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What is whole psychiatry?

In essence, whole psychiatry is combination of the best of traditional psychiatry combined with functional medicine, and a healthy dose of respect for what we do not know. 

Traditional Psychiatry

Traditional psychiatry, one arm of Whole Psychiatry, relies on the use of two tools or disciplines-psychological therapies and psychopharmacology (use of medications, such as Cymbalta, Effexor, Abilify etc.)). Many studies have shown that while these approaches can be very helpful, they are, most of the time, inadequate to help people to recover fully. Thus traditional psychiatrists also resort to more extreme (but sometimes helpful) measures such as polypharmacy (using several medications together), electroconvulsive therapy, transcranial magnetic stimulation (TMS), and vagal nerve stimulation (VNS).

Functional Medicine

Functional medicine, the second arm of Whole Psychiatry rests on the assumption that the mind and brain are strongly influenced by the function of the body. Thus in Whole Psychiatry, each patient is assessed very thoroughly at the level of gastrointestinal function, immune function (including infection and inflammation), detoxification and biotoxin burden, oxidative stress and mitochondrial function, nutritional status and special nutritional needs, hormonal function, genetic and epigenetic function. This assessment is based on a very careful history, questionnaires, physical exam, and targeted laboratory testing.

Orientation of the Whole Psychiatrist

The third and less tangible arm of whole psychiatry is the orientation of the psychiatrist. This orientation is characterized by a keen awareness that we have much to learn and humility is essential; that illness is generally a result of many predisposing factors, combined with triggering events. Thus the ability to look at the WHOLE picture (the symptoms, the person, the biology, the psychology, the interpersonal situation, the family, the community, the culture, and spirituality), while leaving room for the unknown, this is the function of the Whole Psychiatrist.

Physician-Patient Partnership 

Clearly, this approach is thorough and takes time and dedication to finding the truth. It requires flexibility and open-mindedness on the physician’s part, a partnership within the physician-patient relationship, and honesty, reliability and a commitment to health on the part of the patient.

That’s the theory, but how does Whole Psychiatry work in practice?

The best way to illustrate how it works is to share a case history. Imagine you are Julia, a 44-year-old married woman and mother of two young adults. You have had some marital difficulties over the past year or two and in your own mind you have associated this with the fact that your children are grown, out of the house, and your life is lacking a focus. 

Life Is Meaningless

Over the last several months, you have begun feeling that life has become meaningless and you have been feeling sluggish and depressed most of the time. You have become less tolerant and more irritable with your husband and so he has been spending less and less time at home with you. Things just seem to be spiraling down and you are worried about the marriage and the possibility that he may be having an affair. After all, you have not had sexual relations for seven months. 

Feeling Tired and Hopeless

You just feel very, very tired and have noted in the last several weeks that despite psychotherapy, which you have been engaged in for approximately 10 months, you are beginning to feel quite hopeless and even suicidal. You just don’t have any energy left for living; even the smallest chores, such as brushing your teeth, combing your hair, pulling on your boots in the winter, take enormous amounts of energy and are a sheer act of will. 

Get Counseling Yet Feel Worse

You have mentioned this to you internist, who did some routine blood testing but found no abnormalities. It was at his suggestion that you entered counseling to decide what you wanted to do with the rest of your life. At that time you had thought it was a good idea, but here you are, 10 months later, and getting worse. 

Seek Medication

Your therapist has been quite helpful, but the problems continue to escalate and you find yourself not knowing where to turn. Your life seems empty, only a shadow of what it once was. Ultimately, your therapist decides that perhaps medication would be of some help to you and reluctantly (you really don’t want to start going through this all over again) you agree to see a psychiatrist for medication evaluation.

Try Various Medications

You see a psychiatrist who, after 45 minutes determines that you are depressed. She suggests that you take a commonly used anti-depressant called Cymbalta. She tells you about the side effects and benefits, writes a prescription, and you set up a time to meet in 4 weeks. In 4 weeks time, you are not much better, and your sleep is a bit worse. At your second visit (25 minutes), the doctor suggests you increase the dose of Cymbalta, and gives you a sleeping medication, Ambien. At your third visit, 3 weeks later, you are frustrated, perhaps more fatigued, and because of the Ambien, a bit drugged in the first half of the day. With instructions for one more dose adjustment upwards, you go home, somewhat frustrated. 

Find Whole Psychiatry 

On your fourth visit, no better, and perhaps worse than when you began, she suggests an additional change in the medication regimen. Your doctor wants you to add a small dose of Lithium to boost the Cymbalta. While you agree to this, you have a nagging feeling that there might be a better way. After all, you are now on three drugs and no better. 

Feel Hopeful

You do an Internet search and find the link to whole psychiatry.  You make an appointment.

In this psychiatrist’s office, you realize that this is a different approach. The first appointment is 3 .5 to 5 hours long, includes a physical exam, you have filled out a variety of questionnaires and brought in all your old lab work. You have even brought in a loved one for the meeting, for support and an extra pair of ears. The psychiatrist asks you what seems to be hundreds of questions. By the end of the evaluation, it becomes clear, at least in his mind, that your main complaint is fatigue, specifically muscle fatigue. This, the psychiatrist tells you, is preventing you from being active and leaving you feeling frustrated and helpless. He describes to you that this is a perfect paradigm for what he calls “learned helplessness.” Your depression is caused by your fatigue.  You are not sure exactly what he is talking about, but you follow his directions and get some additional blood work. This just seems like one more stress, yet you feel a certain sense of hope.

Get Correct Diagnosis

Ultimately, a diagnosis of pernicious anemia is made. (This is a disorder of the immune system in which the cells of the immune system actually attack parts of the stomach that absorb B12, leaving you in a very weakened state, neurologically. As it turns out, you undergo treatment with B12 injections, and you stop your Prilosec (which made B12 absorption worse) and begin to notice an improvement in your energy. A meeting with the psychiatrist and your husband, about one month after the diagnosis has been made, helps both of you to understand what had really happened: A medical disorder had robbed you of normal nerve function. Not knowing what was going on, you began to feel helpless and spiraled into a depression. Your husband, also feeling helpless, began to work longer and longer hours and wondered about the possibility of separation. Now, with the diagnosis and treatment, there is renewed hope for your relationship and you feet quite relieved that your life, your marriage, and your self-esteem have been salvaged.

Regain Life and Hope

Julia’s experience indicates that what appeared to be a psychosocial problem causing consequent depression was actually a medical problem causing a psychosocial problem.  Julia was assessed very thoroughly using all of the Whole Psychiatry tools. By taking the time to look at her WHOLE picture, working in partnership with Julia’s commitment to health, the Whole Psychiatry approach salvaged her life.

p.s.

Julia’s case also shows how reliance on medication—a kneejerk reaction in the current medical community– is often unneeded and even harmful.  Be thoughtful in selecting your medical care, ask questions, do your research, and be committed to your health on all fronts.  Medication alone is not the solution.