Welcome to our clinic, the office of Integrative Psychiatry, named “integrative” due our preferred diagnostic and treatment approach.
Patients often ask: What is the integrative approach? How is it different from the regular, conventional psychiatric approach? Which approach is best suited to me? The following information will help you answer these questions, and give you a brief insight into our office mindset.
The brain is considered to be one of the body’s main organs, and like other organs, it is functionally and anatomically connected to the rest of the body. Relative to other organs, the brain enjoys the most autonomy and protection. It is protected by the skull from physical damage, and by the blood-brain barrier (an extra layer of cells in the brain’s blood vessels) from many potentially harmful elements passing through the blood. Neither protection, however, is absolute. For example, certain oil soluble compounds (such as hormones and alcohol) may easily penetrate through the blood-brain barrier, and if in excess, may cause toxic effects.
The average adult’s brain weighs roughly 1.2 to 1.4 Kg, which is about 2% of the average body weight, but it consumes about 20% of the body’s oxygen supply. Deriving the energy mainly from glucose and oxygen, the brain requires other nutrients as well, including: vitamins, minerals, amino and fatty acids. While the brain-blood barrier may protect the brain from an excess of chemicals, it will not protect the brain from a deficiency of nutrients. Deficiencies usually develop from a few well-known causes.
Some of the most common causes of nutrient deficiencies are:
1) a poor diet which doesn’t contain all required nutrients. This type of deficiency is rare in industrial societies, except among vegans and vegetarians;
2) a digestive tract’s inability to absorb certain nutrients. This type of deficiency is seen very often across all societies. In the US, nutrient deficiencies due to digestive tract problems are most commonly due to: gastric bypass surgery, the inability of the pancreas or liver to produce digestive juices, low stomach acidity due to a drop in sexual hormone levels (typically seen after medically induced or natural menopause), age advancement or a gluten/milk intolerance;
3) the body’s inability to convert certain nutrients into their active forms. For instance, in order to be biologically active, vitamin folic acid needs to be converted into methyl-folate through a process called methylation. It requires a specific enzyme called MTHFR, which for some us is less active than others. This i not an uncommon genetic condition. The deficiency of the methylated form of folate can manifest itself through depression as well as through other mental and physical conditions;
4) conditions where the body loses nutrients more rapidly than it restores them. Women who suffer from heavy and prolonged menses may eventually develop a significant iron deficiency. Frequently undiagnosed, an iron deficiency may create symptoms such as difficulty concentrating, chronic fatigue, daytime somnolence, and in some more serious cases may cause psychotic mania. Excessive alcohol consumption can also play a role in deficiencies, as it can lead to a chronic vitamin B1 deficiency, and trigger severe memory loss–a condition known as Korsakoff’s syndrome.
5) hormonal deficiencies of multiple origins.
There are, of course, some other less common causes of nutrient deficiencies– which are not worth describing here, but that are typically explored by an experience physician. It clear, however, that health issues originating elsewhere in the body, may eventually affect the functioning of the brain–and be manifested as a mental health condition. Therefore, If a psychiatrist is approaching a mental condition without considering all possible physiological causes, including those outside of the brain, the effectiveness of the treatment may be less effective than expected.
As technology and medical sciences advance, medical specializations are becoming increasingly more narrow. Physicians in each medical specialty are becoming more and more sophisticated in their narrow fields, and less and less in others; a process that is both expected and quite natural. A doctor’s brain is no different than any one else’s, and unfortunately, doctors do not have an unlimited capacity to process and store information. It is also beyond the average doctor’s means to integrate, into one system, information about a patient generated by other medical specialists. Most major insurance reimbursement systems don’t consider the possibility of paying doctors for time spent outside the direct care of the patients. In my experience it takes hours, sometimes days, before the communication between all physicians involved in a particular patient’s care can be established. Meanwhile, the patient remains without appropriate care.
“Borderline” medical conditions can also present themselves as a in issue when integrating treatment. These conditions, which cannot be clearly attributed to any known disease, typically present themselves in the “normal range” when tested by a primary care physician; and at this point the patient is usually referred from one medical specialist to another. Eventually, the symptoms the patient complains about are deemed to be “psychosomatic” and the patient is referred to a psychiatrist for further evaluation, and all previous work is made redundant.
We as psychiatrists have the unique opportunity to spend enough time with patients,collecting a detailed history of the events and getting into the very depth of their complaints.Although psychosomatic conditions do exist, more often than not, we find that a patient’s complaints are usually suggestive of “real” health issues that originate outside of the brain. Willingly or not, a psychiatrist ends up being a “last resort” for a patient looking for a cure.
Of course, providing a more comprehensive diagnostic based treatment takes time, which reduces the number of patients that can be seen in one day–which makes an integrative psychiatry less profitable as a business model, but still more rewarding for the psychiatrist and more effective for the patient.
The Cost of Effective Treatment
While the integrative approach to psychiatry is often viewed as the most effective, it may present itself as the most costly as well. The additional diagnostic tests we recommend for investigative purposes may not be covered by insurances, and treatment is not usually limited to medications alone, which means the patients may have to pay out of pocket for a recommended a list of over-the-counter herbs and nutritional supplements which are not covered by insurances.
Cost is usually the main reason why many patients rule out integrative treatment, although they may also choose a more traditional treatment because so many “straight forward” cases require no more than the conventional, symptom-oriented psychiatric approach. For instance, many kids with the hereditary form of ADHD can be easily diagnosed based on provided history and observations. So-called “situational” depression or anxiety, where there is a clearly identifiable trigger responsible for the onset of condition, should and can be initially approached and treated in a conventional fashion by using a combination of psychotherapy and antidepressant/anti-anxiety medications. In these two instances, there is no reason to undergo expensive and time consuming diagnostic work, as a possible cure is readily available to try.
The Integrative Package
Genetic Neuropsychiatric panel and Urine Neurotransmitters levels
are the two tests made by the two different and unrelated laboratories.
The genetic laboratory accepts most of the insurance plans, but might ask you to pay a co-pay, which usually doesn’t exceed $330. We'd recommend you to contact the laboratory (you can ask for their informational booklet at the front desk), and personally inquire, if the laboratory accepts your insurance, and how much copay you might be responsible for.
If it’s affordable, we will be able to help you to correctly collect the genetic material, a swab from oral cavity mucosa - a cheek swab, open the account with the lab for you, and mail the specimen to the lab for you. We charge $20 for this service. You can also do it for yourself without our help as soon as all the required genetic panels are included in the request.
The other laboratory is a biochemical lab. It uses a special analysis to detect 19 brain neurotransmitters and their derivatives passing through the urine. The specimen you supposed to collect and mail is urine. The laboratory doesn’t bill insurances and charges cash for its services. We have an account with the lab, and can provide you with the testing kit, which you take home with you. You’d have to collect the urine in the morning, following the instruction the laboratory provides. The specimen you collect has to be mailed in the prepaid envelope on Monday, Tuesday or Wednesday to avoid weekends arrival to the lab.
Because it takes significant amount of extra time to review, analyze, integrate all the data from the both laboratories in to one system, and develop based on that individualized treatment plan, which, may not always include conventional medications, but nutritional supplements as well.
Instead of charging you separately for Neurotransmitters panel and our extra time, we charge a flat fee of $1500 for the whole process, which, in addition to the laboratory's fees, includes one free of charge (or any co-pays) 30 minutes appointment, where the tests’ results from the both labs be explained to you.
The laboratory is able to include full hormonal panel into the test if needed for an additional charge.
The Purpose of the Testing and the Information provided by the two tests
The genetic test provides information about the genes responsible for brain functioning and a patient’s anticipated reaction to each of the psychiatric medications. Because each gene consists of two alleles: one from mom and one from dad, in the situations when only one of the two is abnormal, it is not possible to predict which one of the alleles dominates, and in to what degree. There are some other factors, including environmental, influencing the genes’ expression, and the net-effect of their action, so called Gene Expression in Phenotype. If the genetic test is not completely able to predict the final results, what would? For that purpose, the urine Neurotransmitters test is used.
Knowing the amount of neurotransmitters helps us to understand the effects of the genotype on the brain chemistry, and which of the neurotransmitters are responsible for the experienced by the patient symptoms. At the same time genetic markers explain the roots of the neurotransmitters' abnormalities. Simply speaking, if each of the tests taken separately would provide us with 25% of the information needed, taken together would give us 90%. We have to also keep in mind, that outside of psychological, electroconvulsive and magnetic therapies, the only other currently used in medicine methods to influence brain activity are chemical. Psychotropic medications, food supplements, herbs and minerals are all chemical substances. Knowing neurotransmitters levels ("brain chemistry") is definitely helping us to use those chemicals more selectively, that way minimizing side effects, and the time spent on "trials and errors”.
The information from the tests is highly technical and specialized. It is advisable to familiarize yourself with basic Genetic and Nerves System terminology before our meeting, if you want the tests to be interpreted to you. You also have to know, that the information derived from the biological tests is not suitable for DSM-5 labeling your psychiatric diagnosis. The names Major Depressive Disorder, Bipolar Affective disorder, PTSD, Panic disorder, Generalized Anxiety disorder, ADHD, and so on are given to the mental conditions based on symptom-oriented descriptive model, adopted by American Psychiatric Association in Diagnostic Statistical Manual (DSM). This diagnostic model has nothing to do with the biological model we use, because it is not based on genetic, physiological, biochemical, or other objective findings related to our brain-body functioning.
The information we derive from the genetic and neurotransmitters tests is biological and objective. It is used to answer a question, what biochemical and genetic abnormalities could be responsible for your mental condition, and which tools, including medications and nutritional supplements, could be used to correct them.
The genetic and neurotransmitters laboratory usually accompany their results with their interpretational reports. Occasionally the patients get frustrated due to not understanding the meaning of what they read in those reports. Because the reports are computer-generated and not integrated with the rest of the information derived from the patient’s, including history, previous and current treatment, other tests results, the reports are not individualized and have very little relevance to the concrete individual. I’d advice to pay little attention to those reports, and leave them to me for analysis.
Hopefully, the above information is found to be helpful.
Vitaliy Shaulov, MD