* March 2009 Practice Alert *

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Jeffrey Zavik: Dr. Hedaya is the director of the Hedaya Clinic and National Center for Whole Psychiatry based in Chevy Chase, Maryland and a clinical professor of psychiatry at the Georgetown University School of Medicine. I just finished looking at his nice website which is a very easy site to navigate and it is easy to find and remember. It is www.wholepsych.com. We recommend our readers and listeners to visit your site and get more information there as well. You are the author of at least three documents, I think more than that, but recently Depression, Advancing the Treatment Paradigm, The Anti-Depressant Survival Program and Understanding Biological Psychiatry. You practice "whole psychiatry". Did you coin the phrase? And could you tell us a little bit about what that is and how you came to this approach?

Dr. Hedaya:Yes, I did coin it and I have played around with the idea of integrative psychiatry and comprehensive psychiatry and functional psychiatry, but I settled on whole psychiatry because each of these approaches are limited in a sense. The idea of whole psychiatry, the idea behind it is that it is ever-changing, depending on what we learn. And so right now I am using a lot of functional medicine and depth psychology but, you know, in the future, who knows what it will be. So the idea is just to keep it broad and open-minded so, for example, part of the concept is looking at politics and culture and how they affect psychiatric problems.

Jeffrey Zavik: So the functional medicine and functional psychiatry is certainly an integral part of it but you do not limit it to just the biochemistry that is often associated with the functional side of it.

Dr. Hedaya: Right. And the other part of your question was how I came to this. It is really evolutionary. I think when I was in medical school - I was actually in medicine school the first two years in Mexico and just got fed up with it so I took six months off to study for the boards to transfer back to the United States. In doing so I spent 10 hours a day six days a week studying all the basic sciences. It was really a wonderful opportunity because if say I was studying pneumonia, you know, I could study the histology and the histopathology and the microbiology and then look at the anatomy and I could really integrate all of the basic sciences. So it was just a wonderful way of learning medicine. I came to the states and went to Buffalo University and then when I went into psychiatry I stumbled upon a textbook of general systems theory, which is a beautiful paradigm. When I went into psychiatry, I saw was that everybody had their own little niche. Everybody was explaining psychiatric problems in their own way and it seemed just very strange because everyone was so sure that they were right. Most of the residents in training I think either maybe had a predilection to one approach or another or it was too anxiety-provoking. But I just kind of kept an open mind for four years and it took me about four years to kind of put it all together so that I did not throw any theory out but kind of enabled myself to kind of synthesize it and understand how they all fit into the picture.

Jeffrey Zavik: In essence it sounds like you were on your own then.

Dr. Hedaya: Yes. I had a lot of great teachers, but I was on my own in terms of putting it together.

Jeffrey Zavik: In terms of your own mind set, I mean you were looking at it from a much broader perspective and hearing all these different individuals and different focuses and commitments to certain ideas, but staying real open and broad to it. That is pretty interesting.

Dr. Hedaya: Yes, it was a challenge. Then I went into practice. I had a patient early in my practice that had a panic disorder. She was a 50 year old woman with a recent onset of panic disorder and I thought well, this would be pretty easy, you know, do some cognitive behavioral therapy and that should take care of it. It did not, so I started adding some medications. I tried one after another. Then about a year into it, she paged me on a Saturday night having a panic attack. It just struck me as, "what is going on here, this woman should be better by now."

Jeffrey Zavik: Right.

Dr. Hedaya: So Monday morning I went into the office a little early and I opened her chart. I had done a couple of preliminary blood tests when she first came in, a CBC and a chemistry of something like that. I looked at the CBC and the MCV. The size of the red blood cells was a little bit elevated. So when I had first seen it, I ignored it because we were not really taught anything about it and besides, I did not know what it meant and I had my model. I was supposed to do therapy and medication. I did a little research and saw that it could be related to a B-12 deficiency and so I worked her up for that. Sure enough, she had a B-12 deficiency. I gave her B-12 injections and her panic disorder went away in days.

Jeffrey Zavik: That is fascinating because such a relatively speaking, slight alteration or abnormality in the blood chemistry and a patient, an actual patient is what took you to the next step and opened your mind further. That is fascinating.

Dr. Hedaya: Well then I realized that if this is going on, what else is going on?

Jeffrey Zavik: Exactly.

Dr. Hedaya: The head and the brain are connected to the body by this thing called the neck, you know.

Jeffrey Zavik: Since when?

Dr. Hedaya: Yeah. I said, "Gee, I must have missed that lecture." And so, then it was just a matter of just following the leads, learning the science, listening to patients, reading and being open to all possibilities.

Jeffrey Zavik: What sorts of syndromes or age groups respond best to your whole psychiatry approach?

Dr. Hedaya: Well I would say two things. I would certainly say mood disorders (depression, manic depression, anxiety disorders, OCD). And then I would also say children respond exceptionally well very quickly. I have had some kids with supposed bi-polar disorder. One child, who was about 11 maybe 12, was the sweetest kid and the brightest kid but he had an extremely aggressive temper and even pulled a knife on his parents. It was a horrendous situation. Eventually he ended up at the hospital. I managed to keep him off medication. Now, about 10 years later, he is in college, he has not been on any medication and he is doing very well.

Jeffrey Zavik: That is exciting. And really when you start mentioning people with mood changes, depression, OCD, I mean you are talking about impacting millions potentially.

Dr. Hedaya: Yes, there is no question that the current model is very limited. It is not that it is without benefit, but it is very limited.

Jeffrey Zavik: And then in your more traditional background and training in pharmacology, you still use medication I believe at times. So how does your use of medication then compare with that of your colleagues who are more traditionally oriented towards the patient treatment programs?

Dr. Hedaya: Well I use less medication, probably 50% less. It is a difficult thing to answer because nowadays most people come to me on medication. Generally they are on two or three or four or five medications. My task is to stabilize them, get them well and then start tapering the medication. If they have been on medication for some time, it is usually not likely that we are going to taper them off the medication completely. If people come to me not on medication and free of medication or even medication naïve, then I would say there is probably a 50% chance that I can keep them off medication and get them well. If not, if they need medication, it is generally not more than one medication.

Jeffrey Zavik: That is fantastic. That is a huge difference from what we see conventionally and what the media reports with respect to the numbers of people on medications. It is astounding really.

Jeffrey Zavik: Getting down to the nuts and bolts of it, how do you evaluate a patient? What is your process to your protocol to do so?

Dr. Hedaya: First thing I do is I speak to them on the phone before they come in. I make sure that we are a good fit...

Jeffrey Zavik: That is each patient. You just literally have a phone interview first?

Dr. Hedaya: Yes. And then if we decide that it makes sense and they understand my approach and I understand their problem and it seems to me like it is a good fit and to them it is a good fit, we will set up an evaluation. An evaluation is usually two and a half hours, sometimes three and a half, even four hours, but typically two and a half hours. I will do a partial physical examination, go over their history in a lot of detail and review all the lab work that they have had done. I will always have a historian, somebody they trust be present for most of the evaluation so that I can get some collateral history and also so the patient feels some support. It is pretty stressful to go see a doctor and I think most people are well-advised not to go see a doctor without some support.

Jeffrey Zavik: That is an interesting piece of advice. What percentage would you say of the patients who get to the phone interview process become a right fit and become a patient?

Dr. Hedaya: Probably 60%.

Jeffrey Zavik: Wow. So there is really quite a few that it just does not happen with them.

Dr. Hedaya: Yes, they may not be ready for it or they may not have the money to pay for the treatment... actually very interestingly I have one woman who I just saw this week. I spoke to her four years ago and I evaluated her. She could not afford the treatment because there is a fair amount that is just not covered. You know, Blue Cross/Blue Shield does not think nutrition, they think it is experimental.

Jeffrey Zavik: That is fascinating but true.

Dr. Hedaya: She actually paid down her car loans and whatnot and saved up money and then she just came in and I mean I think the U.S. government should hire her.

Jeffrey Zavik: She had a plan and she worked her plan and when she was ready she came back.

Dr. Hedaya: So impressive. There are a fair number of people who for whatever number of reasons, it is not right.

Jeffrey Zavik: I like that process though because I am sure at the same time you tremendously increase your success rate because you have done that. Not just anybody comes in but it is the patients that you feel and the patient feels it is a proper fit. In a variety of ways they are committed then to the program and to working with you to get well.

Dr. Hedaya: Yes. I mean even with the screening it is not that uncommon to find people who are, and it may be because it is psychiatry but probably because it is the human race, ambivalent about putting in the energy to get well. But, you know, that is something that we work through.

Jeffrey Zavik: Right, and there are so many of us, particularly in America, in this particular culture where everything has to be fast; we are looking for a quick fix, a quick answer to just about everything. And anybody that can streamline something becomes more appealing to us, whether it is a mortgage application or a doctor or anything we are doing, we just want it to go fast.

Dr. Hedaya: That is why I like the whole psychiatry concept because there you see how culture affects health outcome with advertising, the fast food culture, and the immediate gratification culture.

Jeffrey Zavik: We are very geared towards that and the idea of taking time is almost contrary to the way we are wired it seems.

Dr. Hedaya: It has a huge effect. I think those are all things to be aware of.

Jeffrey Zavik: And what about something like genetics in your evaluation. Does that have a role at all?

Dr. Hedaya: Yes, more and more. When looking at genetics, whether it is for risk for celiac or some of the snips, the polymorphisms that are associated with psychiatric disorders, like COMT or MTHFR, are really useful because they can actually guide treatment. I have found them very useful.

Jeffrey Zavik: So in terms of more conventional approaches to psychiatry versus the whole psychiatry approach, would you comment a little bit about costs and benefits as you see them being different from conventional?

Dr. Hedaya: I think the way it is, is kind of like there is a flip, like the cost of conventional treatment over the long-term is much higher. But the cost of the whole psychiatry approach is lower over the longer term but much higher in the short term because in the short term you have to do a very comprehensive evaluation, spend a fair amount of time with the patient, and change lifestyle habits. It could be, say $10,000 or $15,000 for the first year. But down the road patients use less medication, they are not hospitalized - it is very rare for me to hospitalize a patient, and they are co-morbid medical conditions come under control. They do not run into diabetes and osteoporosis and cardiovascular disease risk goes down. So I am not really strictly treating the psychiatric condition, I am treating the whole person.

Jeffrey Zavik: Right. And the interesting thing then is that when you have somebody with a lot of the conditions you have mentioned, whether it is depression, OCD and so forth, these are generally long-term chronic conditions. They probably did not find you first.....they found you after they have made a few other attempts I would imagine. And so I think the refreshing thing is that there is an immediate sense of hope because you are taking a very different approach from the moment they speak with you on the phone. That is different right there. And then when they start to see the type of evaluation, I would think there would be a lot more hope realizing wow, this doctor is taking a completely different approach and is really assessing all of me as opposed to just the "it is all in my head" idea.

Dr. Hedaya: Yes, many patients say they think it is well worth it because I am four or five doctors in one.

Jeffrey Zavik: That is great. I like that. And the numbers of people in western societies with depression just keeps growing. We talked a little bit about culture playing a role. Do you want to reflect depression?

Dr. Hedaya: Yes, there are a number of factors. First of all, in our culture the family system is broken down. Sometimes I think of us as giant neurons—the more connections a neuron has with other neurons in the brain, the more vibrant it is. If you cut the connections between one neuron and other neurons, that primary neuron will actually get smaller, shrivel up, pull into itself and eventually it will die.

Jeffrey Zavik: Wow.

Dr. Hedaya: People in that sense are giant neurons. The more connected they are, the more networked they are, the healthier they are. That is without question. So that is a cultural phenomenon because we put money above connection. Typically people will leave their families for a job somewhere. This goes way back I think to the industrial revolution, the breakdown of the farm and that kind of thing. So the value system in the culture is material, inanimate types of things instead of live relational types of things. I think that is one thing. The other thing is that we are disconnected from nature. I am a mountain biker and every year I mountain bike. In the winter I do not really mountain bike and then when I re-visit the forest every year, I see that it is changed a little bit. I kind of get the feel of nature changing over time and the forest changing over time. I think that we really do not really understand time. We do not value time as highly as we should and we do not understand that death is a natural part of life. We are disconnected from that. We do not see it in our world. And so we run from it. We hide from it, such as when people get plastic surgery, and we end up losing the meaning of life and the value of life and we become robots. We are a reflection of the cities we live in and the mechanistic cities and societies that we live in.

Jeffrey Zavik: Do you have some suggestions then? I mean what do we do about that?

Dr. Hedaya: I think getting into nature as much as possible is a good thing. Going to the beach, or walking on the trails, or....

Jeffrey Zavik: One way or another getting outdoors. But I imagine you are not saying with an iPod in your ears and a cell phone.

Dr. Hedaya: You want to be in nature. Maybe just sit and try to just listen and observe instead of just walking, which, again, is a goal-directed activity. Find a space and sit for a couple of hours.

Jeffrey Zavik: Wow. For the average person, that is asking a lot. I love the idea. And you feel that plays a major role in depression? That contributes to depression in our current lifestyle?

Dr. Hedaya: Yes, it is a background. So my model is this.... If I look at a problem, whether it is depression or osteoporosis or whatever it is, I imagine myself with a lens. The lens is either high power, low power or medium power. If I look at a broad field with a low power lens, I am looking at the effect of nature and culture and the chemicals in the environment. If I look with a high power lens, I am looking at molecules.

Jeffrey Zavik: You have had a diverse and pretty unique background and experience that you have shared. How can the average doctor that reads our newsletter, who has not had a similar experience, learn more and take it to the next step if this is something they want to bring into their practice or even into their life for that matter?

Dr. Hedaya: They can look at the anti-depressant survival program. It is very readable and it has technical information and information for patients. So for doctors, they do not even have to read the whole book. There are sections for the doctor with references. Or if they want to delve in a little more deeply, they can read the recent monograph that I wrote. And then I would say, you know, try to open their mind up and just follow their passions and their interests. I think that the most important thing is to be open-minded and follow your interests.

Jeffrey Zavik: Great. Let us talk a little bit about the challenges and benefits of writing books. The reason I like to do that is in my travels meeting with many of our doctors, I find many doctors feel they "have a book inside them" but they never get it written. What kind of advice do you have for doctors that feel they have had some experience or knowledge they really want to capture in a book?

Dr. Hedaya: I have written my books in two ways. The first book that I wrote was very satisfying because I took off a week for each chapter. There are only six chapters even though it is 200 something pages. I totally immersed myself in it; that was very satisfying. Of course, you learn a lot when you are writing a book. The second one, The Antidepressant Survival Program, I basically downloaded my knowledge to a writer and we traded drafts back and forth. I pretty much used the same model for the third one.

Jeffrey Zavik: When you say downloading do you mean by writing, recording or both?

Dr. Hedaya: Just by talking.

Jeffrey Zavik: So in other words, you had exchanges with the writer and the writer made notes?

Dr. Hedaya: Yes, we would meet for a couple of hours once or twice a week and she would take notes and then write. Then I would correct, modify, and try to put in something that was my language.

Jeffrey Zavik: What length of time did that take compared to your six week period to write your first book?

Dr. Hedaya: Well the first book took me about a year to a year and a half, partially because I did not have an outline. I thought I had it all straight in my head. I wrote six chapters and handed it in and she said, "thank God you wrote the last chapter because now I know you can write. Now go back and rewrite the first five." I went back and spent another week per chapter until it was finished. You have to write an outline up front.

Jeffrey Zavik: So you enjoyed the process?

Dr. Hedaya: I loved it; it was worthwhile because you learn a lot. The best thing to think about writing a book is that the process is the most valuable part.

Jeffrey Zavik: Well that is a great gem. So there is a lot to be gained just in the process of doing it.

Dr. Hedaya: Yes, that is the best part of it.

Jeffrey Zavik: What about pitfalls? Any warnings or pitfalls you have come across for the doctor that is writing a book for the first time?

Dr. Hedaya: Well one is make sure you do an outline. And two is the publishing industry has changed dramatically between my last monograph and the first book. Also I would say do not expect a lot of marketing by publishers. You have to do the marketing on your own.

Jeffrey Zavik: Okay. That is good to know. So do not live in the illusion that they are going to go and make you a best seller or something like that.

Dr. Hedaya: Right, you just have to market it on your own.

Jeffrey Zavik: Okay. And what impact has being an author been on reaching other doctors? Has that been one of the venues of actually having other doctors coming your way and learning more and...

Dr. Hedaya: Yes, I think it has a big impact. At Georgetown where I teach, one of the guys I teach with said the residents asked him what do people think about Dr. Hedaya's approach? He said, "Well, they think he is out on a limb. But we're slowly crawling towards him".

Jeffrey Zavik: I like that.

Dr. Hedaya: The other thing he said is that my second book put me on the map.

Jeffrey Zavik: So it elevates you to another level of credibility or expertise as an author, particularly of multiple of books.

Dr. Hedaya: Yes it does. It is a big process and some people just roll out one or two a year. It gives you credibility and you learn. It refines what you do and who you are.

Jeffrey Zavik: What about the impact of it on the success of your practice? Would you say that it accounts for any significant number of patients just from reading your book?

Dr. Hedaya: Yes, without question.

Jeffrey Zavik: Any guesstimate on a percentage?

Dr. Hedaya: 50%.

Jeffrey Zavik: Wow. That is really a profound impact. The other thing I like about it is a patient that has read your book is more than halfway to being a cooperative, turned on, open-minded patient.

Dr. Hedaya: Yes, without question.

Jeffrey Zavik: That is great. The best way to reach you, is it through your website?

Dr. Hedaya: The website is probably the best way to reach me.

Jeffrey Zavik: Which is WholePsych.com. And as I said in the beginning when we chatted, it is a very easy site to navigate, which I compliment you for because often times they get very complicated. It is very clear and very easy to find your way through the site. People can access the books and information about them.

Dr. Hedaya: The other thing I would mention is I was just invited by Psychology Today to do a blog. That is something people might like. I generally put up a post every day or two.

Jeffrey Zavik: That is great. Is that blog then strictly online at Psychologytoday.com?

Dr. Hedaya: Yes.

Jeffrey Zavik: Fantastic. So they can stay current with you. I appreciate your time and all the information. It is certainly a unique and novel approach that I am sure many of our doctors that are reading this will find interesting. I wish you a very successful 2009 and I look forward to the next time we cross paths.

Dr. Hedaya: Great. Thank you.