Welcome back to the Healing Pain Podcast with Dr. Kelly Brogan
Upwards of 50% of those diagnosed with chronic pain also receive a diagnosis of depression. Along with this diagnosis, they are frequently prescribed a narcotic painkiller, for the pain of course, and an SSRI medication for the treatment of their depression. The question we ask on today’s podcast: Is this a wise pharmaceutical combination, and are SSRIs effective for treating the depression that often accompanies chronic pain?
Joining us today is Dr. Kelly Brogan, who is a Manhattan-based Holistic Women’s Health Psychiatrist, author of the New York Times Bestselling book, A Mind of Your Own, and co-editor of the Landmark textbook, Integrative Therapies for Depression. She’s Board Certified in Psychiatry, Somatic Medicine and Integrative Holistic Medicine and specializes in a root cause resolution approach to psychiatric syndromes and symptoms.
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Healing Depression and Chronic Pain with Dr. Kelly Brogan
Dr. Kelly Brogan, welcome to the Healing Pain Podcast.
Total pleasure to be here. Thank you for having me.
I’m super excited because you’re the first person I have on the podcast that is going to talk to us about the link between depression and chronic pain, and of course how we should treat the depression so people can move on with their life where they not only feel better about themselves physically, but also emotionally. In your practice, of course you’re seeing people who are on these depression-type medications. Do people also come to you with a history of being on narcotic painkillers as well? Are you seeing that in your practice?
Yes. In fact, this was recently investigated even in the mainstream media that those who have been diagnosed with depression and anxiety are statistically more likely to be prescribed narcotics. You could ask of course, is it a chicken or an egg phenomenon? I tend to, as I know you do, look at a long list of diagnoses and try to envision what is the common threat that they all share. Where is the point of origin of all of these different diagnoses that actually collapses them into one meta syndrome? That’s obviously not the way the allopathic model is set up because you’re setup to go to all of your different specialists rather than to think about, what could be the common driver of all of these different presenting symptoms?
I love the platform that you’ve built. Everyone can learn more at KellyBroganMD.com. What I love about your platform is that you’re really encouraging people to find a root cause solution for their problem without prescription medication. Can you talk about your journey and how you arrived at that place? I think whether you’re a physician or whether you’re a physical therapist, you mentioned that allopathic model where both of those professions take pharmacology courses. That’s what some of the tools they’ve been provided or tools that they expect that patient should use. Can you talk about your journey?
I come from a very conventional background. I was raised second generation. My mom is Italian. Anyone who has immigrant parents knows that you basically have two choices, you can become a doctor or you can become a lawyer and you better make a lot of money. That’s pretty much the ethos I went into my career with. I actually ended up falling into the specialization of psychiatry because I was working on a suicide hotline while I was at MIT in college. I also was studying neuroscience. It was the perfect storm that led me to believe that we had cracked the code of human behavior. Really, we just need to get people more access to these very effective lifesaving treatments in the form of pharmaceuticals and specifically psychotropics.
I went to medical school to become a psychiatrist and very much believed in medication-based medicine. In fact, I was very derisive of any seeming alternatives. I became very good at prescribing. You can actually become good at prescribing. Really, to be honest, what makes someone a good prescriber is that they have a confidence and a cavalier nature about their willingness to combine different medications, to raise doses above even sanctioned FDA recommendations. It’s called cowboy pharmacology. I was very much that kind of a doctor. Of course, any doctor you talk to who’s left the conventional fold has done so because of their own personal experience.
We don’t change our minds because of information. We change our minds because of experience. I had an experience of radical healing of an autoimmune condition called Hashimoto’s Thyroiditis. I only pursued that experience because I knew that conventional medicine had absolutely nothing to offer me, that I would be on Synthroid for the rest of my life feeling never quite right. I decided, very uncharacteristically, to pursue naturopathic treatment. When I watch my antibodies go from the high 2000’s and my TSH go from 20 to completely normal with lifestyle-based interventions, I was actually really angry. I said, “Hold on a minute. I’ve been a bookworm my whole life. I have never learned that this was possible.” I never had a mentor telling me that this was possible, that nutrition has anything to do with anything. Medical doctors, if they have any, they have about couple of hours of nutrition education in an entire sometimes decade of training.
I decided to take it upon myself to go back to the data itself. I’ve always been very comfortable in PubMed.gov. I’ve spent every Saturday for fourteen years. I’ve spent at least four hours there. I said, “What else am I not being told?” That was the beginning of the end of my $200,000 investment, blood, sweat and tears into a medical training that I basically don’t use at all anymore. I put down my prescription pad. It’s been almost nine years, I haven’t started a patient on medication.
It’s a very similar story that I’m starting to hear in the realm of pain and pain science. At first when the CDC came out and said that narcotic pain medications are not a long-term fix, we have plenty of information. The first people were very angry because, “You’re taking my medication away from me.” Although, now especially with the platform I’m building, other people are building, around natural ways to heal and moving more toward what’s called the biopsychosocial model for healing pain as well as depression. People have this wakeup call and they say, “I never knew once I instituted other things, like healthy nutrition being one, into my lifestyle that this could affect my physical body, but also my mental health.”
Along the lines of pain and mental health, I talk a lot about the brain and I talk a lot about the brain being as the cause of someone’s pain. It helps give them a different perspective that it’s not just their body but there are other things you have to take into account. Knowing that the central nervous system is so important to the human body, having a healthy central nervous system, can you talk about the risk of being on an SSRI and maybe the combination of an SSRI with a narcotic pain medication?
This was one of the big jaw droppers for me because when I started to do my own research into the evidence based for natural medicine, I was shocked that there even was such a thing. Then I began to look, “Why are we using medications if we have these effective largely side effect reactions?” That’s considering natural substances like herbs, for example. If we look at these medications under a more neutral microscope, we take out industry-funded data and we look at what is the actual efficacy and how well has safety been explored?
For these two categories, if we’re looking at opiates and antidepressants for example, they have a very similar sorted history of not only diminishing efficacy, tremendous risk, but also the fact that they set you up to require more and more medications. There’s a domino effect that emerges directly from the institution of the first prescription. I know that some recent research has looked at the fact that many patients are prescribed opiates who are in fact depressed. It’s this idea of what came first, but I would wager that many more are actually taking both. They’re considered comorbidities and so they’re combined.
Let’s just take antidepressants, although we could have the same conversation about any of the psychotropic medications, whether it’s stimulants or benzodiazepines, mood stabilizers or antipsychotics, is that far from actually correcting an identified imbalance, these medications generate a demand on specifically the central nervous system. Now of course we know that the central nervous system is inextricably connected to the immune system, to the hormonal glandular nexus, that there’s no just pulling one thread of the spider web. We are seeing that actually they generate this demand. They actually set a new bar for balance for homeostasis so that the body has to adapt to this chemical exposure. I think in common perception we know that opiates, narcotics are habit forming. I think that trickled down to the masses.
The problem is that when we are given this prescription by a priest of medicine, so a doctor in a white coat, we say, “They must have considered the risks for me and this must be a situation at which I really need to just take advantage of it despite the risks.” In the realm of antidepressants, we don’t publicize the fact that, in my opinion, they actually are the most habit-forming chemicals on the planet because while I have helped patients come off of opiates, there is nothing that compares, in my opinion, just my clinical experience, to tapering off of psychotropics. I would put antidepressants at the top of the heap, I would put benzodiazepines after those and then I would put mood stabilizers and antipsychotics after those where literally the physical disability that can emerge from a very cautious taper is shocking. What is going on when we actually take these medications? Unfortunately, we don’t really know.
We’ve bought into this simplistic, reductionist concept that all they’re doing is raising some serotonin here, raising a little dopamine there or balancing out a little glutamate there. Of course, it’s childish to even consider that that might be the extent to which they’re influencing the body. The truth is, we really don’t know, but since about 2014, we do have data that suggest that there can be medium to long-term neurologic damage, whether it’s cognitive damage, whether it’s gross motor skill damage, whether it’s fine perceptual damage, sensory damage. It’s really a total black box. Of course, I don’t believe in permanent anything. I believe that recovery is always possible. Of course, in my practice that’s what I see, perhaps because I believe that. There certainly are more and more anecdotal cases coming forth of people who are wheelchair bound from Klonopin taper for example. Of course, they were never warned about these potential risks. That’s just one of the categories.
We have a lot of fancy names like antidepressant tachyphylaxis for why antidepressants just basically stop working and then you just have the physiologic dependency or tardive dysphoria for the name of the type of long-term depression that can actually be induced by antidepressants. Unfortunately, there’s just no free lunch with pharmaceutical products. I would say, in general, it has been the conclusion based on my clinical experience and my review of the literature. I have specific concerns about the medications that are offered to patients to just take the edge off of their suffering and struggle.
So often patients, they come to me and they’re on opioid medications for decades and they say, “I don’t understand why my pain keeps getting worse. I’ve been taking this medication.” It’s the same with an SSRI as it is with an opioid where there’s something called opioid induced hyperalgesia, which is the longer you’re on these medications, it gets worse. Your symptoms can increase, unfortunately.
It’s exactly the same model, so interesting.
As we move into our ICD 10 of the gods years, I look at all these diagnoses coming out and people come to me with this laundry list of, “I’ve had fibromyalgia for ten years. I’ve had an autoimmune disease. I’ve had osteoarthritis. I’ve had neuralgia now.” This list of diagnoses that come in. So often I find that the diagnosis can be the one thing that causes someone to have even more harm and more fear, which leads to more symptoms. Should we be giving this diagnosis of depression to so many millions of people? Is it really a true diagnosis?
It’s interesting because I think that there was a point at which, in the history of modern medicine, where it actually did have a powerful placebo effect. It had a healing effect to be labeled. You relabeled, you understood that that validated your felt experience of what was wrong and then there was a pursuit of healing. Now that we are in the realm of modern disease, which is chronic in nature and we have in no way made any attempt to look at what it means to heal anymore, we’re just managing. This label can really be a sentencing. It can be, in many ways, like the externalization of your agency so that you give up your power to that label. Then we loop in all of these old science and genetics so people feel like, “It was in my family and so now obviously, I’m strapped with this for life.”
As I began to resolve diagnoses like schizoaffective disorder and bipolar disorder and suicidal depression, I began to really wonder about the nature of chronic mental illness because how could it be that the patients that I was working with and the I worked with have a total disappearance of their illness if these are in fact, by design, chronic. Obviously, the exception challenges the rule. We need to go back to the drawing board. The thing that’s unique about psychiatry relative to many other specialties is that we do not have any objective testing. There is no brain scan, blood test. There’s no assessment of electrical activity, testing of cerebrospinal fluid, there’s nothing.
There’s a conversation sometimes as short as ten minutes. Often, it’s not even with a specialist, often more than 60% of antidepressants are prescribed at primary doctors. It’s this very brief interaction. You are labeled with a descriptive term. Our diagnostic manual is ballooning by the year and it’s just a dictionary of phrases that essentially capture the cultural balance of normalcy. Homosexuality used to be in that book up until the ‘70s. It’s a reflection of what the culture deems is consistent with functioning, but unfortunately, the majority of the people who sit on these committees to determine these diagnoses have direct and known industry ties so they are taking money, literally, from the pharmaceutical industry and then making decisions about how to bring the pharmaceutical industry more clients.
This isn’t a conspiracy theory. It’s just basic human behaviors. It’s particularly important maybe in the realm of what we call mental illness to understand that this is just a descriptor for your experience. I like to say it’s like saying you have a fever. When you have a fever, you want to know what’s driving it, what are my options for what I can do about it or maybe should I just let it ride? When your decision is going to be based on your personal details, depression is no different, it’s just like pain. It’s this descriptor that suggests that there is an imbalance that the body is seeking to correct and nothing more. We’re not getting any more information about it just from that label.
I love this topic. I could do a whole podcast or a whole summit just on, I think what we’re talking about really is the core belief, someone’s health and their coping skills and their ability to get through a chronic crisis, whether it’s a chronic pain or depression. Would you agree we’ve created one huge nocebo effect for so many different types of conditions?
Yes. That’s what I was trying to articulate is that we’ve transitioned into a place where now, being labeled actually is a nocebic experience where it’s almost like a hexing. The data is the strongest actually in the realm of cancer diagnoses, where there are actually significantly worse outcomes once you had that bone pointed at you, once you’ve been hexed. If we understand diseases to be chronic, how could you not feel your life contract into a very small place when you’ve been labeled? No longer do I think patients are relieved to get an ICD 10 diagnosis. I think now it’s like, “I guess now I have to adjust to a smaller life.” Maybe that’s what I feel and I imagine you do, most passionately about is that that’s the greatest myth of our time, that it’s 100% possible.
As you suggested, this took me a long time to learn, but I have learned that the mindset shift is what the potential for radical healing is predicated upon. In my practice, I used to take anyone and everyone who wanted to come in because there was no case too hard, I was ready to handle any of these cases with my passion and zeal for lifestyle medicine. It was only after working with my now late mentor, Dr. Nicholas Gonzalez, that I began to appreciate that actually there’s a special alchemy to radical healing and that it is almost entirely dependent on the belief system. Now, the only patients I work with are those who already believe that they can shed their diagnoses and come off their medications and enter an entirely new chapter of their life. That belief is the criteria for acceptance into my practice and that’s it. Of course, there’s so much research in the realm of placebo to substantiate that the belief itself is what is the greatest predictor of outcomes.
As we move in this direction, we’re starting to move into what they call a biopsychosocial model of care. Within that, one of the things that I find work so well with people with chronic pain is mindfulness-based stress reduction. It’s so simple except it could be difficult for patients to say, “I’m ready for that step and I’m going to take on this eastern practice, if you will, that seems woo-woo. I have to maybe be sitting Indian style on my kitchen table in the morning.” How do you approach your patients and say, “This is something that is going to help you move from a place of sadness to a place of joy.”
I basically say, “You want to get better, right? You want to feel regenerated and you want to feel the palpable visceral sensation of healing, right? Your body only enters that phase of sometimes spontaneous healing and recovery when your rest and digest nervous system is online. That’s why you can’t be afraid. That’s why your anxiety and worry about worrying is not serving you. That’s why we need to create support because you can’t talk yourself out of worrying.” Personally, I am not a huge CBT supporter because I think that entering in the realm of thoughts is still, you’re in the realm of thoughts. If we can enter your nervous system at a different layer, then your body will do the work, but we need to send that signal on a daily basis.
If you can’t talk yourself in to relaxing, which most of us can’t, then you need a technology. That’s why people are reaching for these eastern technologies because they work. I personally knew the literature on mindfulness-based stress reduction for many, many years before I ever implemented it myself, because often the people who need it the most are the most resistant. Almost because we get entrained by our own fight or flight system. It almost feels uncomfortable to relax. The people who need it most tend to be the ones who want to do it the least. I’m speaking from experience. That’s why I’m very passionate personally about Kundalini Yoga, which is one of the older branches of yoga that actually recruits a lot of different modalities. There are hand gestures and specific preps and sometimes specific mantras, sometimes there’s movement involved. It’s like really almost busy so that it keeps you focused on what you’re doing and you can get an outcome.
I start my patients out with three minutes a day, just three. Literally, you can go online and Google Kundalini Yoga, anything like digestion, pain, fear, cultivation of intuition, PMS. There are thousands of them online for free. A lot of them are videos. It might be eleven minutes or half an hour, whatever, but you just do it for three minutes and you can have an experience, literally a shift in your nervous system in three minutes. All you have to do is commit to the three minutes a day because your body will take care of the rest. It’s really, unfortunately, not optional in today’s approach to health and wellness. It’s really not optional. You must have a daily pause. I tell my patients, “This is my preferred method. I don’t care if you pray to a leprechaun for three minutes, but you have to stop and you have to sit and you have to put everything away and stop talking and just pause,” because that’s how you send your body the signal that it’s okay to pause. If you’re being chased by a tiger, you wouldn’t pause for three minutes, but that’s what we experience when we go through our day constantly in this low grade cloud of productivity and demands and worry and anxieties. I have become not only a passionate believer in it but I actually don’t know that it’s optional any longer if you actually want to feel better.
I love that you brought up the distinction between CBT and mindfulness-based stress reduction because there’s literature on both. I think the MBSR for Pain is a little bit newer. However, the studies that are out there for it blow away the CBT studies. I’m hoping that we really wrap a big move more on that direction and quite frankly, away from the CBT or at least integrate the mindfulness-based stress reduction with the CBT. What else is part of your program? Obviously in your book, A Mind of Your Own, you talk about it, but what else is part of your program other than meditation to help patients?
It’s pretty basic, to be honest. I came upon this after a lot of years of personal tinkering with my own health. Then I really felt like it was anointed by my mentor, Nicholas Gonzalez, who had, in the 27 years that he practiced as primarily a holistic cancer doctor, outcomes that had never been replicated in medical history. We’ve just published the foundation in his legacy, the second of two volumes of 125 cases of long term survival, meaning upwards of 10, 15, sometimes 30 years of metastatic cancer on his protocol. Having his eyes on my work really gave me the confirmation that I was on the right path. Of course, the outcomes that I have in my practice and even through my book and online program convinced me that we need to begin thinking differently about chronic illness and specifically about mental illness.
The components are pretty basic. I have a templated diet that is perhaps only notable for its inclusion of red meat, which I’ve gotten a lot of flack for. As a former ethical vegetarian myself, I understand a lot of the resistance there, but there are reasons for it and I’ve written about them, if anyone needs to be convinced. It’s basically a templated month to clear the slate. His model was all about the autonomic nervous system. We’re speaking to the nervous system imbalances that are specific largely to people who struggle with inattention, with things like fibromyalgia, with depression, with chronic fatigue, with multiple chemical sensitivities. These are the people who benefit most from this approach, in my experience. It’s a specific, no cheating at all, not once diet for a month. It’s three minutes of meditation a day and then it’s detox. Of course, as the detox we all know about, subconscious consumerism, thinking about your products a little bit differently, filtering your tap water.
For most of my patients and a lot of my program participants, they are on medications seeking to safely come off medication. I recommend coffee enemas that I learned from Nick Gonzalez, that actually have completely revolutionized my practice. I think I would’ve been pretty skeptical had the information not come from him but with 27 years of experience and the science to explain why they are essential for effective, at least, medication detox, in his case it was for cancer treatment specifically. I have become pretty much a passionate believer in coffee enemas. There are other methods of detoxing like skin brushing, baking soda, Epsom Salt Baths, rebounding, any ways that you can get lymphatic flow improved. It’s basically those simple pillars and then a lot of work on mindset, which I find is facilitated by community-based process.
We have a Facebook community and I actually have found that that probably accounts for the outcomes in my online program being quicker and often more, really to be honest, miraculous than my practice, which often can take many months to get to where people have seem to be getting without my help. Maybe I’m just getting in the way. I do think that the online community is an increasingly important piece. This idea of feeling held and guided not just by a guru or a doctor, but by your peers who can deeply empathize with your experience that that’s a big part of the process as well.
Of course, if you’re interested in Kelly Brogan’s book, it’s called A Mind of Your Own. You can find it at www.KellyBroganMD.com as well as the information about her online program. The question I have I find a big challenge is so often patients don’t have the opportunity of informed consent when it comes to the prescribing of medication. What would your advice be for a patient who has chronic pain and they’re asking for help and they’re provided with a prescription for an SSRI?
It’s a great question and it really is why I wake up every day. It is because I am not here to tell anyone what to do because as you and I have discussed, your belief system determines the kind of medicine that you need. I think it is an unacceptable state of affairs that people are not being presented from their prescribing physicians with the full spectrum of scientific evidence for efficacy, safety and alternatives. That is the nature of an informed consent process. The average prescribing doctor is unequipped to provide that information, trust me. As someone who was once that person, we just don’t know what we don’t know.
The beauty of the internet is that it democratizes information. The information is out there. Sometimes it’s helpful to find someone you trust, and obviously, this is what I’ve set up my entire platform to deliver, to access free information about what you may not be told by prescribing doctor so you can make a decision that resonates for you. Part of that decision is understanding that there may be risks you’re not being told about, that the medications you may be prescribed are over promising relative to what they’re actually going to deliver. Then what else could you do that might be more in line with what you really want?
Of course, the big surprise for me is that the outcomes that I have seen since approaching these conditions through lifestyle medicine blow away anything that I ever thought was possible when I was prescribing. You have safe, effective and often, less expensive alternatives. You should at least know that that’s possible so that you can make an informed decision.
It’s a great way to end the podcast. I want to thank Dr. Kelly Brogan for being on the Healing Pain Podcast this week. Of course, you can follow her and find out more information at www.KellyBroganMD.com. You can read about her book, A Mind of Your Own, as well as her online program to help people with depression.
With every podcast, make sure you share this out with your friends and family so we can help spread the word of how to heal 100% naturally without prescription medication or surgery for those who have chronic pain. Thank you so much and we’ll see everyone next week on the Healing Pain Podcast.
About Dr. Kelly Brogan
Kelly Brogan, M.D. is a Manhattan-based holistic women’s health psychiatrist, author of the International and NY Times bestselling book, A Mind of Your Own, and co-editor of the landmark textbook, Integrative Therapies for Depression . She completed her psychiatric training and fellowship at NYU Medical Center after graduating from Cornell University Medical College, and has a B.S. from MIT in Systems Neuroscience. She is board certified in psychiatry, psychosomatic medicine, and integrative holistic medicine, and is specialized in a root-cause resolution approach to psychiatric syndromes and symptoms. She is on the board of GreenMedInfo, Functional Medicine University, Pathways to Family Wellness, NYS Perinatal Association, Price-Pottenger Nutrition Foundation, Mindd Foundation, the peer-reviewed, indexed journal Alternative Therapies in Health and Medicine , and the Nicholas Gonzalez Foundation. She is Medical Director for Fearless Parent and a founding member of Health Freedom Action. She is a mother of two.
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