Depression, anxiety, and mood disorders with psychiatrist Dr. Kelly Brogan. We detail very important information regarding anti-depressant medications, what common causes of depression and anxiety are, and cover highlights from Dr. Brogan’s new book.
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Dr. Kelly Brogan MD Bio….. 2:35
Antidepressant Medications and the Placebo Effect….. 6:00
Risks and Side Effects of Antidepressant Medications….. 15:48
Problems Discontinuing Antidepressant Medications….. 22:44
Treating the Cause of Depression or Anxiety….. 26:22
Lifestyle Factors and Treating Depression….. 36:17
Other Diagnostic Areas to Look at in Treating Depression….. 40:16
Dr. Kelly Brogan’s Book “A Mind of Your Own”….. 45:23
Neurotransmitter Testing….. 47:41
Dr. Brogan’s Least Healthy but Most Fun Thing….. 52:43
- A Mind of Your Own
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Dr. Kelly Brogan MD Discusses Depression and Her New Book
Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I am here with Dr. Kelly Brogan who has just written a pretty fantastic book on depression. And I’m excited to have her expand upon that. Kelly, hi. Welcome to the show, and thanks for being here.
Dr. Kelly Brogan: Awesome to be here.
DrMR: You and I first met a couple years ago. It was, I believe, the 2014 AHS in Berkley, right?
DrKB: That’s right. That’s right. I still have memories of way too long a conversation happening standing in some kitchen. What was it called?
DrMR: Yeah. It was that Mission Heirloom.
DrKB: Yeah. Yeah, it was good. We’re very much on the same page, so it was a great opportunity.
DrMR: And we’ve stayed in touch ever since then. And by the way, are you going to AHS this year in Colorado?
DrKB: You know what? I am not. I’ve had to start to make very selective travel plans. But I think Burning Man is going to win out this year in my priority scheme.
DrMR: Well, it’s all about life balance, right?
DrMR: And as you said, you’ve had to make some choices about “I can do this, I can’t do that” because you’ve been really busy with this new book that you’ve written which is now on—is it on the New York Times bestseller list? Or was it the Amazon bestseller?
DrKB: It actually did. It hit the first week after publication—hit the New York Times bestseller list. Amazing.
DrMR: That’s awesome.
DrKB: Yeah, I know. It’s crazy to me.
DrMR: It makes sense though because you’ve written a book on depression. And I don’t feel like there are a lot of great books out there on depression. I could be wrong, but I don’t see a whole lot coming through on depression. So I think there was definitely a void there that needed to be filled. And you definitely stepped in, it sounds like, and filled that void.
Dr. Kelly Brogan, MD, Bio
Before we jump into this topic—which there are a thousand directions that we can go—and I want to get tangled in all these tangents in a second—can you tell people about your training, your background, briefly?
DrKB: Yes. It’s worth mentioning I come from a totally conventional family. No new agers in my midst. And I went to MIT. I studied neuroscience there. And while I was there, I actually worked a suicide hotline and was supervised by—suicide’s actually a big issue at MIT, unfortunately. And I was supervised by a psychiatrist there.
So it was something about the complement of my academic studies there in neuroscience and being supervised by this clinician essentially that created this sense within me that we had cracked the code on human behavior. So I wanted to head to medical school so that I could alleviate human suffering. And that’s why I became a psychiatrist.
And so it really wasn’t until my further specialization and my fellowship in reproductive psychiatry, which means basically that I was trying to master the art of writing prescriptions for pregnant and breastfeeding women, believe it or not, that I began to take a bit of a left turn. And it started because of small voices inside me. I was pregnant at the time. And I remember writing a prescription for Zoloft for a pregnant patient of mine.
And I remember this small voice inside saying, “I would never want to take this medication as a pregnant woman” and sort of dismissing that and thinking, “Well, there are 25,000 cases in literature. And there is no evidence of birth defects. So what’s the concern?” And I just totally ignored it.
And so it wasn’t until I developed Hashimoto’s autoimmune hypothyroidism, as your audience well knows, in my ninth-month postpartum that that same voice came up. And I essentially felt strongly like, “I don’t want to take a prescription for the rest—I’m going to take Synthroid for the rest of my life? There’s got to be a way out.”
And so strangely, I had the inclination to see a naturopath because I knew that conventional medicine had nothing to offer me but a lifelong prescription. And I was desperate to sort of eek my way out of my first diagnosis. And so it was through that process that I began to raise some red flags around things that I hadn’t been told in my conventional training, like “You can put chronic disease into remission,” like “Nutrition actually matter,” and like “Some prescription options can actually interfere with the process of healing.”
Everyone has their personal entry point. That was mine. And I began to turn over pretty much all the stones because I have a very naturally skeptical mind. And this really fired it up where I began to question pretty much everything from psychiatric medications to birth control to antibiotics to vaccines to you name it.
I left no stone unturned. And I wanted to know everything that I didn’t learn about in medical school in terms of non-industry-funded literature. And that’s when I began to think differently about not only my own health but my patients’. And of course, then I had two kids to care for. So it helped that I had a new thinking hat on for them, as well.
Antidepressant Medications and the Placebo Effect
DrMR: Now, when we talk about the issue of depression, there are a lot of different things we can talk about. One that maybe we can start with and then work our way down from there would be the anti-depressant medications—SSRIs, SNRIs, what have you.
I know that there was a study published a few years back. I think it was actually in the New England Journal of Medicine. It was a systematic review that essentially showed—again, for the audience, very high-level science—that essentially showed that anti-depressants, anti-anxiety medications, only had a benefit for people that were classified as severely depressed, which essentially comes down to, you are literally bed-ridden with depression, your depression is that bad. For patients that have mild, moderate depression, which is going to be the majority, there was no difference over a placebo. And that was a very cathartic paper.
And there was another paper published around the same time. It may have been a Cochrane review—we reviewed both these in our newsletter awhile back—that showed that many of the “successful” trials using the anti-depressants have been shown to have a very risk of bias. So there has definitely been some high-level scientific criticism of the efficacy of anti-depressants. And I’m sure you probably agree with that. But would you like to add anything to that, because I’m sure you’ve dug into the details way more than I have?
DrKB: So it’s been the most shocking series of revelations I could possibly have ordered up for myself. So I have deep empathy for anyone who is exposed to this information and feels immediately a knee-jerk reflex to reject it, especially if you’re listening and you’re taking medication and you feel even that medication has helped you. What we are talking about feels very provocative. And so I can deeply empathize, because it took me a long time to be able to even accept that this literature was out there.
But essentially, the truth of the matter is, there’s a lot more to the story than we are led to believe. We are led to believe essentially that you’re probably born with depression. It’s probably genetic in nature. It manifests as a chemical imbalance, probably, maybe a low serotonin state. And then you’re going to need chemicals to manage it for the rest of your life. So this is sort of the myth. It’s called the serotonin myth by some.
And what is compelling is that when you listen to some of the particularly psychiatrists like Joanna Moncrieff or David Healy and psychologist Irving Kirsch who have been delving into this arena for a decade. What they have to say is these medications don’t work. They’re quite dangerous. And in fact, they are in no way the magic pill that you think they are.
So when it comes to their efficacy—so we sort of think it’s irresponsible not to do something about your depression. You might have friends or family members that tell you, “You should really think about medication for what you’re going through.” And then they would potentially judge you for not getting on that medication. Well, the implication is that this medication is helpful.
So the person who did the most compelling work on that was this guy, Irving Kirsch. He’s arguably the world’s placebo-effect expert. And what he found through a series of meta-analyses, including the unearthing of unpublished literature—so psychiatry has a very dirty practice of hiding all of the literature outcomes that don’t conform to the pharmaceutical industry’s expectations. They just literally put them in a locked file drawer. And that’s permitted by the FDA.
So he, through the Freedom of Information Act, really included a broad swath of data. And what he found was not only did more studies demonstrate that anti-depressants were outpaced by placebo—so more than half of the studies he found, when you include them all, actually showed that placebo was more effective than anti-depressants.
But in the ones that showed that anti-depressants were more effective, if you control for something called the “active placebo effect” which I’ll explain, then the efficacy diminishes to something totally clinically insignificant. And for these very, very severe cases, he said it was like an infinitesimal, irrelevance, how many cases we’re actually talking about in that 10% realm of severe, major depression that actually showed some degree of efficacy.
So the active placebo effect is a really interesting concept because we think of the placebo effect as being this sort of nuisance we have to get rid of and control for so that we can really see what science has to show us. But in fact, what we’re learning, really across disciplines in medicine from surgery to anesthesia to psychiatry—we’re learning that the placebo effect may be the single most powerful driver of what we are calling intervention benefit. And the placebo effect itself we’re just beginning to understand. But it’s obviously much more than we think it is, which is just fooling the patient. It’s actually a very complex biochemical process that we think has something to do with the opiate system, actually. Certain patients are more susceptible to it. That’s a reality. But it’s a very real, physiologic occurrence.
So what he found was that when patients begin to feel side effects in a trial, they tell themselves, in their minds, “Oh, I’m in the treatment arm. I’m actually going to get better. And all of my chemical imbalances are being addressed.” And they actually do start to get better. But if you compare them to patients getting a medication that has the same kinds of side effects like atropine for example—and that was a Cochrane review—that there’s absolutely no difference between the anti-depressant arm and the active placebo arm. So the suggestion is that it’s actually the side effects which unblind the study and lead patients to experience this cascade of beliefs and associated physiologic changes that account for their experience of healing.
One of the most interesting studies, just briefly, was one that actually took patients who were treated to remission on Prozac. And so these are the patients who would stand up in an audience I’m lecturing and say, “I don’t care what you say. Prozac saved my life.” And so they’re treated to remission on Prozac. And they’re told that they’re going to be randomized to either a sugar pill or continued on their very same dose of Prozac. And what happens is that randomization, both groups actually became depressed. Like Mary taking 40 mg on Tuesday takes 40 mg in the trial on Thursday, and she becomes acutely depressed even though she’s still taking her same dose of Prozac. And of course, this reveals the role of what’s called expectancy in psychiatry, which is your belief around what’s happening actually is more powerful than what’s happening.
So it’s also, in many ways, you can address it with common sense alone because we have medications like Stablon, which is a serotonin reuptake enhancer, labeled as anti-depressants. We have Prozac, a serotonin reuptake inhibitor—literally the opposite mechanism—also approved. We have Wellbutrin, for example, which doesn’t act directly on serotonin at all, approved for depression. And they have comparable efficacy, which is in the 30% range, to things like thyroid hormone and beta-blockers and benzodiazepines. So it seems like there is something driving some relief from depression which has very little to do with the specific mechanisms of anti-depressant medications. And so you might say, “I don’t know. Even if they work a little bit, we might as well use them.” And that’s where some of my really grave concerns come in, which is essentially around the untold story of the risks of these medications.
DrMR: Yes. And that was the next question I wanted to ask you, which was essentially—okay, if we have something that may induce most of its benefit through a placebo, the next question I ask in my mind logically is what are the risks? And usually, there are one or two risk categories that I think about. Of course, the negative side effect for the person taking the medication from a physiological perspective. Can it do them physical harm? The other would be cost. And this is one that I sometimes criticize with excessive treatment and testing in functional medicine.
DrMR: Albeit being natural, if you cause a cost burden to the patient, then that’s also something that can be detrimental because there are some patients that really get floored financially from a functional medicine doctor’s bill.
DrMR: So it’s something that I think we have to be cognizant of.
DrMR: So I definitely want to expand on the side effects in just one second. But I just want to quickly echo your statements on placebo. In some of the research we’ve been doing for the book on gluten enzymes and on other trials in IBS, there have been a few—there was one review notably that showed that up to 75% of effect, of positive symptomatic reduction in IBS trials can be attributable to placebo. And they average—and this is in randomized clinical trials. This is not Mary Sue who goes to her doctor for medication expecting a result. There was an average of 45% placebo shown across randomized, control trials—
DrMR: Where placebo is supposed to be designed out.
Risks and Side Effects of Antidepressant Medications
DrMR: So we can infer that it’s probably going to be much higher without that type of control. So definitely, the placebo is something legitimate. If the placebo is something safe that can help someone, I’m open to it. But why don’t you elaborate on some of the negative side effects that need to be counterbalanced with the potential upside from the placebo?
DrKB: Right. Exactly. I love that. And I think there’s more and more literature coming out to substantiate this and validate this perspective that patients’ beliefs around their treatment—because you and I probably have both had patients who fundamentally were at odds with natural healing in their belief system. And guess what? You can do all the fancy functional medicine testing and provide them all the best guidance. And they still are not going to get better. So I’ve actually come to appreciate beliefs in my work with my now-late mentor, Nick Gonzalez, only helped to reconfirm my instinct that your beliefs about your body’s ability to heal, your beliefs about what medication’s role is in your life are some of the most critical factors in your healing of all.
So with that said, I would say that there are probably three major pillars to considerations around anti-depressant risks and dangers. And the first one is a bit abstract because it really invokes the message that I’m working very hard to drive home, which is that depression is not a thing.
DrKB: Meaning it’s not a disease in the way we have been told it is. It is not a discrete illness. And it’s really nothing more than an indication of bodily imbalance. So you just look at the comorbidity with all of these other diseases, whether it’s autoimmunity or cardiovascular disease or cancer, liver disease. And depression is comorbid with all of these things not because it’s another diagnosis that you have but because it is a meta-manifestation of the body’s imbalance. So I’ve said that you wouldn’t want to treat low thyroid function with Zoloft. That just doesn’t make any sense, right?
DrKB: Would you want to treat blood sugar imbalance with Prozac? Or would you want to treat gluten intolerance with Effexor? Or what if you’re on birth control? Do you really want to treat the side effects of birth control with Cymbalta? So it’s really a lost opportunity to identify a reversible cause of what is being called depression if you mask over it with the available medication. None of which, by the way, are a quick fix. If they’re a fix at all, it’s not a quick one because any prescribing psychiatrist will tell you it takes six to eight weeks for any sort of medication effect. So again, we’re not talking about correction or healing or anything like that. It’s a chemical effect, some of which—like sedation—or some of which you may actually find desirable in the same way I’ve said that if you were to drink vodka for your social anxiety, you might actually find the effect desirable and your symptoms relieved. But in no way should you assume that that means you have an alcohol imbalance or that you should use alcohol long-term for prophylactic treatment.
DrKB: So it’s a similar idea. So when we are looking at the opportunity to examine our symptoms that we’re calling depression or anxiety—or, by the way, mania or psychosis or OCD or panic disorder or chronic fatigue or ADHD or the many different labels that patients get in the psychiatric realm—so when you take medication, you’re sort of opting out of what in my opinion is one of the more important opportunities that you’re being presented to really change your experience for the better. So that’s literally an opportunity cost, right?
DrKB: But then there is—the most flooring to me, as I did this research, were two categories of risk that have been totally downplayed and even dismissed in my conventional training. And the first is more acute. And it just sounds really sensational. But I think it’s actually really of vital importance and in many ways warrants the wholesale discontinuation of the use of these medications.
If I were in charge, that’s what would happen, because they have the potential to induce impulsivity of a violent nature that is well documented in the literature that has been suppressed by pharmaceutical company data itself, meaning that they have again tried to conceal this, especially in children. And that is largely responsible, if not completely responsible, for at least all of the media-making faces of homicide, school shootings, infanticide, and even the German Wings pilot taking the plane down.
These individuals were all, without exception, recently started on an anti-depressant medication. Who cares? The reason this matters and the reason you cannot just say, “Oh, well, these are mentally ill people; obviously, they were started on medication,” is because now we have a signal in the literature that suggests that even in the trial setting patients who had no history of suicidality go on to attempt and sometimes complete suicide within weeks of their first dose of medication.
And in one particularly important study from 2011, they investigated ten cases of totally normal citizens who went on to murder their children, murder their spouses, and otherwise act in completely erratic, violent ways. And they found that they all had a cytochrome variance, like liver metabolism variance, that accounted for their essentially being induced into a state of serotonin toxicity within even several doses of starting these medications if not a couple of weeks. And so is anyone screening for that level of susceptibility to risk? No, of course not.
DrKB: Is your family practice doctor in ten minutes who writes you a prescription for Zoloft aware of this? No, and I bet if they were, they might think twice about the Russian roulette that this prescription can involve because, believe me, none of those people—some of whom, by the way, are spending their lives in jail—none of those people had any indication that this would be how things would turn out for them. So that is something I feel pretty passionately about. And Dr. David Healy, a psychiatrist out of the UK, has really devoted his career to exposing this through his work and research. So that’s one big one.
Problems Discontinuing Antidepressant Medications
And then the other is more of a long-term concern. So what happens if you’re not one of those people? And you end up on Prozac and you sort of—I don’t know. Maybe it helped a little bit. Maybe it didn’t. But now, you’ve been on it for a couple years and might as well not rock the boat even though you’ve gained weight, you have no libido, your hair is falling out, and you often find yourself struggling through dark windows and feeling a lot of irritability throughout your life. It could easily be the case that 10, 15 years later, for whatever reason—maybe you want to get pregnant, maybe you just want to try something different, maybe you read an article that inspired some different kind of thinking about your health, maybe you want to come off medication now.
Well, what I’ve learned through almost a decade now of working with patients coming off medication is that, in my unequivocal opinion, these are the most challenging chemicals on the planet to discontinue because I have never heard of heroin, crack, OxyContin, alcohol, or any other medication requiring decrements of 1000th of a milligram a month just to maintain basic medical stability. And this is what I sometimes have to do in my practice around patients who have been on Lexapro for ten years.
And now, finally, a grassroots movement around peer-to-peer support with psychiatric medication discontinuation has been validated by primary literature. Giovanni Fava’s group out of Italy has been publishing their data on meta-analyses essentially exposing the fact that these anti-depressants have a withdrawal syndrome that is as complicated as benzodiazepine or barbiturate withdrawal.
DrKB: And that we should begin to start taking it seriously that we cannot tell patients that they’re just relapsing and that it’s evidence that they need to stay on medication long-term, that there’s a lot more to the story. And so I have deep regret that in the hundreds of patients I started on medication myself over the years, that I never one time said, “It’s possible that you may never be able to get off this medication. And it’s not because you need it.”
And I think that this is part of the informed consent process that is so essential for anyone who is considering a medication, and that it’s also validating for people who have been on medication and tried to come off around how challenging it really is. Of course, I believe it’s absolutely possible and that everybody deserves a trial off medication. And of course, I have done my best to try and shine a light on the elements that make it easier, not the least of which is building bodily resilience through dietary change. But it’s a very real issue and one I think that deserves more attention.
DrMR: Yeah, gosh, especially with the subset of people that may really have an episode of suicide or homicide, then, gosh, that’s such a strong side effect.
DrMR: As is the dependency. So you make a great case for not just trying this willy-nilly where I’ve got a period of stress coming up or I’m trying to grieve with a really devastating loss. Not to take anything away from that.
DrMR: But sometimes, you hear about people just using it in the short-term. And I wonder how many of those people end up on it for a short-term application but end up not ever being able to come off it because of that.
DrKB: That’s exactly right. And I think it’s even worth semantically reframing it, not as effects and side effects.
Because if we acknowledge that there is no illness and disease-based effect that we’re achieving here, then all we’re looking at are side effects, right?
DrKB: So all of the effects we’re looking at “side effects” because there is no actual effect. We’re not fixing anything in the brain anymore than Tylenol is fixing the root cause of a headache.
DrKB: So it’s a very different model. It’s just that this model isn’t quite as effective as Tylenol is for a headache. We usually have to consider the risks more seriously.
Treating the Cause of Depression or Anxiety
DrMR: Now, coming to treating the cause. I’ve got a few things that are high on my list when someone comes in with depression or anxiety or any kind of mood disorder. I try not to get overly wrapped up into is-it-depression versus is-it-anxiety.
DrMR: What have you. Intestinal health, gut health—I think everyone listening here probably shares or at least somewhat understands my view of a gut-first approach. And just to share my own experience with this, when I had my amoebic infection, the food reactivity I was having was so bad. And I would not eat for hours before an exam because it was kind of like a Russian roulette of I might get brain fog from this meal or I might not. And since I have no way of knowing even after all my food journaling and everything else, I’m just not going to eat because I can’t afford to feel like an idiot for the next two hours.
And I remember at one point sitting in the medical library when I had just been hit by a really bad food reaction/brain fog. And oftentimes with the brain fog, you kind of get into this depressive state because you feel like you can’t think. And you don’t want to talk to people because you feel like you’re not making any sense.
DrKB: Yes. Absolutely.
DrMR: And I remember thinking to myself, “If this is how it’s going to be, I don’t want to live anymore.” And I wasn’t contemplating, but you hear that voice in your head sometimes. And you take stock of it. So that to me is something I will never forget, but I will always remember that the way I got through that was addressing an intestinal infection that was causing rampant food reactivity.
And so definitely the gut is high on my list. And that kind of ties in with inflammation. Many times, a chronic inflammatory burden could be coming from the gut. Hormones can also be important. Of course, this is why there’s the joke in our society, “Don’t mess with a woman when she’s in that time of her cycle.”
DrMR: And we all make light of it. But estrogen, as I understand it, does function as an SSRI. So it does impact your serotonin directly. And progesterone effects GABA. So there’s definitely a hormone-to-brain-chemistry connection.
There’s also autoimmunity. And a lot of autoimmunity comes down to good gut health, good diet, stress management, what have you. But there have been some papers showing that those with depression had a higher finding of autoimmunity against serotonin receptors. So something else to consider, not really something to test for, in my opinion, but just going through the good, core foundational health practices that would make someone’s gut healthy, overall healthy, and also has a nice effect on their immune system.
A couple of thing that people might want to be aware of—histamine. Histamine is also something that when people go to a paleo-type diet—
DrMR: They can sometimes—and especially if it’s paleo, low-carb—
DrMR: They can sometimes start eating more of these high-histamine foods—lots of fermented foods, lots of avocado, lots of cured meats and spinach. And all these things have a fair dose of histamine in them. So sometimes, depression can just be something as simple as scaling back your histamine intake. Glutamic acid—some patients I notice—we have patients sometimes do a soup fast kind of like you see in the GAPS Protocol. And for some people, and actually I found this out through my own personal experience, there is a fair amount of glutamic acid in slow-cooked broth.
DrMR: And for people that don’t clear that, well, that can cause really bad brain fog and irritability and depression. And I had the same thing. And a GAPS practitioner I was asking for advice said, “Just stick through it. It’s a healing reaction.” And I know, now, better that that sometimes can be true. But in a lot of cases, I feel like the healing crisis is just blamed for when stuff isn’t really working.
DrKB: Yeah. Exactly.
DrMR: Yeah, exactly. And then there might be some deficiencies, like protein deficiencies and omega deficiencies and other oil deficiencies. But those are some of the big things that I like to look at. So I’ll just throw it out there as fodder for the fire. And do you want to expand on any of those or add any to that?
DrKB: Yes. What it sort of comes to is that our greatest point of leverage in reconnecting to so many elements of our abandoned ancestral lifestyle is the diet. So that’s why so many of us are focused on this. Is it FCD? Is it GAPS? Are we supposed to do high-carb, low-carb? It’s just it becomes an echo chamber or neuroses, as you and I were even just talking about earlier.
And it’s led me to appreciate so profoundly again—for those of you listening who aren’t familiar with Nick Gonzalez’s work, there was sort of in my life a B.C.-A.D. phenomenon in encountering him and his work. He was a holistic oncologist actually practicing in Manhattan who treated much more than metastatic cancer. He treated chronic fatigue and diabetes. And he essentially worked with metabolic typing in his own flavor. And so he worked with ten different diets actually that ranged from vegetarian diets—none were vegan. They ranged from vegetarian diets to fatty red meat three times a day diets in that there were patients with different types of temperaments, different disease susceptibility, different character traits who would thrive in different dietary models. So this is actually—essential popped into context what I had been working with, which you ultimately could characterize as a moderate carb-type paleo diet with my patients who are women, for several years. And I had been getting very good outcomes with a simple intervention that I couldn’t understand because I never believed that everyone should eat the same thing. That doesn’t make any sense to me. But I didn’t have a good way to understand who should be eating what.
And so this man’s outcomes essentially, in my opinion, render him the most important figure in modern medicine. Literally, you’ve never heard of the outcomes, but yet I witnessed them first-hand in his practice—metastatic pancreatic cancer alive 34 years later, metastatic necrotic breast 32 years later, insulin-dependent diabetes resolved on a high-natural-carb diet. Just totally mind-boggling stuff.
And he seemed to never fail when the patient was motivated enough. And his protocols involved dietary change, detox primarily through coffee enemas, and a fair amount of supplements, including pancreatic enzymes and glandulars. So I have a deep appreciation for the power of food. If you ever doubted that food was relevant, all you have to do is look at his outcomes to understand that it’s the most relevant thing.
But you’re right, that sometimes undoing some of the damage of our decades of trashing our bodies in terms of our gut health and dysbiosis, opportunistic infections, poor digestion, local and systemic inflammation—much of which drives, in my opinion, histamine intolerance, for example. These factors aren’t so directly and easily resolved necessarily with just eliminating processed food.
In my experience, though, when we can be very—I don’t know. I rule with a bit of an iron fist around the dietary piece. And when we can take it extremely seriously even for a period of 30 days where I ask patients to commit with zero cheating for 30 days of their life to a whole-foods diet, which is again nothing—it’s not rocket science. It’s not anything really even incredibly unique. But it’s not a low-carb diet, by the way, which I think for women, in particular, can be problematic. Then we see a lot of shifts in the microbiota. We have data to show, as you well know, that within three days of dietary change even certain prebiotic exposures or fermented food exposures can change the microbiota in a couple of days.
And then there are some cases I would say it’s maybe 20% of my practice that I do need to do a stool test. And I do use other types of probiotic interventions or anti-microbials. But it’s definitely not the majority because I think that I have developed a sense of how much red meat should you be eating. Should you be dosing up on leafy greens? Should you be eating citrus fruits, for example? And I’ve refined that sense through my work with him. So it’s been a tremendous gift.
But I also ask my patients to do other things, which we now know do impact the microbiota too like meditation and working with thought patterns. And I also ask them to do detox including coffee enemas. So it’s always this multi-modal approach that can account for shift in the puppet master, which is the microbiome.
But I don’t know that I have a good sense what exactly it is that is accomplishing it. I just know that if we throw everything at the wall in the beginning in terms of very low risk, potentially high-yield interventions, that we can really eliminate a need for a lot of testing, as you’ve alluded to. It’s absolutely my interest too.
Lifestyle Factors and Treating Depression
DrMR: I love it. I love that perspective of keeping these things practical yet effective. And yeah, I didn’t really mention in my list I gave a moment ago lifestyle, but absolutely foundational. And it reminds of a number of the studies I’ve gone through with my research in the microbiota, looking at something called “forest bathing.”
DrMR: And what’s so interesting about that is some of these studies have really shown with just 15 or 20 minutes walking in a forest, patients report increased levels of vigor, mood, decreased scores of fatigue and anxiety and depression. And I think it’s really important for people to understand that some of these basics are far more well documented to work—
DrMR: Than some other stuff we recommend in functional medicine that might be some crazy amino acid protocol based on X, Y, Z test.
DrMR: So it’s easy to get wrapped up in the stuff that sexy. But sometimes, the simplest things are really the most effective.
DrKB: I love that. I could not agree more. And you know what? I went through that trajectory. I probably spent nine months of my life obsessing about omega-6 and omega-3 chain longation and desaturated enzymes and how much vibratory capacity does it have? You could get so pulled down the rabbit hole. Methylation is another one. And I’ve been down there.
But you know what? That is still trying to heal with your intellect. And in my experience, when you develop a relationship to your patient, then you develop a relationship to your own body and your own experience, that actually honors this more subtle and, in my opinion, more feminine mentality around our interconnectedness, around community, around this sense of blurred boundaries between us and nature.
Then that’s where the money is. That’s where actual shifts in healing happen. And that’s where you become less afraid and less neurotic because you can actually plug into a sense of deeper connection to something so much bigger that holds you, that holds your trajectory. And it’s beautiful. So I couldn’t agree more. I’ve really, really come to appreciate these simple top-down interventions as being so much more effective.
But for whatever reason, we’re still in this bridge phase where this kind of information—it matters more when it comes from science, when it comes from doctors. And so I feel like sometimes all I’m doing is holding the space for common sense.
DrMR: Yeah. Well said.
DrKB: Because people need to hear it from somebody with my credentials. Of course, I was one of the last ones to even learn that this was relevant because of my training. But it’s a powerful thing. And that’s where basic things like exercise, meditation, spending time in nature. This friend of mine, Alan Logan, who’s the researcher who has written a series of articles on paleo deficit disorder—he talks about that, about green space and exposure to these environments that we used to inhabit. And it’s really elegant science that’s just reconfirming what, of course, deep down we already know to be true.
DrMR: And we are getting the more sexy science behind it. There is some literature now documenting—there’s a compound that is released by trees. And we smell it—some sort of phytochemical, that when we smell that it actually reduces our blood pressure.
DrKB: So beautiful.
DrMR: So there’s actually really specific scientific stuff going on in there. It’s just sometimes you need a very scientific way of explaining the simple thing that we knew worked to begin with.
DrKB: Yeah. Yeah, and in fact, that’s all science should be doing probably.
DrKB: That’s the only business is to support the intuitive knowing. Exactly.
Other Diagnostic Areas to Look at in Treating Depression
DrMR: Now, are there other—let’s say that there’s someone who feels to have a pretty good—like myself when I was in college and struggling with this. I had a pretty good diet and lifestyle, but still the wheels were kind of falling off.
Are there things other than gut health—or what are a few of the big, more medical type things that you have to do after diet and lifestyle to give the people listening a sense as to, “Okay, I’m trying to find a local doc to work with me. I don’t want to get pulled down the rabbit hole. But I also don’t want to do nothing.”
DrMR: “I’ve already gotten my diet and lifestyle dialed in.” What are the next couple things that you would say are important to work with their doctor to look into?
DrKB: Yes. So I’m very sensitive because I’ve been—I doubt that you were this person. But I’ve been someone who said, “Oh yeah, I totally have the diet thing down” because I think that often there are blind spots. When I first worked with a naturopath, I went off gluten and dairy. And guess what? For a year and a half, I ate a whole bunch of crap, the way everyone does.
DrKB: And I was like, “Oh my god, I totally get how diet is so important. And I’m not eating any processed food.” And lo and behold, I was eating probably nothing but. So I do think it’s worth always reexamining with a bright light—how much have you really taken out processed food? Have you taken out coffee, alcohol, sugar? Have you taken a look at things like your water? It’s huge. I’m very big into contaminants in water. Have you taken a look at some of your other environment exposures? But diagnostically, I do think it’s still worthwhile to investigate some very basic things. And these days, you can even do it yourself frankly through outlets like direct labs or just to sort of once you have the parameters to at least identify whether this is relevant to you.
So of course, I am very interested in the role of thyroid in mental health, whether it’s post-partum psychosis or anxiety or depression, what we’re calling ADHD or chronic fatigue. The role of autoimmune thyroid conditions, which of course account for, as you know, most thyroid dysfunction—whether it’s Graves’ profile or Hashimoto’s profile or a mixed profile as is the case in post partum thyroiditis.
This is hugely relevant. If you have ever been diagnosed with a psychiatric problem, this is the first thing to look at, in my opinion, because it’s eminently treatable, reversible as I and many of our colleagues are living proof. And it so often masquerades as a psychiatric problem.
I would say the other major big one, apart from medication side effects and food intolerance, as you mentioned, is probably blood sugar imbalance. I see a ton of it in the women that I treat. These are not women who have been diagnosed with diabetes, although there is tremendous comorbidity with depression there as well.
But these are thin, healthy-looking women who basically are riding a roller coaster of reactive hypoglycemia all day long. And the seeming antidote to that has been, in my experience, to increase natural fats. So it’s why one of the most popular blogs I’ve ever written was some stupid blog I wrote in ten minutes about what I eat for breakfast, which you and I were joking about is this smoothie that’s essentially just like a bunch of fat.
And the reason that it’s so popular in my practice and online is because it actually is a pretty effective antidote to the types of things we eat for breakfast typically like cereal, bagels, and muffins that of course kick off, even if they’re gluten free or especially if they’re gluten free—kick off a blood sugar destabilization cascade that persists throughout the day and can account for things literally as severe as panic attacks.
I had a patient I think I wrote about in the book who came in having, according to her, six panic attacks a day on three psych meds. And in a month, she came back after really committing to a high-natural-fat diet. And she said, “It’s the first month of my life I haven’t had a panic attack.” And she was literally teary eyed about it. And I knew at that point—she had a hemoglobin A1c of 9 and a fasting blood sugar of 62. And she was heading on that rollercoaster ride. And all we had done was, in the space of a month, balance her blood sugar to at least some extent.
So that’s how forgiving the body is that you really don’t need much time or much commitment. But once you’ve taught yourself that that’s possible, it really shifts your psychology, because then you can reclaim so much of what I think we tend to give away because if it was under your nose the whole time to heal yourself in this way, then it seems like there’s a lot more in your control than you perceived to be before. So there’s also a really profound value in this type of self-experimentation again, so you can teach yourself that you have all the tools you need in some regard.
DrMR: I like it. I like it.
Dr. Kelly Brogan’s Book A Mind of Your Own
So what about the book [A Mind of Your Own]? I think you’ve probably already showcased a lot of what’s in the book. But do you want to tell us a little bit more about your book, maybe some of the nuggets embedded within and anything else relevant to that?
DrKB: Yeah. So I think it’s relevant pretty much because so many people are like, “Oh, is this just for women who are depressed? What’s the deal?” And I think a reframing would be that it’s for anyone who’s considering medication for mental health—really mental health at large, by the way—anyone who’s on medication and not totally happy with it, or anyone who really would like to come off it. The protocol, per se, is really the same.
So it’s optimizing physiology and being to shift consciousness around consumerism so that you can really see, “Well, what am I struggling with still?” And then you can optimize your odds for discontinuation of medication if you’re on it. So it’s a broad sweep. And obviously there is much need to personalize the process. I try and help you do that as much as possible through a book.
And then I’m just finishing up a companion course called Vital Mind Reset, which is if you want to take a deeper dive after the book, my intention is really to keep you from having to work with a clinician, because there just unfortunately aren’t enough clinicians aware of how this information applies to psychiatry really apart from yourself and a handful of people. It’s just such a dearth—so many people are afraid of the psych patient. That’s what I have discovered.
DrKB: And they feel like, “Oh well, we can apply holistic and functional medicine to gut health and to autoimmunity. But if it comes to psychiatry, you probably should see a psychiatrist and maybe take medication.” And my interest is in really opening the closet door, letting some light in, and showing us all that it’s absolutely relevant to consider all of these basic principles that we’ve talking about when it comes to mental health. So that’s my intention. It’s really informed consent, at the end of the day.
DrMR: Yeah, well, they say that the patient can only give informed consent if they’re aware of all their options.
DrMR: And it sounds like you’re just making them aware of that.
DrKB: Exactly. Exactly. Yeah.
DrMR: One thing I have to ask you before I forget—what’s your quick-take on neurotransmitter testing? There are a few labs that offer urinary neurotransmitter testing and then accompanying amino acid supplementation to help with that. Controversial. What’s your take on that?
DrKB: Yeah. So listen. I want to preface what I’m about to say with the fact that anyone who is working with natural medicine I think is probably doing a service to their patient because the alternative in the pharmaceutical realm, as I have tried to make very clear, is dangerous and largely ineffective. So parsing out what is the most effective natural intervention is something we could talk about all day long because it’s going to be different for everyone.
So while I am sure that single amino acid interventions have been helpful and there is some literature to support that—without throwing my respected colleagues under the bus, my concern is that some of us have bought—I was going to say hook, line, and sinker. But that’s not the expression. [Laughs]
Let’s just say bought into. They’ve bought into the notion that we can relate specific neurotransmitters to specific signs, symptoms, and pathologies. And particularly around tryptophan, 5-HTP, and serotonin meme, what I’ve tried to explore is that I just feel that that’s pharmaceutical propaganda.
Serotonin is not a happy chemical. And you can’t even walk through a Whole Foods without seeing advertising nonsense about boosting your serotonin. So it is, unfortunately, not what we think it is. In fact, high serotonin states are associated with everything from carcinoid to serotonin syndrome to even autism.
Serotonin, at best, is an energetic resource allocator that is a sign of imbalance, acute imbalance. But it is absolutely not something that we want to wholesale amplify. So when we are looking at the metric of—dopamine is your concentration/motivation chemical. Serotonin is your happy chemical. GABA is your relaxation chemical. Well, who knows? There may be little threads of that that are true.
But unfortunately, with 100+ neurotransmitters and unnamed peptides that work in our brain chemistry, not to mention the immune system, which seems to be even more relevant in terms of its managerial role than neurochemicals, then working with these reductionist models, I think it’s time for us to move past that and to really begin to engage the types of interventions that activate whole networks at once. And so that’s where things like forest bathing become really curious, right?
DrKB: Or nutrition or meditation or exercise, because they activate whole systems at one time. Needless to say, I don’t do neurotransmitter testing in my practice. I never have. I have publishable outcomes every single week of my life.
And so I’m not convinced that it’s necessary. I’ve actually scaled back so much on the testing that I do to the extent that I’ll do a stool test on a patient who has not had sufficient improvement after about a month, month-and-a-half of strict dietary change. And that’s really the big one beyond just basic blood work. So I am still a big fan of basic blood work. I think it can be pretty helpful even if it just shows you that you have a serum B12 level of 128.
DrKB: And probably would benefit from injections. Simple interventions that can be high yield. So it’s a great question. And I think if you’re not in the trenches working with psychiatric patients the way I am, it would be an easy thing to just assume is probably a good idea.
DrKB: I totally get that. And so I have no interest in sort of—because a lot of my colleagues get offended when I talk about this because they feel like, well, they’ve been offering tryptophan and 5-HTP to their patients. And listen. It may absolutely be helpful. But it’s not something I’ve been drawn to specifically.
DrMR: Okay. Well, thank you for sharing your perspective. And there are two-fold reasons why I ask. One is because you’re in that field, so of course I want to get your perspective there. The other—the more conversations I’m having through doing these podcast interviews with clinicians that I respect, I really find that the really experienced clinicians rarely advocate really copious amounts of testing. And people listening probably know that I think where functional medicine needs to go is a more efficient model.
DrMR: And it’s just interesting to see the other clinicians that I respect and hold in high regard are moving, I think, in that same direction—
DrMR: Of not doing tons of testing but trying to be a little bit more prescriptive.
DrKB: Yes, 100%. So that’s fascinating and very resonant.
Dr. Brogan’s Least Healthy but Most Fun Thing
DrMR: Last question I want to ask you, and knowing you, I think you’ll have a good answer to this question. The short preface is sometimes in trying to become healthy, we get overly fixated on our health and start to make ourselves less healthy because we get too wrapped into doing healthy stuff—staying in; cooking all of our food from scratch; never going out; never being up late, never smoking, drinking, or what have you.
DrMR: So what is the potentially least healthy but most fun thing that you’ve done lately?
DrKB: Oh, God. Well, I love to party and have a good time.
DrMR: I know you do. That’s why I know you’re going to have a good answer.
DrKB: I do. No, I have a really, really full life and a very active social life. And I travel a lot. And I love to go out dancing. And really, really enjoy my life. And honestly, I have come into a place of such deep joy through some of the greatest pain in my life in the past couple of years, not the least of which included losing this mentor I’ve mentioned now several times, Nick Gonzalez, very suddenly when he died last July. And you also have to move through a space of suffering to understand what it is you need to do.
So one of the things I needed to understand was how to embrace a more spiritual practice. And I’ve been an atheist my entire life. And it wasn’t until I was really brought to my knees by a series of losses and disappointments in the activism realm, for example—I’m very involved in a lot of activist efforts—and then in his death that I began to understand that I needed to surrender, that I’ve been living my entire life from this base of, “Well, I can do it. I can architect it. I just need to work harder, do harder, be more prepared. And this is what my life should look like. And this is what it needs to include. And these are—” So working from this base of intellect. Sometimes, you get to a point in your life where you realize you can’t anymore. And you need to throw up your hands.
And part of the way to throw up your hands with grace is to really embrace a model of relating to your own mind, body, and soul through an ancient technology. And I began doing Kundalini yoga. I began waking up before dawn every day to do a practice for 45 minutes. I couldn’t make five minutes for meditation up until that point, despite knowing all the literature on it, in my life.
And when I began to do that, I began to experience an abundance that was just insane. Things just started falling into my path that I needed. I started to feel like I had so much more space for fun and joy even though I was busier than ever. So it was a weird—like I shed all of this fear and neuroses that was apparently taking up a lot of my time and energy because when I let go of that, I seemed to have all this room for a lot of pleasure.
And so, yeah, I know my boundaries in terms of what I can push my body in terms of sleep deprivation and travel. I’m pretty neurotic still in an empowered way about my diet but not about everything—prioritizing organic and gluten/dairy/sugar/corn/soy-free. That’s not hard to do actually. And I do that around the world. Wherever I travel, I stick to that without exception.
And then I drink alcohol socially. But I’ve found that the deeper my meditative practice goes, the less I can tolerate it. And it’s a weird thing. It’s a funny transition. And I see this happen with my patients too because I practice in Manhattan. And all we do in Manhattan is drink. That’s pretty much the social currency. Almost like a very big social crutch.
So when I ask my patients to stop drinking for a month, it’s a big conversation often. And they don’t consider themselves alcoholic. But what they find is that as they begin to layer in a meditative practice, it’s an interesting transition. And we could have a whole conversation about what it’s about.
But I see it in my patients, and I’ve seen it in myself that the more they come in line with what they’re meant to be doing here and the more they fine tune their instrument, the less tolerance. I’ll have one drink and feel hung over the next day. And that never used to be the case. So it’s a work in progress. But I do love to go out and let loose. That’s really a big part of my agenda.
DrMR: Cool. Cool. And thank you for sharing that experience. I can tell you’ve learned a lot just through listening to that. And I’m sure people listening are feeling that come through. So thank you for sharing that. Thank you for the awesome book that you’ve just written and for taking the time today. And hopefully, we’ll have you back on some point in the near future. We can pick another topic to kind of delve into.
DrKB: Total pleasure. I always love talking to you. So this was a great pleasure.
DrMR: All right, Kelly. Thanks again.
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