An interview with Drew Ramsey on nutritional psychiatry.
Chris Aiken, MD, Kellie Newsome, PMHNP, and Drew Ramsey, MD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Published On: 11/29/2021
Duration: 12 minutes, 13 seconds
Referenced Article: “Nutritional Psychiatry in Practice,” The Carlat Psychiatry Report, November/December 2021
Today we interview Drew Ramsey on the new research behind nutritional psychiatry. And pay attention, because at the end there’s going to be a test. That’s right – a real CME test so you can start earning credits directly from the podcast.
Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
CHRIS AIKEN: I first became aware of nutrition and depression in 2006. I was treating a man who did not change. At every visit he had the same bleak expression, the same monotone voice, and when a new medication or psychotherapy was suggested he would decline the offer with the same morose passivity. He didn’t socialize. He was unable to work. He didn’t have goals. He didn’t have complaints. What he had was chronic depression.
Then one day he came in with a spring in his step and a glow in his eyes. He spoke spontaneously, and his conversation flowed – he was playing cards with old friends, reading books, gardening. I asked him what had made the difference. “I gave up fast food three months ago,” he said.
In all my attempts to help his depression I had never thought to ask what he was eating, but if I had I would have learned that he was on a steady diet of 2 fast food meals a day.
At the time there were no clinical studies of nutrition and mood, but there was basic science, and the general picture there was that the Western style diet was as bad for the brain as it was for any other organ. Trans-fats, processed foods, sugar, refined flours, fried and fast foods all took a toll on brain health just as they did on the heart, the kidneys, and the liver. Some nutrients like folate, omega-3’s, and flavonoids seemed particularly good for brain health, but in general the kinds of foods that were good for the body looked good for the brain as well.
KELLIE NEWSOME: The next big leap came in 2017 when the first clinical trials of diet in depression came out. But the news didn’t make a big splash in America because the researchers were all in Australia, although the studies came from 2 independent groups in Australia. But a few American psychiatrists have taken up the cause, and today we’re going to interview one of them, Dr. Drew Ramsey.
Dr. Ramsey has written several award-winning cookbooks, and this year he released a patient friendly guide to this research based diet: Eat to Beat Depression.
CHRIS AIKEN: Thank you for joining us Dr. Ramsey. Can you start by telling us – why do psychiatrists need to know about nutrition?
Dr. Ramsey: All mental health professionals should be talking about food and lifestyle because it’s foundational for our patients’ health. You can’t have brain health and mental health without proper nutrition. And as clinicians who are looking for levers to pull – you know being a psychiatrist or being a mental health professional it’s a hard job, and trying to find a way in to really help patients get better we really want all of the tools we can have. That’s where nutritional psychiatry I think offers a lot of promise.
CHRIS AIKEN: Patients are very interested in this approach, and so is the media – is it being overhyped?
Dr. Ramsey: Certainly, I think mental health professionals and psychiatrists are often frustrated because nutritional psychiatry gets misrepresented. It often gets presented as a singular super food or some wild spice or supplement that you know suddenly everything is going to be better about your mental health. And that’s not nutritional psychiatry; that’s the BS – I don’t know what you’d call that – probably should put something quotable or what. That’s a misrepresentation of the science.
But I think what should also be clear is that there is now a lot of science. I would argue that if you’re not talking about nutrition in your practice and you’re a mental health clinician you’re not really practicing evidence-based care anymore in 2021. Nutrition certainly isn’t the only thing you should focus on. I am an avid practitioner of psychotherapy and psychopharmacology
CHRIS AIKEN: Those are all good approaches, but does nutrition bring anything new to the table?
Dr. Ramsey: Talking about food I think does a few things for us as a field: 1) It puts us in the prevention business; by talking about food and nutrition around the country I get to talk to people about their mental health before they have mental health concerns. I think that’s really important for us as a field. It’s often hard to engage people about mental health though it’s getting much easier, but nutrition – and especially nutrition related to mental health really leads to a very organic conversation with a lot of people about their inner world.
CHRIS AIKEN: Yea it can build trust when the patient knows you’re not just interested in how medications affect the brain. Tell us about the research on diet and depression.
Dr. Ramsey: There are now a number of randomized trials showing that individuals with depression even with severe depression can have significant benefit from dietary change added on to treatment as usual. We know we have millions of Americans who have treatment-resistant depression and most of them have not gotten any dietary interventions or dietary encouragement from their mental health professional team because we’ve lacked the evidence. Between the SMILES trial and the Healthy Med trial you know along with Heather Francis’ Trial in Australia, there are now three strong randomized trials showing that speaking about food and nutrition and influencing individuals’ diets to increase their nutrient density, to sway people towards a more “Mediterranean-style diet” has significant health impacts that last up to six months.
CHRIS AIKEN: Depression can get better just by taking on a new challenge, including a new diet. So how did they control for that in these studies?
Dr. Ramsey: The controls in the SMILES trial were a “befriending” protocol. So this is a research protocol that it tries to control for the aspects of being in a new group, having someone who is listening and concerned and cares about you. And in the Healthy Med, which was a group intervention … and so this I think has a high placebo effect – I often joked that you know it certainly would help my depression if every Tuesday night I get to go to my group Mediterranean-style cooking class and you know taste olive oil and hang out with my other friends struggling with their mood. I mean you know that just – regardless of what we cook I think that’s gonna help. That was also well controlled in terms of having an activities group.
CHRIS AIKEN: I think there are 3 positive trials now – two in clinical depression, one in non-clinical depression, and then there are a lot of other studies of diet in medical illness where they looked at depression as a secondary outcome and most of those are positive. But I start to get suspicious when all the studies are positive. Are there any negative trials?
Dr. Ramsey: There was a negative trial – the (Good Foods Trial) was a complicated trial looking both at nutritional interventions and also at supplementation. So there were four groups in this trial, really good commentary and discussion of that trial by Felice Jacka, one of the leaders in nutritional psychiatry and one of the leading researchers. So I would encourage folks to look into that. One of the critiques of that trial was that it was psychologists who were trained to talk about nutrition. As much as I’m excited about the evidence, there is a limitation in the evidence.
And part of our message and our hope and what we teach is to help individuals and help clinicians restore joyfulness with food. I think so many patients; so many people are just really in an awful relationship with food. Food is filled with guilt, filled with burden, filled with a lot of fear, so we really hope that in our work – we don’t just help people eat more wild salmon and more leafy greens and rainbow vegetables, and the foods that we tend to emphasize help to restore more of a traditional dietary pattern, but also to really use food for its full power, which is how it can influence our ability and engagement in our own self-care and in those around us.
CHRIS AIKEN: Thank you Dr. Ramsey.
KELLIE NEWSOME: Catch more of Dr. Ramsey in our Nov-Dec double issue where he gets into the nuts and bolts of how to teach the diet in practice, what types of patients respond best to it and what types of patients you should avoid it in, as well as other pearls like how to modify the diet for vegetarians.
Drew Ramsey is an assistant clinical professor of psychiatry at Columbia University and the author of several books on nutrition and mental health including 2021’s Eat to Beat Depression. He runs an online course in nutritional psychiatry through drewramseymd.com.
And now for the word of the day….Flavanoid
KELLIE NEWSOME: Plants are full of polyphenols that we use to dye fabric, make natural plastics and to eat. One class of polyphenols that’s showing up in brain research a lot lately is flavonoids. The general trend is that foods that are high in flavonoids reduce depression and improve cognitive functioning. Flavanoid-rich foods include berries, red grapes, green and black tea, coffee, dark chocolate, parsley, and citrus fruits.
This month, a new study on flavonoids came out that looked at flavonoids in new mother’s after childbirth. Katie Barfoot and colleagues at the University of Reading, London, randomized 41 new mothers to add a daily flavonoid-rich food to their diet or to a control group that was monitored with no intervention.
Here’s the list of foods they gave the women: 120 grams of berries; 2 large squares of at least 70% cocoa dark chocolate; 4-5 cups of tea or coffee; 1 glass of red wine; 1 serving of dark green leafy vegetables like spinach, broccoli or cabbage; or 1 glass of fresh orange or grapefruit juice (not from concentrate).
The women were not selected for having any psychiatric disorders, but nearly 2 thirds of them had high levels of anxiety – not unheard of for a group of young mothers. And here’s what happened after only 2 weeks of this simple intervention – their anxiety levels went down, and their quality of life went up; but only the women on the flavonoid diet – the control group didn’t change.
CHRIS AIKEN: Wait a minute. These women were given a list of flavonoids to add to their diet, and one of those options was a glass of red wine. How much wine are we talking about here?
KELLIE NEWSOME: It was about a metric cup. But surprisingly wine was one of the least popular items that they chose to add – second only to bitter grapefruit juice. Most of the women went with the berries, coffee, tea, or orange juice.
CHRIS AIKEN: I’d love to see the breakdown on coffee vs. tea, because caffeine can raise anxiety, but tea has extra ingredients in it like L-theanine that balance that out and lower anxiety levels. When you get into it, nutritional psychiatry is full of surprises, much like psychopharmacology.
Join us next week for a special edition from our child team, A Child Psychiatry Research Update Extravaganza
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