According to Dr. Bob Hedaya, it’s malpractice NOT to use functional medicine when practicing psychiatry. ALL of the nodes on the Functional Medicine Matrix [gastrointestinal, endocrine, immune, toxicity, nutritional status and especially psychological, social and spiritual] influence mental health, mental function and brain function. The bottom line is, a good functional approach yields better health, less medicine. In this case-focused inspiring podcast, hear about Dr. Hedaya’s years of clinical experience in using functional medicine to address tough psychiatric conditions.
For more info about Dr. H Rejoint and our professional program, go to www.rejointyourself.com and use the code DRKARA
Pearls from Bob Hedaya, MD
- Whole Psychiatry: what is it, how does it align with Functional Medicine?
- Stepping outside of your clinical box- even the big box that is functional medicine.
- The DID-GONE acronym and FxMed
- SNP testing in psychiatry
- Methylation in psychiatry
- Infectious diseases as triggering events for psychiatric disorders
- Treatment resistant depression and FxMed: A 34-case retrospective from Bob’s practice
- The single most important skill for all clinicians.
Dr. Kara Fitzgerald: I’m so excited to have Dr. Robert Hedaya with me today. He is a pioneer in the field of functional medicine. I have been aware of his work, heard him lecture for my entire career. Let me tell you a little bit about him.
He’s the Founder of The National Center for Whole Psychiatry in Chevy Chase, Maryland as well as Functional Herbals LLC, the makers of Dr. H Rejoint and Herbal Anti-Inflammatory that works, by the way. He’s board certified by the American Board of Psychiatry and Neurology and is a distinguished fellow of the American Psychiatric Association.
He’s a clinical professor of Psychiatry at Georgetown University Medical Center and active member of the Endocrine Society, certified as proficient in psychopharmacology by the American Society of Clinical Psychopharmacology. He’s a faculty member at the Institute for Functional Medicine and has been recognized as a certified clinician in functional medicine.
Dr. Hedaya is a recipient of the Physicians Recognition Award from the American Medical Association and has been voted Outstanding Teacher of the Year multiple times by the students at Georgetown, University Medical Center’s Department of Psychiatry. He’s authored books for both practitioners and consumers and has been featured as an expert consultant numerous times in the media. He writes a blog for Psychology Today.
Dr. Hedaya is the developer of Whole Psychiatry Methodology, which we’ll talk about today in addition to the functional approach to psychiatry, which offers a comprehensive physiologic and psychosocial spiritual approach to mental health and chronic physical illness.
His method evaluates and treats mind, body dysfunction by focusing on the detailed evaluation and by directional interactions between and among a person’s hormonal system, immune system, gastrointestinal system, nutrition, environment, social and spiritual status, genetics, detoxification, cell signaling, life circumstance, age and gender.
Dr. Hedaya, it’s wonderful to have you.
Dr. Robert Hedaya: Oh, it’s great to be with you, Kara. Thank you very much for the introduction. And I guess it’s been a long trek from Brooklyn for me that I’ve accumulated all that stuff.
Dr. Kara Fitzgerald: And I wouldn’t mind some of it today. Our clinicians will be so interested in pearls from your years of experience and I know that you will give us many. So I really want to jump right in and talk about this concept of whole psychiatry.
You practice functional medicine. You are a faculty with me over at IFM and you’re certified. So you took that long large test as did I. But what’s the difference between whole psychiatry and functional psychiatry?
Dr. Robert Hedaya: That’s a great question and I think it’s important conceptually. When we think of functional medicine or functional psychiatry, we think of the different nodes, we think of the antecedents, triggers, mediators, lifestyle factors. And we have different categories of things that we look at and interact with each other.
The reason I call it “whole psychiatry” is because there has to be room in your mind and your approach to the patient for the fact that you don’t know, that actually you don’t know a lot more than you think you don’t know. And you have to realize that the paradigm you’re using today, in 10 years or 5 years or 20 years, it’s actually going to be outdated.
So this is very important because what enabled me to get into, whether you call it functional medicine, whole psychiatry or functional psychiatry, was the ability to say, “Hey, my paradigm is not working. I have evidence that it’s not working okay. What’s going on here?”
So that’s why I call it whole psychiatry because you have to be – as much as we love functional medicine, we have to understand that the day is going to come where functional medicine paradigm will not be adequate. We’ll build on it. We’ll step outside of it.
Dr. Kara Fitzgerald: Right. So really expanding and being open, recognizing the limits of one’s own knowledge with regards to the patients sitting in front of us. I got it.
Dr. Robert Hedaya: Yeah, I like to say that if you don’t think out of the box, you stay in the box.
Dr. Kara Fitzgerald: Can you give me an example of that? Is there anything where you needed to step outside of the box, well outside? I mean we’re already, as functional medicine doctors, outside of the box. And where you needed to step out further with regard to whole psychiatry, how did you develop it? When did you face that?
Dr. Robert Hedaya: You mean coming from the functional whole psychiatry method, when did I step outside of the box, out of that box?
Dr. Kara Fitzgerald: Yes.
Dr. Robert Hedaya: Okay, this is a very good example. I actually manufacture an herb and [inaudible 00:05:25] herb, which is anti-inflammatory. And I developed it when I injured myself biking. And this was maybe four years ago or something like that. I was doing not only traditional methods, but I was working on my diet and stretching and whatever I could think of, lifestyle, et cetera. But it didn’t get better.
So then I stepped out of my paradigm, which was to look at “Okay, meds aren’t working and acupuncture is not working and chiropractic isn’t working and changing my mattress isn’t working. What can I do?”
So I started to do a research on herbs. I got more and more and long story short developed this thing, this formula. Pretty much in two days, I recovered in my pain. There’s a whole story after that. But I really had to step into another world because really I never really knew enough about herbs to really give them much credence. Now I’ll tell you that if I was going back for my training today, I would probably study herbs before psychopharmacology or at least with psychopharmacology. They’re very, as you probably know, very powerful.
But for me, that wasn’t in my box. That wasn’t in my – do you see?
Dr. Kara Fitzgerald: Yeah. It’s such a great example. And there are many, many powerful traditional healing methods globally that we may need to expand our awareness around, just as you talk about in this experience. Okay, that’s a great example.
We’ll come back to your product again because mechanistically, being anti-inflammatory, it would be applicable in a number of instances, not just muscle and joint. I know we’ll talk about the inflammation association with psychiatric illness and we can circle back to talking about this as well. So that said, getting back to thinking about functional medicine, what are the advantages of using the functional medicine model with mental health?
Dr. Robert Hedaya: Actually, it’s huge. I think I’ve said this before. I’ll say it again. In my opinion, if you really look at the data, practicing standard psychiatry without functional medicine is a key into malpractice, not in the legal sense, but in the sense of poor practice.
As you know, everybody listening, there’s a tremendous body of evidence that shows that all of the nodes on our matrix all influence mental health, mental function, brain function, et cetera. So the basic, the bottom line is better health, less medicine. That’s the basic bottom line of the advantage.
Dr. Kara Fitzgerald: Yeah, I got it. And folks, those of you who are not familiar with the functional medicine matrix and the nodes that Bob is referring to, I will put the PDF. You can actually see that there’s a PDF you can download with the matrix nodes on them and I’ll put a link over to the IFM so that you can read about it.
So let’s go through the nodes. Let’s go through the matrix and talk to me about how each one of them can apply to mental health.
Dr. Robert Hedaya: Okay. So what I use in my mind is a little pneumonic, which I find helpful. And it’s DIDGONE. So D is digestion. I is immune infectious inflammatory. D is detox. Then G is genetics. O is oxidative stress. N is nutrition. And E has two meanings. One is endocrine and the other is epigenetics.
So if we start with digestion, clearly as we many people know, so much of what affects our overall health happens in the gastrointestinal tract. Now you have to when you eat – let’s not talk right now about what you’re eating because that would go on in nutrition. When you do eat something, you have to be able to break it down and you have to be able to absorb the nutrients within that food.
So if a patient comes who’s on an acid blocker – here’s a fabulous story. I have a patient who was actually treated the first time in 1985 for panic disorder. He was 20 when he was hospitalized with panic and depression. And I treated him with standard treatment cognitive therapy, medication.
When Prozac came out, I switched him from his MAO inhibitor and put him on that. And we did some group therapy and individual therapy. He was stable. And then maybe 10 or 15 years into the course of the treatment, he came into me and he was having panic attacks again.
Now, I know that if someone is stable on a medication and now they’re having breakthrough symptoms, something else is going on. He’s trying to convince me to change medications. “Let’s go on the medication merry-go-round.” And I refused.
So taking a good history, it turns out that his father died. He had to leave his career and take over the family business and his mother was a bipolar woman who was creating havoc. His wife developed fibromyalgia, chronic fatigue. She has been sexually abused when she was young. She became unemployed. You can see the world came crashing down around him.
And he started getting interested in oral reading. And so he went to his internist. He’s having reflex. They put him on Prilosec. And that was a year before. Prilosec inhibits the absorption of B12. B12 deficiency can cause any kind of psychiatric, neuropsychiatric syndrome.
So it took me a year to convince him to do a work up believe it or not. Finally he did and sure enough he was deficient and I gave him injections of B12. And it was just a matter of few weeks and he was completely better.
So that’s a digestive issue, which obviously is connected to stress and his ability to absorb B12, but of course, it could be breaking down proteins and absorbing the proteins or breaking down into fats. You can have bacterial overgrowth of the small intestine, which impairs the absorption of B12 or you can have other problems or infectious agents, et cetera. So that’s just the little overview of the digestion, but the digestion is critical to have the basic building blocks of neurotransmitters and healthy molecular mediators, et cetera. So now, it would be digestion.
The immune system, I take special interest in immune system. The immune system plays a big role in mental health. And just to give you an example of that, I have a family that I have been treating. I started treating my grandfather and then I treated the father of this girl that I saw. She was 14. She came in. She was a star athlete and a straight A student, sweetest girl. And she came in and she had deteriorated intellectual function, academic function and social function over the course of a year. It turned out she had Lyme disease.
So I gave her Minocycline because it penetrates the blood brain barrier and it has effects within the brain.
Dr. Kara Fitzgerald: It’s actually a good anti-inflammatory.
Dr. Robert Hedaya: Yeah, exactly. And overtime, she improved. Now, what does immune activation do? Obviously lots of things, but when you have a shunting, one of the important things is that if you do have tryptophan in your system, then the tryptophan is not converted as efficiently into serotonin. So you have deficiency of serotonin. You have excess dopamine.
And instead of the tryptophan going down the normal pathway, it gets shunted into the quinolinic acid, kynurenine pathway. Then what you have is the activation of the microglia and astroglia imbalances and you have excited neurotransmitters, glutamates, which cause anxiety.
So that’s just a little piece of what happens when the immune system is activated from whatever the cause is. I mean it could be mold. It could be Lyme infection. It could be from the gut. When the immune system is activated, the brain chemistry changes.
Dr. Kara Fitzgerald: That’s a huge statement. I want to say it again because it’s huge. So when the immune system is activated, the brain chemistry changes.
Dr. Robert Hedaya: That’s right.
Dr. Kara Fitzgerald: So you’re…
Dr. Robert Hedaya: And the important thing here is it’s in anywhere in the body because there are four pathways known. Maybe there are more now, but the last time I checked, there were four pathways known by which peripheral body infection, inflammation causes changes in brain neurochemistry. That is clearly going in places, into PANDAS, which if you want to talk about it, we can.
Dr. Kara Fitzgerald: You can briefly. Just briefly touch on it.
Dr. Robert Hedaya: PANDAS is a situation where children become exposed to strep and what happens is the immune system reads the strep and reacts and creates antibodies against the certain protein and the streptoccocal bacteria and it happens to cross-react with proteins and certain parts of the brain and these proteins attack those parts of the brain, which happened to be involved in, for example, cingulated gyrus. These are parts of the brain that are involved with OCD.
So you can have a child who could be fine today, gets a strep infection this afternoon and in two or three days, they come into a case of severe OCD. And if they do plasmapheresis, clearing the blood of these antibodies, then the OCD clears up. It’s really remarkable.
So that tells us again another example of how the immune system is critical in brain function and mental function. I can’t emphasize that enough to listeners that that is critical when dealing with mental health issues.
Dr. Kara Fitzgerald: Thank you so much. It’s such an important point. And I just want to point out that they’ve implicated a number of infectious triggers for this whole presentation of OCD actually. I think Lyme is one of them, correct?
Dr. Robert Hedaya: Lyme is one of them. I’ll give you another case, which I think is a fascinating case. This guy came to me. He was 18 years old. And he was actually going to be going to Princeton, but he had this severe case of OCD. So he didn’t want to take meds or do any therapy. So his parents brought him to me.
He had a contracture on one of his fingers. So he hadn’t straightened out his fingers in two or three years because he has a superstition that if he did, something bad would happen. Now, he looked like a perfectly normal guy, but he has a severe OCD.
So we did a workup and it turns out he had five different infections. This is five or six years ago. I can’t really tell you about it. But there were three in his gut and a couple of others.
Anyway, we treated them. It didn’t take long. By three months from the onset of treatment, the OCD has completely gone with the treatment of the infections and some cognitive behavioral therapy. No meds. No meds at all. And it really basically was dealing with his immune system and just re-correcting his behaviors and his thinking.
Dr. Kara Fitzgerald: And so we’re looking at primarily bacterial infections you identified or viral also?
Dr. Robert Hedaya: Yeah. He had yeast. He had bacterial infections. He had a parasite. He had a variety of things.
Dr. Kara Fitzgerald: Wow. Okay, I got it. In your approach, I know this is a while ago, but you’re using diet for those who are willing to go in that direction, lifestyle, et cetera, obviously you’re doing therapy. Are you using primarily antimicrobials, pharmaceutical antimicrobials, which I know are important in some of these more intense infections? Or have you tried alternative interventions?
Dr. Robert Hedaya: Yeah. I have tried alternative interventions and I didn’t have great results and that can be because I don’t have enough training in that area. So I, of course, obviously do all the other things like diet and probiotics and prebiotics. But I’ll use antibiotics if I need to or antifungals, et cetera.
Dr. Kara Fitzgerald: Yeah, absolutely. There are important tools and you know when well applied, especially in these few cases you’ve just given us. I think they are truly lifesavers.
Dr. Robert Hedaya: Yeah.
Dr. Kara Fitzgerald: Do you know what’s interesting? You’re talking about the whole quinolinine, kynurenine pathway. Obviously just going back to the product that you designed, I mean that could be an appropriate intervention. I mean it’s going to modulate quinolinate production by just blunting the whole inflammatory cascade. It’s going to preserve. It has the potential to preserve serotonin, which incidentally gets converted to melatonin.
So even though you’re directing it towards joint and back, it could, in certain individuals, work as a mild anti-depressant. Have you seen that in practice?
Dr. Robert Hedaya: I wish I could say yes, but I can’t. I can say that in theory, I would agree. So first of all, if you’re sleeping better because you have less pain, you should feel better. But if you have a lot less inflammation, you certainly should feel better. You should have improvement in your memory and your anxiety and your mood, et cetera. But I haven’t looked at it for that. I’ve just really used it where I see people having muscular, skeletal problems, sometimes neurological problems, autoimmune problems and things like that.
I have had a few people tell me that it gives them energy. It can increase serotonin, but it can also actually increase histamine. One of the herbs can increase histamine. But in theory, you’re right. But I haven’t tracked that. I haven’t seen it or heard it reported.
Dr. Kara Fitzgerald: Right. I mean you also have Boswellia in there, which is going to inhibit the leukotriene. So it’s going to be a good agent towards allergies.
Anyway, I just wanted to ask you. I wanted to circle back to something that you said and then we’ll move on to talking about methylation. So if you’ve got this quinolinate, kynurenine pathway up-regulated and you’ve got this glutamatergic excitotoxicity happening, serotonin is low and dopamine is high, what is the clinical presentation of that, elevated dopamine, brain dopamine, low brain serotonin?
Dr. Robert Hedaya: Well, OCD would be one thing. So that’s under the heading of an anxiety disorder. And so certainly you have anxiety and you have mood instability. You can have panic attacks. You certainly can have depression. And it has an impact in bipolar disorder for sure.
Schizophrenia, it’s tougher to say. Does it have an impact? Yes. Is it a layer in any psychiatric disorder? Yes. If you have immune dysregulation and any psychiatric disorder, that is going to play a role. How much it plays in each person…
Dr. Kara Fitzgerald: It varies.
Dr. Robert Hedaya: It will vary. But it will always play a role.
Dr. Kara Fitzgerald: Right. I want to just jump ahead because you’re getting me thinking here. I just want to ask about the enzyme Catechol-O-methyl transferase, which metabolizes dopamine, norepinephrine, epinephrine, estrogens, et cetera.
Dr. Robert Hedaya: Right.
Dr. Kara Fitzgerald: So you’ve got this inflammatory picture in these imbalances, low serotonin. And you would have higher brain dopamine because of the inflammation. But then you can’t metabolize it either because of this mutation in COMT. I just wanted to get your thoughts on that because I know that you’ve thought about the influences of these single nucleotide polymorphisms. So answer that one and then if you want to go more broadly around thinking about genetics, we can move into that. But we will circle back to methylation, folks. I promise.
Dr. Robert Hedaya: If you look at it in a simple sense as you’re talking about, you’ve got a lot of dopamine, maybe you have a lot of estrogens and et cetera and you have trouble because your COMT is sluggish. You’re not able to break down these neurotransmitters. You have more of the neurotransmitters in the synapse, therefore stimulating the postsynaptic neuron. So then depending on where that’s happening, you are going to have more symptoms of anxiety activation or instabilities, et cetera.
Speaking more broadly though, I don’t know if you know, I lead a panel discussion at the May IFM symposium on Genetics and Mental Health. And we had three presenters from different labs presenting what they thought were the most important test in mental health and why they were very important.
I’ve spent a lot of time on this genetic stuff. I got involved with somebody who people may know. I don’t want to mention a name, but he does a lot of genetic work around methylation. Long story short, genetics are very, very complex.
Dr. Kara Fitzgerald: Yes.
Dr. Robert Hedaya: Let’s just take your example. If you have somebody who has a sluggish COMT that has a double SNP, so they really have a sluggish COMT, you can’t really look at that in isolation.
Dr. Kara Fitzgerald: That’s right.
Dr. Robert Hedaya: I found clinically that you cannot make a really great correlation if you see someone has that SNP. That depends really on what’s going on with the MTHFR and the SAMe production and that also depends on how sensitive or the reuptake pumps. Do they have a serotonin transported defect? There are so many modifying factors that, in a certain sense, don’t hang your hat so much on these fiends, “Is it worth doing some testing? If it’s covered by insurance, it’s a piece of information.”
Dr. Kara Fitzgerald: Yes.
Dr. Robert Hedaya: But always realize that you’re dealing not only with these SNPs, but also how methylated are the SNPs themselves. Are those genes turned on or are they turned off?
Dr. Kara Fitzgerald: Right.
Dr. Robert Hedaya: It’s just very, very complex and these are only little hints of what you might consider.
Dr. Kara Fitzgerald: Yes.
Dr. Robert Hedaya: Now, to take the other side of the argument, I did a test through a Genomind. I use different labs and I did a test from Genomind on a patient who was about 70 and his sister brought him to me because he was diagnosed schizophrenic.
What happened, the real history is that he was born normal. He had encephalitis or meningitis. It’s probably encephalitis. Anyway, he was deaf after some infectious process at age four. He went along and did fine. He became a mathematician and then worked for NASA in the ’60s. They were doing some experiments, preparation for the flight to the moon.
They put him and other people who had certain types of deafness into a giant centrifuge. They would spin them around for hours at a time to mimic some of the things that would happen in space. And around that time, he had a head injury. And then about a year later, when he was about 30 or 31, he started to hear voices. So this went on. He quit his job. He eventually went to Alaska because he thought whoever was putting these voices in his head won’t be able to find him.
Anyway, he came into my office and he seemed like the nicest guy. He certainly didn’t appear schizophrenic and I was able to piece out the history. And then I did some testing and I tested his CAC and A1C, calcium channel, which is very important genetic marker. There’s a lot of coverage coming out of that.
His abnormality made me think that I should give him calcium channel blockers. And gradually, over the course of several months, along with other functional medicine interventions, he actually started to have days where he wasn’t hearing voices. And it’s the first time in 40 years or something along those lines. So it’s not a slam dunk, but that did tip me off.
So my message really is genetics, there’s a lot of push from these companies to order the genetics. Some of them, you can get through Qwest and Lab Corp. They’re covered by insurance.
Look at them. You can use them, but use them judiciously. It’s not like, “Oh, you have this, therefore this” because all of these genes are modified by other genes and by experience and by methylation factors and acetylation factors, et cetera.
Dr. Kara Fitzgerald: Yes, that’s right. Thank you for that very nice I think realistic assessment of the utility.
When we look at the genome-wide association studies for the various SNPs and diseases, they’re just not really strong at this point in the game. I think as we move into really being able to data capture in the systems and a true systems model, we’ll be able to glean more. I think you’re right. They are just profound, profound number of variables. So I appreciate that.
But tell me. I just want to know a little bit around your reasoning for treating this gentleman with schizophrenia with a calcium channel blocker. I mean you identified that SNP. Connect the dots for me in the association with schizophrenia.
Dr. Robert Hedaya: I would say that first of all, I don’t think schizophrenia was an appropriate diagnosis. So I wouldn’t say treat schizophrenics with calcium channel blockers. I don’t know that there’s much evidence for that.
In his case, I think that it was a function of multiple antecedents and trauma that were presenting and basically causing instability and hormonal instability because of this depolarization, excessive instability. And certain neurons maybe were injured from both his infection at age four and then, I don’t know what this NASA experiment did and then the head injury. So I think it was a multiple hit theory combined with the genetic vulnerability in terms of the depolarization instability of the neurons, which happened to happen in some part of a neural track that was processing, the auditory generating the auditory stimuli.
Can you follow?
Dr. Kara Fitzgerald: Yeah. It’s so brilliant. I’m just thinking I did an interview for the IMCJ recently and they asked me about – that’s Integrative Medicine Clinician’s Journal I think. We were talking about case studies specifically and just about codifying our knowledge.
I mean we need to quantify this. I mean you’ve just presented. Every single case you’ve talked about today on this podcast, they’re just extremely interesting and remarkable and it would be nice to – if you feel like, in all your free time, writing somebody’s case. I know you don’t have any.
Dr. Robert Hedaya: If anybody’s listening and wants to write it up, give me a call.
Dr. Kara Fitzgerald: It’s just so interesting to me. Anyway, you’ve mentioned methylation a few times and of course it’s been a huge buzzword for some time and you already talked about this more nuanced approach, which I’m so in agreement with you on. But talk about methylation in psychiatry.
Dr. Robert Hedaya: Okay. So that gets a lot of press now. In a simple way, there are studies that show and it’s been repeated that if you give someone fluoxetine and you give them folic acid, just straight folic acid, 15 to 50 milligrams, you will both reduce side effects and improve response rates significantly.
Why? The reason why is because you’re improving neurotransmitter production. You’re activating the folate cycle.
Now do we know how many of those people had MTHFR deficiencies? We don’t know. Most of them not and that’s why the folate worked. We don’t know.
But in practice, what I do is I do a few things and one is obviously do a CBC, looking at the red blood cell count, look at the MCV, which is the size of the red blood cells.
And look at the homocysteine. My cutoff, normal in my homocysteine would be eight. And over the years, the upper limit has gone down from 21 to 19.9 to 18.9. So it just keeps going down. So in my mind, eight is the upper limit of where I like it to be.
I look at iron indices. When you look at all these things, you can look at the dynamics and you don’t even necessarily have to have the MTHFR genetic test. If someone can afford it, great, that’s another piece. But by looking at the MCV and the iron and the RBC, you could see. Where is the balance here in terms of production of red blood cells and where is the balance in terms of the size of the red blood cells?
So if your iron indices are normal and your MCV is high and your RBC number is low, you’re tipped off to a B12 deficiency. However, you can have normal MCV and you can have a B12 deficiency because you’re also iron deficient. Iron deficiency pushes you to microcytosis and B12 to microcytosis. And then you of course look at the homocysteine, which will tell you about B12 and folate. It’s not specific.
Based on those things and if you get the genetic test, then you can intervene with methylfolate or folic acid. One of the effects of intervening this is the increase of the production of SAMe. You could also get SAMe directly.
With SAMe, you have to know. It can help or it can backfire because the SAMe can help the COMT enzyme to function because you need that methyl donor to help COMT break down the neurotransmitters. But also, SAMe can go towards production of neurotransmitters. So you really have to test it carefully.
That’s an overview of how I work with it. The last thing I would like to say is that it’s fashionable now or fad to use tons of methylating agents. Even that study of Prozac and 15 to 50 milligrams of folic acid, we have no idea what that is doing to the genetic function in all the other genes. So if you need to use it for someone who has say a mood disorder, use it, but follow the indices and also use it for as short period as possible.
I use methylated folate to treat a woman with endometriosis. It cured her endometriosis because endometriosis, in part, is a genetic methylation defect. So there are places for these things, but don’t overdo it. Don’t overdo it.
Dr. Kara Fitzgerald: Right. Thank you. I’m in complete agreement with you. There are many, many unknowns with regard to the yin and yang of methylation, demethylation and epigenome that are big question marks for us and could be oncogenic or not. So I do think that caution is very smart.
So with this endometriosis patient, did you look at any SNPs in her? Or did you just do a therapeutic probe as David Jones says?
Dr. Robert Hedaya: No, no. I’m sure I did the SNPs. I’m sure I did. And then I treated her not knowing what the research was showing. She had such a really incredible response. I started to do a little research to see what the connection might be. I was treating her for anxiety and I wasn’t treating her for endometriosis.
Dr. Kara Fitzgerald: Gee. Yeah, I was going to say. I was going to say. I don’t think that – right.
Dr. Robert Hedaya: She just happened to have endometriosis and the pain was obviously part of the anxiety, but there are a lot of other reasons for the anxiety. So in the process of my treating her, her endometriosis disappeared. It disappeared literally.
Dr. Kara Fitzgerald: Yeah.
Dr. Robert Hedaya: I was like, “What’s going on here? This is pretty odd. I don’t think I’m doing anything that should cause this.” So I did some research and low and behold, the research showed that a methylation defect is a significant factor. So I think that that was just something I stumbled onto.
Dr. Kara Fitzgerald: Wow. That’s another great pearl. Okay, so what does a clinician need that’s going to the office Monday morning? What would you say is a good take-home for them when faced with treating depression? I mean we all see individuals with depression. It’s such a huge issue today. And so we’re all working.
So you have your regular “in the trenches” functional medicine clinician or somebody new transitioning into this model, what kind of advice would you give them for actionable things?
Dr. Robert Hedaya: Okay, a few thoughts. I guess first of all, for people who are moving into functional medicine, I would say don’t build functional medicine around your practice. Build your practice around functional medicine.
If you try to build functional medicine around your existing practice, it will be difficult and frustrating and you’ll really be missing the essential benefits and joy of doing functional medicine. But if you say, “I am doing functional medicine” and you adapt other things around that, then it will be transformative for you and for your patients. So that’s one thing. The other thing…
Dr. Kara Fitzgerald: Then basically what you’re saying is that you can’t do a functional medicine in a 15 minute visit. Is that one of your…
Dr. Robert Hedaya: I have to say that every way you go, it’s against – unfortunately there’s a cross [counterview] between the economics and the science. The science is saying functional medicine and the economics are saying, ”You got six minutes.”
Dr. Kara Fitzgerald: Yeah, right.
Dr. Robert Hedaya: But no, I’m actually with a new patient and I would spend three and a half hours taking history, reviewing records, physical exam. I didn’t start doing that. I started by extending my evaluation, which was 45 minutes. By 15 minutes, then I edit on a little more and little more.
Dr. Kara Fitzgerald: I got it.
Dr. Robert Hedaya: You just really make the functional medicine the cornerstone and build around that.
Dr. Kara Fitzgerald: Okay.
Dr. Robert Hedaya: In terms of depression, I think it’s very important in the general sense to really think of depression as – I like to look at it at different levels. I think it’s often about looking with different lenses.
So if you have a high powered lens, you’re looking at the molecules. And if you lower the power of the lens a little bit, maybe look at neurons or glial cells. And if you lower a little further, you maybe look at organ systems like the whole brain and brain circuitry and the gastrointestinal link or the endocrine systems.
You lower it a little further, you look at the person as a whole. And you lower a little further and you look at their psychology. And then back off a little more and you look at their relationship, their wife, their husband, their children, extended family and then their community, economics and their psychospiritual. And then ultimately what’s the culture that we live in?
So depression operates at all those levels and it’s very important when you talk to a person with depression to help remove the stigma and to explain to them that what’s happening to them, yes, they are experiencing it primarily or their family and say their fellow employees are experiencing their depression to some degree being impacted by it. But fundamentally, what they’re experiencing is not their fault. It occurs in the context, a much broader context on all of those levels, but it is their responsibility.
And that’s very important because sometimes [inaudible 00:43:44], you say, “Oh, you have depression and it’s biological. Here, take this pill. Or here, take these pillbiotics” or whatever it is. That’s way too simple. You need to help them understand that this is not all about them. It’s not because they’re deficient.
I can’t emphasize it enough. We have an epidemic of depression in this western world and it’s heavily influenced by the breakdown of families, by the cultural expectations, by income inequality, by chemical soup we’re all swimming in, by the stress response. There are so many levels.
So I say make sure you don’t stigmatize a patient. Make sure you explain that to them and then use appropriate treatments. Figure out what are the pieces, what parts of the node of the matrix are playing a role.
And I like to target them all at once whenever possible because if you want to change the system, the homeostatic setting or set-point of a system, you need to connect, if you can, those many critical points as possible at the same time to bump things up. It’s not always possible, but to me, it makes the most sense.
Dr. Kara Fitzgerald: Right. Thank you. Yeah. And I think that you finished some of the matrix nodes that I know I took you away from completely circling all of the IFM nodes and the influence. But I think you’ve addressed and gotten into the psychosocial component, which I appreciate.
Just going back to the DIDGONE acronym, was there anything that you wanted to add to that because I know we’ve diverted. It’s my fault, but any other piece around that?
Dr. Robert Hedaya: I think endocrine is critical.
Dr. Kara Fitzgerald: Yeah.
Dr. Robert Hedaya: That’s so important. You can’t have neurological function, you can’t have a normal function of the [batteries] up there without adequate T3, free T3 and adrenal function obviously, intimately related. And the adrenal dysfunction, the adrenal axis dysfunction is a big deal in depression and anxiety and really pretty much all, that PTSD, many, many psychiatric disorders.
I think this DIDGONE, if you may notice, doesn’t have anything addressing the psychological or the social spiritual. As a psychiatrist, I think about the psychological and social and spiritual as essential to what I do. So remember when you’re using that, there’s no place in there for what is most important, which is the person.
I have a patient who had a gluten sensitivity that appeared and a lot of tendonitis and whatnot. And I used my product with him and it helped him tremendous. And he’s had a great deal of stress. When the stress was resolved, it’s remarkable, but his gluten sensitivity disappeared and he was able to come off my product because I think the stress was closing a breakdown of his gastrointestinal immune barrier.
So you can’t forget the psychosocial because we have different mind states that actually carry different physiologies. If you switch into a mind state that is happy, whatever trigger is, the physiology changes.
Dr. Kara Fitzgerald: Right. Listen, I definitely don’t hear many clinicians these days talk about resolving gluten sensitivities. So thank you for that.
Dr. Robert Hedaya: I’m not even promising.
Dr. Kara Fitzgerald: Right.
Dr. Robert Hedaya: The main point is the power of the psychology and the stresses.
Dr. Kara Fitzgerald: Yeah, absolutely. And so he’s got healed and then ostensibly he’s not experiencing fallout. Absolutely.
Dr. Robert Hedaya: Right.
Dr. Kara Fitzgerald: Okay, I appreciate going back to DIDGONE and that you stated the whole sociospirtual piece. And we did mention toxins. We got through that and oxidative stress and inflammation.
Dr. Robert Hedaya: Hmmm.
Dr. Kara Fitzgerald: You’ve given us already wonderful cases. But how effective is functional medicine with bipolar disorders or very severe depression?
Dr. Robert Hedaya: It’s very effective. Here’s what I found. In recurring depression, severe depression, I did a retrospective analysis in my own practice. After I was blown away really by functional medicine, I was like, “I wonder how this is really working.” So I actually did a retrospective analysis and I really treat treatment-resistant people.
So I had 34 treatment-resistant depressed patients. And with the Beck Depression Inventory, the mean was 39. Normal is under 10. And I treated them with the functional medicine model, really making very little medication changes. And after 10 months, at the end, 10 months, they were all under 10, meaning their Beck Depression Inventory is normal except for one person.
So that’s how effective it is regarding depression. And I could give you case example after case example on that.
The bipolar disorder, I separated out milder forms bipolar or a psychothermia or a hypomania with milder depression. It’s very treatable with functional medicine and standard psychosocial approaches without meds. I’ve been able to take people off medications really routinely.
When it comes to bipolar type one, the more severe, psychotic mania and severe suicidal depressions, et cetera, I haven’t been able to treat people without medication, but I certainly can. I don’t go through multiple medication changes. We can reduce the meds to some degree. We get better response, fewer side effects and so many of these meds cause metabolic syndrome overtime and we can reduce that and avoid that and even reverse it.
And even in schizophrenia, you can have massive improvement. But the problem is always compliance. That’s always the issue.
Dr. Kara Fitzgerald: Yeah.
Dr. Robert Hedaya: I personally think that we know so much of what we need to know to help people get well. But people have trouble maintaining a healthy lifestyle. I think that change literally has to occur in groups. And so we need to figure out ways of supporting people in terms of their changes in health.
Dr. Kara Fitzgerald: Yes. Right. We’ve been talking a lot of my practice about establishing some ongoing group support among different populations that have shared issues be it weight loss, which is pretty standard and how we might be able to really leverage that. I know some functional medicine docs who have done a nice job with that. And I do think you’re absolutely right.
We do a little detox program here and we have some group contact on Facebook and we have a group dial-in. It’s so fun. That one mid detox meaning really keep people going.
Dr. Robert Hedaya: Right.
Dr. Kara Fitzgerald: So give one pearl. You’ve actually shared a lot of pearls with us today, a tremendous number (and I’ll try to capture them, folks and write them down), but what is one pearl you can give to clinicians that would increase their impact with their patients?
Dr. Robert Hedaya: I would say that the most important thing would be to listen. That sounds easy and we all think we listen actually. We all think we listen, but listening is a discipline and remaining silent and allowing space for somebody to really put it out and giving them the time to develop their thinking and develop their story is very powerful because if you’ve ever been to a doctor who actually listens, it actually has a very big effect on how you feel then, but also in your hope for the partnership and getting your health back.
It sounds so simplistic, but that’s what I would say. You can learn science, but if you really listen, listen carefully and make space for your patient to speak. That will be it. And it’s a very powerful thing.
Dr. Kara Fitzgerald: That’s a wonderful note for us to end on. Dr. Hedaya, thank you.
Dr. Robert Hedaya: My pleasure.
Dr. Kara Fitzgerald: It’s just been a wonderful, great conversation. I’ve been over here taking copious notes for my own practice. Now, how do people reach you, through your websites? How do folks reach you?
Dr. Robert Hedaya: I have a website. It’s WholePsychiatry.com. There are tremendous – it’s over 200 pages of recordings and radio interviews and videos. And I got a two-hour presentation I give to the Washington Psychiatric Association on Whole Psychiatry. And then the website for the rejoin is DrHRejoint.com.
I’m glad to answer any questions that people have. Just contact me through actually either site.
Dr. Kara Fitzgerald: Okay. And all of those links will be right next to the podcast. So you’ll be able to access everything we’ve talked about today. Okay.
Dr. Robert Hedaya: May I say this? If anybody’s interested, I have spent hours making a very good diagram on information and mood and I can easily e-mail that to people.
Dr. Kara Fitzgerald: Okay.
Dr. Robert Hedaya: That’s it. It’s very colorful and people seem to like it.
Dr. Kara Fitzgerald: Okay, good. I’ll make a note. I’ll make a note of that and put a comment to that on the site. Okay, thanks again, Bob.
Dr. Robert Hedaya: My pleasure. Take care, Kara.
Dr. Kara Fitzgerald: Okay. Bye-bye.
Robert J. Hedaya, MD, ABPN, DLFAPA, is a pioneer in functional medicine. He is the founder of the National Center for Whole Psychiatry in Chevy Chase, Maryland, as well as Functional Herbals, LLC, the makers of DrH ReJoint, an herbal anti-inflmmatory.
He is board certified by the American Board of Psychiatry and Neurology and is a Distinguished Life Fellow of the American Psychiatric Association. He is a clinical professor of psychiatry at Georgetown University Medical Center, an active member of The Endocrine Society, certified as proficient in psychopharmacology by The American Society of Clinical Psychopharmacology.
He is a faculty member of the institute for functional medicine and has been recognized as a certified clinician in functional medicine. Dr Hedaya is a recipient of the Physician’s Recognition Award from the American Medical Association and has been voted Outstanding Teacher of the Year multiple times by the Georgetown University Medical Center’s Department of Psychiatry.
He has authored books for both practitioners and consumers, has been featured as an expert consultant numerous times in the media, and writes a blog for Psychology Today. Dr Hedaya is the developer of the Whole Psychiatry methodology, which offers a comprehensive physiological and psychosocial-spiritual approach to mental health and chronic physical illness.
His method evaluates and treats mind and body dysfunction by focusing on the detailed evaluation and bidirectional interactions between and among a person’s hormonal system, immune system, gastrointestinal system, nutrition, environment, socio- spiritual status, genetics, detoxification, cell signaling, life circumstance, age, and gender.
Read about the Functional Medicine Matrix.
Interesting could you point me to the research on a methylation defect being a factor in endometriosis? How would it be involved? What might be some of the mechanisms involved? I have a daughter with endometriosis who given the genetics of other family members has to be at the very least heterozygous for either a1298c or c677t, if not worse.
Hello, the mechanism connecting methylation and endometriosis is related to hormone metabolism and well as detoxification. Dr Ben Lynch has a great post on the topic: http://mthfr.net/endometriosis-mthfr/2012/03/24/
The following review article details the relationship: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805102/
A reminder we’re not slaves to our genes – genetics can be influenced significantly by lifestyle factors like diet, exercise, sleep, and stress management. There’s a lot of good evidence in the field of epigenetics that we can modify risk significantly. We discuss that in detail in the Methylation Diet and Lifestyle book, this blog summarizes: https://www.drkarafitzgerald.com/2016/06/28/methylation-diet-lifestyle-introduction/
~Lara Zakaria, Staff Nutritionist