Integrative Treatment For Mood Disorders In Kids and Teens

Episode Transcript

Dr. Nicole Beurkens: 

Hi everyone, welcome to the show. I am Dr.Nicole and today we are going to be talking about mood disorders in children and teens. An increasing number of kids and young adults are being diagnosed with things like bipolar disorder, depression, dysthymia, Disruptive Mood Dysregulation Disorder which is a newer diagnosis in the last several years — and the standard treatment for these kinds of issues in kids and teens tend to be counseling and medication, but the challenge is that many kids don’t get fully better, their symptoms don’t really improve with those approaches alone. And there are many integrative treatment options that can support symptom reduction for these types of issues. 

I’m thrilled today to have Dr. James Greenblatt as my guest to talk about some of those options. I have been learning from him for years through his seminars and books and find that he just has a wealth of knowledge and experience related to integrative and innovative treatment approaches for these issues. So let me tell you a little bit more about him. Dr. Greenblatt is an integrative psychiatrist with over 25 years of experience treating patients with mood disorders and complex eating disorders. An acknowledged integrative medicine expert, Dr. Greenblatt has published several books discussing the scientific evidence supporting the use of nutritional interventions in psychiatry. 

Expertise in the areas of biology, genetics, psychology, and nutrition as they interact in the treatment of mental illness has lead to numerous interviews by the media on television as well as in written articles for consumer audiences and he does have lots of different things available online, we’ll make sure you know where to find his resources. Dr. Greenblatt currently serves as the Chief Medical Officer at Walden Behavioral Care in Waltham, Massachusetts, a treatment facility specializing in the treatment of eating and psychiatric disorders. Dr. Greenblatt also serves as an Assistant Clinical Professor at Tufts Medical School Department of Psychiatry and Dartmouth College Department of Psychiatry. Dr. Greenblatt — so thrilled to have you here, welcome to the show.

Dr. Greenblatt:

Great, it’s good to be here. Thank you very much. 

Dr. Nicole Beurkens: 

So I want to dive into this whole realm of mood disorders and exposing our listeners to potentially some treatment options or ideas that they haven’t learned before, but I’m curious just for you to be able to take a moment to share with our listeners how it is that you came to be working in this field of more integrative psychiatry — I mean you were trained as a traditional psychiatrist, right? How did you get into looking at these kinds of integrative options for treatment?

Dr. Greenblatt:

Well, I actually went to medical school hoping to cure all of the mankind’s ills with brown rice and kale, so I went in a little idealistic thinking that was how we could change medicine and I came out 9 years later as a child psychopharmacologist and going out in practice, it was quite clear that the traditional model for psychiatrists was medications and that model, very quickly, you find out is both limited — kids don’t always get better, some kids are getting worse and I kind of went back to my roots and why I went into medicine and started, almost 30 years now, looking at this integrative approach to mental health care.

Dr. Nicole Beurkens: 

I think that so many of us in the field had a similar experience, I mean I did as well of being trained in a very traditional model of psychology for kids and adults and then getting into the real world of practice and realizing — oh wait, there are other things that are needed here. People aren’t necessarily always getting better with these more traditional approaches. So let’s talk about mood disorders in kids and teens specifically. How are these diagnosed? What are the common kinds of symptoms that are happening for these kids?

Dr. Greenblatt:

Sure, the problem with all of psychiatry, and I think more tragic with our kids is that all of the diagnoses are based on symptoms, a list of symptoms. So a child might be sad, not sleeping, irritable, have thoughts of wanting to die. Some parents will just ignore it and that’s a growing concern now. Parents who are shamed and saying they’re just doing this for attention. Other parents that take their kids to providers are given a diagnosis of, let’s say, depression based on that list of symptoms. Whereas nobody is looking at what might be contributing. Whether it’s bullying or trauma or in my world a nutritional and metabolic problem. There’s no concept in traditional psychiatry about what, if anything, might be contributing to those symptoms.

Dr. Nicole Beurkens: 

It’s that need to really look at root-cause issues, right? We can have 10 people who exhibit similar types of symptoms but there may be different underlying reasons why those symptoms are happening.

Dr. Greenblatt:

Absolutely. And our system doesn’t allow for that individually. So if you’re sad and depressed, you take a sad or depressed “anti-sad” pill, you take an antidepressant. If you’re anxious, you take an anti-anxiety medication. If you’re a therapist, you’ll put them in a box of this therapy or that therapy. So really, there’s no model for looking at the individual.

Dr. Nicole Beurkens: 

And it seems that we have continued to expand the number of labels or names that we give to these types of things, and especially, you know with kids that the new label that we have, the Disruptive Mood Dysregulation Disorder, which really to me — it’s well, we see these irritable kids in practice who are struggling with managing their emotions and their behavior and that’s become a new sort of box to put them in, but again — it’s not entirely helpful because it really doesn’t tell us anything about why they’re experiencing this chronic irritability or these chronic issues with not being able to regulate themselves well.

Dr. Greenblatt:

Yeah, I think that diagnosis, in particular, is concerning because a group of professionals as we just added it to the new list in the DSM, didn’t want to call or label theses kids bipolar, which many kids were labeled 10 years ago. And that particular diagnosis, that DMDD (Disruptive Mood Dysregulation Disorder), I believe is a physiological reflection of something going on and our job is to find out what because most of these kids are not irritable and angry for no reason.

Dr. Nicole Beurkens: 

Right, and I think that’s a great point that when kids especially are acting out in these ways, that’s a red flag that there’s something going on beneath that that we need to figure out and I think especially for kids, they are even more sensitive to some of these nutritional issues. Things like sleep disruptions, things that maybe adults can manage a bit better in kids, I find especially with things like sleep and diet and those types of things — even small issues with that can have a snowball effect over time and create really significant symptoms.

Dr. Greenblatt:

Absolutely. 

Dr. Nicole Beurkens: 

So you take more of this root-cause. Let’s dig into what’s going on that’s causing or perpetuating or contributing to these symptoms. What are some of the common things that you see that are underlying causes or reasons why children and teens are exhibiting these types of mood issues?

Dr. Greenblatt:

Well, the complicated part for many clinicians is that the list is long. And sometimes it takes a lot of effort to kind of sort it out. But some of the major ones would be elevations in heavy metals. Everyone’s kind of concerned about lead since the Flint, Michigan crisis. But we check for lead. One of the things we’re seeing even more common is elevated copper, creating irritability and anger in kids and young adults. And in Massachusetts where I live, the school systems tested for lead after the Flint, Michigan crisis — they also tested for copper. 

And over half of these elementary schools had elevated levels of copper and this is in the drinking water and copper contributes to this. So that’s just one of many. Deficiencies in vitamin D can contribute, deficiencies in vitamin B12, gut problems — kids who are taking too many antibiotics can have some disruption in their gut that can cause some behavioral symptoms. So as you said earlier, 10 different kids with mood problems — which one has high copper? Which one has low vitamin D? You need to test to find out.

Dr. Nicole Beurkens: 

So testing is a really important component of this, then, to figure out what is underlying this. What kinds of testing do you commonly use or recommend?

Dr. Greenblatt:

It’s a lot of testing. I think that the rest of medicine, if you go to your doctor with chest pain or some ailment — they’re going to test to find out what it is. And that’s our medical model. And I’m trying to bring that back to psychiatry. So we do a blood test, looking at levels of vitamin B12 and D, we do blood tests looking at levels of essential fats and amino acids. We can determine the gut bacteria by doing urine and sometimes stool tests, and with heavy metals, we can look at hair levels, a genetic test. So it’s a comprehensive battery of tests but if we have a very aggressive, depressed child — we want to know what’s going on, otherwise stuck in the mental health system, it’s probably going to be polypharmacy, multiple meds that often have side effects.

Dr. Nicole Beurkens: 

Well, I think that’s the challenge, it’s many parents and children have been sort of what I call that hamster wheel of mental health treatment where it’s been identified that there’s challenges and then they just get sent from one person to the next and go round and round with adding more medications, trying different types of counseling approaches — it’s not at all uncommon in my practice to see even younger children, you know — younger elementary-aged children coming in on cocktails of 3, 4, 5 different medications that have been added over time in an effort to address these behaviors where there is mood-related issues and parents are saying, “Help! My kid is still really symptomatic — I’m doing everything that we’re being told to do and things just start really getting better and so I think there’s a lot of parents listening who can really see what you’re talking about with that and it’s really helpful for them to hear that there are tests that exist they can start to look at and sort of peel back the layers of some of these root issues that might be present. 

Dr. Greenblatt:

Absolutely, and it doesn’t mean that medications might not be necessary, but it does mean that if there is a metabolic problem, it might interfere with the medications and just educated guessing about which medicine and adding medicines on top of medicine barely results in remission of symptoms.

Dr. Nicole Beurkens: 

I want to ask because I know that there are parents who have experienced this as well, so I want to ask about lab testing, specifically for things like nutrients. You mentioned things like B12, Vitamin D — those types of things. What about situations where parents have some of that testing done through the primary care, maybe even through their psychiatrist or specialist and the results come back and the physician or the prescriber says everything’s within normal limits, none of this to be worried about. Can you speak to that?

Dr. Greenblatt:

Sure, I think there are some lab values where the normal lab reports kind of make sense. There are others that over the years, integrative physicians have found are not clinically relevant. B12 being the most dramatic. So a vitamin B12 range that you would get back from your doctor is very broad, from like 200 to 1100 and we see very significant clinical symptoms in some of those ranges that a primary care doc might say are normal. So I think it’s important to find clinicians that do have a knowledge of integrative medicine and can understand interpreting some of these lab tests.

Dr. Nicole Beurkens: 

Yeah, I think that’s really important too. So when we look at some of the nutritional pieces of this, I know that there are many specific nutrients that you talk about that can be helpful for children, teens, young adults with these types of mood issues. Let’s dive into that — what types of specific nutrients should parents be aware of that may be contributing factors or that they maybe want to look at as part of a treatment protocol for their child?

Dr. Greenblatt:

Sure — again, the list is long in our depression book — we have something called the ZEEBRA Approach — there are 2 E’s in ZEEBRA — So each letter stands for another intervention, but to summarize, I think the simplest ones that parents could do would be looking at vitamin D levels and vitamin B12. It might be normal, but they might be very low, contributing to a depression and would also contribute to poor response to medication. So those are critical. In terms of trace minerals, I think magnesium would be one nutrient that every parent should read about and understand. It’s hard to test but it’s usually deficient in kids, certainly if there are irritability and anger issues as well. And zinc is another nutrient for lots of reasons, environmental toxins, dietary intake, particularly with vegetarians or vegans not getting adequate zinc. So B12, D, magnesium, zinc and then the trace mineral that’s not talked about a lot is a nutrient called lithium. And this is often deficient in our kids with mood disorders, particularly those that are prone to anger and irritability.

Dr. Nicole Beurkens: 

I want to go a little bit deeper into that because I spend a lot of time on just furthering my own education about these kinds of things and you’re really one of the only ones out there who is really talking about this lithium piece. When I heard you first discuss it many years ago at a conference, I was like — Hmm, that’s really interesting and then read your book about that and have explored that further. Most people, when they hear, lithium think about the drug ‘lithium’ or maybe had that prescribed for themselves or their child. Could you talk about the difference between prescription lithium and what you’re talking about with nutritional lithium and just why lithium is important to consider for these types of conditions? 

Dr. Greenblatt:

Sure. Well, lithium is an element. It was around in the big bang 13 billion years ago and it settled in the Earth, so it’s an element just like potassium and sodium and chloride and all the other elements in the periodic table. So it’s a natural element that in the ’40s, somebody found very high doses calmed guinea pigs down and then they started using it for bipolar illness. It was approved in this country as a medication many years after the rest of Europe but around 1970. So we’ve been using it as a medication and the numbers are really important — so as a medication, we might use 1500-1800 mg. 

The prescription medicine, and like any medicine — has side effects. But as a medicine, it is very effective for the treatment of bipolar illness and so psychiatrists have to balance side effects with efficacy. My work is focused on sometimes prescribing the medicine, but also the nutrient that you can buy on Amazon, I mean it is a vitamin pill and so I prescribe it in these micro-doses. 500 micrograms. And these low doses have been shown to affect mood. 

So I can go on for hours, but let me just give you one quick example of how dramatic these micro-doses are. So we have studies that were done around the world in countries like Greece, Italy, Japan, Lithuania — and in the United States. And the amount of lithium in the soil, tested by the water, so they pick up water, they test of lithium — it predicts a depression and most dramatically suicide-risk. So high lithium in the water, there’s a low-suicide risk. So very small amounts of lithium have dramatic effects on the brain and over the past 20 years, researchers have tried to untangle some of those effects.

Dr. Nicole Beurkens: 

What I know from sometimes when you speak about this, there are waters out there that have lithium out there added to them specifically because it just tends to make people feel better, right? 

Dr. Greenblatt:

Well, for many years — 7UP, the 7UP drink was labeled as a — 7 is the atomic weight of lithium — or actually, 6.92 so they couldn’t do that, so they rounded it up to 7 and UP — lift your mood. So up until 1950 was a lithiated soft drink. So there are companies that have found high lithium in streams and have bottled water — there’s one company called happy water with small amounts of lithium.

Dr. Nicole Beurkens: 

I didn’t know that about 7UP — that makes sense, that’s great! So what specific form then — so people are thinking, you know cases, the medication lithium but then there is this nutritional lithium. What type of product are we talking about or what type of formula do you tend to find most helpful?

Dr. Greenblatt:

The prescription lithium is called lithium carbonate — the nutritional lithium is lithium citrate or lithium orotate. The orotate, the smallest pill you can get is like 2.5 or 5 mg. So for children, I typically start with liquid lithium citrate and they can titrate it up from 500 micrograms — a quarter of a dropper, up until 2 mg. I think one of the most important factors to consider besides the symptoms of irritability and anger is a family history. If you have a family history of substance abuse and/or depression or suicide, those are the kids that tend to respond better to nutritional lithium.  

Dr. Nicole Beurkens: 

Very helpful to give people some guidelines in terms of thinking about whether this might be something to look at for their child. Can you give us an example of maybe a child or a teen that you treated in practice who responded really well to lithium?

Dr. Greenblatt:

Well, I mean over the years, it’s almost 30 years now, I think I have hundreds, if not thousands. But again, a lithium kid is pretty typical — has usually a family history, substance abuse is most common. So alcoholism and other drug use — and it might not be the parent. It can be aunts/uncles/grandparents — sometimes a family history of depression, again can be a generation away and the kids are presenting, besides mood disorder, there might be sadness — but there is an irritability. An internal sense of restlessness. Sometimes rage or anger and these kids respond to these lower doses of lithium. We can test with a hair analysis — sometimes we can look at levels of lithium on the hair, there should be a level and these kids often have what is called ‘undetectable lithium. So if you and I did a hair test, we would have lithium that could be detected. For some of these kids, they have undetectable lithium and that’s one of the indicators of recommending the nutritional supplement.

Dr. Nicole Beurkens: 

So what type of timeline do you typically see for kids if they’re having these kinds of symptoms — they start on lithium, what — just give us a range of the types of things that parents might see improve, you know more quickly and what the timeline is to expect for something like that.

Dr. Greenblatt:

Sure, I mean the good news about lithium supplements with that clinical picture: family history and symptoms of irritability and undetectable lithium in the hair — You might notice a difference in 2-4 weeks, certainly by 4 weeks as you get up to a couple of milligrams. But what’s really worrisome, I’m sure you see a lot as well, is when you learn about a new supplement or a new treatment program you tend to just kind of focus on that and some of these kids might need that lithium but if they were bullied at school or other trauma or they were at vitamin D levels that were very low, or they had abnormal gut the lithium alone is not the answer. So we just have to be careful that we don’t take that kind of pharmacological model — that it’s one pill for one solution. You have to always look at the big picture. 

Dr. Nicole Beurkens: 

I couldn’t agree more and I think that it’s that tendency we all have, right? Looking for that magic bullet, especially when it comes to our kids and the family that’s really struggling, it’s like what’s that one thing that’s going to make a difference? And I really appreciate what you’re saying is that in a lot of cases, in most cases — there are a variety of things that need to happen and some of them may be in the more integrative medicine realm of things and some of them may be more in the realm of things with family dynamics or as you said, bullying, things going on at school, things like that. And we need to make sure that we’re looking at all of those pieces.

Dr. Greenblatt:

Absolutely, yes.

Dr. Nicole Beurkens: 

So I think the lithium piece is really interesting for people to consider just because many people have not heard about that. What do you think are some of the most common things that are important to look at for kids who are on medication. Let’s say we have a child with one of these mood or behavior disorders and they are on psychiatric medication and that seems to be helping somewhat, but it’s not managing the entire symptom picture. What do you think are some important things for parents to consider with that? 

Should we look at these nutrient levels then and see? Are there things that can help medication work even better? Some people think it’s an all-or-nothing, you know I either need to do more of nutrient or a non-medication approach, or a medication approach — and those of us who are integrative say, well, there is room for all these pieces depending on the child, right? But can you talk a little bit about how medications sometimes are helpful in combination with other things?

Dr. Greenblatt:

Sure, I mean I think both as parents and as professionals — they are either in two camps, right? Medicines are evil or medicines are the answer. And our integrative approach, to me, is the only way to get successful outcomes. So if you do choose to use medications for your child, you still should follow through with some of these nutritional tests because 1 — we can minimize side effects. Side effects of stimulants can almost disappear completely with magnesium supplementation, that’s very common. Side effects of the antidepressant can often disappear with nutritional interventions. 

So side effects are one reason where nutrients could help. The other piece is there’s lots of good research by traditional medicine on what’s called augmentation strategies. So someone’s on an antidepressant, they’re not doing as well as they would hope. Some improvement, but you can add nutrients like folate, like zinc, like Omega 3’s to the medication and there’s enhanced efficacy. So there are lots of areas where nutrients can, and in my opinion and practice, should be used with medication.

Dr. Nicole Beurkens: 

Awesome. From a food perspective, you know we’re talking about nutrition and we’ve touched on several specific nutrients and supplements. I’m curious for you to just share in the big picture — what are some of the things that you think are important or helpful for families to understand around food and what they’re feeding their kids and these types of mood and behavior issues.

Dr. Greenblatt:

Well, I think food is both the answer and the problem as we obsess about food and we create problems around eating and disordered eating in our culture. So I think that two big areas that I think are pretty clear as a scientist and as a physician would be limiting the refined sugar. If you restrict it 100%, I can’t say how many kids or parents will just overeat when the parents aren’t there, so it’s kind of just understanding and educating our kids around sugar. And the other really important piece for me to share with parents is understanding a vegetarian or vegan diet. A lot of my time now is working with anorexia nervosa. It’s a growing disorder, it is a life-threatening disorder. Kids are dying from this disorder and I believe, and we know for a fact that a vegan/vegetarian diet is part of that kind of pathway and it’s not necessarily not eating meat, it’s the restricting of certain nutrients. So I would caution any parent about a vegan diet because you need those nutrients. Vegetarian diets are fine as long as people are monitored, but a vegan diet does not have enough B12 or zinc for most adolescents and I believe is a risk factor for both mood disorders and eating disorders.

Dr. Nicole Beurkens: 

I’m really glad you raised that because it’s something that I see often in practice too, particularly with teens and young adults where the child was maybe doing okay, or was actually doing well and then all of a sudden read something or heard something or decided — came home one day and said I’m going to be a vegetarian or I’m going to be a vegan and then 6 months later, 9 months later, 2 years later — whatever it might be, they’re in my office with really significant debilitating mental health problems and there is that connection there for many people, so I think making parents aware of some of the risks of that and that if we are going to have kids do those types of diets, we need to be informed and we need to help them do that in a safe and healthy way that mitigates some of these risks that can come up.

Dr. Greenblatt:

Yes. It’s really important. And to me, there is a big distinction clinically between vegan and vegetarian. So a vegetarian might be eating eggs and dairy and probably will be able to get adequate nutrients. A vegan getting through puberty, I believe, is a physiological challenge and a concern.

Dr. Nicole Beurkens: 

Yeah. Great. We’ve touched on so many things, this has been so helpful, I could keep you here another several hours asking questions, but I know that we need to wrap it up here. I want to make sure that people know where they can find more information about you, about what you’re doing, about the resources you have available.

Dr. Greenblatt:

Great, thank you — our webpage is my name: jamesgreenblattmd.com where I list some of the books and some of the projects that we’re doing. A lot of my focus now is training physicians and clinicians and consumers and that is a new project, and that’s called “Psychiatry Redefined”. And so I think the webpage is psychiatryredefined.org where we have training courses for professionals. 

Dr. Nicole Beurkens: 

And your courses are wonderful, I have taken several of them myself — highly recommend them for professionals. And if you are a parent who has a healthcare professional that you are working with around your child who you think would be interested in learning more about the kinds of things that we talked about today or furthering their own education, sending them to Dr. Greenblatt’s websites and resources would be a great entry point for them to just get more information about that and be exposed to opportunities for further training. Can’t recommend that enough — as well as the many books that he has available too. And your newest one, I think, is specific to ADD/ADHD, right?

Dr. Greenblatt:

Yes, we have a book — going through, very easy to understand for parents called ‘Finally Focused’. A plus-minus plan for ADHD that should help many parents.

Dr. Nicole Beurkens: 

Yeah. Great. Great practical resource. Many families at our clinic have found that helpful, so I recommend that as well. Dr. Greenblatt — thank you so much for being here today and for sharing your knowledge and expertise with us. We appreciate it. 

Dr. Greenblatt:

Great — my pleasure. Appreciate it.

Dr. Nicole Beurkens: 

That’s it for this episode, we will see you next time on The Better Behavior Show.