Lecture 4, June 16th - Dr

1INTEGRATED CLINICAL STUDIES – JUNE 16th, 2008 DR. JONATHAN PROUSKY – ORTHOMOLECULAR PSYCHIATRY LECTURE 4 From page 2:

ICS JUNE 16TH, 2008 – PAGE 1

Above slides are from page 2/3 in notes. ICS JUNE 16TH, 2008 – PAGE 2

Link between sleep disturbance and mental illness. Page 2: “Nervous Breakdown”: • Can no longer function in their normal life • Lowered ability to perform ADLs • Hopelessness, despair • Inadequate coping ability Manifestation: • Can’t work • Disintegration of relationships • Social isolation • Can’t get out of bed All of us could have a nervous breakdown: depends on our threshold. All of us have a point at which we can no longer function. Approach patient with this perspective The kind of OCD that Dr. Prousky sees in practice is obsessive thoughts: they do things that stop them from thinking about the thoughts. Eg. Partner is having an affair: interrogates partner for hours, relationship disintegrates. Grades of evidence: Systematic reviews are not the only reliable forms of evidence! Valerian: great evidence about this. Dr. Prousky uses this to manage anxiety (along with niacinamide!) CAN’T ABRUPTLY STOP VALERIAN! Will have same kind of side effects as benzodiazapine if they stop quickly. Doses as a supplement, rather than tincture. Can dose with SSRIs. May feel more fatigued during day. Reducing dose of benzos? Have to work with patient’s psychiatrist to reduce the dose together. Not easy to combine: nothing written about it. Have to have involvement from the other doctor. SJW: MOA: Acts like SSRI, more serotonin, NE, DA are available to patient. Great anti-anxiety, OCD therapy. OCD: better response to SJW and 5-HTP rather than Valerian Note high dose. Very effective at high dose. CYP 3A4 interaction, therefore disrupts metabolism of all other drugs (maybe not Advil, other OTC drugs). Use with care! Combine SJW and Valerian for anxiety. Somatoform disorders: http://en.wikipedia.org/wiki/Somatoform_disorder (I know… it’s wikipedia…). Symptoms don’t show up on lab test. Need to have a relationship with the patient beforehand to help the patient deal with/accept this diagnosis. Suggestion made to give TCM diagnosis as well as western one. SJW: amazing herb! Pg. 5 is summary of evidence. Not a lot of evidence for EFAs and anxiety. Theoretically, Fish Oil should have an effect… Low EFA levels in anxiety patients. But Dr. P hasn’t found that the use of EFAs have reduced the symptoms of anxiety significantly. Avena sativa: Not strong enough (in Dr. P’s experience) DEPRESSION: Have to have some kind of counselling component: builds up inner resources. Can add folic acid, chromium to SSRI to improve performance of drug. SJW: works as an SSRI: has taken pts off Celexa, put on SJW a couple of days later, smooth transition. Ginkgo: MOA-A: serotonin, NE uptake inhibitor MOA-B: DA uptake inhibitor No significant interaction with SSRI drugs. ICS JUNE 16TH, 2008 – PAGE 3

Can offset sexual dysfunction of SSRIs. Dose of SSRI unchanged, but this side effect changed. Has effect on platelet aggregation: don’t give with warfarin, unless doing INRs weekly. Dr. Prousky uses Life brand for many patients: extract concentration relatively good. Neurapas Balance (Pascoe): combo of Passiflora, Valerian, SJW: removed hyperforin component which is what interacts with drugs. http://www.pascoecanada.com/main.php?module=product&id=29 BIPOLAR DISORDER: EMpowerplus: have to take a lot of tablets per day, very costly for patient. Dr. Prousky has had good effects with methylcobalamin: helps to normalize circadian rhythms. Melatonin to improve sleep cycle: see improvement in symptoms.

ICS JUNE 16TH, 2008 – PAGE 4

Above slides are from page 11. Re: Glycine: Dr. P starts patient at 15 grams, and works up to 60g. Will see effects in 3 months. Don’t give to patients on clozapine: interactions. Is given as ‘last resort’ to patients: don’t want to mess with it. Selected cases: Be careful about putting your issues on patient, sharing personal information that might trigger patients. You can’t argue someone out of their delusion. Not hard to upset a psychiatrically ill patient… Pt with depression entire life. Had been out of work for 4 months. MV, 2000mg B12, 900mg SJW, EPA, B12 shot. 1 month later, had great changes: hopeful, taking care of self, ICS JUNE 16TH, 2008 – PAGE 5

2 months since first visit: working, sleeping well, felt 75% better. Beck depression inventory: 26 to 3. Pediatric patient: Learning disability. Slow to engage with peers. No visible physical symptoms, but is shy, does well in smaller settings. Wakes up feeling scared in the middle of the night. Needs constant reassurance that parents are going to come back. Given Valerian 200mg at dinner for 1 week. Increase to 400mg after 1 week. 3 weeks later: patient responded well, reduction in symptoms. Came in 2 months later, not waking in night. Don’t know how long she will need to take it, but she is creating positive structure in life. Will work with family to take her off when ready. Niacinamide 500mg tid. Had 38 on Beck Anxiety inventory. Dx of panic disorder, on lorazepam, but still experiencing symptoms. Much better on Niacinamide. 12 y.o. boy, bullied at school. Stressed during recess, never with a friend, always last one picked. Few friends that come over once a month. Feels sad, not wanted by peers, rejected. Has been to principal for outbursts of anger, at home too. Suicidal thoughts. Called “gayboy” and “stupid” at school Neurapas balance, fish oil. Beck depression score was 22, went to 5. Also referred to psychologist. Went from 3-4 bad days a week to 1 bad day a week. Treatments don’t have to be complicated to help people. Can treat aggressively and simply. COMMON PITFALLS OF TREATMENT: Discontinue meds? Work on feeling better than you are now. If you improve, we can talk about discontinuing treatment. Don’t tell patient that you can do this right away. Patient in denial? Incredibly hard. Have to be compassionate, hard to overcome. There’s no trick. If you have good rapport, may be able to call patient’s attention to level of wellness. Reflect it back in a way that they can accept. Resistant psychiatrist? Can write letter, ensure that you are not undermining treatment. Can be persistent, but may have to work without their cooperation. Lots of side effects? Is there a need to go off treatment, lower dose, period of adjustment? Not improving? Re-evaluate treatment. May have to start again, refer out. Is patient complying? Interactions? Yes, be concerned, but doesn’t mean that you shouldn’t give stuff.

ICS JUNE 16TH, 2008 – PAGE 6