A recent article in the Boston Globe titled “A Broken Covenant” outlines the dismal failure of Massachusetts’s efforts to manage mental health over the past few decades. A long line of Governors, politicians and bureaucrats has closed many of the state’s inpatient mental health facilities over the past 20 years. The large amount of money saved was supposed to be diverted to outpatient mental health facilities but in general this never happened. Some of these community based mental health centers were built but not nearly the number originally planned. The next chapter in this sad tale is when the state decided to turn most outpatient mental health care to private companies.
Outsourcing Mental Health—A Really Bad Idea
Initially this seemed to be a good idea. Tons of money was saved and most patients seemed to receive reasonable care. There was only one problem with this rosy picture. Medical Assistance covered most of these patients and payments for mental health care never came close to covering the cost of this care. In other words practitioners who cared for these challenging patients lost money on every single patient. Small practices either went out of business or refused to take more Medical Assistance patients. Large for profit corporations struggled to hang on but now most of them are bankrupt.
The Right Balance
In this state it is almost impossible to hospitalize a mentally ill person against their will for more than a day or two, certainly not long enough to stabilize a complex patient, including those who appear to be a risk to themselves or others. As I write this I am in my home south of Athens Greece. I have a friend who is a Psychiatrist and he told me that over here, they place the welfare of society ahead of the freedom of unstable patients. In other words they stay in the hospital until they are stable enough to safely leave and their follow up visits are highly structured. This is how is works in some states in the US but not in Massachusetts.
A Slow Drift Down the List
At one point Massachusetts had a reputation for providing some of the best mental health care in the country. Now they are at the bottom of the list despite a booming economy. When competing for limited dollars mental health issues have lost their appeal among just about all players—the government, bureaucrats, providers and insurance companies. They have simply ignored the problem and looked the other way, hoping that somehow things would work out on their own. You can imagine how that has worked out.
Bad Decisions Almost Always Lead to Bad Outcomes
The Boston Globe article also details how two unstable psychotic patients murdered their caregivers. They also outlined the case of a lady with schizophrenia who had voices that told her to kill her children or others. These usually occurred when she failed to take her medication. Over many years on three occasions she slashed strangers with a knife including a child. Each time she was found innocent by reason of insanity and eventually was released to go about her business. To me this state has almost a schizophrenic approach to mental health. The state took away custody of a 15 year old girl for very dubious reasons, yet they allow violent psychotic patients to roam the streets and repeatedly slash strangers with a knife. As a Hospitalist I have seen many unstable psychiatric come and go from the hospital with little improvement in their mental status. Follow up is very spotty and these folks almost always end up back in the hospital or worse.
It’s the Diet Stupid
I agree that at this point there are no easy solutions. It will take a lot of time, money and effort to turn this mess around. I do have one recommendation that is relatively cheap and very safe—focus on the food we are feeding these folks. There is mounting evidence that consuming highly processed food over a period of time can trigger a form of food-induced brain dysfunction called Carbohydrate Associated Reversible Brain syndrome or CARB syndrome. Patients with carb syndrome can develop up to 22 symptoms that overlap with many traditional disorders. Because these symptoms tend to come on very gradually, clinicians tend to attribute them to their pre-existing psychiatric problem. They increase their SSRI or atypical anti-psychotic medications but these drugs make CARB syndrome worse.
It’s Time for Physicians to Go Back to School
Because CARB syndrome is a relatively new concept, most clinicians are unaware that it exists. They received little or no nutritional training in medical school so nutrition is often an afterthought. They just keep adding more diagnoses to explain their expanding symptoms until these patients have “labelisits” requiring handfuls of pills every day. They have half a dozen diagnoses (depression, ADHD, bipolar II, IBS, fibromyalgia, CFS, anxiety disorders, insomnia and others). The incidence of all of these disorders is rapidly increasing and nobody seems to know why. I think I do—it’s our diet of toxic highly processed food. Moore’s law proposes that computer processing power doubles ever 2 years or so. I am proposing Wilson’s Law—the toxic level of our food doubles about every 5 years. If you look in he year view mirror I think you will agree.
Finding Our Way Out of a True Crisis
Getting healthy whole food diets to these folks will be a challenge. The diets served in most of our hospitals are simply terrible, based on science that is over 20 years out of date. They feed diabetics loads of carbs and then have them count their carbs so they can appropriately increase their insulin. Type II diabetes is caused by sugar and starch so these elements should be severely limited. Carbohydrates should mostly come from fruits and vegetables. Insulin traps fat in your cells so it can’t be used for energy. You brain senses starvation and pushes you to eat more. You want to reduce or eliminate insulin, not increase it to match your carbohydrate intake. Talk about a dog chasing its tail!
Our Enabling Government
Most people with mental health issues (and many others) now receive food assistance from the Supplemental Nutrition Assistance Program or SNAP. This used to be called food stamps and years ago you could only buy healthy staples with food stamps. Today those on the program can buy any type of food they want including soda, sugary breakfast cereals, candy and a long list of highly processed food. Everyone at one time was worried about “food deserts” and “low food security” which somehow implies hunger and lack of food. The problem is, most of the folks living in these situations are already obese and many already have the disabling symptoms of CARB syndrome. How is this possible? Even if you under eat, if what you are eating is highly processed food sooner or later you will store too much fat and your brain will end up in the toilet.
The Obesity Poverty Connection
Today I watched a TV program on the DW German TV channel where they interviewed residents of Rio de Janeiro’s worst favela. Unlike here these folks have no welfare or SNAP food assistance programs, yet virtually all of them were obese. How is this possible? Whatever food they could beg, borrow or steal was likely cheap highly processed food. In this favela they have horrible problems with illegal drugs and murder. This suggests there are lots of people making bad decisions in this setting. There are likely many reasons for them doing so but I suspect that a poor diet plays a roll. CARB syndrome results in poor impulse control and some degree of cognitive dysfunction. In other words you tend to impulsively do foolish things without thinking about the possible negative consequences.
Complex Problems Demand Complex but not Necessarily Expensive Solutions
Now let’s go back to Massachusetts. Is there any way to improve the diets of those with mental illness? I can think of a few although for many reasons there likely would be a lot of political resistance.
- Have a subset of the SNAP program for those with mental illnesses that will only pay for high quality whole foods. The goal would be to eventually expand this to all people on the SNAP program. The libertarians will likely have a stroke but if society had no government or effective institutions, you can image a worldwide Syria. It’s time for our government to do the right thing.
- Develop a “meals on wheels” program where healthy whole foods are delivered to the homes of those with serious mental disorders. This would involve some expense but it would be much cheaper than our current trajectory.
- Work with hospitals and inpatient mental health facilities to provide healthy whole foods diets to their patients. This would likely result in a massive battle with the established dieticians. Just ask my South African friend professor Tim Noakes, a very scary story indeed. When you challenge existing dogma the key is to avoid being nailed to the cross or burned at the stake! So far I have managed to avoid both fates.
- Try to convince the medical community, the scientific community and the government that the CARB syndrome is valid. Don’t worry, I’m on the case but being in Greece the mythology of Sisyphus comes to mind. My only advantage if I have one in this endless battle is my stubbornness and strong belief that the concept can help countless patients, especially those with pre-existing brain disorders, especial mental illness. If you combine CARB syndrome with another mental disorder it’s like pouring gas on a fire. I don’t know how to reverse schizophrenia or bipolar I but I do know how to reverse CARB syndrome. It’s always better to have fewer brain diagnoses and to focus on those like CARB syndrome that are eminently treatable.
- Convince the government to tax food and beverages with added sugar or highly processed food. This one is a bit tricky. Mexico has a 10% tax on sugary soda without much drop in consumption. Currently 86% of the cost of a pack of cigarettes goes to various taxes. It takes a sizable tax to reduce consumption and of course this would trigger a massive battle with the food-industrial complex. Nobody said this would be easy and it will take a lot of time and effort. When I started practicing medicine we smoked freely throughout the hospital. Now you can’t light up a cigarette any where near a hospital. The problem is, if we don’t do anything about our toxic food, within the next generation or two we will become a 3rd world country with no money for schools, defense or infrastructure because we will be spending all our money on healthcare. In addition to the epidemic of diabetes, obesity, heart disease and cancer related to our poor diet, we will be stuck with a boatload of folks with both untreated mental illness and CARB syndrome. Remember that classic Mel Gibson movie “Mad Max”? Multiply that by 10 and see what the future will look like. It is our job to take care of the coming generations so we better get to work.
- Teach clinicians how to properly use psychiatric drugs. SSRI drugs work by enhancing serotonin in the brain. People with serotonin deficiency symptoms either have low levels of serotonin or their receptors have been down regulated. Diet plays a key role in this process because it seems to deplete serotonin over time. SSRI drugs do not raise serotonin levels in the brain. They simply allow serotonin to stay in the synapse a bit longer before being reabsorbed by the reuptake system. When you suddenly stop taking an SSRI many patients get serotonin withdrawal symptoms. That’s why some believe that these drugs are somehow addictive. In my opinion these folks don’t understand how to safely use SSRI medications. If you combine these drugs with supplements containing the precursors L-tyrosine and 5-htp like the CARB-22 product I sell on my web site, you can get by with much lower doses of drugs and when you stop the drugs patients never experience withdrawal symptoms. I also have a lot of other tricks about how to use these drugs more effectively that are beyond the scope of this article.
- Change the law so that dangerous patients with mental illnesses can be confined as long as necessary to stabilize their condition. This would also involve a rigid follow up system. If the Greeks can do it with their trashed economy we should also be able to easily do this if we have the wisdom to understand why this is a good rather than a bad idea.
- Check homocyteine levels on all patients with mental illness. If the level is above 10 they should take a combination of L-methylfolate, vitamin B6 and vitamin B12. L-methylfolate is the only form of folic acid that can get through the blood brain barrier and you need folic acid in your brain to make neurotransmitters. A low homocysteine level suggests low level of brain folic acid. L-methylfolate is the only vitamin approved by the FDA to treat a disease–depression under the brain name Deplin. It is available OTC at a much lower price. I buy mine from Life Extension.
- Encourage those with significant mental illness to take enough high quality omega 3 to get their AA/EPA ratio between 1 and 3. This is the average level of people in Japan and they have a very low incidence of heart disease. It’s hard to know their incidence of mental health but it appears to me that they likely have a low incidence of CARB syndrome. Barry Sears has been recommending this approach for years and recently Dr. Mercola also started promoting the AA/EPA test. Adequate levels of omega 3 fatty acids are very important for proper brain function, especially those with mental illnesses or CARB syndrome.
Give that rock another push
Although in my opinion these measures would be of immense value to our citizens with mental illnesses, I am also a realist. Most of these measures are relatively inexpensive and doable. It simply involves getting the involved parties to look at the problem in a new way. As they say, good luck with that! Nonetheless l will keep pushing that rock up the hill as long as I can. And yes, I could use a little help!