Podcast: Understanding the Link Between Physical and Mental Health

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hello, folks. Good morning, good afternoon, good evening. Wherever you are joining us from, and whatever time you’re joining us, thanks for joining us today to chat about the intersection of physical and mental health.

I’d like to introduce myself. I’m Jenn Kearney. And I’m a digital communications manager for McLean Hospital. And I’m joined today by Dr. Chris Palmer.

And it’s been determined over heaps of research that physical activity, good nutrition, and a quality night’s sleep can actually really improve how we feel and can help manage the symptoms of a bunch of health conditions.

And it sounds a little prescriptive and it turns out that a lot of doctors are recommending we start with these basics to be in better overall health. But on the other hand, poor physical health, including some chronic physical conditions that can manifest in pain, lethargy, et cetera, can really directly impact our state of mind.

So today, Dr. Palmer and I are going to talk about how we can better understand the link between the brain and the body and how we can incorporate positive mental health practices into both our day-to-day lives and how we treat our health conditions.

We’ll also talk about some strategies to support our health journeys, whether it’s our own personal ones or supporting our friends and family on their own health journeys. And we’ll talk about how we can just feel better physically and mentally overall.

So I’d like to introduce Chris before I start barging him with questions. Dr. Palmer is internationally known for pioneering the use of the ketogenic diet in psychiatry, especially treatment-resistant cases of both mood and psychotic disorders.

And currently he’s serving as the director of the Department of Postgraduate and Continuing Education here at McLean Hospital. So, Chris, thank you so much for being a frequent flyer. I love having you on the webinars to chat about all things physical and mental health.

We’ve talked a ton about diet and exercise before. So I’m really looking forward to having this chat with you today. I wanted to get started by asking you, can you talk some about the connection and relationship between the mind and the body?

Chris: Yeah, so this is a huge topic. And I could talk for hours and hours on this topic. I think to at least get us started, there are several fields in mental health but also in the medical field in general that have looked at this relationship, and some of them are thousands of years old.

So there’s a whole field of medicine often referred to as mind-body medicine that really looks at the connection between what’s happening with people mentally and what’s happening with them physically.

And that field of medicine as a rule of thumb is more interested in physical disorders. So things like heart attacks, strokes, pain disorders, other things. And they are focused on what different mental states are, or more commonly, they focus on stress, what stress can do to those disorders.

So a lot of those clinicians tend to be primary care docs or other kind of doctors or practitioners who are focused on physical disorders. And they are interested in the connection between what stress and relationships and other things can do to that.

But then there’s a whole other field of medicine looking at people with mental health problems or mental illness and looking at the physical manifestations of their illnesses. And we have long known that people with mental illness have significantly higher rates of numerous physical disorders.

So it can be gastrointestinal disorders. A lot of these are kind of vague disorders too, for which we don’t really have good objective tests. We say, yes, you’ve got this. But there are things like irritable bowel syndrome where people can get bouts of diarrhea or constipation. They can get cramping, pain.

They include things like migraine headaches, diagnoses like chronic fatigue syndrome or fibromyalgia, but all sorts of disorders.

And so there’s a whole group of mental health professionals that sometimes specialize in those disorders and primary care docs are, as a rule of thumb, unfortunately, primary care docs don’t like these patients. They don’t like people with those diagnoses and those labels.

And they think that they are just mental, that they have a mental problem. And that’s what that is. There’s really nothing wrong with their GI tract. There’s really nothing wrong with their muscles. They don’t really have pain. They just think they have pain. It’s all in their head.

And so they send them to a mental health professional to describe antidepressants or antipsychotics or just prescribe them something, and make them stop complaining. It’s interesting, because there’s one syndrome in particular that a lot of people have heard of.

The romanticized version of it is called broken heart syndrome. And it’s a real thing. It’s got this Japanese name takotsubo syndrome where when people have highly stressful or traumatic losses or events happen in their life, they can actually die of a heart attack.

And this happens in the most romanticized version of it are couples that have been married 40-50 years, and one person dies, and within a year, the other person has a heart attack. And a lot of people will say, well, he or she just lost the will to live, something happened.

And it turns out that that’s not just some mythical romanticized thing. It’s actually a real thing that the medical profession recognizes. You can actually die of a heart attack from a mental state. But I’ll stop there.

Jenn: So I wanted to ask, ‘cause there are a lot of folks who are joining us who are curious about the connection between chronic illness and mental health. What exactly is that relationship like? And can those two things actually feed off of one another?

Chris: So that is a really important question. One that I’ve been particularly interested for the last several years. And there’s no question that people with chronic medical conditions are much more likely to have mental illnesses or symptoms of mental illness.

And people with mental illnesses are much more likely to already have or newly develop chronic medical disorders. And they fit into several different categories. The first category I’ll put in the metabolic category.

So we know that people with mental illness are much more likely to become overweight or obese, but it turns out the other way around also works. People who start off being overweight or obese are actually much more likely to develop a mental disorder. Same goes with diabetes.

And that connection we’ve known about since the 1800s, that diabetes and mental illness seem to run in the same families. And again, if you have a mental illness, you’re much more likely to develop diabetes.

But if you have diabetes, you’re much more likely to develop a mental illness. And which ones? Well, depression is the most commonly studied one. So people who have diabetes are twice as likely to develop clinical depression, but when they get it, it lasts four times longer in them than it does in people who don’t have diabetes.

But people with schizophrenia are actually three times more likely to develop diabetes. And interestingly either illness can make the other one worse.

And what I mean by that is that if you have somebody who has diabetes and a kind of chronic low-grade depression, if their depression starts getting worse, their blood sugars actually start getting worse at the same time. And vice versa.

If you have that same person and they start binge eating, let’s say it’s Thanksgiving. And they just imbibe on too many sweets and treats, that that could actually make their clinical depression worse.

Same goes for cardiovascular disease. People with cardiovascular disease are much more likely to develop clinical depression. People with mental disorders are much more likely to develop cardiovascular disease.

We can go to other illnesses like the neurodegenerative disorders: Alzheimer’s disease and Parkinson’s disease. If you have chronic depression, you’re over twice as likely to develop either one of those, Alzheimer’s or Parkinson’s later in life. If you have schizophrenia, the statistics are pretty staggering.

So most people with schizophrenia don’t live very long. Their lives are reduced significantly. And I’ll come back to that in just a sec. But if you do have schizophrenia and you happen to make it to age 66, you are 20 times more likely to have early onset Alzheimer’s disease compared to people who don’t. And lots of other illnesses.

It turns out that as a broad rule of thumb, that people with chronic mental disorders appear to be aging at a faster rate than people who don’t have mental illness. And we can measure this in a lot of different ways.

We can measure this through levels of inflammation. We can measure it through the ends of your chromosomes. These things called telomeres, which are associated with how fast you’re aging.

There’ve been several studies that have looked at telomere length in people with chronic mental illness including depression, bipolar disorder, schizophrenia. And they are aging more rapidly.

People with mental disorders are aging more rapidly than people without mental disorders. Levels of inflammation tend to be higher in people with mental illness.

And in fact, all of this translates into some really sobering kind of realities, which is that if you have a mental illness, whether it’s chronic or not, you have a mental illness, you are more likely to die early than somebody who doesn’t have a mental illness.

And this is across the board for all mental disorders. It includes the severe ones that people commonly refer to as the severe or serious mental disorders. Things like schizophrenia, bipolar disorder, chronic depression, but it also includes things like attention deficit disorder, anxiety disorders, personality disorders, all of them.

And on average, in one really large study of over, I think, seven million people, they found that, on average, men lose about 10 years of life and women lose about seven years of life if they have a mental illness. I will stop there with that sad statistic.

Jenn: I feel like I’m like, well, that’s it. Thanks for joining. So I’m curious about, you have alluded a little bit to people who tend to like over-indulge, so on and so forth. They don’t sleep well, et cetera, tend to end up having some chronic conditions and/or worse mental health outcomes.

So have there been really proven relationships between poor continuous self-care and having a worse mental health outcome?

Chris: So that is the million-dollar question. And really the kind of the real question behind that question is why? So why does this happen?

Why do people with mental disorders have higher rates of chronic medical disorders and medical conditions? And why do people with mental disorders die earlier death? And there’s a lot of controversy in answering that question.

So there are two primary reasons that most people go with. And I’m just going to say them and then I will tell you what I think. The two primary reasons given are, number one, the one that you kind of alluded to, which is if you have a mental illness, you’re probably just not doing a very good job taking care of yourself.

And maybe that’s because of your mental illness. People with depression or schizophrenia have a lack of motivation. They have a lack of energy. They don’t feel well. They lose their confidence.

So guess what? That means they’re staying home more often. Means maybe they’re not exercising. Maybe they’re overeating. Maybe they’re stress eating or comfort eating. We know that people with mental illnesses are much more likely to use and abuse substances.

That includes tobacco in any form: vaping, smoking, chewing, but it includes marijuana use. It includes alcohol use, it includes recreational drug use.

And we know that people who use those substances, all of them across the board, if you use those substances on a regular basis, it’s not good for your health. And that’s going to take a toll on your physical health and maybe even your lifespan.

So that is probably one of the most predominant theories out there. A close, another one, which depending on the person, it can be number one or number two, the other one is that the treatments that we’re giving to people with mental illnesses are actually causing these problems.

So antipsychotics, mood stabilizers in particular, we know with certainty that they cause weight gain. They can actually cause diabetes. They increase your blood sugar. They increase your insulin levels. This is all on the package insert. I’m not saying anything inflammatory. I’m just saying, it’s kind of inflammatory, isn’t it? But I’m just-

Jenn: You’re just reading the fine print out loud.

Chris: I’m just speaking the truth. And every clinician knows this. And any clinician who denies this, I would run like crazy from that clinician because that clinician clearly is in denial and doesn’t even have common sense.

And every patient who has taken one of these medications pretty much without fail, knows it to be true. And these side effects are not a side effect of willpower. They are not a side effect of laziness. The side effect is not to make people lazy slobs.

The side effect is profoundly influencing hormones and metabolism and other things in your body that make it next to impossible to not gain weight, to not develop pre-diabetes or diabetes.

And those are the two reasons largely given that it must be one of those. It’s either people with mental illness are unmotivated and depressed because that’s what mental illness is. And so of course they’re not taking care of themselves or maybe it’s the treatments we’re putting them on and that’s what’s causing it.

So there’s no doubt that both of those things are true. Both of those things have truth in them. There’s zero doubt in my mind. And they’re kind of common sense. They’re pretty obvious, that those things hold truth.

I actually believe that it’s a lot more complicated than those two explanations. I actually think that some of the mechanisms that are causing mental illness are actually some of the same exact mechanisms that are causing these other disorders.

And so we know this from some studies in the last 5-10 years in particular. We know this from studies of people with first episode psychosis. So people who come into the emergency room with a new onset psychotic disorder. They haven’t received one pill yet.

We know that in some of those studies, they’ve actually taken blood or even done brain scans on some of those people before they even get one pill, and they already show signs of pre-diabetes or diabetes, even though most of them are a normal weight.

So most of them are not overweight or obese. They simply developed a psychotic disorder, but already they’re showing signs of pre-diabetes and diabetes.

And then when we give them the pills, that’s just adding gasoline to the fire, and we’re just making an already brewing bad situation worse. As I said, this connection between diabetes and mental illness actually dates back to the 1800s, long before we had antipsychotic medications.

And psychiatrists and neurologists even back then kind of noticed that these disorders run in the same families and people with these mental illnesses were developing diabetes at much higher rates.

And so there’s a lot to these connections and it’s these connections between all of these disorders that I’m most interested in, because I think they actually hold really important clues to big fundamental questions such as what causes mental illness.

Jenn: So if somebody is struggling with their mental health and it has a relationship to a physical issue that’s manifesting, which one do you start treatment on first?

The physical symptoms or the mental symptoms or is there the third option of having them be successfully treated at the same time?

Chris: I actually think you have to at least talk about them at the same time.

I really do think these relationships go in both directions. And so if you gave me, like if you said, Chris Palmer, can you do an experiment on a human being? And let’s say I get to be some evil, awful scientist who gets to torture people and do all sorts of unethical things to them.

But if somebody came to me and said, under those parameters, could you make a really thin fit athlete who is mentally healthy, could you make that person overweight, diabetic and mentally ill?

I would say, yes, I could. And the place I would start is I would put that person on corticosteroids, medications like prednisone. And I would also go ahead, just to add insult to injury, and put them on massive doses of antipsychotic medications.

And there is zero doubt in my mind, zero doubt in my mind that that person, no matter how disciplined, no matter how wonderful and admirable that person is, there is zero doubt in my mind that person would gain weight, a tremendous amount of weight.

That person’s eating habits would change. This person would start eating more junk food, even beyond his or her control. They would just, within two months, I can almost guarantee it, because if they continued eating their regular normal healthy diet, it would quickly become unsatisfying.

It wouldn’t fill them up. They would feel constantly hungry. And the only thing that would hit the spot or the thing that would most easily hit the spot, and get them to at least feel satisfied or kind of full, would be very high-calorie, high-carbohydrate junk food. And that would make them feel better.

People can only torture themselves with hunger, extreme hunger for so long before they have to give in. And they’re just like, okay, I’ve had an awful day. I can’t take it anymore. I don’t care about my health right now. I just need to stop feeling hungry. I need to not feel famished.

And so if these medications are doing that to your brain and your body, almost everybody is going to give in. And then if I want to make this person psychiatrically ill, more than likely they will become psych... they will start developing psychiatric symptoms, just taking those two sets of medications.

They will start developing probably depression. But with the corticosteroid, with the prednisone, they’re actually more likely to become manic, but they will get something almost certainly.

And then if they don’t, if you give me three or four months on these high doses of both medicines, if I really want to like torture them and make sure they’re mentally ill or have some mental illness, I would just stop them cold turkey.

I would stop those therapeutic medications cold turkey and we would see what happens. And guess what? I can almost guarantee you, they would develop symptoms of a mental illness. And that kind of, in my mind, outlines that these are physiological processes that are having a direct effect on the brain and the body.

And if I can manipulate them in people in those ways, and I’m not an evil torture person, but as a psychiatrist who has prescribed these medicines to people for 25 years, including really fit athletes, marathon runners, and others, and then I just watched them time and again, and again, I watched them over the next six months, gain 50 pounds, 75 pounds.

Now they can’t run anymore. Now they can’t really even exercise anymore. Now they come in and tell me, “Oh my God, I don’t know what’s come over me. I’m eating junk food at night. And I can’t help myself. I can’t believe, like what’s happened to me? I never did this before. What’s going on?”

They don’t always see it as the medication, because it might take a month or two for that to kick in. I see it as the medication. And I explain it to them that like, “This isn’t your fault. This is what the medicine is doing.”

But the opposite works as well. That if I took somebody who is really fit and athletic and I simply mentally tortured them, I made sure everybody in their life bullied and teased them. I made sure that all of their friends and family kind of abandoned them.

Just fake it, like just, but really fake it. Don’t clue the person in that this is just a joke. And if everybody in your life starts turning on you and abandoning you and making fun of you, you will suffer.

You will suffer tremendously, no matter how resilient you are. Because we’re hardwired that way. And those are, a lot of people think of those as mental things. And they are mental things. ‘Cause again, this is just the joke, like we’re just playing a joke on someone for one week.

We’re going to make all their friends and family completely turn on them. And nobody’s going to give away the joke. That person is going to be tortured. That person is going to be tormented. And that is going to take a toll on their sleep. It’s probably going to change their appetite.

A lot of their behaviors are going to change. They’re going to have a severe stress response and that is going to start leading to anxiety symptoms, depressive symptoms, and possibly even worse.

Jenn: So if your body is having like an adverse reaction to a medication, say for example, you’re put on a mood stabilizer and you have manic symptoms, you gain a lot of weight.

If you stop the medication, does the physical manifestation go away? So like do you become less manic? Do you lose that weight? What does that look like on the other side?

Chris: It’s a great question. And the sad reality is that for some people, for some lucky people, which is a minority of patients, it does seem to go away. And it just, you can kind of achieve your old set point weight.

And so if a medication made you gain 50 pounds, maybe you’ll lose ideally 50 pounds. For the majority of people, that’s not the way it works out.

For the majority of people, the way it works out is that once you’ve gained this weight, even if you slowly, safely taper off that medication and stop it in a medically safe way, and even if you’ve now been off of it for six months or a year, it has changed your metabolism, is the way that I put it.

And it seems to have changed it in a lasting way. Now that doesn’t mean it’s hopeless, ‘cause I don’t want to, so what I would say is that your metabolism has been injured by exposure to that medication. That’s the way I would phrase it.

You can repair that injury, but it’s going to take work on your part to repair it. And unfortunately, that’s really unfair. It’s not just, I can get off the medicine, and then everything will go back to normal. No. Things have been damaged in your body.

And as a result of that exposure, things have been damaged. And the easier, the more scientific way to put it is you have had inflammatory reactions. You have had epigenetic changes, so changes in your gene expression. You have had hormonal changes. You’ve had changes in your gut microbiome.

You’ve had all these kind of changes in response to you gaining weight. And once you’ve removed that medication, those changes don’t automatically just reverse. So you have to kind of go out of your way now to work at trying to reverse those changes and get your old health status back.

Jenn: Out of curiosity, does the pain that we feel physically from a physical ailment use the same neural pathway as the pain that we feel emotionally?

Chris: It’s a great question. And there are definitely connections. There’ve been several studies identifying different brain pathways that do overlap.

So they’re not at all, they’re not completely identical, obviously, because if I feel depressed versus if I feel a burning sensation in my foot, I know there’s a very profound difference between those.

So for the most part, different brain regions and sensation, sensory pathways and others are affected, but there is overlap between physical pain and emotional pain. And they, in some ways, do take a similar toll or at least a related toll on your health.

Jenn: We’ve had a few folks write in expressing GI issues as a result of an anxiety disorder. Do you have any suggestions on how they can address these issues while in treatment for anxiety?

Chris: It’s a great question. It’s hard to give a one-size-fits-all answer, unfortunately, because GI problems can run the gamut. I mean, we could be talking about pain or discomfort.

We could be talking about a bloated feeling. We could be talking about diarrhea. We could be talking about constipation. Obviously diarrhea and constipation are polar opposites. And the treatment for one might be very different than the treatment for the other. Although some of the treatments might overlap.

As a rule of thumb, I would say, yes. You absolutely should be targeting those GI symptoms. You shouldn’t ignore them and you shouldn’t let your doctor or healthcare professional, therapist, or other, dismiss it as though it doesn’t matter.

Because I’m here to tell you whether you like it or not, and whether your healthcare provider likes it or not, I’m here to tell you it actually really does matter. It is a legitimate thing. Your body is not working right. Plain and simple.

So the way that I usually look at mental illness at the end of the day, like I don’t think stress reactions are a mental illness. I don’t think if somebody really close to me dies and I get depressed for one week after that, I don’t consider that a mental illness myself. I call that grief.

So I want to be clear. I think there are, we all have mental experiences and mental reactions to normal life events. I don’t think those are mental illnesses. I think people still need support and help to get through those things, especially if they’re really traumatic and devastating.

They absolutely need help and support, but their brain’s not working improperly or incorrectly. Their body’s not doing anything disordered. Their body’s doing precisely what it’s supposed to be doing.

And I usually look at a mental illness as a time when the brain is actually doing something that it’s really not supposed to be doing. Or vice versa, it’s not doing something that it’s supposed to be doing.

So if I’m supposed to remember something, and I can’t remember something, that’s a problem. That’s a symptom of an illness. If I’m having a panic attack for no reason out of the blue, that’s an illness. My brain’s not really supposed to be causing me to have a panic attack right now.

But for some reason it’s going off when I don’t want it to go off. If your GI tract is having similar symptoms, if your GI tract is causing pain or discomfort or diarrhea or constipation for no good reason, that’s a problem. And ignoring that problem is actually not going to be helpful.

And I would actually argue that if you look at the statistics, if you look at the data, the longitudinal data, it suggests that if you don’t get those symptoms under control, you’re going to have worse health outcomes than other people.

The more diagnoses you have that go unaddressed or untreated, the worse your health prognosis. And so I do think it’s really important to take symptoms seriously and try to come to some answer.

But again, I would encourage you to work with a healthcare practitioner who is willing to take those symptoms seriously. If they’re brushing them off and just saying, oh, you just have anxiety, just take some deep breaths and that should stop your diarrhea.

I would go find somebody else myself. I don’t need somebody telling me to take deep breaths to stop diarrhea. That’s not really going to help.

Jenn: So you’ve tee, I can’t believe how well you teed me up for the next question. Someone wrote in saying that they’ve had problems finding doctors who are able to spend time with me to help them learn and better understand their condition.

Are they expecting too much? And how can they approach their providers about it?

Chris: So you just heard me. I would say you’re not expecting too much at all. How do you find a provider that can live up to my expectations?

Well, that’s challenging in today’s healthcare environment. I can tell you that. There are providers out there. I will just say that. There are providers out there who are very interested in this stuff.

The providers that are much more likely to take these things seriously and spend time with you are providers who use the label mind-body medicine practitioners or psychosomatic practitioners, functional medicine, complimentary, integrative physicians.

Those are a lot of the labels to think about and look for because most of those practitioners believe in most of what I’ve already said. And they do take these other conditions and other symptoms quite seriously.

And they will work with you to try to find a solution. Finding a solution isn’t always easy and it’s not always just, here’s a pill. And that’s going to solve all of your problems.

I can’t tell you how much I wish that were true, but I can tell you with certainty it’s not. So please get that out of your mind. And stop looking for the magic pill to cure everything that ails you.

Sometimes pills are absolutely going to play a role in your treatment, but sometimes dietary changes or exercise or stress reduction or prioritizing sleep or minimizing substance use, or lots of other things are going to play a really important and powerful role in your recovery healing treatment.

Jenn: So I know that there are some physical conditions that are actually brain-based. And one of them that folks wrote in in particular about are like long-term concussion issues.

Do you have any insight into how depression or anxiety related to brain-based physical conditions are typically addressed?

Chris: It’s a really good question. And so we know that people who’ve had traumatic brain injury are much more likely to experience psychiatric symptoms later in life. And immediately after the injury as well. And the diagnoses are all over the map.

People are more likely to have post-traumatic stress disorder, they’re more likely to have depression, anxiety, substance use disorders. When they get older, they’re more likely to develop neurodegenerative disorders: Alzheimer’s disease and Parkinson’s disease.

And so there’s a wide range of disorders that can occur. And unfortunately for all of those disorders that I just mentioned, if you really get into the nitty gritty and the details and ask any expert, like what really causes that? Like what’s the real cause of that?

The answer for every one of those disorders is we don’t know. And so unfortunately because the field right now is in a state of we don’t know to all of those disorders, it means we don’t know what to do to effectively treat it or to effectively prevent those other disorders from taking hold.

And so what that means is that for now the treatments are the standard treatment. So if you have depression, we’re going to use antidepressants or psychotherapy, or in severe cases ECT or TMS. If you have anxiety, we’re going to use anti-anxiety treatments.

And so on and so forth. I’m hoping again that by understanding all of the connections of all of these, that we might get to a very different place soon.

Jenn: So I know some mental illnesses, like a good example would be chronic anxiety, they send the brain into fight or flight response.

What I’m curious about is does something like a sustained fight or flight response create a sustained increase in cortisol, and in turn does that affect the rest of your body functioning healthily?

Chris: So we know that prolonged stress is associated with all sorts of adverse health outcomes. And they’re not just mental health, they’re physical health as well.

So if we look at people who have had abuse, trauma or severe neglect in childhood, often referred to as adverse childhood events, and that includes even things like parents getting divorced, moving multiple times, not having friends, those kinds of things.

That we know that people, the more adverse childhood events somebody has, the more likely they are to develop a mental disorder. Which one? Almost all of them. It’s not just post-traumatic stress disorder. Yep. That’s an obvious one, PTSD.

But they’re also more likely to have a substance use disorder. They’re more likely to have an anxiety disorder. They’re more likely to have clinical depression. They’re even more likely to have hallucinations, which get diagnosed as bipolar disorder or schizophrenia.

So pretty much, kind of sort of, all of them, with the exception of maybe the developmental disorders like autism spectrum disorder, that has usually taken hold already. So it’s just a timing issue, I think, on that one. But most of the disorders.

But then they are also associated with a lot of physical disorders. All of the metabolic disorders that I mentioned. People with traumatic childhoods are more likely to be overweight or obese. They’re more likely to develop type 2 diabetes. They’re more likely to develop cardiovascular disease.

And researchers at the Harvard School of Public Health have looked at a longitudinal set of women, the Nurses’ Health Study, and they found that the women who’d had traumatic events in their life were in fact much more likely to develop everything I just mentioned.

But yet lifestyle factors didn’t seem to be the big thing. So everybody again assumes, well, they’re just getting all stressed and lazy. And they’re just not exercising. They’re eating a bad diet. They’re doing all those things. And so it’s their fault.

And in at least one of the studies that followed this very large cohort of women over time, it only accounted for like maybe 20-30% of the variants that are for that findings. And so there’s something about, there’s something about exposure over long periods of time to traumatic or stressful events that does take a toll.

And there’s no question that I’m going to say it dysregulates the cortisol system. And the reason that I’m choosing the word dysregulates is because for most people, that means there’s an increase in cortisol most of the day throughout the day.

So normally our cortisol levels are kind of going up and down different times of day over day to day.

And one of the findings that we see in people who’ve had a lot of stress exposure or trauma is that they tend to have elevated levels of cortisol, and they’re kind of just, they stay elevated, and they don’t have these phases.

But there’s another group of people with post-traumatic stress disorder in particular who can actually end up developing very low levels of cortisol. And it seems like the cortisol system almost burns out or something.

Like we’re not quite sure what’s happening, but they have very low levels, like abnormally low levels. And that’s why I say dysregulation, because cortisol is actually a really important hormone. And people always want to blame things and like, oh, cortisol, that’s a bad thing.

Like, let’s get rid of it. Well, no, if we get rid of cortisol, we’ll all die. So we don’t want to get rid of cortisol. We really don’t. Cortisol is a great hormone. Keeps the human species alive. Keeps us going. Wakes us up in the morning.

It helps us run when somebody’s chasing us that we don’t want chasing us. Helps us defend ourselves. Helps us do all sorts of things. But we don’t want excessively high or low levels of cortisol over time.

Jenn: So I feel like you’re going to love this next question. What are some types of things that someone can do to reverse damage done to their metabolism after they’ve taken an antipsychotic medicine for many years?

Chris: So that is a really important question. And it’s one that I’ve been doing a lot of work on the last five years in particular.

So I think that there are a lot of different interventions that play a role. The way that I see it is metabolism is, it’s a very complicated thing. Most people think about metabolism as it relates to just burning calories.

It’s actually, like that is just a tiny tip of the iceberg of what metabolism is. Metabolism is so much more than just burning calories. And a lot of different things influence metabolism.

And like I said, including gene expression, levels of inflammation, the gut microbiome, your sleep patterns, exposure to light, getting vitamin D on your skin, sunlight on your skin so you have vitamin D. All sorts of things. But certainly diet is a big one.

And so I think in order to restore your metabolism or heal your metabolism or improve it, you really do have to think about a multifaceted approach. And that means you need to take an inventory of all the things I just mentioned. And try to look for areas that are problematic.

So ideally if you are an adult between the ages of 18 and 50-ish or something, you should probably be getting about seven-eight hours of sleep a night. When you should be able to wake up and feel refreshed. Feel refreshed, most people don’t feel refreshed when they wake up.

Most people are hitting the snooze alarm and dragging themselves out of bed. And so that is a problem. If you’re not getting good sleep, right there, we’ve got a problem that is probably influencing your metabolism.

And influencing your hunger signals, and influencing your gut microbiome, and influencing your levels of inflammation and all sorts of things. So you want to try to get good sleep. You want to get exposure to some light, some sunlight, you might use a bright light therapy.

If that can be helpful, that can be helpful at restoring your circadian rhythm. Also helping wake you up in the morning. In terms of dietary interventions, especially for people who show any signs of insulin resistance, which would be measured by your fasting blood glucose or higher than normal insulin levels.

And there are a lot of people who have insulin resistance. If you do have insulin resistance, I’m particularly a fan of low carbohydrate or ketogenic diets.

And the reason for that is because when you’re insulin resistant, part of the definition of insulin resistance is that your body is having trouble using glucose effectively as a fuel source.

And if you can change that fuel source, even just a little bit of that fuel source over to fats and ketones, you can start fueling your cells more effectively. And that can actually start revving up your metabolism.

We do have a lot of studies showing that low-carbohydrate diets in particular, just across the board, whether they end up being ketogenic or not. Low carbohydrate diets in particular have been found to decrease your metabolism in the first two weeks.

So you heard that right. Decrease your metabolism. That sucks. That’s bad. that means it’s going to be, it’s going to make matters worse in the first two weeks. So that’s what a lot of people will refer to as keto adaptation or low-carb adaptation or carb withdrawal. That it will actually probably lead you to feel worse.

But then after the first two weeks, metabolism actually goes higher than a normal carbohydrate diet.

And so low-carb and ketogenic diets can actually start to repair or rev up or increase your metabolic rate, which will be helpful in terms of getting your brain functioning better and also helpful in terms of helping you lose some weight and restore metabolism.

You don’t have to necessarily stay on that type of a diet for your entire life. ‘Cause if you can get your metabolism revved up and healed, if you can lose some of your fat stores, your metabolism will get closer to “normal.”

And that will probably allow you to process carbohydrates more effectively. And process other types of foods that you might have to restrict, at least when you’re trying to get into this recovery mode.

Jenn: So I know that you are a treasure trove of knowledge. So I’m curious to know if you are aware of any evidence where taking care of yourself, just for example, like a good diet and regular exercise can result in better mental health outcomes?

And I’m not asking as saying like, what evidence is out there that eating fresh fruits and vegetables cures depression? Because obviously everybody’s treatment is different, but what’s out there?

Chris: So that gets into the, well, you kind of asked in a way. I’m going to break it into two separate questions.

So one question is can changing your diet affect your mental health? And then the second question is can exercise affect your mental health? And obviously the third caveat question would be is doing both better? And I’ll cut to the chase. Yes. Doing both is better.

So whenever I recommend a dietary intervention to anybody, I almost universally recommended exercise. Even to people who are wheelchair-bound. Exercise is important.

And it is a way to, not only help people at least maintain, if not improve their functional status in the world, which is really helpful, not just from a physical stance, but from a mental stance.

I mean, when, if I’m wheelchair-bound and I exercise and I can start standing up again or I can start walking again or something, that is huge. That is huge in terms of my mental state. If I have always been bullied and teased because I was a scrawny kid. I’m not speaking personally at all.

But if that were to happen, like if I had been a really scrawny nerdy kid and just got relentlessly bullied and teased, and now I can do pull-ups, and now I can do like pushups and stuff, it’s just going to make me feel so much better about myself. I’m telling you.

I don’t know how I know that, but I kind of know that. And exercise is really important. In terms of dietary interventions, we do have two pretty good randomized controlled trials of people with chronic depression who were assigned to the Mediterranean diet or diet as usual.

And the Mediterranean diet resulted in significant, a significantly different improvement in the patients. So in one of those studies, so these are people with chronic treatment-resistant depression.

In one of those studies, about 30% of the people on the Mediterranean diet got into the classification of remission from depression. Whereas only 8% of the people on the control diet did.

So that’s three-four times as many people got into remission with a Mediterranean diet, I think it was a 12-week study, versus a control diet. I do want to point out, was only 30 something percent. So that left 60 something percent still with chronic depression.

So by no means was that like a home run treatment that’s going to work for everybody, but it was a powerful effect because if we had done an antidepressant trial in those people, which we’ve already done.

We’ve done lots of those studies and the outcomes are actually much worse with another antidepressant. So once you’ve failed three antidepressants, the likelihood that another antidepressant trial is going to significantly improve your symptoms of depression is very, very low.

And the likelihood that psychotherapy is going to do it as well is pretty low. And then in terms of low-carbohydrate ketogenic diets, that research has actually even earlier in its kind of development.

And we have randomized controlled trials of ketogenic diets or even low-carbohydrate diets for weight loss, for epilepsy treatment, for type 2 diabetes treatment. And some of those studies have found improvement in depressive symptoms, anxiety symptoms, insomnia symptoms, but those studies weren’t designed specifically to treat people with clinical depression.

They were designed to treat people with type 2 diabetes or with epilepsy. A ketogenic diet might make those things dramatically better. And then, oh, by the way, their depression also got better.

We don’t really know for sure if it was treating their depression directly or if it was because their epilepsy went away or because their type 2 diabetes got so much better. Maybe they felt better for that reason.

I happen to think it probably does have a powerful antidepressant effect. I’ve seen it have a powerful antipsychotic and mood stabilizing effect, but for better or worse, we need larger, longer, more rigorous clinical trials before I can definitively say that’s the case.

Jenn: My final question for you today is a lot of folks who are tuning in, myself included, identify as being pressed for time, on the go, looking after others, student, parent, child, caretaker, sometimes all of the above.

What can we do to support our health journeys when oftentimes we feel like we don’t even have the time to look after ourselves.

Chris: It’s a really important question, and a good one. And I think, I think at the end of the day, the way that I usually talk with people about it is we all get one life to live.

And we have to make decisions about how we’re going to spend our time, about what’s important to us, about what really matters. And there’s a tremendous amount of variability in the decisions people make.

Some people want pets and they’re willing to put in all of the extra time and effort and money that it takes to have a pet, because they get a lot of satisfaction from that. Other people want nothing to do with pets.

Same goes with taking care of your body, I would say. The same goes. Like does everybody have to exercise an hour every single day? Does everybody have to eat really healthy foods all the time? Never have cheat days. Never indulge. Never, like of course not.

And where is the line? I think that the way that I usually am able to persuade people to try lifestyle interventions, diet, exercise, others, is usually I’m seeing people who are suffering. Usually in very severe ways. And they want their life to be better.

Almost always they’ve already tried dozens of pills that have not worked. Some of them have also tried ECT and TMS and years of psychotherapy, and hospitalizations and all sorts of other stuff. And none of that has worked either.

And here they are in my office still suffering, looking for better answers. So in a way, I have an easy audience. I look at that as an easy audience, because they’re pretty desperate. They want to feel better. They will try just about anything.

And so when I reframe the conversation and let them know that like, look, I would give you a pill if I thought a pill was going to be your magic answer, but you’ve already tried how many of them, 30? Do you really think 31 is going to do it?

When are we going to get realistic and say that that’s not working for you? And so instead could I get you to try this, this and this intervention for three months? I always put a timeline on it because nobody wants to think about doing something that’s uncomfortable or difficult forever.

So I usually say, let’s come up with a three month plan. You can torture yourself for three months. Can’t you? Like you can, even if this diet’s going to be torture. If exercise is going to be torture. Fine. I’m not going to argue with you. Torture. It’s torture.

Torture yourself for three months and let’s see what happens. And it’s amazing how many of those people at the end of that three months will have such profound significant improvement. And they will have gotten through the really difficult phases of all of those treatments.

They got through the difficult phase of changing their diet, of starting an exercise program, whatever. And then a lot of times at three months, they’re like, yeah, no, you’re right. Now I’m trapped. Now I’m stuck on this plan that you put me on, because I know that if I go off of it, I’ll feel horrible again.

And I can’t go back to that. So now I’m on this. And in reality, yeah, it’s not as hard as, as I thought it would be. Now that I’m doing it, now that I’ve been doing it for three months, it’s become a lot easier. And I’ve found ways to enjoy my diet. I have found ways to enjoy the exercise, to make it fun.

So I think it depends on where somebody is at in terms of their health, in terms of symptoms, and in terms of their current level of diet and exercise and everything else. So a whole range of all of that.

But I think that if you are a really busy person, it’s important to just kind of reflect on how’s my life going’? Do I have good energy? Do I have a pretty good mood most of the time? Is my anxiety under control. Am I sleeping okay? How’s my life going?

If your answers to most of those things are, no, my life is really good. I’ve got a good life. And I’m really busy. You’re not motivated to make any change. And I would say you probably shouldn’t make any change.

If things are going really well for you, that’s great. Clearly whatever you’re doing is working. If your answer to those questions though is, oh, I’m really busy and I’m so burned out. I am so exhausted. I can barely keep up. I kind of hate my life.

I just, I look at other people, and they smile and I can’t even do that. I’m just so worn out and exhausted. Then I would say you have a problem. And that is a really awful way to go through life.

And even though you think you don’t have the time to fit in lifestyle changes, I would actually argue with you and say, you don’t have time to not fit in lifestyle changes. ‘Cause here’s the deal.

If you make some lifestyle changes and start feeling dramatically better, you’re going to have more energy, more motivation. You’re going to become much more efficient at getting done what you need to get done. You’re going to be able to start smiling.

You’re going to be able to start having fun, doing what you need to do, and life will become so much more enjoyable and less burdensome to you. And it’s amazing to me. Like I can tell you, I’m a pretty busy person. I have lots going on in my life. And I always fit in exercise for myself.

I always fit it in, no matter what. Even when I travel. Because I know that if I don’t, I will immediately start to slump. Within two or three days, I can take a day or two off, but much more than that, I will really start to slump.

And my energy level will start to slump. My motivation will start to slump. And then I will start dragging through life. And I just know that about myself now, that I know if I want to keep up my level of activity and productivity, that I have to keep exercising.

Like that’s a basic self-care thing. It’s kind of like you’re running a marathon, do you really have time to stop for a water break? You really do want to finish the race. You want to get a good time. So do you really have time to stop for a water break?

I would say you’re a fool if you don’t stop for a water break. You’re going to collapse and not finish the marathon if you don’t take the time to stop for a water break. So if you need exercise or a dietary change in order to be running on all cylinders and have a happy, content life, you don’t have time to not do it.

Jenn: As a distance runner, I think that was probably one of my favorite analogies you have ever brought up but you’ve, I think there’s so much value in what you’ve said. First and foremost, it’s figuring out what works for you and what doesn’t work for you.

Not everything is going to be, not every diet’s going to work for somebody and not every exercise is going to work. But even at its most basic, just asking yourself how you’re doing.

If you only have five minutes to check in and say, how am I feeling today? That is like the baseline of mental health. And that is, I mean, I think that’s something that people could very easily implement.

Chris: Yeah. No, absolutely. And I, it’s a never ending process. It really is. Our lives are always changing. Our circumstances are always changing. Our physical health, our mental health is always changing.

Nobody gets to be perfect and live forever. None of us get that. No matter how hard we work at it, none of us get that. So things are always changing. It’s always important to check in with ourselves.

And again, if your answers are I’m doing pretty well, then whatever you’re doing is probably working really well for you. Keep doing that. And at some point, if it turns into, yeah, I’m not doing so hot anymore. I don’t know how much more of this I can take. Then, okay. Time for a change.

Jenn: Well, Dr. Palmer, this has been phenomenal. You have provided so much information that we took up more than the hour that I asked of your time. So thank you so much for taking the time, plus some, to spend some time with us today and chat all about physical and mental health.

And to everybody out there, yes, you, thank you for joining. This actually concludes the session. And until next time, be nice to one another, but most importantly, be nice to yourself. Thank you again, Dr. Palmer. And thanks, everyone. Take care.

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Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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