Category: Eating Disorders

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Nutritional Psychiatry and Wellness

By Anna I. Guerdjikova, PhD, LISW, CCRC
Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program

The connection between health in general and the foods we consume has been known since the dawn of human kind, and Hippocrates is credited with the “Let food be thy medicine” saying. The narrower connection between overall diet quality and common mental disorders, in particular depression and anxiety, is a much newer field and the term “nutritional psychiatry” was not coined until the most recent decade. Initially, the focus of this discipline was on researching single foods or nutrients and their role in mental health. Gradually, it has been recognized that proper nutrition for good mental health is a very complex landscape. What we consume and how it affects us cannot be researched in isolation and what we eat in excess can be as important as what we do not eat enough of.

The growing data in the field of nutritional psychiatry is encouraging. A recent systematic literature review derived a list of antidepressant nutrients linked to the treatment and prevention of depression1. The twelve identified antidepressant nutrients included: folate, iron, long-chain omega-3 fatty acids, magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc. The most nutrient-dense individual animal foods to fight depression were oysters, mussels and seafood, all rich in DHA which helps form strong membranes that easily transport nutrients into brain cells, lowers inflammation and raises serotonin levels. From plant-based foods leafy greens, lettuces, peppers, and cruciferous vegetables received the highest score, suggesting that regularly incorporating those veggies in one’s diet might improve mood dysregulation.

Another study followed up with patients for 12 weeks in a randomized controlled design study to examine efficacy of adjunctive dietary intervention in the treatment of moderate to severe depression2. The intervention consisted of seven individual nutritional sessions to support adherence to the recommended diet, encouraging consumption of the following key food groups: whole grains (5–8 servings per day); vegetables (6 per day); fruit (3 per day), legumes (3–4 per week); low-fat and unsweetened dairy foods (2–3 per day); raw and unsalted nuts (1 per day); fish (at least 2 per week); lean red meats (3–4 per week),chicken (2–3 per week); eggs (up to 6 per week); and olive oil (3 tablespoons per day), while reducing sweets, refined cereals, fried food, fast-food, processed meats and sugary drinks (no more than 3 per week). The group receiving dietary support along with therapy or medication, showed significantly greater improvement in depressive symptoms suggesting dietary improvement may provide an efficacious and accessible treatment strategy for the management of depression.

A recent review summarized data from 20 longitudinal and 21 cross-sectional studies and concluded that adhering to a healthy diet, in particular a traditional Mediterranean diet (meals built around plant-based foods like  vegetables, fruits, herbs, nuts, beans and whole grains with moderate amounts of dairy, poultry,  eggs and seafood), or avoiding a pro-inflammatory diet (deficient in fruits and vegetables and containing excessive amounts of meat, refined grain products, and dessert foods) might confer some protection against depression in observational studies3.

A healthy gut environment (microbiome) supports production of vitamins, helps train the immune system, supports cleansing of the body and helps modulate the nervous system. The microbiome can be influenced by our diet, providing the direct link between the brain and the gut, as 90% of our serotonin receptors are located in the gut. Consuming a diet rich in both prebiotics (the fiber that feeds the probiotics in our gut found in onions, leeks, asparagus, bananas and garlic) and probiotics (good bacteria that are found in fermented foods like sauerkraut, yogurt with active cultures, pickles, kefir, kimchi, kombucha) is recommended for keeping the microbiome well balanced. Probiotics are associated with a significant reduction in depression and anxiety in two recent analyses, reviewing over 30 individual studies4,5. Moreover, overconsumption on ultra-processed food leads to inflammation in the gut and might dysregulate the microbiome, possibly contributing to a plethora of diseases6.

While the field is still working through challenges to identify a clear set of biological pathways and targets that mediate the brain-gut connection, the following few simple recommendations might be helpful as complementary interventions benefiting mild to moderate depression and anxiety:

  • Regulated eating habits (3 meals and 1-2 snacks/day) decrease blood sugar variations and helps stabilize moods
  • Follow a diet comprising mostly of real foods (Mediterranean diet)
  • Probiotic-rich foods and limiting processed food (shopping the “perimeter of the store” preferentially )supports the health of the gut-brain axis and can be beneficial for mood regulation
  1. LaChance LR, Ramsey D. Antidepressant foods: an evidence-based nutrient profiling system for depression. World J Psychiatry. 2018;8:97-104.
  2. Jacka F, O’Neil A, Opie R, et al. A randomized controlled trial of dietary improvement for adults with major depression. BMC Med. 2017;15:23.
  3. Lassale C, Batty GD, Baghdadli A, et al. Healthy dietary indices and risk of depression outcomes; a systematic review and meta-analysis of observational studies. Mol Psychiatry. September 26, 2018
  4. Ruixue Huang, Ke Wang, Jianan Hu  Effect of Probiotics on Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Nutrients 2016 Aug 6;8(8):483
  1. Richard T Liu, Rachel F L Walsh, Ana E Sheehan  Prebiotics and probiotics for depression and anxiety: A systematic review and meta-analysis of controlled clinical trials Neurosci Biobehav Rev,  2019 Jul;102:13-23.
  2. Marit K Zinöcker, Inge A LindsethThe Western Diet-Microbiome-Host Interaction and Its Role in Metabolic Disease Nutrients   2018 Mar 17;10(3):365.

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By Nicole Mori, RN, MSN, APRN-BC
Research Advanced Practice Nurse, Lindner Center of HOPE

Depression is a common mental health complaint.  Although there are effective treatments available, many patients fail to experience satisfactory improvement.  There has been increased interest in nutritional supplements as an adjunct or alternative to medications in the treatment of depression.  This has contributed to the growth of the dietary supplement industry (projected to reach 230 billion by 2026).  Let’s examine the evidence for the dietary supplements that have generated interest in recent years.

Omega-3 fatty acids (EPA/DHA)

A systematic review shows mild-moderate improvement in depressive symptoms, with the best outcomes in studies where omega-3 supplementation is concomitant to standard antidepressant therapy.  There is a great deal of heterogeneity in dosing, duration of treatment and EPA/DHA content.  Products with a high EPA content appear to be more efficacious than other omega-3 supplements.    However, quality of evidence is low due to methodological flaws.  Differences in study design and methodology makes it difficult to analyze data across studies.  Omega-3 supplements have a favorable safety profile and are well tolerated.

 

B group vitamins

Folate- Possible dose dependent response in depression but level of evidence is low.  Although folate is well tolerated, it has been associated with risk for proliferation of carcinogenic cells in the colon.

L-methylfolate-Available as pharmaceutical product FDA approved for depression.  Data shows efficacy at 15mg/d.  Some studies show efficacy as augmentation strategy for depression as comparable to lithium and atypical antipsychotics.  Usually well tolerated with lower risk for proliferation of cancerous cells than folate.

Vitamin D

A 2019 systematic review of clinical trials showed improvement in depression ratings associated with supplementation.  Findings remain tentative due to paucity of studies and methodologic bias.  Vitamin D is a fat-soluble vitamin commonly found in multivitamins and other commercially available products.  In the absence of a deficiency, the recommended dose is not to exceed 600IU/day.

SAM-E (S-Adenosyl methionine)

Clinical trials show mixed results.  A 2016 systematic review suggested SAM-E was no better than placebo.  The low quality of evidence makes it difficult to draw conclusions about efficacy.  There is a need for randomized clinical trials with antidepressant comparators.  SAM-E usually well tolerated but there is a possible risk for inducing mania in patients with bipolar depression.

Tryptophan/5-HTP (5-Hydroxytryptophan)

There are few high quality studies of 5-HTP.  Two depression studies suggest 5-HTP is superior to placebo.  Overall, level of evidence is low.  Possible risk for serotonin syndrome when administered concurrently with SSRI antidepressants.  Maximum recommended dose is 50mg/kg/day.

 

Magnesium and Zinc

There is some positive data from animal studies but evidence for efficacy in humans is low quality. There is no conclusive data on the efficacy of magnesium and zinc as coadjutant therapy in depression.  Zinc and magnesium are common micronutrients and usually well tolerated.

Probiotics

Depression has been associated with poor diet and altered intestinal flora.  Research has shown a relationship between gut health and mental health.  A 2016 metaanalysis of probiotics showed an effect in reducing risk of depression in normal subjects and reduced symptoms in subjects with depression.  The effect was limited to subjects under age 60.  Clinical studies vary greatly in terms of bacterial species, dose, duration of treatment as well as the method of measuring of depressive symptoms.  Probiotic supplements are vastly heterogeneous in terms of species composition and dosage.

There is a need for further research to determine optimal composition, dosage, duration of treatment for efficacy.  Furthermore, it is important to remember that quality of diet is a major determinant in the composition of gut flora.

In conclusion, evidence for the efficacy of dietary supplements in depression remains limited.  Commercially available dietary supplements vary significantly in terms of composition and bioavailability.  Although supplements are well tolerated, it is important to be aware of increased risks for adverse events in some patients.  Supplementation with omega-3 fatty acids as an adjunct to standard antidepressant therapy seems to hold the most promise.   Further research in the area of dietary supplements is needed to determine their role in the management of depression.

For more information about Depression research studies at the Lindner Center of HOPE

call 513-536-0707 or visit https://lindnercenterofhope.org/research/

https://redcap.research.cchmc.org/surveys/?s=YKW8CE4FRF

 

References

Firth J, Teasdale SB, Allott K, et al. The efficacy and safety of nutrient supplements in the treatment of mental disorders: a meta-review of meta-analyses of randomized controlled trials. World Psychiatry. 2019;18(3):308-324. doi:10.1002/wps.20672

Martínez-Cengotitabengoa M, González-Pinto A. Nutritional supplements in depressive disorders. Actas Esp Psiquiatr. 2017;45(Supplement):8-15.

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Binge eating disorder (BED) is the most common eating disorder, with an estimated prevalence of 3% in the US population. It is also the most common eating disorder among men. BED is characterized by regularly recurrent episodes of eating unusual amounts of food within a discrete time frame (usually <2hrs), which are associated with loss of control and significant psychological distress. Unlike people with Bulimia nervosa, those with BED do not engage in purging behaviors (such as fasting, driven exercise or self-induced vomiting). Untreated BED is a risk factor for obesity, metabolic disorders, mental health problems and poor quality of life. Although psychotherapy and medications have demonstrated effectiveness in treating BED symptoms, the vast majority of patients with BED remain undiagnosed and untreated.

Patients with BED face significant barriers to evaluation and treatment. First, there are patient-related barriers such as lack of awareness of BED as a medical condition, where the patient may attribute their loss of control to having no willpower. Moreover, patients may be reluctant to discuss their eating behavior and weight out of shame or fear of being judged. Finally, past experience may lead patients to assume that their primary care provider is unwilling or unable to address their disordered eating. Providers also face challenges in identifying BED in the primary care setting: Some patients with BED may have a normal BMI, which makes providers assume that they do not have an eating disorder. In addition, BED often co-occurs with psychiatric disorders such as depression and anxiety, which can lead to attributing the BED symptoms to the patient’s mental health diagnosis or the effects of psychotropic medications. Finally, lack of knowledge about treatment options and underestimation of the impact of BED on medical conditions, leads many primary care providers to overlook BED as a target for evaluation and treatment.

The reality is that primary care providers have much to offer patients with BED. Screening, education, self-management tools and in some cases, referrals to specialty care or medication. Screening for and treating BED can be advantageous when managing patients with diabetes, where decreasing the frequency of binges can lead to significant improvement in metabolic parameters. A BED diagnosis is useful when selecting psychotropic medications with lesser potential to aggravate binge eating. Finally, diagnosing a patient with BED can alleviate the patient’s distress and stigma. Patients who struggle with BED are often relieved and thankful that they have a treatable medical condition rather than attributing their bingeing to a character flaw and feel empowered and thankful for any help in managing their disorder. Since untreated BED poses a challenge in treating conditions such as diabetes and dyslipidemia, diagnosing and managing BED can benefit all areas of patient health.

Although there are still significant barriers to screening, diagnosis and treatment, primary care providers have the means to improve health outcomes among their patients with binge eating. Primary care is the ideal setting for raising awareness of the problem of binge eating among the general population, to address patient’s disorder eating concerns and start patients on their journey to recovery. First of all, routine procedures such as weighing patients, offer opportunities to ask patients whether they have any concerns about their weight or eating patterns. These questions can also be added to the medical history updates hat patients complete prior to office visits. Routine screening of special populations such as patients with diabetes, those attempting weight loss or receiving psychotropic medication is of great help in managing those comorbidities. The SCOFF questionnaire is a brief screen for eating disorders suitable for primary care*. Providers interested in providing medication management for BED should also screen for psychiatric comorbidities and substance use disorders to guide their medication choices.

In summary, patients with BED are largely undiagnosed and untreated, which complicates the management of their medical and mental health issues. Although access to specialty continues to be a challenge, primary care providers have the means to start patients on their road to recovery and improve overall health outcomes and quality of life.

The Research Institute at the Lindner Center of HOPE is a world leader in Binge eating disorder research. For more information about our current studies, call 513-536-0710.

*The SCOFF questionnaire is available at:
http://cedd.org.au/wordpress/wp-content/uploads/2014/09/The-SCOFF-Questionnaire-SCOFF.pdf

References:
Chao AM, Rajagopalan AV, Tronieri JS, Walsh O, Wadden TA.
Nurs Scholarsh. 2019 Jul;51(4):399-407. doi: 10.1111/jnu.12468. Epub 2019 Mar 1.

Javaras KN, Pope HG, Lalonde JK, et al. Co-occurrence of binge eating disorder with psychiatric and medical disorders. J Clin Psychiatry. 2008;69(2):266-273. doi:10.4088/jcp.v69n021

Nicole Mori RN, MSN, APRN-BC
Nurse Practitioner, Lindner Center of HOPE Disorder Services

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Elizabeth Mariutto, PsyD
Clinical Director of Partial Hospitalization and Intensive Outpatient Adult Eating Disorder Services and Staff Psychologist, Harold C. Schott Foundation Eating Disorders Program, Lindner Center of HOPE

“Every time I try a diet, I do okay for a while, and then I go back to my usual eating.” According to the National Eating Disorders Association, this is an incredibly common phenomenon, as 95% of those who diet regain any weight lost within one to five years. Despite the ineffectiveness of dieting, those that fall under the overweight category on BMI charts are often encouraged to do so by the medical community. Not only is this ineffective, but dieting has been found to be associated with increased binge eating and greater weight gain.

So what is the alternative? Mindful eating.  Research has found that those who struggle with binge eating, diabetes, and/or obesity may benefit from mindful eating. Keep in mind, mindful eating is not recommended for patients in the process of weight restoration or food exposure, specifically for those with Anorexia Nervosa, or those with gastrointestinal symptoms that may complicate hunger and fullness cues.

Author and psychologist Susan Albers defines mindful eating as awareness of the physical aspects of eating, the process of eating, and triggers for mindless eating. Individuals who eat mindfully slow down and take pause in their busy schedules to pay attention to their bodies and cues of hunger and fullness. The emptiness of one’s stomach, irritability, low energy, and difficulty concentrating can all be signs of hunger. When one eats, one should feel full but not stuffed, satisfied yet comfortable. Many who struggle with unhealthy eating have been so disconnected from their bodies that either they do not have awareness of these cues, or they wait until they are famished before eating and eat until they feel as if their stomachs could explode. They may focus on external cues to start and stop eating, such as if others around them are eating, rather than the internal cues of their body. To start the practice of mindful eating, it can be helpful to focus awareness on how long it has been since one has eaten and the content of what one ate at that time. Regular eating should take place within one hour of waking up in the morning, then at three to four hour increments throughout the day. Meals should balance carbohydrates with lipids and protein sources.  Starting with these guidelines can help one’s body self-regulate so that the hunger and fullness cues can kick in.

Mindful eating also distinguishes physical from emotional hunger.  Food has become tied to emotions in our society. People celebrate birthdays by baking a cake, revel in a promotion by going out to dinner, and calm themselves down after a stressful day by getting ice cream.  While all of these can still occur within mindful eating, a mindful eater will be intentional about this, as well as develop other self-soothing strategies. A mindful eater will tune in to the qualities of the foods he or she is choosing and ask him or herself, “Does this taste good? Does this food energize me or make me sluggish? Does my body thrive when I eat this?” A mindful eater will balance cravings with nutrition, allowing oneself to have all foods in moderation. This does not always mean choosing the “healthy” choice, but rather having self-compassion and flexibility around food. Mindless eaters may overeat sweets, chips, or fast food, tell themselves that they are a failure for consuming these items, and fall into hopelessness and despair, only to lead them back towards these foods repeatedly.  In fact, many comment that they do not even enjoy what they are eating. In contrast, a mindful eater may pick up fast food on a road trip, have a handful of chips with a sandwich, or try a coworker’s chocolate chip cookies; however, he or she will savor these items and consume them as part of a well-balanced diet. If one is full, one will stop eating, even if there is food left on the plate.

Lastly, mindful eaters set up an environment for success. They sit down at a table for meals rather than eating in front of the TV or grazing in the pantry. They do a lap at buffets prior to plating their food. They fill their house with diverse foods and ingredients and avoid buying trigger foods in bulk.  While it takes work, many learn to gain control over their eating with the principles of mindful eating.

References:

Albers, S. (2008). Eat, Drink and Be Mindful. Oakland, CA: New Harbinger Publications, Inc.

National Eating Disorders Association (2018). Statistics & Research on Eating Disorders. Retrieved from https://www.nationaleatingdisorders.org/statistics-research-eating-disorders.

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Nicole Mori RN, MSN, APRN-BC
Nurse Practitioner
Lindner Center of HOPE

Obesity is an important comorbidity among psychiatric patients and is associated with increased morbidity and a complicated clinical course.  Many frequently used psychotropic medications can contribute to weight gain, which commonly accompanies adverse metabolic outcomes.  Weight gain is distressing to patients and leads to decreased quality of life and lower adherence.  Psychotropic-mediated weight gain is particularly problematic for patients with bipolar disorder who, regardless of treatment status, experience higher rates of overweight and metabolic abnormalities than the general population.  Patients with bipolar disorder face additional risks for weight gain because the mainstay treatments for bipolar disorder such as mood stabilizers (e.g., Lithium and Valproate) and atypical antipsychotics carry a risk for accelerated weight gain and metabolic disturbances. The effect of many psychotropic medications on histamine, alpha-1 and serotonin 5HT 2A and 5HT 2C receptors has been associated with higher weight gain potential.  In addition, many psychotropic medications can interfere with the activity of leptin, which regulates food intake.  The effects of antipsychotics and mood stabilizers can also lead to dysregulation in lipid biosynthesis, insulin resistance and increased risk for type 2 diabetes.

Strategies for managing weight changes include lifestyle interventions aimed at improving diet and increasing physical activity, selecting medications with a lower weight gain liability and prescribing medications aimed at promoting weight loss or mitigating the weight gain effects of psychotropics.  Selecting medications with lower risk for weight gain or switching medications can be helpful but this may not always be possible due to efficacy considerations.  Studies show that lifestyle modifications can be modestly helpful in mitigating the effects of psychotropic medications on weight, but weight loss is often insufficient and difficult to maintain.

Some medications have been studied and used off label for their potential to attenuate the effects of antipsychotics and mood stabilizers on weight.  Metformin has the most data for efficacy and safety, especially when used in combination with lifestyle modification.  In addition, metformin has shown significant benefits in improving glycemic control and dyslipidemia.  Metformin requires monitoring of renal function and carries a risk for metabolic acidosis (rare) and hypoglycemia.  Gastrointestinal adverse effects associated with metformin (flatulence and diarrhea) can be a barrier to dose escalation and tolerability.  There is some evidence supporting the use of topiramate for mitigating the weight gain effect of psychotropics.  However, rates of discontinuation are high due to adverse events such as dizziness, paresthesia and cognitive impairment.  Norepinephrine reuptake inhibitors have shown a marginal effect on weight gain, and carry a potential for adverse effects on heart rate, blood pressure and psychiatric symptoms, which limits their use.

Although the FDA has approved a handful of new antiobesity medications in the past decade (lorcaserin (Belviq), topiramate/phentermine (Qsymia), bupropion/naltrexone (Contrave) and liraglutide (Saxenda)) there is little research on the efficacy and safety of anti-obesity medications in patients for bipolar disorder.  Orlistat is one of the few FDA-approved medications with clinical trial data for use in psychiatric patients but study results were mixed and the subject population was limited to patients with schizophrenia.  Although orlistat carries a relatively low risk for mood destabilization, it can decrease the absorption of certain medications (including antiepileptics, warfarin and levothyroxine) and is associated with intolerable gastrointestinal side effects (flatulence and incontinence) that lead to discontinuation.  There is no published data on the use of the new antiobesity medications for patients with bipolar disorder.   Most antiobesity medications are combinations of drugs that target the central nervous system and modulate neurotransmitters, raising concerns for risk of destabilization and drug-drug interactions for patients with bipolar disorder.  Liraglutide is the only recently approved medication that primarily targets the gastrointestinal system, and in theory, carries a lower potential for effects on the central nervous system.

There is a need for safe and effective treatments to prevent psychotropic-induced weight gain or enhance weight loss in overweight patients with bipolar disorder. Until research brings new treatments to market, timely detection and management of weight gain and metabolic abnormalities remains the most important intervention to reverse or attenuate these undesirable effects from psychotropic medications.

References

Dent, R., Blackmore, A., Peterson, J., Habib, R., Kay, G. P., Gervais, A., … & Wells, G. (2012). Changes in body weight and psychotropic drugs: a systematic synthesis of the literature. PLoS One, 7(6), e36889.

G Fiedorowicz, J., D Miller, D., R Bishop, J., A Calarge, C., L Ellingrod, V., & G Haynes, W. (2012). Systematic review and meta-analysis of pharmacological interventions for weight gain from antipsychotics and mood stabilizers. Current psychiatry reviews, 8(1), 25-36.

Saunders, K. H., Umashanker, D., Igel, L. I., Kumar, R. B., & Aronne, L. J. (2018). Obesity pharmacotherapy. Medical Clinics, 102(1), 135-148.

The Lindner Center of HOPE is conducting a randomized, placebo-controlled study of Liraglutide in overweight patients with Bipolar disorder.  For information, please call 513-0704 or visit https://is.gd/weightlossbipolar

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By Anna I. Guerdjikova, PhD, LISW, CCRC

Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program

University of Cincinnati, Department of Psychiatry, Research Assistant Professor

We spend about one third of our lives sleeping, yet more than one third of Americans do not get enough sleep. Adults, ages 18-60, are recommended to get between seven to nine hours of sleep each night. The need for sleep varies in children and teenagers, with 13-17 years olds needing eight to ten hours per night for optimal wellness. Getting adequate sleep each night is mandatory for maintaining one’s overall mental and physical health and insufficient sleep is associated with a number of chronic diseases and conditions including diabetes, cardiovascular disease, decreased sex drive, obesity, depression and even increased thoughts of suicide and death. While its exact biological purpose remains unclear, sleep is found to be crucial for proper nerve cell communication and possibly plays a housekeeping role in removing toxins that build up in the brain when awake.

Insomnia is a sleep disorder that can make it hard to fall or to stay asleep, or causes early awakenings and inability to get back to sleep. Insomnia is common (6-10% of population struggles regularly with at least a few insomnia symptoms) but it remains under recognized and under treated. According to recently published guidelines from the American Academy of Sleep Medicine (1), psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia and should be utilized as an initial inter­vention when appropriate and when conditions permit. Cognitive behavioral therapy for insomnia (CBT-I), for example, is a structured program and an effective, non-medication treatment for chronic sleep problems. CBT-I teaches identification of thoughts and behaviors that cause or worsen sleep problems and encourages habits that promote healthy sleep. Some basic techniques used in CBT-I reinforce good sleep hygiene that can be easily implemented if one struggles with poor sleep are described below:

  • “Yes” to fixed bedtime and an awakening time through the week- establishing a consistent sleep routine and allowing for no more than 30min variation, including on weekends, will reteach the body to “get used” to falling asleep at a certain time.
  • “Yes” to sleep rituals -from relaxing stretches or breathing exercises, reading something light, meditating, or taking a hot bath to sitting calmly with a cup of caffeine-free tea, pre-sleep rituals can vary, but are needed to break the connection between all the intensive daily activities and bedtime. The sleep rituals might be equally important for enhancing healthy sleeping in both children and adults.
  • “Yes” to using a sleep diary. Tracking amount and quality of sleep can be a very helpful tool in establishing realistic goals and following progress when working on improving sleep.
  • “Yes” to comfortable bedding, moderate room temperature, limited excess noise and a well ventilated room.
  • “No” to naps: avoiding activities/ taking naps because of tiredness or poor sleep the previous night perpetuates the insomnia issues. If a nap is needed, limiting it to no longer than 30 minutes, before 3pm, is recommended.
  • “No” to caffeine 4-6 hours before bedtime, including caffeinated beverages like tea, many sodas and chocolate. Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime.
  • “No” to exercise before bed. Regular exercise no less than 3h before bedtime promotes better sleep, but exercising shortly before going to bed can increase insomnia issues.
  • “No” to clock-watching and no electronics in the bedroom. Using a cell phone at night can increase depression and lower self-esteem, especially in teenagers.

On note, various smart phone apps that promote sleep hygiene via calming music (ex. Pzizz app), enhance circadian rhythm regulation (ex. Sleep Cycle app), teach meditation (ex. Long deep breathing” app), help with tracking sleep and can be used as a sleep diary (Sleep diary pro app) or even deliver mobile CBT-I support (ex. CBT-i Coach App.) can be helpful in insomnia management.

It takes up to one month before the body will naturally respond to some of the behavioral changes consistent with healthy sleep, thus patience and persistence while “relearning” sound sleep related habits are the key factors in psychological management of insomnia. Occasional restlessness at night can be normal, however if you have tried and failed to improve your sleep using some of the above mentioned strategies, you may like to consider professional help. Besides psychological interventions, an armamentarium of medications approved for insomnia is available and timely diagnosis and proper management of insomnia can significantly improve everyday wellness. Overall quality of life and life satisfaction should not be postponed, especially if symptoms are affecting daily functioning.

 

  1. http://www.aasmnet.org/Resources/ClinicalGuidelines/040515.pdf

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Nicole Mori, RN, MSN, APRN-BC

Research Advanced Practice Nurse, Research Institute at Lindner Center of HOPE

Obesity, defined as a body mass index (BMI) ≥30 mg/kg, remains one of the main contributors to preventable disease and health care costs. It is also associated with increased risk for Type 2 diabetes, cardiovascular disease, and some cancers, in addition to lower quality of life and functional impairment.   Patients with psychiatric illness are 50 percent more likely to be obese than the general population.  The higher rates of obesity are contributing directly and indirectly to the marked reduction in life expectancy among those with mental illness.  In addition to being an important medical comorbidity, obesity has been associated with a more severe course of psychiatric illness, lower health-related quality of life, poor self-esteem, stigma, and discrimination.  Obesity, like mental illness, is a complex, chronic condition requiring long term management.  The treatment of overweight psychiatric patients poses unique challenges and both the psychiatric illness and the weight problem must be targets for treatment in order to achieve optimal outcomes.

The strong relationship between obesity and psychiatric illness is evidenced by the high prevalence of obesity among drug-naïve patients. Commonly-occurring symptoms such as psychomotor retardation, inactivity, hypersomnia, increased appetite, and hyperphagia are thought to contribute to weight gain.  Furthermore, binge eating behavior, eating unusually large amounts of food with a sense of loss of control over eating, is very common in people with psychiatric illness.    Binge eating behavior is a risk factor for obesity, and when present in psychiatrically ill people, is associated with greater psychiatric and medical morbidity.  Lastly, treatment with most mood stabilizers, antipsychotics, and some antidepressants is associated with significant weight gain, which renders them less acceptable to patients and leads to discontinuation.

Weight management poses unique challenges to psychiatric patients. As we have seen, both the behaviors associated with psychiatric illness and the use of certain psychotropic medications, contribute to weight gain.  In addition, the symptoms and cognitive deficits associated with mental illness are a barrier to participation in behavioral weight loss interventions.  Finally, the use of most weight control drugs is limited by their psychiatric side effects and their interactions with psychotropic medications.  Obesity and excessive weight gain place a disproportionate burden on psychiatric patients’ health, complicate adherence to treatment, and reduce quality of life.  Treatment of psychiatric illness needs to include weight management strategies and a greater integration of behavioral and medical care.

Clinicians can help improve outcomes by maintaining a focus on both the psychiatric condition and the weight problem when treating this population. First of all, regular monitoring of psychiatric symptoms should be accompanied by monitoring of weight, BMI, vital signs as well as metabolic lab parameters (e.g., lipids and glucose).  Assessing for binge eating behavior or an eating disorder is important because additional referrals and greater integration of behavioral and medical care may be indicated for patients with disordered eating.

Prescribers can mitigate weight gain associated with psychotropic medications by selecting medications with lower potential for weight and metabolic disturbances whenever possible.   Knowledge of the pharmacology of obesity and eating disorders is helpful in guiding treatment choices and avoiding adverse events.  Some FDA-approved weight-loss agents have antidepressant effects, and some off-label adjunctive medications may be beneficial to depressed patients who binge eat.  Treating mental health patients with FDA-approved weight-loss drugs requires caution due to the potential effects on psychiatric symptoms as well as drug-drug interactions.  For instance, in treating patients with bipolar disorder, medications with lower risk for mood de-stabilization should be used and most medications should be avoided in patients with hypomanic, manic or mixed symptoms.

Although new weight-loss medications have come to market in recent years, there is no research to inform their use in mental health patients.   Clinical trials typically exclude people with a psychiatric illness and those taking psychotropic medication.  Research to find effective weight-control medications that are safe for this population is greatly needed.

 

References

Allison, D. B., Newcomer, J. W., Dunn, A. L., Blumenthal, J. A., Fabricatore, A. N., Daumit, G. L., … & Alpert, J. E. (2009). Obesity among those with mental disorders: a National Institute of Mental Health meeting report.American journal of preventive medicine, 36(4), 341-350.

McElroy, S. L., Crow, S., Biernacka, J. M., Winham, S., Geske, J., Barboza, A. B. C., … & Frye, M. A. (2013). Clinical phenotype of bipolar disorder with comorbid binge eating disorder. Journal of affective disorders, 150(3), 981-986.

McElroy, S. L., Guerdjikova, A. I., Mori, N., & Keck Jr, P. E. (2016). Managing Comorbid Obesity and Depression through Clinical Pharmacotherapies. Expert Opinion on Pharmacotherapy, (just-accepted).

The Research Institute at the Lindner Center of HOPE is conducting a 40 week, placebo-controlled study of liraglutide, a novel weight loss agent, in patients with bipolar disorder with a BMI ≥30 or with a weight-related medical comorbidity and a BMI ≥27. For additional information, contact Anna Guerdjikova @ 513-536-0721. [email protected]

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On October 28, 2015, Dr. Elizabeth Wassenaar, Lindner Center of HOPE Psychiatrist and Williams House Medical Director, joined Lon Woodbury on the Woodbury Report radio show.  Their discussion focused on outlining the benefits of a residential assessment for mental health concerns in adolescents.

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By Scott Bullock, MSW, LISW-S

Lindner Center of HOPE, Clinical Director and Family Therapist Child/Adolescent Services, Harold C. Schott Foundation Eating Disorders Program Clinical Consultant, Cincinnati Children’s Hospital and Medical Center at The Lindner Center of HOPE University of Cincinnati, Department of Psychiatry and Behavioral Neuroscience, Adjunct Instructor

Despite numerous recent advances in the field of brain research, our understanding of the principles that guide the development and operation of the brain and its complex functioning remains elusive. This is particularly true when attempting to understand a multi-faceted illness as anorexia nervosa (AN), however having a comprehensive grasp on the neurobiology on AN brain is mandatory for successful treatment. Thus, with the narrative below, we will be providing some fundamental assumptions about the neurobiology of AN brain, as researched extensively by Dr.W.Kaye.

In AN all body organs, including the brain suffer from malnutrition. Malnutrition affects all parts of the brain and especially the anterior insula. This region acts as the “brain switchboard” assuring that all parts of the brain adequately communicate with each other. The anterior insula plays a key role in the brain’s ability to recognize and process the connection between emotions and cognition and when affected in AN patient, presents with typical symptoms of altered taste, abnormal response to pleasurable foods and body distortions. The neurotransmitters dysregulations in AN are very complex and involve many systems, circuits and brain regions. To date, most research has focused on serotonin function and dopamine/reward systems function that are found to be compromised in AN as briefly outlined below.

Serotonin

Brain imaging studies suggest alterations of 5-HT1A and 5-HT2A receptors and the 5-HT transporterin AN. Dysfunctions of these circuits may affect mood and impulse control as well as the motivating and pleasurable aspects of food consumption leading to a dysphoric mood. In an attempt to reduce their dysphoric mood, the patients engage in dieting and exercise which results in malnourishment of the brain leading to the lowering of tryptophan and steroid hormone metabolism. This then reduces serotonin levels at these critical sites, further increasing dysphoric mood thus perpetuating starvation.This becomes a cyclical action as the patient tries to control their dysphoric mood while driving themselves deeper into the illness.

Dopamine and Reward System

Dopamine system dysfunction might contribute to altered reward and affect, decision-making and executive control, and decreased food ingestion in patients with AN. Dysregulation in this circuit might contribute to patients with AN not being able to correctly act on immediately important tasks but rather focusing on planning and remote consequences.

In conclusion, this is just a glimpse of the complex function of the Anorexic brain. Genetics, puberty, stress, trauma, cultural and social expectations as well as the temperament of the individual also play important roles in the development of AN in adolescents.

 

Ref: Kaye, Walter H., Fudge, Julie L., and Paulus, Martin. New Insights into symptoms and neurocircuit function of Anorexia Nervosa. Nature Reviews/ Neuroscience. 10, 573-587 (2009)

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The goal of National Eating Disorders Awareness Week  is to put the spotlight on the seriousness of eating disorders and to improve public understanding of their causes, triggers and treatments. By increasing awareness and access to resources, we can encourage early detection and intervention, which can improve the likelihood of full recovery for millions.

This year the National Eating Disorders Association is focusing on the importance of early intervention and recognizing the diverse experiences of people personally affected by disordered eating. Too often, signs and symptoms are overlooked as insignificant behaviors when in fact many of these are early warning signs of eating disorders.

If someone is exhibiting signs or thoughts of struggling with an eating disorder, intervening during the early stages of development can significantly increase the likelihood of preventing the onset of a full-blown eating disorder. It also leads to greater chances of a full recovery. It can prevent years of struggle and can even save lives. A key goal of NEDAwareness Week is to direct individuals to a free online screening for eating disorders at MyBodyScreening.org.

Educating yourself and those around you about eating disorders is a great way to get involved. Correcting myths and spreading awareness about the facts are important steps to eating disorder prevention. Visit NEDAwareness.org to review information about how eating disorders develop and why they are so complex, as well as finding out how you can be proactive in recognizing contributing factors and being a part of the fight against these life threatening illnesses.

While eating disorders are serious, potentially life-threatening illnesses, help is available and recovery is possible. It is important for those affected, and their loved ones, to remember that they are not alone in their struggle. Others have recovered and are now living healthy fulfilling lives. Let the National Eating Disorders Association (NEDA) be a part of your support network. NEDA has information and resources available via our website and helpline: www.NationalEatingDisorders.org, NEDA Helpline: 800-931-2237.