An Integrative Approach to Depression & Anxiety with Dr. Peter Bongiorno: Rational Wellness Podcast 328

Dr. Peter Bongiorno discusses An Integrative Approach to Depression and Anxiety at the Functional Medicine Discussion Group meeting on September 28, 2023 with moderator Dr. Weitz.  

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Podcast Highlights

9:27   The Neurotransmitter Theory of Depression and Anxiety.  This theory is that specific neurotransmitters are responsible for mood disorders. For example, this theory includes the idea that depression is caused by a deficiency of serotonin.  In 2008 the New England Journal of Medicine published a paper suggesting that maybe this whole serotonin theory wasn’t true, and a lot more people who took SSRIs actually didn’t have as positive effect. [Belmaker RH, Agam G. Major Depressive Disorder. N Engl J Med 2008; 358:55-68.]  Then Fournier in JAMA published a paper showing that SSRIs had no better effect than placebo for mild to moderate depression, though they are beneficial for severe depression. In 2020 a paper discussed that the evidence is that “The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations.” [Moncrieff, J., Cooper, R.E., Stockmann, T. et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry (2022).]  Some studies show that a medication, Stablon, which lowers serotonin, is equally effective as SSRI drugs that raise serotonin levels.  This is not to say that serotonin has no effect but only 27 to 35% of patients who take an antidepressant have a positive response.  Even if serotonin is a factor, there may be other factors that affect whether that antidepressant can be effective, such as do they have enough amino acids in their diet to make neurotransmitters?  It could also be because estrogen or other hormones are low or their adrenals or thyroid are off. Even if depression or anxiety are related to a neurotransmitter issue, we should be trying to figure out what caused this dysregulation of neurotransmitters.  Those reasons can include physiology, nutrients, hormones, inflammation, digestion, lack of sleep, not enough exercise, too much exercise, mitochondrial dysfunction, toxicity, mold.

16:02  SSRIs.  Drugs that potentially modulate serotonin and the other neurotransmitters, like the Selective Serotonin Reuptake Inhibitors (SSRI) even when they do work, tend to stop working after a period of time. And there are many problems with these drugs, including that they are very difficult to get off of these drugs when you want to stop taking them and they have significant side effects, including a significant increase in all-cause mortality.  Dr. John Neustadt spoke at the Connecticut Naturopathic Conference about how SSRIs increase the risk of osteoporosis by changing osteoblastic and osteoclastic activity.  Also when you place someone on these SSRI medications, it does change the function of the HPA axis and does change the ability and the balance of how the body regulates things like circadian rhythm, how it regulates the production of neurotransmitters, how it regulates the production of receptors.

20:32  Dietary Factors.  Two of the most important factors are the patient sleeping and pooping?  It is critical that the patient is having a good bowel movement daily.  We need to facilitate that whether it is adding fiber, water, magnesium, etc. If the patient has a lot of anxiety, that tends to put them into sympathetic mode, which shuts down the bowels. So we need to calm their anxiety, whether that is through supplements or acupuncture. Then the next step is to look at their diet and see what we can change to get them eating better.  The best diet is probably some version of the Mediterranean diet, which Professor Almudena Sanchez-Villegas showed in several papers how it improves the endothelial lining of the blood vessels and reduces inflammation and also that this diet both prevents and helps to treat anxiety and depression. [Sánchez-Villegas A, Henríquez P, Bes-Rastrollo M, Doreste J. Mediterranean diet and depression. Public Health Nutr. 2006 Dec;9(8A):1104-9.]  [Sánchez-Villegas A, Delgado-Rodríguez M, Alonso A, Schlatter J, Lahortiga F, Serra Majem L, Martínez-González MA. Association of the Mediterranean dietary pattern with the incidence of depression: the Seguimiento Universidad de Navarra/University of Navarra follow-up (SUN) cohort. Arch Gen Psychiatry. 2009 Oct;66(10):1090-8.]  [Sánchez-Villegas, A., Martínez-González, M.A., Estruch, R. et al. Mediterranean dietary pattern and depression: the PREDIMED randomized trial. BMC Med 11, 208 (2013). https://doi.org/10.1186/1741-7015-11-208

23:35  Blood Sugar.  Blood sugar is especially important for anxiety.  Kids who have anxiety often have high blood insulin and low blood sugar from eating highly processed, high carbohydrate foods, which stresses out the primitive brain.  Dr. Bongiorno will sometimes see kids who are eating poorly and will have high insulin, low blood sugar, and low iron (ferritin) and that is a recipe for anxiety.  A patient like this may have multiple nutritional deficiencies.  Such patients often have trouble focusing, so they may get put on medications for focus and ADHD, which ramps up the dopamine and this makes the anxiety worse. We may now have a young girl who other than her poor diet is otherwise healthy and now she finds herself on medication for focus and several medications for anxiety and we still haven’t fixed the underlying issues yet.  This patient is likely not eating enough protein to give her brain enough of the amino acids and other nutrients needed to produce the serotonin that she is taking medication to try to increase, so this approach is likely to fail.  Or they may have poor digestion or low stomach acid or they may not be chewing their food well because they are anxious and in a rush, which means they are not breaking down their proteins.  Or their microbiome may be out of balance and this may affect neurotransmitter production and hormone production, etc. A good recommendation for such patients is to make sure to have a good breakfast in the morning when their digestion is its strongest.  While intermittent fasting can be beneficial for a number of reasons, for the patient who is anxious and undernourished and has low blood sugar, it may make more sense to have smaller, more frequent meals.  On the other hand, for a postmenopausal woman who is having trouble taking weight off, intermittent fasting and detoxification may be beneficial.

30:54  Coffee.  Coffee can be healthy and beneficial, especially for those with depression, and its a good way to get the bowels moving.  On the other hand, depending upon the person, it could increase anxiety.  It depends upon how well that person processes caffeine. It should be organic and we should avoid putting sugar and dairy in it.

32:58  Alcohol.  We used to think that a modest amount of alcohol was healthy, but now the studies seem to be showing that for cancer, no amount of alcohol is good.  It may have a slight benefit for heart health in raising HDL levels.  Alcohol has a relaxing effect, so that may have some benefit, esp. for anxiety.  Dr. Bongiorno told how his parents used to drink a Manhattan before dinner, which they placed gentian bitters in, which they would do while his mom was making dinner. The alcohol relaxed them and the bitters promoted the release of digestive enzymes, promotes better digestion.   

36:17  Sleep.  Sleep is crucial to good health and mood.  During sleep is when we detoxify our brains and where our mitochondria build back up.

38:19  Exercise.  Exercise is crucial for mental health and if you are feeling stressed and you don’t move your body, the stress hormones tend to affect your brain more.  When we are under stress, we are in a fight or flight mode and we need to move to equalize that stress, while we work on creating better balance in our nervous system.  Exercise helps us build better mitochondria, which we need for our nervous system to work really well.  In the short term, exercise increases gut permeability, but when we exercise regularly, we have less gut permeability and we have better digestion.  People who exercise regularly feel better and live longer.

47:04  Labs.  Dr. Bongiorno likes to run labs for mental health, whether the problem is anxiety, depression, schizophrenia, or bipolar disorder.  But first we should take a good history and make sure the basics are there, including sleep, exercise, eating green vegetables and consuming essential fats.  Then he will usually run the basics like a CBC, blood sugar, insulin, A1c, a full thyroid panel with antibodies, vitamin D and an iron panel, incl. ferritin for iron storage. And then looking at some of the vitamins, magnesium, zinc, zinc-to-copper ratio, B12.  Depending upon the patient, he will also run sex hormones and then look at adrenal cortisol testing, melatonin and glutathione levels, and mycotoxin testing can be helpful. Stool testing can also be beneficial to look at the microbiome.  He will try to work through Quest and LabCorp when possible for the basic lab work in order to have them covered by insurance and then he relies on specialty labs like the DUTCH panel, Genova for adrenal testing, Diagnostic Solutions for genetic profiles and stool testing, RealTime Labs and MyMycoLab for mycotoxin testing.

55:25  Nutritional Supplements. NAC has some impressive research findings for its benefits of depression, including severe depression and even as an acute intervention for patients who are suicidal. [Hans D, Rengel A, Hans J, Bassett D, Hood S. N-Acetylcysteine as a novel rapidly acting anti-suicidal agent: A pilot naturalistic study in the emergency setting. PLoS One. 2022 Jan 28;17(1):e0263149.] It’s beneficial for bipolar disorder and for trichotillomania or hair pulling, which can be part of an obsessive compulsive disorder. [Nery FG, Li W, DelBello MP, Welge JA. N-acetylcysteine as an adjunctive treatment for bipolar depression: A systematic review and meta-analysis of randomized controlled trials. Bipolar Disord. 2021 Nov;23(7):707-714.]  NAC is a precursor for glutathione and its a good mucolytic.  Some of the other most effective supplements supported by research for mood disorders are St. John’s wort, SAMe, curcumin, and Rhodiola.  St. John’s wort is supported by many studies and meta-analyses but some are concerned about the fact that it affects the metabolism of certain drugs, such as blood thinners like Plavix. [Canenguez Benitez JS, Hernandez TE, Sundararajan R, Sarwar S, Arriaga AJ, Khan AT, Matayoshi A, Quintanilla HA, Kochhar H, Alam M, Mago A, Hans A, Benitez GA. Advantages and Disadvantages of Using St. John’s Wort as a Treatment for Depression. Cureus. 2022 Sep 22;14(9):e29468.] Fish oil supports healthy cell membranes, which facilitates the flow of nutrients into cells and ability to remove toxins from the cells.  Dr. Bongiorno likes using the omega check to measure essential fatty acids is helpful.  Fish oil helps the anti-depressants to work better. S-adenosyl-L-methionine, can help the body move some of the cycles that help create better neurotransmitters, especially if people have poor methylation.  This is also needed to make CoQ10.  Methylated B vitamins can also be very helpful.  Rhodiola is a natural COMT inhibitor and it can work synergistically to keep neurotransmitters at a higher level.  Curcumin is also a natural anti-depressant as well as an anti-inflammatory.  Saffron has been shown to have benefits for libido for patients with libido problems when taking SSRI drugs.  Lithium orotate, aka nutritional lithium, is effective in helping to calm anxiousness and impulsivity. It helps to calm the amygdala. You can check on lithium levels with hair analysis to make sure you don’t end up having too high a level.  The dosage is usually between 5 and 20 mg.  It also works well combined with CBD.  [Hamstra SI, Roy BD, Tiidus P, MacNeil AJ, Klentrou P, MacPherson REK, Fajardo VA. Beyond its Psychiatric Use: The Benefits of Low-dose Lithium Supplementation. Curr Neuropharmacol. 2023;21(4):891-910.]  Specific amino acids can help to support the production of various neurotransmitters, including 5-HTP for serotonin, Mucuna and tyrosine for dopamine, GABA, etc.  Vitamins B6, Vitamin D, and zinc are important co-factors.  Dr. Bongiorno likes to use 5-HTP for daytime and tryptophan at night for sleep.                                        



Dr. Peter Bongiorno is a Naturopathic Doctor and Acupuncturist and he is the co-director of InnerSource Natural Health and Acupuncture, with offices in New York City and on Long Island.  He also works with clients around the world via phone and Skype.  He did research at the National Institutes of Health in the department of Neuroimmunology and then went to Bastyr University to study naturopathic medicine and acupuncture.  He wrote a number of books, including Healing Depression in 2010 and Holistic Solutions for Anxiety and Depression in Therapy: Combining Natural Therapies with Conventional Care in 2015, both targeted for physicians, as well as How Come They’re Happy and I’m Not, and Put Anxiety Behind You: The Complete Drug Free Program

Dr. Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.



Podcast Transcript

Dr. Weitz:                   Hey, this is Dr. Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.  Okay. Hello everybody. I’m Dr. Weitz, in case you don’t know. Thank you for joining our functional medicine discussion group meeting tonight with Dr. Peter Bongiorno on an integrative approach to depression and anxiety. I hope you’ll consider joining some of our other upcoming meetings. October 26th, we’ll be discussing integrative cardiology with Dr. Howard Elkin, and this will be our first in-person meetings since 2019. November 16th, we’re going to meet again. Topic is most likely going to be long COVID, though I still have to confirm it. December, we’re going to be off, and then January 25th, we’ll start off the year with Dr. Vojdani. I encourage you to participate in the discussion by typing your question into the chat box, and then I’ll either call on you or ask Dr. Bongiorno your question when it’s appropriate.  If you’re not aware, we have a closed Facebook page, the Functional Medicine Discussion Group of Santa Monica. This is for practitioners that you should join, so we can continue the conversation when this evening’s over. I’m recording the event and it’ll be included in my weekly Rational Wellness podcast.  The Rational Wellness Podcast is available on Apple Podcast, Spotify. There’s a video version on YouTube. If you don’t listen to it regularly, please check it out. If you do listen to it regularly, please give me a five star review on Apple or Spotify. And I’d like to thank our sponsor now, which is Integrative Therapeutics, and we have Steve Snyder on the line to tell us about a few Integrative Therapeutic products. Steve?

Steve Snyder:             If I can unmute. I always hate talking at these things because I know that everybody’s waiting for the speaker to talk and they’re way more interesting, but this one happens to be kind of right up our alley, and we have a few products that I just want to remind people about. The big one is Lavela, which is our lavender oral essential oil, essentially for anxiety. This is one of the products that we grow ourselves and market in Europe. So there’s about 25 clinical studies on it showing significant reduction in symptoms and similar efficacy to pharma products. It’s the real deal. Really the only side effect to it, and Dr. Bongiorno, you might be able to … people burp lavender. It’s not the worst thing in the world. It’s better than fish oil, but we also have a product called Neurologix that includes saffron, citicoline, and a unique spearmint extract that’s mostly for kind of a cognitive improvement, but it does also have a serious impact on mood, and we feel like those are sort of connected. And then… Yeah.

Dr. Weitz:                   Hey, Steve, can you just address the concern that some people have about using lavender? There’s this thought out there that’s going to decrease testosterone levels.

Steve Snyder:             So this is one of those urban legends that we can’t get to go away, and thanks for letting me throw this one out there, too. Sort of like black pepper and curcumin. The lavender issue is related sort of, if you do a little Google searching, it all comes back to one doctor who had one patient, it was a kid who used to bathe in lavender and he got gynecomastia. It went away when they stopped bathing him in lavender. But there’s really nothing to that other than that sort of snowballed into all of these references that basically go back to that same thing.  We have a warning on it to not use it in prepubescent men or males, but it’s literally one of our top five selling products, and we’ve never had any report of it. So if you know us, you know how conservative we are on labeling stuff. If there was any kind of worry about it, we would have it plastered all over the product and we don’t. And literally, this is one of the most heavily studied nutritional supplements out there. It’s over 20 studies now, so it’s not something we’re worried about. And if we’re not worried about it, I’m fairly certain you shouldn’t be worried about it. So does that help?

Dr. Weitz:                   Okay. Great. Yeah, thanks Steve.

Dr. Bongiorno:            And then the Theracurmin, the curcumin supplement, that’s a big one for mood and memory as well, all kinds of cognitive stuff. We actually have a new one that’s better than Theracurmin called Curalieve. There’s no clinical studies on anxiety and depression yet, but there’s a great one on memory and mood. And then Cortisol Manager, that’s everybody’s favorite for everything, so we always say that one. So I’ll throw some links into the chat and if anybody [practitioners] wants to know more about them or sample any of these, we can make that happen.

Dr. Weitz:                   That’s great. Thanks, Steve.

Steve Snyder:             Yeah.

Dr. Weitz:                   So, let me just quickly introduce the topic and then we’ll introduce our speaker and we’ll get started. So we’re going to talk about mood disorders. Depression is a mood disorder characterized by a persistent feeling of sadness and hopelessness and a loss of interest or pleasure in previously enjoyed activities. Gallup research found in 2023 that the percentage of US adults who report having been diagnosed with depression at some point in their lifetime has reached 29%, the all-time high and 10 points higher than in 2015. Anxiety is characterized by feelings of worry, nervousness, or fear that are strong enough to interfere with one’s daily activities.  In 2023, 28% of US adults reported symptoms of anxiety disorder in the past two weeks, though this was lower than the all time high in 2021.

                                   Dr. Peter Bongiorno is a naturopathic doctor and acupuncturist in New York City, and he also works with clients via phone and Skype. He’s written a number of books including Healing Depression, Holistic Solutions for Anxiety & Depression, which is an incredible book, and I’m reading it again for the third time. And there’s just so many great clinical pearls, especially for functional medicine practitioners.  And he also wrote How Come They’re Happy and I’m Not?, and Put Anxiety Behind You: The Complete Drug-Free Program. Both of these are for patients. His website is drpeterbongiorno.com. Peter, thank you so much for joining us.

Dr. Bongiorno:            Thank you, Dr. Ben. Thank you for that introduction, and thank you for bringing people together and spreading good energy. Really appreciate it.

Dr. Weitz:                   Absolutely. Yes, it’s my mission. So it sounds like anxiety levels were highest during COVID, which I guess is understandable, but it sounds like maybe depression has resulted from all this, and I wonder if this might even be a untalked about symptom of long COVID.

Dr. Bongiorno:            Yeah. Well, I mean, I think there are a lot of similar underlying factors that contribute to long COVID, and a lot of those factors and mechanisms also play a very strong role in depression as well. So it makes a lot of sense to me that we’re going to see this clinical and subclinical long COVID syndrome. And along with that, we’re going to see more depression, too.

Dr. Weitz:                   Right. So let’s start by talking about the neurotransmitter theory of depression and anxiety for those who aren’t … I’m sure we must all be familiar with it, but the concept is that somehow depression, for example, is caused by a deficiency of serotonin, and that specific neurotransmitters are responsible for these mood disorders, and that’s somehow we can modulate this by taking medications that increase serotonin or norepinephrine.  Where are we in terms of this theory?  Have we learned?  Is there more evidence for this concept, or is it even more in doubt?

Dr. Bongiorno:            Yeah.  Well, I mean, in the end, it really depends on the patient, right?  But if you look at the literature, the New England Journal of Medicine in the early aughts, I think it was maybe 2008 or nine had published a paper suggesting that maybe this whole serotonin theory wasn’t true, and a lot more people who took SSRIs actually didn’t have as positive effect.   And then a few years later, a fellow named Fournier in JAMA, right?

Dr. Weitz:                   Yeah.

Dr. Bongiorno:            The Journal of the American Medical Association, published a paper looking at all the studies that supposedly weren’t looked at. Some people felt they were hidden, and that’s why we didn’t see them. And when he looked at them all, what he noticed was that SSRIs really for mild to moderate depression, really didn’t have a better effect than using a placebo. In severe depression, there was a beneficial effect, but not in mild to moderate.  And then really about a year and a half ago, another paper came out of strongly suggesting that serotonin itself might not be as strong a player in depression as they thought originally. And it’s interesting because again, maybe about 10, 15 years ago, there are some studies on another medication called Stablon, which is the opposite of an SSRI.  It’s a serotonin…it actually helps keep less serotonin around.  And they found that about 30% of people did well with that drug, about the same amount that did well with the SSRIs.  And so, kind of people scratching their heads going, “Wait a second. One drug that does the exact opposite has as good effect as the drug that’s supposed to keep the serotonin around.”  And in my opinion, that’s not to say that serotonin has no effect.  What we need to understand is that neurotransmitters are real. If you think about disease, very typical metaphor, the disease is like an iceberg, right?  So neurotransmitters are the tip of that iceberg. So the question is, and there are maybe 27 to 35% of people when they take an antidepressant, they do feel better. And I believe that’s true. I’ve seen that clinically. So it’s not that no one does well with it, but it’s not, unfortunately, the high rates that originally that were being told to us. And the reason is is because there’s many, many other factors in depression besides serotonin, and maybe for 25, 30% of people, that is a major piece of it, but for many people it’s not. And then for the people that serotonin is a major factor then we have to ask, well, why is serotonin low that when we use the drug, it does work?

                                                And that could be so many other reasons. It could be not enough amino acids in their diet. It could be because estrogen is low or other hormones are low or adrenals are off, or thyroid. I mean, so there’s a whole lot of reasons. So that’s the question that we need to ask, not whether neurotransmitters themselves are the only reason. And that’s unfortunately where I think modern psychiatry has been for a long time. And when you think about psychiatry, I’ve worked with many psychiatrists over the years, and the ways explained to me was that before there were psychiatric meds, psychiatrists themselves weren’t looked at as, quote, “Real doctors,” because they didn’t have drugs. So they themselves felt like they weren’t real doctors because when somebody got sick, there wasn’t a drug to use. And then as the years went on, they developed all these different drugs. They accidentally, they were unearthed that they had some benefits. It was actually in the beginning, it was studying TB is actually how they started isoniazid. And they started figuring out this whole idea of mono means and the blocking of those. And anyway, that’s another story.

                                                But the point is then psychiatry started having drugs that they did notice having an effect, especially for patients who were originally put in sanitariums and locked away. And so, like the magic pill for so many other things, that seemed like the approach to take. And unfortunately, that’s still the approach that’s being taken. And we’re not getting to the point where we’re saying, “Okay, this human being has a lot of physiology going on.” And there’s a lot of different reasons in that physiology, nutrients, hormones, inflammation, digestion, lack of sleep, not enough exercise, too much exercise, mitochondrial dysfunction, toxicity, mold, all of these things that are going to play a role in why neurotransmitters change. So that’s what I’m hoping, as the years go on, that we’re going to start to understand is we have to really treat that whole person and all of those issues. And maybe it is a neurotransmitter issue, but we don’t want to just focus on trying to regulate a neurotransmitter. We want to figure out what the underlying cause of that dysregulation is if it is a neurotransmitter.

Dr. Weitz:                   Absolutely. And it also sounds like there’s a large number of neurotransmitters that have a number of different complex roles, and it sounds like it’s not as simple as just serotonin for depression and just another neurotransmitter to make you happy. There’s this complex symphony of various neurotransmitters that play various roles that we probably only scratching the surface on.  And then of course, we have the problems with these drugs, which are number one, that even when they do work after a while, they tend to stop working. They’re very difficult to get off of, and they have significant side effects, including a significant increase in all-cause mortality.

Dr. Bongiorno:            Yeah. I recently went to the Connecticut Naturopathic Conference and I gave a talk there, and one of my colleagues, Dr. John Neustad, he was speaking about SSRIs and the effect on osteoporosis, for example. And that was something that I’d heard a little bit about, but I didn’t know too much, and I didn’t realize how deeply those mechanisms lied and how they changed osteoclastic and osteoblastic formation.  And so, that was something kind of new for me in the world of SSRIs, which I always think about them even from a hypothermic pituitary adrenal access standpoint, how they really do change function. And I do find when patients are put on these medications, which sometimes in an urgent care situation where somebody might hurt themselves or somebody else, sometimes it can be lifesaving. So I’m not trying to say that they should never be used, but I think at this point, the prescriptions way outnumber the need for it by a factor of many.

                                    And unfortunately, when you place someone on these medications, it does change the function of the HPA axis and does change the ability and the balance of how the body regulates things like circadian rhythm, how it regulates the production of neurotransmitters, how it regulates the production of receptors. And especially in younger people, I see that sometimes can make it much harder to actually treat them because even if they feel better for a while with the medication, it still becomes more of a challenge to work on the underlying issues because now you have this HPA axis that’s now been manipulated and changed a bit, and that sometimes can make it a little more challenging to really treat the underlying causes.

Dr. Weitz:                   Interesting, interesting. So our challenge from a functional medicine approach is more difficult.

Dr. Bongiorno:            Yeah. And look, like I said, if you have somebody who can’t get out of bed, is thinking of hurting themselves-

Dr. Weitz:                   Absolutely.

Dr. Bongiorno:            .. when you want them to do all this nice testing and go to Whole Foods and buy some salmon, if anyone’s ever gone through it, you know. It’s nice to think about these things, but you feel awful and there’s nothing.  So sometimes medication can get you out of that place and bless it if it can, but it is a challenge once it’s there to figure out how to help the body rebalance. Not impossible, but it’s definitely, I think as functional medicine, naturopathic, holistic practitioners, and especially those of us who are working with the conventional psychiatry world, we have to create a process and maybe a flow that allows us to question like, “Okay, do we need this medication in the beginning? Is it safe to start with that one? Can we start by working on more of the basics? Does this person monitored properly and in a safe place? And are they a single mom who needs to take care of a child and isn’t taking care of this child?” We have to ask all these questions to find out whether, be a little more judicious when we start using medications and see if there’s an opportunity to not use it because I think that allows the functional medicine to work even better once we bring it in.

Dr. Weitz:                   Right. Especially as you’re describing in a case where somebody has mild to moderate depression-

Dr. Bongiorno:            Exactly.

Dr. Weitz:                   … they’re not suicidal, they’re not in a situation where they’re an air traffic controller or taking care of young kids that they might not otherwise be able to take care of. Certainly in those situations, whatever you can do, medication, anything else to get that person doing better is the most important thing.

Dr. Bongiorno:            Absolutely. Yep.

Dr. Weitz:                   So what are some of the most important dietary factors that play a role in triggering depression and anxiety? Is there a best diet? What sorts of things should we be thinking about?

Dr. Bongiorno:            Yeah. Well, when I think about working with someone who has any condition, but especially mental health, I think about two things. Are they sleeping and are they pooping? So as far as pooping, the first thing I think about is are the bowels moving enough? Because if the bowels aren’t moving preferably every day, it is hard to create balance with inflammation in the body, with toxicity, with hormones, with nutrition absorption. All of those things really rely on bowel movements and the bowels moving every day. So I find that that’s critical, and we need to do our best, whether it’s to add fiber, to add water. Sometimes when anxiety is so high, that can be a reason the bowels shut down because, of course, when you’re running from a bear, you’re not going to be sitting down to eat a meal. So the body, the perimeter brain naturally shuts the gut down.  So sometimes doing things more acutely to help lower anxiety can be useful, whether it’s through supplements or acupuncture, just to kind of calm things down a little bit to get the bowels moving. So getting the bowels moving is my first order of business. In a sense, I don’t even get as concerned with what a person’s eating unless I think it’s constipating them too, because we just want them moving. The body’s so resilient, and we all know this. We know people who can eat absolute junk and stay really healthy because the body just wants to be healthy. And sometimes with the right genetics, it could do it even with poor food, not that I’m recommending that.

                                                And then the next step would be sit down and say, “Okay, what are we eating here and what can we change for the better?” And I would say without knowing a person or knowing their sensitivities or their preferences, if I had to pick a diet, I’d probably start with some version of the Mediterranean diet. Sánchez and Villegas in Spain started studying the Mediterranean diet in the early aughts, probably about 2003 or four were the first papers that came out. And so many papers have come out since then. And they’ve really shown how the Mediterranean diet works on that endothelial lining of the blood vessels. And it really helps with inflammation. It really calms inflammatory markers, the benefits it has on anxiety and depression to both prevent and treat the condition.   When you really look at even studies on longevity and the blue zones, people are pretty much eating some geographical version of the Mediterranean diet. So that would be a place I would start in terms of foods.

Dr. Weitz:                   What are some of the other important dietary factors? Blood sugar we know is super important.

Dr. Bongiorno:            Yeah. So blood sugar is definitely, especially with anxiety, I find blood sugar regulation is a key. I was working with a young girl who came in 17 with her mom and very severe OCD and anxiety, and we talked a little bit and it was so clear that her blood sugar was so low. And then when I looked at her blood work, her blood sugar was around 62, her fasting blood sugar-

Dr. Weitz:                   Wow!

Dr. Bongiorno:            … which is pretty low, not the lowest I’ve seen, but pretty low for a fasting blood sugar. And because it wasn’t high, no doctors really talked about it that much. No one had mentioned it to her. No one looked at an A1c, but I bet you the A1c is probably around four, and no one really looked at insulin. And sometimes now in young people, you see these very high insulins because of all the highly processed carby foods we’re eating, it spikes all this insulin and then it drops their blood sugar. So you have kids who really don’t eat much nutritionally, and they’re still eating a lot of sugar. So you get this high insulin, low blood sugar, and if you want to get the primitive brain stressed out and create an anxiety response, just keep the blood sugar low.  And then in this particular case, one of the other things that I noticed was that the ferritin was very, very low. And I see this also because you get these young women who are menstruating typically earlier and earlier, they’re not really eating nutritional food, not getting iron in, blood sugar is low, iron is low, and that’s a recipe for anxiety. By the time they’re 17, 18, now they’re starting to get really anxious and they don’t know why.

Dr. Weitz:                   Yeah, this is somebody who’s undernourished and probably has a huge amount of nutritional deficiencies.

Dr. Bongiorno:            Yeah. And then because they feel that way, they’re not focusing well. And then guess what happens. They get put on medications for focus, ADHD medication.  What does that do? That ramps up the dopamine so they focus a little better, but now the anxiety’s getting worse, and now we’re in this cycle, and I tell you, and you see this pattern over and over, and I think to myself, “Gosh, we have to work on the underlying issues here. We can’t just keep this ongoing,” because now you have a young girl who’s otherwise healthy and is now being told you have anxiety and focus issues, and you have these diagnoses. Now they’re on a couple of medications for anxiety, and we haven’t fixed the underlying issues yet.

Dr. Weitz:                   Right. You were talking about the need for amino acids to be able to produce neurotransmitters. And of course, that could be one reason why some of these medications are not effective in some cases because you take a serotonin reuptake inhibitor, which is supposed to keep serotonin around longer in the brain, but if the body doesn’t have the right precursors, amino acids and other nutrients to make the serotonin in the first place-

Dr. Bongiorno:            Absolutely.

Dr. Weitz:                   … it’s doomed to fail.

Dr. Bongiorno:            Right, absolutely. So then the question is is the person not taking them in or are they taking them in and the digestive tract isn’t absorbing them? If stomach acid is very low, you’ll see people with SIBO, small intestinal bowel overgrowth, their stomach enzymes are very low, their hydrochloric acid is low. They’re not really breaking down their protein. They might not even be chewing their food very well because they eat in a rush and they’re so anxious. And so, how is a person supposed to get enough protein digested for a good amino acid intake to make these neurotransmitters?

Dr. Weitz:                   Absolutely. And they may have H. pylori infection, and that’s usually associated with lower hydrochloric acid secretion. So maybe you can talk about the microbiome and its importance for the health.

Dr. Bongiorno:            Yeah. And the microbiome, so that’s the other side of the gut. So we have the stomach acid being produced in the upper gut and then down in the lower gut, we have … all these bacterias that are so important, and the microbiome and the microbiota is just such a key to keep in balance, to help produce neurotransmitters in the brain, to help keep inflammation balanced, to help process hormones in the gut. The liver, yes, processes a lot of hormones, but a lot of hormones get processed and get absorbed through the gut, and the microbiome has a lot to do with that. Plus the microbiome, that good bacteria also creates a lot of short-chain fatty acids, which has also a very important role in helping keep the brain in balance, too.

Dr. Weitz:                   And of course, to make sure you get enough amino acids, you’ve got to make sure you’re eating good quality protein.

Dr. Bongiorno:            Yeah. So yeah, protein is a key. And I tell my patients, especially first thing in the morning when your digestion is its strongest, it’s a really good idea, have a good breakfast, have good protein. But so many patients who come in, their cortisol levels are so high in the morning and they feel so awful. And I’ve been through it myself during a very stressful time where my cortisol levels are very high and I didn’t want to eat in the morning either. So I know exactly what that feels like. So it kind of sets up the day where you’re not eating in the morning, that your blood sugar is going to bounce around all day because you didn’t get the foods you needed first thing in the morning.

Dr. Weitz:                   And now, of course, a lot of people who are trying to promote their health are doing intermittent fasting, and a lot of them are instituting that by skipping breakfast.

Dr. Bongiorno:            Yeah. And for some people, it’s fine. If their blood sugar’s balanced and they’re getting their macronutrients in and their digestion’s good, then that could work for them because it does make sense. You give your liver a little bit of a break and it can clean out and do a little more in terms of detoxification. But for people who have that kind of blood sugar imbalance and their sugar gets really low, I do tell them the opposite. Usually using that example of the 17 year old with that OCD and anxiety, she probably needs less detoxification. She just needs more nourishment.  So for her, small frequent meals are better, but maybe for someone, let’s say a perimenopausal woman in her forties, maybe for her a little more intermittent fasting and detoxification would be good for her liver, might help balance her hormones. So there’s almost nothing that’s really good and bad anymore. It’s like, well, what’s going to be appropriate for an individual patient that’s going to really work for them? And that’s really the key.

Dr. Weitz:                   Personalized care, which is one of the keys to functional medicine. Yeah.

Dr. Bongiorno:            Absolutely. So yes, intermittent fasting could be very, very beneficial. It just depends who we’re using it for.

Dr. Weitz:                   Is coffee good or bad for mood disorders?

Dr. Bongiorno:            Yeah, so coffee could be pretty good. No, again, it depends on the person. So I always think about … My father’s going to be 90 and my mom’s going to be 86, right? They’re immigrants from Sicily. And my father can have four espressos and he’ll go right to bed and no problem. I don’t think he’s had a day of sleep problems in his life. My mother can drink decaf and be awake for two days. It depends on you. Some people, their liver, and now we know there’s certain genetic polymorphisms that will make us more or less able to process caffeine in a proper way through phase I of liver detoxification. And so, coffee has definitely been shown to be helpful in terms of cardiovascular health, in terms of liver health, it certainly gets the bowels moving in a natural non-addictive kind of way.  So I ask my patients, as long as the bowel movements aren’t too loose, as long as they don’t have a lot of anxiety or sleeping problems, then I think coffee’s good. I always make sure my coffee is organic because there are a lot of pesticides in coffee. And I do drink it black to make sure there’s no sugar, there’s no dairy in it. And so, for me, I feel like it’s healthy.

Dr. Weitz:                   Do you do the low mold coffee as well?

Dr. Bongiorno:            I haven’t gotten there yet. No.

Dr. Weitz:                   Me neither.

Dr. Bongiorno:            But look, it makes sense to me and especially for people who are sensitive, that might be a good idea. Look, I have patients, that’s something maybe in the beginning I might’ve said, “Oh, what’s the use of that?” But now I think about, I have patients who are celiac, if they use a shampoo that has gluten, their antibodies go up and I’ve seen it. So some people are that sensitive and they need that level of care, so yeah. So it might be a good idea for some people who are really mold sensitive.

Dr. Weitz:                   Right. What about alcohol?

Dr. Bongiorno:            Alcohol? Well, look, again, if you look at the literature, the studies keep bouncing up and down about how beneficial. We used to think that generally a little bit was fine and beneficial, and now it seems like it’s landing in such a way that for cancer, any amount of alcohol is not good, that any amount, depending on the person can help promote cancer. And that for heart disease, there doesn’t seem to be much benefit, but there might be a small benefit because alcohol is one of the few things that raises HDL levels.  So that’s my understanding right now. I also understand that alcohol has a relaxing effect for people, and I think that might have some benefit.

                                    Again, I’ll bring up my parents. I grew up, my parents always had a little bit of Manhattan before dinner, not enough to get drunk or even buzzed, but just a little bit. And when I think about that, I think now my father would come home from work. He worked hard all day. He was a bricklayer. My mom would be making dinner and you’d smell the food in the air. They would make the Manhattan with a little bit of bitters in it. They had the gentian bitters, they sip their Manhattan, they talk a little bit. They listened to some music. Then we sat down and we ate. Nobody does that anymore. So think about the role the alcohol played, it relaxed them. They got the bitters, the digestive juices were flowing. They smelled the food that they were cooking. That promotes good digestion. Those are just all things we’re not doing anymore.  So whether the alcohol is tremendously healthy for them, I’m not sure. But the overall ritual and effect I think was. And that’s what I think is missing in our lives today. We’re all so busy. We’re not sitting down having a little aperitif, cooking our food, smelling our food, our digestions getting ready, what do we do? We order food. We’re eating in the car. It’s a quick meal. “We got to go. Who’s got to go to practice?” And so, I think there’s a lot to be learned from the way we used to live.

Dr. Weitz:                   Absolutely. And herbal bitters is a great way to stimulate digestion.

Dr. Bongiorno:            Absolutely. So good to the liver.

Dr. Weitz:                   Stimulates pancreatic enzymes, stimulates hydrochloric acids, stimulates bile production.

Dr. Bongiorno:            Yeah. And the other thing it does is it helps promote our interest in non-sweet foods.

Dr. Weitz:                   Ah! Interesting.

Dr. Bongiorno:            We’re so used to sweet, sweet sweets, and a lot of us now don’t like bitter food because we’re so used to sweet because the primitive brain wants sugar because sugar, you pack fat and you make it through the winter. So if you have a winter where there isn’t enough food in a primitive world, you’re the one who’s going to live. So we’re so programmed for sugar, but the truth is the bitters are just so, like you’re saying, it has so many beneficial effects on our digestive system. And the more people can eat those bitters, the more they’re going to be inclined to eat more bitters and eat less sweet.

Dr. Weitz:                   How important is sleep and circadian rhythm?

Dr. Bongiorno:            Yeah. So sleep is basically the first chapter of all the books I write. Like I said, if we’re not sleeping and we’re not pooping, it’s hard to fix anything else. So no matter what any patient comes in with, it’s really important. I ask them about sleep and how they’re pooping. And if they’re not sleeping, then we want to work on that because sleep is where we detoxify. It’s where our mitochondria breakdown and build back up and build better mitochondria. It’s where our lymph system cleans out. It’s where our gut lining fixes itself. It’s where the liver fixes itself. It’s where the kidneys do most of their work because when we power down for the night, our body says, “Okay, now we can use our energy to do things we need to do for maintenance.” For years, nobody really understood why we slept, but now we know. We have all this great information and research teaching us why we need to sleep.

Dr. Weitz:                   Do you get into analyzing sleep? Do you have your patients use a Oura Ring or some other device to look at quality of sleep and REM and deep sleep and et cetera?

Dr. Bongiorno:            I do sometimes. Usually a good patient intake will tell me what’s going. I mean, a patient knows if they’re sleeping or not. A great question is when you wake up in the morning, do you feel rested? So oftentimes they know if they’re not sleeping. But yeah, I do think it helps and I find patients do like to see the data to see what their REM and non-REM sleep is, and if they’re getting into deep sleep long enough. So I do think it’s helpful. And I do find those things for the most part correlate with what we’re hearing clinically. I can’t say from my perspective it’s changed too much what we do, but I think it’s valuable. And I think if it helps a patient motivate to make the changes we need to make, then I’m all for it. Yeah.

Dr. Weitz:                   What about the role of exercise in helping them manage mood disorders?

Dr. Bongiorno:            Yeah. So exercise is definitely a key. If we’re not moving our body … One time somebody asked me the question, I had to think about it, “If you could only do one thing, exercise or eat well, which would it be?” And I had to think about that. And when I thought about it, I don’t even remember what I said as the answer, but when I thought about it over a couple of days, and I thought to myself, “Well, if I ate well and just sat in bed all day, I would die,” right?

Dr. Weitz:                   Right.

Dr. Bongiorno:            But if I ate crappy and moved my body, I think I had a chance. So now I’m starting to think, “Okay, well maybe exercise is more important.” I mean, neither is more important. We need both of them, obviously. But exercise, the point is that exercise is crucial and it’s absolutely important for mental health. There’s no question about it. When you get stressed out, you want to run. It’s fight or flight. You want to run, you need to move your body.   So when we have all these stress hormones and we’re not moving our body, what happens is these stress hormones affect our brain. And our brain starts to look around and our brain doesn’t realize that there isn’t a bear coming at us. Our brain just knows that there’s stress hormones up and that there’s something wrong. So if you have an average person who’s just going to work and doing the normal things of a day, but those stress hormones are high, now the brain is going to start conjuring things. And that’s where anxiety comes from and obsessive thoughts and impulsive and all these things come from because there’s something not right. The level of stress hormones in our body does not make sense with what our brain is seeing on the outside.

                                                And so, exercise is a brilliant way to try to equalize that while we’re working on the underlying reasons we are that stressed out. Exercise helps us build better mitochondria, which we need for our nervous system to work really well. Exercise. It’s interesting, there’s studies that show how exercise in the short term actually creates more gut permeability. While you’re exercising, there’s a little inflammation and you get this transient permeability. But people who exercise regularly, what’s been shown is they actually have less gut permeability because now the body reacts by healing it and creating a better gut. And we actually have better digestion as a result and less leaky gut.

                                                So many good reasons to exercise. There’s a study out of the University of Copenhagen that came out of a few years ago and showed that people who exercised moderately by running or some kind of cardio work, the men live 6.2 years longer. The women 5.6, something like that, years longer. I mean, if there was a drug that somebody could sell to you and say, “Hey, you spend $2 a day on this drug, you’ll live six years longer, no side effects, and you’ll feel better, wouldn’t you take it?

Dr. Weitz:                   Absolutely.

Dr. Bongiorno:            I would take it. I would take it. I would buy it.

Dr. Weitz:                   The longevity benefits of exercise are just so many, it’s incredible.

Dr. Bongiorno:            Unbelievable.

Dr. Weitz:                   Maintain bone density, as you mentioned before, maintaining your muscle mass, your balance, because as you get older, that’s crucial for longevity.

Dr. Bongiorno:            Yeah, it’s amazing. And you know what’s amazing to me too is that I never heard of that study in the media. No one ever mentioned it. I never saw it on the news. Five to six years live longer. Why wouldn’t somebody want to talk about that?

Dr. Weitz:                   Well, because there’s no pharmaceutical company that patented exercise and hired a PR firm to get the word out about it.

Dr. Bongiorno:            Yeah, it’s just not right. I don’t know what else to say about that.

Dr. Weitz:                   No, I know. It’s incredible.

Dr. Bongiorno:            It’s why we have a job, right? I mean, in a way, that’s it.

Dr. Weitz:                   Yeah. No, absolutely. It’s good they did the study though, because not enough research is being done on nutrition and exercise and these natural things because it’s not easy to make a lot of money out of it. And that’s who’s paying for most of the research.

Dr. Bongiorno:            Right. And a lot of the studies we see on natural medicines come from other countries because there are other governments who at least see some value in it, and the money’s put in. And if you notice, very few actually come from the United States because it’s just not a priority.

Dr. Weitz:                   No, I know. It’s amazing. I interviewed Dr. Terry Wahls, and you probably know about her.

Dr. Bongiorno:            Yeah, of course.

Dr. Weitz:                   Her story’s incredible reversing MS, and almost all the money coming for her research studies is coming from private donors.

Dr. Bongiorno:            Right, exactly. Yeah. People who care and are interested in making a difference. Yeah.

Dr. Weitz:                   Because the NIH is just not really funding a lot of that type of research on using diet and exercise and natural methods for combating chronic degenerative diseases.

Dr. Bongiorno:            Right. That’s right. Yeah.

Dr. Weitz:                   So what about in today’s world with electronics and social media? Is that something you address with patients with mood disorders?

Dr. Bongiorno:            Yeah, absolutely. Especially patients with focus issues and attention issues, and especially younger people. I mean, these bright screens, and, I mean, look at what I’m doing right now. It’s 10:18 in New York, and I’m staring at a bright blue light screen. I mean, yeah. We’re laughing, but that’s the truth, right?

Dr. Weitz:                   Yeah. No, absolutely.

Dr. Bongiorno:            Right now my melatonin wants to come up, but it can’t because I’m doing [inaudible 00:44:28]. And yeah. And that’s an issue. Plus a lot of screens there’s a lot of fast moving things. When you take kids out into nature, nature’s very slow. It doesn’t move the way a video game moves. And so, they start to get anxious about it because they’re waiting for the next dopamine hit because that’s really what it is. It’s getting addicted to dopamine and producing dopamine quickly, and it feels really good. And then when it goes away, things don’t seem as fun. Things seem bored, and then you kind of looking around for the next dopamine hit, and that’s the problem. And some kids are more susceptible than others. There are some kids, there’s interesting studies during the pandemic that showed how kids, because they had to isolate and be home, that that isolation and having to do things virtually really affected young women very heavily. And they tended to get more depressed and a lot more anxious.

                                                They found for young boys, too much was no good as well, but they found that some was actually more helpful and that some of the gaming and stuff actually kind of kept them up enough where otherwise they wouldn’t have been. So every kid is different, and certainly gender can affect it as well, but there’s no question that we’re all doing too much screen time and that’s not great for our brain.

Dr. Weitz:                   And you mentioned going out in the forest. Forest bathing is a wonderful therapy.

Dr. Bongiorno:            Yeah. Yeah, I talk about that in my books, too. It’s called shinrin-yoku, right?

Dr. Weitz:                   Yep.

Dr. Bongiorno:            And that the forest itself, the trees actually emit something called phytoncides, and that we breathe them in, it gets into our bloodstream, and it affects our nervous system in a very healthy way. It’s very calming. Inflammatory markers go down. Yeah. I mean, we’re made to be in nature.  I remember when I was in naturopathic school, one of the advice, Dr. Mitchell, one of the founders of Bastyr University, used to tell us, he used to say, “I want you to go outside and just find your favorite tree and sit and look at it, talk to it, listen to it, get to know it.” And it’s really powerful. If you’ve never tried it, sit with a tree and just talk to it a little bit and listen to what it has to say. It’s pretty interesting.

Dr. Weitz:                   Cool. So let’s go into lab testing. Tell us about what kinds of labs you like to run with your patients with mood disorders?

Dr. Bongiorno:            Yeah. So I’m a big fan of running labs. I think there’s so many, for mental health, like we were talking about earlier, there’s so many factors involved in why someone’s mood might not be right, whether it’s anxiety, depression, schizophrenia, bipolar disorder. There’s so many possibilities. And so, we want to run some labs to figure out what we need to work on. So there’s some basics that I like to run with everybody, like a CBC, blood sugar, insulin, A1c, a full thyroid panel with antibodies, vitamin D and iron panels, critical and ferritin for iron storage. And then looking at some of the vitamins, magnesium, zinc, zinc-to-copper ratio, B12. Sometimes you can’t run everything on everybody because it’s just too many vials. But what you can do is get a really good history and then start to narrow down.

                                                And then usually depending on the patient, I’ll run hormonal tests. I’ll run tests to look at cortisol and adrenal function, take a look at melatonin levels, glutathione levels, mycotoxin testing could be very important as well. And then looking at stool testing in some patients, too. Looking at the microbiome a little further. Sometimes if I hear some basics are very off, again, we were talking about that 17-year-old girl with anxiety and OCD, if there’s some basics that just aren’t there, then sometimes I won’t run a lot of testing because we know we need to get those basics in. Maybe a person needs to get to bed earlier, they need to start moving their body, they need to eat green vegetables, make sure they’re getting essential fats in their body. So if there are a lot of basics not there, then sometimes it’s not worth running a lot of tests because we know we have to get these in, and then if they’re not better, then we could also run additional testing, too. So everybody’s different.

Dr. Weitz:                   What are some of the favorite lab testing companies you like to use? Do you send patients to Labcorp and Quest, or do you use-

Dr. Bongiorno:            Yeah, I mean, I use, if we can work through their insurance and Labcorp and Quest usually that gets the job done for a lot of the basic blood work. There are a couple of specialty labs I tend to rely on. I do the Dutch panel, which is very good, but Genova also has some very good adrenal testing, too.  I love Diagnostic Solutions Laboratory.  I think they do a good job, especially with the genetics and using the Opus23-powered genetic profiles.  So that’s very helpful, too.  The GI-MAP testing is excellent.  RealTime Labs has their mycotoxin testing. Dr. Campbell has their mycotoxin. I think they all have benefits as well. So, yeah. So there’s a number of different good ones out there. Those are probably the ones I tend to use and rely on the most.

Dr. Weitz:                   For nutrients, are you running serum levels?  Are you doing some of the specialty micronutrient testing?

Dr. Bongiorno:            Yeah, I don’t do too much of those. Not that I don’t believe in them, but just that there’s already so many tests. And usually with a blood panel, it’s almost like you can’t run them all. But I get an idea from the ones we do run, and then we just make sure we cover them all with our intake. And as long as I think somebody’s absorbing, then we’ll do, but I could see some benefits of running specialty labs as well.

Dr. Weitz:                   Give us some insights on some of those labs that are helpful in how you approach patients.

Dr. Bongiorno:            Yeah. So you have somebody who can come in who could be very fatigued, and there are people who have very high cortisol, and that could fatigue them because when cortisol’s very high, it bathes the brain. And especially if DHEA is low, then you’ll see a brain that people feel really tired and almost like this kind of floaty effect at the same time. And then you have other people that are tired and their adrenals are just flat. They’re not making any cortisol, and they can have very similar clinical presentation. So running a test that looks at adrenal function, looks at cortisol could be very, very helpful because it can differentiate between those two things.

Dr. Weitz:                   That’s really interesting because we typically think of cortisol being high as the person has trouble sleeping and they’re overstimulated rather than showing fatigue.

Dr. Bongiorno:            Yeah. And I would say the majority of the time that’s true, but not all the time. So that’s why the tests are so nice. And then, yeah, for nighttime, when people aren’t sleeping, it is nice to see, is cortisol super high at night and is that the problem? Or is cortisol really normal, but they’re not making enough melatonin, or maybe they’re making enough melatonin and their cortisol is normal and it’s completely something else. So that helps differentiate. And what I’ve noticed is it kind of gets me there a little faster to help create a treatment plan that’s effective. So that’s why I like using tests like that because it can help to differentiate

Dr. Weitz:                   And hormones. Do you sometimes recommend hormones when their hormones are low?

Dr. Bongiorno:            Yeah, absolutely. I mean, hormones from pregnenolone, which helps make both cortisol and progesterone through one pathway and DHEA and testosterone, and then into estrogen in another pathway, all of those different steroidal compounds will affect the brain and the receptors that the brain makes for neurotransmitters and the metabolism of the neurotransmitters themselves. So for example, if a woman or a man has low estrogen, that’s going to affect their production of serotonin and affect the ability of the serotonin receptors to be produced, too. So yeah, we’d want to look at that.

                                                Testosterone, of course, is very important as well. In fact, I wanted to talk to Steve about that. Steve, there’s one test. We were talking about lavender and testosterone. They did this test on animals. I’ll have to pull it up, but I remembered while you were talking that they looked at, I think it was rats who were given formaldehyde poisoning to affect their liver and their testes, and they found that these rats that were treated with the formaldehyde, testosterone levels went down. But when they were given lavender, it actually protected the testicles and they didn’t see the decreases in testosterone so I thought that was kind of interesting.

Dr. Weitz:                   Really, really interesting. Yeah.

Dr. Bongiorno:            Something to think about.

Dr. Weitz:                   So you mentioned men with low estrogen that they can have trouble making serotonin. How do you address that?

Dr. Bongiorno:            Yeah, so men have have actually more estrogen in their brain than women does. So estrogen’s important, and that’s why the panels look at estrogen in men. We don’t see progesterone in those panels. We use the estrogen.

Dr. Weitz:                   So what do you do with men with low estrogen?

Dr. Bongiorno:            Well, so the next thing you want to check is are they making testosterone because testosterone gets made into estrogen. So sometimes if that’s low or really flagging, then that could be a reason. And then you want to look down the line. Are they making DHEA? Are they making pregnenolone? Are they making cholesterol? Cholesterol’s the first one that everything else is made from.

Dr. Weitz:                   Or are they taking heavy statins and trying to get their cholesterol as low as possible.

Dr. Bongiorno:            Exactly. Right. That could be an issue. It could be an issue that they don’t have enough fat tissue, that maybe they need … It’s not common, but sometimes that happens, too. So we see that as well.

Dr. Weitz:                   So you’re saying your body fat is too low?

Dr. Bongiorno:            Possibly. Yeah, possibly. So not common, but it’s possible. So then-

Dr. Weitz:                   Right. So then-

Dr. Bongiorno:            I’m sorry. Go ahead.

Dr. Weitz:                   No, I was going to say let’s go into supplements that are beneficial for depression and anxiety. And I wanted to maybe start with NAC. I was going through some of the literature, and there’s amazing research on NAC. There’s studies showing it can be used as an acute intervention for patients who are suicidal. It can be effective for severe depression, not just mild or moderate.

Dr. Bongiorno:            Yeah. Also for bipolar, there’s strong research for bipolar, for trichotillomania, which is hair pulling, which is basically an obsessive kind of [inaudible 00:56:09]-

Dr. Weitz:                   What was that term?

Dr. Bongiorno:            Trichotillomania.

Dr. Weitz:                   Great word.

Dr. Bongiorno:            Yeah, that’s the word of the day, trichotillomania. And so yeah, no, NAC, N-acetyl cysteine, it’s a precursor for glutathione, basically. And in its own right, it’s a very good mucolytic. So the perfect patient is someone who has some mood issues and are all stuffed up all the time. So maybe we get them off of dairy, do some nasal rinses, and take some NAC for all of that, and it could be very helpful. Yeah, I love N-acetyl cysteine, and unfortunately, it’s something that’s been threatened on and off for the past couple of years to be taken off the shelves.

Dr. Weitz:                   Right. Yes. Yeah. Apparently what happened is that it was originally studied as a drug.

Dr. Bongiorno:            Mm-hmm. That’s right.

Dr. Weitz:                   So there was some thought that the FDA might ban it because of that, and so Amazon stopped selling it, but it’s still being made and it’s still being sold.

Dr. Bongiorno:            Yeah. Interestingly, Amazon doesn’t also sell CBD, right?

Dr. Weitz:                   Oh, really?

Dr. Bongiorno:            You can’t even get CBD on Amazon. And I noticed also Fullscript doesn’t sell, Amazon doesn’t sell CBD as well.

Dr. Weitz:                   Really?

Dr. Bongiorno:            Yeah, yeah. Try to get it on those. You’re not going to find it.

Dr. Weitz:                   Oh, interesting.

Dr. Bongiorno:            Yeah. So, there’s still some-

Dr. Weitz:                   [inaudible 00:57:40].

Dr. Bongiorno:            Yeah. Well, it seems like there’s still-

Dr. Weitz:                   Is it the marijuana thing, you mean?

Dr. Bongiorno:            Yeah, I think there’s still some residual regulatory issues about that. I know of cases where PayPal, when people have stores, practitioners have stores, PayPal will shut it down if they’re selling CBD. So there’s still a lot of things like that going on.

Dr. Weitz:                   Oh, wow.

Dr. Bongiorno:            Yeah. We’re not there yet. But that’s an interesting thing too, because we see all this legalization of marijuana, which I’m not necessarily against, but I think the powers that be should have really taken a look at the literature and shown that people who take marijuana every day, especially young people before the age of 25, 26, when the nervous system and the brain is fully formed, it really does affect in a negative way things like the HPA axis. And I do wish, even though I think marijuana clearly has medicinal use along with CBD, I think it should have been regulated to be legal after that age, because I’m very worried about people. I have a daughter who’s 15. In a couple years, she’s going to go to college, and most likely the college she goes to, marijuana is going to be legal for her age. And I really am very concerned about kids and young people using marijuana every day.  And the problem is now marijuana is not the marijuana from the ’60s. It wasn’t like, oh, indica or sativa and sativa’s a little bit stronger. Now. It’s this very, very high THC content, low CBD content. So now we’re getting something that we’re seeing, I’m seeing it now in my practice, a lot more cannabis overuse syndrome, because people are smoking what they think is reasonable amounts, and now they’re getting addicted to it, and now they’re starting to get these syndromes, these cyclic vomiting issues, these digestive. So this is something that’s coming, and it’s going to be a big concern, too. So something that I think has a lot of benefit can also be an issue.

Dr. Weitz:                   Interesting. So what is some of the other most impactful supplements for mood disorders?

Dr. Bongiorno:            Oh, yeah. Sorry. I got sidetracked.

Dr. Weitz:                   That’s okay.

Dr. Bongiorno:            So if you look at the literature and you say, “Okay, just from meta-analysis,” for example, probably the top ones are St. John’s wort, SAMe, curcumin, and I would say Rhodiola, St. John’s wort, Hypericum, is probably the most studied herb of all time. There are meta-analysis of meta-analysis now on St. John’s wort, meaning that meta-analysis is a study of studies. Now, there’s studies of the studies of studies, and so thousands and thousands and thousands of people, and what’s been shown is that St. John’s wort clearly for mild to moderate depression works just as well as SSRIs with less side effects. So we want to be careful with St. John’s wort because if people are on a number of drugs, it can affect the activity of those drugs through the liver. It affects the cytochrome system. So you always have to be a little more careful with St. John’s wort than maybe a few other things because of that processing issue.

                                                But there’s studies that also show, for example, if people are taking Plavix, which is a drug for blood clouding to help protect the cardiovascular system, what they’ve shown is that when people take Plavix and can’t take more because of side effects, and they take some St. John’s wort, they can actually get the effect they need from the Plavix without having to increase the drug. So as much as we’re worried about negative interactions, we need to study more of these positive interactions because now we know there’s benefit there.

Dr. Weitz:                   Exactly. So I’m assuming it’s inhibiting part of the cytochrome P450 liver detox.

Dr. Bongiorno:            Exactly. Yep, exactly. And sometimes we can use that to our advantage.

Dr. Weitz:                   Absolutely.

Dr. Bongiorno:            As long as we know the medications patients are taking, how the drugs work, how the cytochrome system works, then we can make actually good decisions and use them together.

Dr. Weitz:                   Right. You can use grapefruit juice also as a way to modulate.

Dr. Bongiorno:            Exactly. Very strong. Yep.

Dr. Weitz:                   Yeah. Fish oil.

Dr. Bongiorno:            Fish oil, yeah. I mean, absolute favorite. No question about it. Studies keep coming out about fish oil. Fish oil just supports healthy cell membranes, and when you have a healthy cell membrane, you’re going to be able to get nutrients in a cell, you’re going to be able to get toxins out of a cell. You’re going to get tempered, balanced immune reactions because a cell membrane breaks when immune reactions need to happen. And that keeps it a much more tempered immune system.  Probably about a year and a half or two. Yeah, it’s probably two Augusts ago, so over two years ago now. There’s a study that came out in, I forget which journal, I apologize. One of the psychiatry journals showing how in patients who are treatment resistant to antidepressants, when they take fish oil, then the antidepressants work better. Which also made me wonder, did they need the antidepressant or did they were really just low in fish oil?  Actually, one of the tests I probably started using more and more in the past couple of years is an omega check, a fish oil, basically looking at essential fatty acids in the bloodstream. And that’s very helpful to see.

Dr. Weitz:                   Yeah. So what were those herbs you mentioned besides St. John’s wort that you said? [inaudible 01:03:37].

Dr. Bongiorno:            Oh, yeah. So the other ones I think are pretty clear from a meta-analysis standpoint, showing benefits at least as equal as the medications. And I want to qualify that because I said earlier that medications for depression work maybe 25 to 35% of the time for depression. So I’m not even suggesting that the supplements work better. They work probably around the same. So it still tells us we have a lot of other work to do. But I would say, someone with mild to moderate depression who isn’t at risk of hurting themselves or someone else, why would we start with a medication with more side effects? Why not start with something more natural to the body that can work just as well with less side effects?

Dr. Weitz:                   So yes, SAMe, which is S-adenosyl-L-methionine, can help the body move some of the cycles that help create better neurotransmitters, especially if people have poor methylation. Sometimes we’ll see people with things like high homocysteine and they have MTHFR polymorphism and we know maybe if we support the methylation with things like SAMe, you need methylation even to make CoQ10. It’s hard to make proper amounts of CoQ10 without that. So that’s a very good choice for some patients.

Dr. Weitz:                   And then of course, methylated B vitamins to go along with that.

Dr. Bongiorno:            Yeah. And in the right patients, methylated B vitamins can be very helpful, too, to help move those as well and lower the homocysteine. And then I mentioned Rhodiola. Rhodiola has a rich history starting in Russia when it was first studied, and that definitely is something that can be very, very helpful. It’s considered a natural COMT inhibitor. COMT is one of the genes that’s important for how we break down neurotransmitters. So sometimes people who are very depressed, you can use Rhodiola as a way to help keep neurotransmitters at a higher level. So it’s very supportive that way.  And then curcumin. There’s forms of curcumin that have been studied that have very good antidepressant quality and that makes sense because it’s a very potent anti-inflammatory. But there’s a fellow named Aggarwal who’s done a lot of studies on curcumin and he shows that there’s so many more mechanisms than just the pure anti-inflammatory effect that creates some of the benefits.

Dr. Weitz:                   Yeah, curcumin’s an amazing herb. I’ve seen some of the anti-cancer effects and one doctor showed a chart that showed just affecting 20-

Dr. Bongiorno:            Yeah, exactly.

Dr. Weitz:                   … different pathways that all potentially could decrease your risk for cancer growth.

Dr. Bongiorno:            Yeah, absolutely. Yeah, it might’ve been that same fellow. I don’t know because I know he’s someone who’s studied at a high level and it’s just amazing. And I remember him saying in this conference, it was a number of years ago, he said, “There’s no drug that did this, and if there was a drug, it would be an absolute blockbuster cancer drug.”

Dr. Weitz:                   Right.

Dr. Bongiorno:            So I remember those words.

Dr. Weitz:                   Yeah. What about saffron? Steve mentioned saffron. That seems to be a newer herb that seems to have some benefits.

Dr. Bongiorno:            Mm-hmm. Yeah, it’s interesting. A number of years ago I did some formulations for Douglas Labs and the formula I created was actually the first formula for mood to have saffron in it. So it’s something I’ve been interested in for many years. I first caught wind of it when I was looking for something to help patients who had libido issues with SSRI drugs, and, albeit small, there are studies in men and women that show benefits for libido when they’re taking SSRIs. So sometimes I have a patient either can’t get off a medication or really don’t want to, but they want help with libido and there’s some research there. I mean, of course we want to work on all the other underlying factors that contributed to libido, but when you see that clear SSRI-induced change in libido, that’s a reasonable choice to try.

Dr. Weitz:                   Right. Lithium, I know you wrote a paper about lithium.

Dr. Bongiorno:            Yeah, so lithium orotate also known as nutritional lithium, so not lithium carbamate the drug. Is it just very small amounts, milligrams, usually between five and 20 milligrams is helpful. I use it to help people with typically anxiousness, impulsivity, even in children, a milligram, two milligrams up to five can be helpful, too. And it’s known as a way to just help calm the amygdala, help calm that fear center of the brain, help it work better. You can check it with hair analyses and see if levels are low or just start on low levels. I personally have never seen it affect kidney function or thyroid function the way the drug does. I think it’s still a good idea to check those before and during just to make sure. But I’ve been using it for years and I haven’t seen any issues like that, thank goodness.

                                                In fact, I was on a group today, I was teaching nurse practitioners and functional psychiatrists, and one of the fellows, I think it was a psychiatrist, had told me that he saw somebody go up to 30 milligrams and do quite well with it with no issues as well. So I hadn’t actually used it at that high. Usually I don’t go past 20, but he said 30 milligrams wasn’t a problem, at least in the one patient he saw. So yeah, definitely very, very helpful. I actually like combining it with CBD. I find they work really nicely together. So supporting the endocannabinoid system, calming the amygdala seems very helpful.

Dr. Weitz:                   And then there’s specific amino acids and other nutrients to help support the various neurotransmitters. So we have 5-HTP, we have Mucuna for L-dopa, we have GABA. What about some of those supplements?

Dr. Bongiorno:            Yeah, I mean, if you hear that when patients tell you that, “Oh, I took a drug, it raises dopamine like Wellbutrin,” for example, which is very good at raising things like dopamine, then yeah, then it makes sense. Well, why not support the dopamine pathways more naturally if we can? And Mucuna, which is a natural amount of low levels of L-dopa can be useful along with some tyrosine, which helps support the pathway to make dopamine. Of course, we always want the co-factors in there. We want vitamin B6, vitamin D levels, zinc levels appropriate as well, because those are going to be really important for the body’s ability to use those materials to make the eventual neurotransmitters, too.

                                                But yeah, those are great, 5-HTP to support serotonin. Sometimes I use tryptophan, sometimes I’ll use 5-HTP. I find tryptophan helps people stay asleep better at night, so sometimes I’ll use tryptophan at night, but 5-HTP during the day. I know some practitioners from a theoretical standpoint feel that if there’s a lot of inflammation and they’re going through that quinolinic acid pathway, then maybe 5-HTP is a better choice. I find this really interesting, even though theoretically and it makes sense. I’ve seen in practice that hasn’t necessarily affected it, so I just try to use what’s best and what I think is working for a patient.

Dr. Weitz:                   Interesting. Which company do you get the tryptophan from?

Dr. Bongiorno:            I’ve been using tryptophan from Douglas Labs typically. Yeah. They have a little bit of B6 in there, so it’s nice if a patient isn’t taking B6 or doesn’t have enough level, then that’s helpful.

Dr. Weitz:                   Okay, good. Yeah. I think most of the functional medicine supplement, professional supplement companies are carrying 5-HTP, but not so much tryptophan.

Dr. Bongiorno:            Right? Yeah. I know tryptophan’s a little bit old, but I don’t know. They took=

Dr. Weitz:                   Well, you took it off the market.

Dr. Bongiorno:            I’m a little bit old. Well, that was a mistake. That was purely because the company had introduced the bacteria there. In fact, it was interesting. When I did research when I was in my twenties, right out of college at the National Institutes of Health was, it was like this sort of predoctoral fellowship, and there was a doc in one of the labs I worked in. Her name was Esther Sternberg, and she was actually one of the people who testified because she was a well-known tryptophan researcher. So they brought her in to talk about tryptophan. And so, she was one of the people that helped them understand that tryptophan itself doesn’t cause eosinophilia-myalgia syndrome, this EMS, which about 30 or 40 people unfortunately die from. But it was actually just the bacteria that was introduced by the company who I guess shouldn’t have been making that they didn’t know exactly what they were doing.

Dr. Weitz:                   Right. Okay.

Dr. Bongiorno:            Yeah. Very unfortunate.

Dr. Weitz:                   Excellent. Any final thoughts you want to leave us with?

Dr. Bongiorno:            No. Well, what I would say is if you’re listening out there and you have mood issues, and I know what they feel like because I’ve had some myself and I’ve been through a little bit, unfortunately, too. When you’re going through it, it just feels like nothing can help you. It almost feels like this monster from the outside who just comes and goes as he or she pleases and doesn’t let you live the life you want to live. It’s always worth looking for a practitioner who will sit and listen to you and help look at these underlying issues. And I can tell you that there are things that can be done and it’s always worth searching for them. And of course, if for at any time you feel like you want to hurt yourself or something, please call a loved one. There’s wonderful hotlines, people who really want to listen and who care and who are there to help.

Dr. Weitz:                   Anybody on the call right now who wants to ask Peter a question, you feel free to unmute yourself or type it into the chat box. Okay. And then how can folks who listen to this get ahold of you?

Dr. Bongiorno:            Oh, yeah. Thank you. So yeah, so my website is drpeterbongiorno.com. That’s D-R-P-E-T-E-R-B-O-N-G-I-O-R-N-O dot com. It’s a very long name, drpeterbongiorno.com. Yeah, so feel free to. All my contact information is there.

Dr. Weitz:                   Excellent. Thank you so much.

Dr. Bongiorno:            Oh, thank you. And thank you for all the work you do and just having me on. And it’s really an honor and I appreciate everything you’re doing, all the good information you’re putting out there.

Dr. Weitz:                   Thank you, thank you.

Dr. Bongiorno:            Thank you, Dr. Ben.



Dr. Weitz:                   Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way, more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective.  So if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.


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