue of hepatotoxicity) Valerian Melatonin—0.5-1 mg qhs
40	Anxiety Treatments: Body Nutrition No caffeine Low sugar Complex carbohydrates Food allergies Watch additives/nutrasweet
41	Anxiety Treatments: Body Exercise Walking Swimming Yoga Tai Chi
42	Anxiety Treatments: Body Somatic Acupuncture Cranial manipulation Massage Trager Hot baths
43	Anxiety Treatments: Body Medications SSRIs Buspirone Clonidine Clonazepam Beta-blockers
44	Anxiety Treatments: Mind Biofeedback Relaxation Training Breath Work Meditation Education EMDR
45	Anxiety Treatments: Spirit Faith vs. Fear Death Ritual Centering Prayer Spiritual Community
46	Addictions—Overview Nutrition Acupuncture EEG Biofeedback AA/NA Exercise
47	Addictions: Nutrition High protein Avoid sugar, simple carbohydrates Taper off caffeine EFA = EPA/DHA (1-2 gm twice daily)
48	Addictions: Supplements Detox Period B Complex—50-100 mg of each in a.m. and p.m. Vitamin C (ester)—1,000 mg 2 or 3 times a day Zinc—25 mg twice daily Cal/Mag (Citrate)—200-400 mg 3 times a day Inositol—1-2 gm twice daily Melatonin—1 mg qhs
49	Addictions: Acupuncture Michael Smith, MD–Lincoln Hospital, Bronx 500,000 plus treatments there 4 needles in each ear Proven protocol–NADA, 200 plus facilities Reduces cravings and recidivism Hazleton and Hennepin County, MN
50	Addictions: Summary Coordinated, combined treatment critical Bill W’s three legged stool—Body, Mind, Spirit Support, inspire and confront
51	New Research Changes in prefrontal activity predict anti-depressant drug side effects 32 healthy subjects without depression Changes occurred prior to drug treatment Predictive of number of side effects noted in 4 week study How does the brain modify drug effects? Hunter, Neuropsychopharmacology, April 2005
52	New Research Depression recurs despite ongoing medication maintenance 103 subject followed for 20 years Includes TCAs, MAOIs and SSRIs 25% experienced recurrence Median time to recurrence: 31 weeks J. Clin. Psych. 2005; 66: 283-290
53	Summary People are unique and multi-dimensional Education, support and motivation are invaluable Avoid simple solutions and one-dimensional thinking Strive for balance and harmony Embrace the complexity and potential in each person Love yourself and those you serve
54	Micronutrient Supplementation in Young Adult Prisoners RCT in 231 young offenders Broad array of minerals, vitamins, EFA’s Active group—26.3% fewer rule violations Active group—35.1% fewer violent acts Gesch et al (Oxford), British Journal of Psychiatry, 2002, 181:22-28
55	Multivitamins and Mood Placebo controlled trial of 129 adults for one year Quarterly psychological testing 10x DRI of 9 vitamins At 12 months hostile subscale significantly improved Mood status related to thiamine (B1) riboflavin (B2) and pyridoxine (B-6)status The delay in results suggests resolution of chronic nutritional deficiencies is responsible (Benton et al, Neuropsychology 32:98-105, 1995)
56	Multivitamins and Mood Randomized placebo controlled trial of 80 adults B vitamins, calcium, magnesium, zinc (12x DRI) Within 28 days—significantly lower anxiety Depression scores significantly improved Perceived stress significantly lower (Carroll et. al. Psychopharmacology 150:220-225, 2000)
57	Multivitamins and Mental Health 8 week placebo controlled trial of 1081 men Compared mood, cognitive factors: MVI vs. placebo Deficiency levels = increased irritability, nervousness, fear, depression Significant improvement only in deficient group (Hesker et. al. Annals NY Academy of Science 669:352-357, 1992)
58	Multivitamins and Mental Health Baseline Vit C deficiency when supplemented = significantly reduced depression, anxiety and mood lability Baseline folate deficiency = significantly improved mood lability, concentration, self-confidence, extroversion and mood Conclusion: nutritional status is correlated with psychological functioning and that even slight deficiencies, if chronic, can result in clinically significant impairment (Hesker et. al. Annals NY Academy of Science 669:352-357, 1992)
59	References Depression Apparent fish consumption and the prevalence of major depression: a cross-national perspective[letter]. Lancet 1998;351:1213. Essential fatty acids predict metabolites of serotonin and dopamine in cerebrospinal fluid among healthy control subjects, and early and late onset alcoholics. Biol Psychiatry 1998;44:235-42. A replication study of violent and non-violent subjects: CSF metabolites of serotonin and dopamine are predicted by plasma essential fatty acids. Biol Psychiatry 1998;44:243-9.
60	References More on Omega-3 Fatty Acids in Depression Low plasma concentrations of DHA predict low CSF levels of 5-hydroxyindolacetic acid. A marker of brain serotonin turnover Such low concentrations are strongly associated with depression and suicide World Rev Nutr Diet 82:175-86, 1996
61	References Depression Omega-3 Fatty Acids After 5 years, switching subjects to a cholesterol-lowering diet in which fish consumption was increased was associated with reductions in measures of depression. Ann Intern Med 117 (10): 820-3, 1992
62	References St. John’s Wort Shelton, RC and Keller, MB Effectiveness of St. John’s Wort in Major Depression, JAMA 2001; 285: 1978-86 Linde, K. et al., St. John’s Wort for Depression–Overview and Meta-analysis, Br.Med. J. 1996; 313: 253-8 Hypericum Depression Trial Study Group: Effects of Hypericum in Major Depressive Disorder, JAMA 2002; 287: 1807-14
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67	Resources Larsen, J. Seven Weeks to Sobriety Ballentine Books: NY 1997 Murray, M., Encyclopedia of Nutritional Supplements, Prima Press: NY 1996 Norden, M., Beyond Prozac, Regan Books: NY, 1995 Pizzorno, J. and Murray, M., Encyclopedia of Natural Medicine, Prima Press: NY 1997 Shannon, S., Handbook of Complementary and Alternative Therapies in Mental Health, Academic Press: San Diego, CA 2001 Stoll, A., The Omega-3 Connection, Simon and Schuster: NY 2001 Zuess, J., The Wisdom of Depression, Harmony Books: NY 1998
68	Resources Nordic Naturals (Pro EPA), 1-800-662-2544 ext. 102 www.nordicnaturals.com Omega Brite (Hi EPA), 1-800-383-2030 www.omegabrite.com Pharmax (Frutol), 1-425-467-8054 www.pharmaxllc.com Synergy (EM Powerplus), 1-888-878-3467 www.truehope.com
69	"7603 Colland Drive" 7603 Colland Drive Fort Collins, Colorado 80525 970.663.2686 scottshannon@cowisp.net www.wholeness.com