Is it appropriate to link the possibility if a person’s symptoms improve on a drug like Zoloft that they’re suffering from gut issues and that spending the money to do a Doctor’s Data stool test is well worth the investment? This patient has done a great deal of testing, but gut testing hasn’t been done for a few years. She’s cleared up many symptoms with the GAPS diet, etc., and eats very clean. She is being treated for Lyme, etc. Here is a communication from her after she started Zoloft: [This is the patient here.] I ended up in the ER about three weeks ago with a major panic attack and was diagnosed with depression and anxiety. I had not been sleeping well for months. I’m now on Zoloft and doing very well. A lot of the symptoms that were bothering me are gone. I also do not have any bad cramping or heavy bleeding with this period. I’m on day four. I honestly have just needed a break from obsessing about my health issues and have been enjoying it. I am meditating and doing yoga, listening to hypnosis videos, juicing a lot, and napping in the sun. [So this is back to Julie.] My question is, do you see gut dysbiosis or infections depleting serotonin and creating depression, anxiety, etc.? I would like her to proceed with the Doctor’s Data stool analysis, but want confirmation that it’s a good place to spend her money since financially she’s been very depleted with chronic health challenges. She has already completed DUTCH testing.

Chris Kresser:  This is a great question, and it actually points to a number of other questions that are perhaps even more important than the details of this question itself. What I’m referring to is how we collaborate and cooperate with our patients. One of the reasons patients choose functional medicine practitioners, one of the many reasons, is that we tend to take a more collaborative approach, cooperative approach rather than the more autocratic approach that’s typical in conventional medicine where the doctor or clinician is the authority and makes the decisions and the patient complies. At least in my practice, the way I practice functional medicine, I don’t approach it that way. I have a discussion with the patient. I feel like it’s my responsibility to educate them about their condition, what I believe to be the causes of that condition, and then to cooperatively choose a course of action that is the best fit for where they are at in that particular point in their life.

It may be true, for example, that the root of this patient’s problem is a gut-brain axis dysfunction. I think we covered a bit of that in the gut unit. We’re probably going to cover it again later. I’ve written quite a bit about the gut-brain axis, so definitely check that out. There are multiple mechanisms. It’s not just depletion, or I’m not even sure if depleting serotonin is part of it, but it’s more of an inflammatory relationship. When you have dysbiosis or food intolerances or other issues in the gut, you get inflammation in the gut and those inflammatory cytokines travel through the blood, across the blood-brain barrier, and suppress the activity in the frontal cortex. So it’s called the inflammatory cytokine model of depression and it is quickly gaining ground as one of the primary explanations for how depression occurs.

So all of that could be true, and you might do a stool test, SIBO breath test, and organic acids.  You might find that she has gut issues, and that may be the best way to proceed. But this patient is also giving you a pretty clear message that she is tired of obsessing about her health and is getting, it sounds like, some healing by using Zoloft. That might seem like anathema in functional medicine, but as I said I think way back in the introduction, functional medicine does not exclude drugs or surgery. It just doesn’t look at them as long-term solutions, and I think that in certain situations drugs can be what in the Zen tradition they call “skillful means,” which is like a raft that can get a patient from one side of the river to the other side. In Western medicine, the idea is once you’re on the other side of the river, you pick up the raft and carry it on your head with you wherever you go. In other words, you just keep taking the drug. In functional medicine, we want to at least invite the patient to consider once they feel more stable and are doing better to slowly titrate off of that medication as they are … or maybe even while they are on the medication and you’re doing the testing, if they are ready to come back into the fold of doing that kind of investigation. You’re doing that testing and once they feel stable and strong enough and ready to dive back into this exploration, then you can treat their gut, and if they’re starting to feel better, you can gradually titrate them off the medication, or if that’s not in your scope, you can work with their psychiatrist to do that.

So I guess what I’m trying to say is, yes, the Doctor’s Data stool analysis, SIBO breath test, or both would be good options, but only if the patient feels like she is ready to move in that direction. To me, just from the little bit that you shared, it sounds like that’s not where she’s at and she needs a time where she’s just actually able to function and enjoy life and not really worry too much about looking for the underlying cause. So you might have a discussion with her similar to what I’ve just had with you and figure it out together.