Aug 28, 2019
Roger McIntyre, MD, joins Lorenzo
Norris, MD, host of the MDedge Psychcast and editor in chief of
MDedge Psychiatry, to talk about obesity, inflammation, and
treatment implications for mental health conditions. They spoke at
Focus on Neuropsychiatry 2019 meeting, sponsored by Current
Psychiatry and Global Academy for Medical Education.
McIntyre is a professor of psychiatry and pharmacology at the
University of Toronto, and head of the mood disorders
psychopharmacology unit at the University Health Network, also in
For a complete video of this interview, please visit the
Don’t miss the “Dr. RK” segment by Renee Kohanski, MD, who discusses how
to think through whether sharing personal information with patients
helps move their therapy forward. Dr. Kohanski, a member of the
MDedge Psychiatry Editorial Advisory Board, is a psychiatrist in
private practice in Mystic, Conn.
Show notes by Jacqueline Posada, MD, consultation-liaison
psychiatry fellow with the Inova Fairfax Hospital/George Washington
University program in Falls Church, Va.
Reconceptualizing mental illness by looking at
- Mental illness should be viewed as a disease involving many
organs – including the brain – and psychiatry should expand its
understanding of the etiology of mental illness.
- Increasingly, research suggests that a subgroup of people with
mental disorders, including those with a variety of diagnoses, have
symptoms related to alterations in their immune system and
- Inflammation plays a role in disparate psychiatric diagnoses,
including childhood disorders such as obsessive-compulsive
disorder, ADHD, and autism, and adult disorders such as
schizophrenia, depression, and Alzheimer’s disease.
- Currently, psychiatry uses the monoamine
paradigm to explain psychiatric diagnosis, and most medications
were developed using that paradigm.
- A subgroup of people is not sufficiently helped by current
medications, so looking at inflammation as a driver of mental
illness provides another biological avenue to pursue drug
Role of obesity and chronic health conditions in
- Obesity, particularly abdominal obesity, is overrepresented in
people with mental illness and is not fully explained by either
social determinants of health or medication side effects.
- Obesity and mental illness have a bidirectional relationship;
each affects the body as multiorgan system diseases.
- Mental illness can be conceptualized as a kind of “metastasis
to the brain.” Adipose tissue releases a surfeit of neurochemicals
hazardous to brain function and that disrupt neurocircuitry.
- For example, compared with an individual with major depressive
disorder (MDD) only, an individual with MDD and obesity is more
likely to have symptoms driven by inflammation, such as anhedonia,
cognitive impairment, limited motivation, and a dysregulated reward
- Obesity should also be a target symptom worthy of a focused
- Heart disease is the leading cause of death in schizophrenia,
and coronary artery disease is an inflammatory illness. Research is
identifying connections between psychiatric illness such as
schizophrenia and potentially inflammatory driven symptoms, often
called “sickness behaviors,” such as low motivation, anhedonia, and
Clinical implications of obesity and
- Alterations in inflammation and metabolism are not just a
consequence of obesity. For example, patients will bipolar disorder
who report sexual or physical trauma are more likely to be in a
proinflammatory neurochemical state and benefit from
- Are patients with early trauma who do not respond fully to
“traditional” monoamine medications part of the subpopulation who
respond to anti-inflammatory interventions because trauma is
- The genetics of mental illness already are complicated and will
be influenced by the environment and a “proinflammatory
Which tests show inflammation?
- Current inflammatory markers, such as erythrocyte sedimentation
rate and C-reactive protein, are not specific enough to direct
treatment of inflammation in mental illness.
- Elements of a patient’s history, including history of trauma,
disrupted sleep and circadian disturbances, cigarette smoking,
poverty, housing dislocation, and exposure to racism, can indicate
- We can conceptualize as anti-inflammatory several current
treatments, such as mindfulness-based therapy, electroconvulsive
therapy, and selective serotonin reuptake inhibitors.
- Alternative treatments to treat inflammation exist; however,
specific anti-inflammatory treatments, such as NSAIDs,
cyclooxgenase-2 inhibitors, and minocycline, are not yet
recommended for patients with mental illness.
Targeting inflammation as prevention of psychiatric
- Clinicians can target drivers of inflammation as a means of
treatment and prevention of mental illness. They can also target
the basics, such as sleep, diet, exercise, and socializing, as
preventive measures that also target inflammation.
- The incidence of depression can be decreased by targeting
lifestyle changes and metabolic illness with treatments such as
exercise and statins.
- Interventions focused on inflammation are being investigated as
a means of prevention for people at risk of mental illness. For
example, a study in China in which Dr. McIntyre was involved
explored whether exercise can decrease the development of bipolar
disorder in children who have a genetic predisposition to the
illness. Caloric restriction can reduce inflammation and improve
Inflammation and the absence of ‘meaningful
- In social baseline theory, human beings allocate energy in
proportion to their social connectivity.
- People with fewer social connections are more likely to be in a
proinflammatory state and more likely to consume high-carbohydrate
- Loneliness can be conceptualized as an epidemic associated with
serious health outcomes, such as suicide, addiction, and other
chronic mental and physical health problems. We are living in a
society of anxious despair.
- Psychiatry needs to broaden its understanding of mental illness
by investigating a variety of underlying causes, from inflammation
to the monoamine theory.
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between inflammation and mood disorders.
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Harvey SB et al. Exercise and prevention of depression: Results
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Redlich C et al. Statin use and risk of depression: A Swedish
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Leclerc E et al. The effect of caloric restriction on working
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Schwabel D. “Vivek Murthy: How to solve the work loneliness
Forbes.com. Oct 7, 2017.
Ho RCM et al. Factors associated with risk of developing
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Dantzer R. Cytokine, sickness behavior, and depression. Immunol
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