What would be a curious question you would think about is how can we do health care better? I guess I'm curious if you could see yourself, you know, referring someone with a serious mental health condition to do this type of treatment.

And it's a bigger question too, I think what you're asking is what is missing and how can we get there as a network, as a community? And I think that is really supportive of a vision that takes us beyond our own practices, but to other elements of what's needed.

My curious question is, what do you feel like is the biggest thing that you're taking away from this conversation today? My biggest thing is I really honed in on this idea of metabolism and really feel that that's where the conversation sometimes needs to begin.

Welcome to the To Curious MD podcast. I'm Dr. Ali Ahmed. With the wisdom from holistic, alternative, and these conventional medicines, we are here to challenge the status quo.

We're curious about the connectivity and complexity between diverse fields of knowledge as they relate to consciousness, chronic illness, mental health, resilience, and beyond.

Learning more about the art and science of healing, or listening to stories of extraordinary healing. You're in the right place. Let's dive in. This is a space for the curious.

And today we're going to dive in with our conversation with Dr. Matthew Bernstein, known as Matt Bernstein, and Sophie Kwas. And today we hope to have a conversation on metabolic psychiatry, where metabolism, psychiatry, especially in complex care, type psychiatry I imagine, helping patients rediscover how that approach in mental health can be approached by restoring cellular energy.

And I'm going to also introduce Dr. Matt Norenstein, who is a Harvard-trained and in psychiatry, and so happy to have you, and a member of the Open Mind Foundation.

He also has a practice in Elhorn Center, as well as a core center where leading kind of center and really approaching metabolic and integrative psychiatry with nutrition and lifestyle changes to address sometimes the biological roots I would imagine of mental health.

And Sophie Hwas is a clinical social worker who earned her undergraduate at University of Vermont in Burlington and her master's degree in social work at Simmons University and has also worked alongside with Dr.

Matvernst at the Center Court Center as a social worker and at McLean Hospital in Belmont, Massachusetts for over eight years where she leads an inpatient program in specializing in bipolar and psychotic disorders.

and I believe together both Sophie and Matt really work on a variety of patient population. But specifically, I hope we can really talk about in this conversation is how does mental health or mental psychiatry, metabolic psychiatry, show itself in our adolescent and young adult population.

What has been your experience there? And that's what I hope we can talk about today in this podcast. But before we start, what's your story? What is it about this work that brings you to this place where this is such an important component to healthcare for you?

Yeah, so I can share. So I worked in the traditional mental health setting for many years and found that there were many passionate providers, people who provided excellent care.

And I always felt like there was something missing. The message was often given that meds and therapy is the treatment for mental health, and that's the standard of care.

And if you don't follow treatment recommendations, you're at high risk of ending up back in the hospital or symptoms continuing. And I always felt that there had to be something more that we could do, that there had to be another way.

I would treat a lot of patients who their psychiatric symptoms improved with medications, but then often struggled with their ability to fully function and to really thrive in their life.

A lot of people who were former athletes, who were put on antipsychotic medications, and then really struggled just to get up off the couch and to live their life and to exercise and move.

And so while the traditional system really helped people in these acute crises, there are a lot of times that it was difficult to see some of the side effects that people were struggling with.

And so when I learned about metabolic psychiatry, I thought it was really incredible because it aligns so much with what I see help our clients, which is Nutrition, exercise and movement, practicing mindfulness, their sleep schedules.

And seeing all of those things come together and really help people is something that I'm really passionate about. And so I learned about the Accord program.

I started doing a lot of my own research on metabolic psychiatry and just found it really aligned. And I'm really honored to be a part of the Accord team and to be here today to be able to talk about this work in this field.

Thank you. Powerful message of kind of recognizing that the side effects and the effects of treatment can really have on the outcome. So, and I can hear your passion towards something that makes more sense to you, right?

Yeah. Exactly. Exactly. It really does make a lot of sense. And I noticed for myself, too, that when I'm exercising and moving and I'm eating well, I feel better both physically and mentally.

And I think those things are so interconnected. We often separate physical and mental health when in reality they're so interconnected and we can't really separate them.

Right. Tell us more about you, Matt. What's your story and what brings you to this place that you're doing the work? Yeah, I'd be happy to share a bit.

I've been in practice for about 25 years as a psychiatrist. So I've, you know, I've seen a lot and I mostly worked with this kind of population with people with more serious mental illnesses.

And exactly as Sophie describes, we just don't have great functional outcomes with with these people. The best we can hope for if people take their medication and go to therapy is maybe stabilizing, staying out of the hospital, reducing symptoms.

But we're not getting people back to living their full, productive, full lives. And that's really what we should all be caring about. And a lot of that does have to do with the medications themselves having such tremendous side effects.

metabolic side effects, but also sedation and just generally reducing motivation and cognition and energy and those types of things. So I've always observed that.

And then, you know, even still, I was practicing pretty traditionally until I really had a change in my mindset. You know, two of our three kids got sick with What seemed to be looked like a psychiatric disorder turned out it was much more medical in the end when we when we finally figured it all out.

They had autoimmune encephalitis from exposure to infections and toxins. And, you know, eventually, you know, we found our way to getting them help. But it really highlighted for me that a lot of people are out there suffering with what looks like a brain condition, but it's really originating in the body and in our field of psychiatry, unfortunately, has really separated the brain from the body.

And that was another reason why this metabolic intervention is so attractive because we're back to thinking about the whole system as one. due to the body with food and exercise and movement will have beneficial effects on the brain and mental health.

And that's exactly what we see when we do these interventions. We have really profound benefits on brain health and mental health through these interventions that seem to be focused on the body.

Yeah, the body, the mind, the emotional health, the spiritual health, the context of what's happening to that body in the space that they're living in, right?

Especially for our younger adolescents, which has been my experience in health, mental health care, extensive amount where you're seeing the victim, I would say, the child, the adolescent that's growing up in an environment and then becomes the problem for the family when there's a complex situation.

But all the focus is on that young adult, that child that's you know, really a representation of so many things. And when it comes to adolescents and our young adult population, the mental health, that care that's being provided, what do you feel is working and what is not specifically for our teens and young adults today?

So I did a lot of work in inpatient psych in my training as well and spent some time working in that field post-graduation too. I think we do a really good job at crisis stabilization.

There's some good programs around family work. And I think where we struggle the most is giving these teens and young adults the message that there's something wrong with you, rather than let's really look at all these environmental factors.

And we often put kids on medications. We don't really evaluate a full biopsychosocial model of what's going on within their environment, what's going on within the family dynamic, what's going on at school.

How do we make changes to one's lifestyle to really help them get better? And so I think that's one of the biggest things that I see is missing. And a lot more work around keeping kids within their environment and how do we make these changes within their own environment so that they can build connection, build community, meaning and purpose in their lives.

I think all of those things are so important for teens and young adults. Yeah, as we see our numbers rise and our access decrease as we become even more complex and our generation and the generational differences to that approach to their care, right, is also present.

How do you reach a generation like this with this focus that you have in metabolic psychiatry to really address that core issue, which you talked about, Matt, which was that there's something else that could be happening, that autoimmune effect.

How do you make that approach in the care that you provide now? Yeah, well, we're really trying to help people, you know, make this connection again between what's going on in their body and then their mental health, which if you take a look at what's around in the culture, we divide these things up completely.

You know, we have, you know, maybe a video about how to take care of your anxiety or something like that. And then, you know, the next thing is all about, you know, a commercial for eating some kind of fast food, you know, wings and this and, you know, French fries and sodas and all of that.

No one makes the connection that if we keep eating that way, we're getting metabolically sick. And there's an epidemic of metabolic illness, not just among adults, but among kids.

And there's actually direct data to show that the metabolic health of kids will directly affect their mental health as they get older and into their twenties.

So, I mean, I can just throw out some statistics that kids with the highest levels of insulin at age nine, have a three-fold increased risk of psychotic disorders in their early 20s.

And the kids who gain the most weight in puberty will end up with a five-fold increased risk of major depressive disorder in their 20s. And so these things are intricately connected, and yet people are going around as if it doesn't matter that if you eat pizza and burgers and fries all day, then try to take care of your mental health later.

But we need to actually be thinking about it all around, including what people are eating. I do agree, but if for our audience, how would you really relay this idea of their insulin level and that effect on their mental health?

How does that actually happen? Yeah. So, I mean, I'll try to explain it in a way that's kind of easy to understand. It gets a little complicated, but it has to do with brain energy, essentially, the energy of each neuron or brain cell.

And we know now in all of these mental illnesses, whether it be depression or psychotic disorders, bipolar, autism, ADHD, Alzheimer's, and name any brain disorder, disorder of energy.

Essentially, we can't get the energy into the brain. And that has to do with this idea of insulin resistance. So if the neuron can't get an insulin signal because it's insulin resistant, it can't get that glucose into the brain to burn for energy.

And so we need to reverse that insulin resistance and provide this different source of fuel coming from fat. Fat will get chopped up into these little ketones that get into the brain and that doesn't need insulin to get into the neuron.

So we bypass that blockade of energy essentially. And in addition, what these ketones do is they are better fuel for the mitochondria. The mitochondria are these little energy factories in the cell.

And so we're providing this fuel that the mitochondria like better and the mitochondria will reproduce and become healthier and they make more energy.

But the mitochondria do a lot more than make energy. They're also, people call them sort of like the little CEOs of the cell. They control kind of everything that's going on in the cell.

And so we're going to make every brain cell healthier and happier. But really every cell in the body, we see all kinds of physical health benefits when people do this diet in terms of You know, sometimes having more energy, better concentration, losing weight that they wanted to lose.

People's skin gets clear. We just see all kinds of benefits. And so that's sort of a basic explanation of sort of a little bit how this works. very complex, but it makes a lot of sense when you look at it from a cellular way.

That is how energy is metabolized or used and the efficiency factor of how that's done and the interaction that that energy has even on the body and the response of that energy breakdown or metabolism on the psyche.

So walk us through a little bit about if I was a patient depressed or anxious, extensive amount of trauma, imagine, been medicated on medication. How would this conversation look like to get me to where you think I could be?

I often talk to people about also helping them understand what hasn't worked. Many of the folks who are reaching out to us have been through other treatment programs or have been in and out of psychiatric hospitals and are still not thriving, living their lives to the degree that they want to be living them.

And so, you know, the biggest question is, are you willing to make changes in your life to feel better and to give yourself a chance at really living a full, successful life?

And, you know, it's easier for some people to just take a pill every day, and that's what they prefer. And actually making changes in your lifestyle is really hard.

So a lot of what I'm doing is kind of assessing motivation and also helping people build motivation. Oftentimes, we get people to a point where they're willing to try these things, these changes in their diet and getting them exercising and moving and sleeping in good cycles and practicing mindfulness.

And then that motivation really grows as they start noticing that they're feeling better. So a lot of my initial work is getting people kind of willing to give this a try.

It's different. A lot of people aren't as familiar with how ketogenic therapy can help mental health. A lot of people think it's just kind of like this fad diet for weight loss.

And so a lot of what I'm doing is just educating people, helping them understand how could this help you feel better? What could your life look like if you were feeling better?

And then we work together on growing that motivation as they start to notice these changes within themselves as well. So that's kind of a lot of what I'm doing.

It's just educating, helping people understand and seeing what their life could look like. And also that there's always other options. I talk to a lot of people who feel hopeless, who feel like I've tried everything, nothing's worked.

You know, what's the point? And part of what I do is like, I always think that there's a point. I feel like we can always keep trying different things to help people to get well.

And this is a different approach that does take some effort. It takes some work to change our lives. But then so many people feel like, actually, this isn't that hard.

When I feel this much better, I can't imagine not doing this. Yeah. Yeah. I think it sounds like, you know, kind of asking for that place where they're at, right?

Where are you at? What has worked? What's not worked? What do you imagine for yourself? How do you see that part of you? And these are the ways, and educating sounds like it's a very important factor to that awareness that is often needed to make change.

What are some of the questions? What are some of the things that come up in the type of cases that you see at your center, especially because it's an inpatient program?

Tell us a little bit more about the experience that people have in this residential way of addressing their mental health. So I personally meet with every client before they come to a cord and I'm evaluating going all the way back to birth.

You know, were there any complications with your birth? Did you meet your developmental milestones on time and kind of going through their whole life?

When did things start to become harder? you know, what was that like for you? What has your treatment experience has been like so far? You know, tell me about any other programs you've been to.

You know, many of our clients have had hospitalizations and so they're sharing those experiences with me as well. And really just hearing people's story, which I think is so powerful is, you know, just sitting back and letting somebody share their story with you as well.

And then assessing, you know, are they willing to make these changes in their life? And really talking through that and sharing like, what is that going to look like?

And then we're also doing really extensive metabolic lab work before they come in to get a baseline of where they're at as well. We're doing body composition tracking, continuous glucose monitoring, daily ketone level checks, mental health screenings.

So we're really gathering a lot of data, some before they come in, some while they're in the program as well, so that we can really best support them.

Tell us more about the program that you have and, again, what they're, you know, any particular stories of transformation or things that worked and what didn't work.

I think the biggest thing is a willingness to try. When, you know, it's really the parent's idea and their loved one doesn't want to make these lifestyle changes, right, it doesn't really work.

Someone needs to have a degree of willingness to come in and to make these changes. And then, you know, once they're with us, we've seen really incredible outcomes.

And through our program, they're working with myself. I'm a licensed social worker. I'm also the program director here at Accord. And they're also working with our dietician who's there full-time crafting meal plans to their own unique needs, measuring out macros.

They're working with our chef on going to the grocery store and then preparing the meals. And the months that we can here in New England, they're out gardening as well, using really fresh ingredients, learning how to do that.

They're in groups, you know, primarily educational groups with Matt, with myself, with our dietician, with the chef, you know, really learning, like, how do I make these lifestyle changes, but also how do I sustain them?

long term, because if we just do it for people, then they're not going to know how to continue it when they go home. So sustainability is a huge part of our program.

They're also working out with personal trainers in the community, ideally working out on their own as well. We're going for walks after meals, helping stabilize glucose levels.

We're teaching them different mindfulness strategies, different approaches, and really figuring out like what works for each individual person. We're working on their circadian rhythm alignment.

So really, really individualized approaches to improving metabolic wellness based on each client's goals. And we really value clients being in the driver's seat of their treatment.

You know, what do you want to get out of this? What are your goals for yourself and for your life? And how do we align our care to help them work towards those unique goals?

We've seen really incredible outcomes. We've seen significant improvement in people's level of functioning. We've seen improvement in people feeling heard from their treatment team, which I think is so important and so powerful.

We've seen improvement in various metabolic markers and various mental health screenings too. We've seen people feel like they've gotten their lives back on track, seeing reasons to keep going and to move forward with their life as well.

Your clinical focus, Matt, in this, you're bringing in metabolic psychiatry into the realm of healthcare currently. How do you see that? How do you see this approach in conventional health, conventional psychiatry?

Why do you think it's not there right now, or what do you think is going to happen? Yeah, I mean, it is pretty new in mental health to think this way.

You know, we've for a long time decided that, you know, everything's going on in the brain. There's, and it's all about neurotransmitters essentially in psychiatry.

So, you know, we've got some imbalance or deficit in serotonin that might lead to. depression or anxiety, and we've got some imbalance in dopamine that might lead to a psychotic disorder.

And, you know, that's the way we've kind of think of things in psychiatry. We've decided that, you know, what's going on in the brain in the primary. But there is actually a long history of thinking this other way, thinking about diet and brain health.

Going back to over 100 years ago is when the ketogenic diet was invented. And again, you know, people sometimes think of it as this fad diet from the internet, but it was invented at the Mayo Clinic.

in 1921 as a treatment for epilepsy. That's where this diet was invented. And there's abundant evidence that it's incredibly affected in epilepsy. There's over 12 randomized controlled clinical trials, two Cochrane reviews, which is sort of the highest standard of evidence that you can have, that it not just works in epilepsy, but it works in medication-resistant epilepsy.

which is a really important factor because, you know, it's another brain disorder and this diet is more effective than the medications. And that's exactly what we're seeing now, you know, doing this clinically is that there's a bunch of people who come to us who have been tried on dozens of medications and they haven't gotten the outcomes that they want.

They're having lots of side effects and they're still having symptoms, they're not functioning. We put them on this diet and all the adjunctive treatments.

The other stuff really matters too, exercise and mind-body practices and circadian rhythms that all kind of works together with the diet. And when people do all of that, they're getting results that they haven't gotten on any medication before.

Their symptoms go down. We can start reducing their medication. They start having energy again. Their brain comes back online where they can start thinking and focusing again.

And now all of a sudden, they're back saying, now I want to go and get a job. Now I want to go and start meeting my friends again. Things that they haven't been doing for some of them for many years, actually.

So it's actually just incredible to watch people's, you know, world kind of open up again from this intervention. Yeah. Yeah. Well, I'm a pediatric hospitalist and have seen and witnessed this change that you described when we used to admit children with, you know, really treatment resistant seizure, refractory seizure conditions around four or five different epileptic medications.

And then they were coming in for this ketogenic diet approach, getting them really on that. And it's not an easy diet or nutritional status state to first induce and then to maintain.

It's a very intensive process as well. But I've also seen patients come off their seizure med just with this alone. There's definitely a strong, I mean, as you said, strong clinically evidenced benefit for treating the brain in this way, right?

To really treat the brain as an inflamed state and making it more efficient. Why do we give seizure medications to children or even to adults with treatment-resistant conditions?

For the same reason, we're trying to stabilize the energetics of that system. Tell us about how this works, say, for other conditions, say for bipolar or schizophrenia, as you've worked with that population as well with this approach.

Yeah, we now have a number of really good-looking research trials that have been published in schizophrenia, bipolar disorder, treatment-resistant major depression.

These are some of the studies focused on inpatients, some of them focus on outpatients, but we're seeing incredible results in these studies. And that's exactly what we're seeing as well when we're instituting this in the program.

People come in, they could be on sometimes four or five different psychiatric medications, sometimes additional medications just to deal with the side effects of those medications.

They have lots of side effects. They're still having symptoms. You know, within a couple of months, we've They've been able to reduce those medications.

Their symptoms are much lower. They now have energy back online. We see reduction even in things like people hearing voices. The voices get lower when they're in ketosis for a period of time.

You know, when I first heard that, when I was a traditionally trained psychiatrist, I had been working on an inpatient unit. When I first heard that it was a little hard to believe actually, you know, I think for a doctor who's thinking that certain way that only these strong dopamine blocking medications could possibly reduce voices.

And even then they often don't. How could food do that? And again, we do have abundant amount of science about how this diet produces ketones and how ketones really do improve brain health.

We've got all this data from epilepsy and now we're seeing the data come out regarding mental health conditions as well. There are a bunch of randomized controlled trials going on right now in psychiatric conditions with the diet.

And so we'll see some of that data coming out in the next couple of years, but I'm really a strong proponent that we don't need to have randomized controlled trials to want to try this at this point now, because it is such a safe intervention, you know, seen data for over a hundred years showing how safe it is.

And so, you know, when people learn how to do it the right way and as long as. under a clinician's care, there's really no reason to be concerned about safety with the diet itself.

Not to say that there aren't some pitfalls, and I do encourage people to work with a professional, not just to do it completely on their own. But given it is so safe, why wouldn't we give people a try now if people who want to try it?

And so that's why we opened the program to get this out there and get people access to this potentially life-altering, life-saving intervention. I imagine though, as you get patients or your clients into that state of induction, that that's, tell us how that your treatment approach is to get patients into that inductive state and what's that maintenance space like for them as they, it's beyond your center outside to their own home.

Sometimes people think of the ketogenic diet in the epilepsy space and they think this incredibly high ratio of, and just to explain to people what it is, it's a high fat diet, moderate protein, very low carbohydrate diet.

Sometimes people think about a ketogenic diet and they think high protein diet, but it's actually not high protein. You have to keep the protein levels kind of moderate or else people won't get into ketosis.

But we don't have to have such a high ratio of that to protein and carbohydrates to get people into ketosis. We're often starting at a 1.5 to 1 ratio.

And occasionally, we go up to a 2 to 1 ratio. In the program that allows people to get into ketosis, we're measuring ketones every day. And we do see a correlation between the levels of ketones and the clinical benefits.

So it is important to actually measure those ketones and see that they're getting into a therapeutic range. Once people are in that range, we can often start reducing medications.

And then as Sophie described, we're spending lots and lots of time, most of the time, educating people about how to do this when they get back home and also educating their families and their support networks so that they can receive them back home and know the right ways to support them.

And we've seen a lot of people continuing to get back in touch with us six months in or a year in and telling us that they're still doing it, they're still getting benefits.

So we know that people are able to keep this going at home when they learn how to do it with us, which is really great. Obviously, that's really what we're looking for, these long-term benefits.

And unlike medications that you only get some amount of benefit in the first couple of weeks or first couple of months, the benefits from this intervention keep coming month after month after month.

People keep getting better and better and better. I like to say, you're going to feel better at month six than you do at month two, and you're going to feel better at month 12 than you do at month six.

If you can do it in a second year, you're going to feel better in year two than you do in year one. You're going to keep healing, essentially, which is really cool.

What would be the symptoms that you would look for that looks like better? What do people describe? What do your patients describe feels better for them?

Well, not just that they're reducing their symptoms. If they have a psychotic disorder, they might hear voices or have delusional beliefs. Those get better.

If they have bipolar disorder, they're having mood instability. They're having manic episodes or hypomanic episodes and depressive episodes. Those all get better.

If someone's depressed, their mood gets uplifted. So that's sort of on the symptom side. But in addition to that, there's a whole other range of things that kind of universally get better when someone's in ketosis, like having more energy, better focus, attention, and cognition, better memory.

People often will lose excess weight that they want to lose. Those things are pretty universal when someone's in a state of ketosis. And so they're getting all of those benefits in addition to the reduction of their mental health symptoms.

And like I said, depending on the person, we see all kinds of other benefits for people's skin clearing up and having energy to go to the gym and lift weights.

And they say, oh, I can lift more weights than I did before. Or they couldn't even get into the gym before. They couldn't get off the couch, as Sophie described, which is pretty common when people have been ill for a long time and taking medication for a long time.

People's taste buds change too. They come in, eat sweets all the time, and then all of a sudden, a couple of weeks or a couple of months in, they'll say, someone handed me this dessert.

I didn't even want it. I don't have any taste for it anymore. So that's also something that people are worried that they're not going to be able to satisfy their cravings forever.

But the cravings change if you change what you're eating. Yeah, I used to have a Down syndrome clinic in the Middle East and I had over 300 patients of Down syndrome that used to come in and I used to provide the health kind of oversight for their care based on, you know, Academy pediatric guidelines and did a lot of health supervision for those families and children and always observing as the child was growing, what was going to happen to the nutrition?

How is that behavior going to change as the nutrition changes? Because the understanding of this was such a key component to And just knowing that there was a trajectory to that possibility could happen.

So sugar is addictive. It's truly addictive. So I'm addicted to sugar. I have these symptoms that are really treatment resistant. I'm on these medications.

I'm addicted. It's an addiction. When you detox somebody, how do you get them to that place where they actually can overcome this addiction and dependence?

I mean, first of all, I agree 100%. You know, sugar is very addictive and many people are quite addicted to sugar. I'll tell a story of one person who, this is someone who I follow in my outpatient practice who was very addicted to sugar and she was actually taking one of these GLP1 medications and had lost a lot of weight.

At one point, about maybe a year into taking the medication, she confided in me that she hadn't been honest about what she was eating. She was actually eating, you know, just all sugar and carbohydrates, but just a lot less of it because she was on the GLP-1 medication.

And her mental health was, you know, getting really deteriorating. But she came into the program and, you know, it's amazing that, you know, you eat delicious, healthy ketogenic food and the cravings go away pretty quickly.

We do also help people along the way in that our chef makes some sort of food that tastes sweet, even though it doesn't have sugar in it. We use this sweetener called Allulose, which is a newer non-nutritive sweetener that seems to have a really good health profile.

It's a natural product. It's a rare sugar that exists in crops like corn and tapioca in very small amounts. So you can purify it and it looks like sugar we can make They actually make syrups that tastes very good and you can make desserts that are very high in fat.

They don't have any sugar because they're sweetened with allulose and they taste delicious. So in that early period when people are transitioning away from sugar, sometimes that can be a really helpful intervention to use something like that.

And so it depends on the person. Some people like to go cold turkey, but a lot of people say, no, no, no, I still need these sweet things. And so she's made all kinds of delicious chocolate chip cookies and brownies.

And she makes these things called fat bombs that are just like candy, essentially. And they're very high in fat, very low carbohydrate, no sugar, and made with healthy ingredients.

Like the cookies and the brownies are made with almond flour, essentially. So that can be a really helpful intervention. It really helps to have a super talented chef around to help you when you're making these kind of transitions too.

I think in addition to that, having an immersive supportive environment where you're not going through it alone, but other people are there with you and we're with them every step of the way really helps too when someone's making these changes in their lives.

Let's go there, Sophie. I like that. I like that connection is a very vital part of this experience and connection has a healing component to it. Tell us more about how you see or witness that connection, whether it be to others or to themselves.

What does that look like? I think our clients often build connections with each other. And I get the question a lot of how do you work with a 20-year-old male and a 60-year-old female?

And I'm like, it actually works quite well because everyone's in the program working to improve their metabolic and mental health together. Everyone has this purpose that they're working towards.

When people come together with a mutual goal and they support each other, they are there for each other. It's a really powerful thing. I think groups and, you know, going through lifestyle changes.

together is really helpful. And also, like you said, with ourselves, how do we learn about ourselves through this process? And I'm doing therapy with clients throughout the program and helping them self-explore.

And also, what's coming up for them as they're making these changes? What do they need in their lives? What kind of connections do they need? not just within the program, but also within their communities.

I'm a true believer that we all need connections, meaning, and purpose in our lives. And so I'm often talking with people about how do we foster that when you go home, right?

Like maybe you're thriving in this type of environment where you're socializing more for the first time in a long time. And you're going back home where you've become quite isolated for, sometimes people have been isolated for years.

And so how do we figure out like, what are your interests? What are your hobbies? And maybe they haven't had any for a long time, but how do we get you back to those things that bring you joy, that, you know, bring happiness into your life?

How do we get you reconnected with your community at home? So that's something that I'm working with people on a lot as well. Yeah, I love how you bring this idea of connection.

It's layered with so many things like the connection to yourself, it's connection to others, it's connection to your community, to who you are, to your purpose as well.

I'm always very curious when I do my intakes is, you know, asking that question of what is your relationship to food like? How do you see food and what's your relationship with food like?

to you. I often get a variety of answers with that. What are some of the things that you observe in how people approach food and why is it that they're sick?

I think one question I get a lot kind of related to that topic is, well, I don't need to lose weight or you know, my loved one, I want to use this approach doesn't need to lose weight.

So why would they go on a keto diet? And I think that that's just such a misconception and helping them learn that, you know, we've had people who have gained weight using ketogenic therapy, who have developed significant increases in muscle mass.

And so helping them learn and understand how the ketogenic diet can actually help treat people with challenging relationships with food as well. There's some evidence with anorexia.

There's a study that was done regarding that. And so I think helping them learn and understand. And also as they're making these changes in what they're eating, we're there to talk through it with them.

Like what's coming up? What are you noticing? Are you eating because you're hungry or are you eating because your emotions are strong? And when we're in an immersive program, we can talk to people throughout the diet and at different points throughout the day around like what's coming up for you as you're going through this experience.

Yeah, people have a lot of psychological connections to food. From a young age, often people use sweets as a reward for good behavior or as a way to soothe someone.

And so it's not a wonder that people at this point, you know, as they're adults, that's often their connections. They use it to soothe themselves or as a reward for going through a hard experience.

And we're trying to, you know, As Sophie said, we're around all throughout the day that we can help people as those kinds of emotions are coming up and they're starting to have cravings.

So we can help them through that. Is this about actually being hungry or is this about you're trying to soothe some kind of emotional experience? And that's where the therapy and also the mind-body practices really come into play and that we can rewire essentially.

those connections so that some emotional dysregulation can be handled in a different way. It doesn't have to be handled through eating sugar or some other kind of soothing foods like that.

And also, it's not just our personal relationships with food, but society, right? You go to a birthday party and it's expected that you're going to eat cake.

And if you say, no, I don't want that cake, people often say, why? Right? And so we're teaching people, how do you navigate social gatherings and social outings as well?

And what do you say to people when they kind of question, why are you eating this specific type of way? We also take them out to eat and practice, how are you going to order off of a menu?

Because food is a big part of our culture and a lot of people gather for meals. And so how do you navigate those different types of situations? And I think that's such a crucial part of helping someone sustain this type of intervention.

Have there been relapses in this approach? What would lead to that? Yeah. I mean, I can talk about, you know, again, someone that I work with who did the accord program.

I continued to work with her after a couple of months. She was doing amazing. I mean, she's like had said, you know, I haven't felt this well in 25 years.

You know, I've essentially been suicidal for the past 25 years is the first time I haven't felt suicidal in that whole amount of time. So, you know, incredible result.

But then she started having some GI disturbances, maybe a little bit of malabsorption. And she went to a primary care doctor and the primary care doctor literally yelled at her and said, get off that diet.

You know, this is what's causing it. Of course, you know, there was a lot of other ways to handle that. She did go off the diet and then her mental health really plummeted really quickly actually.

And then she came back to me and it was a very easy problem to fix. We just added some you know, pancreatic enzymes, which she actually needed to take for about a week.

Malabsorption got better. She's back doing the ketogenic diet. She's back to feeling amazing again. So that's just, you know, one type of story, but, you know, people come off of it for various reasons.

What we try to tell people is that, you know, this is a marathon, not a sprint, you know, It's okay to, you know, falter. You're going to have cravings.

You're going to, you know, for whatever reason, you're going to travel or be at a certain, you know, situation where you feel like you don't want to do it.

That's fine. You know, you can just come back to it. And if you're doing it most of the time, it's going to provide a lot of benefits. Now there are some people, if they come off of it, disaster happens because their mental health can plummet very quickly.

And so, you know, for someone like that, we can't be quite as casual and be sort of like someone just abruptly stopping their medication, which we wouldn't advise someone to do.

But for many people, it doesn't need to be quite as strict as that. That, you know, if they're doing it and they're going along and they've done it for, you know, three months or six months, they come off for a little bit.

You know, they don't feel quite as well. They realize they don't feel as well. They can just go right back on it and they know how to do it. They know how they feel.

They know they're going to feel better. And that's what I would recommend. Yeah, I think that's quite a realistic approach and a practical approach to kind of really have those observations that, you know, these are things you might have met may show up and how do you, you know, recognize that ahead of time.

And also when it does happen, it's okay. There's that self-compassion to oneself. It's okay. I can… and I'll be still okay. I can come back to something that worked.

And I think that there's a sense of hope and the hopelessness is what we see. I see a lot of that sense of hopelessness that I've tried everything and nothing has worked.

And that story comes up quite often. And then concern that I often in narrative medicine, we talk about what we're really treating in mental health is social injustice.

We're really just, that's all we're treating. We're treating social injustices all the time. I mean, once we kind of really call it out, this is social injustice that we're treating and understanding what does that social injustice look like for this person and who they are.

How is that showing up and why is that showing up? So would you be able to speak to a little bit about some of the things that you see in the context of why are people this sick anyways?

What is making this happen? Why are we seeing this trajectory of mental health getting worse? Yeah, I mean, I agree that social factors are incredibly important, especially once someone already has some kind of a crisis or a mental health issue.

They often fall out of their social system and they're seen as someone who has a mental illness. They're not seen as someone who any longer has full agency as a full human being.

And that really perpetuates whatever initial problem there was. So, I mean, we do see a lot of people who are socially privileged and they still get a mental illness.

So it's not all about social injustice. There are people who just for whatever combination of psychological factors, biological factors, vulnerabilities, metabolic factors, they'll develop one of these severe mental health conditions, even with there's no trauma history, there's no social discrimination.

And yet this will still happen to them. Yeah. So, you know, it is complicated, these interactions between biology and psychology and social factors and spiritual factors.

It's incredibly complicated. And sometimes we just don't even know exactly what caused this person to have this problem. One thing that's really great is that we do have now this treatment that is incredibly powerful and incredibly safe and incredibly healthy for the rest of the body, which to me is incredibly exciting.

Because in the past, we were often making people choose between their physical health and their mental health. And now people don't have to choose. They can have both.

Well, I'd like to bring that up because a lot of these medications that we do give to patients do make weight occur. People gain weight. They have more insulin resistance with particularly certain psychiatric medications.

And we're creating a problem that we're trying to treat if you really think about it that way. How would this be recognized in conventional health? How do you make that argument to say a colleague, hey, you know, what you're doing is actually making things worse?

It's really tricky, I have to say. You know, and again, I was a traditional psychiatrist myself, so I have a sense of sort of what that feels like, especially people who have been doing it for a long time.

You know, they've done all this incredible amounts of school and training and clinical experience and working hard in their practice and people mean well and they want to help people.

They didn't learn any of this in school. I didn't learn anything about metabolic psychiatry, metabolism and mental health. about ketogenic diets in the brain.

I didn't learn any of that in my residency training program. So all of a sudden, you're hearing something that you didn't learn about in your whole four years of medical school and four years of residency training.

How could that possibly be? And it's only a diet. I understand why people are skeptical, but I just implore people to keep their minds open because this really does work and it really is.

tremendous amount of basic supplements out there about why it works and how it works. And there's now growing amounts of clinical evidence as well about its efficacy.

Think about the people who can benefit who are not actually getting better with the traditional treatments. We may be able to keep people out of the hospital, but they're not living a full life.

They're not thriving. They've gained 50 or 60 pounds. They're now pre-diabetic or diabetic. And we know that people with serious mental illnesses have a 10 to 20 year shortened lifespan.

We really just need to think about all those things and try to have an open mind. And there's plenty of good places to learn more about the science. And so I implore people to go out there and learn.

Well, I believe patients also teach us too and we learn from our patients every single day and we can, you know, utilize what we learn and really build that in because there's a deeper understanding to that, you know, what it feels like, what does it feel like for somebody to be depressed, really seeing it and witnessing it.

I myself taught, used to teach narrative medicine to medical students and residents and recognizing that even that just that's presence of listening and that understanding somebody's story of why they're coming to you and what they're really asking you, not what you think you're, you know, wanting to dispel to them.

They're really seeking something that you want to be able to elicit. What are the things that you're learning both biologically and psychologically from your patients?

What would you say that looks like for you? Yeah, I mean, I agree 100% that, you know, as clinicians of any kind, our job is to listen and really listen deeply.

What are they trying to tell me? And again, what do I know that might be helpful to this person? Ultimately, being a clinician is about trying to teach something.

And first, we have to, though, listen and figure out what is this person asking? What are they telling me? What might they benefit from learning first?

We often skip over that step and just try to teach people the thing that we think we know, as opposed to really listening and hearing what they want to tell us.

And it could be so many different things. You know, they can be telling us about their deep psychological connection to food, or they could be telling us about the loss that they had of their family member from 10 years ago, and they've never really been the same since.

Yeah. And so as someone's telling their story, we have to really pay attention to what's the emotional resonance, like where's the affect in the story, where's the really important part of the story.

And that's something that, you know, I think we kind of hone and learn as clinicians over many years is how to really listen for the, what the key important part of what they're trying to tell me, not just all the facts.

I agree completely and I think just creating a safe space for people to share their story is so important and so powerful. Like Matt was saying, like really hearing like where someone's at, what it is that they need.

I'm a true believer that while we bring the clinical expertise, they bring the expertise of their life. They know themselves best and we're there to help them figure things out together.

Thank you. Thank you for sharing that. I think it's important that our audience really hear that as well because our audience is a mix of you know, clinicians, healers, but also patients.

And patients think feeling that sense of safety is often not the clinician's office sometimes. It's often the opposite feeling. I'm something's going to unfold here that I'm not going to be prepared for.

So I'm going to be told something that I may not be able to believe or understand. And so that sense of safety. How do you create that sense of safety in your program?

I think fostering a space that's welcoming, that's inclusive, you know, everybody's accepted. And we're just here to help guide and to help educate. And each client is in the driver's seat of their own care.

And really helping them to feel heard is so important in creating that safe space. Our house is also very bright, kind of cheery. So I think the physical environment helps.

I think we have a team of people who genuinely do care and who really want to see people get better. And so I think that that helps a lot as well. And you know, we don't tolerate any sort of hateful language, anything like that.

You know, we really care that people are there supporting each other and cheering each other on. And I think we all work really hard as a team to foster that.

and to have a sense of community and trust among each other. Trust goes in both directions. We need to trust our clients in order for them to trust us too.

We have to build that in its mutual. I would add too that we don't have very clinical looking offices or spaces to talk with people. It looks like a regular house or like a little, we have a little sun room where there's windows around and we can see all the people walking by and the cars going by as we're sitting and having conversations.

And then we also often eat with all together, the clinicians and the clients, people take walks all together. I know Sophie, you've sometimes done your best clinical work.

taking walks with people and people come back and say like oh we had this amazing talk while we were walking you know I learned all this stuff about that's really important that now I know and I was like oh when did that happen oh yeah when I was taking a walk with Sophie and so people often really feel more comfortable side by side with someone as opposed to like looking straight at each other sometimes and all of a sudden you know as and also when moving you know sometimes people can The movement of walking and moving goes together with parts of the brain being activated, and it kind of activates the ability to share and open up in certain ways.

So it depends on the person, but we try all of these different things as ways to try to find connection with people. And we've had success in lots of different ways of doing it.

I often, you know, when I've taught social work students and, you know, had interns as well, I often say some of your best therapeutic work is not going to happen where you're taught, where it's a 45 minute session once a week.

You know, it's, it's in the times that you're playing a game together, that you're just having a conversation that things kind of come up. Like Matt was saying, well, you're just, you know, you're going for a walk.

conversation flows and people open up more. Sometimes it's intimidating and there's a feel of a power dynamic when we're sitting in an office together, no matter what we do to try to break that down.

And so I think being creative in ways to connect and doing activities that are fun, you know, eating together, walking together, playing games together.

You know, I've played tennis with clients, gone to workout classes, you know, just building relationships in different types of ways to help us feel comfortable together.

Well, thank you for sharing that. I think it's important that people see even their healer or the person taking care of them is also taking care of themselves.

And I think that's sometimes the best advice as I reach over for my smoothie, which I wanted to impress you with. I got this smoothie and I started to really.

I don't know what your thoughts are on smoothies, but I think that's sometimes the only way I can get my nutrition in. My protein powder, my coconut milk, my blueberries, mix of spinach and some chia seeds.

What would be in your smoothie? This would be my last question for you guys. That looks like I did one. Yeah. I like putting a little MCT oil I would add in sometimes because that's a very ketogenic fat, then it gets a little extra fat in there.

I really like basil seeds also because they have a great nutritional value and they don't have some of these anti-nutrients in them that some of the other seeds have.

Things like some greens, a little bit of some berries, definitely something to make it creamy and delicious. A little cacao sometimes is really delicious too.

Yeah. I'm a big fan of some high fat yogurt, the 5% Greek yogurt in my smoothies as well. I can't get away from that with just a little bit of berry in there too.

It's one of my favorites. Yeah, the coconut yogurt too. Hard to get sometimes at the regular grocery stores, like looking around for that coconut yogurt.

And you know, when we talk about social disparity and we talk about access to food, that is also something that we're really struggling with in our society.

We're really, there is a big distortion to what is healthy and what is seen as healthy and how that's marketed to our, especially our ends of the spectrum.

I mean, the broad spectrum in our population, but really to that. ends of the spectrum of what their nutrition is, what their access is to nutrition. I think we see that a lot in hospital settings and in a lot of treatment programs.

I know a lot who are trying to improve their nutrition in their programs because it's, you know, not very healthy. I worked for about five years running a group in a jail working with young male offenders.

They're not being served well-balanced nutrition meals at all. So some of our most, you know, our people in very vulnerable positions or who are greatly struggling aren't having access to you know, good nutrition as well.

And that's something that I hope we can see change. Even in schools, you know, growing up, there's pizza day once a week, you know, or when I was in school anyway, there's a lot of things that are, you know, just not very nutritiously dense.

Anything you want to say, Matt, about how we can approach access to food in, especially in our disparate communities? Yeah, well, I think Sometimes one of the resistances or concerns people have about this kind of intervention is that, oh, well, it's so expensive to eat a healthy ketogenic diet.

That's not necessarily true. There was a study done in the South Bronx with people on food stamps and supplemental nutrition programs, Medicaid, who had diabetes, and they instituted a whole foods ketogenic diet.

And they were able to do that in that environment and have tremendous success reversing type 2 diabetes with the ketogenic diet. And if you think about it, not all of this food needs to be expensive.

You can get the least expensive ground beef that's got the highest fat content. You can get some eggs and some cheese and some onions and peppers, which are not expensive, and even almost any grocery store would have.

And all of a sudden you can make a very ketogenic whole foods meal. The key is that people are motivated and they were willing to cook some, cook their food.

You can't go out and buy all that at a restaurant for an inexpensive price, but you definitely can do it if you go to the grocery store and make some baby food.

And shown that actually can happen. So I think it's always a share that this is not just for people who buy fancy, you know, pasture, you know, pasture raised eggs and grass fed beef and wild caught salmon.

You know, all that stuff is nice and there are some additional health benefits, but it's not the core of what we're talking about. I'm going to give a little shout out to Costco.

that I went one day and I specifically went with this in mind. I'm going to look for some healthy options. And I found so many. I was so impressed. I was like, Costco, you got this.

You really changed. Both options were available, but then definitely there was more options for both. And I thought, wow, it is about choice here. Cost is similar.

There's choice here. I can have choice. Wow. Right. But you have to know what the difference is. You know, what is the healthy option, unhealthy option.

And that's one of the problems is that, you know, we're not really being clear with the population and doctors are not being clear with the population, how important it is to choose these options versus those options.

And instead people just throw up their hands and say, Oh, well, you know, I tried to counsel about diet, but The person didn't do it. And so we're just going to give medication instead.

But it's really worth it to, you know, go through the process of really learning and teaching what you can do with health, with food, because it is incredibly powerful.

Yeah. And then there's always TikTok. Right. So thank you. I mean, again, thank you for being on the podcast today. We really enjoyed this conversation and I feel like there's so much more we want to talk about.

I would ask you in terms of the last question, usually the last question is, what would be a curious question that you'd want to ask me or ask this topic of metabolic psychiatry?

What would be a curious question you would? think about is how could we do health care better? What would be a question that you would ask? It could be anything.

It could be me. It could be about this podcast. Just a curious question you'd have. Well, I guess I'm curious if you could see yourself, you know, referring someone with a serious mental health condition to do this type of treatment.

Yeah. Good question. I think it's really coming the type of patient that I would consider referring. Is that the question? Well, could you see yourself referring some experience?

Oh, of course. Oh my God, yes. In fact, I just had a call from an inquiry call with a patient who was in Montana who was disguised. The questions I usually ask is, what are you looking for?

Where are you at? What are you looking for and what do you imagine for yourself in that process and how? and what's made it not achievable. So looking for an intensive process like this where people really live and immerse in that experience, I think it's the ideal option for most patients because they get to live it.

And the whole, you know, we do ketamine-assisted treatments with patients, and we have a little bit of a crutch here. You know, we start with ketamine.

We do some preparation, of course, before they start their treatment. And I talk to patients. They say, you have to treat your mind, body, and soul, and you have to prepare for this process.

It's not an easy one. So ketamine is really that, I would say catalyst that gets patients into a good place. But, and I often see is what happens is, well, there's, you know, they can't relive their experience.

It's hard for them. So having a program like this would really be able to demonstrate that you can live this experience and it's achievable and that other people doing it with you and you're not alone.

I would try to send you on my page. And it's a bigger question too. I think what you're asking is what is missing? and how can we get there as a network, as a community.

And I think that is really supportive of a vision that takes us beyond our own practices, but to other elements of what's needed. So thank you for asking that question.

Sophie, what do you think? What's your curious question or unasked question that you have? My curious question is, what do you feel like is the biggest thing that you're taking away from this conversation today?

Wow. My biggest thing is I really have honed in on this idea of metabolism and really feel that that's where the conversation sometimes needs to begin.

It's like, what's your metabolism? What's your body's metabolism? Really understanding that core and then seeing the patient as whatever their symptoms are, but really living and understanding that idea of metabolism.

And it can present in different ways, I imagine. So somebody's metabolism could be like this, and somebody's metabolism could be like that. And then the uniqueness of that metabolism, that effect, is what I'm kind of really taking away from this conversation.

Thank you. So this was Two Curious MD's podcast. This is the era of curiosity. I hope today's podcast really made you curious about something that you want to learn about, especially in integrative medicine, psychedelic treatments, and narrative medicine, our favorite.

So thank you, Matt, and thank you, Sophie, for being here. We hope to have more enriching conversations ongoing. Thank you. Thanks for joining us on the Too Curious Andy podcast.

We hope today's episode inspired you to ask new questions and explore fresh perspectives. We challenge you to ask us those unasked questions that you're curious about in your medical practice, condition, health and wellness.

If you enjoyed the podcast, don't forget to subscribe, share it with somebody just as curious and leave us a review. It helps us keep the curiosity alive.

Post a comment with a question or curious inquiry that you have and seek to explore or learn with us. Stay curious and we'll see you next time.

Mental Illness Isn’t Just in the Brain

Alya Ahmad, MD, FAAP

Matthew Bernstein, MD

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