I'm at the @APApsychiatric conference, and there is a conversation happening here that deserves a much wider audience.

Psychiatric medication deprescription. When to taper, how to taper, and who should be making that call. It is one of the most underserved questions in mental health care. 🧵 The administration has called for greater discussion about deprescribing psych meds. That has created real controversy here.

APA leaders openly acknowledge overprescription is a problem, especially with antidepressants. But these medications are also genuinely necessary and life-changing for many people. Both things are true.

In metabolic health, the most dangerous words a clinician can say are 'the science is settled.'

Here are six debates that are very much not settled, and that affect every patient I see. 🧵 Controversy #1: The Lipid “Paradox”

Is elevated LDL/ApoB inherently causative of heart disease for everyone?

Or is it one of many contributing factors that is less “causal” if your:
→ BP is normal
→ TGs are low
→ HDL is high
→ Inflammation is near zero?

Should we be studying this more?

Your veins and arteries carry the same blood. Same LDL. Same ApoB. Same everything. Yet veins almost never get plaque. Arteries constantly do.

Maybe you've seen the recent discussions about this. It's an interesting question that provides clues in cardiovascular science, and could challenge how we think about LDL and ApoB. 🧵 If ApoB-containing lipoproteins were "sufficient" to cause the disease, we should see plaque everywhere.

But we don't.

We only see it in the high-pressure, high-turbulence environment of the arterial system.

The real "experiment" happens during bypass surgery (CABG).

When a surgeon takes a pristine vein and grafts it into the arterial circulation, something changes.

Subjected to arterial pressure, that vein suddenly becomes susceptible to atherosclerosis.

Lowering TGs with pemafibrate doesnt lower CV events. Does that mean we can ignore TGs? No! A brief thread nejm.org/doi/full/10.10… Changing a lab value with a drug has NOTHING to do with changing it with a lifestyle approach Just look at HDL and CETP inhibitors.

1/ As medical director at @DietDoctor, it's my responsibility to ensure our material is accurate and trustworthy according to the latest science. Our veg oil guide has received a lot of attention lately, so I want to make sure we have objectively relayed the evidence 2/ So we will have one of our experts on our medical review board thoroughly review the guide to help us in our mission of being objective and helpful with our information. I appreciate those of you who provided constructive feedback to our guide.