During my time at Providence, I developed educational programs for patients, their families, and the community as a whole. While working at Butler Hospital, I was able to use the historic Ray Hall Conference Center to this end. After moving into private practice, a large waiting room in my clinic was where the same activity took place. Occasionally, I presented in other venues, such as a meeting or conference room at a hotel. Typically, in the early evening hours, after a long day at work, I went to a designated gathering point for the educational event, equipped with an old-fashioned slide projector that held a carousel on the top filled with slides.
The style
I was accustomed to teaching psychiatry residents, medical students, and mental health professionals. Psychoeducation of patients and other laypersons was a new self-imposed task that required a different set of skills. Presentation of material needed to be adapted to the secondary school education level and to include basic but pertinent information using nontechnical language with an optimistic twist and many practical instructions that could empower patients and their families. The emphasis was on the locus of control. This concept is an aspect of the psychology of personality. A person's “locus” could be internal (a belief that one can control one's own life) or external (a belief that life is controlled by outside factors which the person cannot influence, or that chance or fate controls his life). * Through the development of an internal locus of control, an individual feels in charge of his own destiny and is motivated to act with a purpose. Of course, this attitude is beneficial if it is tempered by the degree of acceptance, so brilliantly expressed in the serenity prayer used by 12-step support groups.
God grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
and Wisdom to know the difference **
I was trying to instruct my listeners on how to navigate that fine line where wisdom resides and where decision-making is based on knowledge, experience, understanding, common sense, and insight. The reason why this was important was that many patients with mental health concerns have developed learned helplessness, another psychological concept, originally connected with depression. In this view, clinical depression and related mental disorders result from an actual or perceived lack of control over the outcome of a situation. *** People who “learn helplessness” believe that events are uncontrollable. They find it difficult to solve problems and are less likely to change unhealthy behaviors related to diet, exercise, and medical treatments. It is crucial to change this mindset from powerlessness into an empowered state where the locus of control moves from outside to inside. This was one of my main educational objectives.
The audience
The primary participants in these educational activities were my patients and their families. I had about 800 to 1,000 active patients, and my colleagues in private practice had 500 to 600 more. Therefore, there was a lot to invite and those who were interested in taking part. It goes without saying that the programs were well attended; at times, we did not even have enough space for everyone. My patients had an opportunity to see a different side of me when I was wearing a “professor’s hat” rather than my customary “doctor’s hat.” But because I knew them, they were comfortable enough to ask questions or talk about their personal experiences. On some occasions, I even decided to arrange the room for everyone to sit in a circle to create a large group experience rather than a typical split between the presenter in the front of the room and the participants across the way.
Topics
I discussed subjects related to my expertise which interested my patients. There was talk about depression from a descriptive and experiential point of view. I offered a definition of clinical depression that made sense to me. I stated:
Major depressive disorder is an episodic and frequently recurrent condition manifested by the profound and sustained sadness or absence of joy and rewards, accompanied by the clinically significant change in psychological and biological functions related to zest for life, motivation, cognition, vitality, appetite, sleep and other important areas leading to suffering or impairment in relevant life roles. ****
In addition, I covered the neurobiological model and etiopathogenesis that incorporated the stress-diathesis perspective. I talked about how early life stressors in combination with genetic predisposition created a vulnerability that in the presence of immediate triggers led to a major depressive episode. I spent a couple of lectures presenting a comprehensive biopsychosocial approach to treatment. I emphasized the role of social support and meaningful relationships, rewarding experiences and activities, as well as depression-focused psychotherapy. The goal was to shift thinking from negative to positive or neutral, learn problem-solving and stress-reduction strategies, etc.
Among other things, I pointed out the importance of a healthy lifestyle, including a diet composed of whole foods, elimination of processed foods, sugar, and inflammatory foods such as dairy and meat, and the use of supplements with vitamin B12, folate, vitamin D3, and omega-3 fatty acids. Another component of a healthy lifestyle is exercise, in particular, a combination of aerobic and muscle building. Exercise makes the brain healthier thanks to better circulation, higher levels of neurotransmitters of growth, neurogenesis, and a reduction of stress hormones. The removal of alcohol, tobacco, and other toxic substances is an important part of healthy living, as is the implementation of sleep hygiene activities that provide deep regenerative night rest.
Biological therapies were primarily related to pharmacotherapy with different types of antidepressant drugs, and neurostimulation with lights and electricity (older), or vagal nerve stimulation and transcranial stimulation (newer).
Bipolar disorders talks were a big hit, because back then “everybody was bipolar.” They were frequently misdiagnosed conditions. First of all, it was important to distinguish bipolar I from bipolar II types, because Type I was a medical emergency whereas Type II usually presented in the form of clinical depression and only on rare occasions showed its “superhuman” side in the form of a mildly elevated mood episode.
To illustrate what I mean by saying that Type I was a medical emergency, I briefly present here a prototype of a manic episode of bipolar I.
His mind is racing, his speech is pressured and punning, and his body is in perpetual motion. There is nothing he can’t do, and the usual limitations in life no longer apply. There seems no need for sleep or eating, or for the routines of the everyday. Impulses are unleashed— wild shopping sprees, reckless investing, expansive new projects, intense new relationships, fast cars, adventurous drugs, and restless travel. Eventually, the euphoria morphs from high spirits into impatient irritability (especially when other people refuse to join the party). Increased energy merges into restless agitation, then dissolves into utter exhaustion; expansive thoughts can become psychotic delusions of grandeur or paranoia. ****
Unlike clinical depression, bipolar disorders are highly heritable and highly recurrent conditions with an early onset around age 18, frequently triggered by “party life” and other stressors. Patients with these conditions needed to be treated with medications (mood stabilizers), avoidance of mood dysregulation, and establishment of daily routines.
My private practice was called the Center for Mood and Anxiety Disorders, so it was appropriate to talk not only about mood disorders but also about anxiety disorders. Generally speaking, the experience of anxiety is related to the anticipation of danger. It resembles fear but occurs in the absence of an identifiable external threat, or it occurs in response to an internal stimulus perceived to be threatening. Anxiety is often associated with muscle tension and vigilance in preparation for future danger. Fundamental components of anxiety are psychophysiological arousal, future-oriented thinking, inaccurate risk appraisal, avoidance, and rituals.
Generalized anxiety disorder (GAD) was the most common anxiety disorder encountered in the outpatient psychiatry practice. It typically presents with somatic symptoms (e.g. headache, back pain and other muscle aches, gastrointestinal distress, etc.) for which patients seek help in the primary care setting. Worrying and anxiety are excessive, persistent, intrusive, and disruptive. There is nothing the person could do to stop worrying. An overwhelming feeling of apprehension and dread is present. The inability to tolerate uncertainty is pervasive. Avoidance of anything and everything is frequently present. Cognitive and mindfulness-based psychotherapies seem to be very helpful, especially when carefully combined with drugs that regulate serotonin in specific parts of the brain such as the amygdala, our alarm bell that is hypersensitive and overactive in these patients. Different forms of exposure therapy are used if phobic avoidance is prominent.
By and large, the lectures were a success. Patients often spoke about them during their one-on-one meetings with me. They felt better equipped to actively participate in their treatment as co-creators with an improved internal locus of control. Family members were more likely to be part of the solution rather than part of the problem when they understood more about their loved one’s mental condition. I was rewarded by this activity with a surge of positive chemicals passing through my body at the end of a busy day that would otherwise lead to exhaustion.
Something totally different
Many of my patients struggled with being overweight or obese. At first, I thought their weight was associated with living in a “toxic environment.” In no country on earth is food more available, promoted, and inexpensive than in the United States. We, humans, are programmed to eat calorie-rich foods, because 99.99% of our existence as a species, we have lived in an environment with a shortage of food resources. Therefore, we have a robust genetically based defense against undernutrition and a weak response to overeating. In a current environment where there is plenty of food, most people are almost defenseless. It was clear that America was on a trajectory of becoming a fatter and fatter country following “supersize me” advertising of liquid and solid calories and reduced physical activity. Consequently, a typical American adult “earns” about 20 pounds of body weight between the ages of 25 and 55.
In addition to these environmental factors, I observed that patients with specific types of depression (atypical, premenstrual, bipolar, and seasonal) gain weight as one of their symptoms. Some of my patients were addicted to food (binge eating), and others used food as a strategy for managing stress. To make matters even worse, a lot of psychiatric drugs can cause weight gain as a side effect.
Talks about obesity
I decided to organize a series of talks for patients and the community. I realized that there is a need for everyone to understand obesity by learning about the epidemiology and biopsychosocial factors associated with weight gain. I informed my audience that a combination of diet treatment, physical activity, and behavioral therapy were the most important aspects of weight management.
In order for weight loss to occur, it is necessary to create a deficit of 500-1000 kcal/day, which is why awareness of the caloric values of food is crucial. Reduction in dietary fat is the easiest way to achieve this goal. Limiting fat to 30% of total calories and increasing complex carbohydrates, fiber, and proteins is the way to do it. Developing specific lifestyle techniques may lead to greater success. For example, keeping an eating diary, identifying triggers for eating, weighing oneself regularly and keeping a weight graph, eating in one place (but not in front of the TV), shopping from the list, buying foods that require preparation, and keeping healthy food visible.
Physical activity contributes to weight loss by decreasing abdominal fat. Likely mechanisms linking exercise with success at weight control are energy expenditure, minimization of lean body mass loss, appetite suppression, increased metabolic rate, diminished dietary fat preferences, improvement of risk factors associated with obesity, and positive psychological effects. Tips for a successful exercise include a gradual approach, the selection of enjoyable activities, and regular exercise at a pace that optimizes safety and comfort.
Behavioral therapy is a third essential component in the treatment of obesity. It deals with the psychological aspects of eating, such as the effect of stress as a disinhibitor of inhibited behavior (e.g. dieting). Thus, adaptive coping with stress including present-moment awareness, balanced life, conflict resolution, and meditation become extremely important for overall success. The implementation of self-monitoring of eating habits and physical activity, as well as the removal of obstacles that impede this process, is enabling. The recruitment of a support system by the identification of a partner and telling him how to help makes everything easier.
The role of a psychiatrist in the weight management program is very important. Volitional weight loss with hypocaloric diets triggers counterregulatory biological mechanisms as an automatic body response to “starvation.” This may make long-term weight loss difficult to achieve. Pharmacological intervention is thus often necessary to aid in inducing and maintaining weight loss. Drug treatment of obesity needs to follow accepted evidence-based guidelines related to efficacy, safety, and duration.
Weight gain can be caused by medications as an adverse reaction, which may not be appreciated by prescribers or those taking them. Thus, careful evaluation of pharmacological agents (prescribed, over-the-counter, and illicit) for their weight gain potential is a necessary step for every patient. Many individuals who participate in weight management programs have other psychiatric conditions that require assessment and treatment. Treatment of these co-occurring disorders with pharmacological agents that are at least weight neutral or with weight loss potential needs to be considered. Coordination of care with other physicians and clinicians in the identification of metabolic syndrome or other medical consequences of weight gain and appropriate choice of treatment is frequently necessary.
I presented two studies in which I implemented pharmacological agents in the treatment of obesity. In the first study, topiramate, then a novel anticonvulsant drug known for its tendency to cause weight loss was used. I treated 16 female outpatients diagnosed with major depressive disorder and mild to moderate obesity by adding topiramate to ongoing other medications. At the end of the study (after 6 months) 44% of patients had a weight loss of 6 to 8 % from baseline weight, but unfortunately, many of these patients had significant central nervous system (CNS) side effects (predominantly short-term memory impairment). *****
In the second study, I used orlistat, at that time a recently approved drug that inhibits gastrointestinal lipases so fatty foods are excreted and not absorbed. Unlike topiramate, orlistat is not active in the CNS and does not affect plasma concentrations of psychotropic medications. Due to these favorable features, it was a good candidate for use in a psychiatric patient population. I treated 14 outpatients for up to 10 months with this medication. 10 out of 14 patients lost around 6% of their baseline weight. Side effects were few and mostly related to the passage of unabsorbed fat and associated gastrointestinal symptoms. Individuals who were able to avoid eating fatty foods experienced few or no side effects and tended to stay on orlistat for a longer duration. ******
Vigor and force
I became involved in public psychoeducation slowly and with a dose of uncertainty. It was something new to me and my patients. Like many other things, proper preparation, intent setting, and experience gained momentum characterized by robustness and strength. The trust that I was doing the right thing increased and the comments I received were encouraging. I expanded my professional role beyond the walls of the hospital or clinic and became a presence in the wider community by using tools of pedagogy with good measures to ensure that benefits were high, and risks were low.
* Generalized expectancies for internal versus external control of reinforcement, by Julian B. Rotter, Psychological Monographs: General and Applied. 80 (1): 1–28, 1966
** Living the Serenity Prayer: True Stories of Acceptance, Courage, and Wisdom, by JG Littleton; and JS Bell, Avon, 2008
*** Helplessness: On Depression, Development, and Death, by Martin Seligman, W. H. Freeman, 1975
**** Manual for descriptive psychopathology course, by Zelko Leon, 2018
***** Carpenter LL, Leon Z, Yasmin S, Price LH. Do obese depressed patients respond to topiramate? A retrospective chart review. J Affective Disorders, 69 (1-3):251-5, 2002
****** Carpenter LL, Schecter JM, Leon Z. A Case Series Describing Orlistat Use In Patients On Psychotropic Medications. Medicine and Health/Rhode Island, 87 (12): 375-7, 2004
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