Is it ever normal to hear voices and is ginger ale really the best treatment for nausea? 

CME: 

Publication Date: 10/13/22

Duration: 16 mins,  59 seconds

Article Referenced: “Medication Side Effects: Nausea, Sweating, and Dry Mouth,” The Carlat Psychiatry Report, June/July 2019

Chris Aiken, MD, and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Transcript: 

Kellie Newsome: Is it ever normal to hear voices and is ginger ale really the best treatment for nausea? 

Chris Aiken: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. 

Kellie Newsome: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Kellie Newsome:  Our summer double issue arrived in the mail. 

Chris Aiken: We'll start with tips from an interview with Doctor Rajneesh Mago, who is the editor in chief of simple and Practical Mental Health and the author of the book Side Effects of psychiatric medications. 

 Kellie Newsome And it's full of tips on how to manage side effects, including nausea. 

In this issue, we recommend Ginger as a first line treatment for nausea on psychiatric medication, but not ginger ale. We're talking about ginger capsules 

Now originally I thought that this was like an old wives tale, but it turns out there's a lot of evidence to support their use in nausea. There are randomized controlled trials where ginger capsules treated nausea in GI disorders chemotherapy patients in pregnancy. This is very different to what usually happens in practice. As a nurse, what I've seen in practice is that we give ginger ale and when that doesn't work, we move on to antiemetics. But we wouldn't expect Ginger Ale to work because it's 50 times less potent than the ginger in capsules. The dose of the ginger capsules is 550 milligrams, given two to three times a day. 

Chris Aiken: Yes, and I've actually used some of these ginger capsules in practice, but what I found out from Doctor Mago, who brought them up in the interview, is that I was doing it all wrong. He recommends giving the ginger capsule 30 minutes before a meal that gives it time to absorb and enter the bloodstream, and then taking the medication immediately after eating a full meal. And he's found that much more effective for preventing nausea, so this has really changed my practice. 

Kellie Newsome So, Doctor Aiken, why aren't we using this more often? 

Chris Aiken : Well, one reason is that there's little awareness of this kind of research, in part because there's no money behind it. But another thing is that even if you know about it, it's hard to know which product to use. And that's one thing Doctor Mago did was he listed a couple products that have good ingredients that you can use with your patients. 

This episode first aired in June of 2019, and we’re updating it here with new research and CME credits. Here’s a sneak preview of the CME test you’ll find in the show note links:

Which treatment has evidence to prevent schizophrenia in people who are at risk for the illness?

1.  Lithium
2.  Sleep hygiene
3.  Low dose risperidone
4.  Cognitive behavioral therapy (CBT)

Chris Aiken: There are other treatments for nausea mentioned in the interview, along with antidotes for dry mouth and sweating on psychiatric medicines. 

Kellie Newsome: Another article that caught my attention in this issue was the one on healthy voices. Doctor Pierre talks about how relatively common it is for people with no mental illness to hear voices. I get it. My patients have been a little depressed at times. I've been a little depressed, but a little psychotic? What does that even look like? 

Chris Aiken: So the idea that normal people who have no mental illness can actually hear voices has been around for a long time. There's about 36 studies on this with thousands of people, and around one in 30 people actually hear voices and have no mental illness. Now there's two ways of looking at this.  One is that this is a totally different thing from psychosis, that it has no relationship, kind of like a shark and a dolphin. They look similar, but they're totally different creatures. A shark is a fish and a dolphin is a mammal.  Another way of looking at it is that this is all part of the psychotic spectrum. Now, you're right, Kelly, we are familiar with the anxiety spectrum, the mood disorder spectrum, the idea that everybody has a little bit of anxiety and depression, and when it gets too severe it crosses a threshold into a full disorder. 

But that we all share in common this symptom. So the question is, can there be a psychotic spectrum? Can we all share in common a little bit of psychosis from time to time. And that's what doctor Pierre gets into. He discusses all the research behind it and the different ways of looking at it. I'm not going to get into that now. I do want to talk about something called the Spectrum project, which is related, and this was started by Doctor Giovanni Cassano in 1995. He developed a series of rating scales to look at spectrum mental illnesses is that is all of the soft symptoms that affect people who may have mild versions of a mental illness, and they also affect people with the full version as well. 

His rating scales are available online, you can go to www.spectrum-project.org that's spectrum-project.org. He's developed rating scales for mood spectrum, anxiety spectrum, anorexia, eating disorder spectrum, addiction spectrum. Like we can all have a little bit of addiction, right? And he has on their a rating scale for psychotic spectrum. 

Kellie Newsome: Well, wait, what's on that rating scale? Can you read us some of that? 

Chris Aiken:  Here are some of the items from the scale. 

Have you ever thought that there is a hidden reason for apparently trivial event? 

Did you ever think that you understood many things that other people didn't? 

Did you ever feel like something strange was happening to your mind? 

Kellie Newsome: So if you saw a young person coming in with these symptoms. Could this be an early sign of, say, schizophrenia? 

Chris Aiken: Yes, that's one possibility when you see a patient with mild symptoms of psychosis and they don't have any other symptoms of mental illness. It could be an early sign and that's something called people at ultra high risk for psychosis and this has been extensively studied as well. In fact there was hope that if we gave adolescents with symptoms like these, anti-psychotics, that it would prevent progression into schizophrenia, but that hope failed. All of those studies failed, and the antipsychotics were not successful at preventing that. So this isn't not an area where you'd want to give people who just have those kinds of symptoms and nothing else going on in antipsychotic. 

 Kellie Newsome: There was a study for Omega 3s. Is that something you could do for them? 

Chris Aiken: Yes, there was a lot of hope about Omega 3s preventing psychosis. Mainly that came from a study that was done 10 years ago out of Vienna. And they took about 80 young adults and adolescents who had early signs of mild psychosis. They gave half of them Omega 3s for three months and followed them up again a year later and there was a significant reduction in the ones who went on to have full blown psychosis and the ones who got the omega-3 fatty acids. 

Even more remarkable, this group followed those same patients up seven years later, and at that point, only one in 10 of the people who got Omega Threes went on to have psychosis, compared to nearly half of the ones who got placebo. So they only got those Omega 3s for three months, and they could see preventative effects seven years later, meaning that those Omega 3s may have helped them pass through a critical phase of development where their brain could have gone either way towards psychosis or toward a healthier development. Now that got people excited and a lot of people were using Omega 3s in their practice with these kinds of patients. But the hope faded when a much larger study of 300 patients failed to find a difference in prevention of psychosis with Omega 3s. But I, like the listener to know that there is still a ray of hope there because this larger study only followed them up for six months, so it may not have been long enough to see a difference and more importantly, in the larger study both groups, the placebo and the Omega 3s, got cognitive behavioral therapy, which we know can actually prevent to the transition to psychosis. 

Kellie Newsome: Can CBT really prevent psychosis? 

Chris Aiken: Yes, in adolescents at high risk for psychosis CBT actually has some of the best evidence for prevention, better than antipsychotics and probably better than Omega 3s. It's probably likely that CBT helps people manage stress, and any kind of stress can increase the risk of psychosis and someone who's already vulnerable to that. That could include stresses like head injury as well as stresses like bullying or divorce in the family. 

Kellie Newsome: Wait, what does the dosage for these omega 3s look like? 

Chris Aiken: Thank you for bringing us back to the practical tips. To use Omega 3s the dose is 1.2 grams or 1200 milligrams. And the important thing is that there would be a lot more EPA than DHA. 

So there's two kinds of Omega. And it should be of the EPA of 700 milligrams and DHA of 480 milligrams. That's what they used in this study. Turns out most products on the shelf have more DHA than EPA. So you have to have the patient search around to find a product with more of the EPA. This is the same way that we use Omega 3 in mood disorders. 

In all the studies of mood disorders like depression and bipolar, omega-3 only worked when there is a greater amount, specifically 1.5 times as much of the EPA than the DHA, and the dose was the same that when you add the two together, it should be 1 to 2 grams for mood disorder. 

You can find specific omega-3 products with high levels of EPA at Doctor Magos's website www.magopsychiatry.com/omega, or my own website www.moodtreatmentcenter.com/omega3

Kellie Newsome: All right, so what about the adults, the ones that hear healthy voices? 

Chris Aiken Right. That's what the article in the Carlat Report is really about. It's surprising to me that one in 30 adults who have no other evidence of mental illness hear voices. If someone came into my office and said they were hearing voices like a bird telling them to keep going, I might really wonder if they're psychotic and turned to an antipsychotic to treat them. And one thing this article did was help me see that differently, which is to remind us all nobody has a mental illness unless they have significant distress or impairment from the symptoms. And so, yes, there's a whole breadth of humanity who hear mild voices that aren't distressing, that sometimes help them get through their day, and they don't have any depression or mania or anxiety or signs of psychiatric illness. And it's important to understand that 'cause they might come into our office for other reasons. And in fact there's a whole group of them on the Internet called normal voice hearers, and they have support groups. 

They get together, basically, they're really against psychiatrist pathologizing them because they value this experience and don't want to see it labeled or treated with the antipsychotic. 

So the bottom line is if a patient comes into your office and has very mild symptoms like that, I guess you've got to read the article to learn more about what they're like. 

You wouldn't jump to an antipsychotic, you would wait and watch and handle it very cautiously. 

Chris Aiken: Well, our double issue covers a lot more, including three new medications that have entered the marketplace in recent months. Esketamine for treatment resistant depression, brexanolone for postpartum depression and solriamfetol for fatigue in narcolepsy. This is a dopamine and norepinephrine reuptake inhibitor that might have a role in the future in psychiatry, but hasn't really been studied in psychiatric populations yet. 

Kellie Newsome: So we'll also be discussing new medical risks with mood stabilizers, 2 new treatments for OCD, and an exciting new strategy to taper SSRI antidepressants to prevent withdrawal symptoms. 

You can send us your feedback and questions to…

 Chris Aiken: In that podcast we introduced the idea that hallucinations do not always point to psychopathology and may be a part of everyday life. In our update, we have the opposite news: people with schizophrenia sometimes see things more realistically than the rest of us.

Try this at home. Go to youtube and search for “Rubik’s Cube Optical Illusion!”  You’ll see a Rubik’s cube with a bright yellow spot in the square, and a brown square on top. But the square is not bright yellow – it’s brown. My cortex has distorted the colors through some evolutionary wiring that probably helped our ancestors escape death or find food dim light but is causing me to question my own reality here.

But that’s not the real surprise – people with schizophrenia are not deceived by this kinds of “high level” optical illusions – the type where our hyper-evolved cerebral cortex takes over and reshapes the sounds or images to suit our own expectations of reality. People have studied this for decades, but it was news to us, and a recent review cataloged over 2 dozen studies that bear it out.

But there’s another type of misperception that people at risk for psychotic disorders are more susceptible to – conditioned hallucinations. The idea goes back the early days of classical conditioning. Imagine you’re a subject in Ivan Pavlov’s lab in 1920 – this will take some imagination because Pavlov worked with non-human animals. You’re sitting at the table, and everytime the Russian doctor rings a bell he flashes a bright light. After a while, he stops flashing the light, but you still see it go off when the bell is rung. The hallucinations has become conditioned – and that is what a conditioned hallucination is.

Don’t worry, the effect will go away, but in people with psychotic disorders these conditioned hallucinations tend to stay around longer. And this year a study in Biological Psychiatry added further confirmation to this idea. They tested conditioned hallucinations in 450 people, half of whom had already had clinical hallucinations and the other half didn’t. Their conclusion is the opposite of what we see with optical illusions. People with clinical were more likely to develop conditioned hallucinations.

Kellie Newesome: I take two things away from this, though really it’s hard to know what to do with all these mind-bending findings. One is that psychiatrists don’t have a monopoly on reality. We’re all misperceiving the world, but in different ways. On the other hand, we shouldn’t take this idea of normal hallucinations too far. In practice, we are working with a very enriched sample. Generally, people are coming to see us because they have a mental illness, and any hallucinations they present with – however mild – are likely part of that syndrome.

Kellie Newsome: Thank you for joining us on throwback Thursdays. If you’d like to earn CME credits, follow the link in the show notes. Subscribe to the full journal with the promo code PODCAST, and follow us online where Dr. Aiken is releasing a daily dose of psychiatric research on his linked in and twitter feeds, @ChrisAikenMD.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.