DEVELOPING YOUR METABOLIC TREATMENT PLAN
When a flower doesn’t bloom, you fix the environment in which it grows, not the flower.
-Alexander den Heijer
The above quote is a powerful metaphor for addressing problems with metabolism and mitochondria. In most cases, there is not a “defect” in the person but in the environment. “Fixing” a mental illness requires identifying the problems and addressing them. The “environment” in this case is writ large. It includes all factors that affect metabolism and mitochondria, such as diet, exercise, stress, light, sleep, hormones, inflammation, relationships, love, and meaning and purpose in life, to name just a few. Yes, some people may have inherited epigenetic factors, such as micro-RNAs, and these might be a contributing cause to their mental illness, but these can be changed, too. Metabolism is malleable, and there are many ways to improve it.
You will recall that I compared all mental illnesses to delirium. Each and every case of delirium is different, even though the symptoms can be similar and the diagnosis the same. Solving the problem of delirium requires medical detective work to understand what is causing it. Oftentimes, it’s more than one thing—a perfect storm in which many assaults on mitochondria are occurring at the same time. They all need to be identified and dealt with. This applies to every case of mental illness as well.
The brain energy theory supports existing treatments for mental disorders. These will continue to play an important role. However, it also calls for radical changes. To address problems with metabolism, comprehensive approaches are usually required. Sometimes, identifying a simple problem and delivering a single treatment can work. Vitamin and hormone deficiencies are examples, and sometimes, simply taking an antidepressant can do the trick. But unfortunately, more often than not, simple solutions are usually not the answer.
This goes against a pervasive message that we hear on a daily basis. Everyone wants simple solutions. We see on television every day that we can fix our problems with a pill. We just need to talk to our doctors and get those new prescriptions. If one pill doesn’t do it, by all means, take more. We hear the same messages from diet gurus and health experts. Don’t eat fat, and you’ll lose weight. Take this vitamin or supplement, and that will fix things.
These messages, of course, are alluring. All we need to do is take a pill or do a simple intervention to fix our problems. They are much more appealing than doing the complicated work of figuring out what’s actually wrong, and then correcting the problem or problems, which might include making lifestyle changes. In reality, the simplistic fixes usually don’t work, at least not fully or permanently. The skyrocketing rates of mental and metabolic disorders are a clear testament to the failure of this approach. The field of medicine is increasingly recognizing this with its push toward personalized medicine, which acknowledges that there are many pathways to illness and that one-size-fits-all solutions often don’t work. People need unique treatment plans tailored to their individual situations and requirements.
Working with a Clinician
When treating serious mental disorders, it’s critically important that you work with a competent clinician. Serious mental disorders can be dangerous, and people should not expect to treat these without help. “Serious” symptoms include things like hallucinations, delusions, suicidal thinking or behaviors, self-injury, aggression, out-of-control substance use, severe eating disorders, and other dangerous behaviors. These are not do-it-yourself projects to handle on your own at home. You deserve competent and compassionate medical care, so please get help developing and implementing your metabolic treatment plan. It’s important that you have support and expertise to get to a healthy and safe place as quickly as possible.
For those with chronic disorders, even if just mild or moderate, you may also need to work with a clinician. A thorough medical evaluation might reveal factors that are playing a role in your illness.
Where to Start
All the contributing causes and interventions I have discussed are interrelated and affect each other. If one factor is off, others will be, too. For example, if your sleep is off, your eating behavior and use of substances might be as well. Even something like the gut microbiome can be affected by sleep, light exposure, and stress. So if your microbiome is off, changing these other contributing causes might correct that issue. Alternatively, changing your microbiome might improve your sleep or stress levels. Think of everything as being part of one or more feedback loops. Therefore, all the treatments outlined in this book are possible treatments for you, even if you don’t recognize that you have a problem in these areas. Addressing mental symptoms might require changes in your sleep, diet, or light exposure.
In some cases, it won’t be clear what’s causing your metabolic dysfunction. Worry not. Treatment approaches can still work. The goal of treatment will be to use interventions that are known to improve mitochondrial function and/or increase the supply of mitochondria. In most cases, if our cells have enough normal and healthy mitochondria, they function properly. Mitochondria know what to do. They can often fix the problem on their own.
Some of you might be overwhelmed by all the treatment options. When trying to improve your metabolic health, recognize that success requires a multifaceted approach that will take time. But this means you don’t have to do everything at once—nor should you. Start with one treatment, try it for a few weeks or months, and then add additional treatments as needed. Oftentimes, as your metabolism begins to improve, it gives you more energy and motivation. This makes it easier to make other changes. As people begin to feel better, they often surprise themselves with how much more they can accomplish. When people complete their “metabolic treatment plans,” they often don’t recognize themselves. Not only can they reduce their symptoms of mental illness, lose weight, or have more exercise endurance, but they usually also notice stress reduction, more self-confidence, more connections with people, newfound abilities, and other life-enhancing positives.
In most cases, you can decide what intervention you want to start with. Once you choose one, make it a SMART goal: Specific, Measurable, Achievable, Realistic, and Timely. Once you master one intervention, add another. Keep going until you achieve your desired results.
In some cases, however, one intervention may need to take priority over all others, as it could be having catastrophic effects on your metabolism. Two obvious examples are heavy substance use or living in an abusive environment. For those who are heavily using alcohol or drugs, the other interventions will likely be futile until the substance use stops, so address that first. For people in physically abusive relationships, the first step should be to focus on a plan to get out of that environment, as difficult and dangerous as that might be. People in this situation will likely need tremendous support from family, friends, or a domestic violence program. Trying other metabolic interventions without this first step will likely be futile to address their mental and metabolic problems.
All the interventions I’ve discussed have the potential to change your metabolism. As a rule of thumb, metabolic interventions can have four types of effects on the body and the brain:
1.Initiation—When you first make a change, this can abruptly shift your metabolism. Sometimes, this can be helpful. Other times, it can make things worse, at least initially.
2.Adaptation—Whenever you make a metabolic change, your body will work to adapt. These adaptations are usually designed to counteract the effects of the metabolic intervention. They usually don’t negate the intervention, but they will often lessen its effects compared to the initiation phase.
3.Maintenance—At some point, your metabolism will become fully adapted to the intervention and your body and brain will feel more stable. You can always increase the dose or intensity of the intervention, which will then take you back to the initiation and adaptation phases again.
4.Withdrawal—If metabolic interventions are reduced or stopped quickly, there is usually a withdrawal reaction. Metabolism will often rebound too high or too low in these situations, which can produce withdrawal symptoms.
All these situations can happen with all the treatments I’ve mentioned, including medications, light therapy, changes in diet, changes in the gut microbiome, supplement use, and even psychological and social interventions.
Remember that you’re looking for interventions that will improve your metabolic health over the long run. So, even if an intervention makes things worse initially, such as experiencing irritability when starting a new diet, if the maintenance phase will lead to improved metabolic health, it’s worth pursuing. Obviously, it needs to be done in a way that is safe and tolerable, but getting to the maintenance phase is the goal. Likewise, other things, such as heavy alcohol use, can make things feel better in the short run (initiation phase), but can impair metabolism over the long run (maintenance phase). Stopping its use (withdrawal phase) can be particularly difficult and dangerous for heavy drinkers. It’s important to keep these in mind, as starting and stopping treatments needs to be done safely.
Inpatient and Residential Treatment Programs
For some people with serious mental disorders, designing a comprehensive treatment plan might be impossible to do on their own. By definition, they have impaired brain function. They may not be able to stay on task, learn new information easily, stick to a diet, or fit all the changes into a daily schedule. It doesn’t mean they can’t do it, or that they won’t benefit from it, but they may need help. For others, mental symptoms can sometimes threaten their safety or the safety of others and trying treatments on an outpatient basis may be dangerous. For all these people, we need to develop inpatient and residential metabolic treatment programs. These programs can customize treatment plans to people’s specific needs. They can provide support not only through professionals working at the program, but through the peer support from other participants. These will be environments where everyone is working to improve their mental and metabolic health together.
Designing Your Treatment Plan
•If you have serious, dangerous, or chronic symptoms, you should work with a clinician.
•Identify contributing causes that are leading to severe metabolic impairment or threatening your safety (e.g., suicide attempts, severe substance use, living in a physically abusive environment, an out-of-control eating disorder, severe lack of sleep, etc.). If you have any of these, you need to address them first.
•Choose one or more of the treatments outlined in this book that you think might help.
•Implement the treatment and give it at least three months to start working.
•If the treatment improves any of your symptoms, even if just a little bit, keep doing it.
•If a treatment doesn’t help at all after three months, feel free to stop it.
•If a treatment helps but doesn’t resolve all your symptoms, add another treatment. You are now developing your multifaceted treatment plan.
•Continue to add or try treatments until you achieve your desired results.
Your goals might change over time. Initially, you might only want to get rid of one symptom. That’s fine. As life goes on, you might decide that you’d like to improve some other areas as well. Life is a journey. We all have areas of strength, but we also all have areas of weakness and vulnerability. No one is perfect. I hope that you will make the most of your life and strive to improve your health as much as possible. But I also hope that you can reach a point of gratitude for the health and strength that you do have and simply enjoy it.
Success Story: Beth—Overmedicated and Still Sick
Beth began psychiatric treatment at age nine after being diagnosed with ADHD. She was prescribed stimulants and did well in school, getting mostly As and Bs. However, she was still impulsive and often interrupted people. As a result, she didn’t have many friends, often felt criticized or rejected by others, and struggled with low self-esteem. By high school, things were much worse. She had chronic depression, was frequently suicidal, and began cutting herself with knives or razor blades. She tried antidepressants, more stimulants, mood stabilizers, anxiety medications, and even antipsychotics, but her symptoms only worsened. By the time she was in college, she had been hospitalized many times.
Beth was twenty-one when I first met her. She was diagnosed with chronic depression, panic disorder, borderline personality disorder, premenstrual dysphoric disorder, and ADHD. She was on five medications, and they clearly weren’t helping. In fact, she was often lethargic and out of it. She had been in a few car accidents as a result. She had returned home during her summer break from college for more intensive psychiatric treatment. At first, I prescribed even more antipsychotic and mood-stabilizing medications, which often gave her new side effects or simply didn’t work. At the same time, we began dialectical behavior therapy (DBT), which is a type of psychotherapy focused on skills that can help people better manage their emotions, suicidal impulses, and self-injury.
Beth and I both believed that medications had not helped her and, in fact, may have contributed to her problems, so we agreed to slowly taper her off them. This was extremely difficult and dangerous. Almost every time we reduced a medication, even if just by a tiny amount, she would experience an increase in symptoms—depression, suicidal impulses, or urges to cut herself. We used DBT skills to manage these symptoms and keep her safe, but we continued on with the medication taper. It took several years to get her off everything. By the time we did, things were much better. She was able to keep herself safe, had been able to hold a job, and had finished college.
The next phase of her recovery started with exercise. She began riding her bicycle outside and really got into it. She decided to work up to a charity ride. She then joined Weight Watchers to lose some weight, which helped even more. Her psychiatric symptoms were all but gone now. After many long discussions between us and her family and friends, we agreed that she no longer needed therapy or any psychiatric treatment. But that didn’t stop her metabolic treatment! Beth went on to become an accomplished athlete, competing in triathlons and ultramarathons. She got married. She got a full-time job.
Today, about ten years later, Beth continues to feel great and has no psychiatric symptoms. When I ran into her father (who happens to be a physician) recently, he gave me an update on how well she was doing and said, “You know that you saved her life. You really did. I can’t imagine that she would still be here today if it wasn’t for you.”
Beth’s case illustrates the common problem of having multiple diagnoses, getting lots of treatment, and still not doing well. In fact, it appears all but certain that the medications were contributing to her problems, if not causing them. This doesn’t mean that medications can’t be immensely helpful for some people. I think they can be. However, for Beth, they appeared to be making matters worse. Some of the medications that she was taking are known to impair metabolism and mitochondrial function, so the brain energy theory offers an explanation for her improvement off the medications. But that wasn’t enough for her full recovery. She also exercised, and lost weight, and found love, and a job, and self-respect. These all played a role in her extraordinary recovery.