This is such an important take! I am downloading it for future reference. Its salient points will be in my next presentation. We must be more aware of the long-term harms we are causing, especially since there are other options available.
As a now semiretired psychiatrist looking back at my career, the issue of weight gain on so called atypical antipsychotics was clearly an issue as they first became available. But we were so enthused to have options we tended to be less focused on this side effect than we should have been. Over time though, the question I began to ask myself over and over was, in the cases where there was only minimal benefit was it more prudent on the risk vs benefit scale to not treat with meds at all, even in some well documented cases of schizophrenia, in the presence of strong family support, minimal psychosocial improvement with meds, and determined noncompliance by the individual.
The second insight which seems obvious but yet somehow is overlooked, was that people become overweight when they eat, and they eat when they are hungry, and brain chemistry drives hunger. Talking down to overweight people as though there is some moral weakness in their hunger levels is unfair. Or trying to tell people they can just diet with enough willpower despite being uncomfortably hungry. Only now are we actually starting to understand how appetite works as we find ways to change satiety and appetite pharmacologically.
I appreciate your articulation of the problem and your self-disclosure. Mentioning TMS for depression is helpful but you don't share how you got off antipsychotics without going insane. That is a big, huge problem and is the reason so many of us are on them. The cost of psychosis and mania is higher than the cost of the metabolic consequences. At least that's true for a whole hell of a lot of people on the bipolar sub reddit with 253,000 followers and all the FB groups for people living with bipolar. And me.
I still don't understand why the APA or Psychiatric Times won't address common criticism in psychiatry.... the iatrogenic harms of the drugs and the coercion.... I LOVE LOVE LOVE that you and Dr. Awais Aftab take the time to thoughtfully and carefully discuss these things and are open to hearing feedback from folks like me with horrible lived experiences but I dont see any "main stream" effort to bring these things to the front? I obviously know that the "MAHA" movement is against psych drugs but that doesn't really give "credibility" considering RFK Jr. is a quack.... I think that the discussion needs to be led BY psychiatrists yet there seems to be a reluctance to do so...
However in more positive news:
1. In Michigan, bills to add oversight to abusive facilities has passed the first round:
No dispute here. I would yes and you for a second, because what we also don't do is enough benefit. Plenty of medical care could be harmful, just think of surgery. However, perhaps an account of our collective caution and defensiveness, we are both less likely to engage in the harms our profession can cause, less likely to engage in a conversation about the lack of benefit of our most common interventions, and, just round out the picture, have to deal with criticism that is unique to our medical specialty. Nobody goes after orthopedics like they do psychiatry. We could cure depression tomorrow, and we'd still be pilloried for it. But for me, there's a risk benefit ratio question, and since we're neither hitting risk nor benefit, we really have to take a strong look at the mirror and decide how we're spending our time, what we're advocating for, and why
Metabolic psychiatry as practiced by Chris Palmer and Shebani Sethi may have some directions to explore. See the research of the Metabolic Mind foundation.
This is such an important take! I am downloading it for future reference. Its salient points will be in my next presentation. We must be more aware of the long-term harms we are causing, especially since there are other options available.
Please take it one step further and share it with others. getting the word out matters.
As a now semiretired psychiatrist looking back at my career, the issue of weight gain on so called atypical antipsychotics was clearly an issue as they first became available. But we were so enthused to have options we tended to be less focused on this side effect than we should have been. Over time though, the question I began to ask myself over and over was, in the cases where there was only minimal benefit was it more prudent on the risk vs benefit scale to not treat with meds at all, even in some well documented cases of schizophrenia, in the presence of strong family support, minimal psychosocial improvement with meds, and determined noncompliance by the individual.
The second insight which seems obvious but yet somehow is overlooked, was that people become overweight when they eat, and they eat when they are hungry, and brain chemistry drives hunger. Talking down to overweight people as though there is some moral weakness in their hunger levels is unfair. Or trying to tell people they can just diet with enough willpower despite being uncomfortably hungry. Only now are we actually starting to understand how appetite works as we find ways to change satiety and appetite pharmacologically.
I appreciate your articulation of the problem and your self-disclosure. Mentioning TMS for depression is helpful but you don't share how you got off antipsychotics without going insane. That is a big, huge problem and is the reason so many of us are on them. The cost of psychosis and mania is higher than the cost of the metabolic consequences. At least that's true for a whole hell of a lot of people on the bipolar sub reddit with 253,000 followers and all the FB groups for people living with bipolar. And me.
Can't tell every story in every post but it's a good story to tell for future?
Thought you might like to see my post about involuntary holds https://open.substack.com/pub/patriciajwentzel/p/involuntary-holds-the-messy-truth?utm_source=share&utm_medium=android&r=35kr23
I still don't understand why the APA or Psychiatric Times won't address common criticism in psychiatry.... the iatrogenic harms of the drugs and the coercion.... I LOVE LOVE LOVE that you and Dr. Awais Aftab take the time to thoughtfully and carefully discuss these things and are open to hearing feedback from folks like me with horrible lived experiences but I dont see any "main stream" effort to bring these things to the front? I obviously know that the "MAHA" movement is against psych drugs but that doesn't really give "credibility" considering RFK Jr. is a quack.... I think that the discussion needs to be led BY psychiatrists yet there seems to be a reluctance to do so...
However in more positive news:
1. In Michigan, bills to add oversight to abusive facilities has passed the first round:
https://www.wxyz.com/news/local-news/investigations/bills-to-add-oversight-accountability-to-michigans-mental-health-system-move-out-of-committee
Its a baby step, but a positive one.
2. Asheville Academy Closes following 2nd suicide:
https://www.citizen-times.com/story/news/local/2025/06/03/after-2nd-child-dies-by-suicide-asheville-academy-announces-closure/84010228007/
WAY TO MUCH HARM HAPPENS IN THE NAME OF PSYCHIATRY AND MENTAL HEALTH RELATED FIELDS.
No dispute here. I would yes and you for a second, because what we also don't do is enough benefit. Plenty of medical care could be harmful, just think of surgery. However, perhaps an account of our collective caution and defensiveness, we are both less likely to engage in the harms our profession can cause, less likely to engage in a conversation about the lack of benefit of our most common interventions, and, just round out the picture, have to deal with criticism that is unique to our medical specialty. Nobody goes after orthopedics like they do psychiatry. We could cure depression tomorrow, and we'd still be pilloried for it. But for me, there's a risk benefit ratio question, and since we're neither hitting risk nor benefit, we really have to take a strong look at the mirror and decide how we're spending our time, what we're advocating for, and why
Metabolic psychiatry as practiced by Chris Palmer and Shebani Sethi may have some directions to explore. See the research of the Metabolic Mind foundation.
A quick search of nutritional ketosis in the search field will reveal more about that ;)
Super, sorry to be dense but i don’t see how to search your posts but will soldier on looking. Thank you for your work.
https://open.substack.com/pub/thefrontierpsychiatrists/p/nutritional-ketosis-for-bipolar-disorder?r=1ct8f&utm_campaign=post&utm_medium=web&showWelcomeOnShare=false
Thanks and bravo. Epileptic here and frustrated that the uptake of this treatment is so slow.
It's all about the payment model! I love innovative treatments, but I love it a lot better when they're paid for.
Upgraded sub, fyi