Forever fascinated by the neurobiology of various mental health presentations, addiction included, two medical news items caught my attention this week. If you’ve ever heard me speak on addiction, in somewhat simplistic terms, it is very much about the reward centre of the brain and how strongly all recreational drugs hit on this. Think rats tapping levers with their feet to continually self-administer cocaine…to the exclusion of all else….kind of magnitude of reward hits. You may have also heard me quote or misquote (!) someone famous who once said something to the effect of….and I am totally paraphrasing poorly here: if we can’t seek pleasure legitimately, we will seek it illegitimately.
So this story from ABC news about a Newcastle addiction group support program showing some early signs of greater retention and engagement and therefore potential success with addicts…because they incorporate prizes…well that makes so much sense!
The article is important to read in its entirety as it creates the context – especially for many people suffering from addiction who tell tragic stories of lives where the only rewards/prizes and even gifts they’ve ever known, being drug-related – even from a young age. So to normalise reward to some extent, and give individuals an experience of constructive legitimate versions of this, is actually desperately needed and ground-breaking.
How can we incorporate some element of this in our interactions with these patients?
The second ABC news item touts ‘a new generation drug that restores balance to the brain’ but is actually just a teaser about…wait for it…cue stage right…a not so old favourite…N-acetyl cysteine! Although this is effectively a recruitment drive for methamphetamine addicted individuals into a new 12 week trial of NAC, run by the National Drug Research Institute, taking place in Melbourne, Geelong and Wollongong, it gives NAC a great wrap and rationale for being a good adjunct in addiction, of course. Just a reminder folks that naturopaths belong on that multi-modality health care team for people struggling with addiction, and we do have some potent therapies to contribute.
A couple of years back I was asked to deliver an educational session to a group of hospital based mental health specialists on the merits of NAC. My favourite question/comment at the end of my detailed presentation from a very experienced psychiatrist was, “Well if N-acetyl cysteine is so good for mental health…why haven’t I heard about it before now?!”
I hope they follow the ABC news 🙂
Want to Get Up Close to N-acetyl Cysteine in Mental Health? Previous ideas regarding the pathophysiology of mental illness have been profoundly challenged in recent times, particularly in light of the limited success of the pharmaceuticals that ‘should have worked better’ had our hypotheses been correct. Novel drivers such as oxidative stress, inflammation and mitochondrial dysfunction are on everyone’s lips and N-acetyl cysteine is in prime position in this new landscape, to be a novel and effective therapy for mental illness. This presentation brings you up to date with the current NAC research in a large number of mental health conditions & translates this into the clinical context.
I was lucky enough to hear Jason Hawrelak’s excellent presentation at the Australian Naturopathic Summit last weekend, titled: A Case of Blastocystis Infection – Or Is It? Timely, highly valuable, immediately usable, provocative education (just how I like it 😉 ) on how perhaps often Blasto is playing the scapegoat for another condition/cause of patients’ GIT symptoms. During this case study, Jason detailed the shonky diagnostic work-up of his current patient by a naturopath 12 years prior…that naturopath was him.
There was so much to love about his telling of this case study and the discourse around it but here are my Top 3 Takes:
- None of us know everything or practice perfectly but rather we do what we do, until we know to do differently…even Jason 😉
- As there are 9 strains of B.hominis found in humans and many of these are in fact benign commensals, even perhaps important ‘apex predators’ for the microbiome, attributing someone’s health problems (digestive or otherwise) to the presence of this parasite should in fact be a diagnosis of exclusion…always asking yourself first, what else could it be?? e.g. coeliac, SIBO, food reactions etc etc
- The cost of being a ‘premature evaluator’, to your patients and to yourself, can be very high…
If you’ve not seen Kitty Flanagan’s skit on current coffee culture...it’s essential viewing. In true Kitty-fashion, she wants to simplify coffee ordering down to 2 basic lines – White or Black – says all our pretentious coffee orders; macchiato, skinny, decaf, half strength, latte etc can essentially be reduced down to a much faster 2 queue system. But she’s forgotten the line for taking your coffee rectally. Sorry – did I make you just spill your coffee? Knowing How across health trends Kitty is, she’ll add this 3rd queue soon, if the number of patients asking me about this or telling me they’re already doing it. Now, while enemas had a place in naturopathic history, my training never covered them and, consequently, I’ve never included them in my practice. But the more hype I heard around coffee enemas specifically, the more I thought we better find out as much as we can, so at least we can better inform ourselves and our patients. And of course the monkey on your back, called FOMO, jumps up and down, incessantly asking, “Are you (and your patients) missing out on an amazing therapy?”
The first patient who told me they were using coffee enemas daily was a celeb. A very anxious one. Who also told me she couldn’t possibly drink chai let alone coffee because of the caffeine. This had me a bit stumped…I knew she wasn’t inserting decaff up there and I thought…well given the colon is SUCH an absorptive surface surely this is why she reported feeling, ‘so energised, more clear headed’ etc. with every enema?
But I wanted to find out for sure (more…)
I’ve had my nose in all the research on Gilbert’s Syndrome again..watch this space…in the interim just thought I’d share this image and a couple of important details I may not have been able to convey when you last heard me talk (very fast!) about this important and common polymorphism:
- While the incidence is approximately 10% of Caucasian population, rates are heavily influenced by ethnic background and the highest rates (up to 1/4) are seen in Middle Eastern populations
- Gone are the days of thinking this condition only effects bilirubin levels and the enzyme responsible for its clearance – more recent research has shown over 3/4 of patients with Gilbert’s Syndrome have multiple SNPs that compromise clusters of enzymes within the glucuronidation pathway – with varying patterns – this goes a good chunk of the way to explaining the variability we see in bilirubin levels and symptom pictures across patients all deemed to have Gilbert’s Syndrome. This also explains why figures of reduced glucuronidation activity vary anywhere between 10% less to 90% less! It depends on your cluster..but the average reduction is around 50%
- UGT enzymes, the ones affected in Gilbert’s, are also expressed all the way down the GIT and constitute important food and drug handling. These UGTs are most active in the small intestines,as you can see above, but may explain why Gilbert’s patients are ‘more sensitive’ to medications than just paracetamol!
- And are you still thinking you need to run an $$$ gene test to confirm your Gilbert’s hunch in a client whose bilirubin sits consistently high normal or high? Think again… here’s a great little diagnostic short-cut that even the Royal College of Pathologists Australasia cites as sufficient evidence to confirm the polymorphism:
In the face of elevated total bilirubin levels and in the absence of liver pathology or increased haemolysis to explain this..”If the diagnosis is uncertain the serum bilirubin fasting level can be measured and should exceed the non-fasting level by >50%.”
Nice. So that means you only need to demonstrate that the patient’s fasting total bilirubin levels go up by at least 50% compared with their fed levels and BINGO you have your diagnosis. Much easier. Oh and this image comes from an interesting paper from Tukey & Strassburg 2001 – but is probably not for the faint-hearted 😉
Stay tuned for more 🙂
Just new to this condition and need a soft place to land with understanding Gilbert’s Syndrome? This previous UU30 is just the thing! Affectionately called Gilbert’s Girls because in particular it details a set of twins with this condition, this short audio explains the basics about this common polymorphism and why we tend to see a lot of patients who have this…even if no one has pointed it out to them yet! You could be the first to provide them with this important understanding about how genetics is impacting their detox pathways, changing their sex hormone handling and perhaps setting them up for both mental health issues and some serious upset guts! Better still, what to do once we have that diagnosis.
Help!!! I’m about to share the stage at the 3rd International Acid-Base Symposium on the 25th-27th Jun, with the best acid-base researchers in the world, all of whom I actively stalk (well read and recite everything they’ve ever published but close enough!) I’m terrified and excited in equal doses…but urgently need to change my presentation approach because until now I’ve had the privileged position of simply fulfilling the town-crier role, announcing far and wide the findings of their incredible research into acid base physiology and their findings about impact of chronic mild metabolic acidosis. But I can’t quote Arnett to Arnett! I can’t tell Dawson-Hughes about the incredible insights of Dawson-Hughes’ large body of work in this area! Oh my Goodness (cue, shaking knees), I’m going to meet Thomas Remer…of Potential Renal Acid Load Formula Fame!!
Yes, my partner is a musician and through him I have brushed shoulders with all kinds of famous…but nothing that has made my heart beat quite this fast!
Must buy an autograph book for them to all sign.
Joking (kind of). (more…)
Quite the month for it, I hear. My inbox has run hot with practitioners deeply concerned about some serious finger pointing that’s been going on.
The fingers in these instances have belonged to medical practitioners and the direction they’re all pointing, is seemingly at any complementary medicine their shared patient is taking.
Here’s a couple of good examples: “Your high blood pressure is the result of the combined mineral formula you’re taking!” These were the words of a GP to a 50 something female patient when he discovered she was taking a calcium, magnesium, potassium containing formula. The patient was hypertensive at the initial appointment, at which time the naturopath encouraged her to actually seek review, assessment and prescription of an anti-hypertensive, however the patient declined. The nutritional prescription was recommended in response to high acidity (raised anion gap) and prematurely low GFR (impaired renal function). Patient’s HBP continued to be problematic so the next doctor she sees, points the finger and says, it must be this product!
Would anyone like to explain that to me? In fact, that was my advice back to this very concerned and understandably rattled practitioner…just to cordially request the GP to outline the mechanism by which this might occur. (more…)
“I always give some Glutamine to heal their leaky gut”
Cue pained expression on my face. No, I’m not a fan. I take that back, I have no problem with the amino acid itself and I’m still in awe of its incredible multifaceted role in the gut. What I do have a giant issue with is the mismatch between everything we are being told Glutamine is going to help our patients with, and the dosages that apparently will do that, and the reality. I know, I’m attacking the Holy Grail of Gut Health 101….right? But it’s time to set the record straight. Firstly, where’s the evidence at in terms of Glutamine interventions in GIT pathology, particularly in relation to reducing excessive intestinal permeability and improving lining integrity Well if you’re a rat – Good news! Rats’ GITs have a greater dependence on Glutamine than ours, a deficiency of this amino produces clear reproducible negative effects and supplementation fixes these brilliantly!
But if you’re treating humans not rats – well – the evidence & the case for Glutamine for the Gut is not so straight forward or impressive. (more…)
I promised I would keep all you fellow desk workers posted. Over 6 months has passed since I started standing for work….and I LOVE IT!
Here are the pros I can wax lyrically about so far:
- Back ache from long days at the computer, gone…seriously
- I am more energised about coming to work, starting work, staying at work…because I am not sitting! YAY! I move around…everyone I meet with on Skype will vouch for that!
- I am fitter & stronger as a result of standing for approx. 35hrs a week ( I know this because it took a while to develop this…after the first 2 slightly grueling weeks!)
- At the end of a long day/week, my mental fatigue and physical fatigue finally match – which means I am no longer brain-dead but in desperate need of a run around the block! The previous mismatch used to make winding down etc hard
- I get to actually walk my constant talk to patients about being active, avoiding sitting etc. Soooooo much better than sitting there for client after client and saying…’you know you really should move more!’
- And at the end of a big day…sitting never felt so good…it’s been restored as the luxury item it should be 😉
Here are the cons I can also attest to: (more…)
And then you don’t, right? Because if my experience is anything to go by, there are some patients that just don’t respond to the usual iron repletion strategies. Depending on how low their ferritin is, this can then precipitate ‘practitioner panic’ (we’ve all had it right?!) where we’re inclined to go higher & higher with the dose and number of doses per day. Typically, this also fails. I hear about this from other practitioners all the time and I see the ‘normal’ doses of iron sneaking up and up. Remember the days when we couldn’t get a non-pharmacy supplement with over 5mg elemental iron in it and now we have > 20mg? But still, I hear you say, this fades into insignificance when you think about the standard medical model for iron correction which provides 100-200mg/day and you’re right.
Gee… after hundreds of years of knowing about this deficiency and being the most common deficiency word-wide, you’d think we had our supplemental regime nailed.
But that’s where you’d be wrong. (more…)
May was the month of teenage girls presenting with severe digestive problems, especially ‘food intolerances’, leading to avoidance of specific foods and at times significantly reduced food intake overall. As integrative health practitioners, validating and creating insight for clients on the nature and source of their food reactions is our bread and butter, right? Is it wheat? Dairy? Gluten? FODMAPs? Salicylates? Oxalates? We are not surprised by how many ‘sick’ patients we see in spite of a theoretically ‘healthy diet’ – healthy for others perhaps but not for the individual in front of you, right? But what if I told you that each of these teenage girls had a BMI < 18 kg/m2, does that change your opinion about your role? Would you assess, monitor and manage these teenage girls differently? You should.
Take the example of one of my clients: 14yo female with a BMI 16.3, who had her first confirmed food reaction under 2yo with failure to thrive, which was attributed by a paediatrician & dietitian at the time to severe salicylate sensitivity. She underwent jejunal biopsy at 3yo for suspected coeliac disease, due to ongoing concerns and a primary relative with CD but it was NAD. In the 11 years since, there have been a couple of other digestive diagnoses based on solid evidence, such as mainstream stool PCR testing. So surely, the fact that she is underweight & that she skips lunch at school due to digestive discomfort is proportionate and explained by her organic digestive issues. Or is it? (more…)
Got any patients on Natural Thyroid Extracts (NTE)? Me too…and I am finding it’s on the increase. What’s the deal? What do we need to understand about this form of thyroid replacement therapy to best monitor and manage those patients already on it or contemplating taking it? Does it really offer advantages to all hypothyroid patients or just to a subset of those and how would we recognise these people who might benefit the most?
NTE are marketed as being superior to synthetic thyroxine primarily based on the fact that they provide the patient with some T3 as well as T4 and in addition to that, being extracts of pig thyroid glands, there are other thyroid and iodine based actives e.g. mono and diiodotyrosine, present in the extracts. So in essence this is giving us more iodine and more of the other ingredients we need to make our own thyroid hormones. Based on this, many proponents of NTE say this is a major advantage over synthetic thyroxine replacement because it is more ‘holistic’ and it supports the patient’s gland in its own hormonogenesis. (more…)
I just want to scream with joy…and then keep on screaming with utter frustration! Last week I presented the culmination of months of work looking into the extraordinary manifold relationships between thyroid health, fertility, pregnancy & post-partum health for mum and bub.
The findings are breathtaking: whether it’s about being able to put thyroid Abs firmly on the ‘Must Screen’ list for preconception care, given their ability to double-quadruple the rate of early miscarriage or their propensity for triggering post-partum thyroiditis in 50% of women who possess them or being able to state emphatically that maternal low iodine (prior to conception as well as during pregnancy) remains the number one risk for the thyroid’s healthy transition to pregnancy. The evidence is overwhelming that we need to pay very close attention to the thyroid. (more…)
This year has kicked off with lots of time spent re-calibrating my own and other practitioners’ businesses models via business mentoring and it’s such a privilege. One symptom that seems to creep into almost every practitioner’s business model though, is one of over-delivery. (Curse that empathy and all those good hearts hey!) Over-delivering comes in many forms, it might sound or look like this…
“I always run over”
Rather than responding to this with further self-criticism and , pledging better allegiance to the clock – we could hear this as a reflection that our appointment structure is out-dated or unsuitable. We need to restructure to allow for the time we really do spend and need to spend with our clients and then adjust the appointment fees appropriately. Having said that be aware of the other golden oldie: (more…)
Ask me to name a lymphatic herb other than Cleavers and Poke Root and I might struggle (sorry Sue!) but some other things stay with us forever. One of my stayers pops into my head every time I eat a carrot. Every time I make my partner or my kids eat a carrot. Every time I see those kids in shopping trolleys slurping on those awful yoghurt squeeze pouch thingamabobs and I want to ask their parents…does your child have teeth? Well when was the last time they ate a carrot?!. A whole carrot. Yup.
Remember to Chew. (more…)
Want to start 2017 with some good news? Sometimes working with patients challenged by mental health I get scared. A well-known colleague of mine introduced me to the notion of the ‘clinician in crisis’. The practitioner who, in the face of their patient’s extraordinary pain & distress feels overcome by the need to Do Something…Anything. Over time I have learned to spot, what we call a ‘desperation prescription’, the patient who is on 3+ psych medications all from different drug classes and still remains tragically symptomatic. It is potentially frightening stuff. I’ve had the same experience with patients using herbs and nutrients. The patient’s biological drivers may seem straight forward on paper, but they fail to respond as predicted. Nobody has a 100% success rate…not me, not Ben Lynch, not Kelly Brogan…as much as their marketing machines might make you think otherwise. (more…)
Often we assume our patients know at least the basics about health – especially about things soooo seemingly basic…that we fear mentioning them would offend and make us look like someone trying to teach grandma anything! But there are some instances where I’ve found I have simply assumed too much.
I think the issue of what I affectionately call ‘Vag Care’, is right up there as an example.
Soapy water? Female deodorisers, daily panty liners, re-enacting bad movie scenes with soapy suds sex…what the??? It’s been my astonishing discovery that women of all ages, but especially a frightening majority of younger females (<30 yo), in this time of increasingly unreal ideas about sex and sexuality, feel inclined or pressured to adopt these practices in order to erase all trace of natural odour and healthy discharge. The abnormal has become normalised. (more…)
Back a few weeks ago I had the pleasure of presenting at the Integria Symposium and the even greater pleasure of listening to some of the fabulous speakers …you see I’ve heard my stuff before! 😉 The ‘Mosaic of Autoimmunity’ was delivered by the very funny and knowledgeable Professor Yehuda Shoenfeld, who reiterated the sequence of events now well recognised to precede and precipitate autoimmunity: genetic susceptibility + endocrine context + environmental trigger –>autoimmunity.
Clinicians know that overwhelmingly women dominate when it comes to autoimmune disease epidemiology and most understand that this is a consequence of oestrogen’s immunostimulatory effects. Professor Shoenfeld, described the female, or E2 dominant, immune system as being ‘super charged’ and that increased rates of autoimmune diseases were a reflection of this. Sometimes practitioners do initially great work with a/immune clients – clearing up the diet & gut, ensuring vitamin D adequacy etc and then get ‘stuck’ or plateau with antibody levels that ‘won’t budge’. Going back and checking the hormonal contribution in the case is often indicated. If the patient has an unhealthy E2 dominance and /or impaired detoxification and clearance of this hormone then working on this aspect often kickstarts the next stage of improvement.
A new thing to me (I know I’m a bit slow sometimes 🙁 ) was his mention of the potential link also with high prolactin (PRL). The literature on this is extensive and hyperprolactinemia (HPRL), even just mild elevations, have been correlated with a very long list of both systemic and organ specific diseases including: (more…)
Most practitioners are pretty knowledgeable about Zinc and are quick to recognise a deficiency and the opportunities for zinc supplementation as an effective therapy and those same practitioners are often plagued by nagging questions that come up, in spite of loads of clinical experience, like:
- Are plasma and serum zinc levels interchangeable?
- What does zinc adequacy look like? Is it just a single number on a page or do we always have to factor in copper levels and get the ratio right as well?
- What can I expect from zinc supplementation in terms of changes to the patient’s plasma zinc?
- What should I do when a patient’s zinc marker is refractory to the intervention?
- Is there really a significant difference between the different supplemental forms available?
I became interested in working in mental health not entirely of my own free will. I guess you could say, it had made it’s way into my world via family members and friends as well as my own problems when I was younger. So when I was at uni and I came across any information about mental illness, whether it was pathology or prescription, it was when I undoubtedly resonated most strongly with what I was learning. I’ve had some great opportunities throughout my career to feed my interest, met some wonderful mentors and some other powerful teachers who were often my patients. It’s now become a running joke among my teenage children that all my friends are either psychologists or have some sort of mental health diagnosis, ‘…and what does that say about you?’ they love to add teasingly. Well it says a lot probably: that I enjoy people who are comfortable talking about the psychology of our lives and ourselves, that I deeply appreciate that to be human is to suffer and we all suffer it’s just a question of degrees and the bravest of us share that with others. Lastly, I think it tells you that I live in the real world with real people 🙂 (more…)
Fresh faced students, new graduates and seasoned practitioners alike, are forever reminding me of the challenge we experience as practitioners when it comes to instigating real change in our patients health related behaviours … the change we KNOW will make a difference to their health and wellbeing. ‘If only they actually listened to us!?!’ has been screamed by the novice and seasoned practitioner alike. With an overwhelming desire to share our wealth of knowledge, the discovery that information ≠ change can lead us to despair at times.
In a recent interview with Dr. Azita Moradi (Consultant Psychiatrist) as part of our Access the Experts webinar series, I was quite surprised (and pleased) to hear that Azita sometimes spends a whole session with a patient discussing the possibility of change, before even touching on the reality of change. Azita’s discussion surrounding the neuroscience of change and the challenges this may pose in the therapeutic relationship was fascinating, and certainly resonated with the practitioners taking part in the webinar. Azita’s interview was full of clinical gems reminding us that just as in other settings, if we give a man a fish he eats today but if we teach a man to fish we feed him for life. Hand and in hand with this, we need to have a strong understanding and appreciation of how to engage clients in making positive changes to their lives, often when it seems most difficult to do, such as in mental health patients.
Knowing how to improve behavioural change in patients generally, is integral to everyday practice, and its value cannot be underestimated. (more…)