Nutritional medicine as mainstream in psychiatry

[Dr. Mr. T]

Was wondering how nutrition figures into the practices of the docs on here. Do people make specific dietary recommendations? Supplements?

How does nutrition figure into residency training?

http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00051-0/fulltext

Summary
Psychiatry is at an important juncture, with the current pharmacologically focused model having achieved modest benefits in addressing the burden of poor mental health worldwide. Although the determinants of mental health are complex, the emerging and compelling evidence for nutrition as a crucial factor in the high prevalence and incidence of mental disorders suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology. Evidence is steadily growing for the relation between dietary quality (and potential nutritional deficiencies) and mental health, and for the select use of nutrient-based supplements to address deficiencies, or as monotherapies or augmentation therapies. We present a viewpoint from an international collaboration of academics (members of the International Society for Nutritional Psychiatry Research), in which we provide a context and overview of the current evidence in this emerging field of research, and discuss the future direction. We advocate recognition of diet and nutrition as central determinants of both physical and mental health.

Jump to SectionIntroductionCurrent evidenceFuture directionConclusions

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[wolfvgang22]

Overall health is important for mental health, obviously. Overall health has a lot to do with nutrition. I encourage all patients to try to eat right and get some exercise, just as any physician should.

 

[birchswing]

I'm a patient and my psychiatrist is particularly interested in prescription supplements such as Vayarin and Deplin.

She is the exception, though, and she doesn't touch on the larger picture. I haven't ever had a psychiatrist tell me to eat well or exercise, for example.

There is good research on fish oil's efficacy and on the benefit of trace amounts of lithium naturally occurring in drinking water.

I guess it's sort of considered self-evident that exercise and good eating are beneficial and because there is such limited time in appointments doctors don't mention it. But I do think there is a benefit in "prescribing" it. Exercise and diet sort of become like these throwaway ideas, like "Yeah, yeah, I know about that, but what's the actual answer." It seems like no matter how emphasized they are, they're not flashy enough somehow, and I think for that reason codifying them as specific, on-the-record treatments makes sense.

 

[whopper]

I'm one of the only docs I know that tells patients to eat healthy. (We all had a debate about my vegetarian diet idea). But in all seriousness, I tell even outpatients doing well to take omega 3s, reduce red meat intake, make sure they don't have a vitamin D deficiency (the more I look into this the more I find most of my patients have one), and avoid processed carbs.

On the inpatient unit last week a patient eating breakfast dumped an entire packet of syrup into her cereal with her whole milk. This is terrible. So many docs divorce the importance of a healthy diet. High cholesterol-statin, high BP-antihypertensive, etc.
Decreasing red meat could reduce inflammation, fish oil could augment existing treatments and prevent illness, exercise works wonders.

I'm also the only psychiatrist I know of telling patients to consider SAM-E, N-acetylcysteine, and SAD lamps. Why I don't know. The data on all of these practices are solid. Actually I do know the answer. There's no drug rep pushing those.

 

[heyjack70]

I'm one of the only docs I know that tells patients to eat healthy. (We all had a debate about my vegetarian diet idea). But in all seriousness, I tell even outpatients doing well to take omega 3s, reduce red meat intake, make sure they don't have a vitamin D deficiency (the more I look into this the more I find most of my patients have one), and avoid processed carbs.

On the inpatient unit last week a patient eating breakfast dumped an entire packet of syrup into her cereal with her whole milk. This is terrible. So many docs divorce the importance of a healthy diet. High cholesterol-statin, high BP-antihypertensive, etc.
Decreasing red meat could reduce inflammation, fish oil could augment existing treatments and prevent illness, exercise works wonders.

I'm also the only psychiatrist I know of telling patients to consider SAM-E, N-acetylcysteine, and SAD lamps. Why I don't know. The data on all of these practices are solid. Actually I do know the answer. There's no drug rep pushing those.

And lack of formal education. I know it's a weak excuse, but how many had medical school classes really covering these topics. And who had attendings modelling this type of care. It's our job to do this...

 

[wolfvgang22]

And lack of formal education. I know it's a weak excuse, but how many had medical school classes really covering these topics. And who had attendings modelling this type of care. It's our job to do this...

I got a lot of education regarding nutrition during my cardiology rotation. I do think that pursuing education on nutrition is part of what professional physicians ought to do to improve their practices. I'm not sure if a whole course about nutrition is necessary in the basic sciences portion of med school. It's worth thinking about.

 

[Information Underload]

I see nutritional consultation as pretty essential in my child psych gig. A lot of times it's an in-roads into further treatment. Honestly, I've seen maybe 2 patients who have shown massive clinical improvement with dietary modification. Most ADHD kids get improvement by cutting simple carbs. Rarely I see someone who gets better with red food dye restriction. More frequently, I see occasional benefits with omega 3s.

That said, I see countless parents terrified by stimulants who want to try the naturopathic route first, so I send them down that road, knowing full-well they're 99% of the time going to come back begging me for some Adderall or Ritalin. 🙂 It's okay. If it helps a parent feel better about treating their kid, I'm all for it.

With my eating disordered patients or especially with perfectionistic girls, the emphasis on healthful nutrition including lean meats, clean carbs, and the like is pretty vital. The emphasis is on moving to healthful lifestyles and pro-social activities. It's also a nice avenue to begin coming after substance usage.

I'm also regularly screening for and correction low 25 OH Vitamin D and low ferritin levels in depressed patients.

 

[skunky386]

Fellowships in integrative family medicine accross the county provide training for this, as well as psychiatry residency programs in Arizona, California, and Oregon which are more open to such integrative approaches in psychiatry.

Such approaches likely won't have much of a perceptible impact upon a low-functioning patient, though for your typical worried-well depressed patient, child with mild or moderate ADD, etc, they can be fantastic alternatives to prescription medication.

Things integrative psychiatrists do in addition to the standard of care include testing and targeting the upper range of normal for vit d, b6 and 12, subacute hypothyroidism, testosterone, rbc-magnesium, zinc, MTHFR testing, celiacs, glabellar botox, etc.

The issue is that while yes, you may uncover something with all this testing and therapy which can definitely help patients, and I've seen it happen a number of times (lots of subacute hypothyroidism with satisfied patients, and low testosterone in those who don't complain of a low libido and have a pretty dramatic response to testosterone therapy), the yield is often lower than you might like.

Integrative psychiatrists tend to have cash-only practices in high-income areas, and some of the tests and treatments are not be covered by insurance yet unless you have a good insurance plan. Furthermore, the time spent with patients in psychoeducation and treatment planning is more intensive than what an insurance company might typically support.

Integrative psychiatry is a growing niche, and there is some talk among the body of integrative psychiatrists in practice to form a national organization akin to ACAP, AAPL, APM, etc.

 

[wolfvgang22]

Having done residency in one of the states you mention...what?? I didn't find it any more "integrative". Lol

 

[MacDonaldTriad]

There is a huge difference between teaching people to eat a balanced diet, and recommending mega vitamin therapies. There may be something to essential fatty acids, but no one has shown health benefits to vitamin supplements unless you are vitamin deficient of course. With all of this emphasis on evidence based medicine, let’s be clear that “nutrition” does not equal herbal life purchases.

 

[skunky386]

Having done residency in one of the states you mention...what?? I didn't find it any more "integrative". Lol

I guess I should be a more program specific...University of Arizona in Tucson is the largest hub integrative psychiatry, really neat stuff is happening there from both a research and clinical practice standpoint. Second is Good Samaritan in Corvallis, OR and to a much lesser extent OHSU in Portland, OR. Harvard has a small following, though primarily research-based and not clinically implemented like these others. In California UCLA-KERN in Bakersfield has a faculty-member who is amazing with integrative psychiatry in treatment-resistant depression and other mood disorders. Loma Linda also comes to mind. UCSF as well (http://www.ucsfhealth.org/treatments/integrative_psychiatry/)

Another to think about is University of Wisconsin given their strong fellowship in integrative family medicine, though from a psychiatry perspective I'm unaware of any training they offer.

It's a tough area to practice in...given that the "standard of care" for integrative psychiatry is different than that of conventional psychiatry, and that there is no official american society for integrative psychiatry as of yet to back you up, you put yourself at a high legal liability in this practice setting without the proper know-how of how to safely incorporate integrative and conventional practices.

 

[F0nzie]

This thread is making me think about Doritos.

 

[Indodo]

What kind of doritos?

 

[Shikima]

Psychodyamically, how are you relating to the Doritos?

 

[F0nzie]

Buffalo ranch but they don't make those anymore. Shikima is on to something...

 

[splik]

Psychodyamically, how are you relating to the Doritos?

he needs to do some free associations with doritos and see how they remind him of his mother's vagina

 

[MacDonaldTriad]

Hummm.... Doritos. The name derives from Spanish doradito, meaning "little golden thing" or "little golden boy". Maybe it is significant that they are made by Frito-Lay... Good thing your mother's you know what is labled "No(t)cho(r) Cheese.

 

[Shikima]

he needs to do some free associations with doritos and see how they remind him of his mother's vagina

🤔