Depression, Anxiety, & Suicide: Addressing Mental Illness with Dr. Jonathan Prousky

How do we approach patients with mental health disorders? How do you engage someone who’s really depressed to get off the couch and get outside? To turn the TV off or put the phone down? The pandemic has led to an increase in mental illness, with more people reporting symptoms of anxiety, depression, and suicidal thoughts. My guest in this podcast, Dr. Jonathan Prousky ND, has been deeply entrenched in the world of integrative medicine to support patients with mental illness. Dr. Prousky has worked in the field of mental health as a naturopath, chief medical officer, and professor at the Canadian College of Naturopathic Medicine, and was inducted into The Orthomolecular Hall of Fame for his commitment to mental health. Together, we dive into the essentials for supporting patients with targeted supplementation, including mechanisms of action and dosages, how to best engage patients who are struggling with mental illness, and how to create safety planning for suicidal patients. You won’t want to miss this episode — I’ve been thinking about it every day and so will you after listening. Please let me know your thoughts — share, comment and rate if you would be so kind. Thank you! ~DrKF

Depression, Anxiety, & Suicide: Addressing Mental Illness with Dr. Jonathan Prousky

The prevalence of mental health disorders has increased during the pandemic, with more people reporting symptoms of anxiety, depression, and suicidal thoughts. What role does nutrition and lifestyle play in optimizing mental health and managing stress? Our guest, Dr. Jonathan Prousky ND, has focused extensively on mental health as a naturopathic doctor, chief medical officer, and professor at the Canadian College of Naturopathic Medicine. In this episode of New Frontiers, we dive into an orthomolecular approach for addressing mental illness, including targeted supplementation, why nature is so important for optimizing health, and how to respond to patients who are suicidal. Dr. Prousky shares his unique approach curated over many decades, including dosages of specific nutrients for mental health and why self-care is vital not only for his patients but also for himself.

In this episode of New Frontiers, learn about:

Dr. Kara Fitzgerald: Hi, everybody. Welcome to New Frontiers in Functional Medicine, where we are interviewing the best minds in functional medicine and, of course, today is no exception. I’m thrilled to be talking with Dr. Jonathan Prousky. He is a naturopathic physician, like myself. He’s Chief Medical Officer and Professor times 20 years at The Canadian College of Naturopathic Medicine. He focuses in all things mental health.

I’ve actually been using his work in my clinical practice for the entirety of my career. Actually, back when I was doing my post-doctorate training, I first became aware of Dr. Prousky’s work. I want to give you his background, who he is, and then we’re going to jump right into it. I won’t forget this, but I’ll start right now and say if you head over to our show notes, you will see an extensive bibliography from Dr. Prousky and many of those pieces are available to you. I just want to tell you that it’s so useful for the clinician in practice.

With that, let me just tell you that he graduated from Bastyr University in 1998 with his Doctorate in Naturopathic Medicine. He did a residency in family practice at National College of Naturopathic Medicine, my alma mater. In 2008, he got a Master of Science Degree in International Primary Healthcare from the University of London, focusing on clinical epidemiology and evidence-based research. In 2016, well, you just keep going to school, he obtained a Master’s of Arts Degree in Counseling Psychology from Yorkville University. And as I said, at Canadian College of Naturopathic Medicine, he is a professor as well as Chief Naturopathic Medical Officer. He’s been in the clinic treating people for years with this focus on mental health.

He received the Orthomolecular Doctor of the Year Award in 2010, and he was inducted into The Orthomolecular Hall of Fame just, again, recognizing his commitment to mental health and natural interventions for mental health. He’s the author of several texts, peer-reviewed papers, articles, and one of them is my favorite, I just pulled it off the shelf, called Anxiety Orthomolecular Diagnosis and Treatment. This was published in 2006 and it’s a slender volume, but it’s very clinically relevant and I’m going to ask Jonathan in a second, I’m sure much of it is still useful today.

The dosing instructions, what he’s done in practice, just the utility of it for the busy clinician just continues to this day for me and it’s just one of those dog-eared volumes that I’ve got papers tucked inside and yellow sticky notes. Anyway, welcome to New Frontiers, Dr. Prousky.

Dr. Jonathan Prousky: Well, thank you so much, and I’m so happy to be here. I always love talking about mental health and I look forward to seeing where this conversation goes.

Dr. Kara Fitzgerald: Well, give me… You know what? Just so I don’t forget, first, your 2006 volume, this dog-eared copy that I’ve been using for years, I just want to button this question up. Has your thinking from this volume changed considerably? Or would you say that this is still a useful book for folks to be referencing?

Dr. Jonathan Prousky: When I wrote that book, I think I was a lot more biochemically inclined, although, of course, I still am to some degree, but since I published that book in 2006, I’ve learned so much more. We’re so much more than our biology in a sense, even though we’re biologically-embodied beings. I would add so much more if I could just do another edition of that book. It would certainly include many more studies, updated information, but then I would like to juxtapose that book with psychological information.

How do you work with someone who’s anxious? How do you work with someone who’s depressed? How do you work with someone who’s suicidal? So on and so… I think I have to do another edition at some point because it is now outdated, but yes, I do think it’s still useful for someone who’s in practice.

Dr. Kara Fitzgerald: Okay, good. Yes, and I encourage you to do an updated version, and we’re going to touch on some of the additional pieces, but for me, the big aha using your book was how to dose nicotinamide so that it’s actually effective, or lithium, or how to dose GABA. I see in your current work, though, you continue to give guidelines and they tend to be different and higher than certainly if you read the label or some of the studies out there where dosing is very conservative. That was a piece that I found useful. It was you were recommending therapeutic quantities.

Dr. Jonathan Prousky: Yeah, I mean, we could talk a little bit about that because I think it is interesting. When anybody reads a study, at least when I read a study, I try to think, “How do I properly translate that to the patient in front of me?” As you know, when we work with people in a clinical setting, they don’t have the luxury of going through some kind of inclusion and exclusion criteria, so we can’t pick an ideal patient who is going to be working with us. As a result, we have to really think, “How do I, then, approach this patient and use the best available information that I have to effectively treat them?”

That’s how I think about a lot of the things that I do with my patients and in my teachings with my interns. We spend a lot of time translating information in an effective manner to the patient in front of us. You’re right about dosing because if you look at some good quality studies, some of them do dose patients and you see good clinical outcomes, but then if you look at other studies with the same particular ingredient, let’s say, or a natural health product or a micronutrient, they’re underdosing and they’re getting a bad outcome. We can learn a lot by these kinds of studies.

Often, if they’re using inferior dosing, they’re not going to get the kind of outcomes that could be expected from what I would say is a clinical intervention that could be quite useful. I think there’s a lot of nuance that we have to understand as practicing clinicians, and I don’t think patients quite get how nuanced we have to be when we’re working with them. It does become rather complicated, but once you apply things I think appropriately, you can really see good outcomes when people are dosed appropriately and safely.

Dr. Kara Fitzgerald: Yes. Yeah, and you do, again, just recommending folks to head over to the show notes, you do talk about your case experience. It’s just very deeply woven through your work, and so people can see your approach to care. How did you choose to work with patients having mental health struggles?

Dr. Jonathan Prousky: Yeah, so I will give a bit of self-disclosure. When I was quite young, I think I was born with a fairly reactive phenotype, so I could easily become quite shy and socially anxious, and that continued I would say in a rather florid form up until my late 20s. I had been battling in a sense with just feeling quite socially anxious for many years, and it takes one to know one in a sense because I’ve had my own life hardships, as we all do.

I’ve been wounded at times by my own experiences, in my own existence, so to speak. I think you sort of build a certain level of empathy, hopefully towards yourself and towards other people, and the more I immersed myself on my own work so I could feel more comfortable in my own skin, the more I just gravitated to people that were suffering from just life in general.

I really feel it’s my calling. I love this kind of work. I think everybody has a struggle in life. I don’t think life’s meant to be easy. It’s tough and I do feel that naturopathic medicine has a real role to help people because we offer all sorts of opportunities for people to regulate their emotional selves in a way that’s similar and different than psychiatry and other types of care.

It’s just something that I love to do because it takes one in a sense to know one, and I get how hard life is. I get how complicated it is. I get how many moving parts there are and I can see just how there’s so many opportunities for other strategies that people aren’t just aware of. When I can open up these doors for patients with my interns or in my own clinical practice and help people to see opportunities they never saw before, we can really enhance their clinical outcomes and the quality of their life and improve their functionality.

In a sense, I’m a fellow traveler with my patients. I’ve been there to a large degree and so I feel a connection to them, and then so I feel there’s opportunities.

Dr. Kara Fitzgerald: Well, thank you for that. I hear it and I appreciate it. I think that actually comes through in your writing. You write in plain language, but useful and erudite language. I guess that kind of leads me to my next question. We talked a little bit about freeforming this chat. What’s the ideal? How do we approach our patients with mental health? How do we do it? What’s the best entry into the connection, the exchange, the encounter?

Dr. Jonathan Prousky: I don’t know if I know the best way, but I certainly think I’ve been able to accrue certain skills that can be helpful. I don’t always hit a home run, and sometimes certainly visits don’t go the way I want, and then I’ll try harder the next time. I tell my patients that. I say, “Listen, if you have any feedback so I can do better next time, let me know and I really do want to hear it.” When I approach anybody, and my hope is for those listening, the best thing to do is to be curious and empathetic and warm and kind and nonjudgmental as best as you can. Those are not easy to do because sometimes people push our buttons. Sometimes we have our own responses to their ways of being and it is tough, especially if you’re going through your own stress in your own life. That can certainly bleed into your own practice as a clinician.

I do think that if you can just be warm, inviting, and curious with anybody and show them a level of care and a level of commitment, they’re more likely to share with you and to open up themself. They’re more likely to reveal to you what is necessary during the encounter, but I think that’s like anything in life. We’ve all met people who don’t come across like they care too much and they’re sort of cold and they’re aloof and maybe not easy to connect with, and though maybe they would be over time, it’s just a different type of energy that you feel.

When you’re with patients because they’re already under some kind of distress, they’re already feeling out of sorts, it is upon us as doctors to make sure that we are available to them and we are ready to receive whatever it is they want to share with us and that we’re going to do so in a manner that’s going to enhance the encounter, not going to take away from the encounter. I guess that’s a bit of what I think we all should do, but I don’t have a method or I don’t have a special set of skills. I just think you have to figure this out in a sense. That’s why we call it an art of practice, not perfection. It’s a practice and it takes time to develop your own comfort so you can be available to the patients that you’re working with, particularly those with mental health struggles.

Dr. Kara Fitzgerald: Right. There is an acronym in functional medicine called GOTOIT, and it just walks you through taking a case, et cetera, and the G in GO is gathering yourself. That’s not just gathering the history or reviewing the medical questionnaire, et cetera, et cetera, prior to the encounter, but actually gathering yourself sort of emotionally or spiritually or just becoming present for the encounter prior to the encounter. I have found that alone, that piece from that acronym, to be the most helpful for me to just remember, even if it’s a moment, to take a breath and center and prepare to tune into the human being who’s requested me joining with them in their journey. I appreciate what you’re saying.

Dr. Jonathan Prousky: Yeah, I agree, and I do think we have to almost intentionally get a certain level of readiness before we begin our days with our patients. If we don’t do that, I think it’s going to find its way into the encounter and maybe it won’t be helpful. It really behooves us to sort ourselves out in a sense when we’re with our patients that we can give them the attention they deserve because it is an intimate situation. They are revealing things to us that are very sacred, and in a sense we have to be available to that information. If we’re sort of too busy in our minds because of our own stuff and we’re not really present, that does get in the way.

That’s why I had to work on my own anxiety. You see, when I was with patients and struggling with my own anxiety, it would get in the way. It would impact the encounter. I would feel out of sorts and I couldn’t give them the type of attention and presence that I was hoping for. In a sense, my whole work is sort of selfish because I’ve been always trying to sort myself out as I’ve been trying to be available to the patients I served. It isn’t just about helping people. In a sense, I’ve been working on myself for decades now.

Dr. Kara Fitzgerald: Do you take a moment to do a little bit of a meditation? I mean, what is your gathering process, if you will?

Dr. Jonathan Prousky: People ask me that all of the time. My students say, “How do you leave this shift?” We have a mental health shift at the school and then my whole practice is all mental health. “How do you function? How do you sort of separate yourself?” I say to them that, “My patients are living their complicated lives and so I am, and so when I leave the day, I have to first know that I’ve done a committed job and the right job for my patients. That eases my own mind. Then, I go home to my own complicated life and invest myself with the people that I love and who love me. I keep that separation.”

Then, what keeps me grounded, then, with my own practice now is just that. I have a life that sustains me. I have people that care about me. I care about them. I do a lot of my own self-care, and all of that to me keeps me above water in a sense, but by no means is it perfect. I struggle, too, but I work at it and I don’t give up, and that enables me to be available to my patients. I don’t do any particular meditation before I see a patient. I don’t do anything that’s sort of programmed. I just make sure that I’m committed to my own state of being, in a sense, and as that commitment is there and it’s persistent and it’s steadfast, then I find that I’m much more available to the people that I serve.

If I do waver and I don’t sleep well, I start ruminating, I start worrying, I start getting into my own head in a sense, but not in a good way, then certainly it can bleed into my own work and undermine the work that I do. I’m very disciplined in how I approach my life in a sense and it’s really precisely because of that discipline that I feel I’m much more available now than I’ve ever been with the people that I work with, but 15, 20 years ago, it would be an up-and-down battle because in my own head, there was a war that was waging. Until I sorted that out, I couldn’t be as available, and I think we all have to do that. We will all have our own wars. We will all have our own battles and it’s important. Doctors have to work on themselves as they help their patients. You have to have it that way. You can’t sort of do one and not the other.

Dr. Kara Fitzgerald: Yeah, right. I just want to continue on this line. I’m going to ask you one more question.

Dr. Jonathan Prousky: Yeah, keep going.

Dr. Kara Fitzgerald: Right. Well, you know, I’m also dying to….

Dr. Jonathan Prousky: I’m very transparent. I don’t really have any secrets. I feel what’s most personal is most general, so I have no issues sharing a lot of my own stuff, in a sense.

Dr. Kara Fitzgerald: I just love all of your biochemistry stuff, but I also want to get into dosing and various, you know-

Dr. Jonathan Prousky: Sure.

Dr. Kara Fitzgerald: … all of those things, but this is just such an important conversation, and I want to say especially now in the backdrop of this pandemic, physicians caring for themselves. Of course, the increase in folks that we’re seeing struggling with mental health issues. I’m curious, when you say you live this disciplined life for self-care, it’s been hard in my life just the isolation. Our clinic, thank God, is very active and we’ve got a very large virtual platform, so I’m close to my colleagues in a virtual setting, but my in-person world has become much smaller than pre-pandemic.

It’s starting to expand a little bit, but that’s been hard. Thinking about my self-care, exercise is extremely important and I do notice a shift when that isn’t happening. I just have to make time for it. It’s such a mental floss for me, you know, meditation, time with my family and connections with friends and, of course, time with my daughter and even family via Zoom or whatever. I’m curious about some of the tools that you’re doing that help you stay present in your work.

Dr. Jonathan Prousky: Yeah. I mean, this sort of veers, but there’s actually data on it, which is interesting. I never knew what an impact a pet would have on myself. My wife loves dogs and we got a dog about a year and a half ago. As a result, we go in nature almost every day with our dog for 45 minutes, sometimes to two hours, and it’s had a huge impact on just the quality of my life, just being outside. What’s fascinating about that is there’s a whole body of literature on nature and nature experiences-

Dr. Kara Fitzgerald: Yes.

Dr. Jonathan Prousky: … and how that is good for the brain, in a sense. That sort of opens up maybe our conversation because I published four papers recently and all of them have to do with both the stress brain and then protecting the brain, in a sense. Nature is one of the things that can protect the brain, and one may ask, “Well, why? Why is that?” Well, first of all, let’s define what nature is. Nature experiences can be even looking at beautiful landscapes of nature, it can be walking outside and being in nature, being in the wilderness. It could be just being around plants and having a garden. The definition of what nature experiences are is quite expansive, but what’s interesting is what you derive from nature.

There’s a lot of psychological theories that have been developed as a result of that, and we know there’s different hypotheses. One is the biophilia hypothesis, which is sort of interesting that we have this innate drive to be in nature. Another one is the stress reduction hypothesis, whereby being in nature seems to attenuate our stress response systems. Or, there’s the attention restoration theory, which is, I think, probably more accurate where being in nature sort of reloads and resets our cognitive resources so that we can reestablish our own capacity to concentrate and pay attention later on.

Nonetheless, all of it brings some, I would say, allostasis to our whole organism, in a sense, and especially our stress systems. When you bring that stability, even amidst change in your life by being in nature and by resetting everything, I think it gives you an opportunity to feel more good and nourished when you go back into your life.

Having this wonderful dog has sort of brought nature back into my life, and I’ve always been an outside sort of guy, but it’s now been blown out of proportion in the sense. I’m outside a ton. This little dog has so much energy I can’t believe it, but the love I have for the dog and how it’s just been so good for our family and how much time we spend outside in nature has just been tremendous. I know not everybody has access to the forest that I have access to since I live in a sort of city/rural area in Ontario, Canada, but if you have any ability to get outside and just be with a pet or just be with your family and walk and feel the fresh air and breathe in good air, that can do a lot for one’s soul.

I think for me, that’s one of the big game changers is just being in nature, and that’s what the pandemic has done. As much as there’s been a downside to the pandemic, which I won’t minimize because it’s been massive for a lot of people in terms of their employment and their social isolation and I only have massive empathy for everybody that’s suffering. The flip side or the upside of the pandemic is it’s caused and forced me to be involved in things I never would have thought about like nature, and that’s had a huge impact in the quality of my life, personally speaking.

Dr. Kara Fitzgerald: Yes, yep. That’s absolutely correct. Right, we’ve all pivoted and we’re home and we’re outside in the world, I think, much more so. All right, well, let me just ask you this. How do you engage the… Well, first of all, I’d like to hear about the folks that you’re seeing. What kind of patients you’re seeing in clinical practice. What you’ve just described is incredibly inviting. I’m right outside the woods here and I’m just… Our office, we’re across the river from a state forest and I’m just really wanting to go out for a nice hike here. How do you engage someone who’s really depressed to set their toe outside? To get up off the couch? To turn the TV off or put the phone down?

Dr. Jonathan Prousky: Yeah, so when I do see people, I see them and they’re in different sort of phases, let’s say, of their illness because sometimes people have mild depression, which could be just like having a common cold that just doesn’t get better and is interfering with the functionality and quality of their life, but they’re still able to do some things or quite a bit. Then there are people who have more moderate and, I would say, severe forms of major depression, let’s say. You’re right, their functionality becomes severely impaired, and sometimes their whole circadian rhythms are shifted so that they’re awake when their family is sleeping and they’re sleeping when everybody’s awake and they’re just living a life that’s out of sync with everybody else.

The question you’re asking is a good one. How do I engage somebody, let’s say, who’s depressed and really not engaged in life the way you would want them to be? They are lacking motivation. They’re feeling hopeless. They’re despairing a lot, and maybe even they’re having thoughts of suicide. That’s a fairly heavy encounter, but not uncommon at least in my experience. The first thing I think is, again, you have to open up an opportunity so that you can understand the person’s narrative. You want to hear their story, and if you can do so without interrupting too much, I think that can offer a great opportunity to learn from the patient and for you to gain a little bit of insight into what’s going on in their world.

Their world is not a good one. It’s a world that they’re descending into some sort of chaos. They’re probably feeling on some level like, “Why is this life happening? It’s not worth living. What’s the point?” You see a lot of people who are sort of succumbing to those types of thoughts. You don’t want to give anybody false hope because you don’t want to tell them their live is going to be great when it sucks and it’s not, but what you want to do is just invite them into the possibility that things could move or shift a little bit more. That’s sort of what I do. I don’t overpromise anything. In fact, I like to over-deliver on my services and under-promise on everything.

What I hope is to help people to understand that if they move a little bit differently, aim a little bit differently, even if clumsily, it’s probably going to be better for them. If they try just a little bit with something, then we could hopefully shift little by little over time and start seeing some real progress. It is complicated because, you’re right, sometimes the most a person can do is just sit with their family and not talk to them because they’re so depressed, but at least they’re sitting with their family.

Then, maybe after a while with good treatment that activates their mind and activates their biology, gets them a little more motivated, maybe they can start having a few conversations in the morning. Maybe their sleep can start improving with a little bit more movement. You want to behaviorally activate people, but not overdo it. You don’t want to put pressure on them because they have an illness that they’re battling, and then you want to support them the whole time.

There is a lot of art to this. It’s not something I can distill so easily to you on a podcast, but I think you’re getting a sense, and it’s just a little bit by a little bit you just want to work with the person in front of you and you want to motivate them. You want to show them there is a potential to shift things a bit and you keep reinforcing things when they’re doing well. You don’t want to reinforce when they’re not doing well. You want to certainly appreciate it, but you don’t want to reinforce the very things that keep them contained in that state of inertia. You want to really reinforce the things that help them to overcome their own inertia and their own misery. I think that’s probably what I could say at this point, unless you have more questions.

Dr. Kara Fitzgerald: How frequently do you see folks that are in this degree of struggle?

Dr. Jonathan Prousky: All of the time. I mean-

Dr. Kara Fitzgerald: I mean, well, how often do you have an encounter with a given individual who’s in this level of struggle? Do you see them weekly? Or biweekly? Or-

Dr. Jonathan Prousky: It’s weekly. I see patients like this weekly-

Dr. Kara Fitzgerald: Okay.

Dr. Jonathan Prousky: … and I see patients that have either a primary concern of anxiety, but they do have depressive symptoms, or primary depression with anxiety symptoms. They tend to be married to each other. These are emotionally-based problems with a lot of overlap. Then, I also see patients with psychosis or I would say schizophrenia and psychotic disorders. That’s probably more appropriate, and then I also see patients with bipolar spectrum disorder. Very few with dementia, and I don’t see a lot of patients with autism spectrum disorder, though some. Most of the patients I see have just primary mental disorders, I would say, if we wanted to put some kind of label on it. I see them weekly, a lot of patients weekly.

Dr. Kara Fitzgerald: Just to finish up your previous comments around just approaching them, engaging them in the journey, I’m assuming that your interventions may, therefore at the start, be very simple, like it’s not going to be a typical functional medicine practice where we’re doing a pretty heavy lab workup and starting them on a relatively involved supplement and dietary intervention. Is that true?

Dr. Jonathan Prousky: I think somewhat true, but somewhat not. I think it’s a phenomenal question because I think you’ll see how I approach patients may in some ways be similar to you without maybe a lot of the testing. We just may not fundamentally see testing in the same way, and that’s totally fine. I’m not here to convince anybody, but what I do with my patients is I do aggressively treat them, so when I see them, I don’t just take a slow approach to someone who needs more immediate help. I don’t believe that you can expeditiously necessarily change people overnight, but you can pragmatically and then expeditiously give them aggressive treatment to start shifting things hopefully sooner than later.

I do load them up on a base level of interventions, and this is not atypical to all of your listeners and probably including yourself. I give them good amounts of omega-3 essential fatty acids, vitamin D3, B complex vitamins, vitamin C, things that I think are foundational. Then, for every patient that has particular issues, then I would give specific treatment for their problem, whether that’s depression, anxiety, and so on. I would use high doses if I feel there won’t be too many issues with tolerating the intervention. Of course, the dose is slowly increased over time, but I don’t waste their time.

I don’t think there’s value in undertreating any human being who’s in distress. I do give people a fairly aggressive amount of treatment right when I treat them or right when I see them, I should say, so that we’re trying to maximize the clinical outcome here.

Dr. Kara Fitzgerald: Okay, good, so they know from the get-go?

Dr. Jonathan Prousky: Yeah, I don’t want to waste time. Maybe I’ll-

Dr. Kara Fitzgerald: Absolutely.

Dr. Jonathan Prousky: … only have a few visits with someone. Maybe this will be the only visit. I’d rather see how much I could help somebody chemically because they are in this horrible biological state. When you think about it, most of my thoughts emanate from a stress, I would say, foundation. I think when you look at this construct that we call stress, it almost permeates or runs through all mental disorders.

If we would agree that stress could amplify anything and make things worse, particularly chronic and enduring stress, then I think we have a real obligation, then, to not only give specific treatment for whatever emotionally-based or other mental health issue they have, but we also have an obligation to see if we can reduce some of the awful and cascading impacts that stress can have on their biology. To do so quickly is probably a smart idea than to waste a patient’s time by doing just too little at the first encounter, so I’m someone-

Dr. Kara Fitzgerald: Yes.

Dr. Jonathan Prousky: … who believes patients should be treated aggressively and their time is just as valuable as mine. I should treat them as quickly and expeditiously, though again, I know the outcomes are variable, but I should do whatever I can as soon as I can to help these patients. That’s my mindset.

Dr. Kara Fitzgerald: That makes sense. I appreciate that. That makes good sense. What’s a typical omega-3 starting dose for you?

Dr. Jonathan Prousky: Yeah, so it may have like, I don’t know, 1500 milligrams of EPA or 500 DHA, or sometimes I’ll go to three grams EPA, one gram DHA. I really do push things, but to me, omega-3s are sort of weak interventions. They’re-

Dr. Kara Fitzgerald: Sure.

Dr. Jonathan Prousky: … not strong enough in terms of their impact on outcomes with mental health. They certainly can lean things in a better direction, but I don’t think as an intervention itself it’s very strong. I think if you look at the data on, let’s say, saffron extract for major depression, well, that has some interesting comparability to SSRIs, though, of course, its mechanism is much different. Saffron seems to amplify norepinephrine and dopamine, so it has some really good uses potentially for patients that are, say, tired, they just feel like they’re mopey and fatigued. Certainly, they don’t feel like they want to do anything.

Then, when you think of a dose of saffron, well, you’re not going to help somebody with a 15-milligram dose. They probably need somewhere between 30 and a hundred milligrams to have any benefit from it, so I would dose people pretty high on that if they’re depressed, but I wouldn’t think that an omega-3, for example, would help to the degree that a high-dose saffron extract would. That’s sort of my thinking. I would give them an omega-3 because it can lean things in a better direction. Certainly, if you look at data even in bipolar spectrum disorder, you can see in any kind of meta-analysis things lean towards omega-3s helping with depression. Certainly can improve depressive symptoms, but it’s not to me a very strong intervention. It just helps-

Dr. Kara Fitzgerald: Right, yeah.

Dr. Jonathan Prousky: … when it’s given in combination with, say, proper treatment like mainstream psychiatric treatment, but when you look at a saffron extract, for example, it can have to me an efficacy for a major depression that’s fairly similar to drug treatment-

Dr. Kara Fitzgerald: Right.

Dr. Jonathan Prousky: … for major depression if it’s dosed appropriately. That’s sort of how I think about a lot of these different interventions that we have access to.

Dr. Kara Fitzgerald: I gotcha, I gotcha. I was actually just more curious about how aggressive you dose, but I certainly understand that it takes a while before omega-3s are going to be incorporated into the lipid membrane and actually turn on the various cascade of anti-inflammatory events, so that does make sense. Then, let’s just jump over there. I mean, you’re not just using saffron, you’re using lavender extract, you’re using St. John’s Wort, you’re using 5-HTP, and you’re using then, again, in doses beyond what we might normally be thinking of. I mean, let’s just talk about the major depressive patient. What are your top go-tos, would you say?

Dr. Jonathan Prousky: Well, let’s-

Dr. Kara Fitzgerald: Let’s say somebody who….

Dr. Jonathan Prousky: … let’s go back a little bit-

Dr. Kara Fitzgerald: Right, okay, okay.

Dr. Jonathan Prousky: … because I think it could be interesting, so-

Dr. Kara Fitzgerald: Yep. Mm-hmm (affirmative).

Dr. Jonathan Prousky: … when I wrote some papers on stress, I did so because I just felt I wasn’t knowledgeable enough on stress. I don’t think I still am. I think I’m just someone who’s a stress junkie, but not in a bad way, in a way that I want to learn more and more about it because there’s people like the late Bruce McEwen, who was just brilliant in terms of his stress research. There’s so many other people that have just done incredible work in this field, but I thought to myself, “What’s going on in the patients I’m working with from a stress perspective? Can I on some level stop some of these deleterious effects?”

First of all, what I know is that for a lot of mental health issues, particularly anxiety and depression, there seems to be some bottom-up control that’s sort of running the show, which isn’t helpful. When you look at depression, for example, what you see is these patients are sort of not cognitively quite there as you and I. They have trouble making decisions. They tend to lean more to thinking negatively or pessimistically about things.

Then, they tend to not have good top-down control, so their prefrontal cortex seems to be underperforming in a sense, and then their amygdala, which is certainly a very subcortical part of our brain, it’s a very ancient part of our brain, it’s part of our limbic apparatus. This amygdala tends to be, in a sense, running too much of the show, and they’re more emotionally controlled than having good top-down control over their emotional center, in a sense. You’ll see that sort of circuit happening in a lot of mental health issues.

Now, I’m very much simplifying it, but I think it’s a good model when you kind of think about, is the cortex sort of underperforming and the amygdala overperforming in a sense? When you kind of understand how that can have profound implications on a chronic stress sort of outcome and how people are managing in their life, it gives sort of good reason to give not only a lot of natural health products or other avenues of support, but then you could see just what would happen to this person if they’re not treating themself in any way over the next five, 10, 15, 20 years of their life when they’re going to have a lot more than mental health issues.

When your stress system becomes so amplified because of chronic and enduring stress and you can’t somehow mitigate the demands that are being placed on your whole biology, well, as you know, you get damage to your cardiovascular system, to your metabolic system, to your central nervous system. You’re more apt to die early or at least have disease, whether that’s some type of cardiovascular chronic issue like hypertension or maybe even atherosclerosis that gets to the point where start having clogged coronary arteries. Maybe you’re even increasing your risk of a myocardial infarction. Maybe you’re setting the stage for neurodegenerative disease later on because cortisol can be very toxic to certain brain centers that are very vital to our own sort of I would say nuance and survival in this very complex world.

I think I look at all of my patients now from this perspective that their system is sort of out of whack, in a sense, when I’m seeing them. If we can sort of give interventions that helps one brain system sort of be relaxed and another brain system gain some measure of control, then they can start having more agents (There is a big pause here in the recording and jumps to the next paragraph)

Yeah, so what I’m referring to is when we give natural health products, we should try to think, “Okay, so this product may influence a certain neurotransmitter system, but then how might that impact a brain circuit that’s sort of not functioning in the way that we want? Can that bring more nuance or functionality between, let’s say, the prefrontal cortex and amygdala? Maybe even the hippocampus as well because that’s an important part, too.” I’m not probably explaining them well enough at this moment because the details on how they work is pretty complex, but in the sense, if your listeners can get just a little bit interested and start doing their own research into this, I think that it makes a lot of sense.

We should be thinking beyond chemistry, that’s what I’m saying. We should be thinking about, “Can I sort of influence a brain circuit that may also be undermining a patient’s ability to function in this world in an appropriate way?” I think that’s why a lot of natural medicines have potential value beyond their immediate chemical effects because they may have durable effects that do bring some level of, I would say, regularity to our brain systems that are so fundamentally important in the quality of our life.

You were talking about things like 5-HTP. I mentioned saffron or St. John’s Wort or even Sam-e, all of these agents certainly impact different chemicals. I think if you start thinking about the chemicals they impact, then they should have the ability not only to activate people and to help with depression, but to bring, again, some balance or some regulation to a neural circuit that needs some kind of corrective action. I know it almost sounds too reductionistic and it is, and I don’t really think reductionistically, but I think there’s some value in some reductionism when you’re working with people, particularly those that are in distress.

If you look at 5-HTP, you mentioned that, well, 5-HTP as you know is a precursor to serotonin, and I only use timed or sustained release formulations because I’m really unconvinced that formulations that aren’t timed or sustained release do very much. I’ve seen far better clinical results when I use 5-HTP that is either time release or sustained release, and I don’t think you’re going to get much benefit in doses that are below 400 milligrams. I’ve gone as high as 1200 milligrams, and on rare occasion even higher, and what I-

Dr. Kara Fitzgerald: Divided doses?

Dr. Jonathan Prousky: Yeah, and divided doses or even sometimes a one-day dosing. It really depends on the patient and their own compliance. I don’t typically see a lot of adverse effects, either. I’ve even given up to 400 milligrams of 5-HTP with patients who are taking standard SSRI treatment and I don’t see any ill effects. In fact, if you give an appropriate dose of 5-HTP with an SSRI, I don’t think you’re going to have any adverse outcomes with that. Nonetheless, I do this and you could see. Again, “What does 5-HTP do?” It increases serotonin. You’re hoping appreciable amounts will get into the central nervous system. I assume it does do that.

Now, serotonin certainly is a chemical that has multiple effects. It’s one of the most well-studied neurotransmitters, I would say, in the history of psychiatry, but we know it does enhance well-being. We know it probably has all sorts of other cascading effects that just give people some levity over their complex life and how uncomfortable they may be feeling. In doing so, I think it gives them a little bit more top-down control. It gives them a little bit more agency over their difficult emotions so they can start, then, seeing things through a more positive affective bias than a negative affective bias.

When you take something like 5-HTP and you start upregulating serotonin, then you start shifting people from this negative affective bias that is causing them to feel so emotionally distressed and despairing to a state of mind that can be more open to positivity. It doesn’t happen right away. It takes several weeks for this to build up enough to have any effect, but that’s a good thing. These are time-dependent treatments that need time to exert any positive outcome, but there’s so many that we have access to and, in a sense, so little as well. I don’t think in terms of naturopathic medicine we have hundreds of treatments for depression or anxiety, but I think we have a sufficient amount of treatments for depression and anxiety to help people.

When you think about depression, we’re talking maybe about eight to 10 treatments that can have some real value, but I don’t think we have more than that.

Dr. Kara Fitzgerald: Well, what are those eight?

Dr. Jonathan Prousky: Yeah, so it could be 5-HTP, it could be acetyl-L-carnitine. Acetyl-L-carnitine is really interesting. It’s a fast-acting antidepressant. Certainly, it can help with brain energy, if you wanted to use that term, but it’s interesting because it seems to amplify the production of BDNF (brain-derived neurotrophic factor) from the hippocampus, which is really one of the main reasons why they think that… or why I would say researchers have shown that antidepressants seem to kick in several weeks later. It takes a while for the hippocampus to start sort of amplifying its own production of BDNF, and acetyl-L-carnitine seems to have an effect that does amplify the production of BDNF from the hippocampus, too, and it seems to be rather fast-acting.

It seems to work, in my opinion, better in older people. I’m not sure why, but I do think it tends to work better in older people than younger people, and the dose, again, is high. Three grams a day, I think, is necessarily typically. You can go as high as 4,000 milligrams a day. There’s even Rhodiola. As you know, it’s like an MAOI inhibitor, or a monoamine oxidase inhibitor, I should say. It seems to increase all of the monoamines like serotonin, dopamine, and norepinephrine, but Rhodiola is a good treatment. It has another effect on the HPA access that seems to be helpful. It seems to bring, again, some calmness to that storm of HPA overactivity that can be part of the chronic stress I would say apparatus that happens to a lot of the patients that I work with, so Rhodiola does have antidepressant effects.

Now, not all of the studies show that. Some studies show that it doesn’t seem to be better than placebo, but other studies show that it is better than placebo. Nonetheless, I still use it, but I don’t use a small dose, typically. I almost put all of my patients up to 750 milligrams, and some go over a thousand milligrams of Rhodiola rosea extract. That’s standardized.

Dr. Kara Fitzgerald: When you’re-

Dr. Jonathan Prousky: … go ahead.

Dr. Kara Fitzgerald: … giving a dose-

Dr. Jonathan Prousky: Yeah.

Dr. Kara Fitzgerald: … I just want to clarify, when you’re giving these doses-

Dr. Jonathan Prousky: Yeah.

Dr. Kara Fitzgerald: … are you dividing them? Can you just maybe be a little bit more specific when you’re-

Dr. Jonathan Prousky: Yeah.

Dr. Kara Fitzgerald: So how

Dr. Jonathan Prousky: I don’t always. No-

Dr. Kara Fitzgerald: Okay.

Dr. Jonathan Prousky: … I don’t. If someone has a busy day, I maybe would have them take their Rhodiola rosea extract with breakfast, I find that-

Dr. Kara Fitzgerald: Okay.

Dr. Jonathan Prousky: … this is a kind of herbal product that is best taken with food. It can be really nauseating-

Dr. Kara Fitzgerald: Okay.

Dr. Jonathan Prousky: … in some people, and if they don’t take it with food, they can get pretty nauseous. I’ll have them take it with breakfast with a pretty high dose.

Dr. Kara Fitzgerald: What about their four grams of the acetyl-L-carnitine?

Dr. Jonathan Prousky: I’ll have them take that away from food because, again, food will interfere with its absorption. That one, you’ll have patients take like 1500 milligrams, let’s say, 30 minutes to an hour before a meal, say, twice a day. Then, you can certainly increase the dose from there, so it really depends. 5-HTP timed or sustained release, that can be taken with food because it certainly doesn’t seem to be undermined if it’s a time release version whether it’s taken with food, so I mean, there’s a lot of nuance there and I appreciate you wanting me to clarify because that is important.

Dr. Kara Fitzgerald: Right. I just want to tell folks again, show notes. Head over there. You’ll see, again, the… You can find Dr. Prousky’s top interventions and how he’s suggesting daily dosing, and I’m just trying to ping him a little more specific on the dosing structure, but you’ll be able to find these and others, as well as his references and rationale for use. Go ahead, give me another couple of your favorites.

Dr. Jonathan Prousky: Yeah. I mean, it’s hard to say a favorite because when-

Dr. Kara Fitzgerald: Or maybe… Oh, go ahead.

Dr. Jonathan Prousky: … yeah, because when you’re working with people, you gain a certain gestalt about what to do. There’s a certain instinct that you develop over time as a doctor, so I can just try to distill it. I think Sam-e, unfortunately, has poor utility because of the cost. I hardly recommend it because when you look at clinical studies that have effectively used Sam-e in major depression, for example, the doses can be anywhere from 800 milligrams a day to 3200 milligrams a day.

I don’t know many who could afford 3200 milligrams a day of Sam-e because, yes, it’s a methylating compound, yes, it has some real value in that sort of biochemical pathway, and by virtue of that you can increase, again, production of monoamine neurotransmitters. The problem is its utility is poor. I don’t have many patients who could afford that at all, so I don’t use that. I certainly think St. John’s Wort extract is fine. The problem, again, is when someone’s on any medication because of its impact on the CYP3A4 system in the liver as well as other cytochrome P450 systems, I think you’re sort of at a loss of how to use it because it just has too many interactions with medications.

The truth is when you’re dealing with depression, you have to be creative and you have to sort of get a gestalt about what maybe appropriate, what isn’t. The good news is I use a lot of things in combination. I may push 5-HTP with saffron and maybe curcumin and theanine, for example. I just don’t rely on one thing, and then I have all of those other foundational approaches.

I try to just give my patients an opportunity to start feeling better and I’ll use as many of the evidence-informed treatments that I think have fairly good evidence when I’m working with them, but certainly, every depressed person is different. Every one of their situations is different and that does dictate more nuance. That’s hard to speak to on a podcast. It’s something that I should probably articulate in future publications so that people would know perhaps how to better apply these things when they’re faced with different patient presentations.

Dr. Kara Fitzgerald: Yes.

Dr. Jonathan Prousky: I would like to do that in the future.

Dr. Kara Fitzgerald: That would be great. A little algorithm and how you might walk through-

Dr. Jonathan Prousky: Yeah.

Dr. Kara Fitzgerald: … a case. Well, I mean, as clinicians, you’ve given us these really lovely resources and we’re going to start in, and if they’re not on medication, or even if they are, I think 5-HTP is, excuse me, St. John’s Wort aside, we might start with a couple or more. When are you going to know that you are heading in the right direction? When are you going to tweak your interventions?

Dr. Jonathan Prousky: I think you have to certainly engage your patients in regular care, and that could be two to three weeks after you see them. Some people need weekly appointments. They just need that extra support, but when you engage them in regular care, you should use some kind of clinical rating instrument to see if there’s at least some symptomatic improvement. Then, of course, talking to them, you could see how much more functional they are or not functional, let’s say, or they’re not functional enough. Then, you have to make changes going forward. You know how it is, it’s just a constant sort of up-and-down battle where you have to add something here, take something away, increase something there-

Dr. Kara Fitzgerald: Yeah.

Dr. Jonathan Prousky: … and it is something that is a work in progress, but if you’ve committed to your patient and they’ve committed to working with you, then at least I would say two to six months should be sufficient to get them on the right track, particularly those that start off rather impaired by their own mental health struggle. It is a lot of work and you should be tweaking things all of the time. I mean, I tell my patients, “Email, call me, I’m available.” They don’t overstep those boundaries. They tend to only get in touch when they need my help, and I’m happy to do so.

You just got to be available and be receptive to the idea that you’re not going to hit a home run most of the time. You’re going to have to make a lot of adjustments and tweaks as you’re working with them because when you’re dealing with so many moving parts and the lives of our patients, particularly those that are struggling with mental health issues, it’s not straightforward. It’s very, very complex work, but let’s sort of touch upon anxiety, too. We didn’t mention that and I think there’s value in at least mentioning a little bit about anxiety, if we have time, but you know-

Dr. Kara Fitzgerald: Yep.

Dr. Jonathan Prousky: … depression and anxiety, as you know, are considered both emotionally-based disorders in a sense. There is a lot of overlap between both of those situations, and what I do when I see an anxious patient where I would say their anxiety symptoms are more dominant, again, I try to throw as many treatments after foundational treatments as I can to shift things in a positive way so they feel more comfortable in their own skin. They feel like they can be more present in their life. They feel they can do things without feeling so overwhelmed by their own anxiety. Ashwagandha-

Dr. Kara Fitzgerald: Yeah.

Dr. Jonathan Prousky: … there’s probably now about four to six studies now clearly showing it reduces symptoms of stress and anxiety and even depressive symptoms, but more for stress and anxiety. What’s fascinating is in three of the studies that have been published, all of them have shown a reproducible effect in lowering the mean level of cortisol when they compare baseline to end of study cortisol levels by around, I think, five measurements, five units. I forget the uniments. Maybe like micrograms per liter or something. I could be wrong, but again, very interesting that it’s been consistently able to lower the mean level of cortisol over about 50 to 60 days.

If you look at the data of those studies, it’s the withanolides, that’s the component of ashwagandha that’s important, and most of my colleagues, and I say this with only kindness, they tend to be underdosing ashwagandha-

Dr. Kara Fitzgerald: Yes.

Dr. Jonathan Prousky: … and not giving enough of it to get the substantial amount of withanolides that patients need. You need at least 30 milligrams to have any appreciable effect, I would say, but I’ve gone as high as 120 milligrams of withanolides. A study on OCD used 120 milligrams of withanolides to augment clinical outcomes from SSRIs for patients who are diagnosed with OCD. Even though OCD’s not formally an anxiety disorder anymore, you can see these patients struggle immensely with just overwhelm and anxiety. I use ashwagandha a lot. I use chamomile extract. I use Holy Basil….

Dr. Kara Fitzgerald: You use that pretty aggressively.

Dr. Jonathan Prousky: … lavender and so on. Go ahead?

Dr. Kara Fitzgerald: Chamomile, you go very aggressively there as well.

Dr. Jonathan Prousky: Yeah, because you have to. I mean, it does interact with the GABA system in the brain. It does certainly bring some resonance to that, I would say, amygdala apparatus, so it helps people to, again, feel less over aroused by their anxiety, less uncomfortable. Then, again, it gives them more agency to live in the world without feeling so horrible about just their physiological state in a sense and their mental state. You need things to settle people down.

I tell my interns like, “No one’s going to see you or want to come back if you’re not giving them treatment when they’re uncomfortable.” You have to treat them, and I think undertreating people is never good, so I use high doses of chamomile because it does have effects that can help people, but I don’t think it’s as powerful as, say, a lavender extract. I’m fairly impressed with lavender, but again, 160 milligrams seems to be at least the key.

I’ve gone way higher than that. I have some patients that take well over 600 milligrams of lavender extract a day and they find it to be very helpful. I haven’t seen any adverse effect except maybe some lavender burps or some reflux, but it’s all very manageable. Again, you have to dose really high with lavender to get that strong sort of GABAergic effect to bring, again, some resonance to their amygdala and to help calm their whole physiology down in a sense.

Then, I still use niacinamide. Niacinamide has really no good studies on it for anxiety. I’ve written case reports. I did an N-of-1 federally-approved trial in Canada on niacinamide. Isn’t that funny? An N-of-1, federally approved. My government of Canada approved an N-of-1 study that I did many years ago. It was fascinating to go through the process, but the truth is, niacinamide is still is a very helpful anti-anxiety agent. It has a strong effect on the GABA receptor complex in the brain as far as I am concerned, and there are some patients that can’t believe the value it’s brought to their anxiety just be calming that part of their whole, I would say, anxiety apparatus down.

It has a strong affinity for the GABA receptor complex and I’d love to do a clinical trial, even if a small one with 30 patients at some point in my lifetime just to see if what I observed clinically is true, but I go-

Dr. Kara Fitzgerald: This is going-

Dr. Jonathan Prousky: … high, I go high-

Dr. Kara Fitzgerald: … way back.

Dr. Jonathan Prousky: … I go high with it. Yeah. Way back.

Dr. Kara Fitzgerald: It’s going way back to like, what, the ’60s maybe was it?

Dr. Jonathan Prousky: Yeah niacinamide’s been studied for decades, like since the 1950s at least, and there’s been a lot of animal research to show it does have GABA effects and does get in the central nervous system. We know it certainly does that, but we just don’t have good clinical data on it other than just anecdotal reports.

Dr. Kara Fitzgerald: Wow.

Dr. Jonathan Prousky: Passionflower extract is another agent. Again, strong GABAergic effects. I go high again with it. I don’t think, again, you’re going to see much value unless you don’t go high, and some people worry, “Will it be over-sedating?” Well, let your patient tell you. If your patient says they’re over-sedated, then back down the dose a bit. When you see someone that’s just so in distress and uncomfortable, anything is sort of pushing them towards more uncomfortable feelings, like maybe their breathing is more shallow.

Maybe they’re having some chest tightness. Maybe they’re just sweaty a lot. Maybe they’re just feeling on edge and irritable. Maybe they’re just worrying so much during the day they just can’t shut their mind off. Well, they need to be settled down. I think if we don’t use appropriate doses as I’ve said throughout this whole podcast today, I don’t think we’re going to give them the kind of outcome that they’re looking for.

Same with Valerian. People shy away from Valerian, but I think it’s a strong GABAergic agent, and the only negative is you have the few people who get a paradoxical effect with it where they get agitated and then more anxious from it.

Dr. Kara Fitzgerald: Why is that? I’ve seen that-

Dr. Jonathan Prousky: I don’t know.

Dr. Kara Fitzgerald: … a couple of times.

Dr. Jonathan Prousky: I have no idea, but I can tell you in my own experience that when I take about 500 or 600 milligrams of Valerian root, I’m fine, but if I double it to, say, 1200 milligrams, I am wired, I’m activated. I’m up all night. For me, there’s a sweet spot with Valerian, and I assume that’s probably like that with a fairly large percentage of people. I think people tend to do well with it at 5 or 600 milligrams. When you sort of go double or above a thousand milligrams of Valerian root extract where it’s standardized, you’re probably more likely to cause that paradoxical reaction. I don’t know why. No idea, but I just know that it’s something that can be very uncomfortable for people when it happens, so I try to be a little cautious in my dosing.

Then, theanine’s interesting. I mean, theanine sort of modulates alpha waves, which of course is good. It gives us that calm, that focused attention, but it does have some GABA effects. It’s really not that strong. I think I’m just learning about theanine and its value. I don’t think it’s a strong anti-anxiety agent. It certainly impacts the GABA system. It may have more of an effect on alpha sort of waves, but I’m not so sure. Again, as a complementary treatment to other things, sure, try it and see what outcome you have, but again, you’ve got to go at least 400 milligrams, I would say, to have any appreciable impact.

You can see, there’s not a lot of treatments for mental health in my mind, specific treatments that we can use, and that’s why you have to use a lot of them in combination in my mind to get good outcomes. Otherwise, you’re not going to give your patient the chance that they need to get a little bit better in their life.

Dr. Kara Fitzgerald: You talk a lot about minerals, and that’s very orthomolecular of you. You prescribe a lot of microminerals. You wrote specifically about broad spectrum micronutrients.

Dr. Jonathan Prousky: Yeah. About 15 to 20 years ago, this sort of became new and novel to use a large amount of micronutrients in combination, but not just like a one-a-day multivitamin mineral supplement, but using them in fairly high doses spread throughout the day, like five pills three times a day. What’s interesting is that dramatically raises, obviously, the concentrations of micronutrients in one’s body, let’s say, and obviously you’re going to get all sorts of enzymatic changes. You’re probably going to compensate for SMPs and you’re probably going to push certain reactions towards end products that may upregulate or amplify neurotransmitter systems.

It’s probably a broad spectrum amount of benefits from giving people large doses of micronutrients spread throughout the day. What we found now is there’s a lot of data to suggest that’s true. Data showing insomnia, or bipolar spectrum disorder, or psychosis, or people that have been through trauma. I mean, the publications on this approach now are expanding a lot, and I think it’s a worthwhile treatment, but I don’t use it a lot because it has a utility, but I’m not finding it as a utility for everything. I think it’s not as fast-acting, and that’s the problem. It takes a while for it to build up in people’s system, and I don’t always have that luxury of time.

For me, I use it when I see more of the patients who have a bipolar spectrum disorder and they’re wanting to see if they could be on a little bit less medication-

Dr. Kara Fitzgerald: Okay.

Dr. Jonathan Prousky: … and get more regulation, or someone who has a schizophrenia and they have a chronic situation. Again, they want to see if they can lower their doses for example. I do think a broad-spectrum micronutrient approach could definitely lower doses of mainstream medications, but you can’t do that without being very careful, and you can’t do that without being collaborative with their prescribing psychiatrist, for example.

Dr. Kara Fitzgerald: Mm-hmm (affirmative). All right, and so just a really high-dose multivitamin mineral formula?

Dr. Jonathan Prousky: Yeah,  multiple times throughout the day. It’s not one a day, it’s up to 15 pills spread throughout the day.

Dr. Kara Fitzgerald: Yeah, yeah, absolutely. Okay.

Dr. Jonathan Prousky: Then, I use a lot of magnesium. I think-

Dr. Kara Fitzgerald: Yeah.

Dr. Jonathan Prousky: … one needs to when you’re dealing with a mental health population. It’s NMDA receptor antagonist. It certainly can help in people who may even have treatment-resistant depression because of that effect. There’s a lot of interesting papers coming out about magnesium and depression, but magnesium also seems to be something that we excrete rather rapidly when we’re stressed-

Dr. Kara Fitzgerald: Yes, right.

Dr. Jonathan Prousky: … which is fascinating. We may have to compensate for people that are under chronic stress by loading them up with actually sufficient magnesium so they actually can replete their stores that are being depleted. It has a lot of effects that I think are quite therapeutically important, and I do use a lot of magnesium in my practice, too.

Dr. Kara Fitzgerald: Do you use single higher dose amino acid therapies?

Dr. Jonathan Prousky: I’ve tried. I mean, other than 5-HTP and, say, theanine and the ones that I’ve mentioned, I don’t do a lot of them. I’m rather unconvinced that they’re as useful as I used to think. I’ll use tryptophan by prescription. In Ontario, I have some prescriptive rights as a naturopathic doctor, so I can prescribe, say, tryptophan when needed. It’s okay. I mean, I think if you’re going to give somebody tryptophan for sleep, it’s sort of not always a good… it’s hit or miss. I don’t think you’re going to get a predictable response.

Dr. Kara Fitzgerald: Well, if-

Dr. Jonathan Prousky: It’s not-

Dr. Kara Fitzgerald: … you have… if the kynurenine pathway is upregulated, if you suspect inflammation, then it might be contraindicated. Would that be correct?

Dr. Jonathan Prousky: Yeah, I totally agree. It could be-

Dr. Kara Fitzgerald: Okay.

Dr. Jonathan Prousky: … contraindicated, absolutely, and-

Dr. Kara Fitzgerald: What about-

Dr. Jonathan Prousky: … go ahead.

Dr. Kara Fitzgerald: … glycine?

Dr. Jonathan Prousky: Yeah, so I’ve been using glycine more for sleep, and here’s sort of a little trick that I’ve been doing. Glycine, as you know, tastes sweet. We know in evolving literature on sleep, it seems to do a few things. It seems to increase that sort of deep phase of sleep, so the third stage of sleep we’re in delta sleep where we’re more parasympathetic. There’s a lot of heart rate variabilities, a lot of coupling between our breathing and our heart rate. It’s all very important.

It’s restorative, but what’s fascinating is glycine seems to increase our third stage of sleep. Seems to help our temperature drop more, which is important when you actually have to have a drop in temperature to have a better sleep. It seems to help with, I would say, the fatigue that some people can get when they’re not getting enough sleep, they’re a little tired the next day, so glycine can seem to overcome some of that insomnia-related fatigue. I’ve been using it. I have my patients take a tea typically that could have, say, passion flower, Valerian, or Melissa, or lemon balm, just typical things in a sleepy time type of tea, and I have them put a teaspoon of glycine about an hour before bed and I’ve seen a lot of patients respond beautifully to that to help them with sleep.

I’ve been using glycine for sleep more than any other issue because insomnia-related problems or insomnia disorders we would say or sleep disorders are fairly common among the population I work with. Either it could be a problem that’s comorbid, or it could be consequence of their depression or anxiety. Nonetheless, they need to sleep, it’s important, and glycine can be quite helpful for that. I don’t use a ton of single amino acids. I use certainly some, but I mentioned the ones I will use like acetyl-L-carnitine, 5-HTP, glycine, theanine. Those are a lot of the ones that I have used or use at the moment.

Dr. Kara Fitzgerald: Obviously, you’re looking at diet and you speak, again, about inflammation as an underlying driver.

Dr. Jonathan Prousky: Mm-hmm (affirmative).

Dr. Kara Fitzgerald: You reference in your paper in The Townsend Letter on Stress, I think it’s part one, palmitoylethanolamide, which we’ve been using here more and more. Basically, you have to deal with the underlying inflammatory or pain conditions if you’re going to turn around depression or any mental struggle. Do you want to kind of speak to this a little bit as we head towards close?

Dr. Jonathan Prousky: Yeah, I mean, it’s interesting because, as you know, there’s a lot of I think papers now that have come out to show clear relationship between inflammation and mental health issues or mental illness, let’s say, but it’s more than that. If you look at a lot of the patients that have problems that are mental in nature, let’s say, it’s not just that. Again, we’re more than just our mind, in a sense, so they’re typically going to have metabolic issues. They’re typically going to have other problems like chronic pain issues. It’s amazing how chronic pain can destroy someone’s life. They can’t focus on anything because the pain is just so horrible and they can’t find any way to get it under control.

I think when you’re working with a mental health population, you have to sort of look at all of the cascading impacts that an inflammatory state can cause, whether that’s impacts on cholesterol, whether that’s impacts related to just general inflammation that may be causing problems, or whether that is something to do with chronic pain. I think you have to load people up, so I use all sorts of treatments, whether that is PEA, like you mentioned. It’s just a fatty acid, PEA, amplifies the endocannabinoid system. Probably has some antihistamine effects as well, but it has a whole cascade of other interesting effects, whether that’s on nitric oxide, whether that’s on glial cells even. These are non-neuronal cells that have important roles. There’s so many interesting avenues with our medicine that I love because there’s just more than one impact.

PEA actually could be a very useful antidepressant. I don’t know if people are aware there was a study where they added it to SSRIs to improve outcomes and it worked rather well, but it has a wonderful effect on pain regardless of etiology. I think it’s very useful for neurogenic pain. I see patients who have chronic pain. I don’t think I’m an expert in chronic pain, but certainly I’m very interested in trying to do what I can. I think more recently PEA is showing itself to be helpful, but you have to dose it, again, I think at least 1200 milligrams a day for over two months to see if it’s going to benefit anybody. I think that’s important.

I use berberine in high doses because I think, again, someone in their 40th year, 50th sort of year and so on needs all of the support they can get to mitigate harm later on in their life, and berberine has good effects on modulating the cholesterol profile, but also helping with insulin sensitivity. Again, these are important things to think about because a person who struggles mentally and who’s getting older doesn’t just have problems, let’s say, of the mind or brain, if you want to say. They have problems with their whole being, and we should be giving them things that attenuate risks, whether that’s lowering cholesterol, whether that’s mitigating pain or lowering inflammation. I use every available tool that I can think of, and I think that’s an important part of, I think, a holistic or comprehensive practice.

Dr. Kara Fitzgerald: All right. We could just continue this conversation I think, but clinicians are going to find it very helpful. Just couple final questions for you. One is lithium. Are you using lithium in practice?

Dr. Jonathan Prousky: Yeah, I wish I could. Unfortunately, in the Province of Ontario, any form of lithium, even if it’s orotated at like five milligrams or 10 milligrams a day, is considered a drug, and though my patients can find it and they could buy it, they could order it, I can’t recommend it or give them guidance on it because that’s contravening my scope of practice. I would love to be able to give lithium orotate as a treatment. I think it has real value. I think it’s interesting.

It may even have some value in mitigating risk of suicidal impulses, though I can’t say that’s true, I can say it looks like there could be some data there to suggest that. It also has good effects on mood. Lithium can absolutely help with mood and I wish that I could use it clinically. I can’t, which is regrettable. Yeah.

Dr. Kara Fitzgerald: Well, that’s my… Well, I guess I have two more questions now. I wanted to ask you just a little bit of your thoughts around supporting patients that are suicidal, speaking of lithium. I know, obviously, we’re at the end of our time.

Dr. Jonathan Prousky: Yeah, but I can briefly-

Dr. Kara Fitzgerald: … yeah-

Dr. Jonathan Prousky: … talk.

Dr. Kara Fitzgerald: … give me some-

Dr. Jonathan Prousky: When someone’s talking about that their life isn’t worth living, that doesn’t mean that they’re going to kill themself. That’s just they’re in despair, but when you ask more questions to people, sometimes they will open up and tell you, “Yeah, I’ve been thinking about killing myself. I even have been thinking about how.” The truth is when they have that level of thought and they’re actually thinking about it in a real way, then you really should take action. That that person should know at that moment that you’re very concerned about their well-being and they should take the right steps and get them to a hospital for an evaluation.

There’s a lot we can do, too, when someone doesn’t say they’re suicidal. See, the problem is we have this mythology that people have to say they’re thinking about killing themselves and they have a plan to do anything. That’s not true. A lot of people may say nothing and they could still kill themself, right?

Dr. Kara Fitzgerald: Mm-hmm (affirmative).

Dr. Jonathan Prousky: There’s a lot of things to look for. Does the person have a sense of feeling entrapped by their life? Do they feel that they’re a burden to others? Do they look like they’re mobilized and ready to do something? When you see an absence of a blink reflex, for example, that could be an important sort of clinical sign. Maybe they’re getting themselves mobilized to do something very, very risky that puts their life in jeopardy. Maybe they have lost good cognitive control over themself. Maybe they’re not sleeping. They’re getting more and more anxiety every day and they’re just not sleeping day after day and they’re getting more and more nihilistic.

They don’t have to say they want to kill themself to be at risk, and I think there’s a real important point I’m trying to make is that your listeners should really investigate for themselves something called suicidal crisis syndrome. This is an important construct now that’s being more and more studied. These are certain signs and symptoms that people can display even without saying they want to kill themself that puts them at very high risk of killing themself in a sense. There’s now studies being done all over North America and the world that are showing this to be a very valid sort of diagnostic entity in the sense that gives people a sense of something that may happen in someone’s future that’s not good for them, which is once you’re dead, you’re dead. There’s no coming back.

The idea here is you have to be perceptive enough to realize that someone doesn’t have to say they want to kill themself to kill themself. I’ve regrettably worked with five patients to my knowledge that have taken their own life. There could be some I don’t know that have, too. I’ve been in practice a long time, but it’s just so devastating as a doctor when you lose a patient like that. It really strips a little part of your own soul away from your own identity. You feel crushed by that, not to mention you feel a lot of guilt and despair for the family that now has to deal with a loved one that no longer is alive.

What do I do when I see people aren’t to the level of really wanting to kill themself or I don’t feel that their signs or symptoms are presenting that way, but I feel that they’re sort of on the cusp of going down that nihilistic I would say train in a sense? You try to just commit to them and try to help them to sort of see there’s an opportunity to live a little bit better, but you don’t overdo it. You don’t overpromise anything. You just say, “What are you willing to do? What are you willing to do that’s a little bit different today than tomorrow?” Like you would with any depressed patient, let’s say-

Dr. Kara Fitzgerald: Right.

Dr. Jonathan Prousky: … and you try to give a glimmer of opportunity there, but I can tell you it’s messy work because there’s a lot of reasons for people to be in despair and to be sad and maybe even to contemplate their own death because their life could just be abysmal. Maybe they’ve lost a job. Maybe they lost a loved one. Maybe they’ve had so many hurts over their lifetime that they don’t even feel they can go on anymore. They’re just so wounded by their own existence. Who knows?

The point is, we have to try as doctors. We have to do whatever we can to help somebody when we feel there’s a need for them to get some kind of help, and maybe it’s beyond our competency, but then we should find the resources to help that person. I don’t have anything magical to say about it, but I can tell you, if you are ever worried about a person, that should tell you you should act on it. You shouldn’t just pretend it’s not there. You should trust your own instincts of worry and make sure you’re getting your patient to the safety that they need, or at least implementing the proper treatment plan for them.

Dr. Kara Fitzgerald: I’m assuming you’ve got an offering of community resources to help bridge patients?

Dr. Jonathan Prousky: Yes, and I’ve been involved in some legal cases where I’ve been providing expert opinion on the work of others about patients that unfortunately have died by suicide. What I notice across the board is doctors aren’t planning for safety. You can’t determine what a patient’s going to do in between an office visit and you can’t predict their life, but what you can do is when they leave your office with a treatment plan, there should be a measure of safety planning in that plan. It’s not a suicide contract where they sign something that’s so silly like, “I won’t kill myself.” That doesn’t do anything but makes the doctor feel artificially better, but it makes patients feel really crappy because they’re forced to sign something that is really useless.

Safety planning is different. Safety planning is a litany of things that patients can do when they’re distressed. “When I’m feeling a certain way, who do I reach out to? When I’m feeling a certain way, what should I do to help myself?” Whether that’s exercise or calling a friend or whatever. You go through planning with a patient and you are clear on the set of tools that they’ve identified during the encounter that are helpful for them so they know who to reach out to when they’re feeling this distress. When doctors don’t do any safety planning, when they have people that are at, say, some level of risk, moderate risk, let’s say, well, you’re putting yourself in jeopardy as a doctor. You’re not doing your due diligence.

I think the only thing I would tell you, is I think your listeners, if they’re not doing it already, get your own resources in order and make sure that if you have patients that are expressing things in a way that makes you concerned that you do (huge pause here) and something to do when they are getting dysregulated, when they’re regressing, when they’re starting to get really perturbed by their own mental state. They need to know what to do at that point, and if you don’t do safety planning, you could find yourself in some kind of legal quagmire later on if your patient should take their own life.

Dr. Kara Fitzgerald: You have a write-up that’s actually quite interesting, again, discussing micronutrient therapy. That’s in the title, but in patients at risk for suicide, I think that it’s more broad than just the intervention you’re talking about and I’ll recommend it. Again, it’ll be listed in our show notes. You sent us a pretty extensive bibliography. If there are any other resources, even things that you haven’t authored that you think our readers should be aware of, we’ll ping you later and we’ll add those to the show notes as well.

This has been extremely useful, Dr. Prousky, and I just want to thank you for taking your time with me and with our listeners today. I think folks listening will find it very, very valuable and meaningful, both personally and those of us who are clinicians professionally. Thanks for your hard work in this arena.

Dr. Jonathan Prousky: Yeah. I really thank you for the opportunity and I hope people just get a little bit inspired to do a little more work on themselves and maybe on their own clinical path to just expand their own practice, let’s say, and they could review some of the articles, some of the information that I’ve published and maybe it will be of help. Thank you so much for the opportunity. It’s been a real pleasure and I’ve really enjoyed talking with you. Thank you kindly.

Dr. Kara Fitzgerald: Absolutely.

And that wraps up another amazing conversation with a great mind in functional medicine. I am so glad that you could join me. None of this would be possible, through the years, without our generous, wonderful sponsors, including Integrative Therapeutics, Metagenics, and Biotics. These are companies that I trust, and I use with my patients, every single day. Visit them at IntegativePro.com, BioticsResearch.com, and Metagenics.com. Please tell them that I sent you and thank them for making New Frontiers in Functional Medicine possible.

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Dr. Jonathan Prousky (ND, Bastyr University, 1998; MSc, University of London, 2008; MA, Yorkville University, 2016; RP, College of Registered Psychotherapists of Ontario, 2020) is the Chief Naturopathic Medical Officer at the Canadian College of Naturopathic Medicine (Toronto, Ontario). His primary responsibility is ensuring the delivery of safe and effective naturopathic medical care to patients, as well as ensuring the safety and effectiveness of the medical training in the naturopathic program. His clinical practice focus is primarily on the evaluation and management of mental health problems. He has spent over 20 years advocating for patients that wish to receive integrative care to help their mental health struggles. He was the first naturopathic doctor to receive the “Orthomolecular Doctor of the Year” award in 2010, and later to be inducted into the Orthomolecular Hall of Fame in 2017. Dr. Prousky is the author of more than 60 publications, and several texts including Anxiety: Orthomolecular Diagnosis and Treatment, and the Textbook of Integrative Clinical Nutrition.

www.jonathanprouskynd.com

Complete list of Prousky published papers: ResearchGate

The Townsend Letters:

• The Stressed Brain Part 1
• The Stressed Brain Part 2
• Protecting Your Brain from Stress Part 1
• Protecting Your Brain from Stress Part 2

Article: “What Begets Suicide?” in Naturopathic Doctor News and Reviews

Prousky Interventions: Towards a Multi-Micronutrient Anti-Suicide Strategy

Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic

 

Dr. Kara Fitzgerald FxMed Resources

Clinic: Patient consults with DrKF physicians

Clinician Professional Development: DrKF FxMed Clinic Immersion

DrKF FxMed Nutritional Residency Program