Ask A Psychiatrist Erik Messamore

This episode deals with the question of weight gain from antipsychotic medication:
I'm on 20 milligrams of olanzapine. It's helping me and I don't want to change it. The only thing is that I've gained a lot of weight that makes me feel very unattractive. I’ve spoken to my psychiatrist about it, but I haven't gotten any guidance on the matter. Are there any solutions to weight gain from this kind of medicine?
Modern antipsychotic medications can be very helpful for some people. And they are less likely to cause neurological side effects, compared to their first-generation predecessors. However, many of these newer medicines can cause someone to gain significant amounts of weight.
This is a serious problem that the psychiatric profession (in my view) has been very slow to address.
In this episode, Dr. Erik Messamore describes several strategies that can reduce the risk of medication-related weight gain or that can reverse weight gain once it has started.
 
Strategy 1. Choose antipsychotic medications with low weight gain risk
Different antipsychotic medications come with different degrees of weight gain risk.
Table 1 in this open-access medical journal article lists medications with higher or lower risk of weight gain. The graph in this article also illustrates the differences in weight gain risk among the various antipsychotic medications.
 
Strategy 2. Switch to an antipsychotic medication with lower weight gain risk
People who have gained weight from higher-risk medications – like quetiapine (Seroquel) or olanzapine (Zyprexa), for example – may lose weight after switching to a lower-risk medication.
On the other hand, some people (like the person who sent in today’s question) might mostly like their current medication, or may not want to take the risks involved in medication switching (e.g., the switched-to medication might not work as well, or might have other side effects). In situations like these, there are several weight loss options worth considering.
 
Strategy 3. Diet and exercise to reduce weight from antipsychotic medication
Many studies show that antipsychotic-induced weight gain does respond to standard diet or exercise interventions. A relatively small reduction of 150 calories per day can lead to about 16 pounds of weight loss over a year. For many people, that can be achieved by sticking to natural, whole foods and avoiding processed foods with a lot of carbohydrates or added sugars.
Exercise and physical activity can enhance weight loss. And numerous studies show that exercise can improve mood, reduce anxiety, increase cognitive performance, and reduce symptoms of psychosis.
Very low carbohydrate diets like the ketogenic diet are popular these days. These diets are designed to reduce insulin levels, which can make it easier to lose weight (because insulin is a fat-storage signal). Many people who undertake these diets can maintain calorie deficits without feeling hungry. Several case reports and a small clinical study suggest that the low-carb/ketogenic diet might help some people with schizophrenia, psychosis, or bipolar disorder to experience fewer symptoms.
 
Strategy 4. Metformin to reduce weight from antipsychotic medication
Metformin is a widely-used treatment for type-2 diabetes. It improves the body’s insulin signals and reduces spikes in blood sugar. Metformin can also help people without diabetes to lose weight. And there are many studies showing the metformin can reduce weight in people who have gained weight from antipsychotic medications.
 
Strategy 5. GLP-1 Agonists to reduce weight from antipsychotic medication
GLP-1 is an abbreviation for glucagon-like peptide 1. The GLP-1 agonist drugs mimic the action of natural GLP-1. They optimize the body’s insulin responses and reduce appetite. Some of these medications – liraglutide (Victoza, Saxenda); semaglutide (Ozempic, Rybelsus, Wegovy) – even have FDA approval for treating obesity.
Lirgalutide has

What is akathisia?
Akathisia is a relatively common medication side effect. Akathisia is a feeling of restlessness that many people find difficult to describe. Many people with akathisia say that it makes them feel like they would like to crawl out of their skin.
 
What does akathisia feel like?
Akathisia can be just an uncomfortable feeling. But for many people that feeling of restlessness translates into not being able to sit still. (Akathisia comes from Greek words that mean “not able to sit down”). It can involve fidgeting, or not being able to sit down or lie down for very long without having to move. Akathisia can manifest as walking or pacing as well.
 
What causes akathisia?
Akathisia is sometimes a symptom of neurological illnesses (like Parkinson’s disease), but most of the time akathisia is a medication side effect.
Medications used to treat psychosis or schizophrenia are the most common cause of akathisia. But antidepressants can cause akathisia. So can some treatments for nausea or vomiting.
 
Akathisia treatment
 
Akathisia is relatively easy to treat. The most common treatments for akathisia are: reducing the dose of the medication that’s causing it, or getting rid of the medication and switching to a different one. The most common medication treatments for akathisia are propranolol or lorazepam. Other treatment options that have been studied include: cyproheptadine, vitamin B6, benztropine (Cogentin), or diphenhydramine (Benadryl).
 
In this week's episode, Melissa and Dr. Erik answer questions like:
What is akathisia? What causes akathisia? What are the best treatments for akathisia?  
 
Topics covered:
0:44
What is Akathisia?
 
02:11
Akathisia can consist of feelings or of movements.
 
3:32
What causes Akathisia?
 
6:36
Akathisia is a frequently missed or unrecognized side effect.
 
7:59
Why is Akathisia an often-unrecognized side effect?
 
10:40
The feeling of Akathisia is hard to express
 
14:25
A description of what Akathisia looks like
 
20:20
What to do when a medical problem does not respond to textbook solutions?
 
23:59
Antidepressant medications can cause Akathisia
 
26:17
Some medications for nausea or vomiting can cause Akathisia.
 
28:25
A tragic story of missed Akathisia in the emergency department
 
30:18
Advice and possible solutions for someone who might be experiencing restlessness
 
33:07
Weighing your options and choosing the right medications
 
 
 
 
About the Podcast:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
Send us a question
Useful Links
Dr. Erik’s website and blog
Podcast website
Ask A Psychiatrist YouTube Channel

This week’s listener question was “is there any new research about curing anosognosia?”
Anosognosia is a medical term derived from Greek root words that mean “lack of disease knowledge.”
Although anosognosia started off as a neurological concept, it's also very common for people with psychiatric conditions to have no awareness that their symptoms are unusual, or that they could indicate the presence of a mental illness. Emerging data suggest that impaired insight in mental illness might -- like neurological anosognosia -- involve those outer layers of the right side of the brain.
It turns out that a unique form of brain stimulation that activates the right brain can temporarily reverse anosognosia in people who have had strokes... and in people with insight-impairing bipolar disorder or schizophrenia.
The studies are small. And the findings are preliminary. But the results open the possibility of treating bipolar disorder or schizophrenia without medications. And the data also suggests very strongly that insight impairment in psychosis is more like the anosognosia typically seen in neurological disorders than the commonly assumed psychological denial or willful disregard.
Companion YouTube video about vestibular stimulation as a possible mania-reducing, psychosis-reducing, and insight-improving treatment in bipolar disorder or schizophrenia.
 
Topics covered
1:01 – What is anosognosia?
1:45 – Is anosognosia a form of psychological denial?
3:19 – Psychological defense mechanisms versus willful denial of illness?
4:15 – The difference between denial and anosognosia
4:40 – History of the anosognosia concept
7:28 – What types of brain injury can cause anosognosia?
10:05 – What are some functions of the cerebral cortex?
12:03 – Can anosognosia be a feature of psychiatric conditions?
12:30 – Lack of illness awareness is common in psychiatric conditions
15:08 – An example of insight impairment in schizophrenia
18:26 – Can psychiatric treatment improve insight or illness awareness?
22:36 – What can family or friends do?
22:52 – The controversy of involuntary treatment
26:00 – Strong caring relationships are better than strong logical arguments
28:23 – Do neurological factors contribute to lack of illness awareness in psychiatric conditions?
29:45 – A simple procedure that can temporarily reduce symptoms and improve insight
34:13 – The possibly paradigm-shifting significance of vestibular stimulation studies
 
Quotes
It's been said that people are persuaded by the strength of relationships more so than by the strength of logic. If you look at people that have had bipolar mania or manic episodes because of brain injuries, then you'll find that about 60% of those individuals have brain damage to the right side of the brain only, and about 10% have brain damage to the left side of the brain. We can temporarily create small windows of insight or temporarily eradicate anosognosia in stroke victims by this cold-water simulation in the left eardrum. And we can do the same thing with schizophrenia and mania, apparently.  
Resources
The book I Am Not Sick, I Don't Need Help! How to Help Someone Accept Treatment by Xavier Amador is one of the most helpful resources for friends or family members to understand anosognosia/illness unawareness and how to befriend, support, and effectively encourage someone to accept treatment.
 
About the Podcast:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
 
Send us a question
 
Useful Links
Dr. Erik’s website and blog
Podcast website
Ask A Psychiatrist YouTube Channel

Can Antidepressants Reduce Self-Harm?
Self-harm is a common behavior. About 1 in 8 children and up to 1 in 5 adolescents will deliberately injure themselves without suicidal intent. But even without suicidal intention, self-harm is an alarming and potentially dangerous behavior. Self-harm is a sign that something is wrong… but what’s the best way to help?
It’s not uncommon for someone with self-harming behavior to be prescribed an antidepressant. Most of us would think that someone who is repeatedly harming themselves is very sad or depressed. So, it’s not surprising that doctors might prescribe an antidepressant. But it raises several questions like:
What causes self-harming behavior? Can antidepressants reduce self-harming behavior? What are the risks? Are there any non-medication alternatives to treat self-harming behavior? Melissa and Dr. Erik address these questions and more in this episode of Ask A Psychiatrist.
 
Episode highlights
2:10 – What do antidepressant medications do?
3:34 – The types of conditions that “antidepressants” can be useful to treat.
4:36 – Conditions that might be worsened by antidepressant medications.
5:35 – Some less-publicized side effects of antidepressant medications.
7:00 – Why it’s useful to know about the possible side effects of any medication.
8:32 – How feelings of numbness happen, and how numbness can drive self-harming behavior.
10:13 – Differences in medication response speak to differences in the cause of the symptoms that the medication was prescribed to treat.
11:36 – What we diagnose as “depression” has many different underlying causes.
12:59 – Are there differences in how children or adolescents respond to antidepressant medications?
14:13 – Antidepressant use in children or adolescents is associated with slightly but significantly increased risk for suicide.
16:04 – Could antidepressant medications increase self-harming behavior risk?
17:46 – What are the causes of self-harming behavior?
19:30 – Self-harming to regulate emotions.
23:09 – Self-harming to change the flow of a discussion or the power in a relationship.
24:49 – The limitations of antidepressant medication as a treatment for self-harming behavior.
26:10 – Are there ways to treat self-harming behavior that don’t involve medication?
 
Notable quotes
 
“I sometimes say that drugs don't know what they're supposed to do… It turns out that drugs like the antidepressant medications do many things beyond just maybe treating depression.”
“It's really helpful to know what the potential downsides are so that you don't mistake a side effect for the symptom of some illness and then get more medicine instead of less medicine.”
“If the room is dark, it could be because somebody turned off the light switch… it could be because there's no electricity running into the building… it could be because there are dark curtains over the lights and the windows. There are many pathways to darkness in a room. And there are probably equally many pathways to depression in a human being.”
“What we call depression is almost certainly a whole bunch of different underlying processes that have similar top-level symptoms. That the diversity is the most likely explanation for why some people get great results from a particular medicine while others get no results and others get worse.”
 
About the Podcast:
Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.
 
Send us a question
 
Useful Links
Dr. Erik’s website and blog
Podcast website
Ask A Psychiatrist YouTube Channel

Cannabinoid Hyperemesis Syndrome (also called CHS) is the topic of this week’s episode. 
Melissa and Dr. Erik answer the question “How can something that’s an anti-vomiting medicine be the cause of a vomiting illness”?
Cannabinoid hyperemesis syndrome involves symptoms like loss of appetite, stomach pain, nausea, and vomiting. Vomiting attacks come in waves or cycles. A vomiting attack can last many hours or several days and can be severe enough to cause dehydration or a host of other serious complications. 
Cannabinoid hyperemesis syndrome affects some people who use cannabis regularly. The typical CHS patient will have used cannabis nearly daily for several years. However, there are cases of CHS developing in people who have used it as little as once per week for 6 months. 
 
Time and topics
1:41 -- What is cannabinoid hyperemesis syndrome?
2:53 -- Symptoms are often relieved by hot water baths or showers
04:30 -- The first report of cannabinoid hyperemesis syndrome was published in 2004
05:45 -- Cannabinoid hyperemesis syndrome might have been around longer, but not recognized
06:29 -- Cannabinoid hyperemesis syndrome might be the result of stronger cannabis being easier to get and use regularly
07:12 -- Why has CHS not more widely known?
08:41 -- It’s not profitable to publicize CHS
10:48 -- Why don’t cannabis companies warn consumers?
14:00 -- Cannabis prohibition was a bad policy
15:16 -- State governments are mostly silent about CHS
18:40 -- Knowing about risks is important for consumers to make informed decisions
22:29 -- Is CHS dangerous? What are the possible complications of CHS?
26:26 -- How often and for how long before cannabis use poses a risk of CHS?
28:49 -- Treatments for the active phase symptoms of CHS
31:55 -- The definitive treatment for CHS
33:51 -- What to do if you think you might have CHS
34:59 -- The leading theory about what causes CHS
36:51 -- Tips for stopping cannabis use
 
Notable quotes
 
“If you don’t know that something exists, it’s hard to see it.”
“This could be a newly-recognized fallout from greater access to higher strength, longer-term use of cannabinoids.”
“There can be extremely important medical information that gets published, that probably everybody ought to know about. But there’s just not a mechanism to disseminate the kind of information to people… Absent funding to disseminate knowledge at scale, knowledge dissemination happens at a trickle”
“Because of prohibition, we know relatively little scientifically about marijuana’s risk profile. Through prohibition policies, you’ve made cannabis way popular. And through prohibition policies, you’ve made its safety profile a subject of debate”
“States, in my view, have done a good thing by trying to make a substance available that might help people… But the idea of having a state government endorse marijuana as a medicine, display medical benefits on their website, and not say one word about risks is irresponsible”
“You’re not supposed to feel nauseated. You’re not supposed to have unexplained appetite loss. And you’re certainly not supposed to be vomiting a lot. So, if you have any of those things, do get checked out.”
“It can become very confusing. How can something that is supposed to help with vomiting cause vomiting? The answer is because the body develops tolerance, and the body wants to kind of fight back against whatever the drugs are making it do. So, if you take a drug constantly, which turns down the vomiting response, the parts of your brain that regulate vomiting, are actively pushing back against the action of the drug. In chronic suppression of the vomiting system, the vomiting system like builds muscle and gets stronger.”
“You might be one of these people for whom the body has just revved up its vomiting machinery. The only way to get back to normal is to put a pause to cannabis use and let the body’s vomiting mac

In this episode, Melissa and Dr. Erik discuss Alzheimer’s disease and address the question of whether it’s possible to prevent Alzheimer’s disease.
 
What is Alzheimer’s disease?
Alzheimer’s disease is one of several causes of dementia. The American Psychiatric Association has renamed “dementia” and now refers to this type of condition as “Neurocognitive Disorder.” Either name refers to a decline in cognitive performance. “Cognition” is a broad term which can include things like: attention, decision-making, recognition of language, faces, or situations, learning, or memory.
Dementia (or “neurocognitive disorder”) can have many causes and can involve many different facets of cognition.
What are the symptoms of Alzheimer’s disease?
The most common early symptoms of Alzheimer’s disease are memory loss or confusion. The tricky thing is that everyone can have memory issues or become confused from time to time. Alternately, it’s also possible to have frequent forgetfulness that is entirely benign.
Alzheimer’s disease is a concern if memory loss happens often enough or is severe enough that it starts to interfere with daily life.
Early-onset and familial cases of Alzheimer’s disease
Dr. Erik explains that some cases of Alzheimer’s disease can begin when a person reaches their 50s. Most people who develop Alzheimer’s disease at this age have a form of illness that is strongly determined by genes. The most well-known Alzheimer’s disease genes cause brain cells to produce a protein called beta amyloid, which appears to be toxic and is associated with cell death in memory circuits.
Slowing down the production of the beta amyloid protein is a promising opportunity for Alzheimer’s disease prevention and clinical studies of drugs that may slow down beta amyloid production are underway.
 
Brain health tips
Although we are still waiting for proven ways to prevent Alzheimer’s disease, we can definitely improve our cognitive health at any time. And some of the most useful ways to protect our brains as we age revolve around reducing the risks of strokes, including so-called “mini-strokes” and what Dr. Erik calls “micro-strokes.” Any type of stroke – whether big or tiny – causes brain cells to die. Preventing strokes is therefore a good way to preserve brain tissue. Meanwhile, exercising the brain is a good way to preserve brain function.
 
Here are several ways to prevent strokes:
Don’t smoke, or stop smoking Keep blood pressure at a healthy level Maintain a healthy weight Try to avoid developing diabetes (keeping a healthy weight and minimizing dietary sugars or carbohydrates is the best way to do this) If you have diabetes, keep your blood sugar levels in the optimum range Head injuries can also contribute to cognitive decline. So reconsider your involvement in contact sports, hear head protection when needed, and try to avoid situations that might expose you to unnecessary head injury risk.
 
The bottom line about preventing Alzheimer’s disease is this…
It’s hard to identify surefire methods for Alzheimer’s disease prevention. This is simply because we understand relatively little about what causes it. And it’s hard to design robust prevention strategies for things whose cause isn’t all that clear.
There are some treatments being studied currently that might be truly effective at preventing Alzheimer’s disease risk. But we will have to wait and see what clinical trial tests show.
In the meantime, focusing on whole- body health is probably the best way to promote long-term brain health.
 
The Paleo lifestyle
What Dr. Erik calls “the paleo lifestyle” might be one of the best ways to promote whole-body health and mental well-being.
 
Extending the concept of the “paleo diet,” which suggests that the optimum human diet would be similar to the diet humans were genetically designed for, the ideal human lifestyle is designed around