- The gut microbiome consists mostly of bacteria and that is largely the portion of the microbiome we are focusing on (fungi and viruses exist but their function is largely unknown)
- Communication pathways exist between the microbiota-gut-and brain.
- Multiple mechanisms exist that allow gut microbiota to signal to the brain and control physiological processes.
- These include release of gut peptides from enteroendocrine cells which activate receptors of the immune system and vagus terminals in the gut.
- Studies indicate that these bacteria can manufacture and secrete essential neurochemicals including serotonin, dopamine, NE, GABA, and acetylcholine
- Depression and anxiety have been linked to a less well diversified gut microbiome.
- What can help diversify the gut microbiome? Diet, processed food, sugar, saturated fats, and red meat. Medication can also alter the gut microbiome, a good example is oral antibiotics used to treat an acute infection, sleep, exercise. Sounds a lot like a healthy lifestyle will get you the microbiome you need for optimal mental health.
- However, if you want a treatment there have been several studies that looked at fecal transplant to treat psychiatric disorders. Fecal transplants are much easier these days and now there is a capsule version that you take orally. There is not enough data to recommend this as a practical treatment and if the patient goes back to eating a poor diet, sleeping poorly, not exercising then the gut microbiome will revert after the transplant.
- What are the practical things you can do? Stop eating processed food, sugar, and red meat. Increase your fiber intake and select a diet like the Mediterranean diet or a plant based whole food diet that will provide those prebiotics. You could supplement with a probiotic but most of what you need can be had from a good diet alone and I think it’s far better to change the diet then to try using supplements to treat a poor diet. Fermented products like kimchi, kombucha and sauerkraut are good sources of live bacteria.
- If you choose to take a probiotic make sure it’s a quality, 3rd party tested product.
- Increase aerobic activity, I think if you goal is overall general health and you have limitted time, I think aerobic activity is a better bang for your buck.
- The way I believe you get and keep a healthy gut microbiome is through lifestyle modification. Improving your diet, exercise, and sleep is a good place to start. If you want to supplement with food products like kimchi or kombucha, go for it. I do not believe there is enough evidence to support a probiotic supplement for psychiatric disorders at this point, but if you want to spend $30 or more per month on a product if it’s a quality one that’s fine. Remember you cannot supplement away a bad diet.
I get a lot of comments that go something like this “All psychiatrists do is prescribe medications.” Naturally, people are shocked when I talk about nutritional psychiatry, lifestyle modification, or the value of psychotherapy. I cover a lot of medication information on social media because there is significant confusion, misinformation, and a general benefit for patients to know more about the medications they routinely use.
While medication management is a substantial portion of the work most psychiatrists do it’s not the only things we do.
Most psychiatrists are well trained in at least one type of psychotherapy. The most common ones include cognitive behavioral therapy, interpersonal therapy, and motivational interviewing. Some are trained extensively in psychoanalysis which usually requires a 5-year commitment and engagement in psychoanalysis as a patient.
Many psychiatrists offer procedure-based interventions such as electroconvulsive therapy (ECT), and trans cranial magnetic stimulation (TMS). We may also consult on cases of vagus nerve stimulation or deep brain stimulation used to treat severe depression.
As a psychiatrist you are trained to handle some of the common neurological disorders (e.g. migraine). One third of our board examination is focused on neurological disease. In rural parts of the United States sometimes there is no one else to treat these disorders and the responsibility falls to psychiatry.
Most psychiatrists can treat things like hypertension or hypothyroidism. Many make the choice not to if the patient has a primary care physician. Like the treatment of neurological disorders sometimes there is no choice, and a psychiatrist will need to treat the medical condition.
Not everyone is lucky enough to have designated social workers so they can focus exclusively on the treatment of patients. We all know how important social determinates of mental health are, and sometimes altering these circumstances is the responsibility of the psychiatrist.
I’ve done a soft rollout of the Shrinks In Sneakers YouTube channel over the past several months. I think I’m finally comfortable introducing it on the blog. I made the decision to start making videos because I can create content at a more rapid rate, and I can connect with the viewer in a more personal and intimate way. Please subscribe to the channel for updates. If you have specific topics you want covered, or have questions about existing content please comment. I will try to answer all questions and continue creating engaging content based on your interests.
Link to YouTube Channel
Regular Dental Care and Oral Hygiene
Dry mouth is another common side effect from psychiatric medication. Patients on psychiatric medication often have poor dental care and poor dental outcomes. There is increased incidence of dental caries and oral ulcers in this population. This patient population is also three times more likely to lose all their teeth. Let that sink in for a moment. Now some of this is related to not following the recommended dental hygiene guidelines such as regular cleanings at least every 6-months. Thus, this is the first step in the process. Ensure the patient first has a dentist, and second be sure they are making regular 6-month appointments, and if they have issues with dental health, they should be going for cleanings as often as every 3 months. Oral hygiene is the foundation for the remainder of the interventions.
Gum, Candy, and Pilocarpine
Most patients are told to carry a bottle of water around and take frequent sips throughout the day. This does not work. It provides temporary relief, and does not address the underlying issue. You can educate the patient about drinking more water while eating which can help facilitate the swallowing process especially when dry mouth is an issue. Carrying a cup of ice can be helpful but is not convenient. What I prefer is the use of sugarless gum or candy which can be easily carried and chewed as needed. Studies have demonstrated that xylitol containing gum can reduce the levels of Mutans streptococci and lactobacilli in saliva and plaque. This has the potential to reduce the incidence of dental caries, and is an inexpensive option for most patients. I will also recommend as a second line using a mouth wash for dry mouth such as Biotene. If these interventions are not effective a medication to stimulate saliva production such as pilocarpine. In many cases pilocarpine eye drops which act locally is a better option than a medication that acts systemically.
Dry mouth is a common side effect patent’s experience but may not always bring to the clinician’s attention. There are interventions to treat this side effect that range from simple interventions like xylitol containing gum to pharmacological interventions such as pilocarpine eye drops. Most patients will experience relief with the above treatments. This highlights the importance of asking about specific side effects so they can be treated early and prevent long term Complications such as tooth loss.
The other day I had a conversation with a friend, and the topic of Alzheimer’s disease (AD) came up. My friend’s opinion was basically why would I want to know I have a disease that results in steady decline in function, and lacks any disease modifying treatments? This is in large part true, there have been multiple clinical trials of both symptomatic and disease modifying drugs that failed to produce adequate results. However, this is a very limitted view and neglects the benefits of focusing on modifiable risk factors and primary prevention. We know approximately 1/3rd of AD cases are due to modifiable risk factors, and the implementation of lifestyle modification early may prevent or delay the onset of AD.
Modifiable Risk Factors
Common modifiable risk factors for AD include hypertension, hyperlipidemia, diabetes, obesity and smoking. Management of these risk factors as early as possible may offer a preventative approach for AD. Equally important are lifestyle modifications such as physical exercise, diet, mediation/mindfulness, and social activity.
Physical inactivity has a significant influence on the development of AD. Twenty-one percent of AD cases are attributable to physical inactivity. There is a significant number of studies in the literature that indicate physical activity is neuroprotective. We know one of the areas in the brain affected by physical activity is the hippocampus which is involved in memory. Exercise leads to increased neurogenesis and neuroplasticity in the hippocampus. Other benefits of exercise on the brain include increased blood flow, modulation of inflammatory markers, and increased brain-derived neurotrophic factor (BDNF). The exact definition of adequate exercise varies in the literature. Any activity that is sufficient to increase heart rate and can be sustained for 30-60 minutes is my definition. A basic example would be brisk walking for 30-60 minutes. Physical activity two times a week beginning in middle age is associated with reduced risk of AD. Aerobic exercise is associated with additional cognitive benefits including improved processing speed, attention, and memory in adults with mild cognitive impairment. This recommendation is especially important for ApoE4 carriers, as exercise is associated with reduced amyloid deposits.
Physical activity should be a recommendation for all patients without major health concerns preventing physical activity. The earlier in life a patient begins an exercise routine the better. Some of these studies have looked specifically at starting exercise routines in middle age, but there is no reason to wait. The physical and cognitive benefits of exercise are beneficial regardless of age. It’s much easier to begin training when you are young and healthy. If you build healthy lifestyle habits earlier in life, they are likely to last as you age. Guidelines for regular exercise can be found on the American Heart Association or American College of Sports Medicine websites.
Meditation or mindfulness is a topic that is beginning to get more attention in the medical literature. Chronic stress is believed to effect brain structures involved in memory and may contribute to AD. Psychological stress increases oxidative stress and telomere shortening which could contribute to the neuronal loss seen in AD. Meditation has emerged as a possible way to reduce the stress associated with daily life. The techniques of mindfulness involve directing one’s attention to the present moment to reduce the stress associated with constant thinking and worrying. Randomized controlled trials (RCTs) have shown significant improvements in overall well-being and attention. Improved executive function and reduced inflammatory processes implicated in AD. Additional research and larger RCTs are needed to improve the evidence base. Given the data we currently have there is no reason to not begin mindfulness practices. The techniques are relatively simple and can be learned from a variety of sources. If you are looking for low cost options for learning mindfulness, YouTube has a variety of guided mediations available. I personally like Headspace for beginners because it provides a solid foundation, has a variety of meditation courses, and allows you to track your progress. There is a fee for access to all the courses, but the first 10 sessions are free. Whichever route you choose, spending 10-15 minutes per day practicing mindfulness will lead to a happier and healthier brain.
A great deal of research has been conducted over the last several years on the role of diet with respect to cognition. People with high calorie diets, specifically those high in fat are at higher risk for AD. Traditional western diets high in processed carbohydrates, simple sugars, and saturated fatty acids can impact the hippocampus and memory. When Japan transitioned to western diet the incidence of AD increased. Lower calorie diets with lower saturated fat content are linked to lower oxidative stress, decreased Beta amyloid burden, and decreased inflammation. One diet with proven benefits for preventing AD is the Mediterranean diet. This diet is rich in fruits, vegetables, whole grains, olive oil, and fish. There is moderate intake of low-fat dairy products and low intake of red meat, saturated fats, and sugar. Most of the data supporting the reduce risk of AD with this diet comes from epidemiological studies. Studies have shown combining this diet with exercise further reduces the risk of AD. The Mediterranean diet is associated with better cognitive function and reduced cognitive decline. This is one specific example, but the basic principles can be applied without the need to adhere to one specific named diet.
Some specific foods you may want to add to your diet to prevent AD include fresh berries which have the highest amounts of antioxidants among the fruits. They are also low in calories and work well in diets where weight loss is a goal. Green leafy vegetables and tomatoes have the highest nutritional value when it comes to brain health amongst the vegetables. Foods high in omega-3 fatty acids are considered to be helpful in supporting brain function. The omega-3 fatty acid most important in brain function is docosahexaenoic acid (DHA), which is mostly found in fish. The anti-inflammatory and antioxidant properties of DHA are thought to be responsible for its role in preventing AD. Patients with diagnosed AD are known to have low levels of DHA. Omega-3 fatty acids recommendations from the American Heart association for adults is to eat fish rich in omega-3s two or more times per week. If using a supplement 1-3 grams per day is an adequate dose. Over 3 grams per day, you should consult with your doctor before moving above 3 grams per day.
Finally, curcumin which is derived from turmeric has anti-inflammatory, antioxidant, and anti-amyloid properties. There is low bioavailability of the curcumin lead to mixed results in the initial trials. A new more bioavailable form called Theracumin demonstrated positive results in a randomized double-blind placebo-controlled study on memory, attention, and amyloid plaques in older adults without dementia.
While there is no guarantee that lifestyle modification alone will prevent AD, there are some promising studies indicating it plays a role in the development of this disorder. Most of these interventions are things patients can implement in their lives immediately. They will not only improve cognitive function and lower the risk of developing AD, but it will improve and potential reverse other diseases of lifestyle.
The initial psychiatric interview is the beginning of an important relationship. Many things will be determined in the first encounter by both the patient and the psychiatrist. At times this can feel overwhelming. A large amount of information must be gathered, processed, and incorporated into a cohesive treatment plan. This series of posts is designed to shed some light on the process, and reduce the anxiety associated with undergoing a psychiatric evaluation.
The interview consists of five key parts: (1) introduction, (2) opening, (3) the body, (4) closing, and (5) termination. A good psychiatrist will blend these sections into each other, so it feels more like a conversation than a formally structured interview.
Part 1: The Introduction
This is an important phase and begins as soon as the psychiatrist and patient see each other. The primary goal is to engage the patient and get them comfortable before asking sensitive questions. Like other first encounters the patient will form an impression of the psychiatrist which will shape the rest of the interview and treatment process.
One way to ensure patient comfort is to address anything in the office setting that can be altered prior to starting the evaluation. For example, closing a shade due to light from the window shining directly on the patient’s seat. Another example would be offering a drink of water or tea before starting. A simple gesture of kindness goes a long way in helping the patient feel comfortable in the setting.
The psychiatrist should then proceed with a formal introduction and offer a few details about himself or herself. One fear many patients have is a friend or family member finding out that they are under the care of a psychiatrist. It’s always a good idea to clarify and ensure confidentiality. Confidentiality is strictly maintained with the exception two primary scenarios (may vary by state). If a patient informs the psychiatrist of a plan to kill themselves or someone else, there is a duty to warn and protect the patient.
Once these parts are complete a brief description of how the interview process works is in order.
An example of this interaction may occur as follows:
The purpose of today’s interview is to learn about your concerns and the types of stressors you are dealing with. As the interview progresses, I will get a better idea of the primary concerns. We will then transition to some background questions about your family, medical health, schooling, and any previous psychiatric care you received. At the end of the discussion we can work together on a treatment plan. This process will take approximately one hour. Do you have any questions before we get started?
We want to convey two things to the patient, (1) a sense of understanding about the interview process to reduce fear, and (2) altering the patient to the fact that many questions will be asked, and it will take a fair amount of time.
The structure of the introduction is not set in stone and may be modified. It should take around five to seven minutes to complete.
In the next post we will tackle the opening of the interview process.
All millennial physicians had a lot to process over the last several weeks. The coronavirus rapidly spread across the United States leading to the worst financial crisis since 2008. No generation in history has had to deal with two major events that ravished the economy in a relatively short period of time. It started with the financial crisis of 2008, and now a coronavirus pandemic that once again threatens the financial future of many people. At this point no one knows the full impact this pandemic will have on the economy.
The current crisis presents a number of concerns for young physicians. The primary concern of many recent graduates, or early career physicians is taking care of patients and remaining safe. A big part of what happens to the economy over the next several months depends on the work of public health officials, hospital systems, and healthcare providers.
Understandably, financial well-being is not the primary concern for many. Most physicians make a big financial sacrifice early in life, forgoing the earnings of our early 20’s in favor of education. Once you navigate medical school successfully, you enter another period of low earnings in residency. There is no doubt that our career choice and the multiple financial crises altered the lives of young physicians permanently.
Financial Tips for a Recession
It wasn’t too long ago when I received the first paycheck I ever made as a physician. It was a big moment for me, I received $763.26 for doing the work that I loved. I even have the paycheck framed on my wall. After eight years of not making a single dollar and taking out a six-figure loan to fund my education, I finally felt like this was my time. There were many things I neglected over those eight years that I needed to address. Most of my friends and family who chose different career paths were buying houses, saving for retirement, and not driving an old car. My initial goal was simple, I just wanted to stop worrying about how to pay my monthly bills. Below are several strategies I used over the last three years to save money, pay debt, and improve my financial health.
Living with Family to get a Jump Start
The first choice which helped me immensely was selecting a residency program close to home which allowed me to move back in with parents for the first year. A goal of mine was to practice in the community I grew up in, and when that opportunity presented itself, I could not pass it up. It also allowed me to live rent free for one year to help pay for transportation, build a small emergency fund, and pay off the one private loan I took out for residency applications and travel. I realize this is not possible for everyone and my situation is unique, but if an option like this is available to you, consider it.
Secure Reliable Transportation
I started with selling my old Honda and looking for reliable transportation. I eventually settled on a Honda which I purchased used for $16,500. I know it seems pricy for a person with limited resources, but the investment felt worthwhile due to my expected commutes. I like Honda for their reliability, low cost maintenance, and fuel economy. The other car company that fits into this category is Toyota.
Have a Small emergency Fund
Next, I opened a high interest savings account with the goal of having $1,000 in it for emergencies. I wanted a small amount of cash available to cover any unforeseen expenses.
Develop Good Financial Habits and Protect Your Family
I focused on developing good financial habits, learning to save, and started thinking about how to invest a portion of my earnings in the next few years. Financial education became a big part of my study plan because it’s not taught in any medical school. I also secured own occupation disability insurance, and term life insurance. It’s important to protect yourself and your family in the event you are unable to do your job or pass away unexpectedly. This is even more important with the COVID-19 pandemic.
Housing Is a Major Expense
One of the keys to my success was low cost of living. I made the decision to move out of my parents house 2nd year. This required some significant out of pocket expenses including a security deposit, some furniture, and costs associated with setting up a new place. The biggest impact was related to the monthly rent payment. Although it was reasonable for the location it was still a significant portion of my monthly income. Finding ways to reduce your housing costs may be the single biggest benefit to your financial future.
From all my research, it was clear that index fund investing was the best method and produced reliable returns over time with minimal management on the investors part. The real decision was between opening a personal retirement account like a ROTH IRA or opening an employer sponsored account such as a 401k or 403b. Most advice you will find recommends the ROTH over the employer account given the eventual higher earnings and tax bracket most doctors will be in after completing residency. I have since found that it really depends on your individual situation. If you have a high student debt burden and want to reduce your adjusted gross income, or your employer matches contributions you may want to opt for the 401k or 403b. I settled on the employer-based retirement plan. I was able to select several low-fee index funds and was happy with the options provided. The automatic deductions made the process simple, and helped me reduce my adjusted gross income and thus my student loan payments.
This is a work in progress as the year is ongoing. I’ve been looking at the entire COVID-19 situation in terms of the potential benefits that may arise. If you are still in training or an early career physician, the most important financial asset you have is time. Over the span of a 30-year career the economy will fluctuate, with some bad years and some really great years. Things were bad in 2008, but if you made saving a priority, invested your money wisely, and paid off debt by 2018 you were doing really well. Unlike those who are looking to retire, or are retired we have an opportunity to invest heavily in a down market. I believe it’s a prime opportunity to lay the foundation for your financial future.
We also have the added benefit of some student loan relief which was not an area of focus in 2008. It looks like the economic stimulus will allow for no interest and no payments on direct or federally held loans for the next 6 months. If you are on REPAYE, PAYE, or PSLF you don’t need to do anything to qualify for the payment and interest freeze. It’s refreshing to see the federal government acknowledge the need to provide student loan relief after failing to consider the long term impact it would have in 2008.
We need to prepare ourselves for the next several months and continue to take the necessary steps to secure our financial future. We must believe in our own resiliency and capacity to grow during hardship. We’ve been through a recession before, and this is not likely to be the last.