This article is sponsored by Psychiatry Redefined. This article is based on a discussion with James Greenblatt, Founder & CMO of Psychiatry Redefined and Mariela Podolski, Child & Adolescent Psychiatrist at Psychiatry Redefined. This discussion took place on October 11, 2023 during the BHB INVEST Conference. The article below has been edited for length and clarity.
Dr. Greenblatt: How many people have any idea what we will talk about today? Has anybody ever heard the phrase Precision Psychiatry before? I heard about it about three years ago at a Harvard conference. I said, wow, mental health is getting into the big time, going to treat patients. I spent a lot of money at this conference, and it was all on these genetic snips and a little bit about brain scans. It was probably 20 years away from actual clinical practice, and I was disappointed, if not angry. What Dr. Podolsky and I hope to share with you today, is the future of precision psychiatry and what that term could mean for dramatically changing our mental health outcomes.
How many people have kids? How many people know someone who has children? If you can imagine taking your child or going to your friend or sister or brother to the doctor with your child who has severe crushing abdominal pain. Right, you’re worried about it. It’s not that typical, I don’t want to go to school pain. This is the real thing. Big pain. What happens when that child gets to the doctor? There’s blood pressure, and there’s a pulse check, there’s a physical exam, there are blood tests. If the doctor’s really worried, we’ll get a CAT scan, maybe an ultrasound.
There is going to be a litany, a long list of objective tests to help that doctor go from the symptom to a cause to a treatment plan. Everyone else in this room has something to do with behavioral health. What happens when you walk into a child psychiatrist’s office or a therapist’s office? What do they do? There’s no physical examination; there’s no blood test. There’s certainly not a CAT scan, x-ray, or MRI. Our behavioral health system is set up by the psychiatrist or psychologist or who is treating that patient to make a list of symptoms and come up with a diagnosis, and the treatment is purely based on symptomatic treatment.
If you’re sad, you get antidepressants. If you’re anxious, you’ll get an anti-anxiety medicine. Just take that model for a minute and think about if that pediatrician did that with your child who had severe abdominal pain. Just looking at you and your child, it must be an appendicitis. We’re going to get you over for surgery tomorrow. It sounds absurd when we think about it in our pediatric or our medical or any other part of our medical model, but the foundation of our medical model is objective laboratory testing, right? We have symptoms and we have this incredible technology and treat it, but our behavioral health system is a psychiatrist.
It’s the measurelessness of this medicine. We have no objective tests, so it’s really embarrassing to say, but I can say it, we’re just guessing. It is a field of educated guesses, and if that worked, I guess we wouldn’t be standing up here, but I think one of the dirty little secrets we don’t talk enough about out there, or in our communities is the outcome rates in mental health are abysmal. The relapse rates are tragic, and the model just rolls on, and you guys are investing more and more money in the same model, right? How many more therapists, and how many more times we can pay psychiatrists for this model of symptomatic-based medication?
Are there any pharmaceutical companies in the room before I make a joke? No? This symptomatic-based poly-pharmacy model is just a med and then a second med, and as child psychiatrists, it’s just frightening what’s happening to these kids. We are seeing kids 10 and 12 who are on seven psychotropic medications, and they’re not any better with the first model. Hence, Psychiatry Redefined, the organization I lead takes a different approach. We have been looking at biomarkers the way our colleagues in medicine have done for 30 years now. Many of the things that we’ve talked about over these 30 years, there was just small amounts of research to support it, but now there’s hundreds of academic references supporting our work which is looking at nutritional psychiatry, integrative medicine, a term called functional medicine, and it includes a holistic perspective based on the same biomarker model. Think of a 360 degree look at the patient.
We could go on, actually, we have hundreds of hours of content. We’re an educational platform educating clinicians. I’m going to introduce Dr. Podolsky, who is a child psychiatrist. She can tell you about her work with Psychiatry Redefined, and I really wanted to be able to make this as interactive as we can. Our goal everywhere is to improve outcomes. Move beyond symptom management. We want to engage you in a discussion to help you understand what this model is and why it matters more today than ever before. Dr. Podolsky, do you want to share a few thoughts on precision psychiatry?
Dr. Podolsky: Thank you so much for being here, and my role here is just to tell you a little bit of my story. I’m a child psychiatrist, and so is Dr. Greenblatt. I think he left that out of his CV here in this presentation, but apparently, we’re in high demand, according to the keynote speech this morning. I am happy to answer any questions, but in any case, I was trained in Connecticut at Hartford Hospital Institute of Living for my psychiatry residency, and then I went ahead and did a child and adolescent psychiatry fellowship in Milwaukee, Wisconsin.
After that, I started practicing, like every psychiatrist that comes out of residency does. You see patients, make a diagnosis, prescribe a medication, and move on to the next patient. I did that for many years. I was very frustrated, to be honest, in an outpatient psychiatric clinic where I felt like I was making no difference, and I had the same patient repeat, repeat, repeat. Very frustrating. Then I moved on to different levels of care. I have worked in every level of care. I have been the medical director of an inpatient psychiatric unit that treats eating disorders.
I have worked at partial hospital programs, intensive outpatient, and I have moved back to my clinical work in my private practice. The beauty of it is that I stumbled upon Dr. Greenblatt and his wonderful platform called Psychiatry Redefined. For those things in the world, something spiked my curiosity, and I joined his fellowship, this fellowship that is offered through the educational platform called Psychiatry Redefined. I enjoyed the fellowship so much, and I learned so much that I signed for it twice. It’s a whole-year program, and I learned a lot!
I didn’t know what I didn’t know, right? When you’re not educated in these alternative ways of treating patients, you just simply don’t know. I don’t blame the psychiatrists for not applying this, but at the same time, we’re here to, hopefully, make a change, to really spread our word that we can treat patients and have better outcomes. What does that mean? I never ordered a homocysteine level before, paid much attention to your vitamin D, or even thought about, do you have a copper deficiency. All of these things translate into your well-being every day.
When we combine what we know as psychiatrists, and we have a prescription pad, when we combine that with the roots of the problem, which typically are a combination of genetics, biological, and environmental factors, the actual whole person, we have better outcomes. I can tell you, I’m no longer bored with my job. I love what I do. I do it very well, and I have better patient satisfaction than I ever did before, because my patients do get better. That’s because I was able to learn. We want other people in the world, really, because it’s an online platform, to join what we’re doing, to learn about us, and to learn that this is really the moment that we can change and treat patients better.
Audience member: Regarding getting insurance reimbursement for functional testing, where are we at in that process?
Dr. Podolsky: I think you’re asking about insurance reimbursement for functional testing. Unfortunately, in my experience, not all is covered. Some of it may be. We always offer reimbursement. We always try to get it reimbursed, if that is possible.
Dr. Greenblatt: I’d say sort of. Let’s say that in my brain, I have 250 biomarkers that I want to look at for every psychiatric patient. Probably 100 of them are covered by insurance, so Quest or LabCorp or any other thing. We could go on and on, and I promise I won’t, but vitamin D deficiency is epidemic. 70% of this country, it is the vitamin needed to make serotonin in the brain. Meds don’t work well without adequate serotonin. It’s so much more prevalent in our dark-skinned communities. If we can check vitamin D levels in everyone, we would prevent major psychiatric illnesses.
Some of the tests are not covered by insurance, but many are. It’s a problem that comes up a lot in our fellowship, because we have docs working in community mental health clinics, and they say patients can’t pay $200 for this test, but they can do these tests. There are numbers.
Dr. Podolsky: I think it might be helpful to say that, for instance, in my practice, my current practice, not everybody gets the more expensive tests, right? To your point, people are not always reimbursed or covered by insurance. A simple lab slip, knowing what to look for, makes a world of difference. We had to put a name to a face, right? I had a patient who was 26 years old and all of a sudden they couldn’t get out of bed with severe OCD. When I ordered a lab slip, she was not interested in getting a hair mineral analysis or any of those more fancy tests. Her vitamin D was under 10.
The lab didn’t even give me a report. I treated her with an SSRI and normalized her vitamin D, and we’re now in the process of weaning her off of that SSRI and maintaining really regular checkups for her blood work. That made a difference. Had we not looked at that, this patient would have ended up with a very high dose of an SSRI, plus probably an antipsychotic to treat her symptoms. We’re stuck in that same cycle over and over again. Some of them are covered by insurance. I shouldn’t say that none of them are. Actually the majority of our patients don’t end up getting the full battery of testing that is more expensive.
Audience member: Just how do you prioritize each test? If you’re going to see a patient and do triage, how many prior check-ins does it make you have to have in order to approach, based on those results, do you do additional testing since there’s such a battery of tests that have been done?
Dr. Greenblatt: That’s pretty much why it takes us a year of training. It’s not simple.
Audience member: Is it based on just like a PHQ-9? Is it based on just the interactions of the patient? Is it based on systems?
Dr. Greenblatt: I think the model is based on just our experience over many years that these core tests are most likely to result in major psychiatric symptoms. Then we do those screening first, and then can expand to other tests. There are a core set of tests that have really profound implications for brain function, and 95% are completely ignored by every psychiatrist and every behavioral health program. You can’t even get labs for our inpatient and residential patients because they’re in our per diem rates, so we’re not going to pay for them.
Audience member: You had mentioned the confluence of biological environments with genetic factors. Could you speak to how often one of those, you’re seeing then, for example, if a deficiency in one area, how often is that because of social determinants problem? They live in a food desert, for example, and don’t have access to fresh fruits and vegetables. How often is this actually addressing some other pharmacologic strategy versus addressing a meaningful environment?
Dr. Greenblatt: We can’t piece apart anything as a priority. I think our focus is giving every individual child, adult a biological foundation where they can perform and do what they need to do. We look at genetics, we look at these nutritional markers, we look at all these other parts. Not discounting all the other social determinants, but if their brain does not function optimally, then it just compounds all the other variables. The focus for our group is around optimizing the biological foundation so the brain is functioning better, and there’s certainly profound implications around social, cultural, and all the other aspects.
Dr. Podolsky: As psychiatrists, we don’t always have the resources to make changes in their environment or other limiting factors that they might have. Through learning all of these things, my speech is the same. If you came to my office today, I would give you the speech. It goes something along the lines of, when you’re baking a cake, because everybody has had that experience at least once in their lifetime, even little ones. When you’re baking a cake, you put all of your ingredients together. You really have a chemistry lab in your kitchen.
That’s really what is happening. Let’s say the recipe calls for four eggs, and one stick of butter, and one cup of milk, and half a cup of sugar, and one cup of flour. You’re start mixing your ingredients, and you notice you only have three eggs and half a stick of butter, and you don’t have enough sugar, and the flour you have is not the kind that you wanted. Anyhow, you proceed, and you bake your cake. It’s just not a good-quality cake. You can bake it. Something is going to come out from the oven. It’s just not good enough. It’s the same with our brains.
All of these little micro-nutrients participate in chemical reactions to produce your neurotransmitters and to function properly. If we don’t pay attention to our ingredients, then the end result is not good enough. What we can do, I can’t really change. I wish I could change all of those other factors, but if we give our patients better neuro-chemistry, then they can function much better in all areas, make better decisions, feel better, have more energy, etc.
Audience member: Do you find that patients are good at maintaining that level of nutrient density or homeostasis really after treatment, or do they wax and wane?
Dr. Greenblatt: Let me compare it to what most of us do, right? We’re spending multi-billion dollars, we’re reading an article, and we take a supplement, right? We say, “I need this for X, Y, and Z.” What we’ve been doing is, we’re going to look at a blood test or urine test, and we’re going to say, “You’re deficient in zinc.” They see it. It’s real. They’re not guessing, so there’s more motivation to replete that micronutrient for this period. It’s not forever, so it’s just taking the guessing out of our recommendations. Compliance has really not been a problem. I think the real issue is the finances for those who can’t afford even a supplement. I haven’t found that compliance is a problem.
Dr. Podolsky: Me neither, and particularly because patients do feel better. Once they feel like it, I can truly feel better, and it makes a dramatic change, then they’re more likely to stay compliant. Now, I have seen patients that come off their supplements without my recommendation, and then they return and say, “You know what? That magnesium I was taking actually was very helpful, and I think I’m going to stick to that.” I say, imagine if I could treat you with no Zoloft and only magnesium, right? That’s not possible for everybody, and we still use our prescription pad. Isn’t that so much better? If it were my kids, I would want that for them. Yes, I do think compliance does improve.
Dr. Greenblatt: Please, go ahead.
Audience member: To your biomarkers that you talked about, can that help you narrow down the best medication for a patient so that we don’t have to go through five different tests and address them before you find the one that works?
Dr. Greenblatt: Absolutely. I think we’re getting pretty good. One of the tests is genetic testing, where we can look at medications that hint which is the best. These tests also predict who’s going to have side effects on the SSRIs. So that combination just gives us a better, more targeted, personalized treatment. There’s still some educated guessing in psychopharmacology, but it minimizes the side effects and it targets the symptoms.
Audience member: Why aren’t insurance companies going, absolutely, let’s do this? Because they’ve been doing it before.
Dr. Greenblatt: We’ve been asking that question for 30 years, and I’ve sat with a few insurance companies, and they nod, and they agree, and really, nothing happens.
Audience member: It’s also because they’re not paying for the psychiatrist.
Dr. Greenblatt: Absolutely, yes. Please.
Audience member: One of the questions I have is, when we typically do a diagnostic evaluation that’s like maybe an hour at best that we’re afforded for that time, in adding this component, in trying to do the review of all the information that we need, and then this review, how much time are we looking at for a visit?
Dr. Greenblatt: The visit. We’re paying psychiatrists for an hour, and it takes a lot of time to get that information. If we’re talking about 250 biomarkers, what does that mean? In my world, over the years, I found I had to work with a colleague, a social worker to do that psycho-social. That hour, that history was completed for me. I knew three generations, family history, I knew that history. When I see them, I’m doing my psych eval for my hour, and then ordering those blood tests. Then when I see them back, then I’m going over the results and being able to target either medications or supplements. There’s a few other steps, but some of them don’t require the psychiatrist.
Dr. Podolsky: I think it might be more time-consuming at the beginning, but once the patients are stable, which most of our patients do get stable with this model, you don’t have to see them that often. It liberates your time instead of the frequent revisit for the same problem repeatedly. Does that make sense?
Dr. Greenblatt: Yes, there’s something really strange about this whole model. Patients get better and they don’t come back.
Dr. Podolsky: True.
Dr. Greenblatt: That’s when I tell people that in the last few years I’ve only done consultations and I said, “My job is to get you so you don’t come back anymore.” I couldn’t do that as a psycho-pharmacologist, one, because of the side effects of compliance, and two, because they always needed to come in for a script. You just can’t do that in our current model. It’s just symptom management and then dealing with the side effects of these medications. Both Marielle and I train residents, so we’re hardcore psycho-pharmacologists, but we’re just augmenting the model.
Audience member: I just had a question about how do you incorporate hormone testing in middle-aged women specifically, and do you see a theme in deficiencies as women are going through perimenopause?
Dr. Greenblatt: Yes, part of the training is a lot of hormone changes, so there are modules on hormonal changes in menopause and perimenopause, pregnancy, puberty. There are certain nutritional deficiencies. One of the things that was based on, that’s why hence the precision psychiatry personalized medicine. I’ll pick on menopause because you said it first, okay? 10 women going through menopause, I can’t say they’re all going to be deficient in X. I could see 10 different biological problems, hormonal, nutritional, environmental, that could be looked at and addressed.
Audience member: Do you think that this feeds into the measurement-based care part of that story too, and that you can track these different metrics?
Dr. Greenblatt: It absolutely feeds into the measurement-based care, and one of the terms I’m getting a little frustrated with, but I think you said in your talk, this value-based care, which is getting a little ridiculous as a term, but an outcome that’s a checklist, is meaningless in my book, versus an outcome of a dramatically changed biomarker and someone’s feeling better. It is certainly a measurement that we have, that we can utilize, and then we can measure again.
Audience member: Have you found there to be a significant link between inflammation and anxiety? I’m curious, from a course of action to your patients, what you would recommend from a supplement standpoint and a food standpoint.
Dr. Greenblatt: That’s about a 10-hour answer, but I’ll give you the one minute. Inflammation, right? We heard the word, COVID invented it. It is related to every psychiatric disorder known on the planet, right? The reason we know it is because pharmaceutical companies jumped in, because you can make a drug as an anti-inflammatory, so the research is pouring in. We know inflammation is related to schizophrenia, bipolar illness, anxiety, and depression. Our body’s immune response, childhood OCD, tics, and tourettes all related to our body’s immune response.
The question is, is inflammation this general term, there could be 10 different reasons why someone has inflammation. Our program helps you determine what those are. Is it long COVID? Is it Lyme? Is it a vitamin D deficiency? Is it obesity? Is it stress? The list is endless. You can’t just say, going to take this for inflammation; you got to find out what’s contributing to that inflammation, but absolutely it is related to all of our major psychiatric illnesses.
Dr. Podolsky: I think I just want to make sure that we take a minute to talk about not only what we do, but what Psychiatry Redefined is. It’s an educational platform where clinicians of all types, majorly physicians and APRNs, but also PAs and dieticians and even some other psychologists or whatnot can join to learn. We have a one-year fellowship. At the same time, we also have some other courses that are smaller, like maybe three months, and there is mentorship and supervision. We can discuss cases and discuss outcomes and really learn from each other. It’s all online, and we’re all busy, we’re all adults, we all have jobs. It is, on your time and not necessarily a full-time job either.
Audience member: I was wondering, is there a community, because obviously once you start learning, you can’t stop learning with this type of medicine. Is there a community that continues to work together or how does all that work?
Dr. Greenblatt: Yes, I think if any of you have health care organizations, one of the most rewarding parts for the people we’ve worked with over these past six years is their sense of feeling isolated and lonely in practice because they’re just prescribing meds. They realize there are better outcomes. Coming together as part of a community has been the most fruitful part of this program. There’s a community where they’re interacting daily, sharing cases, sharing articles, references, and how to work with insurance companies or colleagues. That has turned out to be so much of what we’re hearing, that connection and that community is a huge part of people looking for something beyond a prescription pill.
Audience member: I’m just curious if you’re finding more people being interested in this, any certain parts of the world. Are people interested in this in the United States or do they have more interest in more open-mindedness to this in other parts?
Dr. Greenblatt: We have at least 12 countries participating in the fellowship. Many countries are much more invested in psycho-pharm than this country. We’re probably a little ahead. I think it is growing. I gave a talk, there were about 500 traditional psychiatrists, it was at a psycho-pharm conference. I got my opportunity, I got one minute, one second. They were all engaged, and they all asked questions. They asked questions about themselves and their families and their kids. They didn’t really get that they might be able to use this information for their patients. I think there’s a learning curve. I think the consumer, like every other health movement, is going to be pushing this up into the doctors and the clinicians.
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