Integrative Psychiatry with Dr. Robert Hedaya: Rational Wellness Podcast 333
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Dr. Robert Hedaya discusses Integrative Psychiatry with Dr. Ben Weitz.
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Podcast Highlights
1:38 Dr. Hedaya noted that from his time in medical school he was always oriented towards getting to the root cause of things. After writing his first book, he was on the edge of chronic fatigue and he dove into the metabolic medicine approach of Dr. Jeffrey Bland, which later was changed to Functional Medicine. Dr. Hedaya was a neuropharmacologist trained in cognitive behavioral therapy and after bringing Functional Medicine into the mix he found that he was no longer doing this medication merry-go-round and most of his patients were now getting better. Dr. Hedaya explained that after writing his second book, he hired a statistician to assess the patients he had treated for treatment-resistant depression. All 23 of these patients when they started had a mean Beck Depression inventory of 34, which is in the severe range, and by about 10 months everyone was normalized with only one change in medication but also adding the Functional Medicine approach.
4:18 Insights into a Functional Medicine approach to psychiatry. The key to using a Functional Medicine approach is to be a medical detective and to also understand that psychiatric problems are not primarily psychological, but more related to physiology and infections and hormonal problems and genetics and epigenetics and gastrointestinal things, etc.. The mental realm is directly part of the physical realm. If your physical health is lacking, if you’re lacking in nutrients, if you’re having toxins and infections and other things that are affecting your physiology, that’s also going to affect your mind. Dr. Hedaya recalled his first patient from 1984 who was a 50 yr old woman with panic disorders and she did not have a great marriage and had bunch of things going on, but she didn’t get better despite psychotherapy and medications. He determined that she had a vitamin B12 deficiency and after her first injection, her panic went away and that’s when he realized how powerful the Functional Medicine model could be. When assessing B12 status, if your serum B12 is low normal, you probably have a B12 deficiency. But you can also look at the size of the red blood cells, the MCV, on the CBC. If you are B12 deficient, your red blood cells will get larger because they hang around longer–macrocytic anemia. If you are iron deficient, your red blood cells will be smaller–microcytic anemia. But you could have normal size red blood cells if you have both iron and B12 deficiency, because they will offset the effects on the red blood cell size. We should also look at methylmalonic acid (MMC) and homocysteine as measures of B12 status, though MMC only accounts for 17% of B12 status. You also need to look at medications that interfere with B12 status and if they are older they tend not to absorb as much B12 because of reduced HCL production.
10:57 Iron. Dr. Hedaya looks at serum iron and TIBC (total iron binding capacity) and also the CBC. And he will also look at ferritin levels.
11:29 Other nutrients. Fish oil is a very important preventative for depression as is vitamin D status. Zinc is also a very important nutrient and this needs to be balanced with copper levels. It is also very important to make sure the patient is eating and digesting enough protein, since these amino acids are necessary for neurotransmitter production.
12:12 Thyroid adrenal axis. Another clinical pearl is the thyroid adrenal axis. We need to do a thorough physical exam and look for evidence of adrenal insufficiency and low thyroid. The mean TSH in the US population based off the NIH study is about 1.5, though the upper limit of most labs is 4.5. When dealing with neuropsychiatric problems you should look to be closer to 1.5 or even 1, esp. for depression. There’s plenty of evidence that for treatment resistant depression, that hypermetabolic doses of thyroid hormone, particularly T3, will help people come out of depression. Some of this has to do with SNPs variance in the deiodinse 2 genes that control the conversion of T4 to T3 in the brain. Dr. Hedaya used to use Armour thyroid, which contains a combination of T4 with some T3 from pigs, but now he uses a combination of synthetic T4 with some T3. If there is a perceived threat, the body will stop converting T4 to T3 because it perceives that the adrenals can’t handle it.
15:30 Genetics. There are various genes that you can test for that include NR3C1, FKBP5, CRH receptor 1 and 2, CRH binding protein, these control proteins that control the effective steroids inside your cell at the level of the nucleus. Dr. Hedaya has found that a lot of his patients have variants in these genes, which means that when you’re stressed for whatever reason and you release cortisol, your cells at the level of the nucleus can’t convert the stress signal efficiently to the genome, and then your genome doesn’t respond properly, and now you’re vulnerable to stress, to immune dysfunction, to depression, and even to suicide. So these genes are really important since they indicate a genetic cortisol resistance. You can get glucocorticoid resistance from having infections or from over methylation, the different pathways to glucocorticoid resistance and that’s not really recognized. I think that’s part of the reason people are having trouble responding to treatments for Lyme disease, for example, chronic Lyme and certainly chronic long COVID, that’s part of the picture. Dr. Hedaya likes to run the Opus23 genetic panel, which is offered by Diagnostic Solutions Lab as the GenomicsInsight test, though there is also the Intellxx panel.
18:18 Gut Health. The gut is called the second brain and it sends signals to the brain through multiple pathways and of course communication from the brain to the gut. The gut, the brain, and the endocrine system work together seamlessly. We are our microbiome and changes to our microbiome can change behavior.
25:32 Ketogenic diet. Dr. Hedaya will use a ketogenic diet for certain patients, esp. if they have evidence of having seizures, such as seen on quantitative EEG. Dr. Hedaya will use an experiment in his office by having a patient consume a couple of tablespoons of MCT oil while in the office and then see how they feel in 30 minutes. This mimics the types of ketones that are produced by a ketogenic diet. If the patient notices some improvement, he will lean towards a ketogenic or low carb diet or using MCT or beta-hydroxybutyrate. Even if he doesn’t use a ketogenic diet, Dr. Hedaya thinks it is important to balance blood sugar by properly balancing healthy proteins and fats with carbs. He may also recommend 5-HTP to help with serotonin production, though he does not recommend taking tryptophan as this may go down the kynurenic and quinolinic acid pathway and increase glutamate, which can increase anxiety and agitation.
30:24 HYLANE technology. Dr. Hedaya has an advanced set of protocols that he uses that includes includes hyperbaric oxygen, EEG-guided laser, and neurogenic exercises that he refers to as HYLANE technology. Hyperbaric oxygen has been used for many conditions, including for traumatic brain injuries and strokes. Hyperbaric oxygen does increase oxygen delivery to the tissues, but the main ingredient seems to be the pressure that opens up the capillaries and increases the oxygen perfusion and delivery. You would not want to use hyperbaric oxygen if the patient has Babesia, as this may increase the growth of Babesia. Dr. Hedaya also uses EEG-guided laser and he noted that he usually uses a class four laser, either an 810 nm or a 1064 nm. Approximately 2.6 to 2.8%of the light from the laser will likely penetrate the brain. The QEEG allows Dr. Hedaya to target the regions of the brain that are the most abnormal.
Dr. Robert Hedaya is an MD/Psychiatrist who is board certified by the American Board of Psychiatry and Neurology and he also teaches Functional Medicine approaches to psychiatric disorders with the Institute of Functional Medicine. He is also a Clinical Professor of Psychiatry at Georgetown University Medical Center. He wrote a number of books, including Understanding Biological Psychiatry, The Anti-depressant Survival Program, and Depression: Advancing the Treatment Paradigm. He treats patients with psychiatric disorders with a Functional Medicine approach, pharmaceuticals when indicated, and he has now pioneered the use of the HYLANE program, which includes Hyperbaric Oxygen, EEG guided laser, and neural exercises. His website is WholePsychiatry.com.
Dr. Ben 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. Ben 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.
Hello, Rational Wellness podcasters. Today, we’ll be discussing integrative psychiatry with Dr. Robert Hedaya. Dr. Robert Hedaya is board certified by the American Board of Psychiatry and Neurology, and he also teaches functional medicine approaches to psychiatric disorders with the Institute of Functional Medicine. He’s a clinical professor of psychiatry at Georgetown University Medical Center. He wrote a number of books including Understanding Biological Psychiatry, the Antidepressant Survival Program, and Depression: Advancing the Treatment Paradigm. He treats patients with psychiatric disorders with a functional medicine approach, pharmaceuticals when indicated, and he’s now pioneered the use of the HYLANE program, which includes hyperbaric oxygen, EEG-guided laser, and neural exercises. And now, I’ve been informed that he’s added ketamine therapy to this program. Dr. Hedaya, thank you so much for joining us.
Dr. Hedaya: Oh, thank you for very much for having me, Ben. It’s a pleasure to be here.
Dr. Weitz: Absolutely. So you’re a giant in our field. Perhaps you can tell us how you found your way to the functional medicine approach of psychiatry.
Dr. Hedaya: Well, it’s an interesting question. It’s a story that was unfolding before I knew it, really. It goes back to my very early training in medical school and even in my internship. I was just oriented, I guess, to get to the root causes of things. And when you start to do that, you can’t help but end up in functional medicine. What really propelled me ultimately was my own, after my first book, I was on the edge of chronic fatigue, took a lot out of me, and then I really dove in deeply. And that’s when I discovered what was then called metabolic medicine, which was later changed to functional medicine with Jeff Bland. And that one thing led to another, and I was a psychopharmacologist trained in cognitive behavioral therapy, family systems, et cetera, and doing a lot of psychopharmacology.
And then, when I started to bring functional medicine into the neuropsychiatric realm, I was like, after three, four years, I was blown away. I’m like, “Wait a second. I’m not doing this whole medication merry-go-round thing.” Not anti-medicine, but I used to be like, “This isn’t working, try this, add this, all the whole medicine thing.” And everyone’s getting better. I’m like, “Wait, maybe I’m lying to myself.”
So after about three years after my second book, I hired a statistician to assess the patients that I had treated for treatment-resistant depression over the course of, I think it was like two years or three years. And just like no cherry-picking, just every sequential patient and see how they did because we track their objective monitoring of their symptoms, et cetera. And it turned out I was not lying to myself. Everyone, 23 patients, the mean Beck Depression inventory when we started was about 34, which is in the severe range, mild part of the severe range. And by 10 months, everyone was normalized, and I only made one change of medication, which was to put someone who was suicide risk on lithium. And other than that, no medication changes, and their diabetes went away, and their osteoporosis went away, and the depression went away, and blah, blah, blah. And I was like, “Holy moly. So this was really pretty astounding.” It really was very powerful.
Dr. Weitz: Yeah, that’s one of the great advantages of functional medicine or lifestyle medicine is not only can you potentially help the problem they’re coming in for it, but you can make their overall health better and reduce their risk of chronic diseases.
Dr. Hedaya: Yep, absolutely, absolutely.
Dr. Weitz: So I’d like to pick your brain about some of your insights into the functional medicine approach for psychiatric disorders. And I listened to a discussion you did at a grand rounds at Cleveland Clinic and you had some really great pearls of wisdom I think a lot of people could benefit from. Maybe you can talk a little bit about the functional medicine approach, and if you want, I can ask you some specific questions.
Dr. Hedaya: Well, I mean, I think the main thing is you have to be a medical detective and your mental set has to be medical detective. And yet I’m very data oriented, so I don’t like to say, “Hey, I think you’ll need some magnesium. I like to know if the magnesium’s low and then it’s low, great, I’ll treat it and then I’ll retest it, make sure I’ve normalized it.” So basically, be a medical detective. The second thing I would say that I’ve learned is that most it’s what we call psychiatric problems, they’re really, I want to be careful how I say this, but I would say they’re not primarily psychological. In other words, there’s a lot of physiology and infections and hormonal problems and genetics and epigenetics and gastrointestinal things, et cetera. There’s a lot of factors going on. And once you normalize those and treat those things, you still have work to do.
Some people have character problems that they can work on, but that’s modifiable. Personality and temperament, you’re born with those, but those could be managed. If you’re harm-avoidant and fearful, you’re kind of born with that. I wouldn’t call it psychological, it’s not your fault. It is just like what you’ve been born with. And then, there’s the trauma thing that I wouldn’t even, it is psychological, but it’s put on you by the circumstances. Now, you’ve got to manage that. So the whole idea that, “Oh, you have some psychological problems, there’s something wrong with you.” No, there’s nothing wrong with you. You’re dealing with stuff. You’re climbing up the Mount Everest like we all are with some rocks in your backpack, but there’s nothing wrong with you. The only thing you may need to work on for you is your character and your spiritual development, but the rest of it is stuff that rocks that were put in your backpack, let’s say.
Dr. Weitz: Right. In other words, the mental realm is directly part of the physical realm. And if you’re physical health is lacking, if you’re lacking in nutrients, if you’re having toxins and infections and other things that are throwing off your physiology, that’s going to be affecting your mind.
Dr. Hedaya: 100%.
Dr. Weitz: And those are the things that we can easily access and change.
Dr. Hedaya: Yeah. Well, my first patient, you can ask how had this happened. Well, one of the very biggest things that happened to me is, I think it was ’84. I was in practice since ’83, training ’79. ’84, I saw this woman, 50-year-old woman with panic disorder, and she had not a great marriage. Her only kid was going off to college, and my assumption was that she was having panic because of separation anxiety of a bad marriage, she might have to leave her marriage, child was leaving, et cetera. Psychotherapy, medications, long story short, one year, she didn’t get better, and it turned out that she had a B12 deficiency with her first injection. Her panic went away, and I was like, “Whoa, this looked so psychological and it wasn’t it.” And that was, I thought, “Wow, what else am I missing?” And there’s obviously hundreds of things that are involved in how the brain functions.
Dr. Weitz: So I listened to you talk about B12, and you mentioned in that talk at the Cleveland Clinic that a lot of us measure B12. I think conventional doctors look at serum B12, and most of us in the functional medicine world know that’s not a very accurate test, but we think we’re doing better by doing methylmalonic acid and maybe homocysteine, but I think that you have some pearls to tell us about that, right?
Dr. Hedaya: Yep. So who are your listeners? Are they docs or?
Dr. Weitz: Well, I think they’re more educated, functional patients, more educated list, people involved with health, but I think a lot of them are functional medicine practitioners.
Dr. Hedaya: Okay, great. So I’ll go into a little more detail. So if your B12 level is low normal, you probably have B12 deficiency. That’s not so difficult, but most of the time that’s not really the case. We’re looking at what’s the B12 function? So in order to assess that, you’re in the broad scheme of things. You’re looking at two broad categories. You’re looking at the methylation B12 folate, and on the other side you’re looking at the iron, because then what do you want to look at is you want to look at the red blood cell count. Are they tending towards anemia? Maybe not anemic yet, but tending towards anemia. And also, what’s the size of the red blood cells, the mean corpuscular volume? What’s the size? Now, that’s where the tricky part comes in, because if you’re B12 deficient, your red blood cells will get larger because you need B12 to make red blood cells, and if you’re not making them, they hang around longer and the spleen doesn’t get rid of them, so they get bigger. So you’re can have larger red blood cells because you’re B12 deficient. But if you’re iron deficient, you’re going to have small red blood cells, a microcytic red blood cell, microcytic anemia. And so, here you are, you’re going to have the two offsetting each other. You could have normal size of the red blood cells. You got to really remember, you always got to look at the iron because it could be masking a B12 deficiency. Then, you of course look at the homocysteine, where is that going? And then, of course, look at medications that people are on. How old are they? If they’re over 50, they’re more likely to have trouble absorbing B12. So I call it a dynamic assessment of B12, and methylmalonic acid only accounts for about 17%, I believe it is, of the level of the, I’ll put it a different way. Methylmalonic acid is only affected by B12. There’s 83% of the methylmalonic acids affected by other factors other than B12, put it that way. So it’s really not a great measure.
Dr. Weitz: And then, how do you assess iron? Do you look at ferritin? Do you look at serum iron? What are you focusing on?
Dr. Hedaya: I look at serum iron and TIBC primarily, and just look at what’s the iron and how much binding capacity is there, and basically how much iron is stored on the bus and not active, and how much is free roaming around the streets and the blood vessels. And that’s what I use. Sometimes use the ferritin, but basically those two, and of course, CBC.
Dr. Weitz: Right. Maybe you could give us some other clinical pearls about the functional medicine approach. How about the importance of fish oil or omega-3s?
Dr. Hedaya: I would say just the American Journal of Psychiatry did a review of the, what’s the evidence for some nutraceuticals in psychiatry and would come up with vitamin D, very important. Fish oils, very important. These are not treatments for depression, but they’re preventative. Zinc, very important. Zinc has to be managed with copper, and obviously a good balanced diet with adequate levels of protein and ability to digest and absorb your protein. But those are probably the main things there. Another clinical pearl I think is really important is the thyroid adrenal axis when you look at neuropsychiatric problems, and you can’t just say, “Oh, look, the TSH is normal.” You really have to look, well, I look much more thoroughly.
So obviously, first of all, physical exam, symptoms of low thyroid adrenal problems, usually adrenal insufficiency. So the physical and symptoms very, very important. Then, you corroborate it with testing. On the thyroid, interestingly, that the mean TSH in the US population about 1.5, that’s based off the NIH study, which is I think it was 16,000 people. So that’s your mean TSH. So as your TSH rises above 1.5, you’re actually going outside of the moving out of the norm. But the upper limit at most labs is 4.5. Some endocrinologists think that it should be 2.5. In neuropsychiatric problems, you definitely want to be closer to 1.4, 1.5, or even one.
Now, there’s plenty of evidence for depression, treatment resistant depression, that hypermetabolic doses of thyroid hormone, particularly T3 actually will help people come out of depression. Part of that has to do, I believe, with the genetic vulnerability abnormalities in the deiodinase 2 genetics that control the conversion of T4 to T3 in the brain. We obviously can’t stick a needle in the brain to measure the T3 so we rely on their symptoms and on their genetics. So if they have a lot of SNPs variance in the deiodinase 2 genes, then we’re concerned about that. And the other thing, and it could be too technical, what I would say-
Dr. Weitz: By the way, on the thyroid, do you often supplement with T3 as well as T4, or do you try to push the ability for the body to convert to T4 and T3 with nutrients?
Dr. Hedaya: Yeah, I actually often use a combination of T4, T3. I used to use Armour, for example, but a little concerned, I don’t have evidence for this, a little concerned that you’re taking in, first of all, how do they standardize it? Second of all, you’re taking in proteins that come from an animal, a pig, and are those proteins going to cause any kind of autoimmune reaction for some people? So I say, “Well, let me just give the T4 and T3.” So that’s what I’ve settled down to. And it depends on the conversion. Some people convert, some people don’t convert. You have to look at it. Sometimes the body’s not converting to T3 because it’s protecting the body because the adrenals can’t handle it. So you have to think about that. The adrenal system, probably most people know how that HPA axis works. The thing that I would like to point out is one is that perceived threat, doesn’t have to be a real threat, could be a perceived threat, maybe based on trauma, misperceived, we could say, based on trauma. That can throw off your HPA axis.
Dr. Weitz: How about the fear of dying from viral infection?
Dr. Hedaya: Yeah, it could be anything. It could be anything. And then, on the downside, on the genetic side, very, very interesting. There are genes which you can test for NR3C1, FKBP5, CRH receptor 1 and 2, CRH binding protein, these control proteins that control the effective steroids inside your cell at the level of the nucleus. And it turns out that a lot of my patients, not all, have variants in these genes, which means that when you’re stressed for whatever reason, and you release cortisol, your cells at the level of the nucleus can’t convert the signal, the stress signal efficiently to the genome, and then your genome doesn’t respond properly, and now you’re vulnerable to stress, to immune dysfunction, to depression, to suicide even. And so, these genes are really important. This is a deep level of, in a way, it’s a cortisol resistance that’s genetic. You can get glucocorticoid resistance from having infections or from over methylation, the different pathways to glucocorticoid resistance and that’s not really recognized. I think that’s part of the reason people are having trouble responding to treatments for Lyme disease, for example, chronic Lyme and certainly chronic long COVID, that’s part of the picture.
Dr. Weitz: Are you doing a salivary adrenal cortisol test, and what’s your favorite gene panel?
Dr. Hedaya: So salivary cortisol, that’s fine. I use the DUTCH now, but I used to use diagnostics. They’re fine as well. And for genes, I use something called Opus23. You got to get trained on it, but I just really love it. There are other gene programs. Intellxx is very good, which worth looking into. I haven’t had the time to really look into it, but you get other stuff there that you don’t get in Opus23. But Opus23 is a wonderful tool, just a wonderful tool. And you can get the NR3C1, et cetera, on Opus23, which you cannot as of six months ago anyway, get on Intellxx.
Dr. Weitz: Okay. How about diet? How important is diet for functional medicine approach to psychiatry?
Dr. Hedaya: So diet’s essential, foundational, and you’re probably not going to get too far without diet. You’re not going to get too far without getting rid of mold if you have mold. Diet’s essential, and obviously everyone has a specific dietary need. It’s a little different for everybody. Diet is essential foundation, really an essential product.
Dr. Weitz: Gut health?
Dr. Hedaya: Generally, we start with the gut. Gut is they call it the second brain, and it’s obviously sending signals to the brain through multiple pathways and the brain to the gut. It’s a round trip kind of thing, a two-way street, and not really separate, but that’s the thing. Remember, we used to talk about nature versus nurture, and now we know with epigenetics that there is no nature versus nurture. It’s one thing, it’s seamless, and it’s the same with the gut and the brain and the endocrine system and the brain. And it’s all seamless. Everything’s affecting everything.
Dr. Weitz: I mean, to some extent, we are our microbiome.
Dr. Hedaya: To some extent, we are. It’s pretty scary. When you look at the [inaudible 00:19:08] it’s pretty scary. You see some of these studies that show that changes in the microbiome change your behaviors or animal behaviors, at least, social behaviors. Holy moly. Wow.
Dr. Weitz: And then, every time I think about that, and then I have some patient who just had their colon removed or something because they have Crohn’s, and I think, “Oh, my God. That’s got to affect their long-term health.” And it’s hard to say. What do you think about that? So we haven’t talked about the neurotransmitter theory of depression, which I know has all sorts of issues, but it’s often stated that 80% of the neurotransmitters are produced in the gut, but yet the neurotransmitters in the brain are produced in the brain. So what do we think the relationship between the neurotransmitters in the gut, which seem to have an effect on the neurotransmitters in the brain, how do they interact?
Dr. Hedaya: Well, that’s a really good question. And in terms of serotonin, probably 95% of serotonin is produced in the gut, the vascular system, other non-brain systems. But in the brain, there are specific areas like the dorsal raphe nucleus, for example, that produces serotonin, and it’s specifically responding to what the body needs, et cetera. So you can’t, I would say, actually, I moderated a debate between Jay Lombard, very bright guy, and one of the people who was running one of the neurotransmitter labs, this might be six, seven years ago, at IFM, I moderated this debate, and we knew this actually when I was at NIH. You cannot look at the urinary neurotransmitters like 5-HIAA and see what’s going on in the brain. It doesn’t tell you anything about the brain because it’s just mostly the body and it doesn’t correlate. For example-
Dr. Weitz: I thought with serotonin, there was a fairly close correlation.
Dr. Hedaya: No, no, no, no. For example, at NIH, we used to do this. You had to do a cerebral spinal 5-HIAA level to see and see there’s a correlation with suicide, and there was a correlation there. But in terms of the gut, serotonin is not really a correlation with the brain. This is a Venn diagram, so it’s not a complete, oh, this is-
Dr. Weitz: But how are they related? Is there some sort of communication? Does some of the serotonin from the gut or the circulation get into the brain because you have leaky brain?
Dr. Hedaya: So that’s what I was getting. So you have, it’s like a Venn diagram. You have two circles. So what’s the overlap is what you’re asking, right?
Dr. Weitz: Right.
Dr. Hedaya: And there is an overlap because connected to everything. So there’s got to be an overlap. But how much is that overlap? I don’t know, I really don’t know. I mean, there are transporters for serotonin in the blood-brain barrier. Sometimes they’re impaired by genetics. Can they be impaired by leaky barrier? They could. They could, certainly. That’s the best I could give you. I don’t know if people ever really studied that. Maybe you have, I don’t know.
Dr. Weitz: Yeah, I’ve been looking into it, but it’s not clear. Another similar substance that seems to have a similar type of issue is cholesterol. We know that the cholesterol that’s used in the brain, which is essential for producing neurotransmitters, for brain function, is the cholesterol is produced in the brain, and yet we have cholesterol in the body that’s produced in the liver. And then, a lot of us are trying to drive our cholesterol levels down as low as possible to reduce the risk cardiovascular disease. And there seems to be correlation, I’ve seen quite a number of studies showing some correlation between getting your cholesterol levels below a certain level and problems with brain health and increased risk of dementia. And yet others say, “No, no, the cholesterol that’s produced in the brain is totally separate. You’re perfectly healthy driving your Apo B below 40 if you can.”
Dr. Hedaya: Below 40. I don’t know if you could do that, but-
Dr. Weitz: Well, you can if you use PCSK9 inhibitors on top of statins.
Dr. Hedaya: Right. So I think the cholesterol, first of all, just for the listeners, as you know, is the mother molecule of all steroid hormones, and it’s in mitochondria. A lot of these steroids are made actually in mitochondria as well as in adrenal glands, et cetera. Pregnenolone is the next molecule, and then we have the whole sequence down. So it’s a big concern. I don’t know the answer either. Actually, for myself, it’s funny and Bredesen, I was just thinking is my cholesterol okay, it’s normal. But my cardiologist says, “Nah, you got to bring it down.” And he wants to [inaudible 00:24:27] me on one of these inhibitors, and that’s good because they only work in the liver. But I’m like, “Well, what else is it going to do? And what am I going to do?” And I’m in that quandary myself, and I don’t know the answer to it. Obviously, if you have a family history of a risk of neurodegenerative disease, depression, et cetera, you might want to be more careful. On the other hand, like you said, there are some studies that say, “No, there’s a benefit.” And it’s tough because it’s not like you take it and a week later you notice symptoms. It’s a tough-
Dr. Weitz: Absolutely. And heart disease is still the number one killer. So we certainly don’t want to minimize that or decrease somebody’s ability to reduce their risk of heart disease. But I know Dr. Bredesen, I’ve talked to him, and he is convinced that statins can have a negative effect on the risk of dementia.
Dr. Hedaya: Yeah. So he’s a smart guy, and if he says that, that weighs more in line of be careful. So then, you pick your poison, you want to die of a heart attack.
Dr. Weitz: Now, have you experimented with a ketogenic diet for psychiatric disorders?
Dr. Hedaya: Oh, yeah. Well, we use it specifically with certain types of patients. We use it for people who, well, we do the quantitative EEG, for example, and I look very carefully with my patients who had seizures and temporal lobe seizures, and absent seizures, partial complex seizures, fairly common. And so, if we see a signature of that on the qEEG and we have symptoms of that, then we’re going to move towards ketogenic diet, it’s a tough, long-term sell. Obviously, nobody’s going to live on that for… Most people are not going to live on it for 20 years, but we do find it helpful. And there’s a nice easy test, I think, that I do in my office when I see someone for an evaluation. I’ll have some brain octane, the MCTC, the eight-carbon caprylic acid, MCT oil in my office, and about whatever, an hour into my evaluation which is usually about three, four hours, I’ll say, “Let me give you a trial of this and give them a little, couple of tablespoons of this, teaspoons or whatever,” depending on their gut health because it kills yeast so you can get cramps. And I’ll do this, and then I’ll set my watch for 30 minutes, and then, I’ll ask them how they feel in 30 minutes. And if they say, “My pain is less or my headache went away, or I feel more clearheaded,” then I’m like, “Okay, now I know we’ve got some kind of a mitochondrial problem going on here, and that’s some percentage of your problem.” Gives me a little clue, and I might lean more towards either ketogenic or using more MCT or beta-hydroxybutyrate or something like that.
Dr. Weitz: Right, because the ketones are produced when you’re on a ketogenic diet, and some of the data shows that the brain works better on a ketogenic diet that it burns ketones instead of sugar. And obviously, blood sugar is a big factor in mood and psychiatric disorders.
Dr. Hedaya: Absolutely. No question about that because there’s an interesting way of looking at this. Actually, when I was in my training, I saw this most fascinating thing. It was a diabetic guy who went into a diabetic coma, his blood sugar dropped, he went into a coma, and then we put a IV in and give him glucose. As his glucose came up, first he talked like a child, then he talked like an adolescent, then he talked like a young man, then he talked like an adult. I was like, “Wow. It’s like the lower your glucose is, the core parts of your brain that need the glucose, so your animal self, your limbic brain is going to be in charge when your blood sugar’s low.” That means when you were a kid, if you were afraid or you were angry or aggressive or the world was a dangerous place or whatever, that’s how you’re going to see the world. When your blood sugar comes up, you’ll be more like a rational adult. And this can happen through the day when you hear someone going through mood swings through the day, think blood sugar, think diet 95% of the time.
Dr. Weitz: Right. So at that point, you can remove the higher glycemic carbohydrates, even if you don’t put them on a full ketogenic diet.
Dr. Hedaya: And obviously balancing the fats, the carbs, and the proteins balance well, so you keep the blood sugar stable over the course of [inaudible 00:28:58].
Dr. Weitz: And the importance of proteins and amino acids, because I’ve heard you talk about the importance of tryptophan for producing serotonin.
Dr. Hedaya: Yeah, yeah. So we never use tryptophan. We use 5-HTP, 5-hydroxytryptophan is the next step because if you’re inflammatory, which most people are, you’re going to take the tryptophan and that’s going to go down the kynurenic and quinolinic acid pathway and increase your glutamate, which causes anxiety and agitation. So you want to use 5-HTP, which bypasses that step because the activation of 2,3 indole dioxygenase. And so, you give 5-HTP, 5-HTP will go down into serotonin, melatonin, et cetera. I never use tryptophan anymore.
Dr. Weitz: Oh, interesting. I just talked to another doctor who said that he uses 5-HTP during the day sometimes and tryptophan for sleep.
Dr. Hedaya: Yeah, I would never use tryptophan because of the inflammation. If there’s inflammation, which like I said, almost everybody’s in a pro-inflammatory state, you’re going to drive the glutamate up. Glutamate when it goes too high is neurotoxic actually, and GABA goes down. And so, I used to, when I was at NIH, we actually did a study on tryptophan and blah, blah, blah, but I wouldn’t go near it anymore.
Dr. Weitz: Okay. So let’s get into some of the advanced stuff you’re doing now with some of your patients involving hyperbaric oxygen, EEG-guided laser, et cetera.
Dr. Hedaya: Okay. What would you like?
Dr. Weitz: Why don’t we start with hyperbaric oxygen? So what’s the benefit of that and what exactly are we accomplishing with that?
Dr. Hedaya: Okay, so hyperbaric oxygen is a treatment, obviously has been around for a long time. It is used for air embolism, gas, gangrene, diabetes, wound healing, skin grafts, carbon monoxide part. It’s a long history. Now, it’s being used for traumatic brain injury, strokes, in sports medicine I’m sure you’re probably aware, COVID-19, some tick-borne diseases, PTSD. In Israel, they’re using it a lot. And so, basically how does it work? It actually helps increase the delivery of oxygen to the tissues and nutrients to the tissues, because you’re putting oxygen and pressure to open up those capillaries. There are secondary mechanisms like increased catalase and SOD and glutathione peroxidase, et cetera, but it seems like increasing perfusion, nutrient, oxygen delivery through mainly the main ingredient is the pressure that that seems to increase flexibility of red blood cells as well. And so, you can get healing of tissues.
And we have seen actually healing of brain injury, traumatic brain injury years afterwards. It doesn’t mean the tissues are completely normal because you have a TBI, traumatic brain injury. The cell is dead, the cell is dead. But there are cells that are in a liminal state, they’re alive, but they’re barely functional. And those cells actually, you can rehabilitate those cells. And so, we have seen on the qEEG normalization actually of the qEEG pre, post HBOT with TBI. I’m going to be giving a talk at IMMH actually in about a month, show some pictures of the woman who was a really internationally known athlete who was just so clear on her quantitative EEG. You could actually see the line of demarcation, the shock wave from the head injury. And you can see how it healed.
Dr. Weitz: There’s a number of ways to increase oxygen. So besides hyperbaric oxygen, we have ozone which can be injected or put into the body in different ways. There’s increased, decreased oxygen, training with exercise. I forgot the name of it, but there’s this device where you’re exercising and you increase the oxygen, you decrease the oxygen, and these are other strategies. What do you think about various ways of trying to increase oxygen?
Dr. Hedaya: I don’t have any training the ozone, so it’s hard for me to comment on it. There’s a limit to what I can learn. So I have been interested in it, but I haven’t really explored it. So it’s hard to really know. The exercise with oxygen, I actually tried it, got this, so they actually sent me the unit and I don’t want to disparage it because maybe great may be great, but my experience wasn’t great with it, so I can’t comment on it. I read a book on it, very detailed book, and it was very impressive. So that’s the limit of my experience with that. So I would say people should explore these things, but the HBOT is something that I like because, well, I’ve used it successfully and I’ve seen rapid responses, and so I’m happy with it. So maybe those things are complimentary, maybe they do different things, or maybe they would supplant HBOT. I’m sorry, I can’t really give you my opinion on that.
Dr. Weitz: Right. And HBOT, there’s hard chambers, soft chambers. I think I’ve heard you say that you use a soft chamber?
Dr. Hedaya: Yeah, we use a soft chamber. I don’t think you need that much pressure. The evidence seems to be 1.4 atmospheres, good for most people. And although we do have some people, I know some people are using hard chambers, obviously have to be a little more careful, et cetera.
Dr. Weitz: So let’s talk about the-
Dr. Hedaya: HBOT by the way, you would not want to use if someone has Babesia, which is fairly common, right?
Dr. Weitz: Okay. Because the oxygen would increase the growth of the Babesia?
Dr. Hedaya: Right. Exactly.
Dr. Weitz: And for those who don’t know, Babesia is a microorganism often related to Lyme disease.
Dr. Hedaya: Right.
Dr. Weitz: So let’s talk about the EEG-guided laser. Now, there’s a number of, a lot of us in functional medicine world, I’m a chiropractor, a lot of us in the chiropractic world are using lasers. We got class three lasers, we got class four lasers, we got a class three laser. There’s one company that actually has a set-up where you, it’s like a class three laser and it goes around your head. And some practitioners have found good benefits with that. Tell us about the type of laser and why it’s guided by EEG and exactly how that works.
Dr. Hedaya: Okay, well, so we started out using an 810 nanometer laser class four, and now we use a 1064, sometimes 810. But 1064 seems to penetrate the brain better. And the question is, where do you aim? What are you going to do? Where do you aim?
Dr. Weitz: And does it penetrate the skull into the brain?
Dr. Hedaya: Yes, exactly. So Henderson did a very nice study.
Dr. Weitz: Does it depend on how thick your skull is?
Dr. Hedaya: Well, it does to some degree. And a lot of people are thick-skulled, right? But Henderson did a very nice study. He found roughly about 2.6, 2.8% of the light from a laser actually penetrates the brain. So you’re at the surface of the brain, you reap and receive about that percentage of the light. And so, now there’s a little debate about whether the LEDs penetrate the brain or not. And I don’t know, I’m up in the air about that. I’ve tried these things with people, I don’t know yet. There’s some evidence that it does and that people get better. But the problem is that the studies that are published are published by the people who are making the device. So that’s the same problem we have with the pharmaceutical companies, so we don’t know. So what we do though with the QEEG is we can actually map the surface areas of the brain that are abnormal, the nuclei of the brain that are abnormal, the circuitry, specific circuitry and pathways, specific pathways of the brain that are abnormal. And then, we can decide based on that and based on the symptoms where we want to point the laser. And that is obviously more specific and it can be quite astounding actually.
Dr. Weitz: So give us an example.
Dr. Hedaya: Well, my first case really, this was 2017 who I was treating her for early dementia, let’s say, or MCI, let’s say. But she had APOE homozygous and strong family history, head injuries and absent seizures, which had never been diagnosed. It had a lot going on, treated her with functional medicine. And then, actually after that, she was much better, but she still had symptoms. And so, what I did is I said, “Well, I finally learned the qEEG.” Actually, if you want, I’ll share my screen. I could show you. This is her qEEG, so basically, well this is a derivative of her qEEG actually. Everything in gray is normal. Everything in yellow or blue is abnormal. Yellow or orange or whatever is unstable and blue is slow. So what we see here is this is, her eyes are up here, ears are over here, back of the head is here. We’re looking here at the entorhinal cortex here, the base of the brain, the frontal lobes, temporal lobes, occipital. This is the cerebellum. So we’re kind of low at the lower, kind of below your ear lobes with a slice here. This is a side view of the brain here, her eyes, and here is the base of the brain here. And you can see all this gray stuff is normal. This is after functional medicine. And then, this is a slice vertically like this, a coronal section.
Here is the hippocampi, which we know in Alzheimer’s and she had those genes, the APOE4 genes. Her hippocampi, clearly abnormal. You can see that here, the hippocampus. And she’s actually 2.7 standard deviations from the mean. So that’s still pretty abnormal after her functional medicine treatment. And here, this is information flow through different areas of the brain from this particular area, you could actually analyze all these lines. The information flow is poor. Here, this excessive attempt at inflammation flow is really doesn’t work very well. And here’s slow information flow, different areas, and this is telling us the different surface areas of the brain. And here, what we’re looking at is 6 hertz, there’s theta. So this is where she was after functional medicine, but before the HYLANE treatment, which in her case was in particular was laser. We did 30 laser treatments and based on a more thorough analysis than this, we decided where to point the laser.
Dr. Weitz: Now where did you point the laser with her?
Dr. Hedaya: I was on the left temporal area.
Dr. Weitz: Why the left temporal area based on that EEG?
Dr. Hedaya: Well, I’d have to actually, I couldn’t explain it to you from what I just showed you. Really, I’d have to pull up her qEEG and her pathways, which I came up to. But this is after 30 treatments.
Dr. Weitz: Wow.
Dr. Hedaya: You see, she’s completely normalized here.
Dr. Weitz: That’s pretty amazing.
Dr. Hedaya: Yeah, a little. When I saw this, I came home and I didn’t know. My mind was blown. My mind was blown. Now, here’s really where my mind was blown because after the first laser treatment, the first laser treatment, I treated her for maybe three minutes, four minutes. Then, I brought her into my office to make an appointment the next appointment. And she says, “Oh my, God.” She had an accent. She goes, “Oh my, God. I can remember the face of the person I saw last week. Oh, my God, I remember her wife. I remember the dimple on face.” She was like, and I didn’t know she had facial blindness until that moment.
I did not know she had, it’s called prosopagnosia. I did not know she had facial blindness. Now she’s telling me my facial blindness is gone. I’m like, “What?” This was mind-boggling. So I actually had her do this Cambridge facial recognition test, and she came back normal and right here. And then, I was so blown away. We actually published, this is the first case of reversal, of acquired, meaning she wasn’t born with it, prosopagnosia, facial blindness using qEEG guided laser therapy. We published this case. And that’s just one example. That’s the first example. But since then, we’ve reversed partially, like 75% aphasia, visual problems, depression. I could show you, actually, I’ll show you something else here.
Dr. Weitz: So your approximate amount of time of using the laser on patients is how long?
Dr. Hedaya: About six years, maybe a little more than.
Dr. Weitz: And then, when they come in for a treatment, did you say three to four minutes?
Dr. Hedaya: Well, in her case, it was the first treatment we did very slow, very careful. Usually, it’s a 10 to 20-minute treatment.
Dr. Weitz: And normally, the laser is just focused in one place and held in that place?
Dr. Hedaya: No, it’s not held because you don’t want to create excessive heat. You’re going to move it. Right. And it depends on what’s going on because we could treat multiple areas at one time.
Dr. Weitz: Okay. Do you think a class three laser can have benefit?
Dr. Hedaya: I don’t know. I don’t know enough about them. What’s the difference between a class four and a class three?
Dr. Weitz: I think it has to do with power. The class three doesn’t produce a lot of heat and it doesn’t risk injuring the eye, so it’s a little bit easier to use.
Dr. Hedaya: It’s mainly wattage, but you can get the same nanometers, you can do 1064. It should, you might, obviously the time, how long it takes is longer. So you’re going to have to calculate how much you’re delivering to the tissue. There’s a therapeutic window for this. Now, so if you get too much light, you can actually inhibit ATP production too little. It doesn’t work. So there’s a therapeutic range and you kind of get roughly one to two joules at the tissue level.
Dr. Weitz: And are you using infrared or red or what color?
Dr. Hedaya: 64. So it’s specifically an 810, so it’s infrared. It’s not invisible.
Dr. Weitz: Okay, cool. And then, the third part of your program has to do with neural exercises?
Dr. Hedaya: Yeah, so neurofeedback is one type of neural exercise. There are other types of neural exercises, so you could use brain training. One of the things I really like is to have people increase their novelty. So for example, he might have somebody, I just assigned this to somebody last week, for a husband to take his wife to a new neighborhood. She has spatial problems. Let her walk around the neighborhood, let her find her way back to the car, and obviously not for hours, give her 15 minutes or something like that. Enjoy the novelty, try new neighborhoods, do that kind of thing. But we use neurofeedback suit because we can actually look at specific networks in the brain and we can say, “Well, how are they doing?” So for example, we might be able to show you here, actually, I’ll show you if you want, I’ll share my screen again here.
Dr. Weitz: Sure.
Dr. Hedaya: This would work anyway. Let’s just say for example, this is a guy pre-post laser, so it’s different. But let’s just say that this here on the right here, where this red circle is is a specific network, we’ll call it the salience network. Salience network tells you, “Well, where should I pay attention? Should I pay attention to the world out there or should I pay attention to what’s going on inside?” Like a toggle switch. And in some people, salience network is telling you no pay attention inside, sometimes outside. Then, we have the default mode network, which is your inner world. And then, we have the executive network was outside. So let’s just say that this is for example, the salience network. Then we treat this with neurofeedback at a specific frequency, and then this would be what it would look like after the neurofeedback, meaning it’s normalized. The black is normal. This means it’s functioning slowly under functioning. Now, as I said, this slide does not really demonstrate that it is specific network, but it is not, we didn’t do neurofeedback. This was after hyperbaric oxygen laser.
So I think that it’s like weight training in the gym. We can actually say, “Okay, we can measure what’s going on. Let’s say in your salience network, let’s say it’s overactive or underactive, and we can measure it and we get you to watch a movie. You pick a movie that you like.” And then your brain says, it tags it and says, “Oh, this is a reward. I want to watch this movie.” And so, now, what we do is as that network is doing what we want it to do, you get to watch the movie. And as a network stops doing what we want it to do, the movie kind of gets gray, the sound goes down. And pretty soon after four or five sessions, your brain has figured out, not you, not consciously, your brain has figured out, “I want that. I want to hear the rest of this movie. Oh, I know what I got to do.” And it starts working. It’s like weight training and it starts working and it actually gets stronger. And that’s simply put, that’s neurofeedback.
Dr. Weitz: Right. We often tell patients if they don’t dance, take a dance class, they take a dance class, take a different dance class, pickleball, do some novel activities.
Dr. Hedaya: Ballroom dancing is great. Zumba, great. Exactly.
Dr. Weitz: What do you think about the neural exercises on some of the computer programs?
Dr. Hedaya: We use them. We use them. The question in my mind has always been, how generalizable are they to the world? They seem to claim that they are. Again, the study’s done by the companies, but we do use them.
Dr. Weitz: What about some patients say, “Oh, I like to do Sudoku, or I like to play jazz,” things like that?
Dr. Hedaya: Great.
Dr. Weitz: Those would qualify as neuro exercise.
Dr. Hedaya: Yeah. Also learning another language. And really one of the strongest things is being fluent in another language. If you can really be fluent and use other languages fluently, that’s actually shown to actually reduce the risk of neurodegenerative disease, or at least the onset will show up later.
Dr. Weitz: I bet you if more people knew other languages, probably reduced the risk of war too because we know more about each other.
Dr. Hedaya: Yeah, I love that. That’s really true.
Dr. Weitz: Okay, great. Dr. Hedaya, how can listeners, practitioners, et cetera, get in touch with you? Do you have courses available for training for practitioners?
Dr. Hedaya: No, we’re treating patients pretty much.
Dr. Weitz: Okay, great. So how can patients get in touch with you?
Dr. Hedaya: So patients get in touch with me through the website. It’s like Whole Foods, only it’s Whole Psychiatry, W-H-O-L-E, not H-O-L-E. W-H-O-L-E.
Dr. Weitz: Are you willing to sell out to Amazon for $2 billion?
Dr. Hedaya: I don’t know. I’ll consider it.
Dr. Weitz: So I’m sorry. Whole Psychiatry.
Dr. Hedaya: Wholepsychiatry.com. There’s a lot of information on the website. It’s a very rich website that we’ve got sample reports, we have videos, we have my radio shows I used to do. We have a lot of stuff. And then, there’s a contact form of people who want to contact. It’s an intensive program, I have to say. We really, really work hard to get to the root causes of things. Sometimes we like to work very intensely. Sometimes we try to get the low hanging fruit, depends on the patient and et cetera. But if you’re looking to get to the root cause and avoid medicine or the medicine’s not working, then that’s our niche.
Dr. Weitz: Great. Thank you, Dr. Hedaya.
Dr. Hedaya: Well, thank you very much, Ben. It has really been a pleasure and I have to congratulate you because done a lot of podcasts and you dove deeper than most thank.
Dr. Weitz: Thank you.
Dr. Hedaya: Really nice. And that’s a tribute to what you do, because obviously you’re interested in really how things tick. Really, really-
Dr. Weitz: I am. I pride myself on that. Thank you very much for recognizing that.
Dr. Hedaya: Yeah, very good. Very good. It was a pleasure.
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.
