Mental illness is not ‘all in the mind’

Psychiatry is a profession supposedly there to help people with mental health issues such as anxiety, depression and schizophrenia. That’s the idea anyway. I say this because, in reality, it’s not the most effective of disciplines, I think. The drugs often don’t work too well, and usually come with significant side effects too. If I had my time again, there’s no way in the world I would choose to be a conventionally practising psychiatrist.

In my view, one of the major deficiencies of psychiatry is how it views almost all mental illness as a problem which originates in the brain. The psychiatric model of illness is generally based on the idea that brain function goes awry when brain chemicals (neurochemicals) become imbalanced. For example, depression is seen very often as a result of not having enough serotonin. So, drugs that elevate levels of serotonin then become the mainstay treatment for this condition.

Over the years, though, I’ve seen quite a lot of people in practice who seem to have or have been formally diagnosed with some form of mental illness, who actually turn out to have their problem rooted in issues that fall, strictly speaking, outside the brain. Here are a few examples:

1. people with mood swings caused by fluctuation in blood sugar levels

2. people with depression who have low thyroid function

3. people with low mood who have iron deficiency and/or anaemia

4. people with low mood/depression who have weakened adrenal gland function

5. people who have low mood/depression as a result of food sensitivity issues (often wheat, by the way)

6. people who have the symptoms of bulimia nervosa (binging and purging) as a result of blood sugar fluctuation

7. people who have anxiety/depression as a result of a deficiency in omega-3 fats

8. people who have anxiety/insomnia as a result of low levels of magnesium

The important thing is that when the underlying nature of these issues are rectified, the mental state of individuals usually takes on a completely different complexion.

Most psychiatrists, I think it’s fair to say, will generally not entertain such thoughts. This is, to a large part I think, a product of their schooling. If every psychiatric journal and psychiatry conference bangs on about the neurochemical basis of mental illness, it’s perhaps no surprise that many psychiatrists will not have a mind to look further and deeper than this. However, not all psychiatrists are of this persuasion, it seems.

I was very interested this week to come across this article on line in the Wall Street Journal. The article is about the book Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders by US psychiatrist Barbara Schildkrout. The book’s not out yet, so I haven’t read it. But even without the detail, I wholeheartedly support the sentiment of the book. It’s essentially urging psychological therapists to be alive to the fact that their patients may have mental symptoms as a result of pathology the origin of which is not the brain, but the body. Should be compulsory reading, I think, for all psychiatrists keen to do the best for their patients.

27 Responses to Mental illness is not ‘all in the mind’

  1. Margaret Wilde 11 August 2011 at 10:28 pm #

    I like the approach of the (anti-)psychiatrist, Thomas Szasz, too. I’ve read most of his excellent books. My reading of his work is that people need help with their problems, not drugs to interfere with their brains. So they might for instance, like to try a different way of behaving in certain situations, or adopt a different way of thinking about things: different strategies in their social interactions. I found his books terrifically helpful.

    Raj Persaud’s books are also very practical and helpful and not drug-oriented. It’s a shame he indulged in plagiarism. I like to think it was because he was so popular and over-stretched with TV, radio, book-writing, articles, etc as well as his day job, that he strayed into copying stuff without attribution, and not that he really intended to plagiarise.

  2. Margaret Wilde 11 August 2011 at 11:04 pm #

    P.S. I should have added that Raj Persaud’s practical advice helped me in particular to deal with profound bereavement wretchedness after the death of a much-loved close relative.

  3. David 12 August 2011 at 2:01 am #

    Dr. Emily Deans (US based psychiatrist) has a blog dedicated to “evolutionary solutions to the general and mental health problems of the 21st century.” http://evolutionarypsychiatry.blogspot.com/

  4. sam 12 August 2011 at 2:46 pm #

    Dr Briffa,

    This is an excellent post!

    Although I’m sure diet didn’t play a role in the devolpment of my eating disorder. I’m quite sure that it played a major role in the progression of it.

    I have always felt depressed, anxious and trapped throughout the years, at times it has been unbearable.

    I’ve been through times of eating large amounts of dairy products, cereals and beans/pulses.

    Now in the past few months, my diet has consisted of tubers, non/starchy vegetables and fruits ( with fruit being the main article.

    My mental clarity has improved beyound recognition, it sounds cheesey, but it’s like a miracle.

    I am maintaining my weight at a BMI of around 15-16 without downfalls, and I feel like I am on a new path.

    It really is amazing, the role that diet plays in our mental health

  5. jgkarob 12 August 2011 at 2:47 pm #

    I have first-hand experience of misdiagnosis. My husband had delusions, paranoia and panic and was of course, diagnosed with depression.
    None of the anti-depressants worked and one (Venlafaxine) almost killed him, as it built up in his liver.
    Last year, after a strange attack of bad temper, he had what appeared to be a stroke.
    After a few examinations, they gave him a cat scan and he has a very large arachnoid cyst in his left frontal lobe.
    If someone had only done this 8 years earlier, we could have learned to live with this. We have though, learned to manage the escalation of stress symptoms that come from this cyst.

    I’d like to meet the makers of Venlafaxine and kick them very hard. He came within days of death or liver failure and even now, is accused of alcoholism. His liver will never be quite as good as before and tt is a terrible and dangerous drug.

    The ‘stroke’ may have been a TIA. btw. After an MRI, they discovered aplasia in one of his carotid arteries. Suffice to say, he has to lead a very quiet life now.

  6. Sharon 12 August 2011 at 3:05 pm #

    I can relate so many of the above points to my clients that I have been Personal Training over the past 7 years.

  7. Tom McAnea 12 August 2011 at 3:39 pm #

    Dr Briffa,

    To be fair, in General Practice, I would routinely screen patients presenting with mood disorder for many of the physical causes you identify above, as well as B12 and folate levels. I recall from my job as a junior doctor in psychiatry that patients would usually have a standard blood screen too.

    Your description of the model of psychiatric illness is an accurate one. However, in GP-land we try to think fairly holistically.

    Thanks for the interesting post,

    Tom

  8. Tom McAnea 12 August 2011 at 3:45 pm #

    In response to some of the contributions above, there are alternatives to traditional psychiatric medication, and indeed these are often the most appropriate choice. Counselling, cognitive behavioural therapy and psychotherapy all have a place in treating mood disorder. However, sometimes medication is appropriate too (once the physcial causes are excluded) and can make an enormous difference to a person’s symptoms. The key is to tailor the management plan to the individual.

  9. John Briffa 12 August 2011 at 3:47 pm #

    Tom

    I take your point.

    As I’m sure you’re aware, generally speaking, general practitioners do not enjoy the level of kudos afforded to specialists. My own view, for what it’s worth, is that good ‘generalists’ are worth their weight in gold, precisely because they tend to take a wider view.

  10. Trish Cherry 12 August 2011 at 6:45 pm #

    I believe they may be on to a good thing. For myself since I found an intolerance to wheat and dairy foods, and stopped eating them I find I do not have the anxiety and depression that I once suffered. However time will tell.

  11. Jennifer Eloff 12 August 2011 at 7:04 pm #

    Very interesting post. I was fascinated – also by the comments. Sometimes depression has an outside of the body (circumstances) cause – and then the person feels hopeless and helpless to change the situation. In this case, I have a hard time believing it is blood sugar or anything else that caused depression in the first place. Maybe as a consequence of going into depression, those things go awry as well.

    Low thyroid definitely causes depression. An allergy to wheat – I can see that. Blood sugar swings play havoc with moods. Yep, I can see all of those points you mentioned as well – definitely!

    I just think that sometimes it does begin in the head too – something happens and the person very quickly slips into a helpless and hopeless sort of pattern of thinking and the next minute there is a chemical imbalance in the brain possibly. It could be a loved one becomes ill or a loved one dies or a loved one who is supposed to love one does something so wicked that it messes with one’s mind – anything that will make the person feel so out of control and not able to “fix” things can make that person mentally ill.

  12. Heather 12 August 2011 at 8:04 pm #

    A lovely gentle man we know was brought into our local psychiatric hospital who could not stop weeping. He was a seaman and had been taken off his ship in a German port in a straitjacket as he had gone beserk and tried to attack his crewmates with a knife.
    This was totally out of character. Tests found nothing wrong with him and he had no recollection of the event.
    His wife volunteered that he had once, when they were away on holiday, suddenly risen from their breakfast table in a hotel and accused his fellow guests of staring at him and wanting to kill him.
    A very patient and consciencious doctor probed his history and one or two other random events in his life and started to build up a picture.
    Long story short, he had a severe allergy to citrus fruits,particularly grapefruit. In the hotel, he had had a glass of grapefruit juice from the buffet. The ship he had been crewing on when he went beserk, was carrying a cargo of citrus fruit.
    Meanwhile, he had been on a whole cocktail of mind-altering drugs.Thank goodness he was spared a lifetime of their use.
    I myself have profound mood swings, itching all over and mental fogging if I eat anything containing corn or yeast.

  13. mitchO 12 August 2011 at 8:49 pm #

    This is an excellent post!
    It is not about good or bad individuals. It is about a system that does not car about the law, human rights, civil rights, or informed consent. That is “institution, not individual” you not. Those who believe it is a good profession are deluded themselves. If you believe in the constitution and the rule of law and due process Psychiatry simply doesn’t agree with that because it cannot justify itself doing anything according to those things. Dr. Breggin an international authority in psychiatric medicine say “‘Psychiatric drugs achieve their primary or essential effect by causing brain dysfunction and they tend to do far more harm than good. ‘Psychiatric drugs are not specific treatment for any particular mental disorder. ”

    My son have jury trial on August 15, 11 at 8: 30 am. My son has refused to take psychotropic drugs, and he would like to obtain an alternative method of coping with his medical condition; he would like to have therapy instead. Unfortunately, Dr. Alejandro Zapata doesn’t consider such option. He said, “ I will force you to take the psychotropic drug against your will”. Dr. Zapata refuses to communicate with us regarding my son and he does not inform Alex on his matters as well. He is disrespectful when talking to our son. We believe that Dr. Alejandro Zapata – Received money from drug companies as AstraZeneca. Here more info about it: http://projects.propublica.org/docdollars/search?term=Alejandro+Zapata&stateid=

  14. Nate England 12 August 2011 at 9:35 pm #

    Excellent post and comments. However, I’m surprised that no one mentioned Dr. Natasha Campbell-McBride, who I believe is a Brit. She wrote the excellent book the GAPS Diet, Gut and Psycolical Syndrome Diet. Her hypothesis is that there is group of mental disorders that have their basis on a damaged gut (stomach, intestines, etc.). Just like the metabolic syndrome, the GAP Syndrome has a cluster of diseases that are found in various combination in the same patient. Thus, the root cause of these various diseases for both the metabolic and GAP syndrome is the same – carbohydrates.

  15. Radiant Lux 13 August 2011 at 12:42 am #

    Dr. Julia Ross has two books in this vein: The Mood Cure and The Diet Cure. She has been working with former drug and alcohol addicts to help them become healthy. She uses amino acids, vitamins and low-glycemic diet. Each book has a questionaire to help you identify which supplements would be helpful for you. I was already eating a low-glycemic diet but I was frequently thrown off track by carb cravings. All I changed was taking L-Glutamine between meals. It took a while, but I no longer get carb cravings. I don’t need it every day now but I keep it around for whenever I hear the little voice suggesting chips or sweets. That little voice is really the body/brain needing a boost that amino acids can provide.

  16. Jacquie 13 August 2011 at 12:58 am #

    This post is a bit disingenuous. I agree that there is a need to improve training for docs, including psychiatrists, but to suggest that this is the norm is hardly accurate. In my practice it’s common to order what’s considered a full physical workup, but less common issues like magnesium and zinc deficiencies are often not covered well. That’s an education issue for all practising psychiatrists re keeping up to date with the research.

  17. Emily Deans MD 13 August 2011 at 1:22 am #

    I am a board certified psychiatrist – our very first job is to rule out medical causes. I have to say I have caught low B12, anemia, a brain tumor, and hyperparathyroidism in recent years – psychiatrists in general are acutely aware that the symptoms of depression, anxiety, and psychosis etc. are too often shunted off to the land of “it’s all in your head” without a proper work-up. Standard of care is a proper medical work-up.

  18. Carol A. Franks 13 August 2011 at 9:21 pm #

    I nearly died as a result of a GP wrongly diagnosing depression and giving me antidepressants when I knew I was seriously ill. I had been given two courses of a strong broad spectrum antibiotic in hospital plus further courses for six weeks on discharge for a suspected infection when it was actually pieces of the internal dressing pack mesh stuck to my insides all that time.

    Yes, I was depressed, but merely because I was seriously ill and not getting any better!

    Luckily, I had the intuition to stop taking the antidepressants and seeing the recommended counsellor to seek the right help, which actually came via complementary practitioners who were both conventionally and alternatively trained and knew of the long-term dangers of antibiotics.

    I had told the GP that I felt something was seriously physically wrong with my gut and digestion and I had so many allergies, but she just didn’t believe me until I had lost nearly all my hair and my weight was plummeting.
    By that time, seeing a gastroenterologist was useless as I was too ill for any more conventional treatment, verified by another GP that I saw when mine resigned.
    Gastroenterologists know little of the damage of antibiotics in my experience, although things may have changed now as this was ten years ago, but my
    problem was so serious that probiotics were not a quick answer.

    Any advances in understanding how physical ill health can lead to long-term depression/mental health problems certainly has my full support.

  19. Jacquie Broadway 14 August 2011 at 12:21 am #

    Every one should read ‘Not all in the mind’. I suffer from multiple allergies, and when diagnosed I was told to read this book. I am acutely sensitive to mould spores and for years felt miserable in August. The Aerobiology Unit at Worcester University have just issued a warning of very high concentrations at the moment. If it were not for the help I receive from the private sector and in particular, The Burghwood Clinic in the form of vaccine treatment, I too would have been wrongly diagnosed and wrongly treated.

  20. Millie from APRIL charity 15 August 2011 at 6:57 pm #

    Well done Dr Briffa, for highlighting the failure of mental health professionals, as in many cases reported to APRIL, to look further than which drug to prescribe.

    Following my daughter Karen’s death it was found she had auto-immune thyroid disease. We wont ever know if this was prior to the serious psychiatric adverse reactions (ADRs) to everyday medicines, she suffered, or a result of being prescribed psychiatric drugs to treat the ADRs.

    Furthermore, when psychotropic drugs are prescribed, which may help acute crisis, the family is rarely warned of the dependency issues and serious problems that often occur when trying to withdraw from antidepressants, tranquillisers and anti-psychotic drugs.

    I would like to place your posting on the web site http://www.april.org.uk to create awareness. Awareness saves lives and it is up to patients and their families to ask for the tests, question diagnosis and to investigate the possibility of adverse reactions when personality changes occur.

    Millie Kieve APRIL (Adverse Psychiatric Reactions Information Link) http://www.april.org.uk

  21. cheryl j 17 August 2011 at 3:35 am #

    I have found the same things as you in my Hospice practice. the geropsyc is even more stuck in the mind, even when it should be obvious that old bodies are not working as well as they should. keep up the good work informing us of the other side of medical practice. Thanks

  22. Micki 19 August 2011 at 12:32 am #

    Great post. My first ever patient well over a decade ago now taught me to look at wheat,dairy and gluten sensitivity for depression. Not feeling very confident I could help, I did the usual naturopathic medical approach of removing primary allergens and giving gut, liver ad nutritional support.

    Neither of us could believe the difference in her within 3 short weeks. I have never forgotten that and have seen intolerance at the heart of many anxious and depressed patients many many times since. Always worth looking at.

    The body will always heal more effectively if you take physiological as well as psychological stressors off the body in my opinion.

  23. Ani 19 August 2011 at 5:31 pm #

    A professor that lectured me during my MSc (Nutritional Medicine) course back in 2001, Professor Basant Puri wrote a fabulous book that was published in 2005 entitled “The natural way to beat depression: the groundbreaking discovery of EPA to successfully conquer depression” it details how the long chain omega 3 fatty acid, EPA can be used, in conjunction with other therapeutic techniques, to successfully treat depression. At the time of publication Professor Puri had a 100% success rate of treating individuals with depression who had been unresponsive to other treatment. An amazing statistic. He has also written about the usefulness of omega 3 fats in the treatment of ADHD and chronic fatigue syndrome and was the first recorded person to use omega 3 fats to treat a depressive patient.

    There is so much evidence for the use of nutrition and nutritional supplements in the treatment of mental health and mood related disorders. Nutrition within a truly integral framework for health is something I would love to see. It would be tremendous to see nutritional approaches being used as a mainstream treatment by doctors and psychiatrists. A fabulous paper by Lakhan SE & Vieira KF 2008(1) concludes that:
    “ Nutritional therapies have now become a long-forgotten method of treatment, because they were of no interest to pharmaceutical companies that could not patent or own them. Instead, the companies that funded most clinical research spent their dollars investigating synthetic drugs they could patent and sell; these drugs however usually caused adverse side effects. There is tremendous resistance to using supplements as treatments from clinicians, mostly due to their lack of knowledge on the subject. Others rather use prescription drugs that the drug companies and the FDA researches, monitors and recalls if necessary. However, for some patients, prescription drugs do not have the efficacy of nutritional supplements and they sometimes have far more dangerous side effects. So for clinicians to avoid these supplement therapies because of a lack of knowledge and unwillingness to use treatments not backed by drug companies and the FDA, they are compromising their patients’ recovery due to their own laziness or selfishness”.
    “Psychiatrists treating patients with mental disorders should be aware of available nutritional therapies, appropriate doses, and possible side effects in order to provide alternative and complementary treatments for their patients. This may reduce the number of noncompliant patients suffering from mental disorders that choose not to take their prescribed medications. As with any form of treatment, nutritional therapy should be supervised and doses should be adjusted as necessary to achieve optimal results.”

    It was when we first worked together John, back in 2001/2002, that I first became enthralled with nutrition for the brain. Since then I have kept involved with the topic and it continues to fascinate me.

    (1)Lakhan SE & Vieira KF. 2008. Nutritional therapies for mental disorders. Nutr J. January 21:7:2

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