Bruce BassiIn this video & article, Dr. Bruce Bassi gives advice to therapists who work closely with psychiatrists.
KEY TAKEAWAYS
- Consider the vast array of psychotropic medications: not all have the same tolerability or efficacy. Furthermore, some are dose dependent and require daily adherence.
- There a number of myths that can be addressed with patients to lead to improved outcomes and consistency among the treatment team.
What should I know about consulting psychiatry?
As a therapist, there are a number of considerations when consulting psychiatry:
- Timing. Consider a consultation when the patient is interested.
- Values. Understand their values and what they are interested in.
- Fears. Understand their fears to address potential medication nonadherence in the future.
Table of Contents
1. When to introduce a medication option to a patient
2. What is my approach to starting medications?
3. Understanding their fears to medications
4. How do you introduce the idea of a medication as a therapist?
5. Why is it important to understand their fears and concerns?
6. Because placebo effect can be very strong
7. How big of an effect is the placebo effect
8. Who is most prone to placebo?
9. Balance realistic expectations of the medications
10. Myth 1: “I tried antidepressants and they didnt work”
12. Tolerability vs Effectiveness
15. What are my general prescribing philosophies?
16. What are common side effects to medications?
17. Sexual side effects and PSSD
19. Myth 2: It will take 6 weeks to notice anything
20. Myth 3: I’ll get hooked on them
21. Myth 4: I won’t take mood altering drugs
22. Myth 5: I heard antidepressants cause weight gain
23. Myth 6: It’s safer to take a natural supplement
24. What is a typical patient response to medication?
26. Vast Treatment Options Depending on What Patients are Interested In
27. What about TMS?
When to introduce a medication option to a patient
[00:03:29] When you basically see that they’re doing all the right things, they’re journaling, they’re doing mindfulness, they’re coming to all your sessions and they’re really not getting any better, like, what’s going on here? Maybe there’s really some sort of physiologic reaction that they have during an anxiety episode or they’re just not able to break out of this very severe depression that they’re in and they’re functionally impaired and they’re not, you know, not getting to school, not working doing work well.
Their social relationships are being affected. And in my mind the, the risks of untreated depression, the illness continuing to to go on are, are outweighed by, by any sort of potential risks from being on a medication. So, you know, I, I think of them as kind of a option of last resort. I don’t want anybody to be on medications and, and that philosophy, I think I have really kind of adapted for my patients because if I have a philosophy of that, that matches theirs, of not wanting to be on medications, of, of wellness, of trying to go an all natural route, then I think they, they inherently have a little bit more trust in me that, that we are seeing the medications as aligned rather than a doctor who just wants to get them prescribed and get them out of the door and, you know, not have to worry about it anymore.
So, so, and then also recurrent. More than three episodes of depression, because statistically we know that after three episodes, their chance of having a fourth episode or more is very high, over 95% I believe. So it it, after one episode, I don’t know if it’s maybe 50 to 60%, two episodes, 70 to 80%, three episodes in your, above the 95% cell, 4% chance of, of having another episode.
Or if you have strongly strong family history of depression and or suicide, I would say that’s another time to consider medication options.
What is my approach to starting medications?
[00:05:25] What is my approach? So, and you probably have heard from feedback that maybe you’ve gotten from patients who have worked with me and or come back to see you, but I would describe my approach as a gentle curiosity of understanding their values and let them lead in terms of the treatment plan.
Figuring out what to, what to what medications to go on. I’m, I, one of my pet peeves is, Dr. Bassi has me on that kind of phrase. Dr. Bassi put me on. I’m like, no, no, no, no, no. We could take that off if you want. . I don’t have to put you on anything. We decided , about this medication. So rephrase that. We talked about a med and you consented to taking the medication after a conversation about the medication.
So I really do think of a patient coming to me as, as, as wanting to be on the medication. We talk about the risk benefit of being on it versus not being on it. And then they decide use in, they assert their autonomy in the, in the doctor-patient relationship by deciding that they want to be on a medication, knowing and being well informed of, of all the risks and benefits.
I don’t have any sort of requirement that I need to prescribe. There’s no insurance company that’s like, did you prescribe or not prescribe? It doesn’t work like that. The, the billing depends on the content of the history, the review of systems, the, the complexity of the plan, the number of diagnoses.
It’s not really related to prescribing or not prescribing. So I have a patient who’s in his fifties and I counted up for this presentation how many visits I’ve had thus far. And it’s 22 is probably the most, where we’ve been considering number, number of different medication options for anxiety. And rightfully so, like he, he’s very skittish about starting medication and I totally understand and respect his opinions to either be on it or not be on it.
And I continue to see him and I’m not discharging from the clinic or anything. And we. and he’s, he’s very, very astute and he writes down everything we talk about and takes notes and he’s very well informed of the medications and is almost ready to start them. But if he’s not, that’s no big deal either.
So I don’t gain anything by putting a patient on a medication. The reimbursement is the same for me, regardless.
So what would I expect you to so let me take a step back. So, understanding their interests and values is one of my priorities. So I want to consider option medication options as a option of last resort for them. That they’ve tried other things, they’ve tried therapy, they’ve tried mindfulness sleep hygiene, all of these things, and they feel like.
They’re not getting any better still. And I understand nobody wants to be on any medications, and I hear that probably six times a day. I don’t want to be on any medications. I don’t want them to be on any medications either. And if you look at any of my videos on mental health education, I do talk about tons and tons of non-prescription, non-medication options for a adhd, depression, anxiety, sleep, et cetera.
They, we don’t have to do a prescription option. I talk about supplements and over the last three years or so, I have actually been keeping a database of supplements and hearing what patients have to say about them and jotting them down and comparing that to the evidence base for that. And if they mentioned one that I haven’t heard of, rhodiola, I didn’t hear of that until a couple years ago.
I put that in there and because people come to me with different values and they, they’re interested in supplements and we talk about maybe safe supplements for them, and an as needed option versus daily option. That’s also a heuristic that some patients have. They, they think of a daily option as being more severe that it tells them that their mental health issue is more significant, so they don’t want to be on a daily option.
So we talk about as needed options. So there’s a lot of different characteristics and, and requirements that I can work within for somebody who’s wanting to come talk to me. It’s not like they have to be on an SSRI where I’ll say, Can’t see them.
So my recommendations and how I typically start off is up asking open-ended questions to start off with and understand what they know about medications.
What have you heard about antidepressants and medication options? What do you think about them? Just starting off really slow and trying to get a sense of whether or not they’ve heard of any friends or family being overly medicated, quote unquote, on medications to start to address their cognitive biases towards or against medications.
Do you know of anybody taking them that can, that can really go a long way in helping them help put them at ease or talk about any sort of previous stories that they’ve heard of with the medications.
Understanding their fears to medications
[00:09:59] So, as I’m going over this slide, a prompt to the audience is to chat or put in the chat box any fears that you’ve heard.
Of clients starting medications, and I will talk about the ones that I’ve heard of, which is this long list here. So lots of fears, , they feel that they’ve hit a new low and needing medication, so they’re like, I am somebody who needs a psyched. You know, like, that’s, that’s really bad. I don’t want to get addicted to it, for sure.
Yeah, that’s one of these ones in here too. Internally they feel like they’re categorized differently as somebody needing psych meds. They feel as needed. Meds are quote unquote less severe. So if they’re on an as-needed, Xanax that’s quote unquote less severe than, than like a daily Prozac. That’s just something people have told.
it reminds them of a loved one who was overly medicated. I’ve heard of that. Their grandfather or their aunt or uncle was in and out of psychiatric units and they, their personality changed. And is my personality gonna change? Am I gonna be s too sedated like that person was they’ll get addicted to it also, or that they’ll be able, they sh they should be able to get through it on their own.
Yeah. Like they’re weaker if they’re using meds, but we don’t think of that for a diabetic, you know, they’re not like weaker because they need insulin. But yeah, because the brain has you know, voluntary control over some things that we think that we should have voluntary control over depression and anxiety all times too.
Okay. Minds me, oh, I had a patient who used to be forced medications as a child. Against their will. And we, we spent probably five, six sessions talking about various options and how that person was making a very deliberate effort on their own to, to choose to be on it. And it’s not anybody else talking them into it.
And that was a lot, lot of tearful sessions I can remember. Do not trust if a psychiatrist gives it to ’em the first meeting. Absolutely, definitely. They’ll never be able to get off of it. Make them addicted, make them a zombie. Like, sure. Like if you go up really high on wrist all, it could probably make somebody a zombie.
That they will have to report it to their employer, military unit ex-spouse if they’re going through a divorce proceeding. That’s really frightening. You know, you don’t know what people are gonna do with that information. And so there’s this level of how much do I disclose to, to the person? Clinician and they might not even tell you this, this is probably like just brewing on their hamster wheel upstairs, you know, in fear.
They don’t know if they should tell you that, because then if you put that in the note, that can harm them. So there’s a lot of fear surrounding this topic. How’s it gonna interact with other medications? Well, we have a, I have a med interaction checker. If I haven’t, if I ever don’t know, but I can always figure that out.
That’s gonna cause weight gain or sexual side effects. And we’ll talk about these in future slide. It’s gonna be too expensive. Some of them that are under patents still can be very expensive, that they may feel worse. They’ve heard of that suicide label. Warning, the black box warning. Talk about that one.
Future slides. It’s gonna change my personality. That’s scary. You know, like, I want my personality, I just don’t want the depression.
Especially the last two if I become suicidal and personality change. Yeah. Okay.
How do you introduce the idea of a medication as a therapist?
[00:13:09] So I mean, what to do about all this stuff. Well, you know, we as clinicians, we have totally different experiences of meds, of therapy, of mental illness than they do, especially when coming to you for the first time. They don’t know.
They’ve never heard of Zoloft, Prozac, et cetera. Most likely they don’t know what you know about how people get better, how it’s treatable, how there is hope there. So try to normalize their experience. Say what you think is probably obvious, that you have a lot, had a lot of patience who fear the same things you fear and they can get better and get through it.
And you don’t need to be on a medication forever and you go very slowly on the dosage and it’s not gonna change your personality and you can move forward at your own pace that you feel comfortable with asking open-ended questions that elicits their knowledge of medications. Is there anything you worry about with the meds themselves?
Is something I would ask just to address their fears and concerns.
Why is it important to understand their fears and concerns?
[00:14:03] Why is it important to understand their fears and concerns? A, to determine if a referral to psychiatry would be appropriate. So we can talk about that in more depth. So I do think that this probably comes up a lot in therapy. So I’m comfortable just to restate the obvious. I’m comfortable speaking to people with varying degrees of interest towards meds from no interest to, you know, I know what I wanna start.
Can, can we, can you just prescribe it and, and be on with it? They don’t necessarily need to be fully decided upon taking meds in order to see me. But it would be nice if they have some sort of seed planted, like, you know, that’s part of the purpose of going to psychiatry is to talk about medications.
Although, you know, my approach is a little bit different than I think what the status quo is for a patient going to see a General MD psychiatrist is that they might be surprised. I do half hour visits, well, 25 minutes, and I talk about a lot more than just medications.
In fact, I’m, I’m running a group. I used to run group for three years, so we just started group therapy back up on Wednesday mornings. And I had a, I’ve had a lot of patients say I wasn’t expecting you to ask this many questions and that, that’s pretty funny. And I think that that kind of embodies a little bit about my approach there too.
So I want to know more about what they’ve tried and not tried and, and whatnot. Outside of medications, talk about supplements with patients too. I don’t need to prescribe anything to see them. So talk about L Methylfolate, SAM-e. St. John’s Ward, if anybody ever goes on that. And N-acetylcysteine the whole nine yards. Of course marijuana.
Because placebo effect can be very strong
[00:15:40] Why is it important to understand their fears? Because in the background, they have them playing out regardless, and that has a big impact on the placebo effect or no placebo effect, depending on what the outcome is. And I, I think this is just a topic that’s so inherently interesting to anybody in mental health, any psychologist, because it’s this invisible, powerful force that’s going on in the background based on the patient’s beliefs. And it’s real, like, it’s a real brain changes that happen in the fMRI scanner when placebo is administered. There are real changes in certain areas of the brain that in that interpret pain.
For example, there was a study that showed that. Patients who received sham knee surgery where they just basically made an incision in the skin, closed the skin back up for osteoarthritis, actually did better than people with real surgery. That’s incredible. I I couldn’t believe that. And then after two years they did about the same, but that’s just really cool.
So it’s not just psychiatry, but it’s, it’s orthopedics, it’s pain medicine and placebos even decrease our interpretation of pain. They decrease blood pressure and they decrease heart rate. So that’s really cool. So imagine if it has this much physiologic effect. It’s obviously has a huge impact on psychiatric medications.
They come to you, you know, in a really low place and hopeful that the person that they’re finally seeing after waiting three months to see you is going to help them. They’re, they want to, they want to get over this. They’re gonna feel that they finally have the, the ticket there to get back on their life, back on track.
It’s based, based on the patient’s belief. And I think we can kind of use that to our advantage ethically and in an ethical way of kind of gently understanding their, their beliefs. The placebo effect is here to stay. I found an article when preparing for this that you can use the placebo to, to facilitate you in the treatment process by listening, asking questions, and paying attention to the patient.
This, this guy, Dr. Kirsh, he’s from Harvard Medical School has been studying the placebo effect from her about 30 years is really good interviews online. And good research about the placebo effect, if anyone’s ever interested, just Google his name. He said this quote that I thought was pretty succinct, it almost doesn’t even matter what kind of pills doctors give patients for there to be a benefit because the placebo effect is high, pretty high.
How big of an effect is the placebo effect?
[00:18:04] How high is it? Well, an individual who has no prior antidepressant use, it’s the drug effect, which is the y axis here. Or the, the effect on depression, I should say, is, is basically on par with one another drug and placebo. And this is according to a study in 2015 by Hunter. And then for people who have had prior antidepressant use, the placebo effect, this drops in about half or so.
So that’s important to keep in mind. People who have had prior antidepressant use have less of an placebo response. We kind of need to bring, build a framework here of who is more inclined towards having a placebo response versus who’s not. He says that placebo accounts for about 75% of the response from medications, generally speaking.
That’s, that’s kind of why also the, the randomized control trials are so hard to, to prove an effect because you have to get it statistically different beyond just what placebo is. That, so yeah, while there is a large placebo effect, like I mentioned there, there is, there are certain characteristics of particular individuals that are more prone to the placebo effect.
Who is most prone to placebo?
[00:19:09] It’s much lower with people with severe depression. So if you have severe depression, not as much of a placebo effect versus if you have very mild depression, it reduces with age, so children have a very high placebo effect. It’s much reduced with prior antidepressant use, mentioned that on the last slide.
And then individuals with certain factors such as optimism, suggestibility, empathy, and neuroticism have been linked to placebo effects while pessimism, anxiety and catastrophizing have been linked to nocebo effects.
The relapse rate are higher, is actually higher after people receiving placebo. So, the meds do do something like they’re, they’re helping with the relapse rates. So the placebo effect, I think generally short, short-lived.
It could also generate side effects known as the nocebo effects, and I think all of you know about what that is. But nocebo effects are to a lesser degree than active medications.
Balance realistic expectations of the medications
[00:20:05] So, in, in closing of the placebo effect topic, I mean, you need to, I would say, balance realistic expectations with a grounded sense of hopefulness. So if you, you raise their expectations too high think the, you’re putting them in a place where a disappointment can follow.
And then if you also conversely induce feelings of rejection, in the patients, then you can anticipate the treatments are also going to be less efficacious as well.
And this study this quote was from this study down here said, nocebo responses can be provoked directly by inconsiderate behavior, lateness, rudeness, and sensitivity, and by disappointing patients wishes to feel understood.
I guess that’s the theme today. So this is why I think it’s very important to ask the patient if they’ve had a friend or a family member who had a bad experience or a good experience with the medication. So we can talk about that and address it and see how much, truth there is to that, how much data we know about that situation.
Take that into consideration with the recommendation I’m making emphasize the importance of letting the patient determine their treatment plan within reason, you know, and if the patient’s a blank slate about medications with no prior beliefs, i, I would say like using the word meds is, is like kind of a gross overgeneralization because they’re just so different medications in psychiatric medication. It’s like saying therapy. Like I did therapy. Like that’s also kind of a pet peeve of mine cuz I’m like, what therapy? With who? Like what was the dynamic? Like how often did you go? What kind of other place were you in? Were you financially stressed? Were you going regularly? Were you engaged in therapy? Try another type of therapy, you know, so it’s like medication.
Myth 1: “I tried antidepressants and they didnt work”
[00:21:48] So say somebody tells me I tried antidepressants in the past, they just don’t work for me.
Okay. Which one what dose were you on? This is a list of dose minimums according to, oh gosh, I can’t remember the name of it’s like some database that a lot of studies use, random randomized controlled trials use this database to determine if a patient meets the criteria for their study. So if they weren’t on this dose minimum here, then it wasn’t even considered like a previous use of the medication. So the patient needs to be on this minimum dosage for at least six weeks for them to say, okay, you were on this.
I remember there was a study that said it was a ketamine study and they have had to have tried and failed a number of different medications. And so they must have, have had, had like Prozac, at least 20 milligrams, couldn’t have been 10. Zoloft must have been at least 50 for at least six weeks.
How long? you know, hopefully at least six weeks. That’s what the general consensus is. And I, we talk a little bit about timeframe later on. Did you take it daily? Some people think the, they kind of misunderstand, they think Lexapro is supposed to be take taken as needed. They were anxious and there was some sort of miscommunication there with the clinician.
I’ve had to, to correct that with certain clients before. And what is, what is a treatment response like this, these last three words, they didn’t work. And do people know, like how it, how a treatment response is defined in a study? Does anybody know how, like most studies typically define it.
50% reduction in the ham D scale and the, and same with like OCD 50% reduction on Y BOCS. Like that’s not zero, that’s not full remission. People, like, that’s still a response.
And I dunno, there’s multiple ways you wanna look at this. So like, say we know SSRIs is They cause or help 70% of people according to studies as a treatment response, that’s 70% of people who have gotten 50% better or more. You know, that’s like not what most patients think of as a treatment. They want to be better, you know?
So that’s like, if, if I had a patient who had a 50% response in certain ssri, I would, I would actually feel kind of hopeful. Like, okay, let’s try different ssri maybe we’ll make sure they’re taking it daily, make sure we up titrate to the most therapeutic dosage, not too slowly, but not too quickly either, and get, you know, get right up to a therapeutic dosage fairly quickly and see if that helps them more than 50%.
So I think that’s actually like a, a good hopeful measure to get them into a different, different medication option, but I think that’s disappointing to most patients.
And a good reminder, like, and I, I think most patients are pretty realistic. If you say on a scale of one to 10, like, what do you want your depression to be? Most don’t say zero. They’re like, I just want it to be, I just want to like, get up in the morning and not feel like I wanna stay in bed all day. Or, I mean, they have like pretty realistic goals. At first at least, you know, they want to get back to work, they want to enjoy their time with their family and get outta the house and things like that.
And so, so that’s good. If we’re just getting down from a six to four, six to three, I think that’s like a good way of describing how medications work. And for those characteristics, like the, the individuals who are a little bit high strung, I would say like if they’re expecting a zero percent anxiety love score after six weeks, we have to talk about what is anxiety? You know, like not all nervousness is, is an anxiety disorder. Like we need to work on coping strategies for those milder cases of anxiety. So it’s a good segue into like another conversation, I think with patients.
How effective are meds?
[00:25:28] This is a little slide about how all medications are different, and this is a study from 2020 in the Lancet comparing the efficacy of various antidepressants and psychotherapies.
And I know that the font is small, but you can see in here there’s various psychotherapies in here and like this is for children and that’s why these air bars are so wide. So on the right favors, placebo on the left favors the intervention itself. And there’s like, only two that don’t cross zero, and that’s Fluoxetine plus C B T and Fluoxetine, which is pretty wild.
Oh, and down here, waiting list in Nortriptyline, so don’t try those two. But yeah, the really wide air bars for children because of that placebo effect. And then if you look for adults, this, this is flipped a little bit. So placebo is on the left now and active drug on the right. This is also from the Lancet.
Couple years prior, looking at 21 different antidepressants for MDD, systematic review. We don’t use agomelatine. But Prozac is up here. I’ve seen studies and I have next slides that kind of maybe would dispute that this is the most efficacious drug.
Lexapro, nefazodone, citalopram, amitriptyline, and then kind of going down to placebo so they’re not like all the same, you know, you know, when people use the word meds. I always tried on meds. Okay. Which meds, what are we talking about here? How, what what was that efficacy like for that medication, for treating MDD, schizophrenia, schizoaffective Disorder?
Tolerability vs Effectiveness
[00:26:52] I like this table because it, it kind of, it helps me explain in, like, data format why I, I prefer Lexapro and, and Zoloft so much. So this is efficacy on the bottom. So towards the right is good, meaning high efficacy. And then this is acceptability measured by the discontinuation rate of medications and studies.
So, acceptability would be good if it’s really high. So this is the quadrant we wanna look at here. Of highly acceptable and high efficacious. So citalopram and sertraline are, are really good combinations up there. And then bupropion citalopram as was normalized to fluoxetine as a one in one.
Duloxetine or Cymbalta, really not that great effectiveness or acceptability. And same with Luvox. So, and then mirtazapine venlafaxine.
Medications I avoid
[00:27:35] So meds I like to avoid: this is just my general, this is not, this is not evidence based. Maybe it is based on the last slide. So, meds, I generally avoid our Effexor. People hate me when I, when they have withdrawals and it’s really, really bad, really significant.
and it’s not just an hour, like you don’t miss it and you just take it after an hour and you’re fine. Like that can carry into the next day. And you feel pretty lousy. So, and that’s not everybody, but most people, Effexor is like really well known. It is effective, like Effexor a really good effective medication.
But I just think the withdrawal effects out weigh that. So I don’t use it very much.
Paroxetine is very antihistaminergic medication, so it’ll causes a lot of fatigue and weight gain, sexual side effects unless they’re very socially anxious and they’ve tried other med options. I won’t use Paxil or paroxetine.
Mirtazapine is a, is an atypical medication option that has a lot of weight gain and sedation associated with it, but it’s effective for anxiety and depression. So if somebody is, you know, not eating well and they’re underweight and they’re not sleeping well and they’re depressed and anxious. That might be a good option for them.
But for most people, our population, they don’t want to gain any more weight. So I don’t use much mirtazapine. Cymbalta not that effective unless they have chronic pain issues. Luvox I don’t use unless they have OCD.
Depakote, unless you want them to lose their hair and gain weight then I probably wouldn’t use too much Depakote and interferes with oral contraceptives too.
Which meds do I like?
[00:29:07] And then meds, I like Lexapro, Zoloft, trintellix, Viibryd, Abilify, Rexulti, fairly good side effect profiles, although I’ve had people not tolerate all of these at some point. But for the most part, really good for, depression, anxiety . And for augmenting purposes too, for Abilify, Rexulti.
What are my general prescribing philosophies?
[00:29:27] My general prescribing philosophies, try to use a minimum number of meds, minimum dose for the minimum amount of time necessary plan to be on it for about six to 12 months to get to the next phase in your life.
Try to target multiple symptoms with a single medication. If there’s multiple symptoms that we can’t target with use of one med, then I go after the bigger symptoms first, the more problematic ones that are causing the biggest functional impairment. Try to utilize their side effects to our advantage.
Like if they had premature ejaculation and they’re underweight and they had, were socially anxious, maybe peroxetine is a good option for them. So you’re, you’re thinking about like all the side effects that they could benefit from.
Make sure you’re not missing another diagnosis. Obviously we’re don’t want to avoid, don’t wanna miss bipolar, insomnia or some other medical illness that’s causing their symptoms.
I would encourage them to hold any illicit substances to same disc degree of scrutiny as psychiatric medications, especially in this day and age.
And you all practice in California? I I just assume everybody has marijuana for lunch, practically out there. It’s just ridiculous how socially accepted it is. I, I do talk about that a little bit more depth on the future side.
Give them multiple options, elicit change talk, allow them to assert their autonomy to avoid that “you put me on” type of, phrase that I hear.
What are common side effects to medications?
[00:30:42] What are common side effects of antidepressants? So any gI symptom because our GI tract is loaded with serotonergic receptors.
And if anyone has ever heard of carcinoid tumor, that’s a serotonergic tumor that causes serotonin to just dump out. And you get all of the symptoms of serotonin syndrome. And so the, any sort of GI symptom is, is all game, you know, nausea, heartburn, diarrhea. What is the treatment? It gets better with time, time, time, time. That’s what Stahl’s would say.
Any sexual side effects that’s very common. Also, could you know, it’s more or less like difficulty orgasming, blunted orgasm dissatisfying orgasm. Less so changes in libido, but I think. Like, if you’re not having a good sexual experience, you’re not gonna be interested in sex. So I think they go hand in hand.
Headaches, lightheadedness, changes in sleep, and any uncommon presentations of a common problem. I would say like if there’s waking up at night, it could be from heartburn per perhaps.
Sexual side effects and PSSD
[00:31:42] You know, so what is the sexual dysfunction among SSRIs? Like, this is what a study says.
I don’t know if it’s this high or maybe I just don’t ask my patients about this enough. Or never like, wrote it down. Who has heard of PSSD? It’s a, you can just type a yes or no in the chat box. I’m curious who has heard of PSSD?
I think this is gonna be the one of those things where you tell somebody about a new car and then they start seeing it everywhere. Or a new coffee shop or something. So, if you go on social media, maybe maybe your phone’s listening to me now. So now you’re gonna get like a bunch of ads for PSSD or something or, or whatnot.
So post SSRI sexual dysfunction is what it stands for. And that’s the definition of that, of that is where an individual has continued sexual dysfunction for more than three months after stopping the SSRI. And most physicians obviously can acknowledge that there’s potential for SSRI induced sexual dysfunction while you’re on it.
But this is going a step further and saying it doesn’t ever go away. And not only is it sexual blunting, but it’s also emotional and cognitive blunting and , you know, there’s, there’s like patient profiles of people who would be more susceptible to this. There’s not really a good treatment. There’s recommendations for what to do about it.
I’m not sure what Bader of Meyerhoff effect is. Is that something I just mentioned? I’m gonna have to look that one up and Google that later. So where was I? So it doesn’t go away. There’s not a good treatment. It’s more, it’s also a cognitive blunting and it’s a very, very vocal community of individuals who kind of feels that physicians harmed them, caused harm, damage to them long term because they never got back to their baseline sexual functioning prior to the SSRI, so that’s, that’s like another good reason to, to not put somebody on a medication willy-nilly. There are, there are potential side effects, and even if it’s not physiologically well-explained in 2023, maybe we don’t know everything about it, but nonetheless, the patient believes it.
Even if it’s not well explained medically, you know, the patient believes it, and I still trust the patient for, they, they know themselves the best, so I don’t argue with that. I think that that parallels my general philosophy, even with having them lead the treatment plan.
You know, a patient knows themselves the best they lead. I just help them not hurt themselves with medications, options, and we talk about options.
So this is a variety of– this sexual dysfunction. It could be like the difficulty orgasming is the most common, but it could also be premature ejaculation is listed, it’s sexual dysfunction is very common. And that’s another reason that’s so difficult to prove is when the background rate of a particular issue is so high and then you have add a medication on top of it that also has a, a large incidence of it. You’re like, it’s very hard to differentiate between that and placebo. So it’s hard to prove causality with that.
Uncommon side effects
[00:34:43] Uncommon side effects, things that happen, not really like commonly, but flattening of affect. There are two meds that I think of this happening more with. So gabapentin, topiramate, especially at high doses or even Risperdol Haldol Thorazine high doses, feeling anxious or keyed up. Wellbutrin, it’s known to cause that partially like a stimulant, or any stimulants could do this. Illicit substances can do this. Marijuana can do this, a paranoid high.
Fatigue, peroxetine, especially remeron, Trazodone cause fatigue, long-term sexual side effects, more likely peroxetine for PSSD. Sweating like studies say 20%, but I really anecdotally don’t have that experience. 20% are not telling me maybe 5% night sweats, but I don’t have one at every five saying they have sweating.
And then depression, more depression. So this is a, a good. a good debate. I mean, we could probably spend a whole hour talking about the black box warning for SSRIs because it came out after studying children, what, 2007 FDA put a black box on it and like everyone overreacted, took a bunch of medication, took a bunch of children off medications.
There were statisticians who said that it caused, that, that overreaction caused, I don’t know how many, hundreds or thousands of suicides after it just induced fear among child psychiatrists and those patients. And then there were a number of studies that disprove that, but nonetheless, the black box warning continued.
And I guess the rationale behind that is that it, it encourages communication and conversation between the clinician and patient about this. Potential issue because there was a quote that I saw. You know, say, say you have a patient who is depressed, the SSRI medication gives them a little bit more energy.
Then you have an energized patient with depression, and that’s how they’re like so prone to suicide. At that point they, they start to get more insight into like how painful of an experience that was as well. I think that’s al also partially why that that timeframe after initially starting a medication is vulnerable time period.
So an A, not only do you have potential continuation of their current symptoms and the medication’s not working, but B, if they’re responding to the medication and it’s giving them energy to a depressed patient, maybe like they have a new profound perspective of their depression and how severe it was, and that could potentially be disruptive to their stability as well.
So there’s a number of confounding variables to the more depressed aspect that merit, like a longer conversation. But that’s, that’s my take on it.
Myths and misperceptions. So I’m gonna talk about these in the four subsequent slides. It will take six weeks to notice anything. I’ll get hooked on them.
I won’t take mood altering drugs because they’re bad. What, but what kind of CBD would you recommend?
I’ve heard antidepressants can cause weight gain.
So it’s gonna take six weeks to notice anything. So while I’m talking about this, Type in the chat box if you have had a patient who reported a benefit to a medication within days and what your thoughts are on that.
Myth 2: It will take 6 weeks to notice anything
[00:37:58] So, okay, the thought is it’s going to be six weeks until I notice anything, but it’s possible you’re in the 30% who don’t have any response to the medications because not everybody responds to the medication. So there’s, there’s potential truth to this. Like, yeah, you might not respond at all. However this is just to tell you how long you need to be on it to say if it worked or not, but that’s not to say that you won’t get any benefit out of it at all.
70% of people should be starting to see some sort of response, but there are a small subset of people who do respond, but are called quote unquote late responders. And they respond after four weeks. And so the reason for telling people to be on it for more than six weeks is to, to not prematurely take them off of something that could have helped a late responder to the medication.
What we just didn’t know if, if they were like going to respond later on, let me make this bigger.
So we have a Yes, yes. Thinking of stimulants especially Yeah, for sure. Have, yes. Maybe just anecdotal, but I’ve noticed early responding as a good prognosticator for sure.
Yeah. Like, I also too, I like, I don’t know how to explain it. I don’t know. You know, if it’s, if it’s part placebo, they’re just like super, their physiology is just super responsive to the medication.
but it’s happened so many times that I, I think that there is real biologic reason for that too. So, you know, I even tell people that, like, I think that is hope inducing, like telling people, hey, yep. We, we all have had experiences where patients responded in just a couple days. Like, just give it a try. Like see how you do. You might, you might be somebody who has that response and I’ve had people who have been on maybe 10, 12 medications, but they remember like this one particular experience with one medication. They’re like, yeah, I knew right away this was the thing for me. It was like a light just shown down from above. And I, I just feel like totally different with this medication.
Don’t stop it after a couple weeks, if not complete. Yep. I mentioned that we want to treat to full remission of symptoms. That’s another reason we, we try to tell people to be on it for a longer period of time because we don’t wanna.
take it off prematurely and have there be a recurrence of, of symptoms. And then mentioned treatment response. Like say you have a ramp of improvement like that, where they tell where they, they can tell themselves as being on that ramp of improvement. Depends on their perspective. You know, it’s, it’s when you’re in the middle of it, so you’re right at week three or four, if you just have had a mild response so far, you still don’t think that that’s really sufficient. So obviously they’re gonna be pretty frustrated, still having to wait that long. I mean, there’s not, there’s not too many things these days that other than maybe ketamine. But that’s not everybody responds that well to ketamine too.
Myth 3: “I’ll get hooked on them”
[00:40:44] I’ll get hooked on them. Where do I start on this? So, there are some that are known to cause withdrawal symptoms. Like I’m an, I’m an addiction psychiatrist, so I like the language of addiction versus physiologic dependence versus like withdrawal. Like, those are all very different to me.
Addiction means that there’s use to, despite continued harm, that it’s causing.
Physiologic dependence means that your body is just accustomed to it. Well, we’re, we’re accustomed to a lot of different things. That doesn’t necessarily mean it’s a bad issue. So just because Yeah, you you, you’re, you’re dependent on a lot of elements. For example, vitamins doesn’t necessarily mean it’s a bad thing. by definition. So yeah, you could become physiologically dependent, but that doesn’t mean you’re hooked on it for life where you’re, where you need to take it for the rest of your life in order to feel positivity or withdrawal of the symptoms. So I, I generally say that patients should anticipate being on it for six to 12 months to get them to the next phase in their life with good, good therapy, good lifestyle management, getting good sleep, good nutrition good interpersonal relationships. And, and then we come off the medication.
So we have many patients who can safely navigate coming off the medication and they, we discharge them from their practice and they’re, they’re fine and they’ve been treated. They’re in a better place in their life and they don’t need medications again. So, and then we have individuals who are chronically ill with mental illness too, just like people are chronically ill with hypertension and obesity and chronic pain. You know, we have individuals who have chronic depression, chronic anxiety that need to be on medications long term. So there’s a, like everything in psychiatrists is huge spectrum. You can’t overgeneralize.
Yes, some medications could be more addictive than others. Nicotine, cocaine, benzodiazepines, highly addictive medications. Some medications can induce physiologic dependence, just not addiction. And it depends on the person and it’s at various levels whether or not you’re going to have withdrawal symptom. It depends on the person and the medication. Unfortunately, we don’t have a way to predict who’s going to have withdrawal or not, so that we just taper as a way of playing it safe.
Myth 4: “I won’t take mood altering drugs”
[00:43:01] I won’t take mood altering drugs. Okay, so, so what’s mood altering? I mean, hypoglycemia, you’re definitely gonna have an altered mood. So glucose is actually mood altering to there’s various vitamins that if you are deficient in them, you’re going to have an altered mood as well. So it’s this topic I think, goes into a conversation of, of talking about how patients have a predisposition or a favoritism towards the word natural. People tend to like things that are all natural. I buy organic stuff, all natural stuff. I would prefer that over the thing that’s like made in a factory, of course. Like that’s our brain’s cognitive bias towards wanting something healthier. There’s definitely substances that are all natural but unhealthy like Mercury, arsenic.
The, you know, 40% product of THC is not natural. And even the genetically modified cannabis these days is, is way more concentrated than what it used to be in the sixties and seventies. From what I’ve been told wasn’t around back then. But like you, it’s a perfect example. You have a product that you think is natural, but it’s actually, there’s not much about it that’s natural. Like, smoking a plant is not necessarily natural for your lungs either.
And then there are legal substances that are unhealthy, read paint thinner. I mean, that’s legal. You know, nitrous and, and whipped cream up until recently. You can get that without showing an id. I think in New York you need to show an ID now, but there’s lots of– those legal cigarettes, legal over 18, those are unhealthy.
And then there’s non-prescription options that are unhealthy. Like there are certain supplements that can trigger serotonin syndrome or have drug drug interactions can cause psychosis, et cetera. So just because we use one of these words, it doesn’t necessarily mean that they’re healthy or unhealthy. So I like to get into the weeds on, on wording language.
Myth 5: “I heard antidepressants cause weight gain”
[00:44:59] I heard antidepressants can cause weight gain. So the, yes, there are, there are some that are better known to cause weight gain. The, the rate of weight gain for these medications is, is greater than placebo for paroxetine Mirtazepine, Seroquel, Risperdal wouldn’t argue with anybody about that.
And then there are meds that have a rate of weight gain that’s on par, on par with placebo. So, even without medications though, I mean I, we obviously have a major obesity problem. So it’s again, one of those situations it’s hard to prove if there’s a high baseline rate, very difficult to prove causality when the rate is pretty similar to, to placebo.
Hold, hold cannabis to the same standard, you know, that is used for appetite stimulation for cancer patients. So cannabis is known to cause weight gain, but for some reason some people give it a free pass. So point out that cognitive bias to them and then untreated depression. I mean, like who hasn’t done stress eating before, like chocolate end of the day? I have for sure like untreated depression over impulsive overeating behaviors. Some people their appetite goes down like, I wish I was like that, but no, not here. They have impulsive overeating behaviors and I think they’re at a predisposition for, for weight gain. And people are depressed because you’re not as active. You don’t want to be as active, you’re not motivated, probably not sleeping well. So you’re tired if fatigues are, therefore you’re again, not as, not as active. Like toddler part of your brain is wanting to self soothe. You’re, you’re wanting to eat, get some sort of dopamine bump from eating. So that’s just my my depression picture. So I feel like there’s potential for weight gain even without being on an antidepressant.
Statistically from this study from 2000 kind of a long time ago. But mean rate, wake, weight gain, you know, if you look at the study on package insert what was the rate of weight gain for placebo? I think it is a, a few pounds. This one should be red 4.0 with mirtazepine that’s known to, to be fairly high. The other ones I feel like they’re pretty on par with, with placebo.
Fluoxetine in fact showed negative 2.2. When Wellbutrin, I always think of Wellbutrin as like fairly appetite suppressing, but even fluoxetine was not far behind that.
Myth 6: “It’s safer to take a natural supplement”
[00:47:14] Then the other myth that’s safer to take a all natural supplement. Yeah, I, I mean I generally, I, I think that’s a general safe statement to take a all natural supplements, it’s safer than prescription. There’s a lot of, there’s a lot of issues with that, though. A, it’s probably costly, you know, there’s a lot of money to be made in the supplement industry.
So there’s not like data there about safety. Whereas if you looked up, you know, paroxetine on PubMed or Fluoxetine and PubMed, you’re gonna see tons of studies, but you, you don’t, you’re not able to kind of punch in the brand name of, of somebody’s concoction of, of various tinctures and things like that to, to figure out what are the studies on this?
There’s, it’s just not there. You’re putting a lot of trust into that manufacturer that company reselling it.
And is there a risk in potential untreated depression, prolongation of symptoms, functional impairment, maybe suicide if you’re going down the supplement route?
And I, I consider that a risk too. Taking a supplement, you know, is not proven to, to treat depression, and you’re giving somebody a thing there that’s not proven to help with their symptoms. I feel like that’s a risk factor. So I say it’s like low risk, low reward, but maybe it is a little bit medium risk low reward type of situation, if they’re severely depressed, I would probably not say it’s a, a very wise idea if they’re in severe depression with recurrent suicidal thoughts to just be on SAM-e for ex, for example.
What is a typical patient response to medication?
[00:48:51] So typical patient response to the medication, like what, what could they expect? I, I think this is like pretty classic response people have had when they have a response to the medication. I’m talking about SSRIs generally speaking.
I have the same thoughts. They’re just easier to deal with. So is that a personality change? I wouldn’t say so. they were thinking the same way. It’s just like not as gripping. They don’t affect them in the same way. I have the certain thoughts about life, about stressors. They don’t affect me in the same way.
Blank doesn’t get under my skin as much anymore. And you can insert whatever sort of stressor they had, their, their spouse, their work other stress.
And in my opinion, and this is not evidence backed at all, but this is talked about among my colleagues and I like, are the symptoms don’t reme at the same pace. They remit at different rates, so, you know, what is the typical respon or response early on? Well, they might have a little bit more energy, less dark mood, and then you’re going in a few weeks. They might get a little bit motivation back four weeks later, five weeks. I think of anxiety as being something that doesn’t respond right away unless it’s like benzodiazepine, but you have to be on the medication a little bit longer, a little bit higher of a dosage to target the anxiety. Then focus.
Focus is so multifactorial and multi-layered. It really depends on anxiety, depression, sleep, energy, interest in the topic, distractions. So I, I think of that as like the holy grail there. If their focus is back, probably a lot of other stuff, remitted. I don’t see them as like, highly focused at the beginning.
Psychedelics and MDMA
[00:50:25] I had mentioned I was going to go over psychedelics and then I was like kind of debating whether or not I should put this in here, but I think it is so commonly spoken about. Maybe I’ll just have a slide on here. So again, kind of goes into the topic of what’s natural versus proven. I think there is this favoritism towards psychedelics cuz they’re more natural and maybe the pharmaceutical greed is not, not behind them just yet anyway.
Sure there’s gonna be a big blossoming industry on this because it’s expected to become legalized in this year 2023 because of a phase three trial that Bessel VanDerKolk was one of the leads on, using MDMA in ptsd, and it was found to have a very. positive effect.
I just put, put in here some points here as to this study here about MDMA to maybe get people to not just like blindly kind of jump into the MDMA train as being like, this is the new greatest thing ever. There were some, criticisms of, of the MDMA study that I thought were interesting.
I mean, it was being compared to inert placebo, like everybody knew when they’re on MDMA. So it wasn’t being compared to a low dose of mdma. 96% of individuals that knew that they were on mda. So it was, it was not like a blinded study.
So, you know, you’re on MDMA then, I mean, , we talked about how significant the placebo effect is. And then, oh, maybe we should talk about number three first.
I mean, there, most of the people in this study had tried, or 32% had tried MDMA before. And the people who wanted to be in the study were people who like probably wanted to be on MDMA. So, I dunno, it was not like a totally selection bias free study population. People who had bad experiences with MDMA are not gonna enroll in this study if they knew that you could potentially have that experience again.
Therapists were not blinded to this study and you can imagine probably not providing the same type of therapy.
Vast Treatment Options Depending on What Patients are Interested In
[00:52:17] I just popped in a few slides here, about my like general algorithm of the treatment and the spectrum of treatment options available and it ranges quite a bit and I think of prescription and medications as just like one component ranging from less intense to more intense: self-help techniques, nutrients and supplements, coaching therapy retreats prescription meds procedures, intensive outpatient partial hospitalization, admission inpatient.
So lots of different options out there. So I try to meet patients where they’re at in terms of what they’re interested in.
And you know, I’ve, I’ve recommended light box to a lot of people. There’s a lot of support for that. There’s tons and tons of data for exercise of a blog article on all of the data there for exercise.
People don’t wanna pay money to go see a psychiatrist, and then they just tell them to go exercise more, though it’s not very fun.
Nutrients, various nutrients with varying levels of, evidence for them. I always use this website called examine.com has a lot of the evidence base for nutrients and supplements in nice one, nice place.
Prescription options, procedures, various different types of procedures. Tms, ECT, ketamine, I don’t know if people have an interest in this. They could put it in the chat box and I could talk more about these. But otherwise that’s probably pretty much the end of that.
Any particular one of those.
What about TMS? Should you recommend TMS?
[00:53:43] TMS. So tms, I used to work in a TMS lab for like three years before med school, very familiar with tms. I was, we were doing nonclinical and clinical studies for tms. It’s, it’s expensive because it’s very time intensive. The machine is expensive. The tech there is expensive. The patient has to come in like five days a week for at least 30 minutes. You know, with setup it could be 30 minutes, usually 20 minutes. And not like the most effective thing I would say. Even after having that insider interview at Columbia’s Columbia’s stimulation in lab, I wouldn’t say I’m like the hugest fan of tms.
You need to do a lot of sessions though. I would say at least like, 10, 12, 20 before you start to get some treatment response. I think insurance generally pays for like 25 sessions. I want to say it’s a guesstimate. Mostly, I mean, it was FDA approved initially for depression. I think that’s the easiest thing to get approved. I actually don’t know nowadays, like what else the FDA is approved. If it’s OCD anxiety. I think anxiety is approved for deep brain tms.
What about ketamine? Should you recommend ketamine?
[00:54:50] Ketamine definitely there was a meta-analysis that showed that ECT is still the gold standard for depression. People can have bad experiences like bad, like high anxiety with ketamine, but generally I think lower doses are pretty well tolerated and effective for depression. I think that’s why the industry is just blowing up right now with ketamine. There’s ketamine clinics like everywhere. I wouldn’t say ketamine is like the best for a highly anxious person. Think of like low anxiety, unipolar, depression type of person. Maybe if they even have chronic pain plus minus on the pain, that could be a good one for good candidate for ketamine.
