By Jean Lawrence
Feb. 25, 2002 -- The year was 1983. "A woman came to me with a panic disorder," recalls Robert J. Hedaya, MD, a clinical associate professor of psychiatry at Georgetown Medical School in Washington. "She was 55, had one child about to go off to college. Her situation seemed pretty straightforward -- probably separation anxiety." Hedaya put her on some medications and scheduled cognitive (talk) therapy.
A year later, she had another panic attack.
"This opened my eyes," Hedaya says. "I was missing something. She should have been better."
Hedaya went back over the basic blood tests he had performed when the woman had first come under his care -- and this time he caught something: Her red blood cells were slightly too large, which can be a sign of vitamin B-12 deficiency. Sure enough, further tests showed a deficiency. The woman was treated for it and had no more problems with panic attacks.
This got Hedaya thinking: Many people are in the health care system for a long time and don't get well. What symptoms currently chalked up to psychiatric or emotional causes are actually caused by physical -- organic -- problems?
The effort to answer that question led Hedaya to develop his new practice -- "whole psychiatry."
In recent years more and more emphasis has been placed on "holistic" approaches, so the idea that a mental or emotional problem can cause symptoms in the body is fairly well accepted. But what about the reverse? Might a medical problem actually cause psychological symptoms?
According to Hedaya, author of The Antidepressant Survival Program: How to Beat the Side Effects and Enhance the Benefits of Your Medication, the "whole psychiatrist" sees that body and mind are linked in both directions -- making a whole, in other words.
In a sense this approach is nothing new. After all, psychiatrists (unlike psychologists) are medical doctors. It's part of their job to evaluate an incoming patient's physical state, not just their mental state.
"Most psychiatrists get a blood count and blood chemistry done," Hedaya says. "Maybe a thyroid screen and sometimes a B-12 level." (He warns, though, that the latter is actually a poor way to detect B-12 deficiency and can miss half of cases.) But Hedaya, as a "whole psychiatrist," also explores food allergies and toxins, and makes his patients answer a long list of questions.
Some experts are not sold on this approach. "I think this is actually a throwback to the old idea that 'body' stuff is real and 'mind' stuff is less real," says David Spiegel, MD, associate chair of the department of psychiatry and behavioral sciences at the Stanford University School of Medicine in Palo Alto, Calif. "I treat a lot of people with very serious, recognized illnesses, such as cancer and AIDS, who also have emotional problems not related [physically] to those illnesses."
Much of whole psychiatry has to do with medical mimics, which are physical or chemical imbalances that can be mistaken for emotional problems, Hedaya says. In the nutrition area, Hedaya says, many vitamin and mineral deficiencies can cause depression or make it worse -- including deficiencies of the B-vitamins, folic acid, and zinc. He says that a zinc deficiency can also affect sex drive -- another problem that often brings people to the psychiatrist's office. Hedaya adds that problems with fatty acids have been linked to depression, manic depression, and possibly even schizophrenia and attention disorders.
Proteins and carbohydrates in the diet must also be in sync with a person's metabolism to prevent mental or emotional symptoms, Hedaya says. "A lot of people have insulin resistance," Hedaya explains. "Too much insulin can make people hungry and tired. They gain weight. They feel depressed."
A whole range of hormonal problems -- adrenal dysfunction, thyroid problems, or altered melatonin levels -- can also show themselves as "mental" problems, he says.
"Much of the time, there is no one smoking gun," Hedaya says. "It can be a combination of things."
Hedaya is a psychopharmacologist, so prescribing and judging the effectiveness of drugs used to treat mental problems is part of his specialty. "I use them," he says. "Many are very good. But I try to do other things first or in addition." In fact, he says, one sign that a physical problem may be at work is when such drugs stop working for a patient as well as they once did.
"Whenever a drug works for several months and then stops working, I assume something else is going on," Hedaya says. He recalls one patient, an actor, who had been hospitalized for depression before being put on various antidepressants. The actor recovered and for years did well, but then started having panic and nausea attacks before performances.
What was going on? "He was stressed and had started taking [the acid reflux medicine] Prilosec," Hedaya explains. "Prilosec can inhibit absorption of B-12. We fixed that, instead of upping his dose of Prozac or changing medicines as other practitioners might have."
"Medicine is not a one-shot deal," says Spiegel. "You try things. If the patient does not get better, you try something else." That new "something" might be another search for a so-called physical cause. "Antidepressants are not cure-alls," he adds. "Yes, sometimes they stop working."
For his part, Hedaya recommends that patients -- whatever their diagnosis -- balance and heal their lives, eat a high-quality diet, exercise, and find time to play and relax. Not a bad prescription for anyone.
Beth Israel Deaconess Medical Center. Reviewed for medical accuracy by physicians at Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School. BIDMC does not endorse any products or services advertised on this Web site.
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