I am a bit naïve. Yes, I am a psychiatrist, a Clinical Professor of Psychiatry, and the founder of the National Center for Whole Psychiatry. Given my experience, I should, you would think, know better. Yet I was in practice for probably 20 or more years before I realized that some times my patients lie to me about how they are doing, and whether they are following our jointly agreed upon recommendations. I am prompted to write about this, because a week ago I had an experience where a patient told me that she was lying to her other doctor.

Now, using the word ‘lying’ seems a bit strong, but I use it to get the point across. In fact, it is more like hiding the truth, not wanting to disappoint the doctor, avoiding shame, judgment, criticism, or the doctor’s expected anger.  Any reason that might inspire a child or adolescent to lie to their parent can probably be operative here because, understandably, being a patient is a vulnerable state for many.

My patient’s name is Joan.  Joan is a 58-year old married accountant who has, for the past 15 months, been having odd symptoms—feeling like the walls are closing in on her, feeling unsteady on her feet all the time, as if she just got off a boat, seeing faces “melting”. A thorough medical and psychiatric work has revealed some underlying hormonal, nutritional, and immunological dysfunctions, which are contributing to the symptoms.  As part of the medical work-up I referred her to a neurologist (Dr. Blandt), who prescribed a medication for Joan.  When I next met with Joan, I asked her if the medication worked and discovered her lie.  Our conversation went like this:

“Joan, what did Dr. Blandt say when you saw her last week?”

“ Well not that much, she had given me the Scopolamine, but I didn’t like it.”

“Did you tell her that?”

“Yes.”

“What did Dr. Blandt say?”

“She said I should try different drug.”

“How long did you take the Scopolamine for?”

“Not very long, I took it once or twice.”

“Did you tell Dr. Blandt that?”

“No.”

“Why not?”

“I didn’t want her to be upset with me.  I don’t want more drugs.”

“Joan, you have a right to not take a medicine, but you need to tell Dr. Blandt the whole truth and your concerns.  Dr. Blandt may well conclude that the Scopolamine didn’t help you, and so it’s not helpful for the type of symptoms you have and other patients like you have.  She will be less likely to prescribe it for other patients, based on the experience she believes you had.  Dr. Blandt’s ability to help people is somewhat diminished by such erroneous information.  When this happens enough a doctor’s ability to help their patients is compromised.  You need to be more direct.”

I explained to Joan how her inaccurate reporting to Dr. Blandt could easily effect her ability to get relief through proper diagnosis and treatment her problem.  A patient’s reaction to medication tells the physician something about the patient’s biology and clarifies the diagnosis.  

Inaccurate reporting leads to inaccurate treatment not just for you, but for others with similar conditions or symptoms. If you fear telling your doctor the whole truth when you are face to face, consider writing her a note before you see her telling the doctor ALL the facts of your situation – whatever they are.  You can certainly tell the doctor in the note that you have some fear or concern about telling him the whole truth. An understanding physician will appreciate your concerns and your honesty.

Antidepressants have a role in clinical practice but they are grossly over-utilized.  As a certified psychopharmacologist, practitioner of Whole Psychiatry (Functional Medicine and traditional psychiatry) and Clinical Professor of Psychiatry at Georgetown School of Medicine, I prescribe antidepressants, but  only after a thorough multi-faceted  evaluation of the patient.

We rely on drugs as a solution rather than deal with root causes of illness, and the pills generally are not as effective as we would be led to believe by the pharmaceutical companies (publically acknowledged as distorted in peer reviewed journals such as New England Journal of Medicine, Eric Turner, 2008). Nor are these drugs without financial costs and side effects.  I suggest that the solution is to develop better assessments of the metabolic factors leading to the syndrome of depression. The psycho-social-spiritual risk factors are reasonably well spelled out, and we have excellent targeted psychotherapeutic techniques available now.

The fact that the head and brain are connected to the body by something called the neck may be relevant.  In fact, there is a great deal of basic science and a good deal of clinical science indicating the very significant role played in subjective and objective mental health by at least six metabolic systems: nutrition, gastrointestinal physiology, immune/inflammatory/infectious processes, methylation processes, oxidative stress, and all hormonal systems.  This list excludes other factors such as circulatory problems, physical-structural problems, age, gender, and lifestyle factors.

Assessing these metabolic systems, and their mediators in a careful comprehensive manner, and re-establishing multi-system reserves not only helps depression with less medication, but at the same time reduces the side effect burden imposed by medication, and reduces the incidence of known co-morbidities such as diabetes, cardiovascular disease, osteoporosis, sexual dysfunction.  Psychopharmacology is only one small tool in our toolbox.  As Confucius once said, “To do good work, one must first have good tools.”  Anti-depressants are somewhat useful tools; they are just not the best or the only ones.  We have other tools at our disposal.  Why not use them?

Vitamin B12 deficiency and its detection have been in the news lately from the New York Times and The Dr. Oz Show.

B12 Deficiency Effects Widespread
The effects of vitamin B12 deficiency are widespread.  Vitamin B12 has a major influence on the function of neurons and also on the ability of the bone marrow to make red blood cells.

B12 Causes Psychiatric Symptoms
B12 deficiency can cause almost any psychiatric symptom—from anxiety, and panic to depression and hallucinations.  This is because B12 deficiencies trigger symptoms in the nervous system and red blood cells.

Diagnosing B12 Deficiency
While it is not possible to go into the details of the diagnosis and how to interpret these tests, it is important to understand that assessing vitamin B status involves understanding A DYNAMIC (moving & interacting changes in these parameters) not static assessment of the metabolic systems involved.  And because it is a dynamic system, a static measurement (e.g., B12 level) does not suffice.

As an example of the interactive dynamics, a low iron level makes red blood cells smaller; and, low vitamin B12 makes red blood cells larger. Thus, normal red blood cell size can present a false normal because low iron and low b12 counterbalance each other. If one assesses the size of the red blood cells alone once would miss this fact. However if one also looks at the iron and homocysteine, one would not miss it.  Similarly, a homocysteine level is the result of B12, folate, and mercury levels and therefore a normal homocysteine does not necessarily mean an absence of of B12 or folic acid deficiency.  In turn, all must be assessed to understand the homocysteine.

Early Detection Is Critical
It is critical that a vitamin B12 deficiency be detected as early as possible in order to prevent permanent damage to the nervous system.

The Best Way to Assess for B12 Deficiency
Unfortunately a simple B12 blood level is NOT a sensitive test for detection of B12 deficiency.  A variety of studies have shown that a simple B12 blood level misses vitamin B12 deficiency over 80% of time.  There is no one perfect test for the diagnosis of vitamin B12 deficiency.  Therefore, to determine a vitamin B12 deficiency a thorough assessment involves the following tests and other factors:

Tests

1.    Homocysteine level

2.    Red blood cell count

3.    MCV which (mean corpuscular volume)

4.    Iron & ferritin

5.   MTHFR - a genetic test

Other Factors

1.         One’s age and dietary history (the elderly and vegetarians most often have B 12 deficiencies)

2.        Medications used (people on Glucophage/Metformin, and proton pump inhibitors are often deficient)  

3.        Findings from a physical examination

(Methylmalonic acid testing is commonly thought to be useful, however a little known fact is that less than 20% of the variation in the blood or urine level is accounted for by B12 metabolism, so this test is not useful.)

If you think you have a B12 deficiency, get yourself assessed and treated right away.