Belezzion

 

Proponents of cannabis generally dismiss the idea that there is a cannabis withdrawal syndrome. One routinely hears statements such as, “I smoked weed every day for 30 years and then just walked away from it without any problems. It’s not addictive.” Some cannabis researchers, on the other hand, describe serious withdrawal symptoms that can include aggression, anger, irritability, anxiety, insomnia, anorexia, depression, restlessness, headaches, vomiting, and abdominal pain. Given this long list of withdrawal symptoms, it’s a wonder that anyone tries to reduce or stop using cannabis. Why is there such a disconnect between researchers’ findings and the lived reality of cannabis users?

New research highlights the problems of withdrawal, but provides an incomplete picture

A recent meta-analysis published in JAMA cites the overall prevalence of cannabis withdrawal syndrome as 47% among “individuals with regular or dependent use of cannabinoids.” The authors of the study raise the alarm that “many professionals and members of the general public may not be aware of cannabis withdrawal, potentially leading to confusion about the benefits of cannabis to treat or self-medicate symptoms of anxiety or depressive disorders.” In other words, many patients using medical cannabis to “treat” their symptoms are merely caught up in a cycle of self-treating their cannabis withdrawal. Is it possible that almost half of cannabis consumers are actually experiencing a severe cannabis withdrawal syndrome — to the point that it is successfully masquerading as medicinal use of marijuana — and they don’t know it?

Unfortunately, the study in JAMA doesn’t seem particularly generalizable to actual cannabis users. This study is a meta-analysis: a study which includes many studies that are deemed similar enough to lump together, in order to increase the numerical power of the study and, ideally, the strength of the conclusions. The authors included studies that go all the way back to the mid-1990s — a time when cannabis was illegal in the US, different in potency, and when there was no choice or control over strains or cannabinoid compositions, as there is now. One of the studies in the meta-analysis included “cannabis-dependent inpatients” in a German psychiatric hospital in which 118 patients were being detoxified from cannabis. Another was from 1998 and is titled, “Patterns and correlates of cannabis dependence among long-term users in an Australian rural area.” It is not a great leap to surmise that Australians in the countryside smoking whatever marijuana was available to them illegally in 1998, or patients in a psychiatric hospital, might be substantively different from current American cannabis users.

Medical cannabis use is different from recreational use

Moreover, the JAMA study doesn’t distinguish between medical and recreational cannabis, which are actually quite different in their physiological and cognitive effects, as Harvard researcher Dr. Staci Gruber’s work tells us. Medical cannabis patients, under the guidance of a medical cannabis specialist, are buying legal, regulated cannabis from a licensed dispensary; it might be lower in THC (the psychoactive component that gives you the high) and higher in CBD (a nonintoxicating, more medicinal component), and the cannabis they end up using often results in them ingesting a lower dose of THC.

Cannabis withdrawal symptoms are real

All of this is not to say that there is no such thing as a cannabis withdrawal syndrome. It isn’t life-threatening or medically dangerous, but it certainly does exist. It makes absolute sense that there would be a withdrawal syndrome because, as is the case with many other medicines, if you use cannabis every day, the natural receptors by which cannabis works on the body “down-regulate,” or thin out, in response to chronic external stimulation. When the external chemical is withdrawn after prolonged use, the body is left in the lurch, and forced to rely on natural stores of these chemicals, but it takes time for the natural receptors to grow back to their baseline levels. In the meantime, the brain and the body are hungry for these chemicals, and the result is withdrawal symptoms.

Getting support for withdrawal symptoms

Uncomfortable withdrawal symptoms can prevent people who are dependent on or addicted to cannabis from remaining abstinent. The commonly used treatments for cannabis withdrawal are either cognitive behavioral therapy or medication therapy, neither of which has been shown to be particularly effective. Common medications that have been used are dronabinol (which is synthetic THC); nabiximols (which is cannabis in a mucosal spray, so you aren’t actually treating the withdrawal); gabapentin for anxiety (which has a host of side effects); and zolpidem for the sleep disturbance (which also has a list of side effects). Some researchers are looking at CBD, the nonintoxicating component of cannabis, as a treatment for cannabis withdrawal.

Some people get into serious trouble with cannabis, and use it addictively to avoid reality. Others depend on it to an unhealthy degree. Again, the number of people who become addicted or dependent is somewhere between the 0% that cannabis advocates believe and the 100% that cannabis opponents cite. We don’t know the actual number, because the definitions and studies have been plagued with a lack of real-world relevance that many studies about cannabis suffer from, and because the nature of both cannabis use and cannabis itself have been changing rapidly.

How do you know if your cannabis use is a problem?

The standard definition of cannabis use disorder is based on having at least two of 11 criteria, such as: taking more than was intended, spending a lot of time using it, craving it, having problems because of it, using it in high-risk situations, getting into trouble because of it, and having tolerance or withdrawal from discontinuation. As cannabis becomes legalized and more widely accepted, and as we understand that you can be tolerant and have physical or psychological withdrawal from many medicines without necessarily being addicted to them (such as opiates, benzodiazepines, and some antidepressants), I think this definition seems obsolete and overly inclusive.

For example, if one substituted “coffee” for “cannabis,” many of the 160 million Americans who guzzle coffee on a daily basis would have “caffeine use disorder,” as evidenced by the heartburn and insomnia that I see every day as a primary care doctor. Many of the patients that psychiatrists label as having cannabis use disorder believe that they are fruitfully using cannabis to treat their medical conditions — without problems — and recoil at being labeled as having a disorder in the first place. This is perhaps a good indication that the definition doesn’t fit the disease.

Perhaps a simpler, more colloquial definition of cannabis addiction would be more helpful in assessing your use of cannabis: persistent use despite negative consequences. If your cannabis use is harming your health, disrupting your relationships, or interfering with your job performance, it is likely time to quit or cut down drastically, and consult your doctor. As part of this process, you may need to get support or treatment if you experience uncomfortable withdrawal symptoms, which may make it significantly harder to stop using.

About the Author

Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

Polio is a potentially life-threatening or disabling illness that spreads from person to person. Thanks to vaccination, the United States has been polio-free since 1979, and the spread of this highly contagious disease has been interrupted in most countries. Yet on June 22, the United Kingdom Health Security Agency announced that it had detected poliovirus in a most unexpected place: the sewers of London.

Over the past several months, scientists at the agency repeatedly found poliovirus in London sewer water. The viruses were genetically similar, suggesting that they were the result of limited spread within a family or close-knit community. Just how concerned should all of us be about this news?

Health clues found in wastewater

Sampling of wastewater for genetic material from viruses is a powerful tool used by epidemiologists to track outbreaks of polio and other diseases. Surges in the amount of SARS-CoV-2 RNA in Boston wastewater have been highly predictive of COVID outbreaks. Wastewater may also help to detect the spread of influenza and antibiotic-resistant bacteria.

Poliovirus infection was once a common and dreaded disease. Most people with poliovirus either had no symptoms or mild gastroenteritis (stomach flu). But one in 100 people developed paralysis, or poliomyelitis. In half of the affected patients, this paralysis was permanent.

In the UK, wild poliovirus has been eliminated since 1984. Although great progress has been made in many parts of the world, complete eradication of polio has been elusive. Pakistan and Afghanistan have never been free from wild-type polio, and outbreaks have recently taken place in Malawi and Mozambique, countries which had previously eliminated polio.

The reasons for this backsliding are complex. Some contributing factors are diversion of scarce resources toward the COVID-19 pandemic, backlogs in vaccine manufacturing, anti-vaccine agitation, and violence directed at vaccine workers.

Another problem is vaccine-derived poliovirus. In the United States and most other countries, injections containing killed viruses are used. While these vaccines are safe, they are less effective than oral vaccines at breaking the chain of polio transmission. Oral vaccines stimulate long-lived immune responses in the lining of the intestines, where polioviruses replicate. Unfortunately, oral vaccines contain weakened but live viruses, which occasionally revert to a more dangerous form. In fact, the poliovirus found in London was a vaccine-derived strain that the infected individual had likely acquired from travel abroad.

Who is at risk for poliovirus stemming from this source?

Vaccine-derived viruses pose little risk to highly vaccinated populations, but they are able to spread in communities with low polio vaccination rates. In some cases, this can even cause paralytic disease. Because of these risks, steps are being taken to gradually phase out the use of oral polio vaccines.

If you’re concerned about polio, the best protection against this disease is vaccination. Children should receive a full series of four shots of inactivated polio vaccine, given at specific intervals, that helps with developing immunity.

Nationwide, rates of childhood polio vaccination in the United States are still high (nearly 93%). However, some infectious disease experts worry that the weakening of vaccine mandates in some areas has created islands of vulnerability in this sea of immunity. Communities in the US with low childhood vaccination rates have been vulnerable to large measles outbreaks in recent years, and might also be vulnerable to polio outbreaks.

With few exceptions, adults who were fully vaccinated as kids do not need booster shots. These exceptions include travel to a country with active polio transmission, laboratory work with poliovirus, or providing health care to polio patients and their close contacts. A single lifetime booster dose of inactivated polio vaccine is adequate for these high-risk scenarios.

About the Author

John Ross, MD, FIDSA, Contributor

Dr. John Ross is an assistant professor of medicine at Harvard Medical School. He is board certified in internal medicine and infectious diseases, and practices hospital medicine at Brigham and Women’s Hospital. He is the author … See Full Bio View all posts by John Ross, MD, FIDSA

My favorite summer activities officially kick in when the calendar flips to May. It’s prime time for open water swimming, running, cycling, hiking, and anything else that gets me outside and moving. Yet, my first step is to get my legs in shape.

“Legs are the foundation for most activities,” says Vijay Daryanani, a physical therapist at Harvard-affiliated Spaulding Rehabilitation Hospital. “They’re home to some of the body’s largest muscles, and building healthy legs can improve one’s performance, reduce injury, and increase endurance.”

Four leg muscle groups to build for summer activities

Four muscles do the most leg work: quadriceps, gluteus maximus (glutes), hamstrings, and calves. Here is a look at each.

Quadriceps (quads). Also known as the thigh muscles, the quads are a group of four muscles (hence the prefix “quad’). They extend your leg at the knee and power every leg action: stand, walk, run, kick, and climb.

Glutes. The body’s largest muscles, the glutes (your buttock muscles) keep you upright and help the hips and thighs propel your body forward.

Hamstrings. The hamstrings are a group of three muscles that run along the back of your thighs from the hip to just below the knee. They allow you to extend your leg straight behind your body and support hip and knee movements.

Calves. Three muscles make up the calf, which sits in the back of the lower leg, beginning below the knee and extending to the ankle. They work together to move your foot and lower leg and push you forward when you walk or run.

Spotlight muscle strength and length

Strength and length are the most important focus for building summer-ready legs, says Daryanani. “Strengthening leg muscles increases power and endurance, and lengthening them improves flexibility to protect against injury.”

If you are new to exercise or returning to it after time off, first get your legs accustomed to daily movement. “Start simply by walking around your home nonstop for several minutes each day, or climbing up and down stairs,” says Daryanani.

After that, adopt a walking routine. Every day, walk at a moderate pace for 20 to 30 minutes. You can focus on covering a specific distance (like one or two miles) or taking a certain number of steps by tracking them on your smartphone or fitness tracker. You won’t just build leg strength — you’ll reap a wide range of health benefits.

There are many different leg muscle-building exercises, some focused on specific activities or sports. Below is a three-move routine that targets the four key leg muscles. Add them to your regular workout or do them as a leg-only routine several times a week. (If you have any mobility issues, especially knee or ankle problems, check with your doctor before starting.)

To help lengthen your leg muscles and increase flexibility, try this daily stretching routine that includes several lower-body stretches.

Dumbbell squats

Muscles worked: glutes and quads

Reps: 8-12

Sets: 1-2

Rest: 30-90 seconds between sets

Starting position: Stand with your feet apart. Hold a weight in each hand with your arms at your sides and palms facing inward.

Movement: Slowly bend your hips and knees, leaning forward no more than 45 degrees and lowering your buttocks down and back about eight inches. Pause. Slowly rise to an upright position.

Tips and techniques:

• Don’t round or excessively arch your back

Make it easier: Do the move without holding weights.

Make it harder: Lower yourself at a normal pace. Hold briefly. Stand up quickly.

Reverse lunge

Muscles worked: quads, glutes, hamstrings

Reps: 8-12

Sets: 1-3

Rest: 30-90 seconds between sets

Starting position: Stand straight with your feet together and your arms at your sides, holding dumbbells.

Movement: Step back onto the ball of your left foot, bend your knees, and lower into a lunge. Your right knee should align over your right ankle, and your left knee should point toward (but not touch) the floor. Push off your left foot to stand and return to the starting position. Repeat, stepping back with your right foot to do the lunge on the opposite side. This is one rep.

Tips and techniques:

• Keep your spine neutral when lowering into the lunge.
• Don’t lean forward or back.
• As you bend your knees, lower the back knee directly down toward the floor with the thigh perpendicular to the floor.

Make it easier: Do lunges without weights.

Make it harder: Step forward into the lunges, or use heavier weights.

Calf raises

Muscles worked: calves

Reps: 8-12

Sets: 1-2

Rest: 30 seconds between sets

Starting position: Stand with your feet flat on the floor. Hold on to the back of a chair for balance.

Movement: Raise yourself up on the balls of your feet as high as possible. Hold briefly, then lower yourself.

Make it easier: Lift your heels less high off the floor.

Make it harder: Do one-leg calf raises. Tuck one foot behind the other calf before rising on the ball of your foot; do sets for each leg. Or try doing calf raises without holding on to a chair.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

For the longest time, your milk choices were whole, 2%, 1%, and fat-free (or skim). Today, refrigerator shelves at grocery stores are crowded with plant-based milks made from nuts, beans, or grains, and include favorites like almond, soy, coconut, cashew, oat, and rice. Yet the fertile ground of the plant-milk business continues to sprout new options, such as pistachio, pea, and even potato milk. It seems if you can grow it, you can make milk out of it.

So, are these new alternatives better nutritionally than the other plant milks — or just more of the same?

A few facts about plant-based milks

Plant-based milks are all made the same way: nuts, beans, or grains are ground into pulp, strained, and combined with water. You end up with only a small percentage of the actual plant — less than 10% for most brands. Nutrients like vitamin D, calcium, potassium, and protein are added in varying amounts. "Still, many alternative milks have similar amounts of these nutrients compared with cow’s milk," says Dr. Walter Willett, professor of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health.

Plant-based milks are considered "greener" than dairy and emit fewer greenhouse gases during production. However, growing some of these plants and making them into milk requires great quantities of water. Most plant-based milks are low-calorie. On average, though, these milk products cost more than dairy.

Nutrition, calories, and other benefits of newer plant-based milks

Here’s a closer look at three new members of the alternative-milk family.

• Pistachio milk is not green like the nut, but rather an off-brown color. Because it contains little actual pistachio, you miss out on the nuts' essential vitamins and minerals, like thiamin, manganese, and vitamin B6. Yet pistachio milk contains less than 100 calories per cup, which is similar to skim cow’s milk and other plant-based milks. One extra benefit of pistachio milk is that it's a bit higher in protein than other plant milks (which can be light in the protein department compared with cow’s milk).
• Pea milk is created from yellow field peas, but has no "pea-like" flavor. Its color, taste, and creamy consistency are close to dairy, so people may find it more appealing than the sometimes-watery texture of other plant milks. Pea milk has a decent protein punch — at least 7 grams per serving — and each serving adds up to about 100 calories. It also requires less water in production than other plant milks, and has a smaller carbon footprint than dairy.
• Potato milk looks more like regular dairy milk than other plant milks because of the potato's starchy nature. It’s arguably the most eco-conscious plant milk, because growing potatoes requires less land and water than dairy and other plants. Potato milk also is low-calorie: 80 to 100 per serving.

What’s the best plant-based milk for you?

There doesn’t appear to be a huge difference between most plant milks. Ultimately, three issues drive your choice: digestion issues, environmental impact, and personal taste.

Digestion issues. Plant-based milks are a quality alternative for people with lactose intolerance or lactose sensitivity whose bodies can't break down and digest lactose, the sugar in milk. This causes digestive problems like diarrhea, gas, and bloating. (However, lactose-free and ultra-filtered dairy milk are available for those who prefer dairy.)

Environmental impact. One study in Science found that dairy milk production creates almost three times more greenhouse gas than plant-based milk. However, some plant milks, predominantly almond, demand much water to produce. (Some research suggests the water demands of almond milk are about equal to cow’s milk, according to Dr. Willet.)

Still, if you want to do your part to fight climate change, buying plant-based instead of dairy is the greener choice.

Personal taste. Plant-based milks can be an acquired taste, but with multiple choices, there is a good chance you can find one that satisfies your taste buds. Manufacturers try to overcome the taste dilemma by pouring in extra sugar, sweeteners like vanilla and chocolate, and other additives. So always check the total and added sugar amounts and keep the amount per serving below 10%. Of course, the lower the amount, the better.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

Music boosts our mood and well-being, and music therapy may help during treatments for certain health conditions.

Times are hard. The current political climate, war, impact of global warming, continued inequities due to systemic racism, and ongoing physical and mental health challenges from COVID are taking a toll on our feelings of safety in the world and quality of life. Hopefully, each of us can find moments of ease and temporarily shift our thoughts away from the difficult daily news. For many people, music can play a role in making that shift, even incrementally.

How can music impact our quality of life?

Recently, researchers looked at the impact of music interventions on health-related quality of life, and tried to answer the question about the best way to help make that shift toward release, relaxation, and rehabilitation. This recent systematic review and meta-analysis (a study of studies) showed that the use of music interventions (listening to music, singing, and music therapy) can create significant improvements in mental health, and smaller improvements in physical health–related quality of life. While the researchers found a positive impact on the psychological quality of life, they found no one best intervention or “dose” of music that works best for all people.

Complexities of music

As complex human beings from a wide variety of cultures, with a variety of life experiences and mental and physical health needs, our connection with music is very personal. Our relationship with music can be a very beautiful, vulnerable, and often complicated dance that shifts from moment to moment based on our mood, preferences, social situation, and previous experiences. There are times where music can have a clear and immediate impact on our well-being:

• easing a transition to sleep with a soothing playlist
• finding motivation for exercise by listening to upbeat dance music
• aiding self-expression of emotions by singing
• connecting to others by attending a live musical performance.

There are other times when a board-certified music therapist can help you build that connection to music, and find the best intervention and “dose” that could positively impact your health and provide a form of healing.

How can music be used as a therapeutic tool?

Music therapy is an established health care profession that uses evidence-based music interventions to address therapeutic health care goals. Music therapy happens between a patient (and possibly their caregivers and/or family) and a board-certified music therapist who has completed an accredited undergraduate or graduate music therapy program.

Music therapists use both active (singing, instrument exploration, songwriting, movement, digital music creation, and more) and receptive (music listening, guided imagery with music, playlist creation, or music conversation and reminiscence) interventions, and create goals to improve health and well-being.

Some of those goals could include decreasing anxiety, shifting your mood, decreasing pain perception during cancer or other medical treatment, increasing expression, finding motivation, and many others. The approach to using music to achieve these kinds of goals — and to improving your quality of life in general — can shift from moment to moment, and a music therapist can help you find what works best for a particular situation.

My top music therapy tools

Listening

This intervention has been studied the most, in almost every scenario. It can be done either on your own or in music therapy. The music can be live or recorded. Listening can be done with intentional focus or as background listening. You can amplify emotions for release. You can use music to quiet the mind. Or you can utilize the “iso principle” and match music to your current energy or mood, and then slowly change feel, tempo, and complexity to help you shift. Music listening can be paired with prompts for relaxation, or to motivate you to exercise, move more, or do a task you’ve been putting off.

Learning or playing an Instrument

Active music-making truly engages your entire brain. This creates the most potential for distraction, pain reduction, cognition, fine and gross motor development, and expression. Some instruments are designed for easier access to free expression or learning.

A steel tongue drum, for example, set up in a pentatonic scale, has a beautiful resonant sound, has no “wrong notes,” and by design allows you to just play! If you want to engage your cognitive brain a bit, try learning the ukulele. The strings are easy to push, beginner chords only need one or two fingers, and there are many great ukulele resources online. Making music with an instrument can be fun and easy.

A board-certified music therapist can help you find the most direct and success-based path to musical expression. Learning how to really master an instrument and read music takes time, patience, and practice.

Singing

This can be an amazing intervention if you have a good connection to your voice and/or have a good music therapy relationship where the therapist can help you build your connection to your instrument. There are physical benefits of singing on lung function and emotional benefits of singing lyrics that speak your truth. Finally, there is the community connection and power of being surround by strong, tight harmonies.

The bottom line

Although there is not one best intervention, magical song, or perfect genre to make all the hard things in life easier, music can be a powerful agent of change.

Need some extra help finding the best music tools for you? Here are some resources for exploring music therapy and finding certified therapists.

American Music Therapy Association
Certified Board of Music Therapists
American Psychological Association: Music as Medicine

About the Author

Lorrie Kubicek, MT-BC, Contributor

Lorrie Kubicek is a board-certified music therapist at Massachusetts General Hospital, co-director of The Katherine A. Gallagher Integrative Therapies Program, and program manager of expressive therapies at MGH Cancer Center and Mass General Hospital for Children. … See Full Bio View all posts by Lorrie Kubicek, MT-BC

In the aftermath of the killing of 19 children and two adults in an elementary school in Uvalde, Texas, there is a lot of discussion — and argument — about what we should do to prevent shootings like this from happening.

In the midst of all the back and forth between banning guns and arming teachers, there is an important question that cannot be lost: what does it do to a generation of children to grow up knowing that there is nowhere they are safe?

There is increasing research that growing up amidst violence, poverty, abuse, chronic stress, or even chronic unpredictability affects the brains and bodies of children in ways that can be permanent. These adverse childhood experiences put the body on high alert, engaging the flight-or-fight responses of the body in an ongoing way. This increases the risk of depression, anxiety, and substance abuse, but it does so much more: the stress on the body increases the risk of cancer, heart disease, chronic disease, chronic pain, and even shortens the lifespan. The stress on the brain can literally change how it is formed and wired.

Long-term effects on a generation

Think for a moment about what this could mean: an entire generation could be forever damaged in ways we cannot change. The ramifications, not just for their well-being but for future generations and our work force and health care system, are staggering: stress like this can be passed on, and affects parenting.

As we talk about arming teachers and increasing armed police at schools, it is important to remember that research shows that the more guns, the higher the risk of homicide. It’s also important to remember that many children die every year from unintentional shootings in the home. In fact, guns have overtaken motor vehicle accidents as the leading cause of death in children. The idea of “arming the good guys” is an understandable response to horrible events like Uvalde, Parkland, and Sandy Hook, but the data would suggest that it may not be the most successful one. Violence begets violence, and guns aren’t reliably used the way we want them to be.

It’s not just guns, of course. There are other stressors, like poverty, community violence, child abuse, racism and all the other forms of intolerance, and lack of access to health care and mental health care. The pandemic has likely forever altered this generation in ways we cannot change, too.

The communities our children are growing up in and the world they are growing up in are increasingly becoming scary places. If we care about our children, if we care about our future, we need to stop fighting among ourselves and come together to create solutions that support the health and well-being of children, families, and communities. We need to nurture our children, not terrify them.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

While psychiatric medications can be essential for improving mental health and well-being, they often come with unwanted side effects. One particular side effect of many psychiatric medications is weight gain. In this post we will explore how these medications cause weight gain, and what you can do to lessen the impact of this unwanted effect of many psychiatric medications.

What are the different types of psychiatric medications?

There are five main types of psychiatric prescription medications: antidepressants, antipsychotics, anxiolytics (also known as anti-anxiety medications, which can include medications for sleep), mood stabilizers, and stimulants. Stimulants are not likely to cause weight gain. In fact, many of them reduce appetite and can cause weight loss as a side effect. These medications will not be discussed in this post.

Antidepressants can be divided into separate classes:

• SSRIs, or selective serotonin reuptake inhibitors, increase serotonin levels in the brain.
• SNRIs, or serotonin-norepinephrine reuptake inhibitors, increase both serotonin and norepinephrine in the brain.
• TCAs, or tricyclic antidepressants, increase serotonin, norepinephrine, and dopamine in the brain.
• MAOIs, or monoamine oxidase inhibitors, increase serotonin, dopamine, and norepinephrine in the brain.

Why do antidepressants cause weight changes?

All of these medications increase serotonin levels in the brain. Serotonin regulates mood and affects appetite, yet this can have varying results depending on length of treatment. Short-term use reduces impulsivity and increases satiety, which can reduce food intake and cause weight loss. However, long-term use (longer than a year) can cause downregulation of serotonin receptors, which subsequently causes cravings for carbohydrate-rich foods such as bread, pasta, and sweets that ultimately may lead to weight gain. The antidepressants with the highest risk of causing weight gain are amitriptyline, citalopram, mirtazapine, nortriptyline, trimipramine, paroxetine, and phenelzine.

Why do antipsychotic medications worsen obesity-related diseases?

Antipsychotics can also be categorized into two classes: typical and atypical antipsychotics. Both classes can cause weight gain, but they differ in that atypical antipsychotics cause fewer movement disorder side effects. Like antidepressants, antipsychotics affect the chemical messengers in the brain associated with appetite control and energy metabolism, namely serotonin, dopamine, histamine, and muscarinic receptors. In addition to causing weight gain, antipsychotics can also impair glucose metabolism, increase cholesterol and triglyceride levels, and cause hypertension, all of which can lead to metabolic syndrome and worsen obesity-related diseases. The antipsychotics most likely to cause weight gain are olanzapine, risperidone, and quetiapine.

What about anti-anxiety medications and weight changes?

There is no clear link between traditional anti-anxiety medications such as benzodiazepines and weight gain. However, many antidepressants are also used for the treatment of anxiety, and may cause weight gain as discussed above.

Similarly, not all medications for sleep cause weight gain; one that has been associated with weight gain is diphenhydramine (the active ingredient in Benadryl that is also used in many over-the-counter sleep aids). Diphenhydramine can contribute to weight gain by causing increased hunger and tiredness, which can make a person less active. Other sleep aids such as zolpidem (Ambien) or eszopiclone (Lunesta) have not been linked to weight gain.

Trazodone, a medication used for depression as well as insomnia, reduces excess serotonin at some sites, while increasing serotonin levels at other sites, thus affecting appetite as previously discussed.

Mood stabilizers are often used to treat bipolar disease, and can increase appetite or cause changes in metabolism. Although some antidepressants and antipsychotics are also used to treat bipolar disease, mood stabilizers such as lithium, valproic acid, divalproex sodium, carbamazepine, and lamotrigine are the mood stabilizers often used for treatment of bipolar disorder, and with the exception of lamotrigine, they are all known to increase the risk of weight gain.

There are effective strategies to minimize weight gain

For people taking psychiatric medications for mental health, there are strategies to minimize weight gain. Optimizing lifestyle and daily habits is important. This includes eating a healthy diet with whole foods and limiting processed foods and added sugars; staying physically active; minimizing stress; and ensuring adequate restful sleep. Physical activity, in particular, can have a double effect of both improving mental health and minimizing weight gain that might otherwise occur. Cognitive and behavioral strategies under the guidance of a psychologist may be useful for avoiding giving in to any increased cravings for sweets and carbohydrates.

Another strategy to minimize weight gain is to work with your healthcare provider to determine if there might be an appropriate alternate medication option with a lower risk of weight gain. In addition, the anti-diabetes medication metformin has been shown to be effective in treating and preventing psychotropic-induced weight gain. Other medications prescribed for weight loss may also be appropriate to help counteract the weight gain experienced by psychotropic medications.

Be aware that almost all medications have a risk of causing side effects, and it is important to ensure that the benefits of taking any medications will outweigh the risks. Speaking to your primary care provider, psychiatrist, or obesity medicine specialist can be useful in determining which options may work best for you.

About the Author

Chika Anekwe, MD, MPH, Contributor

Chika V. Anekwe, MD, MPH is an obesity medicine physician at Massachusetts General Hospital (MGH) Weight Center and Instructor in Medicine at Harvard Medical School (HMS). Her professional interests are in the areas of clinical nutrition, … See Full Bio View all posts by Chika Anekwe, MD, MPH

Growing evidence suggests that poor sleep is linked to a host of health problems, including a higher risk of high blood pressure, diabetes, obesity, and heart disease. Now, a recent study on people in midlife finds that having a combination of sleep problems — such as trouble falling asleep, waking up in the wee hours, or sleeping less than six hours a night — may nearly triple a person’s risk of heart disease.

"These new findings highlight the importance of getting sufficient sleep," says sleep specialist Dr. Lawrence Epstein, assistant professor of medicine at Harvard Medical School. Many things can contribute to a sleep shortfall, he adds. Some people simply don’t set aside enough time to sleep. Others have habits that disrupt or interfere with sleep. And some people have a medical condition or a sleep disorder that disrupts the quality or quantity of their sleep.

Who was in the study?

The researchers drew data from 7,483 adults in the Midlife in the United States Study who reported information about their sleep habits and heart disease history. A subset of the participants (663 people) also used a wrist-worn device that recorded their sleep activity (actigraphy). Slightly more than half of participants were women. Three-quarters reported their race as white and 16% as Black. The average age was 53.

Researchers chose to focus on people during midlife, because that’s when adults usually experience diverse and stressful life experiences in both their work and family life. It’s also when clogged heart arteries or atherosclerosis (an early sign of heart disease) and age-related sleep issues start to show up.

How did researchers assess sleep issues?

Sleep health was measured using a composite of multiple aspects of sleep, including

• regularity (whether participants slept longer on work days versus nonwork days)
• satisfaction (whether they had trouble falling asleep; woke up in the night or early morning and couldn’t get back to sleep; or felt sleepy during the day)
• alertness (how often they napped for more than five minutes)
• efficiency (how long it took them to fall asleep at bedtime)
• duration (how many hours they typically slept each night).

To assess heart-related problems, researchers asked participants "Have you ever had heart trouble suspected or confirmed by a doctor?" and "Have you ever had a severe pain across the front of your chest lasting half an hour or more?"

A "yes" answer to either question prompted follow-up questions about the diagnosis, which included problems such as angina (chest pain due to lack of blood flow to the heart muscle), heart attack, heart valve disease, an irregular or fast heartbeat, and heart failure.

Poor sleep linked to higher heart risk

The researchers controlled for factors that might affect the results, including a family history of heart disease, smoking, physical activity, as well as sex and race. They found that each additional increase in self-reported sleep problems was linked to a 54% increased risk of heart disease compared to people with normal sleep patterns. However, the increase in risk was much higher — 141% — among people providing both self-reported and wrist-worn device actigraphy data, which together are considered more accurate.

Although women reported more sleep problems, men were more likely to suffer from heart disease. But overall, sex did not affect the correlations between sleep and heart health.

Black participants had more sleep and heart-related problems than white participants, but in general, the relationship between the two issues did not differ by race.

What does this mean for you?

If you have trouble falling or staying asleep, there are many ways to treat these common problems, from simple tweaks to your daily routine to specialized cognitive behavioral therapy that targets sleep issues. These are well worth trying, because getting a good night’s sleep helps in many ways.

"Treating sleep disorders that interfere with sleep can make you feel more alert during the day, improve your quality of life, and reduce the health risks related to poor sleep," says Dr. Epstein.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

Research shows a promising new option for men who experience rising PSA after a radical prostatectomy.

Many men who undergo surgical treatment for prostate cancer (a radical prostatectomy) live out their lives without a recurrence of their disease. But 20% to 40% of them will experience a rise in prostate-specific antigen (PSA) levels within 10 years of the operation. PSA should be undetectable in blood if the prostate has been removed, so elevated levels signify that the cancer may have returned. Doctors call this a biochemical relapse, and ordinarily they treat it by giving radiation to the prostate bed, which is where the prostate resided before it was taken out. Referred to as pelvic bed radiation therapy, or PBRT, this sort of treatment often succeeds in bringing PSA back down to zero for years.

Now, a large study shows that PBRT is even more effective when combined with other treatments. The findings are a potential game-changer for men experiencing a biochemical relapse after radical prostatectomy.

Funded by the National Cancer Institute, the SPPORT phase 3 clinical trial was conducted at nearly 300 medical centers across the United States, Canada, and Israel. A total of 1,797 men were enrolled between 2008 and 2015, all with post-surgical PSA levels ranging between 1 and 2 nanograms per milliliter (ng/mL).

The subjects were randomly assigned in roughly equal numbers to one of three groups. The men in group 1 got PBRT by itself, while men in group 2 got PBRT combined with four to six months of androgen deprivation therapy, or ADT. (Also known as hormonal therapy, ADT blocks testosterone, a hormone, or androgen, that fuels growing prostate tumors.) The men in group 3 got PBRT, ADT, and also radiation to the pelvic lymph nodes, where prostate cancer typically goes first if it begins to spread. The investigators wanted to know which of these three strategies is most effective at keeping disease progression at bay.

Results, side effects, and what’s next

According to their results, the more intensive treatments led to better outcomes. Just over 70% of men in group 1 were still avoiding disease progression after five years, compared with 80.3% of men in group 2 and 87.4% of men in group 3. More specifically, 145 of the men in group 1 developed further PSA elevations during the follow-up period, compared with 104 men in group 2 and 83 men in group 3. Similar trends were observed with respect to how many men developed metastases, or cancer that becomes resistant to hormonal therapy after it begins to spread.

The more intensive treatments also had more short-term side effects, especially diarrhea. But differences in side effects between the three groups disappeared after three months.

The authors emphasized that longer follow-up is still needed to confirm whether adding ADT and pelvic node radiation to PBRT actually lengthens survival. Moreover, the study did not evaluate a newer therapeutic strategy for biochemical relapse, where doctors use novel imaging methods to find exceedingly small metastases throughout the body that they treat directly with radiation.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor of the Harvard Health Publishing Annual Report on Prostate Diseases, says it’s important for men to understand that any measurable amount of PSA after a radical prostatectomy is abnormal and requires further evaluation. “The time-honored normal PSA range of 0 to 4 ng/mL no longer applies when men have had their prostates surgically removed,” he says. “Evidence of further benefits from adding ADT and pelvic radiation during this study is significant. Whether this represents a new standard of care in biochemical relapse requires additional follow-up.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

More than five million Americans use wheelchairs. Getting one repaired is hard.

Wheelchairs restore mobility to people who are unable to walk or have limited ability to do so. Over a lifetime, this may describe many of us due to changes in health, injuries, neurological conditions, or disabling conditions like arthritis. So, when wheelchair technology or parts quit working, a quick fix would seem essential, right?

I know this firsthand. Unable to walk from decades with multiple sclerosis, I keep small scooters on every floor of my 1911 home, which is further adapted for accessibility with stair lifts and ramps. One day when I turned on my second-floor scooter-type wheelchair, sparks arced from the tiller opening atop the steering column, followed by smoke and the acrid smell of burning electrical wires. It was late on a Friday afternoon. No emergency repair service exists for wheelchairs or scooters. Now what?

Wheelchair repair delays are far more than an annoyance

Wheelchairs allow millions of Americans with mobility disability to participate in daily activities and community life (note: automatic download). We know this improves physical and mental well-being and overall quality of life.

On that Friday, my only option was to have my husband bring my first-floor scooter to the second floor. There I stayed, awaiting repairs on the now-inoperable scooter while my husband brought my meals upstairs. Because I have used the same small assistive technology company for more than 20 years — and have the owner’s cell phone number — by midafternoon on Tuesday, I once again had functional scooters on both floors. My confinement had lasted only four days. I know I was lucky on many levels.

But what if I lived alone, didn’t have another operational scooter, or hadn’t been able to wait four days? And what about people experiencing far longer waits for help with an essential device? While the 1990 Americans with Disabilities Act (ADA) prohibits discriminatory policies and requires physical accessibility in public services and spaces, it says nothing about this issue.

How often do wheelchairs break down?

Ideally, a wheelchair should be safe, reliable, and match your activity goals and functional needs. It should provide strong postural support and seating that protects against pressure injuries. Depending on strength and endurance, you might wish to self-propel a manual wheelchair. Or you might need a mobility scooter or power wheelchair propelled by a battery-powered motor, one that might even have sip-and-puff operational assistance or a chin-operated trackball.

Regardless of complexity, however — from basic manual wheelchairs to sophisticated rehab power chairs — all wheelchairs can break down, leaving their users stranded. Factors like broken pavement, inadequate curb cuts or soft terrain, steep inclines and inclement weather, and poor wheelchair design pretty much guarantee this.

In one study of 591 wheelchair users with spinal cord injury, 64% reported needing at least one wheelchair repair in the past six months. Among users requiring just one repair, wheels and casters posed the most difficulties for manual wheelchairs (46%). Electrical systems (29%) and power/control systems (27%) caused most problems for power wheelchair users. Rates of wheelchair breakdowns have increased in recent years, and vary across wheelchair manufacturers.

Repairs are costly, in more than one way. A survey of 533 wheelchair users with spinal cord injury found:

• Out-of-pocket repair costs ranged from $50 to $620 (the median, or midpoint, cost was $150).
• Time spent experiencing adverse consequences from wheelchair breakdown before repair ranged from two to 17 days (five days was the median).
• Among those reporting adverse consequences, 27% were stranded inside their home, 12% were stuck in bed, and 9% were stranded outside their home.

Wheelchair repair delays are lengthening: Could right to repair laws help?

Lengthening repair delays (automatic download) that heighten risks to consumers’ physical and mental health have caused many wheelchair users across the US to voice their outrage. However, reducing repair wait times isn’t simple. Medicare moved to competitive bidding in 2011, causing most small vendors — like my assistive technology company — to leave the business.

The two behemoths owned by private equity firms that now dominate the marketplace focus on boosting profits and cutting costs. By reducing technician hours and parts inventories, restricting consumers’ access to parts and software passcodes, requiring pre-approvals from insurers for repairs, and other practices, these companies virtually ensure delayed repairs.

Furthermore, Medicare and other insurers do not pay for preventive maintenance such as tightening loose bolts and cleaning casters, allowing problems to go undetected until breakdowns occur. Training can allow some wheelchair users to perform preventive maintenance tasks, but such training programs are not widely available.

Trying to reduce repair delays, Colorado’s governor recently signed the first “right to repair” law in the US for power wheelchair users. Complex software programs control many functions of power wheelchairs, and by holding this software as trade secrets, the manufacturers and large vendors have forced consumers needing repairs to use their services.

Much like recent right to repair laws for cars, the Colorado law mandates that power wheelchair owners and independent repair shops have access to the embedded software tools, parts, and other resources required to diagnose, maintain, or repair power wheelchairs. Other states, such as Massachusetts, may follow. Power wheelchair users in Massachusetts are testifying at public hearings about their repair horror stories to motivate the legislature to act.

Given the complexities of the wheelchair industry, it’s not clear whether right to repair laws will shorten repair times for power wheelchairs. Additionally, this law does not address manual wheelchairs or scooters like mine. Clearly, much more remains to be done to ensure timely wheelchair repairs. As wheelchair use surges, with growing numbers of baby boomers with mobility disability wanting to remain active in their communities, solving the wheelchair repair crisis is increasingly urgent.

About the Author

Lisa I. Iezzoni, MD, MSc, Contributor

Lisa I. Iezzoni, MD, MSc, is a professor of medicine at Harvard Medical School, and is based at Massachusetts General Hospital in Boston. Dr. Iezzoni studies health care experiences of persons with disability. She is a … See Full Bio View all posts by Lisa I. Iezzoni, MD, MSc