Psychiatry & Psychotherapy Podcast - 5 Factors and Domains of Psychiatric Care

Episode Date: March 8, 2024

In this Episode, Dr. David Puder, Dr. Adam Borecky, and Joanie Burns discuss the 5-factor approach to holistic, patient-centered psychiatric care. This approach takes into account that each individual who seeks care is unique in their physiological and psychological make-up and that multiple factors influence both physical and mental health (for better or worse).  The 5-factor approach to treatment is based on the importance of sensorium and its pivotal role in regulating thoughts, feelings, and overall mental health. Sensorium is a lens to understand how we focus on various things. Sensorium is total brain function, which fluctuates throughout the day and depends on a number of factors, including sleep, stress levels, and more. By listening to this episode, you can earn 1.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with Joni Burns, Dr. Joni Burns, a nurse practitioner, a psychiatric nurse practitioner who has been in private practice for five years. She was coached by me for two and a half years and then came on my team and sees patients in Florida and California. Joined with me as well is Adam Brecki. He is a psychiatrist in private practice in my group in California and does telepsychiatry and telethyapy. And so, yeah, welcome to the podcast. Thank you. Thank you. And we are going to be going through the five factors and domains of psychiatric care. So this is a holistic, patient-centered psychiatric care approach that we have spoken about in pieces throughout the podcast. And Joni and I, large,

largely Joni has worked on this handout, which will cite everything that we're going to talk about today. And me and Joni meet once a week, and I have been looking at this with her for about a year, I would say. As we, you know, I get busy with everything else. And then we just would find one little piece of something we would want to add. So briefly, just to give you an idea of what we're going to talk about today, we're going to talk about the five facets of the five facets of, of good psychiatric care, including therapy, sleep, activity, aka exercise. Number four is nutrition, and number five is medication,

and the role of medication in the overall approach. So, Joni, tell me what gets you excited about this approach in particular. Well, this is something I'm very passionate about and not only try to share with colleagues, but also with patients, in that there's not a singular approach to psychiatric care. And we're looking at the whole body, the whole person when we're providing care. And medications is just a small piece of that, even if it may not even be appropriate for some patients.

So let's find the specific pieces, specific tools for each patient. What can we fine, tune and tweak to make their overall well-being better? Absolutely, yeah. What is the biggest win? I'm always thinking in the first session, okay, if they were to do one thing, what is that thing, and what would be the fastest, biggest win for them? Yeah, Adam, as you review this, and we've talked over the years, and like what kind of jumps out to you right away is like this approach, holistic approach? I love the framework of the biggest win, and I think as I was reading,

the thing that kept jumping in my mind is this concept of power laws where you have like 20% of change can lead to over 80% of benefit. And I think what's really novel about this approach is not just that these things are good for you, but they also kind of fly in the face of kind of the very modular, like, niches that we as providers kind of get put into by things like managed care, by other, but, you know, other aspects where we defer out therapy, we defer out nutrition, consults. This is, you know, a one-stop shop. And so that's why I think this is so important.

Yeah, absolutely. And this is how whenever I hire someone, it's like a lot of people reach out, want to be hired. It's like, for me, there's two things. Trust, which takes time to build. And I would say kind of alignment with a holistic approach. And so let's start with psychotherapy. And let's talk a little bit about what's happened in terms of, of how often are people seeing a therapist?

Has that increased or decreased? Joni, why don't you jump into that? Well, this is the first step that I usually introduce to patients in that some patients already seeing a therapist. I want to know how often, how long have they been seeing this therapist. Do they feel it's effective work? Are there any barriers to the therapy being effective? For those patients who aren't in therapy, why?

Why not? Is it willingness to attend? Is it financial? I have never found the right fit is sometimes what I hear. And occasionally they're patients that we need to get some of these other steps in first to make them available, open, ready for therapy. So it's not something, and none of these factors or anything that I want to cram down anyone's throat, but we implement them. What can we get started? The whole goal, is just helping the patient feel like they're in control and what's going on around them or the feelings that they're having at that time aren't controlling the situation,

that this is really their thing. Yeah, I think with the advent of biological psychiatry, a couple decades ago, a lot of psychiatrists moved from seeing themselves as a therapist to just a prescriber. I just recently got a critical one-star iTunes review that was like, what kind of content is this? Why is there so much therapy?

Do therapists listen to this? Why? Like, this is an awful podcast for prescribers. They label themselves as a prescriber. And there's something about that reductionistic position to take, right? Where it's like, so, you know, I often will talk about the McKay-At-all psychiatrist effect. it was a study where they looked at a group of psychiatrists who were giving amypremine, which is a tricyclicant antidepressant, first placebo.

And there was a couple psychiatrists whose placebo was better than other psychiatrists amypreming. And so there's more going on in the psychiatry encounter than just giving a medication. Actually, the effect of all of the intangible things that were going on in the best psychiatrists, which are probably things like empathy, therapeutic alliance, and I would add reflective function being high, those things going on made for an impact that the placebo is better than the act of medication. And so, you know, it's a tragedy in American psychiatry that psychotherapy has been downplayed. Largely the gatekeepers of

mental health care are primary care physicians, they will more often recommend medication than they will therapy. And therapy has actually, the rate of prescribing medication has increased and the use of psychotherapy has decreased. And, you know, a lot of it is like what Joni said. Like, what happens when the patient comes in and you talk to them? What has their past therapy experience has been like?

Adam, what do you think, what are some of the hurdles that patients tell you on why they haven't, done therapy. No, great question. And I think you nailed it. I think it's one of these things where, like, when I'm interviewing a first patient for our initial eval, very often, I know that there's going to be expectations about what this is, you know, as a psychiatrist.

And I think what I find is that there is a percentage of patients that have the expectation that they got from all these movies of, like, they're going to sit in a couch and they're going to talk. And there's always this awkward moment where. I have to be like, well, you know, actually, you know, we, yes, yes, that that is what this is. But I think sometimes the expectation is the opposite where like they just want, they want a pill. They want four minutes because that's what they've always trained in and they, they want to leave. But I'm like, they're like, why are you asking me about, you know, my life?

Why are you asking me about my nutrition, right? So it really depends on the encounter. But in terms of, you know, your question about like therapy as well, I think that the first couple sessions for me is about establishing. What are the patient's expectations? Because the word therapy just means so many different things to different people. So I'm also interested in you're and Joni's experience in the same mindset of managing expectations about what is this. Well, I hear a lot of the same thing, Adam, in that you're using those first few sessions just to get to know each other. And I use a lot of like team talk.

We're team. Like you're the quarterback. You know you. know the meds and the other interventions that are available, but I need to hear what works for you, what you feel will work for you. And just saying, hey, like, you know, I'm here to catch the ball. And for those patients who want to the prescription and just leave and don't want to talk about what's going on, I really try to emphasize that there is no medication that I'm aware of or no other intervention that I'm aware of that's just going to be that one, like, golden fixed. And I try to explain and

and kind of getting ahead of myself because I try to leave like medication discussions for the end to kind of emphasize the other steps first. But medications are what I call door holders or doorstops. I think of that little like rubber triangle that you slip under that big, heavy door at work. And all these other interventions work better when that door isn't slamming in your face or hitting you in the backside over and over again while you're trying to make an effort to feel better. So that's all these medications are. They're not, you know, a magic wand or you take it in the next day, everything's better. This is why these other pieces work. And the other factors, if you're taking a medication, my whole goal for you is less medication is better. Eventually, I want you to feel well enough that we have the potential of being on very low doses of a medication and or as little, or maybe nothing. Maybe your symptoms remit and stay in remission for a while. And we talk about coming on. But the only way we get there is with these other interventions in place. Get more bang for your buck.

And so for those patients are just like med, med, med, I'm like this, you know, your long-term wellness. And I try to pull up some of these research articles and explain it. This is not just me saying, I don't want to write the prescription for you or I don't want to do this for you. Really, the research shows what's best for you is this, this, this and this. Yeah, people have been inculturated or a lot of people. happen into more medication, just prescribe.

I'm just here for prescription. I can remember a couple patients who it's like, I'm there, this is a 25 minute appointment, and they're like, I've never started to try to reflect on my life, and I've never tried to look at my interpersonal conflicts and how they relate to my mood issues, you know? And so there is a persuasion almost to get the care that's needed that I sometimes find myself needing to do because it's like it's not enough for someone,

for example, let's say they have a personality disorder. It's not enough to just be on meds. Like you have to actually do the work and it's going to be a lot of work. And so I think that comes to mind. I think a lot of providers have not even been to a therapist. And I would say I've had a couple people apply to work for me who have never done therapy. And it's part of my requirement that they've had that experience and a good experience with therapy. And it can be a personal question to some degree, but it's also like a reflective, you see it in the ability of the reflective function when a person is talking about interpersonal things. If they've done the deeper work, they often have a more articulated way of describing interpersonal conflicts, interpersonal patterns,

and there's less gaps in their sort of understanding of interpersonal conflicts. So I want to jump to, is a specific therapy modality recommended? And we've talked about this a couple times, but I feel like it's always this debate, right? And so you'll get people who have heard it over and over again, like CBT is the answer. Adam, is there a specific modality that you think wins out in studies over and over again? Yeah, short answer is no,

but I think we have to like understand a little more context, right? And so I think like when I was in training, you know, my supervisors, you know, tended to recommend us was, hey, learn the CBT manual, you know, read, you know, go through the whole thing. And I think what's, what is good about

that is that it's manualized, right? But I think that if you or I were to go to a therapist for the first time and, you know, they pull out this, this, this, this, this, this, this, this, this, this, this, regimented. Something about that seems like, it's like you're kind of stuck on level one, right? But I think there is deep value in having guardrails and in, you know, something very, very regimented. But that is the mindset of, you know, 1970s, 1980s, you know, insurance based managed care, right? And I think that what an amazing, the best therapist that I've personally had have been, have had the freedom to transcend the boundaries of these individual schools to meet me where I'm at. Right. So that's, that's what I'm aspiring to.

So if psychodynamic issues come up, we're able to, we're able to investigate that, you know, certain aspects of, you know, repressed desires and things like that. But also, in my experience, I always bring it back to there's cognitive distortions that I, you know, go with, but I have to let the patient, like, lead me there, right? Absolutely. Yeah, I think it can be hard because a lot of people find this idea of therapist effect complicated. And I'm going to be doing more episodes on this in the future. So if it feels still ambiguous to you, that's okay. but there are some therapists that are better than other therapists and it doesn't seem to be modality specific and just like there's some supervisors who are better than other supervisors

there's some bosses that are better than other bosses one of the things that I've studied with adam is adam was a co-author in this connection index where we looked at how a supervisee rated a supervisor the level of connectedness between that they were that they were that that was experienced. And this, you know, went super high, had less, you know, the trainee had less burnout. So even the connection inside of a therapy or a supervisor, supervisee encounter is so important, the connection. And I would say that connection is so important as well between the patient and the doctor or the mental health professional. Adam, any thoughts on the connection index that we haven't talked publicly about that. I don't think you've been in any of those episodes

where I've talked about it. Yeah, no worries. No, that was kind of, when I first met you, our very first projects together were that connection index. And what that looked at specifically was the interactions between medical trainees and clinical supervisors, not just in the psychiatry context, but in others as well. And I think, but the principles, like the core, like first principles of that study are completely relevant to what we're talking about with therapy. meaning, you know, the quality of education, the quality, and you could think of therapy in a sense as education, right? So the quality of that encounter and how much you grow from that experience is directly related to the connection you have with that supervisor, right? And so in that context, you know, in terms of therapist effect, if we want to look at other words like therapeutic alliance, which is another, you know, common buzzword of the podcast, right?

is if we separate that out, that's a core factor that I think transcends any conversation of CBT, DBT, supportive therapy, right? That's the core. And I think reading people like Glenn Gabbard and things like that, that's very consistent as well. It's the core elements of effective therapy. Yeah.

I wanna add, there's a recent study that I found that looks at therapist effect, and they were able to say, that 70% of what made the best therapist the best and the worst therapist the worst related to a measure called reflective function. I'm doing a whole episode on this. It may come out before this or after. Reflective function is measured by looking at the actual adult attachment interviews of the therapists.

So they took the therapist. They put them through the adult attachment interview, which is a dialogue between you and someone trained in this, talking about your childhood, talking about what happened between you and your mom, your dad, you know, the people who you had attachment relationships with, right? And then they looked at the responses, and they looked at the quality of the reflectiveness.

It's at 11-point scale from negative 1 to 9, and 9 is the highest. And people who scored from 7 to 9, their patients got better. The bottom third, the patients did not get better at all. And so it's like, for me, reflective function is my new obsession. It's my absolute new obsession because how they graded it, it's so articulately put together. This was by Phonagy at all.

The person who invented mentalization-based therapy, him and Bateman, invented mentalization-based therapy. There's a lot of overlap between mentalization. and reflective function. But for me, it's like the attachment to the therapist probably is easier to have when you have a therapist who has higher reflective function. And so, you know, what is high reflective function? How do we grow in reflective function? Stay tuned because that is like my new obsession.

Spoiler later. Okay. So how long does therapy take? Let's jump to there. Joni, take us away. Well, I think earlier episodes pointed to the, I guess, what we consider the gold standard or insurance preference would be these six to eight weeks, maybe 12 if you're lucky. And what the research shows us is that significantly longer periods of time are needed for therapy

to stick and provide long-term improvement. One of the incredible studies that you used earlier, let's see, I think this is Vonnegian Bateman again, and Verheel at all, talked about 52 weeks of therapy that not only included an hour of individual therapy, but two to two and a half hours. of group work a week, which ended up being somewhere between 156 to 182 hours of treatment.

And so it's a very significant amount of therapy compared to what, I mean, essentially we're taught or boxed into based off of what insurance has been approving the patients. Right. So a recent meta-analysis looked at CBT, and they looked at what percentage of people got better into remission compared to the control group. And it was 20%. So with CBT, you have 20%, one fifth of people get into remission with that nice 12 session package. Right. So you have to get your mind around that. Like if you are a professional practicing and you refer a client out and they do their 12 sessions, one out of five is going to go into remission for just that treatment,

which it's just the start, right? So we know that Bateman and Fornegut, like, longer therapy for borderline personality disorder as well, which is going to take longer. Those people got better. A lot of them didn't even meet criteria for borderline personality disorder anymore. It's like personality disorder is not for life. Personality is not for life, right? It changes. And if you think about like, okay, is 100, is 300 hours a lot of time? Like in the large scope of life, like, it's, I don't think it is a lot of time, actually, if you think about it.

Like, think about how many hours of potential bad input was needed to get to that place of having a very negative internal voice. If you had, like, a parent who was very punitive, who is very sort of continually beating you up with words, that's not 200 hours of beating you up. That is like maybe 10,000 hours, right? I mean, so the fact that we're able to reverse the course of some of that negative internalization in a couple hundred hours of therapy is like amazing in my mind. But it's a commitment for patients. And if we have a mindset as a provider that it's going to be 12 sessions, were going to be dissuaded from ever recommending therapy.

And, you know, there are some therapists. Like in that one study I showed on reflective function, there are some therapists who the patients don't get better at all, right? And so somehow as providers, we need to be able to gauge the reflective function, the therapeutic alliance ability of different providers. And we may need to get to know in our community who are those people who are exceptional, and it's worth maybe making a financial sacrifice to see. Because it is a sacrifice and there are a lot of money.

There are a lot of things that we could spend money on. And it is a sacrifice to get good therapy. I know I've spent a lot of money on therapy over the years personally. Yeah. I think it's a good thing though. And I think like to kind of to Joni's point, like it just saying, oh, I'm seeing a therapist or if I want to make a recommendation, go see a therapist, like, that's such a hollow phrase, right?

Because there is just a whole rabbit hole of quality, time type of therapy, right, that has to go into that question. So it's like a dangerous thing and just saying, oh, go see a therapist, you know, oh, if I'm an insurance, you know, bean counter, like, oh, nope, that's not going to work. Like 12 sessions, you're not better. All right, bail therapy. It's like, no, no, no, no. Or I know a couple of patients who have a certain type of insurance.

and with that type of insurance, they can only get in once a month. And that is just not enough of a dose of therapy. I mean, imagine in a year only having 12 sessions, like I'm saying in a year you need to have 50 to get that dose response to a place where you'll actually move the needle enough to maybe get out of the situation. The other thing I wanted to mention with psychotherapy

is certain types of disorders like OCD, anxiety, it seems like when they stop the medication, the benefit stops. Whereas if they get the dose of therapy, there's long-term change that lasts a lifetime, which is really cool if you think about it. Any thoughts on that, Adam or Joni? This was back to kind of the five steps in Joni's framework. But the way I kind of pitch this to patient sometimes

is I frame a medication as like, It's almost like a supplement to therapy. And the way that I frame that, it's actually very, you know, this is reflected in the literature, but there's increases in neuroplasticity from some of our meds, right? So, you know, increase like SSRIs boost, you know, BDNF, brain neurodotropic factor, right, in the same way that exercise does, good REM sleep does, that's going to facilitate the change of therapy in a way, but it's not an end, right? So when I, when I pitch that to a patient, they're like, what, I thought that the med

was what was fixing me. And I'm like, well, you know, yes in a sense, but it's, it's so much more nuanced than that. So they really do need to go together. And I think that's reflected in the literature. But has that been consistent with your experience, Joni, like with when you're kind of making this pitch to patients? Yeah, absolutely. That it all works hand in hand. And it's, it's not just one thing. Yeah. And there was this one study on brain-derived neurotrophic factor, which we know is like miracle growth for the brain, which we know increases in antidepressants or exercise increases this.

And BDNF increases actually in patients who are responding to psychotherapy if they have bulimia, if they have borderline per size order, if they have insomnia. So we know that just therapy alone may increase BDNF, but in other patients, they may need the exercise, they may need the medication as well

to increase brain drive, nootroph factor. Joni, any comments on that study? Well, specifically, when you brought this up in a prior episode, I was mind-blown that this is not information that was taught within my program. This is this is brand-new information. And it's stunning and awesome that we see this because one, it shows how impactful therapy and it. of itself can be. It's not just a feeling, a temporary thing. We're making changes, huge changes. And I think this new information we have on hand, I think on my end, it helps solidify for patients who want to, wants to know the why. Why are you asking me to do therapy, Joni? Why are you

asking me to do this? I'm like, this, this is big. Like from a, I mean, yes, I'd like to geek out on this, but from talking to patients, they may not appreciate the nerd side of it. But I'm like, look, we used to say, like, once the brain was impacted negatively, we didn't get to rebound. We didn't, there's no improvement. Like, you're stuck there. And this proves otherwise. And if talking to someone in a therapeutic manner can do this, imagine what everything together can do.

Yeah, great, great point. And I think from that BDNF study, it did seem like there were some disorders like PTSD that there was not a BDNF increased just from the psychotherapy. And this is where combining treatments is so powerful. And I think this is a great place to step into the second domain that is common in our practice in the way that we practice as a group, which is sleep and the importance of sleep. And, you know, as a prior collegiate athlete, I could say like sleep was. the secret that we used as a team like getting a good eight to nine hours of sleep a night while you're pre-med it's tough but um it was like totally necessary to have that level of performance and you know our kids need a ton of sleep i'm surprised when parents don't put their kids down at a

good bedtime we put our kids down at 730 there's they're you know in elementary school 730 is their bedtime. And it also allows you as a parent time to do stuff. But it takes a little bit of planning. It takes, you know, and if you get home late, you might not be able to do it that early. But yeah, sleep is so, so important for your total mental health. So, Joni, talk to me about how do you ask questions around sleep? I think that's a good thing that you can mention. Well, it usually open the door above and just ask, you know, how is your sleep? Do you feel like you're getting enough sleep? And if when you wake up in the morning, do you feel rested?

And depending on where the patient goes with that, oh, I get seven to eight hours, but I'm exhausted all the time. Well, let's look into that. What does that seven to eight hours look like? You know, is it a matter of, is there too much screen time before bed? what other factors are happening before bed, how stressed, do you have time to wind down? Potentially, is that sleep actually restful? Do you have obstructive sleep apnea? Do we need to get him with a sleep specialist and have that assessed?

And so just looking at the various factors, I think the biggest thing is sometimes there are patients who don't necessarily require seven to eight hours of sleep. They're good to go with six. But wherever they are in that spectrum is do you feel refreshed when you wake up in the morning? Yeah, I think one of the big things that starves people of sleep is screens right before bed. And there's this one study using mobile phones at night was associated with the lower quality of sleep. And the beta, the effect size, is negative 1.18, which is huge, right? It's like we never get beta's that big with interventions, right?

So it's like, think about like an intervention that you could do to improve the quality of sleep. And then the amount of screen time. And we'll include this nice table showing you how the nighttime screen exposure, as it increased, it further increased the odds of things like insomnia, a lack of energy, even irritability, daytime sleepiness, and we're talking about the odds jumping from like one to like eight, eight times more likely, right? Stuff like that. So it's like, this is very important to pay attention to, especially in young people who are texting. What are the trends that we're seeing,

Joni, that you found as we looked at this? Well, specifically, it's patients for utilizing the screen right up to bedtime. They are falling asleep with it in front of them. I hear often from patients they do scroll until they pass out. So literally the screen is on in front of them until their eyes close. And then from the article that you pointed out is those persons specifically teens who are keeping their phone in bed with them and checking throughout the night or these are teens that keep it under their pillow or right beside them. So as soon as it vibrates or dinks, they're up at all times of night checking hugely, hugely impactful in a negative way on their sleep. Sometimes I'll like have, and I love that, Joni.

I sometimes I'll have my patients like where if they have like an Apple Watch or a whoop or one of these like Fitbit tracker things, I'll like be like, hey, do you wear it at night? You know, could you do that for a couple weeks? Then kind of come back to me and show me. And so sometimes they'll, you know, especially the, you know, young adults, adolescents. And we'll look at that. I'm like, okay, well, you're in bed for eight, nine hours. that's good. That's a good thing. But look at your sleep efficiency. How much of that are you

actually like sleeping? And it's like five, six hours. And I'm like, what, what are you doing with that time? And, you know, it's not just that they're struggling, like trying to sleep. It's, no, they're doom scrolling. They're on, they're on TikTok for, you know, three or four hours. And that's just kind of part of their established, you know, behavioral routine. So very consistent with what I see too. Yeah. I think we have forgotten as well as professionals how to active recover. I had a period of time where I completely got off of social media and, you know, I'd read before bed and like I was starting to sleep better. I started to recover from like a high stress period of time. And I think that what happens both with our patients and with ourselves is when we

have time off, it's like, okay, I'm going to catch up on binging on my favorite TV shows. And, you know, you may stay up a couple extra hours. It's like those extra hours, you don't recover them. You don't sleep, the sleep in is not as good as going to bed at a consistent time. So for some patients, one patient this week, it was like, it was the one thing where I was like, this is the biggest win that you could have.

And it's like you're starting to, you're feeling fatigue and exhausted. And part of that, it's not depression. Part of that is you're up to one a block binging on Netflix and then waking up at eight, you're just not getting enough sleep. And so it's kind of like one of these things that, you know, being a more psychodynamic attachment-oriented therapist in general, I don't like necessarily focusing on the, because it feels very like behavioral, you know, it feels like a to-do list or you should or it's punitive.

And I don't know if you have any thoughts on that, Adam. So to that, what I initially thought of when you just said that was like the follow-up question to my, like, when I bring this up with patients, you know, how are you sleeping? You know, what are you doing in bed? What I often uncover is actually something rather psychodynamic and almost existential. And the answer that I get is that, well, I'm afraid of being alone with my thoughts, right, when I'm in bed, right? And so having, like listening to something, having the TV on, you know, while I go to bed, it prevents me from actually, you know, that horror of like just, you know, lying there thinking, right?

And so that, I use that as like a little like psychodynamic on ramp to then, okay, let's unpack that a little bit. That's good. And sometimes what happens then is it comes out in dreams, the wake up in the middle of the night with those thoughts. And so for me, my emphasis is, probably on like, what wakes you up in the middle of the night? What wakes you up early? What are you thinking about? Like, that's the good stuff. And even in supervision, when I supervise,

whether it's Adam or Joni, you know, we'll meet together, talk about cases. I like the bidirectional aspect of colleague's supervision as well. So I'll tell them some of my tough cases and they'll empathize with it as well. But, okay, so sometimes it's the middle of the night content that tells you what is important to really process. And yeah, so Adam, I like how you talked about this idea of being alone with their thoughts. It's scary. And that comes, oh, man, it comes back to this initial quote we had at the top of our, top of the episode.

Joni, do you want to read this Victor Frankel quote? Between stimulus and response, there is a space. And that space is our power to choose our response. and our response lies our growth and our freedom. And this is by Victor Frankel. Yeah, so it's like this idea of like, we can choose our response. We can choose maybe how we're going to approach

the conflicts of our life. This is such a great quote because this is the core of everything. This is the premise of therapy, right? And meaning you do have the freedom, you know, to change, right? But I think the first step there is like really un-pocket. the habit loops of thought that patients have lived on autopilot their entire life, right? And so back to the sleep, being the one of my thoughts, like, what are those thoughts, right?

Is there deep, is there deep-seated death anxiety? Is there, you know, crushing insecurity? Are you just, are you, like, oppressed by, you know, intrusive memories of something you did or something that was done to you, right? It's like, does it have to be this way, right? And then that's very often really the fertile soil that then I think a therapeutic change can actually take place in. Yeah, I had a client who would go to bed with the TV every night and then he'd wake up two, three hours later, and the TV was off. And the biggest win I had for him was keep the TV on all night. And for him having that consistency of how he fell asleep and how he would wake up, So the other thing is like sleep association, right?

So if you fall asleep with something, and that's how you fall asleep, then when you wake up in those lighter stages of sleep, you will need that thing to fall asleep again. And so this is where, like, yeah, if you're falling asleep on social media, death doom scrolling, which is like just mindlessly scrolling up looking at stuff,

then you're probably going to need to do doom scroll in the middle of the night to fall asleep again if you wake up. And this is the same thing with an infant. If an infant learns to fall asleep in your arms, then when they wake up in the middle of the night, they may wake up more if they are not in your arms. So it's like how we fall asleep needs to be replicated ideally in the middle of the night. So the ideal is to learn how to fall asleep without a screen in front of you, right? for the one patient who was refusing to not watch TV before he went to sleep, I said, oh, just try to keep it on all night, see what happens.

And he kept it on all night and he actually slept better. So, I mean, maybe that's like sometimes we're looking for that first easy win before we do the deeper work, right? Because for him, he had psychosomatic pain issues, so he had emotional pain that was stuck in his body, a lot of anger in his jaw. And so he would get angry and he would feel. tightness in his jaw. And it was learning how to express the anger in meaningful ways that allowed him

to not have the jaw pain chronically. And then it was, you know, that took a lot longer than one session, right? So sometimes we can find the easy wins early on. Okay. It's important though, because I think the three of us are more, you know, being more psychodynamically oriented. I still think there is space back to the whole concept of, the principle of whole, like holistic care. We have to be behaviorist sometimes, right? We have to sometimes occasionally do what you just did with your patient, like something practical that can unlock the later stages that we so greatly value. Yeah, and so behavioral, when I think of behavioral therapy,

I think about like you're scheduling activities that are meaningful that give patients a sense of purpose and meaning in the past. So sometimes when we're depressed, we just stop doing things that give us a sense of meaning and purpose. And so part of behavioral therapy is starting to schedule those into our day. So yeah, I still do behavioral therapy, especially if people are not ready for the deeper work. Maybe they're, for various reasons, the severity of the illness. If it's higher, sometimes behavioral work is like the starting place to get people just doing the basics of life again. Okay, let's move to activity.

So we have talked a lot in this podcast on exercise. am enthusiastic to see that more psychiatrists are talking about strength training. We talk about the benefit to our brains of exercise, more than the benefit to our bodies and aesthetics maybe like most people focus on with exercise. So, Joni, take us away. Benefits of exercise on the brain. Okay. Well, we talked about the BDNF earlier with therapy.

Well, it should be no surprise now that this is a big mind-blowing component that we now get this healthier brain from exercise as well. And for those patients who are looking for improvement outside of medication, we have maybe the only side-of-fetched-free component here. In that implementing exercise, you get the physical benefit, the psychological benefit, without worrying about some side effects such as sleep disruption or weight gain from implementing more activity into your routine. Yeah. So I think there was an article we did a deep dive on. I think it was episode 165.

and we talked about contracting muscles act as a neuroendocrine organ. Okay? And this is like, this is mind-blowing. So think about it as a neuroendocrine organ that's releasing things that are growth factors that lead to neurogenesis, which means like neuroplasticity, neurogenesis, like brain growth in the right ways. Muscle contraction leads to the secretion of myokines. cathepsin B, erycin, that cross the blood-brain barrier and indirectly increase brain-derived nootrophic factors. So there's all of these things going on. BDNF is not the only one. It's so much more complex.

You could probably spend your whole career just diving into all the changes that happen. And we know that when you change your exercise regimen, it's not like, okay, so we have something called epigenetics, which means we change the environment. and our gene expression changes. And so we know that it's not just one gene that changes when we start exercising. It's literally tens of thousands of genes. There was a study by Dean Ornish where he looked at this, and it's tens of thousands of genes

are being upregulated and downregulated. So just think about how impactful that is. We know that mitochondria increase, and this leads to better heart function. You know, we know that heart function relates to future risk of stroke, future risk of dementia, future risk of death. So we did an episode on how exercise is probably the biggest decreaseer of absolute risk of death in your 50s and 60s. Like if you are in the top three percentile of fit people or the top 10, compare that to bottom 25 percent. your risk of death is about tenfold less over 10 years. So it was like 2.3% of people dying

over 10 years compared to 23%. Those are the absolute risk factors. I mean, there is nothing more important. I can't think of anything more important in terms of longevity, long-term brain function, you know? And so that being said, everyone is on a path. And I don't even like exercise. I would like to call it training, okay? Because it's progressive, it's thoughtful at its best. So when I'm bringing training, like I've studied this for thousands of hours. And so it's very, I'm thinking of what is the next step in their training regimen to get to the next level. So if I, if they are someone who's completely bedbound, they're in bed most of the day, they're doing less than 1,000 steps per day. So if they pull up their iPhone. Their iPhone is going to say they do less than a thousand steps a day. And I know this because

I have a lot of patients pull up their iPhone and show me in their health app how many average, what's their average steps? And it's like, it's really low. And so for them, it might just be going to 2000. And that may be a five to 10 minute walk. Like that's it, but just getting their bodies moving. You know, what is that next step? And I don't want to take them from like zero to 100 percent over the course of one week. I want them to go to, I want them to go like incrementally very, very slowly. They're going to go very slowly. So, Joni, talk to me. How do you, how do you practically do this with patients without making them feel more shame? Well, you know, I, in many senses, I look at it, it's, you know, saying, you try to use the word activity versus exercise. And how can we increase

your activity level or is there something that you look had done in the past or would like to incorporate into your routine and um you i sometimes joke i'm not asking folks to do crossfit extreme i'm like let's can we get a five minute walk in you know today or a couple times this week and um look at it as you know we're taking baby steps what's our win for today and um you these patients will sometimes say, I, you know, I used to walk every evening after dinner. And I'm like, well, is there a way we can get that back in? That sounds like something you really enjoyed in the past, not just to take a break and reset your mind, but the physical benefits of that as well. And we discussed looking for those, the win of the day.

And that's really what I'm looking at patients is that, again, we don't need to go get an expensive gym membership. on that asking you to go in power lift. It just lets do something for that mind, body benefit. Yeah. Adam, thoughts? Yeah, no, this component of the holistic approach, this has changed my practice more than any other thing in the last year. And so just kind of going on a, like I read like Chris Palmer's book,

you know, brain energy that really specifically looks at, you know, mitochondria and its relationship to mental illness. and just how exercise can revolutionize the amount of energy that our neurons have, that are a requirement for thinking well. The benefits are just exponential, right? This is so much more effective than anything I can use with my prescription pad. And to Joni's point, I think it's one thing for me to say that and be passionate and explain to my patients to nerd out on all the benefits.

But I think what Joni said is just the most profound part of this is like we have to get our patients wins. We have to facilitate that dopamine part where there's a seeking, there's a habit. There's something that actually makes them feel like they're improving. So 10% going from 1,000 steps to 1,500 to 2,000, right? And I think this compounds is snowballs because if I can pitch them next step, hey, could we do it within an hour waking up? So you can get some sunlight in your eyeballs to kind of reset your circadian rhythm, right? These things slowly become a flourishing, you know, human being, again, as we, you know, incrementally improve with the training mindset. Yeah. And I would add, you know, when we say it's better than medication, it's better for some diseases, I would say.

There's data to support, like there was a Duke study where they compared exercise in a group with a trainer three times a week compared to Zoloft. And they were about equivalent, this moderate level depression, mild and moderate. They were about equivalent at the end of the study. They were both effective, equally. They studied them for another two years, and the exercise group won out the people who stuck with the exercise. Now, that could be self-selecting factor. They weren't randomizing them anymore.

That being said, like for some things, like we're going to talk about schizophrenia, treatment resistant schizophrenia, bipolar, you know, exercise is not going to be the biggest win, right? And so there's some nuance there, of course. And the other thing is like if someone is severely depressed and they're in bed most of the day, like it's going to be really hard to get them to do anything physically exercise. Like they can barely take a pill. And that's like a very, that seems like a big hurdle for some patients in that state. So, so. So, in my sort of holistic approach, it's like, what are they capable of in the first beginning of treatment? You know, I may mention the importance of it, but I may not beat it in too much

just because I feel like people already have enough shame. And like, you know, there may be other reasons. I treat a lot of patients who are just not able-bodied. They have, you know, rheumatoid issues. They have these issues that keep them from being able to exercise. Like, I have one patient who was a huge fitness guy. He is literally bedbound. So there are some people who, because of physical ailments, they cannot exercise. So it's not a, it's like,

we're saying this with a bit of like humility that everyone may not fit into this category of being able to do this. But even for this bedbound guy, he can't move his legs. That's where his disability is. I'm trying to get him to start doing some exercise with his arms in bed, right?

that won't hurt him at the parts of his body that are hurt. So I do think, like, I try to be very creative with different people on what may help them. There is evidence that the more watts you can produce at a given lactic acid threshold, the higher density of the mitochondria and the better the mitochondria are functioning. So if I want to get very nuanced and granular with patients,

I'll have them do different exercise regimens, like get on the bike for 10 minutes and have your heart rate at 135 and let's see how many watts you can produce on average. And so we can actually measure progress over time and we can stage workouts in such a way that are very progressive. And sometimes I'll do it myself and sometimes I'll have another professional step in and really give them a lot of dedication, dedicated time. So I want to kind of like show the two extremes of like people who are just walking a little bit versus people who really want to optimize their medication regimen. Maybe they suffer from biological depression.

They have a family history of suicide. They have a family history of depression and they want to be pregnant off of medication. They know that medication is a very small risk for pregnant people. But they want to be off medications during pregnancy. It's like, okay, we're going to optimize every single category we can. And they're very motivated patients, right, because they want to do this for their kid. So those patients, I may get more nuanced and more sort of granular and look at like, okay, what are the subdomains that we can really optimize?

How can we increase your, like every single aspect of your exercise in a way that's healthy for pregnancy? Okay. Any final thoughts on that or we'll move on to nutrition? No, I think you nailed it. being nuanced, meeting the patient where they're at, you know, and not being a, like, insider of shame because I come in hot and heavy with my, like, great passion about exercise when it just fills them because they know that they can't, right? That's not what I'm for. Yeah. Yeah. And the final thing I wanted to mention about exercise is in my own personal regimen,

when I go through a high stress time or maybe I've had a migraine the day before, it's like I shift my regimen. And so this morning, for example, I had a migraine yesterday. I was doing it 24-hour fast, so that might have been why. And epigenetically, I was not ready for that. So my brain was like angry at me. Could be a lot of the stress going on in different domains of my life. So because of those stresses, because of that lack of food, I got a migraine. And so this morning, I'm not going to lift heavy. I usually squat, deadlift, bench press, Tuesday, Thursday. And so I got on the bike, did 30 minutes. And normally I'll do about 200 to 210 watts. Today I did about 180, which was pretty light, pretty easy. And so it's like when you're recovering from being sick, when you're recovering from a high stress time,

I tend to like the lower-paced cardio, lighter than what you're used to maybe. And then when you're in a building phase, I like to do cardio, strength training. combined and have maybe two days a week of strength training and three days a week of cardio. And if they enjoy things like tennis, that could be like the cardio portion, you know. So I try to find like what they enjoy for the cardio. Okay. Let's move on to nutrition. So nutrition and Joni, you said this is the part that patients push back the most on.

It is often, I often get questions, like what does this have anything to? do with what we're talking about today. And I'll admit, I'm like, hey, I hear this a lot. And let me, let me just give you, please hear me out. Let me give you my spiel. So I often, you know, similar to when appropriate work in the humor part. I'm like, have you ever been hangary? And they're like, oh, yeah. Or I know someone who gets hungry. And I'm like, well, why does that happen? I'm like, do you think maybe that person's tank is empty? at that time. And like, we got to make sure that we have that fuel in our system to keep us going. It's not just a food. It's not just a physical fuel. It's also driving the brain. And when you think

about the size of the brain in proportion to the body, I mean, it's like this small space, but it uses a quarter of your calories. And if you're not taking anything in where that fuel's not good, you put the cheap stuff in there, then you're not going to get good output. And you, you, I kind of touched on like getting bang for your buck. If you want those medications to work really well, you want that activity level to go better, further, sleep improvement, your therapy to work and your stomach's not grumbling the whole time you're in therapy. I'm like, you got to make sure that the nutrition piece is there.

And there are certain components. They say, hey, look, we can't always have that salad a couple times a day or well-rounded meals. Are there supplements that might be. outful. Fill in those gaps. I'm like, I'm not looking for 100%. I'm like, anybody who tells you that they get it all right and check every box all the time, I'm like, I'm fairly certain there's something that's missing once in a while. And let's take that into account. And we know from research, from evidence, things like omega-3, super, super important for the brain, D3, folate. Those usually, like, for most patients, those are the biggies. How much green leafy vegetables are you getting? Are you getting

exposure to natural light or D3 in some other way? What are you ingesting that contains omega-3? What can we do to make this better? Yeah, I think this is one of those categories. It's like as professionals, if we start recommending this, we can get so much pushback that we can just not want to recommend it at all. And I've seen cardiologists who have gone through the same experience of exercise and diet is so laborious to talk to clients about it. They just stop talking to clients about it, right? In my initial intake, I ask patients, what are their normal meals like? I want to get a sense of how much processed food they have. If you look at the Jaka at all study, the 2017 study that have cited a ton. The Cohen's D was negative 1.16.

compared to the support group. So this dietary support group did fantastic. I mean, that is a huge effect size, largely based on eliminating processed foods. So they selected in this study people with a high processed food diet, like a horrible diet. So they didn't select like the average patient. They selected like a horrible diet patient.

And those patients could make the biggest change. So this is once again what I say, like, I look for the biggest win. If a person's diet is complete garbage, like, that is the biggest win. Now, that being said, do they have an eating disorder? Do they have a history of anorexia? Do they have a history of bulimia? Like, if they do, I'm going to treat this very differently, right, than someone who's never suffered from that.

They don't have any, like, they don't have any obsessions or compulsions around food. So as a mental health professional, we have to be nuanced in our prescription of diet changes. This is the area that like Joni, I get the most pushback on. And it's so funny because I see this like sometimes I'll kind of talk about some core principles, like, you know, first principles of nutrition. And I see this like fire in their eyes. And they're like, why, you know, I only eat like organic grass fed bison meat or, you know, it's just kind of like wild stuff. So people have really, really strong opinions. So I have empathy for those providers that, you know, just kind of avoid this.

But I also think that, like Joni said, like we can meet them where they're at. And like you said, David, just trying really hard to find the biggest win for them, whatever that looks like. But this is the most, like, nuance that I come at it. Like with fear and trembling, do I approach nutrition with some of my patients? Most people, when they think of diet and exercise, they think of weight loss. and that's where most of people's emphasis has been and most of their bad experiences. And so when I'm trying to convert people to this idea

of we're doing this for brain health, we're doing this for longevity, we're doing this for, and maybe those aren't the biggest pain points, maybe weight loss is the biggest pain point that has led them to have such a bad relationship with food. And so I think I'm trying to bring them into a different relationship with food. So it's like thinking about food is nourishment,

thinking about food is like, you know, what is going to help your body recover from this stressful time. Like, what could you eat? That would be helpful. If you are in a high-stress time, you may be drawn more to those high-salt, high-fat, high-sugary foods. But is that necessarily what's going to nourish you and what's going to help you recover? So, yeah, I think this is an important domain. And I think it's not talked about enough in nuance where we need.

to talk about it. And so if you are a mental health professional, if you're a nurse practitioner, a PA listening to this, read the Jacka et al article, read that, let that be a starting place. Listen to episode 3, 59, 131, where we talk about diet and the role of diet. And let it be one of the domains because we need multiple domains to help people. We need multiple areas to get people across the finish line of getting all the way out of depression, anxiety. mood issues, right? Yeah, I had this one patient recently who loves sushi.

So I told his parents, like, you just need to buy more sushi. Obviously, it's very expensive, but it's kind of a joke because that was the biggest, that was the biggest win. He's like, I like this psychiatrist. Oh, one of my favorites

is just salmon avocado sushi. It's like, you get the avocado, get the salmon. So good. reach. Oh, I was also thinking, this is one more thing about food. I had this couple, and I swear, I could time every argument, every big argument with them both being hangary. They didn't have arguments if they weren't starving. And so just a prescription of dark chocolate almonds was all they needed. So they carried it around and like if they knew that they were going to be hanging out

and they hadn't eaten for like six hours, they would eat, you know, a handful of dark chocolate almonds. And that would carry them over. So you get the dark chocolate, you get the, the almonds. It's good. Do you have a conflict of interest with any? Conflict of interest is not there. No, no, I know. I'm joking. Yeah. Yeah. I should though. I should have a conflict there. I think that'll be my goal is to get like, this podcast is brought to you. Bye. If they will send me free chocolate,

I may actually succumb to have my first conflict of interest. First time, yeah. But that really hones in on the patient-centered concept of this is that we're not looking to cookie cutter anybody, that this is going to look, All these aspects are applied uniquely for every individual that comes in front of us. And that could be the dark chocolate almonds. Or, you know, I often try to spin this as like, you know, you'll go see your primary care doctor

and they're going to talk to you about nutrition for your body. I'm like, I'll apologize up front. I'm concerned about your brain. And selfishly, I'm focused on this is like fertilizer for your favorite plant and your garden. We're trying to get this to your brain. So all those neurotransmitters are healthy and ready to uptake these chemicals, whether you produce them getting good sleep, going to therapy, getting good exercise, or if it's a chemical that we're introducing with a medication. It's like, what is the biggest win? If you've just been on antibiotics, the biggest win may be fermented foods, right? If you've noticed a change in

things since you were on the antibiotics, like getting your flora back, building that floor back, there's nothing better than kimchi, sourcrow, kefir, kombucha, you know. Okay. The other thing on diet, I'll just throw it in there, is alcohol. So I had this one couple that came, I'm seeing more couples. It's fun. I like couples at this couple. And they're, you know, smart people, professional people. And I traced every argument. back to him drinking two or more alcoholic beverages. And so for them, it was going to destroy their marriage. So that was the easy win.

And for him, it was like he enjoyed it, but it wasn't necessary. You know, it wasn't like I'm an addict. It was just like he didn't correlate every time he drank two or more. His frontal lobe function went down enough. So that his anger and hostility went up. and they would have these arguments. And so that was the win. So yeah, and we could also go into, I guess, marijuana as well.

Some people don't see the link of that and how that's impacting them negatively as well. So sometimes. Yeah, that's a whole boy. It's been a big point. I'm thinking about redoing my marijuana episodes and really, really getting in the new data as well. There's a lot of new data. That's important. So, yeah.

I always try to frame these things in terms of like tradeoffs, right? And so I always like up front kind of acknowledge, well, it's the alcohol or the marijuana or the bag of Cheetos. It's doing something for you or else you wouldn't do it. And then they'll kind of nod and say, yeah, like, I really. And I'm like, well, you know, but I actually kind of invite them to like, well, could there be a downside to this, right? And they'll kind of reflect and say, yeah, you know, I smoke. I'm high for six hours today. and I don't get anything done and I feel kind of crappy afterwards, right?

So that's how I've kind of approached that without coming in too heavy-handed with my, I don't know if, Joanie, if you have any similar experiences, like, how do you even start that conversation? Well, it's tough because in states where THC products are legalized, they're like, well, it's legal. Yes, well, so are alcohol, you know, alcohol and tobacco. and they're not necessarily great for you. And so I try to go in there and say, right, so you're getting a benefit from it. So what is it helping? And do you ever see, like, does it ever not work?

Or there's certain times that you don't feel like yourself? And a lot of times we can correlate like upticks and anxiety. So anxiety flares, poor sleep on days that there wasn't as much intake or any at all. and say, look, this is your body trying to trick you, your brain saying, I want more of my friend. And so it's addicted. It's dependent on this now. And so we look at that and say, in the long run, this is only going to get worse. And, you know, if there are other interventions taking place, how is the BDNAF?

How is the dopamine? Or how all this chemical is supposed to attach to the neurotransmitters? when they're all tied up with THC. And I explained like, okay, you may intake only at bedtime, but that THC rushes up there, latches on to the neurotransmitters. It's a sprinter, so it just goes up there, grabs on real quick, grabs on like angry little monkeys.

Well, nothing's going to convince it to come off. Your medication that you took sometime between dinner and bedtime, your evening meds, it releases, it's time release. It doesn't just dump into your system. So by the time it gets to the brain or any of the dopamine dump that you had while you exercise that day, it's still floating around in there. But what is this supposed to bind to when it's all taken up with the angry monkeys? And so we just, you know, talk about that. And like, if you want more Bing for your buck, you want on less meds, really we need to get this out of the picture. And I'm not talking about, like, if you're,

consistently utilizing THC that we just say stop. I'm telling you, oh, no, this is bad. You need to stop. How do we taper off? How do we make this look or work in a way where your medications and your other interventions are effective? I mean, we talk about this door staying open and not slamming in your face or hitting you in the backside. Well, the THC just pulled a door stop right out from underneath us. So it tried to see. It's unique for every patient. So the focus is patient-centered care. Some patients are not in a position to have that conversation in depth the first time we meet. I like to introduce the idea and I look for the open door maybe a session or two later. Nice. That's so well said. Yeah. Thank you. All right. We're going to move on to the final domain.

So, Joni, is medication forever? Medications, not necessarily forever, but it is a conversation to have, again, uniquely with every patient situation. We know that there are some diagnoses that will require chronic, lifelong medication therapy. For most of our patients, there is the hope of tapering down to very low doses or off a medication as the symptoms have been remitted over a period of time. We have better success to getting at that point with the other components, therapy, sleep, nutrition, and activity in place. And so this is probably one of the biggest questions or most often ask questions I get

from patients is, you know, is this going to be forever? Yeah. I find that people are like afraid of that question. Like I'm going to be dependent on this. I don't want to be on this forever. And so being able to come at this using, I use the framework of like, this is a tool, right? And I like, Joan, I love your, like, it's the rubber door stop that's holding the door of mental health open for you a little bit, right? This doesn't have to be forever.

But for now, this is going to facilitate the changes that we need to see. You know, okay, so if someone has a single episode of depression, I may keep them on once they're out of the depression for six months before I start considering or we're going to titrate down. if they've had multiple episodes of depression, multiple suicide attempts, you know, they may need to be on forever, right? I mean, that's what they may need to be on, according to the studies. But what if they do therapy?

What if they do exercise? What if they do diet? I'm willing to consider that they don't need to be on forever. And so this is where I take a very sort of holistic approach. Also with bipolar disorder, A lot of them come in with the diagnosis of bipolar. It's very unclear to me if they actually had bipolar. I'll talk to family.

I'll look at their prior medical records, and it seems more like affect dysregulation than bipolar. Those people may need just a lot of therapy and some of these lifestyle things, and they may be able to come off that antipsychotic, come off that mood stabilizer. I patients with PTSD who needed medications to stabilize. they come to me on maybe five medications.

Can they do the adequate therapy? And can I slowly pull them off of these medications? Most of the time, yeah. Actually, I have one client who, it was like life or death that she needed to be on meds. It was like stabilizing her from being in the hospital. And it's only in the last year that we've been able to start to pull them off. And we've been working together for about eight years now.

and it's a testament to one long-term psychotherapy to her getting actually a lot more social support she's been super involved in a church and for her that social support has been really really helpful and so it's like she's getting uh and and the ace score would probably be around a six with this person so adverse childhood experience is very high and so that's going to that's going to be a bigger dose of good relationships that can help fill in the gaps and psychotherapy. And finally, we're able to start to get off the medication, but it's been years. So I think there's like, there's the sort of the cookie cutter, maybe what you'll get at psychiatry residency, which is like, yeah, these people need to be on forever.

And then there's kind of like in practice, case by case basis. You know, there are some cases where I look at them. And I'm like, this person has schizophrenia, they're probably going to need to be on meds for the rest of their life. We just have to find the right dose with the lowest side effects. You know, I think one of my favorite things is like helping patients get off of medication. And again, this is such a nuanced conversation, right? But I think, like, what your point about the, like, maybe put the potential for misdiagnosis in bipolar.

It's very much there because the medication. for bipolar, you know, atypical antipsychotics and mood stabilizers, they do tend to have pretty significant side effects. This circles back to our conversation about activity and nutrition, the insulin resistance, you know, the weight gain of these meds. So again, that goes back to all your, all the episodes that you've done on proper diagnosis, right? Really making sure we have that as clinicians so that we can really evaluate the med list of our patients. And Joni, did you have any points about like polypharmacy. I saw some really good stuff and the work you did. Well, that is a major, you know, concern that we have as providers with the medications,

whether the patient comes to us already on multiple medications or over time there's been inadvertent over, like overlap. Aside from the fact that we know there's not a side effect free medication. All these medications have the potential of creating side effects. There have been some really good research studies on specifics, like patients discontinuing medications due to adverse effects. Read at all from 2017 specifically indicated that sex life was majorly impacted by psychotropic medications. And there's a take. included, which in and of itself, I mean, the article is amazing, but in and of itself, the table really stands out because it says the number of psychiatric drugs in addition to

antidepressants. So the patient is already on the antidepressant, and then they've looked at no additional medication, one, two, and three. And so already, looking at it, they say zero additional meds. Well, that patient is already on an antidepressant and 43.7% of patients in their first category is sex life are noting side effects. Well, that goes up to 63.5% when they're a total of four medications. So in that category where they say three additional meds, that's in addition to the antidepressant. And that's huge. And we're looking at trying to improve quality of life for patients. And if that factor isn't there for many patients, in addition to all the other side effects, we've essentially taken a component of quality of life

from these patients. And we're there to work with people to help integrate some of these other factors to get on the lowest number of medications at the lowest dose. And so in particular, I think these studies are really helpful, especially when I'm talking to patients, to come in on multiple medications and say, look, how are we going to pair this down to reduce these side effects or eliminate these side effects? Yeah, I think one of the things when looking at this specific study is I wonder, okay, is someone who takes three more medications

just sicker? You know, because we do know that people who take more meds may have worse mental health issues to start with, you know, and they go into see. the provider and one med doesn't work and they end up on two they end up on three some sometimes the pain doctor add some as well sometimes their GP has added stuff and so is it that they're just sicker they're more treatment resistant and therefore they have an unhappy sex life you know or is it the actual medication like so this is where I think I always try to get a baseline of their sexual function

before I start the medication and then I will continue to check in with them as they progress. Sorry, I think these studies are kind of risk of something like what's called like healthy user bias where you have this sense of like

the population that you have to look at the base rate of the population you're studying in order to really tell. I do think that there are independent streams of evidence that do corroborate the overall impression that medications do have it. significantly adverse effect on some things, but that can be hard. But so does illness, right? And that's

why the discussion of tradeoffs is so essential for this very conversation. Yeah, and so, especially when I'm considering titrating up a med, let's say someone suffers from really severe anxiety and I'm going up on the Zoloft. You know, I may check in their ability to have an orgasm, their ability to enjoy sex, their ability to have sexual desire. What is that at 100 milligrams? If it changes at 150 and it's like all of a sudden they're not enjoying sex anymore, I'll go back to 100. And we'll try something else. We'll try lifestyle stuff.

But it depends on the client because some clients are like, just get me out of this panic attack. Like if you can stop these panic attacks, I don't care. And that's the starting place, right? So the starting place may be, okay, we're just going to get you out of this. And then we're going to, the therapy, hopefully will take place more over time where you're in a better place where we can slowly get you off or the exercise or the diet or, you know, the sleep, all of it combined, right? So it's very person specific. But, of course, there's side effects and we need to monitor it and we need to be, you know, realizing what we're doing to our clients in a negative way as we're trying to treat things that may be worse. So I remember when I was a new outpatient psychiatrist,

I felt like patients would get better, but then they would have a side effect, you know? And so it's like they were better, but they had this kind of nagging side effect that they needed then for me to address. And so I felt like side effects became like what I became the expert on almost because like that's really what I was trying to manage

and minimize and eliminate the most. So every time. time a patient brings up the concern like are we doing the whole informed consent conversation they'll bring up concerns about side effects and i always try to frame it in terms of like phases okay i said well listen you're here for a reason the symptoms are absolutely awful like you're hearing these voices or you're not sleeping or you're just having crushing panic attacks that are keeping you from work it's like well like what's what's worse right now right and then phase two right so let's get just stable first let's let's initiate phase two which is what you just said you know david let's

find a lowest effective tolerable dose, let's manage the side effects. And then maybe phase three could be the recovery phase of, like, let's see if we can get away with, without it, assuming we've, you know, augmented with the other pillars of Joni's document, right, the sleep nutrition therapy, things like that. Jone, let's move to the next big topic in medication. Do psychotropic medications hurt the brain? Simply stated, no. They're, um, There's a wealth of evidence now that shows that first and foremost, the untreated symptoms. So untreated depression, untreated schizophrenia in particular, their brain imaging studies that show that there is loss of gray matter with the ongoing severity of symptoms. So what when medications do by reducing the symptoms, if not halting them altogether,

is allows the brain to recover. And, you know, as we talked about before, the BDNF, some of these medications have been linked to increasing the BDNF, which allows the brain to recover from these episodes and as a neurotropic factor. So, you know, long story short, medications are actually helpful for protecting the brain. Yeah.

I think there was a recent, study that me and Dr. Cummings talked about that talked about how like there is no serotonin deficiency right and that's not like the big issue with depression and it's like yeah we've known that for 20 years this isn't news that's first of all second of all we do know that people with brain disorders have higher rates of depression people with strokes have higher rates of depression people with parketsons people with dementia people with all sorts of different brain disorders have higher rates of depression. And this is because the depression is, in part, a brain disease. Like, there are things going on that happen that need to be reversed. And so the medications themselves can get

blamed for some of these things. And there are, in the anti-psychiatry movement, which I'm more aware of than I want to be because of Twitter. you can't be a psychiatrist on Twitter and not run into a bunch of anti-psychiatry people there's some critiques which are valid and then there's some critiques which are just absolute fear, paranoia and if you don't know how to read science

if you haven't read a lot of articles you can get kind of pulled into this and I've seen a couple psychiatrists really just get pulled into it and then I see a couple psychiatrists who like you can tell they're making a whole lot of money on being very anti-psychiatry and so it's like they have a whole team of like PR people that are just constantly pushing out very sort of nonsensical statements which don't have a lot of evidence backing them.

Okay. Often overlooked medications. Medications that we emphasize in this podcast include lithium, clozapine, and long-acting injectables. and I think it's a good thing to just note. This will be kind of, I think, where we wrap up the podcast. The potency of some of these old medications that are very cheap, lithium and closopine specifically. Long-acting injectables can be expensive if you're getting the newer atypical antipsychotics. Cheap if you're doing halidol.

But lithium and clozapine are wonderful, wonderful medications, which as if you are a mental health prescriber, okay, if you are a psychiatrist, mental health professional, who can prescribe, and you do not know how to use lithium or chlozapine, go back to episodes where I talk about these things and just read until you can feel very competent. Joni, you want to talk about, let's start with lithium.

Well, not prescribed often enough or utilized as frequently. And I think there's a prescriber provider side of this as well as patients. You know, my own practice, when I bring up lithium as an option, I sometimes get that, you know, deer in the headlights look from patients. Like only patients who are, you know, in the psychiatric hospital are on lithium or that's really bad. So I think lithium gets a bad wrap all the way around, but the evidence shows it's highly effective. And especially studies on suicidality, reduction of suicidality. You're closely monitoring the medications.

We have lab availability to get that done. So it's not like people are having to drive hundreds of miles to go get lab work. Not all labs will run it. it's readily available, easily done, and a highly effective medication for many people. I think that maybe one of the big components behind it, I know going through my program, it wasn't talked about a lot. It's something that I had to do my own education. And that's hard when you're getting up and running in a practice. There are a lot of things pulling you in multiple directions, do you have that extra time to study and figure out, you know, what labs are

going to turn around that lab work in a good, you know, reasonable amount of time and get it to you, educating patients, their caregivers or family members support people? So those are factors to consider, but considering that it's been around for a medication that's been available for quite a while, one of the most natural medications that we provide and highly effective. Yep. Yeah, it reduces suicidality, which is, it's one of the only ones that does that. It, you know, reduced suicidality when it was in the water in Australia when they took it out. Suicidality went up. This is microdoses.

We do need to watch the thyroid function, watch the renal function. It's easier on the kidneys if it's given one dose per day. So amateur mistake is to give it like twice a day or three times a day. Sometimes I might do that the first couple weeks just to get them started, but then I move it all till nighttime. It is really good at treating true bipolar, bipolar type one, and also as an augmenter for depression, especially if there's some bipolarity in it, potentially, you know, like sometimes we're seeing a depression and we're like, is there really some, are we going to see a manic episode eventually? Adam, any thoughts on, any thoughts on lithium?

Lithium is I think probably one of the most under prescribed medications. And the reason I say that is because I think objectively it might be one of the most effective medications that we've ever come across in psychiatry. There's good evidence that you mentioned in the document and in your other episodes of Dr. Cummings that this is one of, if not the only, one of the only truly disease modifying medications. whereas most of our medications would be categorized as symptom modifying, right? So this gets into the second messengers associated with the bipolar process and regulates that in a profound way. And it's like an element, right? So sometimes I'll pitch this in a sense of like, you know, it's, this is like there's nothing more natural than giving you like an element, right? There's nothing more foundational.

But at the same time, there are, you know, there are risks like as you mentioned that need to be watched for. but I think that this is a profoundly effective medication that we should be as prescribing more of. Yeah. And then, okay, medication number two, underutilized, clozapine. In episode 190, I had Dr. Canaan, who literally, historically, brought closapine back to the U.S. I mean, this is a piece of history.

Like, recording that was just wonderful. And he did a lot of the early studies on it. it's the only FDA approved psychotrophic medication. Let that sink in. The only FDA approved psychotropic medication for treatment resistance, schizophrenia. And here's a quote from a systematic quantitative meta-analysis that said,

even though Clozapine is considered one of the most effective medications and is listed in the Who model list of essential medications, there's frequently a delay in chlizapine initiation leading to poor mental health and functional outcomes preceded by attempts of polypharmacy treatment without evidence for effectiveness. So there is strong evidence that if two medications have failed, that this is like the only one that's probably going to work. If two medications have failed for schizophrenia and they're adequate doses, which I would also have checking blood levels might be important. Closopine worked about 56 to 86% of the time.

And so let that sink in, like the other medication, if you put a third medication on, a third antipsychotic, probably work 5% of the time. This is just an amazing medication for treatment resistance, schizophrenia. So, yeah. Adam, any thoughts on Cholospine? No, it's a pain.

And it's a pain in some ways, but I can't argue with the effects, right? I remember working on in the inpatient psych war, both at the veterans hospital and as, you know, where I trained in a Loma Linda. And, you know, you'd have these patients that literally like awoke, right? They, they, they, it was like unreal to see somebody come in so sick, you know, on the streets, disheveled, not taking care of themselves, you know, food all over themselves. Within a couple weeks, you know, they were back. They were having a conversation with me, right?

And I'm like, I've never, you know, I've never had anything like that in psychiatry. So, clasping. From homelessness to graduating medical school. You know, I felt like I had a client literally like that. And then like a couple months before graduation, you decided to stop it and ended up back in a psychiatric hospital. And I'm talking to the impatient psychiatry. there. They're like, oh, we're going to try Cyprexa. And I was like, no, no, like, this is what works. He was literally homeless. And now he's like almost graduating from medical school. Like,

do not put him on anything but this dose. And I said specifically, I mean, it was like, it was like the psychotic symptoms would come at 600, but at 650. Like, the psychotic symptoms would come like maybe once every three weeks. Like he would start rambling late at night. I said he needs to be on 650, maybe 700. You know, like this is the only thing, you know? And they, oh, okay, okay. You know, like, but it's a pain to restart it.

It's a pain to manage Closopine REMs. Like you have to go in and put their labs in once a week. But for the right page, it's life-changing. Joni, any thoughts? No, I echo what you and Adam have shared with us is it is a game changer for those patients that have not had success on other medications and patients who've held their first job ever. And similar to, you know, you have your patient went from homelessness to almost almost

ready to graduate in med school. I mean, I've had a patient who's never held a job before and is now a regional manager for a major nationally known chain. And it's, he, every time we talk, he's like, I would have never imagined I could have done this. And I think kind of drawing back into some of the other facets of this, you know, when he says that I couldn't have, you know, never could have imagined I could have done this. I really try to emphasize that I, piece for him that he chose to take the medication, chooses to take the medication, chose to implement other interventions and have his support people and do check in with certain people daily or weekly. And that's really, I mean, a huge win. And what I do try to emphasize is that every

patient or family that has to circle around a patient to make their support team, that's their work and effort. It's the medication, again, was that doorstop holding a door open so this guy could be successful and every patient who chooses to go in that direction has the opportunity to be successful. Yep.

Yeah, I think you know, just to reiterate the importance of it and also I would say long-acting injectables have been a game changer for me in my practice. You can get patients who are very non-compliant

who I do the injections in my office often. If the family has someone who's a nurse, they'll do the injections. There's centers that do the injections, like different pharmacies, specialty pharmacies will do the injections. The levels are more steady. There's better outcomes and studies compared to oral.

And so long-acting injectables are a total game changer for a lot of patients. I spend the time doing the prior authorizations. I've learned how, how to do the prior authorizations better over time. For example, some prior authorizations have required me to do like this basic checklist of symptoms of schizophrenia. And so I've instituted that as part of my first evaluation

if I'm thinking about long acting injectable. I'll just pull out that handout, fill it out real quick, put it in the chart. That way if they want the notes, it's already there, you know? And it's like obvious. I wanna make it overtly obvious if they failed multiple oral medical medical medical I'll make sure that's documented.

I'll put the dates when they tried the orals, when they were non-compliant. And so it's like I've learned how to document in such a way that if I have to send the note into the to get something approved, it's going to be approved. So there's some nuance there to add that I haven't talked about before, but I think that's important. Any thoughts on long acting injectables, Joni? If for patients who aren't wanting to take a daily medication or feel more comfortable having a consistent level of medication dose to them every 30, 60, 90 days, I believe there's a 120 out available as well, that's a nice, I mean, perk for many patients. And again, when it's ever an issue of, I don't think anybody comes into treatment.

you're wanting to be non-compliant, we all forget, you know, whether it's a vitamin or your certain daily things that just get lost in the shuffle of life. And this just provides that reassurance that, yeah, I have my medication and I get my shot every so many, you know, weeks. And again, providing that level, consistent level of medication helps the symptoms stay abated and provides quality of life for many patients. Awesome. Okay, let's wrap up our time. This is gone longer than I expected, but it was good.

Okay, so we've talked about the five facets, therapy, sleep, activity, and nutrition medications. Adam, any last thoughts you want to put out there before we wrap it up? No, I appreciate this time so much. It was so great talking to you both. Really my take-home point here is, you know, really taking two things number one taking the time to establish a relationship with the patient because if there is trust there if there is an alliance the patient will tell you what they need and then the second thing is taking what they need using these facets and actually tailoring it to them that that is your privilege as a provider to listen to them you know is it is it a marijuana issue is it a lifestyle issue is it a cognitive distortion issue and then tailoring the therapy the medications the recommendations to their unique situation that That's the core.

That's what we're all about here. Joni, any final thoughts? I can't say it any better than how Adam has summarized it. You're just emphasizing that this is focusing on the patient, listening to the patient, becoming a team with the patient, and what are their unique needs and what unique things can we employ to help them feel better? Awesome. Yeah, I think my final.

final sort of takeaway would be I've enjoyed working with Adam, Berecki, Joni Burns, and it's been wonderful to have a team and to have people that I trust. And yeah, it's priceless. So this is a really cool sort of holistic accumulation of material. And I would say if there was something in this episode, as you listened, that was, was new or different, be curious. Don't take our word for it. In this handout, we have everything cited. We have all the episodes cited. Go back, listen to it. You know, you may be missing one aspect of psychiatry, which could make a huge difference for your practice. So let me know what you think on Twitter. You know, you can tweet about it. I'll see that. I'll retweet it. And if you are

needing a provider. Adam and Joni are taking clients right now, Florida, California. And yeah, we'll leave it there for today. Thank you so much for having me. It's been a pleasure. Thank you both.