Conventional, Integrative, and Functional Psychiatry: What’s the Difference and How I Use All Three to Help Clients Feel Better

In our lives, many of us will come to a time where we struggle with a mental illness and seek treatment of some kind. There seem to be a billion different experts talking about what is the best way to treat depression, anxiety, mood lability, hormone imbalances, focus, or psychosis. When you have anxiety, your doctor recommends an SSRI, your therapist wants you to try Exposure and Response Prevention therapy (ERP) or Polyvagal therapy, your acupuncturist advertises the benefits of Traditional Chinese Medicine (TCM), your neighbor scares you with their horror stories about trying to get off Xanax, and then someone on social media starts talking about how to support bifidobacterium strains in your gut to improve anxiety. There are conventional, integrative, functional, and medication-free treatments. Should you take a medication or try to treat the root cause with functional psychiatry? What’s the difference and how should we know when to choose one versus the other? That is a lot to sort through. All of these options may feel exciting but it also might feel confusing and overwhelming, especially if you don’t feel well and need help. In this article we will review your options for psychiatric care, discuss some of the benefits and limitations to treatment approaches, and I will explain why I practice a blended version of all three.  

What is Conventional Psychiatry?

Standard, or conventional, psychiatric care as a medical specialty began in the 18th century. It has evolved from the archaic view that mental health problems are a form of supernatural or religious affliction and appreciates that psychiatric conditions have biological, genetic, and social contributors. Conventional psychiatric care typically centers on the use of pharmaceuticals or medications to manage mental health symptoms. Hopefully, any prescription for a medication follows an assessment or psychiatric evaluation that includes laboratory tests (evaluating thyroid function, nutrients like zinc, iron metabolism, and others), a discussion of the client’s diagnosis, prognosis, treatment goals, treatment options, as well as risks and benefits of the treatment. Ideally a client will get a referral or recommendation for psychotherapy as well. Patients can receive conventional psychiatry from psychiatrists and psychiatric nurse practitioners, or even a willing primary care provider. Insurance will typically cover psychiatric care with any of these providers as well as the cost of most labs, medication, and psychotherapy – depending on the type of plan. Certain labs, brand medications, and out-of-network providers may not be covered by insurance. Specialty training and experience will often be the expertise of providers like psychiatric nurse practitioners and psychiatrists. A good primary care provider can manage stable conditions, but it is recommended to seek a psychiatric specialist as a primary care provider is more likely to miss a diagnosis like bipolar disorder, substance use, dysfunctional eating, or trauma. They may lack sophisticated knowledge on the best methods for treatment. And with everything on their plate, they have less availability and time to dedicate to care.

Limitations of Conventional Psychiatry

There are benefits to the standard approach but also many limitations. Conventional psychiatry is effective for many but it does not work for everyone. Popular and often prescribed medications vary in efficacy, many proving in clinical trials to be barely more effective than placebo. The Number Needed to Treat (NNT), is a statistical measurement representing the average number of patients who need to go through a treatment for one patient to experience a remission of symptoms. For medications used to treat depression, the NNT is 7-9 patients, depending on which medication is used. Granted some people will report improvement, but only one patient out of 7-9 others will no longer feel depressed while under this type of treatment.

Side Effects and Dependence

Adverse effects of psychiatric medications can range from gastrointestinal problems to interdose withdrawal, dependence, weight gain, sexual side effects, and other issues. To prescribe a medication at just the right dose to result in an effect but not cause emotional blunting, numbing, or dependence, requires expertise and, honestly, a bit of luck as the outcome is determined by a myriad of factors, including: genetics, patient adherence to the medication, the accuracy of the diagnosis, the rapport between the patient and the provider, nutrition status, rate of metabolic clearance, and many other factors of pharmacokinetics and pharmacodynamics (the effect the body has on a drug and the effect the drug has on the body, respectively). Many clients may be started on a medication only to later learn that the provider does not have the knowledge of how to stop the medication in a way that does not cause the patient intense discomfort or injury. These problems include discontinuation syndrome for Celexa and other medications or withdrawal and Benzodiazepine Induced Neurological Syndrome (BIND) for any benzodiazepine (Ativan, Klonipin, Xanax, and Valium, to name a few).

Turning the Check Engine Light Off of a Problem We Don’t Understand

With all of this, what I find most problematic is that pharmaceuticals – even if they work and are well tolerated - do not cure mental health problems. We’re just quieting symptoms. When the treatment is stopped, the benefits usually fade. An appropriate comparison often made is ‘turning the check engine light off’. We’re not really seeing the problem and we’re definitely not treating the root cause. Western medicine is great at naming a disease and formulating drugs to treat symptoms but often ignores prevention and rarely understands true healing. Being diagnosed with a type of depression does not identify the cause of the problem, it is just the name for all the symptoms. And being prescribed Prozac is not treatment for a Prozac deficiency, it just quiets the signs we receive that something is wrong. Those signs can be valuable information if we listen, look deeper, and know how to help the body restore health.  

Beginning in childhood, I was interested in learning about our minds. I pursued psychology and later psychiatry partly due to my fascination with human behavior and also my hope to help others. Overtime, I gradually had to come to terms with the reality that my fancy, expensive, many-year education and training had set me up to put people, and children, on drugs that IF they work, often cause side effects, and won’t heal the problem. A number of years ago I started to look around for better options.

What is Integrative Psychiatry?

Integrative psychiatry brings us closer to holistic care and is more likely to help someone heal. There are varying interpretations of what integrative psychiatry is depending on who you talk to. Generally, integrative psychiatry broadly encompasses lifestyle medicine, and effective methods from ancient cultures and modern science. Treatments used often include mindfulness, nutrition, spiritual practices, gratitude practices, ecotherapy, exercise, herbal medicine, vitamins and nutrients, and possibly modalities with less scientific evidence, like energy healing. The training of the practitioner will be variable and impact the lens through which they view care and what treatments they recommend. There are integrative psychiatrists, psychiatric nurse practitioners, primary care providers, and other practitioners of the healing arts. Some integrative practitioners take insurance while others do not. Depending on what tests and treatments are recommended, insurance coverage and cost of care may vary.

My path from Conventional, to Integrative, to Functional Psychiatry

My education at the University of California, San Francisco was rigorous, grounded in science, conventional, and fortunately, included some integrative training. I was introduced to a few methods like motivational interviewing, a single semester on nutrition, and was exposed to the data supporting mindfulness in mental health. It was not much but I was glad to have it.

I began my career as a psychiatric nurse practitioner at a busy community clinic in Oakland, where I saw children and adults looking for help. Many waited for hours, hoping to be seen by someone who would slow down, listen to their problems, and provide treatment to make things better. I worked with excellent psychiatrists and other nurse practitioners who taught me how to evaluate complex cases, mindfully document so that insurance would cover the client’s care, and how to come onto a case of polypharmacy and untangle multiple prescriptions so that a patient could feel better on fewer medications. It was meaningful work but watching clients come back year after year, often asking what else could be done, and if they needed to stay on medications for the rest of their lives, made me want to be able to offer something better. So, I continued to research advancements in mental health care.

When I completed a fellowship in Reproductive and Integrative Psychiatry and a second from the Integrative Psychiatric Institute, I felt that I had more options that were likely to address a client’s concerns and help identify the causes of their suffering. I studied botanical medicines for postpartum mothers, the evidence supporting psychedelic medicines and somatic therapies for trauma, nutraceuticals for attention deficit disorders, how to restore balance to the gut microbiome, and the data supporting humor and spiritual processes in mental health care. I learned that for the treatment of depression, the NNT of exercise is 2(!) and prescribing a whole foods diet like the Japanese, the Norwegian, or the Mediterranean, the NNT is 4. Compare that to a NNT of 7-9 for SSRIs. This means that movement and eating better can be four times more effective than SSRIs without side effects and all of the benefits to other aspects of health.

The Limitations of Integrative Psychiatry

The beauty is that integrative care has much to offer and there is no doubt that it can address the root cause and bring healing to many individuals. The problem for me was that sometimes therapy, exercise, meditation, and nutrition are not enough. Many clients come to an integrative psychiatry provider already having tried many of these interventions. When more is needed to treat their suffering, natural supplements are recommended to mute symptoms and there again, we’re turning the check engine light off. If the client stops the SAMe or St John’s Wort, will their depression come back? What if a woman with postpartum anxiety is not able to repeatedly dose lemon balm to manage her anxiety? I liked that many of these interventions were better tolerated than pharmaceuticals, but I wanted my clients to be cured, not dependent. Fortunately, it was during my second fellowship that I was exposed to functional medicine.

What is Functional Psychiatry?

Functional medicine is a holistic approach to identify and address the root cause of an illness rather than reducing its symptoms. It views health care as systems biology rather than organ or symptom management. The process starts with an assessment and then testing to evaluate a person for infections, inflammation, oxidative stress (cell damage), and catabolic physiology (the breaking down of an organism). If conventional care uses medications to turn the check engine light off, functional medicine is opening the hood and addressing the problem at its source. Functional psychiatry, like functional medicine, will take a whole-systems approach but with the agreed upon goals of working to address mental health symptoms, like depression, anxiety, sleep, energy, focus, moods, rational and linear thinking, and stress.

Who Provides Functional Psychiatry and What Does it Involve?

Functional psychiatry practitioners have specialized training in assessing, testing, interpretation, and treatment of sex hormones, the hypothalamic-pituitary-adrenal axis, the gastrointestinal system, and organic acids (cellular metabolic byproducts). Some practitioners have medical degrees, but others may have training in nutrition or chiropractic care. As functional care is its own specialty, requiring years of education, most primary care providers do not have training in this area and cannot order the testing. When problems are found through testing, treatment often focuses on lifestyle changes to improve nutrition, reduce stress, and balance hormones, and supplements to treat infections and raise nutrient levels found to be inadequate. The length of treatment depends on the number of issues, how adherent the patient is to the protocol and life-style changes, but also the severity of the problem(s). Diligently followed protocols often last a year but if a client has a genetic mutation, certain aspects of the original protocol may be recommended to continue like avoiding a certain food or taking a supplement. Typically, insurance companies will not contract with a practitioner for this type of care but depending on the provider’s license, how the provider documents and codes, insurance may reimburse a client who submits a superbill. Most tests range from $250-$500 and protocols often cost approximately $200 or more per month.

So why would you want to do all this testing and take supplements for multiple months? Our culture and standard medical approach do not orient us to understand that infections, inflammation, oxidative stress, and catabolic physiology can drive mental illness. So, let’s look into this.

Nutrition as a Currency and Its Role in Our Health  

Many of us understand that the billions of functions that occur in our body each minute require nutrients to operate. You have likely heard that iron is critical to quality sleep, studied or seen a picture of the citric acid cycle, or heard that vitamin D plays a role in melatonin synthesis, supporting immune health, sleep, and other functions. As kids we were told, “Eat your fruits and vegetables.” But that was from some adult getting between us and dessert! Most of us don’t spend a lot of time thinking, “Have I consumed enough copper recently to continue fueling my thyroid hormones?” Or ask our spouse, “Honey, please make sure to pick up plenty of sources of B6 from the store so that my tyrosine can effectively convert into dopamine – I want to make sure I continue to feel joy and pay attention.” The reality is that nutrients are the currency of health and infections, toxins, trauma, inflammation, and stress are the expenses.

Fewer Nutrients, Fewer Resources for Health

Our eating habits have drifted far away from consuming the whole foods that our bodies evolved to run on. In addition to moving away from nutrient-dense foods, we’re now eating more commercial produce which has a lower nutrient quotient than before industrial agriculture; the foods we are consuming contain a higher number of ingredients that are likely to inflame our system (sugar, colors, preservatives, glyphosate from Roundup the weed killer). And we’re running into nutrient-demanding problems at a rate that our low-nutrient consumption cannot keep up with.

Our biology developed over a span of six million years with very different conditions than how we currently live, shifting most dramatically in the last fifty years. When we were living in caves or even later in seasonal settlements, we didn’t have many pollutants or toxins beyond volcanos, fires, and some poisonous flora and fauna. We had stress, for sure: getting food, not becoming food, shelter, the chest-beating alpha in the tribe, and avoiding orthopedic injuries were all expected spikes to cortisol. Sweets were rare, found seasonally on a bush or a tree, and we had competition, as the bears or the baboons were heading for the same bush. We ate weird foods, at least by modern American standards. We ate cartilage, organs, and meat off the bone, we ate bugs, roots, and seeds. The ecology of our guts was wonderfully wild; it protected us from pathogens we put in our mouth, helped us generate balanced hormones and crack into the nutrients we collected and consumed. Amino acids were coming from our foods, being put to use building muscles and in so many other important physiologic processes. When the sun set, we gathered around a fire, felt tired, and fell asleep.

Costs, Deficits, and Health Issues  

Now we live longer, with magnitudes more resources but we’re less healthy. Cancer, metabolic problems, cardiovascular disease, infertility, Alzheimer’s disease, and mental health issues are all on the rise. In the United States we spend 20% of our Gross Domestic Product on health. Modern life has brought fascinating advancements and comforts but problems for our wellbeing. We have microplastics in our water and dermal absorption of chemicals from our synthetic clothing causing endocrine disruption. Walls of candy at pharmacies and the hardware store, perfectly engineered to be deliciously addictive, are driving a variety of metabolic problems. Heavy metals coming in through our jewelry and dark chocolate are increasing neurological conditions. Most of what we put in our grocery cart is not food but food products that complicate our metabolic processes, interfere with digestion, and reduce our nutritional resources for every physiological process our body goes through. We unwittingly consume mycotoxins in foods that traveled long distances increasing the incidence of immune issues and other problems. We hold stress from politics, trauma, having kids or not being able to have kids, loneliness, caring for aging parents, bills, declining economic opportunities, and health problems all reducing our adrenal resilience. We’re exhausted and ashamed that we can’t find the motivation or the time to exercise. Human connections have been replaced with likes, posts, and loneliness is at an all-time high. We work long hours, under artificial light, away from the sun and natural world, staring at screens, and sitting for most of our days. Our circadian rhythms are lost in front of the glow of electronics and many of us sleep poorly which hits us on every health index.

When Nutrients are Low, What Happens to Mental Health?

All of our stress, infections, inflammation, oxidative stress or toxins, and catabolic physiology are expensive to whatever nutrients we have available. So now that the bank account is low, are there enough nutrients available to make hormones and neurotransmitters? How effective is our gastrointestinal tract at absorbing nutrients when it’s inflamed, or preoccupied with an infection? How capable is a microbiome that has had six rounds of antibiotics? How about fifteen rounds? Where does the body get the amino acids to go about making hormones, neurotransmitters, and muscle repair when it can’t find them in our diet? And lastly, does any of this matter when we’re talking about mental health?

How Does Functional Psychiatry View Depression?

So, let’s take the example of one of the most common mental health conditions, depression. Again, depression is not the cause of the syndrome, it’s only a name of the symptoms. How does functional psychiatry evaluate and treat depression? Like conventional psychiatry, we would assess the client’s life: are they lonely? Is this actually prolonged grief or some other consequence of social circumstances? Any of these can contribute to low moods but biologically, depression can be due to a number of factors, including:

• Infections and inflammation disrupting the kynurenine pathway, which diverts tryptophan away from serotonin production. This leads to changes in neurotransmitter levels associated with depression.

• A damaged microbiome from infection or antibiotic exposure can reduce the production of neurotransmitters.

• Food intolerances and other sources of chronic inflammation can lead to cortisol dysregulation, which is linked to depression⁠⁠. Long-term elevated cortisol affects serotonin levels and contributes to depressive symptoms⁠⁠.

• Insulin insufficiency or metabolic problems from chronically elevated blood sugars. Insulin resistance impacts the hypothalamic-pituitary-adrenal axis, leading to chronically elevated cortisol levels. This cortisol elevation lowers serotonin levels.

• Low vitamin D due to inadequate sun exposure, can negatively impact everything from estrogen to cortisol to melatonin, all with the potential to lead to depression.

• Habitual antacid use, secondary to untreated gastrointestinal infections, interferes with vitamin B12 absorption which is needed for mood regulation.

• An autoimmune condition driven by consumption of gluten that harms the thyroid can lead to depression.

Functional medicine provides us the testing to see where the overdrafts are happening so that we can stop that spending and then shore up nutrients, or currency in this metaphor. Modern medicine is siloed but the body is very connected and when its burdened with toxins, infections, and inflammation, and does not have the resources to protect us and fight back, are we truly surprised that that would impact how we feel and think? Fortunately, there are clear and effective plans for how to restore the body back to whole that treat the problem without harming the body (antibiotics and prescriptions are not typically used). To support that understanding, I should be clear that functional medicine, and functional psychiatry, are based in lifestyle medicine and behavioral modification. Supplements are used as their namesake, to supplement the changes a client is making to:

• Reduce stress and increase how much time the body spends in a relaxed or parasympathetic state

• Support circadian rhythms

• Increase sleep quality and practice sleep hygiene

• Engage in movement

• Increase the consumption of nutrient-dense foods

• Limit toxins and avoidable exposure to chemicals

For functional psychiatry to work, we don’t need to be perfect and only eat whole foods, meditate, and go to bed at 8 PM but let’s be practical: if a client is drinking alcohol most days, not eating well, and not willing to make some meaningful changes in their life, they are likely not feel much different.

How I Use Conventional, Integrative, and Functional Psychiatry to Help Humans Feel Better

My approach to mental health care is holistic, integrative, and I use functional psychiatry whenever a client is willing. I start with a thorough assessment, order labs, and obtain records of the client’s treatment history, learn about the client from their therapist, understand the client’s goals, and provide recommendations from an integrative lens that will most likely help them achieve their goals in a durable fashion, with the lowest likelihood for adverse effects. I have found that healthy people have better odds at being happy people. Because I want us all to have the best chance at great health and mental health, I recommend that everyone have functional testing to evaluate the gut microbiome, the sex steroids and adrenal resilience, and organic acids. Occasionally, results may indicate that more testing, like toxins, food intolerances, or gluten sensitivity, be done. Depending on the severity of the case, I may recommend pharmaceuticals, often as a bridge to help clients get their feet underneath them while they work on other lifestyle changes. For certain mental health conditions, pharmaceuticals may be necessary to continue while other work we do can reduce the dose and number of medications.

Many individuals and parents come to me specifically because I specialize in treating mental health problems without medication. Other clients know that they are not ready to make changes beyond a few tweaks to how they eat or when they put down the cell phone. And that’s okay! I feel that I have an obligation to help clients get to the root of the problem as much as possible and I feel privileged to be trusted by others making such important changes. If this interests you and you would like to discuss how I may be able to assist you with your mental health goals, please review my practice policies, fees (as I do not accept insurance but do provide a superbill for you to pursue insurance reimbursement), and request a phone consultation. I look forward to talking with you soon.