Runaway Success of Medications
00:00:00
Speaker
This is a different example of kind of like, how does a medication become kind of a runaway success and maybe get used off label and potentially cause more harm than good. But we don't really know. Hello, I'm Dr. Farah White. And I'm Dr. Grant Brenner.
00:00:18
Speaker
We're psychiatrists and therapists in private practice in New York.
Significance of Doorknob Comments
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Speaker
We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time just as we're leaving the office, sometimes literally hand on the doorknob.
00:00:35
Speaker
Doorknob comments happen not only during therapy, but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out. Hi, I'm Farrah White, you're with my co-host, Grant
Psychiatric Implications of GLP-1 Medications
00:01:05
Speaker
Thanks so much for tuning in to doorknob comments today. This week, we'll be talking about the possible psychiatric implications of a class of medicines developed to treat diabetes. Since then, they've become popularized because of purported weight loss benefits. GLP-1 receptor agonists, including Ozempek and Munjaro, have been in the news and in doctors' offices more recently.
00:01:27
Speaker
We're interested in these medicines for a couple of reasons. One is that they can change the way that people interact with food and possibly self-control in other areas. Another is because of the potential to help with the weight-related side effects of psychiatric medications. An open question is whether they may have broader applications in psychiatry.
00:01:48
Speaker
Yeah, great. It's just super interesting how much hype there is around these medications. And I started digging into the research literature a little bit because a few different people taking them reported really dramatically positive changes in many other areas than just around weight control. Yeah, I think it's important for our listeners to know that this is
00:02:18
Speaker
not exactly our area of expertise and we're not offering medical advice and whether people should take them or not. But I do think you're right that we're hearing these sort of anecdotes from people. We're seeing some literature coming out that is pretty positive and not too surprising.
00:02:41
Speaker
What, what literature, cause my, my review of the psychiatric literature and there's been a couple of studies and you know, um, systematic reviews is, is that it's equivocal. There's actually no strong evidence that these medications will be helpful with anxiety and depression. There's enough data in some limited studies to suggest followup would be appropriate. And of course, anecdotal reports can be very strongly influenced by a placebo effect.
00:03:10
Speaker
No, that's true. A placebo effect is when people are taking something that's kind of like a sugar pill, a sugar pill is a placebo, and they feel that it is positively impacting them in some way.
00:03:26
Speaker
Yeah, particularly when there's a lot of sort of hype, like massed social media, and it's almost like a fad, right? It becomes cool. But if you look at the data on the psychiatric effects, there's enough positive indicators in very select people groups, like certain groups with diabetes and a few studies that show that maybe there's a trend toward helping with anxiety and depression. And so,
00:03:56
Speaker
You know, it was interesting because I was like super enthusiastic because a couple of people told me just what a huge game changer it was. And then I started looking at the data and it was like, actually, that's not panning out so far. And even with weight loss, people tend to lose a limited amount of weight and then often gain it back. And then I started looking further and I saw there were
00:04:19
Speaker
some concerns about reports of increased suicidal thinking while taking these medications, which is true of a lot of medications, including some antidepressants and some dermatology medications and anticonvulsants. So I thought that was really interesting because at first I was like, wow, I've heard some truly incredible things, like this changed the way I think. And then I looked and I was kind of like, well, I'm not seeing the data there, actually. I think.
00:04:49
Speaker
that the data is pretty new because we've just started sort of widely applying these meds to people who don't necessarily fall into that category right that's right there has been virtually no data outside of you know those groups of people so.
00:05:08
Speaker
Right. This is a different example of kind of like how does a medication become kind of a runaway success and maybe get used off label and potentially cause more harm than good. But we don't really know. We don't know. And I think there are some people, doctors who I really respect who believe and really see this as a sort of like
Lifestyle Drugs and Market Trends
00:05:32
Speaker
lifestyle, longevity, drug kind of deal, where they see that it really decreases cardiovascular risk and potentially all of the things that follow, different cancers, dementia, and those types of things. And then there are people that
00:05:51
Speaker
are still really, really cautious about it because we don't know what type of effect it's going to show that it has 10, 15, 20 years down the line.
00:06:03
Speaker
Yeah, I'm curious. So when you say people who you respect, see it as like an anti-aging medication, you know, because it keeps glucose levels down, reduces quote unquote, inflammation. And then at the same time, it's like, there's, there's no studies, there's no long-term studies. And there's a lot of people, you know, that's a whole other subject is anti-aging, medication and treatments, which
00:06:28
Speaker
certainly bring in a lot of money for people who offer those treatments, you know, things like IV infusion clinics or vitamin infusions. You know, it's interesting how people think and make decisions. Right. And I think that a lot of times doctors are afraid or maybe not afraid, but they're reluctant to say, like, we don't really know. And this has come up for me because I,
00:06:56
Speaker
basically, you know, started my practice in the sort of post, um, I stop era, right? So really only a few, what's the post I stop era. Okay. So, you know how before you prescribe a controlled substance, you have to look someone up in a database, right?
00:07:16
Speaker
That's a relatively new thing. That's what iStop is. That's the name for New York's database for preventing misuse of controlled substances. So whenever we prescribe a controlled substance, we're required to look in this New York State database
00:07:34
Speaker
And most states have their own version of it and make sure that the person isn't receiving similar meds or other meds from other doctors because people would do that. They would go to different doctors and get different prescriptions for, you know, things like Ativan or Xanax from a few different people. Yeah. And then they could, you know, would even maybe sometimes grab a prescription pad and, you know, write out their own prescription. And so now there are all of these,
00:08:02
Speaker
really, really stringent policies that we as doctors have to follow. Some pharmacies, you know, won't fill certain prescriptions, they can just decline. It's much more heavily regulated. And I think we realized that there were abuses of the system during the pandemic, for example, many companies cropped up that were
Regulations on ADHD Diagnoses
00:08:26
Speaker
really making it very, very easy to get an ADHD diagnosis, clicking through a couple of forms online and getting controlled substances. So there's the FDA and the DEA have really reacted, especially the Drug Enforcement Agency, by being much more strict. So how does that relate back to these diabetes meds? Because I have seen people who were theoretically stable
00:08:51
Speaker
on controlled substances like Klonopin, Ativan, Xanax, Xanax at very, very high doses and whose doctors who had retired thought like there's not really a reason to come off of these. One, because it's very, very difficult to taper off and two, because the patient seemed to be doing well on them. So like really what's the problem?
00:09:19
Speaker
And which is which is erroneous medical thinking for sure. Yeah.
00:09:26
Speaker
But then- Sorry, erroneous because those medications, people develop tolerance to them. And so you could stay on a high dose and it's not really doing anything. Eronious because just because things are okay, doesn't mean that it's what the person is taking is helping. And also because there's significant risks potentially for things like increased risk for dementia or other cognitive problems, as well as increased risks for falls as people get older on these medications.
00:09:56
Speaker
Yeah, I think what you just said is the reason to not be on these meds long term, taking them once in a while, they're very effective. And I do have a lot of patients who take them here and there. And it's a really great thing. But I guess it's all in how we see ourselves using the medicine.
00:10:21
Speaker
It's really really i think important whenever we start any medicine to think about okay what role do we want this to have in our lives and i feel really strongly that being tethered to. Medicine when we don't really know what it's gonna look like twenty or thirty years from now yeah it's not is not something that i would recommend.
00:10:45
Speaker
So that's more of a cautionary note with these glucagon like peptide one agonists, meaning they activate this hormonal system, which is natural to the body that decreases stomach emptying. Basically it slows down the motility, you know, how much the stomach mushes food around so that you stop being hungry faster.
00:11:12
Speaker
basically tricks your body into thinking you're full. Right. I think this, this glucagon like peptide, right? It's in the gut. And so does work on, you know, the gastric emptying and
Medication Effects on Gut and Brain
00:11:25
Speaker
the pace of it. But, you know, we also have some GLP one receptors in, in the brain, right? The same way that
00:11:35
Speaker
serotonin, right? When we prescribe an SSRI, we think, okay, this is going to help someone's serotonin levels in their brain. I don't know why we conceptualize it like that, but that's just how we think about it or how I think about it. But there are a lot of receptors, serotonin receptors in the gut as well. So when people first start an SSRI,
00:11:58
Speaker
You know, they can feel those side effects and they can, you know, sometimes serotonin increases activity of the gut. So people can get bloating or sometimes diarrhea or gas. It usually settles down in a couple of weeks. Right. Right. But often increases appetite.
00:12:14
Speaker
Yeah. So I think the point is that, you know, it's not quite as, um, clean cut as we imagine it to be even taking meds like Ozumpik and Munjaro, even if they have their exact intended effect.
Celebrity Influence on Medication Perception
00:12:33
Speaker
and someone wants to lose 15, 20 pounds, and they're able to do that. I think it brings up some other questions. I think sometimes there's a lot of shame around taking it. There are a lot of celebrities who come out and say, oh, hey, this is what I've taken, and it's great, and OK, everyone should be on it. And then there are a lot of people who are thought
00:12:57
Speaker
to have taken it, who maybe did or maybe didn't. And so it brings up this question in a lot of people's minds. What do you think about that? What do you think about people sharing their personal experiences and personal choices with like a fan base or their followers?
00:13:16
Speaker
Yeah, I mean, I think people do that, but like I said, I think there's a lot of buzz and there's really very minimal understanding of sort of long-term impact. And, you know, history is full of these types of fads with drugs that have ended up causing great harm.
00:13:33
Speaker
But I think there's a tendency for people to almost get annoyed if you bring up the potential downsides when people are really positive and excited. And if you have a celebrity and you have what they call a para-social relationship, like a one-sided imaginary relationship with a celebrity, and that celebrity is talking, is dropping names of specific drugs,
00:13:56
Speaker
I'm sure the companies that manufacture those drugs are very, very happy about it. I do wonder to what extent some of those mentions may be influencers who are essentially paid to advertise, because I don't think that's commonly disclosed, especially with social media influencers. I get comments like that from companies, by the way, periodically. And I have a very small Instagram following, still a hint, hint, follow me.
00:14:21
Speaker
And they're like, oh, we'll give you these free clothing or you'll get these free watches or free sunglasses. So I wonder how much of that goes on in the background. Where I think that I feel more comfortable with influencers is when they talk about their real struggles with mental illness or physical problems with weight, which shouldn't be shamed. And so I think
00:14:45
Speaker
I feel I have mixed feelings about how much it kind of from my from in my opinion, right, for what it's worth moves the needle in a psychologically healthy direction. So if I think something is like pro body image positivity, I think that's great. I think if people feel better about themselves, it almost reminds me of plastic surgery a little bit.
00:15:09
Speaker
then it can be a very healthy part. But I think if it's sort of a substitute for either doing things that are more sustainably healthy or a substitute for certain, how do we wanna put it? Kind of personal development goals that are more psychological and emotional, then I think it could sort of interfere with people developing in ways that I think happen more with life experience and sometimes psychotherapy.
00:15:39
Speaker
I'm wary, I would say. But I feel more comfortable, like I said, when celebrities talk about, you know, how they overcame abuse. I think that's less unclear to me. Right. And I think that that if it can be taken as a message of encouragement and, oh, persevere, you know, but I think we're all sort of navigating this balance between what can we change and how much do we want to change?
00:16:07
Speaker
And what do we have to accept? In terms of your personal kind of path through life. Personal path through life, but I also mean, you know, in terms of our bodies, there are going to be a lot of people who will eat right and exercise and get enough sleep and be pretty healthy, but they may not look the way they imagine they should look. And I think certainly these meds are helpful with that, but then we sort of have
00:16:37
Speaker
you know, another thing now that we can change without accepting. And I think that's, that's tricky. Yeah. I mean, well, it's, it's complicated because body image is large to a significant extent is driven by culture. Yeah. And so you can, you can debate whether wanting to change one's image is quote unquote healthy or not.
00:16:59
Speaker
if you're trying to conform to an impossible ideal, maybe one that's also been like altered by AI so that it's not realistic. What's a healthy body image? And so there's conflicting movements in our culture. Like there's movements for models to have regular bodies or even models who are disabled.
00:17:17
Speaker
or who are disfigured in some kind of unconventional way. And I personally like the idea of being more inclusive and accepting.
Social Media's Impact on Mental Health
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Speaker
And there's very high rates of anxiety, depression, body image disorders that are, you know,
00:17:32
Speaker
clearly driven in part by social media and cultural shifts. And if medications are kind of feeding into the unhealthy side of it, then I'm wary. And if medications are supporting people's healthy development about their body and their psychology, then I feel good about it. Yeah. And that's where I think, I agree with you, but that's also where I think
00:17:57
Speaker
I have never prescribed these meds, and I don't know if you have. No, I don't think they're typically for psychiatrists to prescribe, except possibly if you treat a lot of people with a class of medications called atypical antipsychotics, and you're seeing a lot of abnormal weight gain because those medications are almost like the opposite of meds like this. I think in those cases. Yeah, so what Grant is talking about
00:18:26
Speaker
is that there's a percentage of our population, I would call them the most vulnerable, people who struggle with really, it's called SMI, I don't know, serious mental illness. I think all mental illness is serious. But I guess this, I don't even know where the term came from, refers to people who are really struggling with
00:18:49
Speaker
psychotic disorders that are persistent. Like schizophrenia. Like schizophrenia. Bipolar disorder. Bipolar disorder that really interfere with our ability to do things like maintain healthcare and housing. Yeah, but I think that's true, yeah. However, a lot of the class of medications we're talking about are what are sometimes called atypical antipsychotics.
00:19:16
Speaker
are used to treat these disorders like schizophrenia and bipolar disorder, but they're very commonly used more and more to treat people who have depression and they can be very effective. And so there's a lot of patients who gain weight on psychiatric medications who don't fall into that, perhaps poorly named serious mental illness,
00:19:42
Speaker
And I think that's a real problem because we know for sure that those medications can cause weight gain and put people at increased risk for cardiovascular disease and strokes. And so in those cases, I think sometimes psychiatrists who prescribe a lot of those medications will prescribe like GLIP-1 agonists. Yeah.
00:20:02
Speaker
But otherwise, I think what you're looking at is something that's more like a cosmetic procedure, like if a psychiatrist is giving it to someone to help them lose weight when they haven't had a proper evaluation with a bariatric doctor, because there's a high consumer demand. Right, but what if someone comes to you and says, I've been so depressed, I'm probably going to lose my job, I can barely function,
00:20:31
Speaker
The last time I felt good, I was on Lexapro, but I stopped it because I gained 20 pounds and I do not want to switch one problem for another.
00:20:41
Speaker
Yeah, that's a reasonable indication to consider combining a weight loss medication with an antidepressant. And the New York Times has a number of articles on these meds and they had a report like that, someone who really found that medications weren't working because of reasons like this, or it was so uncomfortable to take them that it was like the lesser of two evils, but she felt quite bad about herself
00:21:10
Speaker
because of the effect it had on the body, let alone the long-term health effects. But I think you're talking about antidepressants that can cause weight gain rather than atypical antipsychotics. And I don't know if the data is quite there yet with antidepressants.
00:21:27
Speaker
Maybe not. I guess it's not necessarily the weight loss is not necessarily sustainable with with these meds. There's many reports of people losing weight and then having it mainly come back. Right. Right. That's that's. But if it were true, if it were true that it helped someone to stay on the medications and they really needed them and they really helped them. Yeah, of course. That makes sense.
00:21:50
Speaker
Yeah. And I think as a psychiatrist, one of the jobs is, you know, not necessarily finding like the right medication or the right treatment. There are a lot of right treatments that people would never accept. Right. And that's why they call it like collaborative care because it's like, well, what can we offer? Right. And what is that person going to accept? And what are you willing to do? Right. Right. If you don't, if you don't agree as a physician,
00:22:19
Speaker
not obligated to do treatments that you think will do more harm than good, for example, or maybe not beneficial. And that's one of the problems when when drugs get a huge amount of hype, because then, you know, people come in asking for those drugs. And of course, that's the purpose of advertising. There's a lot of direct to consumer advertising for a variety of medications, which generate huge amounts of money. Yeah. Yeah. And I think maybe our relationship
Patient Empowerment and Treatment Doubts
00:22:49
Speaker
with our patients is a little bit different. I always tell people that I want them to bring up what they found deep in that Reddit thread, especially if that's the thing that makes them not want to take the medicine or not want to try the medicine. And I'm always really curious about it. I think it's an opportunity for us to unpack the why. And sometimes it'll be something really surprising that I'm working with someone who I don't know that well,
00:23:19
Speaker
And they'll say, well, yeah, I'm not going to take anything that, that could affect my sex drive because it's the one area of my life that's actually okay. You know, and then I think, okay, we've got to go back to the drawing board and we've got to see what else is out there to help this person for what they came in with. And it is hard to say, at least for me, well, right now, I don't, I probably wouldn't feel comfortable prescribing it. I do feel comfortable.
00:23:48
Speaker
working with endocrinologists who I really like and respect and having them be on board and getting their opinion and expertise. But I think for me to prescribe it, I would have to know a lot more than I do and understand and follow things that I don't typically follow when people are in treatment with me.
00:24:10
Speaker
Yeah. Including labs, right? Because medications can cause blood sugar to be abnormally low. Yeah. And you know, some of these side effects are no joke. So there have been some anecdotal reports and I've heard this from more than one person that, that seem different from just being a placebo response. Um, it's hard to tell because there's so much hype with these GLP one agonists that maybe the placebo is just so amped up.
00:24:38
Speaker
But I've had more than a few people tell me that almost immediately upon taking them, they feel a greater sense of self-control and that it's kind of like a global change in the way they experience their mind working. I've had a couple of people say, gee, maybe it's good for ADHD or maybe it's good for other addictions. And again, there's no data, but that's not the only thing. Data isn't the only thing.
00:25:06
Speaker
A lot of medications that turned out to be really, really good for people were designed, you know, for one thing. And then we noticed that they helped with another thing. So you have to take those stories with a grain of salt. But I think you have to take them seriously as well. That's why I started looking through the literature. Right. And there's some studies underway. Right. Yeah. Yeah. But I also think that, you know, how we see things like emotional eating
00:25:35
Speaker
shopping is often called like, Oh, retail therapy. Right. Oh, like it's just like a different, it's dynamic psychodynamic therapy or retail therapy. You know, like these are things that really buys retail. They're just saying the term, I think people still use that term. Is that shopping? I don't know. I'm saying like, I'm always looking for a sale. Yeah. Yeah. I never pay for retail. Right.
00:26:02
Speaker
But again, it's shopping therapy. Yeah, retail therapy. Wholesale therapy. Yeah, the point is that... We tried to be more effective wholesale therapy, but... Right. And we always are sort of reaching out for things, these lifelines to make us feel better. And I think food is the ultimate
00:26:26
Speaker
comfort, right? It's the original thing that soothes us. And it's really, really hard, I think, for people, especially in this generation, to have a relationship with food that feels comfortable. So I always joke like, oh, well, what if we didn't spend so much time thinking about food or our bodies or what we ate or how much money we earned? And what if those things could just sort of fade to the background?
00:26:54
Speaker
Right. Well, this is like an old sort of philosophical question about the roots of human suffering in excessive attachment. And many spiritual traditions have sought to free people from, you know, these entanglements with desire. Exactly. So I think maybe you can take a drug that just knocks that out. Like, why not? Right. Why do all the work of, you know, personal development?
00:27:23
Speaker
Why climb to the top of the mountain when you can just take the lift? Yeah. And, um, there have been, I think tons of like novels and movies and just imagining, Oh, if you could take a pill for something. And I think this is one of
00:27:41
Speaker
the closest things
Mindful Mental Health Treatment
00:27:42
Speaker
we have. And so that's why I'm glad that we talked about it today, but you're right. I think it's presented as one of the closest things that we have, but I'm not at all convinced that that's true. We always say that you're saying that about psychedelics.
00:27:56
Speaker
They say that about certain kinds of therapy. CBT's effect size has been declining. There's always this buzz. And so I think one thing for listeners is to really be thinking about what these things mean. And understanding that there are risks and benefits and limitations and that it's
00:28:20
Speaker
It's a choice that should be made with intention and with your doctors oversight and i think with it within the context of a good sense of how you see the world and your role in it and not just maybe.
00:28:37
Speaker
this kind of quick fix culture, I think doesn't make people happy in the long run. But can I ask you in the last couple of minutes here, we have a couple of minutes, just like an absurd, an absurd example and see what you think. Sure.
00:28:53
Speaker
OK, this is this is going to sound really nuts, but I thought of it when you talked about food being the first form of comfort as well as touch. Right. And food and touch, of course, would go hand in hand for for babies who are being breastfed as it's touch and feeding.
Ethics of Medicating Infants
00:29:10
Speaker
Sometimes babies, they wake up at night hungry, right? And that can be tough on the parents. What if you could give a baby a drug that would suppress its appetite so that the parents could get better sleep? And obviously not enough to affect the baby's development or nutritional status. Would you feel comfortable giving a baby a drug to regulate its appetite so that parents would have a better time as parents? If not, why not?
00:29:39
Speaker
No, I wouldn't because I think. And it's perfectly safe. There's no long-term side effect. It's not perfectly safe though. We don't know that it's perfectly safe. No, it's been proven. Let's say in this thought experiment, they've done all the experiments. It's not going to harm the baby. All it's going to do is give the parents like a better night's sleep.
00:29:58
Speaker
I feel like I'm very mother centered and I want moms to have tons of support and I don't want them to be exhausted. If that means they can't breastfeed, I don't personally care that much. But I do think that we're talking about, you know, when the infant is born, they have a stomach the size of a walnut, right? So they're waking up because they need
00:30:27
Speaker
that touch, they need that care. And of course it's okay to work with the baby's natural biology, in my opinion, to optimize it. So there are all of these books 12 hours by 12 weeks and all that stuff. Do I think that we in our society need to be minimizing the demand
00:30:53
Speaker
of infants when we have so much extra manpower? No. And women power? No, I don't think so. I think we should, you know, certain things I think we'll never know, you know, what
00:31:09
Speaker
the effects are of not attending to a baby's needs, but I see people all day, every day, and could continue to see people for the rest of my life who are struggling because they didn't have their needs met, right? It might be hard to say no if they want a GLIP-1 agonist then.
00:31:31
Speaker
It's the least you can do. It is. And I, and that's why I don't say no. I say, Hey, why don't you go see this really lovely doctor? And let's do it right. Very good. Very good. Anything you want to throw in at the end? No, we'd love to hear about your experiences and you know, either whether you've taken these meds or
00:31:55
Speaker
you know, had a good experience, bad one, what you would want people to know. Like I said, we're not experts.
Final Thoughts and Listener Engagement
00:32:01
Speaker
We looked at a little bit of the data, but it's, you know, I think a lot will be coming out over the next three to five years. Hopefully that will
00:32:13
Speaker
Help to clarify things. Yeah. So you can reach out to us at hello at doorknobcomments.com. And we are on Instagram and Twitter. Stay tuned. Send us questions and look for more from us. We're going to be developing the podcast. So we would love to hear about ideas for guests or topics or any questions you'd like us to answer. So thanks again and happy. Well, I hope you had a good New Year because this is going to come out probably after the new year. Yeah, well, well.
00:32:42
Speaker
I hope you had a good holidays in New Year's. Remember, the Doorknob Comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.