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FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Although vitamin deficiencies and their associated adverse effects are usually considered a public health problem in the developing world, they remain an important clinical consideration for select populations across the globe. In fact, there is concern that we may be confronted with increased negative consequences of poor nutrition due to decreased testing and screening and less education in our medical institutions about the importance of good nutrition to optimal health.

Casimir Funk, PhD, discovered that key nutrients, which he termed 

, are essential to maintaining good health and that deficiencies in these key nutrients led to pathognomonic disease states. This realization was a result of observing birds that were fed a diet of polished rice and developed a diffuse polyneuritis (beriberi). The same birds were then fed a diet of brown rice, and their “nervous symptoms rapidly disappeared.”

 This experiment helped establish the importance of vital amines, later shortened to “vitamin.”

Vitamins can be broadly delineated into water-soluble and fat-soluble categories. Water-soluble 

 are typically absorbed very quickly via the gastrointestinal tract and widely distributed in various tissues throughout the body. However, because these vitamins are water soluble, they are not efficiently stored in tissues. Therefore, this class of vitamins requires regular consumption (either through diet or supplementation) to avoid deficiency. Conversely, fat-soluble vitamins are more easily stored, typically in adipose tissue; therefore, they require less frequent intake.

 Examples of water-soluble and fat-soluble vitamins can be found in 

, also known as folate or folic acid, is crucial for DNA synthesis and repair, as well as the metabolism of amino acids involved in methylation reactions.

, folate deficiency can lead to neural tube defects in the fetus.

 In adults, folate deficiency can result in multiple neuropsychiatric symptoms. These symptoms may include cognitive impairment, insomnia, psychosis, depression, peripheral sensory deficits, and weakness. These manifestations are very similar to those of vitamin B

 deficiency. In patients with depression, folate deficiency can contribute to severity and can impede depression treatment.

Folate, which is absorbed in the small intestine, is obtained via diet or supplementation. Select food sources of folate or folic acid can be found in 

 Most serum folate is found in its active form, methyltetrahydrofolate (methyl THF). Methyl THF undergoes a B

-dependent enzymatic reaction, donating its methyl group to form tetrahydrofolate, which, in turn, is later involved in DNA formation. Any disruption in this process can lead to a deficiency in folate and its associated manifestations.

Folate deficiency can manifest from several different causes. High anabolic states, such as pregnancy, can result in increased utilization and depletion of folate stores. Similarly, chronic alcohol abuse causes poor absorption, impaired metabolism, and increased destruction of folate. Even moderate amounts of alcohol (for instance, 8 oz of red wine or 2.7 oz of vodka per day for a 2-week period) have been shown to reduce folate levels in otherwise healthy men.

 Certain medications have been shown to contribute to folate deficiency. A summary of common medications as well as their mechanism of folate deficiency can be found in 

Patients who appear to be at highest risk for deficiency include individuals with 

; individuals who take the noted medications (

); patients who require increased intake of folate (eg, pregnancy, hemodialysis, chronic anemias); and those patients with poor absorption because of intestinal dysfunction from surgery or inflammatory bowel syndromes. Women of childbearing age are also considered to be at risk. According to the 

National Health and Nutrition Examination Survey

, nearly 20% of women aged 14 to 30 years have inadequate serum levels of folate. The survey also found that almost 25% of non-Hispanic Black women have insufficient intake of folate compared with 13% of non-Hispanic White women.

Screening and testing should occur in individuals who are at high risk, have evidence of a macrocytosis or hyper-segmented neutrophils, and have unexplained neuropsychiatric conditions (eg, weakness, ataxia, paresthesia, 

Folic acid supplementation is recommended for all individuals who are at high risk. Evidence suggests that pregnant women should take at least 600 μg of folic acid daily to prevent neural tube defects.

 Folic acid is also typically given to patients on methotrexate to reduce adverse effects, although the dose given varies among rheumatologists.

 Patients with chronic hemolytic states and renal dialysis are recommended to take 5 mg daily to weekly, depending on requirement.

In 2018, a systematic review of survey data examined global folate status in women of childbearing age. Despite methodological limitations such as nonuniform measurement techniques and/or cutoff values, Rogers et al

 determined that the prevalence of folate deficiency was more than 20% in lower income countries and less than 5% in higher income countries. In January 1998, the United States implemented a mandate to fortify grain products with folate in an effort to 

 the incidence of fetal neural tube defects.

 Since then, folate deficiency has become very rare in the United States, with a prevalence of less than 1%.

Patients exhibiting macrocytic anemia on initial complete blood count and peripheral blood smear should be evaluated for both folate and vitamin B

 deficiency because these 2 conditions often present simultaneously. The diagnosis of folate deficiency is usually made when serum levels are less than 2.0 mcg/L.

 Measurement of serum homocysteine and methylmalonic acid (MMA) can also aid in differentiating between folate and B

 deficiencies. In folate deficiency, only serum homocysteine levels are elevated. In B

 deficiency, both homocysteine and MMA levels are elevated because B

 is involved in both homocysteine and MMA metabolism. Folate, on the other hand, has a role in only the homocysteine pathway

). Clinically elevated homocysteine can result in increased risk of thrombosis and its complications, such as myocardial infarction.

Oral replacement of folate is the recommended treatment. If the patient is unable to take oral medications, intravenous repletion is acceptable. The typical dose is dependent on the deficiency severity but ranges from 1 mg to 5 mg daily.

 Folate-deficient megaloblastic anemia due to dietary insufficiency or medications should be treated with 5 mg of folic acid daily for 4 months. Patients with malabsorptive states should be treated with up to 15 mg daily for 4 months.

s an associate clinical professor in the Department of Psychiatry at The University of North Texas Health Science Center at Fort Worth in Texas. 

 is a research coordinator in the Department of Behavioral Health Research at John Peter Smith Health Network in Fort Worth, Texas.

The authors report no conflicts of interest.

1. Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in US medical schools: latest update of a national survey. Acad Med. 2010;85(9):1537-1542.

2. Piro A, Tagarelli G, Lagonia P, Tagarelli A, Quattrone A. Casimir Funk: his discovery of the vitamins and their deficiency disorders. Ann Nutr Metab. 2010;57(2):85-88.

3. Reinhard T. The Vitamin Sourcebook. NTC/Contemporary Publishing Group; 1998.

4. Chan YM, Bailey R, O’Connor DL. Folate. Adv Nutr. 2013;4(1):123-125.

5. Scott JM, Weir DG, Molloy A, McPartlin J, Daly L, Kirke P. Folic acid metabolism and mechanisms of neural tube defects. Ciba Found Symp. ١٩٩٤;١٨١:١٨٠-187; discussion 187-191.

6. Papakostas GI, Petersen T, Lebowitz BD, et al. The relationship between serum folate, vitamin B12, and homocysteine levels in major depressive disorder and the timing of improvement with fluoxetine. Int J Neuropsychopharmacol. 2005;8(4):523-528.

7. US Department of Agriculture (USDA), Agricultural Research Service, Nutrient Data Laboratory. USDA National Nutrient Database for Standard Reference, Legacy. Updated April 2018. Accessed January 19, 2021. 

8. Greenberg JA, Bell SJ, Guan Y, Yu YH. Folic acid supplementation and pregnancy: more than just neural tube defect prevention. Rev Obstet Gynecol. 2011;4(2):52-59.

9. Gibson A, Woodside JV, Young IS, et al. Alcohol increases homocysteine and reduces B vitamin concentration in healthy male volunteers--a randomized, crossover intervention study. QJM. 2008;101(11):881-887.

10. Hesdorffer CS, Longo DL. Drug‐induced megaloblastic anemia. N Engl J Med. 2015;373(17):1649-1658.

11. Tinker SC, Cogswell ME, Devine O, Berry RJ. Folic acid intake among US women aged 15-44 years, National Health and Nutrition Examination Survey, 2003-2006. Am J Prev Med. 2010;38(5):534-542.

12. Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate, Other B Vitamins, and Choline. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. National Academies Press; 1998.

13. Taylor PC, Balsa Criado A, Mongey AB, Avouac J, et al. How to get the most from methotrexate (MTX) treatment for your rheumatoid arthritis patient?-MTX in the treat-to-target strategy. J Clin Med. 2019;8(4):515.

14. Devalia V, Hamilton MS, Molloy AM; British Committee for Standards in Haematology. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol. 2014;166(4):496-513.

15. Rogers LM, Cordero AM, Pfeiffer CM, et al. Global folate status in women of reproductive age: a systematic review with emphasis on methodological issues. Ann N Y Acad Sci. 2018;1431(1):35-57.

16. FDA. Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Federal Register. August 5, 1996. 

https://www.federalregister.gov/documents/1996/08/05/96-19803/food-standards-amendment-of-standards-of-identity-for-enriched-grain-products-to-require-addition-of

17. Khan KM, Jialal I. Folic Acid Deficiency. StatPearls Publishing; 2020.

18. Vuckovic BA, Cabarkapa VS, Ilic TA, Salatic IR, et al. Clinical significance of determining plasma homocysteine: case-control study on arterial and venous thrombotic patients. Croat Med J. 2013;54(5):480-488.

19. Lever EG, Elwes RD, Williams A, Reynolds EH. Subacute combined degeneration of the cord due to folate deficiency: response to methyl folate treatment. J Neurol Neurosurg Psychiatry. 1986;49(10):1203-1207.❒

A myriad of neuropsychiatric symptoms result from folate deficiency, including cognitive impairment, insomnia, psychosis, depression, peripheral sensory deficits, and weakness. Treatment and prevention strategies are discussed. 

Vital Amines: The Who, What, When, Where, Why, and How of Folate Deficiency

A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial).

2. Faraone SV, Biederman J, Spencer TJ, et al. 

Comparing the efficacy of medications for ADHD using meta-analysis.

4. Opie RS, O’Neil A, Jacka FN, et al. 

A modified Mediterranean dietary intervention for adults with major depression: dietary protocol and feasibility data from the SMILES trial.

5. Chang SC, Cassidy A, Willett WC, et al. 

Dietary flavonoid intake and risk of incident depression in midlife and older women.

Tea consumption and the risk of depression: a meta-analysis of observational studies.

7. Grassi D, Socci V, Tempesta D, et al. 

Flavanol-rich chocolate acutely improves arterial function and working memory performance counteracting the effects of sleep deprivation in healthy individuals.

8. Bowtell JL, Aboo-Bakkar Z, Conway ME, et al. 

Enhanced task-related brain activation and resting perfusion in healthy older adults after chronic blueberry supplementation.

9. Conner TS, Brookie KL, Carr AC, et al. 

Let them eat fruit! The effect of fruit and vegetable consumption on psychological well-being in young adults: a randomized controlled trial.

10. Morris MC, Tangney CC, Wang Y, et al. 

MIND diet associated with reduced incidence of Alzheimer's disease.

The effects of probiotics on depressive symptoms in humans: a systematic review.

12. Morris MC, Tangney CC, Wang Y, et al. 

MIND diet slows cognitive decline with aging

13. Topiwala A, Allan CL, Valkanova V, et al. 

Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline: longitudinal cohort study.

This article was originally posted on September 15, 2017, and has since been updated. -Ed.

Although supported by basic science, it’s still a sea change to think that diet can treat depression. Some research puts that idea to the test.

Can Food Treat Depression?

When considering the relationship between mental and cardiovascular health, most conversations focus on negative emotions and related disorders, such as depression. This is not surprising, given that depression is common and associated with the development and progression of cardiovascular disease.

 This relationship is so strong that the 

 for poor outcomes after a myocardial infarction,

 and this relationship has been the basis for depression treatment programs for patients with heart disease.

 in patients with heart disease is important, focusing solely on negative psychological constructs has a downside. Since major depressive disorder affects only approximately 15% of patients with heart disease,

 depression treatments are applicable only to those 15% of individuals who suffer from that psychiatric illness. This raises the question of whether there are ways for psychiatrists to help all cardiac patients—not just those with depression or anxiety—feel better both emotionally and physically.

Research into well-being and related constructs may provide an answer. In the past 10 to 15 years, researchers have begun to identify relationships between well-being constructs (eg, optimism, positive affect) and cardiovascular health. In individuals without heart disease, these constructs are associated with a reduced risk of heart disease and all-cause and cardiovascular mortality.

 Among those with established heart disease, well-being constructs reduce one’s risk for major adverse cardiac events and mortality.

 Importantly, these relationships are independent of 

 comorbidities, sociodemographic factors, and—oftentimes—depression.

Both biological and behavioral mechanisms may explain the relationship between well-being and cardiovascular health. Positive psychological constructs are linked with physiologic processes that have been implicated in heart disease. This includes better autonomic functioning (ie, reduced sympathetic activation and increased 

), lower levels of inflammation, improved endothelial function, and lower levels of cortisol in some, but not all studies.

 There is even greater evidence for the relationships between well-being constructs and cardiovascular health behaviors. Positive constructs are prospectively and independently associated with more physical activity, a 

 (eg, more fruits and vegetables), medication adherence, engagement in treatment programs that promote cardiac recovery (eg, cardiac rehabilitation), and smoking cessation.

Recent research suggests that well-being may be enhanced through interventions that focus on the reduction of stress, enhancement of calmness or relaxation, and promotion of positive psychological constructs. Meditation, mindfulness training, yoga, tai chi, and other 

 can induce states of relaxation and calmness and can be incorporated into daily life. These types of interventions appear to be 

 at reducing stress, depression, and anxiety in patients with vascular disease (including cardiovascular disease) or heart failure.

 Some studies have found these interventions also improve exercise capacity

 and downstream cardiovascular outcomes, such as hospitalizations.

Positive psychology interventions, which emphasize the systematic completion of activities to cultivate positive psychological constructs, have become increasingly popular.

 These activities are simple to perform and may include writing a letter of gratitude, using a strength in a new way, or imagining a best possible future for oneself. These interventions have been 

 in thousands of individuals and consistently improve well-being and reduce depression.

 Some interventions also have been shown to improve cardiac health behaviors, such as physical activity and medication adherence,

 when delivered alone or in combination with health behavior change interventions (eg, motivational interviewing). There have been preliminary positive results for in pilot trials for acute coronary syndrome,

Although randomized trials for integrative and positive psychology interventions are needed, promoting well-being in individuals with heart disease (and, really, in anyone) makes intuitive sense. Many of the positive constructs—such as mindfulness, relaxation, optimism, gratitude, kindness, life purpose—that these interventions aim to cultivate are things that anyone would benefit from experiencing more frequently. These interventions provide a system or framework to change one’s mindset from focusing on negative things in our lives to savoring and enhancing the positive experiences we have and setting ourselves up for more.

Psychiatrists are well positioned to help all patients cultivate well-being. For example, if asked to consult on a patient with significant anxiety following 

, psychiatrists can teach the patient to use mindfulness (eg, relaxation response training, guided visualization). A patient with heart failure who is demoralized due to the severity of their symptoms can be encouraged to focus on those tasks they can still perform and have meaning to shift their focus positively. Finally, individuals who are recovering from cardiac events who are struggling to increase health behaviors can benefit from focusing on positive future outcomes and the use of strengths to reach their health behavior goals. The goal is to help patients reduce stress, use their strengths to approach challenges, and recognize positive events that are happening around them.

Well-being is important not only for patients but also for physicians, who frequently work under stressful conditions and experience high levels of 

t. Fortunately, there are many simple ways to promote well-being (

). This could include setting aside time to engage in an enjoyable or meaningful activity, making a point to discuss a positive event with a family member or friend, thinking about one aspect of the day for which you are grateful before going to bed, or using the strength of perseverance to work toward a life goal. It could also involve incorporating 

 or prayer into routines, or setting aside time for health behavior activities, such as exercise. Although many of these things seem simple, they are easily overlooked, and engaging in them regularly can help you develop habits that can have mental and physical health benefits.

Many free or inexpensive resources related to positive psychology, 

, meditation, yoga, etc, can be found online. 

 contains a sample of the websites, podcasts, and mobile applications to help begin this positive journey. Although the number of available resources can seem overwhelming, it can be helpful to try a few different resources to see which ones work best.

Well-being and its related constructs are increasingly identified as being important components of cardiovascular health. Cultivating positive psychological constructs is possible through simple-to-perform exercises, and psychiatrists are in a unique position to help patients with and without heart disease feel more positive and hopeful. This, in turn, can have substantial effects not just on mental health, but on health behaviors and downstream physical health outcomes as well.

is associate director of the Cardiac Psychiatry Research Program and Massachusetts General Hospital (MGH) assistant professor of psychiatry at Harvard Medical School. 

is a professor of psychiatry at Harvard Medical School and the director of the Cardiac Psychiatry Research Program in the Massachusetts General Hospital (MGH) Division of Psychiatry and Medicine. He also serves as the associate chief for clinical services in the Department of Psychiatry at MGH and the director of Inpatient Psychiatry Research at MGH.

1. Hare DL, Toukhsati SR, Johansson P, Jaarsma T. Depression and cardiovascular disease: a clinical review. 

2. Lichtman JH, Froelicher ES, Blumenthal JA, et al. 

Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association

3. Dubois CM, Beach SR, Kashdan TB, et al. Positive psychological attributes and cardiac outcomes: associations, mechanisms, and interventions. 

4. Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. 

5. Abbott RA, Whear R, Rodgers LR, et al. Effectiveness of mindfulness-based stress reductions and mindfulness based cognitive therapy in vascular disease: A systematic review and meta-analysis of randomised controlled trials. 

6. Aggarwal M, Bozkurt B, Panjrath G, et al. 

Lifestyle modifications for preventing and treating heart failure

7. Desveaux L, Lee A, Goldstein R, Brooks D. Yoga in the management of chronic disease: a systematic review and meta-analysis. 

8. Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. 

9. Bolier L, Haverman M, Westerhof GJ, et al. 

Positive psychology interventions: a meta-analysis of randomized controlled studies

10. Peterson JC, Charlson ME, Hoffman Z, et al. A randomized controlled trial of positive-affect induction to promote physical activity after percutaneous coronary intervention. 

11. Ogedegbe GO, Boutin-Foster C, Wells MT, et al. A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans. 

12. Huffman JC, Feig EH, Millstein RA, et al. Usefulness of a Positive Psychology-Motivational Interviewing Intervention to Promote Positive Affect and Physical Activity After an Acute Coronary Syndrome. 

13. Celano CM, Freedman ME, Harnedy LE, et al. Feasibility and preliminary efficacy of a positive psychology-based intervention to promote health behaviors in heart failure: the REACH for Health study. 

14. Huffman JC, Golden J, Massey CN, et al. 

A positive psychology-motivational interviewing intervention to promote positive affect and physical activity in type 2 diabetes: the BEHOLD-8 controlled clinical trial

Psychiatrists are uniquely suited to help patients with and without heart disease feel more positive and hopeful. This, in turn, can have substantial effects not just on mental health, but on health behaviors and physical health outcomes as well.

Positivism and Heart Health: Issues for Psychiatrists

Food is an ideal drug delivery system, and an intriguing trio of studies suggest antidepressant potential for 1 food in particular: the blueberry.

All 3 studies hail from a single group lead by Claire Williams at the University of Reading, England.

 the effect of a powdered blueberry drink—equivalent to 1 cup of fresh blueberries—on mood in 144 children, adolescents, and young adults through 3 randomized, placebo-controlled trials. The placebo drink had the same sugar and vitamin C content as the 

 juice, and both drinks were made to look the same by mixing them with concentrated orange juice. The 

 outlines the key points from these studies.

The first 2 studies (which were published in a single paper) examined mood 2 hours after a single drink, and the third looked at longer term effects of a daily drink over 4 weeks.

 All 3 studies were positive, with effect sizes that ranged from small (0.27) to medium (0.65).

The main limitation is the fact that the studies were small and came from a single research group. Also, they all enrolled healthy participants, so we don’t know if blueberries actually treat clinical depression. No risks were identified, though one might wonder if blueberries can trigger mania. Reassuringly, 3 animal studies found anti-manic effects with blueberries, 1 of which compared them with lithium.

These findings are supported in part by a 

 where blueberry juice prevented postpartum blues (ie, the brief lability seen after delivery known as the “baby blues”) in healthy pregnant women, but the juice in that small controlled trial also contained tryptophan (2 g) and tyrosine (10 g).

 In contrast, 2 other independent groups that 

 blueberries in healthy older patients did not find any mood benefits.

This does not mean blueberries are only helpful in the young. Although the berries did not improve mood in the geriatric studies, they did improve cognition, which was the primary outcome. There are 13 controlled trials of the cognitive effects of blueberries and their extracts all age groups, and 85% of those 

What is the medication inside this efficient drug delivery system? Blueberries have several positive effects on the brain. They are neuroprotective, increasing brain-derived neurotrophic factor (BDNF) and insulin-like growth factor 1 (IGF-1); anti-inflammatory; and raise production of 

 Most of these effects are because of anthocyanins, a group of 

 that give the fruit its purplish-blue hue.

Anthocyanins are found in other purple-tinted foods, like blackberries, blackcurrants, acai, black “forbidden” rice, eggplant, and the exotic purple varieties of cauliflower, asparagus, and sweet potatoes. Anthocyanins are also featured in red produce like cranberries, cherries, pomegranate, and red cabbage.

, but super-foods are not what nutritional psychiatry is all about. When working with medications, we shy away from polypharmacy, and aim instead to bring about the miracle of remission with a single pill. In nutritional psychiatry, polypharmacy is the ideal. The brain and body do best with a healthy mix of nutrients, and while 1 cup a day of blueberries is unlikely to cause harm, too much of a good thing is not the intent of this research.

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is the Mood Disorders Section Editor for 

 He has written several books on mood disorders, most recently 

 with his co-host Kellie Newsome, PMH-NP. The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for 

. Effects of acute blueberry flavonoids on mood in children and young adults.

2. Fisk J, Khalid S, Reynolds SA, Williams CM. 

Effect of 4 weeks daily wild blueberry supplementation on symptoms of depression in adolescents.

3. Spohr L, Soares MSP, Oliveira PS, et al. 

Combined actions of blueberry extract and lithium on neurochemical changes observed in an experimental model of mania: exploiting possible synergistic effects.

4. Dowlati Y, Ravindran AV, Segal ZV, et al. 

Selective dietary supplementation in early postpartum is associated with high resilience against depressed mood.

5. Boespflug EL, Eliassen JC, Dudley JA, et al. 

Enhanced neural activation with blueberry supplementation in mild cognitive impairment.

6. Miller MG, Hamilton DA, Joseph JA, Shukitt-Hale B. 

Dietary blueberry improves cognition among older adults in a randomized, double-blind, placebo-controlled trial.

7. Travica N, D'Cunha NM, Naumovski N, et al. 

The effect of blueberry interventions on cognitive performance and mood: A systematic review of randomized controlled trials.

8. Rutledge GA, Sandhu AK, Miller MG, et al. 

Blueberry phenolics are associated with cognitive enhancement in supplemented healthy older adults.

Improved metabolic function and cognitive performance in middle-aged adults following a single dose of wild blueberry

10. Bensalem J, Dudonné S, Etchamendy N, et al. 

Polyphenols from grape and blueberry improve episodic memory in healthy elderly with lower level of memory performance: a bicentric double-blind, randomized, placebo-controlled clinical study.

Three new trials suggest a novel antidepressant hides inside the blue-skinned fruit.

Blueberries Treat Depression, With a Catch

When the email from “Sam” arrived asking about adding a natural weight loss product to his more mainstream prescription medications, I was not surprised. Binge eating was his bête noire. A onetime college athlete who lost his scholarship because of an ankle injury, he had since sat around eating while watching sports on TV and lamenting his lost career. He desperately wanted to shed unwanted weight, but treatments that control bingeing do not guarantee weight loss. He had tried 

 with no success. So, when he heard about a new natural weight loss concoction, he was understandably excited yet skeptical because he knew of the government’s crackdown on hoodia.

Sam forwarded me a laundry list of ingredients without hoodia but with 

 (Pausinystalia yohimbe). Years had passed since I had seen that word in print.

“Was it safe?” was all he wanted to know. Whether it worked seemed to be a secondary concern. My short answer was no, and I promised a longer explanation at his next appointment. In the interim, flashbacks of another patient from long ago popped up. Although psychopharmacology has quickly evolved in the decades since the 

, that related case was too dramatic to forget.

I remember the frantic call from the ED staff, begging me to see their patient posthaste.

As physicians first, psychiatrists must consider the big picture, without reflexive and thoughtless prescriptions for psychotropics—even if many, including medical professionals, assume that is all we do.

Integrative Psychiatry

Vital Amines: The Who, What, When, Where, Why, and How of Folate Deficiency

Can Food Treat Depression?

Positivism and Heart Health: Issues for Psychiatrists

Blueberries Treat Depression, With a Catch

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Healthful Hacks for Improving the Day

Strategies for Keeping Our Prefrontal Cortex Online

Conventional and Integrative Approaches to Treating Anxiety in Pregnancy

A Journey To Relaxation

Mind-Body Therapies for the Management of Pain: How Effective Are They?