Monthly Archives: April 2018

Do Those With Psychiatric Diagnoses Get Enough Medical Care?

After a disturbing article about the side effects associated with withdrawing from antidepressants appeared in the New York Times (link is external), I asked a psychiatrist friend why patients were not being helped to avoid this problem.

“It is very labor intensive,” he answered me. “To taper someone off antidepressants very slowly, which is the only way to do this, the patient should be seeing the physician or nurse practitioner two or three times a week. The medical caregiver must spend enough time with the patient to evaluate the side effects, and adjust the withdrawal rate accordingly. “

“But certainly there would be time in a 30 or 60 minute appointment to do this,” I naively replied.

He looked at me, wondering where I had been the last few decades. “Many psychiatrists have to see four to six patients an hour,” he said. “Not all do this,” he went on, “but if their schedule is that crowded, they may not have time to fine-tune the withdrawal schedule and/or even hear about the side effects. “

Having absorbed that piece of unfortunate information, I asked whether such short visits would prevent the physician from having time to discuss other aspects of the patient’s health such as weight gain or loss, whether the patient was getting annual care like a flu shot, regular dental care or routine screening examinations like mammography. “If they are depressed, isn’t it possible that the only doctor they see is their psychiatrist?” I asked him.

He confirmed that this was so. He had worked for many years as an internist before specializing in psychiatry. He was particularly sensitive to other medical problems of his patients and was able to make sure his patients saw the appropriate medical specialist when necessary. But again, the short visits, and absence of internal medicine training might cause medical issues to go undetected by the therapist.

Certainly the weight gain so common with most antidepressants would receive little attention from the psychiatric professional in an abbreviated visit, but patients can find weight-loss programs to join without physician referral. The program may not address the reasons for the weight gain, for instance, a side effect of the medication, but at least organizations such as Weight Watchers offer sensible, healthy diets. But where does the severely depressed patient who stops eating for four or five weeks go to for help? Who will convince the patient that it is important to eat, even though the depression takes away all desire to do so? Who will make sure that nutrient needs are being met, and that the depressed patient who lies in bed for five weeks does not finally emerge from the depression with muscle wasting from inactivity?

If the patient has family or friends who will take responsibility for the health needs of the patients with depression, then they will make the phone calls and appointments necessary to get them medical care they need; whether it be it for a bad case of the flu, high blood pressure or poor nutrition. However, many people with depression are socially isolated and may be un- or underemployed, and not plugged into a comprehensive medical care system. Thus the only interaction the patients have with a medical care provider is during the scheduled appointment with the psychiatrist every six weeks, or three months, or even after longer intervals.

Of course, the absence of generalized medical scrutiny or support by a psychiatrist is hardly unique. If one goes to a dermatologist to make sure a freckle is not a melanoma, it would be rare indeed if the physician checks the patient’s blood pressure, blood sugar, or asks if the patient is eating four servings of vegetables every day. The issue is the freckle, and not the general state of health of the patient. Yet oftentimes seeing a dermatologist for that freckle-melanoma issue follows a visit with an internist. People with mental disorders who are, for example, in the throes of the depression or bipolar disease, may never get to see the internist.

Perhaps the solution is to combine the visit to the psychiatrist to get a prescription renewed with at least an annual visit to a primary care physician. So, if medical problems exist, they can be identified and treated. Better yet, frequent contact with a seriously depressed patient by a nurse practitioner or physician assistant would ensure that the patient is eating appropriately and not voluntarily confined to bed. Moreover, when the patient is in remission, follow-up medical care should be provided to accelerate the speed of recovering nutritional status, to increase muscle mass, and to identify any other medical issues that may have arisen while the patient was depressed.

Much attention has been given to providing preventive care and early identification of medical problems that can be resolved before they become very difficult, if not impossible to treat. For example, high blood pressure should and can be treated in order to decrease the risk of a stroke. Certainly, if a patient is rapidly gaining weight due to the side effects of an antidepressant or mood stabilizer, the weight gain should be halted before it potentiates diabetes or cardiovascular problems. But these “should do” suggestions are not being implicated for many suffering from mental disorders because of cost, logistical difficulties and probably, to some extent, inertia and reluctance on the part of the patient. Perhaps it is time to turn “should do” into “will do.”

Funeral Potatoes Comfort, But At A Caloric Cost

What are funeral potatoes? People were asking this after an advertisement from Walmart for a packaged version of this dish appeared on their web site. Funeral potatoes are a well known dish in Mormon communities in Utah and Idaho, although it is popular as a cheesy potato casserole in many areas in the mid-west. Funeral potatoes is the name of a casserole traditionally brought to the home of the bereaved to be served at the after funeral lunch. The appearance of an instant version of this dish in Walmart may simply be evidence that in our busy lives, some do not have time to buy and assemble the ingredients. It is easier to find them all in a bag.

The ubiquity of this dish in homes of the newly bereaved, whether it comes from a package or is made from scratch, indicates that it may have an important function during the mourning process. The dish is considered the premier comfort food for after funeral repasts. One reason is that when made correctly, and probably not from a box, it tastes wonderful. Anyone who loves the combination of a creamy, cheesy, and crispy potato dish will have satisfied taste buds after eating funeral potatoes. (See below for generic recipe)  But long minutes after the food is consumed, the eater may experience a feeling of calmness, comfort, and decreased stress. The taste of the dish has disappeared from the mouth, but the effect on the emotions continues to grow.

Why?

The brain, not the gut, i.e., the intestinal tract, is involved in producing this emotional change. Twenty minutes or so after the last mouthful of the funeral potatoes are swallowed and digestion is in full swing, changes begin to occur leading to perceptible improvements in mood. Feelings of calm begin to take the edge off the sorrow and distress felt after the funeral. This occurs because of an increase in the synthesis and activity of the ‘feel-good‘ brain chemical, serotonin.

Funeral potatoes do not contain serotonin. (Indeed, even if one could eat something with serotonin in it, this very large molecule never, ever gets into the brain.) But potatoes are a starchy carbohydrate, and as happens when any starchy carbohydrate is digested, insulin is released. This sets in motion a process that allows an amino acid, tryptophan, to get into the brain . And as soon as tryptophan arrives, serotonin is made and one’s mood improves.

In the interests of good nutrition, or bringing food for a bereaved individual who may be on a Paleo or ketogenic diet, or any adherent to the, “Carbohydrates are Terrible Foods and Should be Avoided!’ diets, shouldn’t the traditional funeral potatoes be replaced by something else? Funeral potatoes may taste wonderful and make everyone feel better, but a dish of chopped egg whites is certainly a preferable dish for people avoiding carbohydrates. Or if not egg whites, perhaps roast chicken or baked fish or a smoked ham? These high protein foods certainly seem more nutritious than hash brown potatoes soaked in cream of chicken soup and covered with melted cheese, butter and crumbled cornflakes.

However, as important as eating protein is for our nutritional well-being, it has no effect on our emotional well-being. The carbohydrate, this funeral potato will nourish the mind, soothe the emotions. Potatoes are not an antidepressant, and of course cannot take away the pain and sorrow of a death of a family member or friend. But the synthesis of serotonin after eating carbohydrate is nature’s gift to us. It allows us to console and comfort ourselves simply by eating the right foods.

Eating protein prevents serotonin from being made. This is due to the absence of insulin secretion after protein foods are digested. The blood stream is flooded with amino acids that come from the digested protein, and although tryptophan is among the amino acids coming into the body, it is unable to get into the brain since the other amino acids crowd entry points to the brain. Eating protein does not truly comfort or console.

There is a problem, however. If going to an after-funeral lunch is something that is thankfully rare, eating funeral potatoes should have no lasting effects on weight and longevity. But if based on the traditions of your community or the ages of the people with whom you spend most of your time, and you are making frequent condolence calls? Eating funeral potatoes may deposit extra pounds you do not want. It is a very fattening dish mainly because of the number of high fat ingredients, e.g. sour cream, cheese, and butter.

Does this mean that you should eat egg whites instead, despite the lack of comfort bestowed by protein consumption?

Fortunately no.

Your brain does not care whether the carbohydrate that will ultimately lead to more serotonin is loaded with sour cream and shredded Cheddar cheese, or is a dry rice cake, bowl of bran flakes, or a boiled potato. Indeed the absence of fat as in a plain boiled potato will lead to a more rapid digestion, more rapid serotonin synthesis, and more rapid feeling of comfort.

Funeral potatoes are a great comfort. But for the sake of a healthy weight and avoidance of one’s own funeral, a plain baked potato (no butter or sourcream) should be eaten instead.

Generic recipe for Funeral Potatoes
Can Cream of Chicken soup
1 ½ – 2 cups shredded Cheddar cheese
2 cups sour cream
2 pounds package of frozen hash brown potatoes
1 stick butter
Chopped onions-1/2 cup
1-2 cups crushed corn flakes

Why Weight Loss Is Rarely Permanent

Many years ago at a meeting that addressed the usefulness of prescribing appetite suppressants for weight loss, one of the speakers (whose name will not be mentioned in case my memory is incorrect) said,

Obesity is a chronic disease.  Don’t think that allowing a patient to use weight-loss drugs will produce a permanent weight loss, or that other weight-loss intervention will also stop future weight gain. Obesity, like depression, alcoholism or autoimmune diseases, is chronic, and chronic diseases may go into remission because of medication and/or effective behavioral changes….So while sometimes one treatment is sufficient, the depression or skin rash never reappears after the initial intervention. The alcoholic stays abstinent.  Rarely is it that the diet plan or diet drug or surgery produces a permanent, positive change and weight stays normal. More commonly? The disorder reappears, more than once, and requires repeated behavioral, and/or medical interventions. Indeed, chronic treatment may be the only way to prevent flare-ups, a return of drinking, or depression.”

He went on to say that there is a bias toward people who gain weight again and again. We all know this…From the cruel remarks we make when someone is on a diet (Another one? Not again!) or gaining back the weight lost from the previous one (See, I knew she would never keep the weight off! ) to the hopeless attitude of physicians who give up helping a patient deal with constant diet failures (There’s no point wasting time talking about losing weight; he/she never listens.)

Weight-loss advice ranges from suggesting the most ridiculous or severe diets, to the simplistic mantra of portion control and exercise. Or else we keep quiet and shake our heads. “See,” we say to each other, “she has gained back all the weight she lost last year.“ And then we judge the currently popular diet with the comment, “Too bad this didn’t work, either.”

Yet so many of us have friends, colleagues, relatives, and acquaintances who have been abstinent and suddenly are found drinking again, perhaps after years of not doing so. When they are able to resume their AA meetings or come out of rehab, we don’t berate them with, “You failed. What is the point of helping when you will fail again? “ Rather, we support their effects to succeed.

If we treat obesity as a disease with a high probability of reoccurrence, as is the case with depression or alcoholism, then our entire approach to treatment can differ. All interventions will be presented honestly as a means of bringing the patient into remission, which may last weeks, months, or years. Still, the interventions will not be presented as a permanent cure. Taking out a diseased appendix is a permanent cure for a diseased appendix. Staying abstinent, if not a cure for alcoholism, is remission one day at a time.  Losing weight is not a permanent cure for obesity. Rather, it is remission from overeating and underexercising, one day at a time.

Treating obesity as a chronic disease allows a variety of interventions to be tried without blaming the patient if he or she fails to succeed at one or the other. Depressed patients are often switched from drug to drug, and the patient is not blamed when the depression doesn’t respond to a particular medication. Just as talk therapy is considered as important as drug treatment for depression and related mental illness, so too talk therapy should be part of the obesity treatment. Recognising what might erode control over eating is essential for success on a current diet, but also in delaying the onset of another weight gain flare-up. Semi-annual check-ups of weight status must be mandatory so the patient and care provider can identify emotional, situational, or even hormonal changes that might start the weight gain process. Such check-ups should remove the inevitability of weight gain in the minds of the patients.

For example, people who suffer from winter depression resign themselves to gaining weight over the dark months of late fall and winter, since weight gain is one of the symptoms of this particular type of depression. People also assume and anticipate gaining weight over the holidays. But why should this be? Would we assume that a friend, a recovering alcoholic, would start drinking over the winter, or that someone who is depressed every winter not be treated because the depression will come back the next year? If a patient had an intolerable flare-up of psoriasis, which can be maddeningly itchy, then every winter wouldn’t a dermatologist take steps to prevent it from occurring?

Because we don’t view obesity as a chronic disease, we simply do not treat it when we should. We don’t say to someone gaining weight, “You are experiencing a weight gain flare-up. It is important for you to be treated now before the situation becomes intolerable or hard to reverse.” A patient who has reoccurring depression should obviously be treated long before the symptoms become life-threatening. When the weight gain flare-ups occur, treatments also should be initiated. They include appetite suppressants, therapy, consultation with a physical therapist about exercise, use of calorie-controlled meals until control over eating is resumed, and participation in weight-loss support groups.

Of course, none of this will work if the weight-gaining patient refuses to acknowledge what is happening and/or resists treatment. Not all alcoholics who have failed to remain abstinent acknowledge what is happening or seek treatment; when they do, many are able to go back into remission. We must tell the obese individual to stop hoping for permanent weight loss. Keep the weight off today, and we will be there to help you if tomorrow is a problem.