Integrative Medicine Treatment of Depression, Schizophrenia & Autism

Louis B. Cady, MD

Continuing Medical Education Commercial Disclosure Requirement

I, Louis B. Cady, MD, have the following commercial relationships to disclose:• Speaker honoraria received from:

• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX

• Speaker’s bureaus (active) for:• Arbor, Allergan (Aventis), Lundbeck, Shire, Takeda

• Historical data – speaker’s bureau for Bristol-Myers Squibb, Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil, Pfizer-Roerig, Sanofi~aventis, Searle, Sepracor, Shionogi, Sunovion, Wyeth-Ayerst

“There are things known and there are things unknown, and in between are the doors.”- Jim Morrison

How to get the MOST out of this presentation:

• Listen for IDEAS – it’s not always about the meds

• Identify the perimeter of the diagnostic “net” & the creativity of BOTH the pharmacology AND holistic, integrated therapies.

• Relax for color

• INTEGRATIVE MEDICINE IDEAS:– HORMONES, food allergies, vitamins, minerals,

supplements, gene testing, OSA diagnosis– Screen for candida and HPHPA (cf. Dr. Shaw!)

Attention class!!

www.slideshare.net/lcadymd

Cady Wellness Institute app – Apple “app”store or Google Android store

Where (else!) to get “the slides”

DEPRESSION

The Case of the Phrustrated Pharmacist:Thyroid, testosterone & nutrient deficiencies in the aging male

• 73 yo MWM retired (2009) R.Ph. “burned out.” Essentially sitting home depressed. Not going anywhere.

• Presenting Rx:– Fluoxetine – 40 mg – Seroquel 50 mg XR for sleep (bipolar)– Hydralazine, amlodipine, Zocor, Metformin, ASA

• ROS: decrease in libido. Profound fatigue.

Mental Status Examination

• Depression:– Sad/depressed/down in the dumps – Lack of/loss of interest in things. – Trouble concentrating– Insomnia/trouble sleeping at times. – Decreased energy – Guilty/worthless – which was irrational – he had nothing to feel

guilty about it. (6 total symptoms; 5 = required)

• Other sxs:– Weakness, hopeless, feeling life is not worth living, sleeping too

much, loss of libido, and full diagnostic criteria met for generalized anxiety disorder

Relevant markers

• Thyroid functions– TSH 0.43 {0.34 – 5.61}– Free T4 1.34 {0.587-1.64}– Free T3 2.8 {2.0 – 4.4}– Reverse T3 32.1 (H) {9-2 – 24.1

• Sex hormone– LH 8.7 (H) {1.24 – 8.62}– Total testosterone 199 (L) {348 – 1197}

– Free Testosterone 3.6 (L) {6.6 – 18.1}– PSA 0.24 {0.0 – 4.0]– Estradiol 13.6 {7.6 – 42.6}

• Coenzyme Q10 0.75 {0.37-2.20}• Raman score 24,000 {>50,000}

– ( =1.44 MICROgrams carotenoids/ml serum)

T vs. Mood in men• Study: 278 men, >45yo, followed 2 years• Compared to eugonadal patients,

hypogonadal men w/TT <200ng/dL had – 4-fold increase risk of depression– Significantly shorter time to depression

diagnosis• Depression risk inversely related to TT

w/statistical significance <280ng/dL

Shores MM, Arch Gen Psychiatry. 61(2004):162-7

Interventions – 8/14/2013• Testosterone IM

– 200 mg ASAP, then 100 mg every 4 days until levels better.

• DHEA – 25 mg timed release• Liothyronine, timed release• Excellent MVI/multi-mineral/fish oil

supplement/phytonutrient/antioxidant supplement (with 200% Selenium; 100% Zinc RDA, 600 mg EPA, 400 mg DHA)

• continued fluoxetine

The Phrustrated Pharmacist – What happened?

• 11/26/2013 – (3 ½ months later)– Going to all grandchildren’s soccer games– Out mowing his yard and mulching leaves– Depressive symptoms ELIMINATED.– Appetite has gone up; but clothes fitting better.– Plenty of energy.

• 1/16/2014– “I’ve been doing good – I’m doing everything. I walk the dog

every day. I go to the soccer games.” – Has gone to get OSA checked.– Has lost so much weight (60 lbs) he’s using clothes pins on

pajamas.

What happened to labs (1/6/2014)?

• Thyroid functions– TSH 0.47 {0.34 – 5.61}– Free T4 0.67 {0.587-1.64}– Free T3 3.8 {2.0 – 4.4}– Reverse T3 14.5 {9.2 - 24.1}

• Hormones (Rx of 80 mg T twice weekly)– Total testosterone 582 {348 – 1197}– Free Testosterone 12.0 {6.6 – 18.1}– DHEA-Sulfate 378 (“H”) {30.9 – 295.6”;

OPTIMAL RANGE – per Cenegenics is about 500}

Phrustrated Pharmacist Follow-up – 4/15/2014

• Animated and alert. • Got hired to tutor pharmacology at local

community college. • Playing in hand bell choir again.

– “I’m not very good – they let me play the half notes and whole notes with the great big bells.”

• Quipped about a customer he recalled who came in ask (in past) and asked for “methyl-testosteroney.”

• On CPAP for six weeks. Doing well.

Raman spectroscopic carotenoid scans:

• 1.44 ugrams carotenoid/ml - 8/27/2013• 2.4 ugrams carotenoid/ml - 9/27/2013• 2.58 ugrams carotenoid/ml - 11/26/2013 (this is

without a lot of supplementation and none in the last two weeks. He is eating more fruits and vegetables.)

• 2.52 ugrams carotenoid/ml- 1/16/2014 on one pack of MVI/multi-minerals and fish oil (7 capsules)

• 2.82 ugrams carotenoid/ml - 7/15/2014

For independent learning: www.pubmed.gov “Raman spectroscopy skin carotenoids”

Antioxidant assessment

Reference:www.cadywellness.com/cadywhitepaper2008.pdf

(c) 2013 Louis B. Cady, M.D. - all rights reserved

As of 8/2/2015; 52 more than in September 2014 (#=241)

“The findings support studies that state that major depression is associated with mitochondrial dysfunction and OXIDATIVE STRESS, and that omega-3 supplementation could reverse some of these changes, probably due to its antioxidant properties.”

Final Follow-up – 7/15/2014

• Animated and alert. • Has lost more weight – now down to 209 lbs.• Played 18 holes of golf two weeks previous.

– “It was 46 – 47 years ago when I did that last time.”

• Local doc has told him he can drop one metformin when his weight gets down to <200 lbs.

• Still on CPAP. Doing well.

Teaching points• No change in antidepressants required to

ELIMINATE depression.• MVI/multimineral/fish oil used to support the

structure & function of the body.• Appropriate allopathic care given.• Predictable results occurred. • BUT WHAT ABOUT THE LAST 20 YEARS?• This way of thinking works in ALL specialties.

“Pending strong evidence …from randomized trials, it appears prudent for all adults to take vitamin supplements.” Fletcher & Fairfield, JAMA 2002

Bruce Ames, Ph.D.397 citations in PubMed, May 1952-August 2015

November 2, 2012

• #2 at present:• Vitamin D and the omega-3 fatty

acids control serotonin synthesis and action, part 2: relevance for ADHD, bipolar disorder, schizophrenia, and impulsive behavior. FASEB J. 2015Aug;29(8):3287-3301

Ames & Micronutrient Triage - deconstructed

1. Inadequate dietary intakes of vitamins/minerals are widespread.

– Excessive consumption of energy-rich, micronutrient-poor, refined food

2. Deficiencies in many micronutrients cause DNA damage in cultured or living human cells.

3. Proposal: DNA damage and late onset disease are consequences of a triage allocation based on micronutrient scarcity.

– Natural selection favors short-term survival at expense of long-term health.

Ames B. Proc Natl Acad Sci U S A. 2006 Nov 21;103(47):17589-94. Epub 2006 Nov 13.

Ames & Micronutrient Triage - deconstructed

4. If proposal is correct, “micronutrient deficiencies that trigger the triage response would accelerate cancer, aging, and neural decay but would leave critical metabolic functions, such as ATP production, intact.”

5. “A multivitamin-mineral supplement is one low-cost way to ensure intake of the Recommended Dietary Allowance of micronutrients throughout life.”

Ames B. Proc Natl Acad Sci U S A. 2006 Nov 21;103(47):17589-94. Epub 2006 Nov 13.

The Effects of high dose B vitamins on work stress

• “Occupational stress is increasing in Western societies.”• 3 month, double blind, placebo control, randomized study• Measured: Personality, work demands, mood, anxiety, and

strain• After variances in personality and work demands were

controlled, the vitamin B complex treated group reported significantly lower personal strain and a reduction in confusion and depressed/dejected mood after 12 weeks.

Strough C et al. The effect of 90 day administration of a high dose vitamin B-complex on work stress. Hum Psychopharmacol. 2011 Sept 8. doi 10.1002/hup.1229 (Swinburne University of Technology – Hawhorn, Victoria, Australia.)

End of the Line depression:Failure of Rx, TMS, ECT, Inpatient, and MAOI. Now what?

• 51 yo MWF presented April 3, 2012• Chief presenting issue(s):

– “frequent bouts of debilitating depression” (seem to be getting more severe and longer in past year).

– “pretty major issue with low self-esteem which interfere with relationship and results in social isolation.”

– “have been really tired and uninterested in much (has gotten better since time change).

– “on Prozac but doesn’t really seem to be controlling things very well.”

• Past Psych History: therapy, Rx. No periods of “excessively high energy.”

• Labs – reasonable. TSH = 1.00 (only one done)• Rx: stop Prozac. Start vilazodone (Viibryd ®) on day #6

Initial response….Then subtle changes.

• 4/30/2012 – on 15 mg vilazodone. Largely better. TFT’s found to be suboptimal– Started estradiol, progesterone, testosterone, DHEA & Armour– See back – 6 – 8 weeks (for titration period)– Referred for therapy for past issues.

• 7/02/2012 – “I think the brain fog has lifted – it’s about 80% functional.” – Vilazodone increased to 30 mg. – Started on sacchoromyces boulardi and Vitamin D3– Hormones adjusted.

• 8/16/2012 – doing well. Stable on 30 mg of Vilazodone• 11/20/2012 – Vilazodone now at 40 mg (patient

selected). Hormones optimal.

Destabilization

• April 2013 Lamotrigine added– Viibryd 40 mg no longer adequate– History emerged of “going manic” on previous Rx of Prozac.

• Reasonable stability until September 2013 (16 mos)

• November 2013 – depression increased– daughter moving internationally.– Had to work 70 hours + overtime previous week due to tech

error at work. – Speech now slightly pressured. Slightly hypomanic.– Low dose olanzapine added at bedtime.

• Late November 2013 – floridly manic

December 2013 – the calm before the storm• Off work due to manic exacerbation• Current RX:

– Lurasidone (Latuda®) 50 mg at night. Used for mood stabilization & presumed bipolar depression and in place of Lamotrigine 150 mg in a.m.

– Hormones – Bi-est, progesterone, testosterone, DHEA, Armour thyroid – all with perfect levels.

– MVI/multimineral/Omega 3 supplements twice daily• Mental Status Examination:

– alert, pleasant, poised, euthymic. Not manic. Very focused. Excited to be going back to work.

The bottom falls out. • 2/11/2014 – “not doing well at all.” Not able to

focus on job.– RX: Lamotrigine (which had fallen off - restarted)– 5HTP & seasonal affective disorder lamp started.

• 2/24/2014 – – “panic attacks. Can’t relax. Having thoughts about

people dying. [ego-dystonic] I think perhaps it’s that I’m just so stressed out at my job.”

• 3/3/2014 – has decided to leave job.• 3/13/2014 – suicidally depressed

– Recent inpatient hospitalization not helpful

3/13/2014A medication review – what does it tell us?

• Latuda for bipolar depression – failed.• Quietapine (Seroquel®) XR started

inpatient • Off of Viibryd and Lamictal (stopped at IP

tx)• Off-label use of Namenda XR in place for

cognitive disorder not otherwise specified • RX planning:

– Restart Lamotrigine– Continue going up on Seroquel XR – TMS recommended and consented.

TMS – March – April 2014

• 20 treatments – no benefit. –Brintellix tried during TMS but

patient felt moods became more unstable.

• Patient reports that she feels all of her problems are “psychological” and there things that she hasn’t worked out.

NO better.

• April 18, 2014– “I’m just suffering. It’s so awful.” – HRT, Alprazolam as needed panic attacks– Seroquel

• 500 mg XR at bedtime• 25mg twice daily and two at bedtime

– Lamotrigine 150 mg per day • RX:

– Cautiously reintroduce Vilazodone with maximal mood stabilization in place.

• DX: clearly bipolar disorder type II, with panic attacks concomitant.

Return from four months of inpatient

• April 2014 – Underwent four months of inpatient hospitalizations & therapy at two different institutions. – Became manic when Viibryd was increased to 40 mg per day off of

adequate mood stabilization (IP) – Stabilized on Lithium at second facility and sent back to Evansville

• July 31, 2014 – – “I’ve been staying in bed all day and just sleeping since

I’ve been back.” – “I just lay there [sic] in bed and worry about things that

aren’t true. • RX:

– Lithium ER 300 mg twice daily, Olanzapine 20 mg 9 pm, Lamictal 100 mg in the a.m., Armour thyroid (1/2 grain) changed to Levothyroxine 100 MICROgrams daily.

September25, 2014 – no better

• Status:– “Really bad. [husband] is divorcing me. I’m not working. I’m living with

my mom. And without [husband]– he was my life… I obviously wasn’t his. And I don’t know what to do. I understand, I’ve been a basket case for six months.”

• Present RX:– Lithium 300 mg #$ twice daily – Seroquel – 500 mg XR at night– Lamictal – 200 mg in a.m. – HRT, Vitamin D

• New RX: – Increase Lithium to 3 – 4 doses per day.– Start Vortioxetine (Brintellix ®)

10/14/2014

• “It’s awful – I’m just spiraling down and down and down. It’s like I’m a hermit. It’s gotten so bad that I don’t do anything.” –RX: still on previous. Only up to 5 mg vortioxetine.• Increased to 10 mg per day.

10/30/2014• “I’m not very smart, and I can’t go anywhere,

and I’m like agoraphobic now. I can’t talk to people very well. It’s getting worse and worse and worse. I’m alienating myself from my family, and my husband left because I’m boring and can’t talk to anybody and I’m intimidated by everyone. He didn’t want to live with a lunatic.”

• Bupropion deliberately added to 10 mg vortioxetine– (note 2D6 interaction)

Hard reset – per patient

• 11/21/2014– Stopped everything except Seroquel XR

and Lithium– Asked about trial of tryptophan –

recommended by brother was “also has bipolar and this works for him”

• 12/2/2014– Perhaps slightly better on tryptophan

and NO ANTIDEPRESSANTS.

12/9/2014

• “Having really crazy thoughts that I’m not going to get better. Just scared shitless all the time.”

• She just “no longer gets out of bed any more. Every second of every day is just hell. And these are the crazy thoughts that I’m having. And I think that I belong in an insane asylum, because I’m having these really crazy thoughts.” “Now I just wake up and I’m scared, every waking minute of every day, because I think this is going to go on forever.”

• RX: Tryptophan stopped. Phenelzine started 2 days later. Lithium and Seroquel continued.

Bad holidays. • 12/23/2014 – no better

– Restarted hormones– Consider TMS while on MAOI.– Referral to Stephen Stahl and others reviewed.

• 1/26/2015– Per husband: “Something has to be done. [patient] is

getting worse.” – “I’m doing so badly …. I’m going to sound crazy when I tell you this –

I can’t talk to people. It’s like I’m intimidated by everybody – I can’t go get my hair cut… and I can’t function. And I’ve always been like that, and I’ve had few friends and would avoid social situations as much as I could…. I always danced around it…. But now I’ve totally lost it.”

• Referral made to Dr. Kondziolka, MD – NYU Langone Medical Center – for psychosurgery. ECT started.

ECT Failure

• 2/23/2015 –ECT limited benefit.– 1st four treatment – no benefit. – After fourth – “giddy”– After fifth – feeling more depressed– Current RX:

• Seroquel 500 mg XR • Phenelzine – (Nardil ®) 30 mg three

times daily • She is OFF the tryptophan!

3/23/2015

• 3/23/2015– Still on Quietapine (Seroquel ® 500 mg

XR, Armour, no other hormones, and Phenelzine at 15 three times daily “after a scare with coffee.”

– RX: go back up to 30 mg three times daily

• Cognitive distortions also reviewed in psychotherapy specifically at this appointment.

EUREKA! A glimmer of hope.

• Prior to 4/9/2015 appointment– On own, stopped the Phenelzine, waited two days,

and restarting Trptyophan at 3 grams. – The day after she took the tryptophan, she was

feeling “really good. “I think I was almost manic – I was feeling too good.”

– Had tremors and shortness of breath. Went to ER• In ER, noted to be very positive. Making plans with her

husband. – Diagnosed with very mild serotonin syndrome.

Treated with diazepam and admitted to medical floor. Treated with IVF.

4/9/2015

• At follow-up– assessment of neurotransmitter deficiency. –Seroquel increased back up to 500

mg XR–Vortioxetine restarted, then

levomilnacipram (Fetzima ® ) added

May 5, 2015 – follow-up and case review

• Status:– “The same. I just can’t talk to people. It’s a nightmare. It’s like

putting someone in solitary confinement. And it’s just my personality which I don’t think can be changed by serotonin.”

– RX @ appointment:• Quietapine 800 mg XR, Vortioxetine – more agitated at 20 mg,

Bupropion 150 mg XL

• New RX:– Increase Bupropion to 300 mg XL. Begin adding l-

tryptophan back to the vortioxetine/ bupropion mix. • Pharmacogenomics testing ordered.

What did the gene testing show?May 11, 2015

Gene Genotype Significance What it means!

Cyp 2D6 Poor metabolizer

Vortioxetine levels will be high

Cyp 2B6 Poor metabolizer

Bupropion levels will be high which will drive vortioxetine even HIGHER!

COMT Moderate metabolizer

Chews up NT’s faster than homozygous negative

SLC6A4 SERT = normal SSRI’s, SNRI’s – should work.

HTR2A Normal response

Serotonin at the receptor will produce a response

MTHFR Heterozygous REDUCED FOLIC ACID CONVERSION = Dec. BH4, = INABILITY TO GENERATE ENOUGH NT’S.

Integrative tip: MTHFR deficiency causes elevation in HOMOCYSTEINE.

How to find this article: www.google.com - type in the title

as of 8/6/2015

5/26/2015: Gene testing reviewed.Informed psychopharmacology• Vortioxetine tapered to nil.• Vilazodone restarted at low dose. • Bupropion continued at 150 mg XL• L-tryptophan lowered to just 500 mg• In three days, start branded l-methylfolate

15 mg• Continue Armour, Quietapine and Vitamin

D as is.

5/26/2015 (reviewed gene testing)

• “So scared that things won’t get better,” she says with an uncharacteristic smile on her face. “I’m just terrified.” Her mood is described as “really down – like I don’t fit into this world – like I’m different from everybody else – like when I leave the house to go to Walmart, I feel different from everybody else – I just feel like there is something wrong with me – like I'm different.” “Then I think maybe I’m being punished. I can’t get that out of my mind.”

• Current RX: – Quietapine 800 mg XR at night. Brintellix at 5 mg. Bupropion at

150 mg XL. Branded l-methylfolate 15 mg per day. Still pushing l-tryptophan dosing up to no > 4 grams per day.

• Changes: vortioxetine stopped. Vilazodone started.

June 9, 2015:She is well.

• History:– Friday night, June 5th, got up to 6 grams of tryptophan. – Mood turned positive Saturday June 6th. Started looking

for a job. Happy, “almost manic.” – Husband insisted she lower tryptophan to 5 grams per day

• June 8th – the day before this appointment:– she went to the gym and did her elliptical and then went to a

body pump class. In the afternoon, she was supposed to be mopping the floors at the marital home. Instead, she ended up talking to her daughter (who was having problems) for two hours.

The Magic Cocktail – June 9, 2015

• Seroquel 800 mg XR at bedtime.• Vilazodone – 20 mg daily• Bupropion 150 mg XL daily.• “Supplements”

– Tryptophan – 5 grams all before bedtime– L-methylfolate 15 mg daily– B-complex– P5P– Vitamin D3 5000 IU per day.– 4 grams omega 3 (600mg EPA/400 mg DHA +

MVI/multi-mineral

Mental Status Examination: June 9th 2015

• In amazing spirits today. She is bright, chipper, and looks wonderful. This is in comparison to her self-report of “Dumb as a stump and lazy” on May 14th, and her persistent feeling that she was in hell. “For the entire last year I was laying in bed doing nothing. I wasn’t able to read or watch TV. I really thought my life was over.”

• She reports that she was getting to ready to sell her Jeep that she used to LOVE. This last weekend, her husband took the top off, and “I’m driving it around and having so much fun!!”

• Showed me 10 reminders on phone; had accomplished 5 of them, as well as gone to gym and done cycling class.

• Now no longer believes husband is going to “dump me.”

The rest of the story

• 7/6/2015 – having more symptoms – Daughter leaving for foreign assignment.– Changed to generic L-methylfolate. – RX:

• Go up to 30 mg of vilazodone per day. • 7/21/2015 – not better

– RX:• Changed back to BRANDED l-methylfolate.• Begin reducing Quietapine XR dosing slightly.• Armour thyroid increased to 1 ½ grains due to TFT’s.

Do not forget the integrative approach

The bottom line: Vitamin D and omega-3 fatty acids help you make more serotonin.

Teaching points• When patient escalates dosing of antidepressants

because they “stopped working” – think MTHFR deficiency.

• It is not a good idea to deliberately commit a drug-drug interaction without pharmacogenomics testing.

• Do not forget integrative treatment.• There will always be a balance between

psychodynamic and biological issues.• “Not to despair” – Stanley Greben, MD

Greben S. On being therapeutic. Can Psychiatr. Assoc. J. Vol 22 (1977) 371-380.

SCHIZOPHRENIA

Schizophrenia – a functional approach?

• Alan – presents on Feb 16, 2007, diagnosed with depression vs. psychosis.– Previous treatment at Pfeiffer Tx. Center

• He appeared notably fatigued and grossly over-sedated.

• Morose and depressed. Lucid. Intelligent.

Past history• “Ever since I can remember, I’ve always had the

same feelings about things – how people treat each other and stuff like that.” “My feelings just kept getting worse and worse the more I was picked on. That was the only thing that was wrong, people just calling you names and stuff.”

• Alan became suicidal in middle school – 8th grade year. “I just thought everyone was making fun of me, so why should I go on.”

• Treated with fluoxetine in the past for depression• Stopped being able to do homework as a sophomore in

high school• “I was just really resentful of my parents a lot during the

past few months [at that time] – I just started yelling at them in front of the therapist guy

• Ultimately stabilized by previous MD on aripiprazole (20 mg), olanzapine (20 mg) and sertraline (50mg).

• Per Mom – “It was hard for him to be out and be around a lot of people.”

Past history

March 2007• Evaluated for OSA& now on CPAP.• Improved energy.• Conventional labs ordered• Sertraline changed to duloxetine, which helped.• Aripiprazole [note slide edit] and olanzapine both

decreased by 5 mg. Modafanil stable at 100 mg• Very specific about self-identified “Paranoid

thoughts.” “I didn’t used to have them.”

Clinical course through July 2007• Continued in treatment with me every 1 – 3 month

appointments. Still isolated.• Seemed to improve on;

– Duloxetine 60 mg twice daily – Olanzapine 30 mg @ 9 pm– Aripiprazole 20 mg in the a.m. – Topirimate – 100 mg at bedtime (originally for weight

loss, but improved mood).– L-methylfolate 7.5 mg per day, empirically started– 5HTP 100 mg tid

2007 - 2009

• More explosive outbursts. Lamotrigine (200 mg) added topirimate continued

• “I know that I’m acting ridiculous – like a schizophrenic, but I feel good, and I’m talking more to everybody, and I’m trying to get my point across, and I don’t feel as evil as I used to.

June 30, 2009• He comments that he

feels his “mouth is going faster than his thoughts.”

• Mom reports that “traveling out here (to appointment) wears on him.” “He does better when he’s quiet and in the house.”

• RX:– Olanzapine 30 mg 9 pm– Aripiprazole 20 mg a.m.– Topirimate 100 mg HS– Lamotrigine 200 mg in

a.m.– Duloxetine – 120 mg / day– Modafanil – 100 mg daily– 5HTP 100 mg in the a.m.

INTEGRATIVE MEDICINE TESTING finally ordered!

FUNCTIONAL TESTING

• Micronutrient analysis (functional intracellular analysis) – deficiencies in:– Vitamins A & D, zinc, Oleic acid, antioxidant

capacity• IgG food allergy testing 7/22/2009

– 12 total sensitivities• 2+ to eggs, cow’s milk, wheat, brewer’s yeast• 1+ to cheese, mung bean, oat, pork, pumpkin, sesame,

tuna & baker’s yeast.

8/12/2009 - integrative treatment

• Very irritable and sarcastic at appointment.• Continue baseline Rx as is. • NEW: start diet – dairy free, gluten free• NEW: start vitamins:

– 4000 IU Vitamin D daily – Flavored cod liver oil– “ACES” – A, C, E, and Selenium

Last four months January 21, 2010• On IgG diet. “He has been doing well on it.”• At Christmas, however, he “went off of it.” Had cookies

everywhere – couldn’t keep him out of the wheat. Following that omnivorous consumption he exploded on New Year’s eve.

• Prior to that, his last explosive episode was in May – and has been good pretty well up until New Year’s eve. When the two brothers got in the car it set Alan off. “It was bad.”

• After the outburst, Alan specifically wanted to go back on the diet program. “He seems really good.”

January 2010 to present• Nov. 2012 – elevated Arabinose on OAT test –

treated with Nystatin• Probiotics added to deal with acid reflux• Macro and Micronutrient deficiencies identified

in hair testing and organic acid testing.• Generally stable. Subtle improvement. No more

meltdowns. No more concerns about going out in public.

June 23, 2015• “The past few days I’m

doing pretty good. It’s been a miraculous few days. This week has been pretty good. We have been going out a little bit more. We’re going to Biaggi’s after this. That’s going to be a first in a long long time.”

• RX:– Olanzapine 30 mg 9 pm– Aripiprazole 20 mg a.m.– Topirimate 100 mg HS– Lamotrigine 100 mg in

a.m.– Duloxetine – 60mg / day– Liothyronine 5

MICROgrams 2x/day

Current supplementation – in collaboration with CWI biomedical specialist

• NAC complex (glutathione precursor) – three capsules twice daily

• D3 (2,000 IU) – one per day • ACES – one tablet per day (Vitamin A – 10,000 IU

in 2 soft gels, Vitamin C 1000 mg in two capsules, Vitamin E 400 IU in two capsules , Calcium 119 mg in two capsules

• Selenium 100ug in two capsules). • Vitamin C (500 mg. twice daily)• Zinc (25 mg. 2x/day) – 50 mg per day • Lithium Orotate (10 mg./day)• CoQ10 (200 mg.)• Fish Oil - Previous had (EPA 1100 mg.; DHA 720

mg.; Other Omega 3: 230 mg.)• Niacinamide – 500 mg three times daily

recommended by Marci. • B5 (Pantothenic Acid) – 250 mg. 1x/day MWF

• Manganese 15 mg./day• Chromium polynicotinate 200 mcg./day• Magnesium glyconate 200 mg 2x/day• P-5-P 50 mg. 2x/day• Grapefruit Seed Extract – as recommended on

the label (for yeast) – liquid form • Olive Leaf Extract – 1 per day (for yeast and

bacterial overgrowth) – liquid form (with the grapefruit seed extract)

• Enzymedica Digest + Probiotics – take 1 capsule at the beginning of each meal

– Probiotic: Ther Biotic Complete from Klaire Labs – 1 capsule per day

• Copper (1 mg./day) – added in a multivitamin (“Headache Free”)

• Potassium was added 99mEq twice daily

As of August 5, 2015

The “top 3” as of 8/5/2015

The “next four” as of 8/5/2015

Vitamin D & Omega 3 fatty acids – relevance for SCHIZOPHRENIA

“VITAMIN D & marine omega 3 fatty acid intake may help prevent and modulate the severity of brain dysfunction.”

JUNE 2015

Teaching points• Just because someone has a classic “biological

psychiatry” diagnosis doesn’t mean that there can’t/won’t be functional (or medical) impairments. [e.g., OSA]

• You may not be able to get rid of the main diagnosis, but you can improve the patient’s quality of life.

• You MAY be able to get rid of a phenotypic diagnosis if there is an underlying physiological problem that can be addressed.

AUTISM

Joey: evolving autism, and resolution

• Growth slowed at 8 – 9 months. Colicky• “The ideal child until 15 months of age. • May 2010 – exposed to bug bomb residue at

14 – 15 mos.• “Not listening well. Fussy. Up 4x / night.” • July 2010 – diagnosed with autism spectrum• April 2011 – multiple nutrient deficiencies

found. • Treated, started to improve then …

Further developments• May 2011 – URI exposure at friends’ house• “He regressed tremendously, lost all words except

‘ma’ and began stimming behaviors, flapping his arms, blinking his eyes and screaming.”– When his mother turned on the blender, he would scream

for no reason. – Ran into stationary objects– Ceased being cuddly as in the past. – Stopped running to Dad when he came home. – Stopped responding to his name.

Seen by excellent pediatrician – June 6, 2011

• Diagnoses:– Autism Spectrum Disorder (299.00)– Urinary Tract Infection (599.0) – Food sensitivity ( 693.1) – based on the IgG test done in January of

2011– Leaky gut syndrome – which was apparently inferred due to food

allergy – Dysbiosis

• Klebsiella (in stool) • Proteus (in stool)

– Hypothyroidism (with TSH of 15) (!!!)• Tx’ed with Armour thyroid and multiple supplements with

improvement.

“Joey” – the medical and legal train wreck – from e-mail May 31, 2012

“A week ago Tuesday the Department of Child Services (DCS) removed my son from our home. It was reported that I administered what was deemed ‘holistic’ care to my child. Under the direction of Dr. XXX XXXX, MD my son receives medications, supplements, IV treatments, and mild hyperbaric oxygen. I happen to have my master’s in nursing. In my background I have a year’s work experience in administering IV nutrients and chelation at 2 specialty clinics.”

Joey: Seen for intake in my office – 9/5/2012• Alert. Serious. Intent on toys.

Played with them loudly. Not speaking in complete sentences. Phonated repetitively.

• Huddled down and pulled his lunch box in front of him when I asked him a question.

• Obsessive play with toys. “Push push push.”

Extensive laboratory testing ordered. Armour restarted.

Immediate interventions• Armour thyroid – ¼ up to ¾ grain titration.• “Starter Pack” of basic supplementation

– Calcium, fish oil, high dose B-complex, minerals– Calcium/magnesium chewables.– Cod liver oil (flavored)

• Supplement with glutathione precursor• DIET: yeast, dairy, and gluten free.• NO CHELATION• NO HYPERBARICS

September 19, 2012

Organic Acid Testing 9/26/2012

• c/w adrenal stress (low thyroid!!)– Also HPHPA with shunting toward dopamine

• Low 5HIAA = low serotonin – why?• Also, Quinolinic/5HIAA ratio very high

Milk allergies??

4.73X!

Hair analysis 9/20/2012 – toxic elements

Hair analysis 9/20/2012 – essential elements

New interventions (Oct. 2012):• Strict dairy free diet.• Tri-enza enzymes with DPP-IV• Increase supplements• Specific addition of B6 50 mg • Lithium ionic liquid (1mg)• Nystatin for yeast• Flagyl – 10 day course for HPHPA elevation• Start high potency probiotic after that is done.

December 5, 2012 follow-up

• RX:– Armour thyroid 1 ½ grains; Nystatin;

high dose MVI with B-complex; GSH precursors, Cod liver oil, B6, Vit C, probiotics, 1 mg ionic Lithium.

– On food antigen diet.• Family now able to go to church and

sit in pew. Went to MGM’s 95th birthday party.

• Mental Status Examination:– Alert, pleasant, happy, engaging. Talking

more. Gait improved. Speech much more intelligible. Played happily and cooperatively with Dad.

Joey – 1/21/2013• Still with foul stools• Mental Status Examination:

– Alert, pleasant, outgoing. Happy play. “There you go, car man!”

– “I ate all of my chicken.”– Normal gait.

• RX:– Continue with current– Add Uva Ursi.– Try stopping Mg for diarrhea.

11/21/12 29.6 lbs 36”

12/28/12 31.2 lbs 36 & 9/16th”

1/21/2013 33.2 lbs 36 & 15/16th”1” in 2 mo’s

Disposition

• March 1, 2013 DCS involvement ended.• April 5th – seen for follow-up. Speech

improved. – Now on Lactobacillus duo for yeast. – Added Methyl B-12 SQ.

• May 17, 2013 – moved to new location. Now being seen by another specialist. Doing well.

The REST of the Story - Joey

9/15/20139/5/2012

9/5/20129/15/2013

Summer – 2014 – with Dad in their organic garden

Apple Store – Chicago, Michigan Avenue © 2008 Louis B. Cady, MD.

“It’s not the customer’s job to

know what he wants.” - Steve Jobs

Contact information and slide resources

Louis B. Cady, MDCady Wellness Institute4727 Rosebud Lane – Suite FNewburgh, IN 47630 USAOffice (812) 429-0772info@cadywellness.com

Available on Apple “app store” and Google Android store.

www.slideshare.net/lcadymd