Reading Lise’s blog just now generated a response that isn’t suitable for print that questioned what I could write that might be appropriate to follow her treatise on universal love and chronic disease.
I’ve been thinking about much more mundane matters; how cold and rainy it’s been in Denver in contrast to Portland which apparently has had a bit of a warm spell. Those sorts of things. OK, let’s try writing this AANP thing:
I was up later than I wanted to be last night following an interesting trail through PubMed. There is growing awareness that serotonin may affect bones for the worse, increasing bone loss and increasing risk of osteoporosis and fractures. The first hints appeared a decade back and have gradually accumulated over the years. At this point it’s pretty much a sure thing. Taking SSRIs in order to increase serotonin levels increases bone loss.
This new knowledge shows up as our suppliers are once again selling l-tryptophan and promoting its use to increase serotonin levels.
OK, so we should be a bit more cautious with blindly raising serotonin levels in our patients. But the bigger issue is what were we thinking in doing this in the first place? After all, we are we not supposed to be naturopaths and is not our goal supposed to be to stimulate the vital force or the vis medicatrix naturae or something along that line. What does feeding our patients with isolated chemicals, in this case l-tryptophan or 5HTP, have to do with stimulating the vis?
What we were thinking of course is that Prozac works by raising serotonin levels and sometimes makes people happier. If Prozac and l-tryptophan do kind of the same thing, well the later is more natural and seems like an ‘alternative medicine.’ The thing is that we are not ‘alternative medicine doctors.’ We did not go to ‘alternative medicine school.’ Perhaps we need to remind ourselves this once in awhile.
The more we understand about the human body, the less sure I am that I really understand anything. Serotonin is made in both the brain and the gut. L-tryptophan is converted into niacin or serotonin and can then be made into melatonin. The gut makes far more melatonin than the brain does. Serotonin and melatonin play at least several roles in the intestine, helping regulate intestinal motility, healing injury and moderating inflammation.
So though exceptionally easy to reach for a bottle of l-tryptophan or of melatonin I still wonder, is it the right thing to do? Might we get a deeper and more profound effect by taking a more ‘naturopathic’ approach? I often find myself imagining how particular patients might respond to a month of old time nature cure. If they were to spend day after day on forced hikes through the Austrian Alps, early to bed and early to rise, bathing in cold water, the whole deal, how many of their complaints might resolve without further intervention? Would this push start a more robust circadian cycle and by strengthening melatonin fluctuations not have some positive influence on serotonin production as well?
Neither we, nor our patients, often have the luxury of really testing out these imagined months away from job and family so we are left with the simple question. How best to restore normal function with the least intervention? In the end, patients don’t come to us for philosophy, they come to us for help. If a bit of an amino acid nudges a patient’s chemistry so that she sleeps better, it’s not the end of the world. Yet, few of us are satisfied that this is a cure, but it is an improvement.
Although my concerns over serotonin and bone mass are new, the questions it raises in my mind are old. Not just for our profession, but through the history of medicine. How much does the physician intervene? How much do we step back and let nature heal? Do we know enough to help nature heal? Are our theories correct or will our misinformed attempts backfire and interfere with nature’s own efforts? Or to ask the sacrilegious question, ‘Does nature really know what to do in the first place?’
As a profession we can be almost cultish in our belief in nature as an all-knowing omnipotent healer. Let me quote a respected medical writer on nature’s healing properties:
“If the organism alone is left to the task, by its own forces and without external aid, …. we then witness nothing but painful, often dangerous efforts of nature to save the individual at whatever cost, which often terminate in extinction of the earthly existence, in death….What the vital force does in these so-called crises and how it does it remains a mystery to us like all the internal operations of the organic vital economy. One thing, however, is certain: that in all these efforts more or less of the affected parts are sacrificed and destroyed in order to save the rest.... In short, the entire operation of the self-aiding power of the organism when attacked by disease displays to the observer nothing but suffering, nothing that he could or ought to imitate if he wishes to cure disease in a truly artistic manner…..Our image of this Vis that we so eagerly wish to embrace and employ to heal all patients of all things is perhaps oversimplified. Great doctors for centuries have professed and debated the nature of this ‘power’ and how best to aid and abet it.
“……the unreasoning life-preserving power when left to itself in disease, which, entirely dependent as it is upon the organic laws of the body, is only capable of acting in conformity with these laws, and is not guided by reason and reflection—the crude nature, which cannot, like an intelligent surgeon, bring together the gaping lips of a wound and by their union effect a cure; which knows not how to straighten and adjust the broken ends of a bone lying far apart, ……which cannot put a ligature on a wounded artery, but in its energy causes the patient to bleed to death; which does not understand how to replace a dislocated shoulder……which in order to remove a foreign body from the cornea, destroys the entire eye by suppuration; which with all its efforts, can only liberate a strangulated hernia by gangrene of the bowel and death; and which by the metaschematisms it produces in dynamic diseases, often renders them worse than they were originally.”
Our image of the Vis is a conglomeration of the ideas put forth by these great practitioners, often very conflicting ideas, that in our innocence we think are all one and the same. The proponents of the Vis Medicatrix Naturae would view our interpretation of their ideas as a hodgepodge of opposing thoughts and our attempts to utilize the healing power of nature as to be inconsistent. We are justified to criticize some of these practitioners for using violent treatments on their patients justifying their actions because they were mimicking the healing power of the body when it triggers vomiting, diarrhea, ulceration and hemorrhage.
So who am I to question whether l-tryptophan is good or bad. The only thing I can say today is that current information suggests the need to balance Tryptophan use against risk of osteoporosis.