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A podcast at the intersection of psychology and culture that intimately explores the human experience and critiques the counseling profession. Your host, Stephanie Winn, distills wisdom gained from her practice as a family therapist and coach while pivoting towards questions of how to apply a practical understanding of psychology to the novel dilemmas of the 21st century, from political polarization to medical malpractice.
What does ethical mental health care look like in a normless age, as our moral compasses spin in search of true north? How can therapists treat patients under pressure to affirm everything from the notion of "gender identity" to assisted suicide?
Primarily a long-form interview podcast, Stephanie invites unorthodox, free-thinking guests from many walks of life, including counselors, social workers, medical professionals, writers, researchers, and people with unique lived experience, such as detransitioners.
Curious about many things, Stephanie’s interdisciplinary psychological lens investigates challenging social issues and inspires transformation in the self, relationships, and society. She is known for bringing calm warmth to painful subjects, and astute perceptiveness to ethically complex issues. Pick up a torch to illuminate the dark night and join us on this journey through the inner wilderness.
You Must Be Some Kind of Therapist ranks in the top 1% globally according to ListenNotes. New episodes are released every Monday. Three and a half years after the show's inception in May of 2022, Stephanie became a Christian, representing the crystallization of moral, spiritual, and existential views she had been openly grappling with along with her audience and guests. Newer episodes (#188 forward) may sometimes reflect a Christian understanding, interwoven with and applied to the same issues the podcast has always addressed. The podcast remains diverse and continues to feature guests from all viewpoints.
199. Michael Ziffra
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[00:00:00] Stephanie: If what should be our best and brightest experts on mental health. A psychiatrist who went to Yale is going to appear to the media saying The best solution we have for political polarization in families is avoidance.
[00:00:14] Michael: Exactly.
[00:00:14] Stephanie: If [00:00:15] that's the best we can do, then we're screwed. Right?
[00:00:18] Michael: Yeah. It's both sad and shocking, and I'm sure you know this, but it's the complete opposite of what we would normally tell patients to do when we are confronting something that causes anxiety.[00:00:30]
[00:00:30] Michael: Avoidance is generally the wrong solution.
[00:00:34] SKOT: You must be some kind of therapist
[00:00:40] Stephanie: today. My guest is Dr. Michael Ziffra. He's a psychiatrist and associate professor at [00:00:45] Northwestern University in Chicago specializing in anxiety disorders. He also has a substack where he writes about the intersection of mental health and sociopolitical events. Dr. Michael Ziffra, we welcome to the podcast. Thanks for joining me.
[00:00:57] Michael: Yeah, thanks for having me. I'm excited for [00:01:00] this conversation.
[00:01:01] Stephanie: Alright, so first of all, tell us what you mean by the intersection of mental health and sociopolitical events.
[00:01:07] Michael: Sure. So earlier this year I started a series of essays on Substack and that [00:01:15] stemmed from. Some interests I've developed in terms of exploring the connections between mental health and what's going on in our political environment.
[00:01:25] Michael: And this really kind of started toward the end of [00:01:30] last year, right after the election, and there were a couple of things I observed in my own patients. There was definitely a high level of anxiety, stress, demoralization, sadness about the election results. I'm, I live in [00:01:45] Chicago, so I'm in an area that definitely skews left of center politically.
[00:01:49] Michael: So understandably, there was a lot of sadness and anxiety expressed by my patient population, people in my life, my community. And [00:02:00] so I was interested in that and I did observe that the levels of stress and anxiety after the election seemed unusually high. Compared to prior elections. So that was something that really struck me.
[00:02:12] Michael: Then another thing that happened was [00:02:15] a little bit after the election, I, I'm re reasonably active on social media in particular Twitter slash x, and I had posted some comments about, and you might've seen this, there was an interview that happened [00:02:30] about a year ago, I think it was on M-S-N-B-C, but this was a psychiatrist at Yale.
[00:02:36] Michael: I'm forgetting her name, but psychiatrist at Yale, a prestigious institution who was talking about, and this was around Thanksgiving, and this was in the context of [00:02:45] how do you interact with family members who voted for Donald Trump or how do you interact with family members who disagree with you politically?
[00:02:55] Michael: And her comments were really kind of striking. She was basically saying that [00:03:00] to. Summarize it. Her statements were essentially saying that you should actively avoid interacting with family members, that you disagree with who or who voted differently than, than you and [00:03:15] I and a whole variety of other people on social media.
[00:03:18] Michael: Commented on this again. I posted some stuff on Twitter on this, and that was something that really picked up a lot of steam. I don't know if Brad Palumbo at all, he's, he's a great political podcaster and [00:03:30] journalist, but he had highlighted my comments on his podcast that kind of caught fire a little bit and that just stirred something within me.
[00:03:37] Michael: I recognized that within my local community, within the country at large, I feel like there, there definitely is [00:03:45] a strong hunger for some new ideas in terms of how do we cope with stress about what's going on in our political world? How do we. Manage when we're [00:04:00] feeling anxious or sad about what's going on in the world, how do we have healthy conversations with friends and family members who disagree with us?
[00:04:11] Michael: And so that's what led to my starting my [00:04:15] substack. And so I've published several essays on these sorts of topics. I think at this point I've published maybe 20 essays, give or take. Um, and I've gotten a very positive response to it, which confirmed which that, which I had originally thought, which [00:04:30] was there definitely is a strong desire for someone taking a closer look at these issues and giving some practical advice on how we navigate this political landscape.
[00:04:40] Stephanie: Yeah. You really highlighted there the issue that so many of my listeners [00:04:45] are fed up with, right? That if our. What should be our best and brightest experts on mental health. A psychiatrist who went to Yale right. Is going to appear to the media saying The best solution we have for political polarization in [00:05:00] families is avoidance.
[00:05:01] Michael: Exactly.
[00:05:02] Stephanie: If that's the best we can do, then we're screwed. Right?
[00:05:06] Michael: Yeah. I mean it was, it's both sad and shocking and it, and I'm sure you know this, but this is really, uh, it's the complete opposite of what we would [00:05:15] normally tell patients to do when we're confronting something that causes anxiety. Avoidance is generally the wrong solution.
[00:05:23] Michael: And so we, to your point, yes, this is someone who in theory, should be providing us [00:05:30] healthy, reasoned, evidence-based advice about how to navigate this very difficult situation. And really, this person was saying the exact opposite.
[00:05:40] Stephanie: Well, it. So much of it ties into one's broader worldview because [00:05:45] there's an underlying assumption that I'm hearing in some of those comments that one knows for sure that they are right and that the opposing party is wrong.
[00:05:55] Stephanie: So there's not even a willingness to entertain the possibility that the [00:06:00] person you've judged as being on the wrong side might actually know something you don't know or might be, might have legitimate motives for the conclusions that they've come to. So there's a false certainty to start with, which I think is not getting us off on a good [00:06:15] foot.
[00:06:15] Stephanie: And then you talk about how we deal with anxiety. Do we learn that we are strong enough to confront circumstances head on? And I just think of how paranoid [00:06:30] of a worldview one must hold if they do in fact believe what that level of rigidity and certainty that they're surrounded by people who have.
[00:06:41] Stephanie: Beliefs that are more or less evil, right? And that their motives [00:06:45] are so dark, and I think that's, it sets up a bit of a trap. It puts someone in a double bind, right? Because if on the one hand, here's some reasonable doctor like you, Dr. Michael Zera coming along and saying, actually, there's a better way.
[00:06:58] Stephanie: Did you know that you [00:07:00] can actually interact with the people you disagree with and live to tell the tale, but the beliefs that person hold still essentially frame a large portion of society as [00:07:15] very ill motivated. Then it's like, well, why should I? That's like going into a war zone. That's like going into, or the term genocide gets used, right?
[00:07:23] Stephanie: These people wanna kill me.
[00:07:24] Michael: It's very simplistic. It's appealing to a lot of people because it is [00:07:30] simplistic and it's for people who have challenges with dealing with the complexity of the world. It's very appealing to be able to box someone into a category of good or evil or friend and enemy, but the world is not like that.
[00:07:44] Michael: [00:07:45] So really unlearning some of the bad habits you've gotten in. So whether it be this habit of compartmentalizing people, again, having these stark boxes, good or bad friend or [00:08:00] enemy in one piece. I write a lot about the language we use and how the language we use colors. Our thoughts about the world colors, our thoughts about other people, and how we [00:08:15] can, just by modifying the language that we use to describe people who might disagree with us, that can go very far in terms of, it may not totally change our attitudes, but it might soften them a little bit and make us more likely [00:08:30] to want to at least listen to the other person, or at least not vilify them.
[00:08:36] Michael: So, for instance, rather than seeing someone who is on the opposite side of the political spectrum, rather than [00:08:45] saying they're, they're evil, they're fascists, et cetera, you can take a step back and say to yourself, this is someone I, they may not share the same values as me. They may have different priorities in life than me, and I may [00:09:00] not totally understand what they're coming from, but the mere fact that they feel differently.
[00:09:06] Michael: It doesn't mean that they're an evil person. And, oh, one other quick point. You talk about the paranoid mindset, and I do think that's another thing we often see [00:09:15] and that's, it can kind of become a vicious cycle. So if you start labeling other people as fascists, evil monsters, what have you, that's really gonna [00:09:30] intensify whatever sort of fear or anxiety you have about them, and that's gonna really, uh, influence the lens through which you see them.
[00:09:38] Michael: So it's kind of a vicious cycle.
[00:09:39] Stephanie: I'm curious how receptive people have. Been to your ideas, but I think first I need to [00:09:45] zoom out and talk about what you do as a psychiatrist. So this is something I wanna clarify for listeners who are not in the mental health field, because in my day-to-day work, I run into people who will use the term psychologist, for example.
[00:09:59] Stephanie: And I'll say, well, [00:10:00] what do you mean? You mean a therapist? Or was that a licensed psychologist? A clinical psychologist ID or, and then they're like, oh, I think it was a social worker. Okay, so that's an LCSW. And there's these different types of licenses that give us the training and qualifications to [00:10:15] do slightly different things, even though there's a broad range of us who do some type of clinical work.
[00:10:20] Stephanie: So. A lot of people don't know that psychiatrist is different from psychologists. For instance, the psychiatrist is specifically a doctor who prescribes [00:10:30] psychiatric medications. That being said, within the realm of psychiatrists, I've heard of the those who meet with patients very infrequently and briefly, all the way to those who do therapy and also prescribe medication.
[00:10:42] Stephanie: So can you tell us about what you do in your role? [00:10:45]
[00:10:46] Michael: As I see it, what I do is it's, it's a process of diagnosis and treatment and the types of treatment I ra use and recommend is gonna vary a lot from person to person. So a lot of times it will include medication but not always.
[00:10:58] Stephanie: Sounds like you're a good point of [00:11:00] entry.
[00:11:00] Stephanie: I often think of psychiatrists as, as a therapist, I would be on the other side referring someone to a psychiatrist if it seems like therapy alone and lifestyle interventions aren't going to be adequate, but it can also be the other way around. [00:11:15] Someone doesn't have to be sure that they want to try medication in order to see someone like you and you can more kind of triage and assess what their needs are.
[00:11:22] Michael: Yeah, I think that's a really good point because I think some people who might benefit from an evaluation with a [00:11:30] psychiatrist might be leery of doing so either because they're under the impression that they're going to be. Given a medication or they might be under the impression that this is not a psychiatrist is only for really ill people, [00:11:45] it's not for people with more minor things.
[00:11:47] Michael: But you know, to your point, yes, the, when someone meets with me, they're not obligated to do anything. My role is to do a thorough evaluation, share with them my impressions, make some [00:12:00] recommendations, and then it's up to them how they wanna proceed with that.
[00:12:03] Stephanie: So I wanna explore the idea of chemical imbalance.
[00:12:06] Stephanie: 'cause when people think of psychiatric medication, they think of things that adjust your neurotransmitters, SSRIs, SSRIs. [00:12:15] But a year or two ago, something floated through my awareness. Like so many other things I've scrolled past social media and headlines that I didn't take a deep look into, and listeners might be shocked and outraged to know that I actually don't stop and dive [00:12:30] deep into everything that you might think is relevant to my work.
[00:12:35] Stephanie: So this is one of those things that is relevant. But I will admit that when I saw the headlines about how the chemical imbalance [00:12:45] theory of depression has been debunked, I made a mental note to look into that someday, and I never really did a deep dive. So I'm curious for you as a psychiatrist, what's your [00:13:00] stance on the idea that people with mental illness have a chemical imbalance?
[00:13:04] Stephanie: What's true? What's false about that? And where does psychiatric meds come in?
[00:13:07] Michael: I think imbalance is not, it's not a good word, because it implies that there's some sort of proper balance, which [00:13:15] we don't really know. 'cause the thing is you can't really, there's no good way of. Accurately measuring.
[00:13:22] Stephanie: It's not like blood work where a doctor can assess that your vitamin D is low.
[00:13:26] Michael: Exactly. Right. Exactly. So there's no test you can [00:13:30] take to determine is your serotonin too high or too low, or your, is your dopamine too high or too low? So to call it an imbalance is, it's not good terminology because it's implying that we're measuring something that we really [00:13:45] can't measure. So I would say a better term to use would be maybe dysfunction in the sense that the activity of certain neurochemicals might be functioning differently [00:14:00] in an individual.
[00:14:02] Michael: Experiencing depression versus someone who is not. I think it's, and one thing we've learned over the past few decades is there's a very complex interplay between [00:14:15] all of these neurochemicals, and we're also learning that there are many more neurochemicals beyond the three that I just mentioned. That's our belief to play a role in depression, and they're all very linked, so, and it's all also dependent on.[00:14:30]
[00:14:30] Michael: Region of the brain as well.
[00:14:31] Stephanie: And what are some of these lesser known, because every now and then I'll hear about some neurotransmitter or hom hormone that I've never heard about before. And it's like, oh, what do you mean? It's not just serotonin, norepinephrine, dopamine, and like [00:14:45] two others.
[00:14:46] Michael: Right, right. So you know, another other examples being, there's a one called glutamate, which is a big one because a lot of the newer agents that have come out recently have been shown to affect glutamate.
[00:14:58] Michael: That's
[00:14:59] Stephanie: an [00:15:00] excitatory neurotransmitter, I think, right?
[00:15:02] Michael: It is. But again, the sulfate, how it's very complex. And I will add, we do not know everything. We don't, we're not even close to knowing everything. And so activity on [00:15:15] glutamate may have downstream effects on other chemicals. So as there's a whole cascade of different chemicals affecting each other.
[00:15:24] Michael: So an agent that might. Pharmacologic agent that might affect [00:15:30] glutamate, might have downstream effects on dopamine or serotonin or what have you. So glutamate is one. There's actually evidence that opioid receptors, so when we think of opioids, we, we think of opioid based, [00:15:45] either pain relievers, codeine, morphine, things like that.
[00:15:48] Michael: Or we also think of sometimes drugs of abuse. There's evidence that opioid receptors may be involved in depression. There's a another. A chemical called [00:16:00] orexin that is being studied more. And orexin is a chemical that is involved in regulation of wakefulness. There's a couple of newer drugs that have come out the past couple of years that act on receptors for [00:16:15] orexin.
[00:16:15] Michael: These are drugs that help with insomnia. And interestingly, some of these drugs have been felt to have potential antidepressant effects. So to your question, there's a lot more we're learning about other [00:16:30] neurochemicals or other receptors that exist on neurons that are believed to play a role in depression.
[00:16:36] Michael: So I mean, really, we're kind of only scratching the surface and there's a lot, there's a lot more to learn. So I think [00:16:45] anyone who would claim that we have a good understanding of this would be incorrect. Either. Either they're lying or they don't know what they're talking about.
[00:16:53] Stephanie: Okay. You said something really interesting.
[00:16:55] Stephanie: You said there's evidence that opioid receptors may be involved in depression, [00:17:00] how
[00:17:00] Michael: it's complex. And I'm not a, a PhD in pharmacology, so I'll only scratch the surface, but there are different types of opioid receptors in the brain and there's, for example, there's one type called kappa receptors. [00:17:15] And the strongest evidence seems to suggest that activity on these kappa receptors may have antidepressant effects.
[00:17:23] Michael: And so a lot of the opioid based pain relievers that we might think of. [00:17:30] They might have more activity on other types of receptors than say the kappa receptors. So some of the drugs that are being studied right now, some of the opioid based drugs that are being studied for potential treatment for depression are, they might [00:17:45] not necessarily have effects in terms of pain relief, but they may end up having more of a antidepressant effect based on the effects on these kappa receptors specifically.
[00:17:54] Stephanie: Does that have to do with endorphins?
[00:17:57] Michael: Potentially? I don't fully know the answer to [00:18:00] that, but there's probably some connection there.
[00:18:02] Stephanie: So I'm gonna pick your brain about something I'm taking. Sure. Since I have the chance. So I'm taking low-dose naltrexone. This was originally recommended to me by one of my long COVID doctors.
[00:18:13] Stephanie: Yep. Saying that it's [00:18:15] been helpful in some cases of long COVID with that it's anti-inflammatory, that it can help with some of the fatigue and malaise. And I can't say I notice a strong effect, and yet if I miss a dose, I feel a little worse. So it must be doing something for me [00:18:30] now anyway. So low-dose naltrexone is something that I take, even though I don't understand it.
[00:18:35] Stephanie: A doctor managed to convince me that it would be a good idea and I, all I know is that it does have to do with the opioid system. Can you explain how a [00:18:45] drug like that works? Because I know it's also used for depression.
[00:18:47] Michael: Right. So you bring up an interesting topic. So this practice of using low-dose naltrexone is something that has really kind of emerged in recent years.
[00:18:57] Michael: I've. A number of my patients [00:19:00] being prescribed it for different diagnoses, but a lot of things similar to what you described often people with chronic pain symptoms. I think that's something I've seen it commonly used for. And just to give an overview of Naltrexone, [00:19:15] so Naltrexone is a pharmacologic agent that locks opioid receptors and it has a number of different uses, as you touched on.
[00:19:23] Michael: It's something that patients with a history of addiction may use. There's [00:19:30] evidence that it's for individuals who have addictive behaviors, alcohol being a good example, it, it's interrupts that whole, we think of circuits that are involved in terms of reward and cravings that are involved in addictive behaviors.[00:19:45]
[00:19:45] Michael: And so the Naltrexone in essence helps to interrupt that. So in essence helps to reduce cravings. And for someone trying to stop use of, again, let's use alcohol as an example, helps to reduce the cravings and makes it easier to stop. But there's evidence [00:20:00] that it can help for other types of addictions as well.
[00:20:03] Michael: So for other drug use disorders, I've seen evidence that they can maybe help with things like addictive gambling. I've seen it used for things like people who have compulsive skin picking [00:20:15] or hair pulling. There's evidence that can be helpful for that. But as you said, low dose naltrexone is. An entirely different, entirely different phenomenon going there.
[00:20:27] Michael: 'cause to put things in perspective, a normal, when [00:20:30] you're using Naltrexone for some of the other things I described, a normal daily dose would be something like 50 milligrams. And so you said you're taking about 4.5 milligrams. I've seen, when I've seen other people prescribe low dose naltrexone, I've seen something [00:20:45] similar like in the range of one two.
[00:20:47] Michael: Five milligrams. And so what it's doing pharmacologically, and I don't think we know entirely, and it's not something I ever prescribed, so I don't know all the firm details of how it works, but [00:21:00] chances are what's happening is that it is affecting opioid receptors. But on a different level, and I don't wanna get too in the weeds in terms of pharmacology, but one thing that we know about medications is that the dose of [00:21:15] medication is often going to influence what sort of receptors get hit, so to speak.
[00:21:21] Michael: So for instance, it may be that at a very low dose. The low dose naltrexone is hitting certain types of [00:21:30] receptors that produce a certain therapeutic response, whereas at a high dose, it's gonna be affecting a different set of receptors. And so that would explain the differential response. If I can use an analogy like the [00:21:45] antidepressant, mirtazapine also called remeron.
[00:21:47] Michael: Is that something you're familiar with?
[00:21:48] Stephanie: Heard of it.
[00:21:49] Michael: Okay. Okay. It's not, it's a very good antidepressant. It can be very sedating and it can cause weight gain for people. So it's not the most popular antidepressant. But I bring [00:22:00] this up because that's another example of a pharmacologic agent where its properties are going to vary.
[00:22:08] Michael: Depending on the dosage. So it, it, it sounds very counterintuitive, but at a, at a [00:22:15] very low dose, mirtazapine tends to be very sedating and it tends to be more likely to stimulate appetite and cause weight gain. Whereas the higher you go up on the dose, those effects lessen. So it's a little bit [00:22:30] counterintuitive that you would get stronger side effects at a low dose versus a high dose, but that's reflecting how the different dosages are hitting different types of receptors.
[00:22:40] Michael: And so it's a similar concept going on with the naltrexone.
[00:22:44] Stephanie: With [00:22:45] naltrexone, it's my understanding, at least with the low dose that I'm on, that part of how it works is if I take it before bed, it suppresses or it, as you said, blocks opioid receptors during the night. [00:23:00] In a temporary way that then there's a rebound effect where I produce more endorphins.
[00:23:05] Stephanie: That's been explained to me. I don't fully understand it though. Is that correct or am I getting that wrong?
[00:23:10] Michael: It's, I'll put it this way. It sounds correct. I don't, again, I don't prescribe the low dose [00:23:15] naltrexone. I don't use it enough to know all the ins and outs about it. But we do know with many types of pharmacologic agents, there's often a rebound effect as the medication is wearing off.
[00:23:27] Michael: So I think an analogous situation [00:23:30] would be with benzodiazepines and something like Xanax would be a very good example. One reason, I mean, this could happen with any benzodiazepine, but it tends to be particularly problematic with Xanax. People will often get rebound anxiety with [00:23:45] Xanax as it's wearing off.
[00:23:47] Michael: So you take a Xanax and you may feel. More relaxed for a couple of hours, but then as it's getting out of your system, all of a sudden that anxiety is coming back and maybe even worse than it was to begin [00:24:00] with. And again, even though that can happen with potentially any benzodiazepine, it's particularly problematic with the Xanax 'cause it has a very short duration of action.
[00:24:10] Michael: So sort of these sorts of effects are seen with agents with a very short duration of [00:24:15] action.
[00:24:15] Stephanie: Let's talk about that. So, and I just wanna flag that it's really interesting to me that the point as far as I'm concerned of someone like me taking low dose naltrexone is to get the rebound effect of the more [00:24:30] endorphins.
[00:24:30] Stephanie: But you bring up a really good point with benzos that, and I've experienced that rebound. I've taken benzos a few times in my life and every time I was like, oh, I see how this is addictive. Absolutely. Because I feel so chill. Tonight and tomorrow I feel like I wanna [00:24:45] panic for no reason, which is absolutely not worth it.
[00:24:48] Stephanie: Absolutely. And one of the most alarming things I've seen in my career as a therapist is people who are prescribed large doses of benzos to be taken daily.
[00:24:57] Michael: Yeah.
[00:24:58] Stephanie: And I always, whenever I [00:25:00] saw that in someone's medical history, sent off these giant red flags for me. But then I'd be very careful in my role as therapists about questioning that patient's prescriber.
[00:25:11] Stephanie: Sure, there's a reason that the prescriber is recommending that they [00:25:15] just be on benzos forever, but, but it is quite alarming. And I'm wondering if you can speak to that as a psychiatrist. Like how did we even end up in a world where people are told to take benzos consistently knowing how addictive they are and how there's that rebound effect.
[00:25:29] Michael: Yeah. [00:25:30] Yeah. It's a great question. And what you're highlighting I, I think is a legitimate concern. And we wanna say that every patient is unique, every. Patient's needs are unique and you know what might be. [00:25:45] Inappropriate for many patients might be appropriate for some, but I think as a general rule, we can say it's not ideal practice to prescribe people a daily benzodiazepine indefinitely.
[00:25:58] Michael: And there are many reasons for [00:26:00] that. And you highlighted some of these, they, they do have potential for tolerance and dependence. They do have negative side effects, sedation impairment, and cognitive functioning. There is evidence that chronic use of [00:26:15] benzodiazepines can potentially increase risk for dementia in later age.
[00:26:20] Michael: So there's a whole host of reasons to not be using them regularly. And there's a lot to explore with this. How does this happen? Why did this happen? What do [00:26:30] we do about this? And in terms of the how and why, I can't say there's any one particular explanation. I can say it's a variety of things. I think when Benzos first came out a couple of decades ago, it's like they, [00:26:45] they exploded in popularity and it was an easy thing to provide relief because keep in mind, benzos first came out, I forget the exact decade, maybe around the sixties or so, and this was before we had things like.[00:27:00]
[00:27:00] Michael: Prozac, SSRIs, et cetera. The only things we had to relieve anxiety were agents that were a lot more problematic. So older antidepressants, antipsychotics, things like that. So you can see why there would [00:27:15] be appeal in prescribing what at the time seemed like something that was safe and effective. And you can kind of see an analogy be between this and the whole opioid crisis with all these people who were prescribed pain [00:27:30] medications kind of haphazardly.
[00:27:32] Michael: In terms of other things that I think might be at play, and I'll preface this by saying that I don't think we, I don't want to criticize Nons psychiatrists or people working in primary [00:27:45] care, but we see a lot of people nowadays getting. Their mental health care, not through a psychiatrist, but through their primary care doctor.
[00:27:55] Michael: And I think primary care physicians are becoming more informed about [00:28:00] best practices, but I think there are still a number out there who may not be fully aware about the dangers of chronically prescribing benzodiazepines, or keep in mind, primary [00:28:15] care doctors are under a lot of pressure to see a lot of patients in a very short time.
[00:28:21] Michael: So it may be very easy to prescribe a benzodiazepine or refill. A [00:28:30] benzodiazepine then perhaps take a little bit more time to explore other treatment options. So I think that's something that plays a role as well. Again, not to fault primary care doctors. I know they, they do a lot of hard work, but they may not always be [00:28:45] up to date in terms of best practices.
[00:28:47] Michael: And another thing that happens is, and I see this in my practice, you inherit patients who have been on benzodiazepines chronically for years, [00:29:00] and it, it can be a challenge to have them come off of it. It can be a challenge from. Physical standpoint in the sense that it's, they will potentially go through some withdrawal as you try to win them off of it.
[00:29:14] Michael: And there's [00:29:15] also some psychological aspects. Someone who's a patient who's been taking a benzodiazepine for many years and they've become psychologically reliant on it, it can be very difficult to convince them that it's important to come off of it. [00:29:30] So it's common as a physician to inherit a patient who's been on a benzodiazepine for many years and it places in our lab a challenge in terms of how do we deal with this?
[00:29:42] Michael: It's very easy to [00:29:45] pick up a new patient who's never been on a benzodiazepine and to say, we're not going to prescribe this. It's a lot more difficult to. Take on a new patient who's been on a benzodiazepine for 20 years and they, and then say, let's get you [00:30:00] off of this. That's gonna be a much bigger challenge.
[00:30:02] Michael: It can take, depending on what dose they're taking and how long they've been taking it, it can take a year, potentially longer to have them totally come off of it. [00:30:15] And so I, I think the best course of action is to not start a benzodiazepine or one practice I like to do with patients is if I'm starting them on a benzodiazepine, I make it very clear from the get go that this is going to [00:30:30] be a very time limited intervention, maybe at most a month or so while we get your symptoms under better control.
[00:30:38] Michael: And if we do need to use some sort of as needed agent after a month, [00:30:45] then we can talk about other alternatives. So really the best way to prevent. Dependence on benzodiazepines is to not start it or to start it with a very intentional mindset to be very limited in how long it's gonna be used. [00:31:00]
[00:31:00] Stephanie: Well, it's my understanding that benzo withdrawal is pretty serious, and the de-prescribing needs to be done really carefully.
[00:31:07] Stephanie: I talk to people all the time who aren't in this field. Maybe they're worried about a loved one, [00:31:15] and they might want a loved one to come off of a medication, and it seems to me most people's understanding of tapering is much too rough. It's my understanding that safe tapering needs to be done a [00:31:30] lot more.
[00:31:30] Stephanie: Slowly and titrated more carefully than people think.
[00:31:35] Michael: Exactly. And as I said, it's how you do it is gonna depend on a couple of variables, what dose they're taking, how long they've been [00:31:45] taking it. 'cause in general, the longer they've been taking it, the slower you want to go. And there's no one sort of universal protocol for how to get someone off of a benzodiazepine.
[00:31:56] Michael: But some people will say, you should only reduce it by [00:32:00] say, 10 milligram. Uh, not 10 milligrams, 10% at a time. Kind of hard to do given the size of pills that are available. But what that means is if you have someone, let's say they're taking four milligrams a day of Xanax, which would be a, a very [00:32:15] large dose, if you reduce them from four to three all at once, now that's a 25% reduction that's going to.
[00:32:23] Michael: Be very poorly tolerated by a lot of patients, and you're not gonna have success with that. [00:32:30] So if you wanna have a successful taper off of a benzodiazepine, you wanna err on the side of being too slow rather than too fast, and you wanna go in smaller increments. And one strategy we will sometimes [00:32:45] do is because.
[00:32:48] Michael: Agents with a shorter half-life such as Xanax are harder to come off of. You're gonna get more withdrawal. One thing we will sometimes do is we will transition that patient to a [00:33:00] benzodiazepine with a longer half-life where it's easier to make that reduction. So you might transition them from Xanax to say Klonopin.
[00:33:08] Michael: That can make it a little bit easier. But going back to your original question, yes, it has to be done slowly, and as I [00:33:15] said earlier, it can potentially take a year, maybe even more so some patients is required on both the patient's part and the physician's part. And I think sometimes, whether it be due to lack of knowledge or whether [00:33:30] there's some sort of strange pressure to get them off of it, A-S-A-P-I, I do think that can lead to some being too aggressive with it.
[00:33:37] Stephanie: Yeah, and it seems like that's, it's partly about safety, it's also about the patients. Hopefulness, [00:33:45] right? Because un, unless there's proper psychoeducation and context, it would be easy as a patient to mistake withdrawal symptoms for your baseline. And if you're experiencing withdrawal symptoms and you're like, oh, this is me [00:34:00] without medication, then you're gonna think, I can't ever go off of this medication.
[00:34:03] Stephanie: I have to live with this.
[00:34:04] Michael: Exactly. Yeah. No, you've hit the nail on the head there. Yeah. So if you did, uh, for instance, going back to my example of making a huge reduction in the dose of Xanax, the [00:34:15] patient is likely gonna experience some withdrawal that will likely feel very similar to what their normal anxiety might feel like.
[00:34:23] Michael: And the conclusion that they're gonna come to is, oh, well this is proof that I need to be on this medication, [00:34:30] and they're gonna be likely very resistant to trying to reduce it further. And so you want to. Do this process in a way that is going to make the patient as comfortable as possible. Now, it is [00:34:45] true that with each dose reduction, there may very well be some mild withdrawal symptoms that come up.
[00:34:52] Michael: So it is important to let the patient know. Usually it will be a time limited thing, and it should really be more at the mild end of [00:35:00] the spectrum. But it's important to anticipate them so that they don't panic if they feel a little bit off. But they really, if it's to the point where they're having panic attacks, they're having severe insomnia, they're having difficulty coping in their day to day, that's a sign you're [00:35:15] probably being too aggressive with a taper.
[00:35:18] Stephanie: So let's say you had a patient who wanted to taper off of a drug, doesn't matter which for this purpose, but they really wanted to be successful. So they didn't wanna lose hope. [00:35:30] They wanted it to go well so that the changes could last. What would you recommend to that patient to set them up for success in terms of the timing of when in their life to do this?
[00:35:41] Stephanie: What extra supports they need to put in place? What kind of [00:35:45] self-care is gonna help that patient be successful going through the withdrawal and tapering process?
[00:35:49] Michael: Couple of good points that are mentioning in terms of when to do it kind of goes without saying, but patients should probably try to aim for a time where they're feeling relatively [00:36:00] well psychologically, where they're not anticipating any big stressors on the horizon.
[00:36:06] Michael: 'cause you wanna do it during a time where you feel relatively. Resilient. So you wanna be mindful of that. Or [00:36:15] another example that comes up is some people do have a little bit of a, a seasonal pattern to their symptoms. So if that's the case for you, you probably don't wanna try coming off of a medication in the middle of winter, so you might wait until spring.
[00:36:28] Michael: So you do wanna be mindful of [00:36:30] the timing in terms of other things to be successful. Again, I would discuss with them that this is a process that it may take several months. That will depend on various factors like I mentioned, and it'll depend on the specific medication you're talking about. [00:36:45] And generally we would do it in a stepwise fashion unless they happen to be at a very low dose of something.
[00:36:51] Michael: Usually we would reduce it in a stepwise fashion. And so we will monitor things at each step. And so I will discuss with the patient that. [00:37:00] Being able to monitor themselves very closely is important. So they need to keep an eye on how they're feeling, and they definitely need to let me know if they're feeling significantly worse at a lower dose.
[00:37:13] Michael: 'cause if that happens, then we need to [00:37:15] have a conversation and decide how we wanna proceed. I mean, it can be very useful to involve loved ones in the process. So the patient should let their, their spouse, their friend's, family, know this is happening, [00:37:30] provide some extra report and please also let me know if you're observing something, if I happen to appear more.
[00:37:36] Michael: Depressed, more anxious, more irritable, et cetera, please let me know. So having that close monitoring during the process [00:37:45] is important. And in general, they need to practice good self-care interventions. So they should be practicing good sleep hygiene. They should be getting exercise, staying socially active, not engaging in substance [00:38:00] use.
[00:38:00] Michael: So there really is a lot they can do to make that process successful. And then if they are seeing a therapist, then I think continuing the therapy is gonna be very important as well. 'cause depending on the nature [00:38:15] of their diagnosis, depending on the nature of their symptoms, they might be. At risk for a relapse off of medication.
[00:38:24] Michael: So having some other treatment intervention on board is gonna be really helpful.
[00:38:29] Stephanie: So [00:38:30] let's say we're talking about someone dealing with nicotine addiction and who's coming to you as a psychiatrist saying, I wanna quit smoking. What would you imagine that this patient's history of smoking had [00:38:45] done to their neurotransmitters that might need support when they're trying to quit?
[00:38:51] Stephanie: I don't know if that's the right way of wording it. Yeah, yeah. If you wanna help me formulate that.
[00:38:54] Michael: Yeah. I don't think. We necessarily know everything [00:39:00] that has happened as a result of the smoking, I think we have a better sense of what could help. And so if we're talking specifically, obviously there are many different approaches to dealing with quitting use of nicotine.
[00:39:12] Michael: But if you're looking particularly at [00:39:15] pharmacologic options, 'cause keep in mind we were talking earlier about the role of dopamine in addictive behaviors, and we know that dopamine is involved in these, what we would call reward circuits in the brain. [00:39:30] So things that give us a sense of reward if we're engaging in something pleasurable, whether that be smoking or something else.
[00:39:37] Michael: And then that also helps to stimulate cravings for whatever, again, whether it be nicotine or something else. So we [00:39:45] do know that, going back to your question, that dopamine is one neurochemical that's very much involved in. Those addictive behaviors. So pharmacologically, we would consider [00:40:00] agents to try to affect what's going on in terms of that reward circuit and what dopamine is doing.
[00:40:05] Michael: And so you may be familiar that Wellbutrin, the antidepressant Wellbutrin is something that's commonly used for smoking cessation. It has a. [00:40:15] FDA approval for that. One of the first agents approved for that particular purpose. So via its mechanisms on dopamine, it would help. So that's one of the more common pharmacologic agents we would think about in terms of quitting use of [00:40:30] nicotine.
[00:40:30] Michael: You may be familiar also with Chantix, which came out, I don't know, maybe. 15, 20 years ago, which is, and that's a drug that acts directly on the receptor for nicotine. And so that's something that helps people to quit smoking. And that's a [00:40:45] sort of via a different mechanism. It's blocking that element of reward that is happening with use of nicotine.
[00:40:52] Michael: So people will usually start Chantix, like right before they're going to quit. And then as they do quit, they will find [00:41:00] this, not that it's an easy process by any means, but it's going to be easier with the use of the Chantix. So those are two prescription medications we would think of. Obviously a person doesn't have to use a prescription medication.
[00:41:12] Michael: So nicotine replacements, [00:41:15] and there are so many different options nowadays. A patch, a lozenge, gum, et cetera, that can be very effective for people as well. But in essence, all of these interventions would have some sort of common thread in terms of you you're trying [00:41:30] to. In some fashion interrupt that whole reward process that goes on such that when you're quitting or when you're trying to reduce use, you're gonna have less of that reward [00:41:45] going on.
[00:41:45] Michael: And so that, that reward is a reinforcing effect, wanting you to use more and have cravings so you're interrupting that whole process. So fewer cravings, less of a sense of reward when you are using. And over time, that will make it increasingly [00:42:00] easier to quit.
[00:42:01] Stephanie: Let's take a quick break, and when we return, let's talk about a.
[00:42:06] Stephanie: Alternatives to psychiatry. When you refer out what kind of labs you refer people for, what kind of medical things get missed and how you [00:42:15] work together with other professions as well as the psychoeducation piece. In other words, what is the role of. Informing patients what's going on in their minds and bodies so that they can take more informed care of themselves.
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[00:43:14] Stephanie: [00:43:15] Alright, so as you were saying earlier, sometimes you are more of an entry. Point for people and patients, at least if they're considering working with someone like you. Shouldn't be worried that seeing a psychiatrist necessarily means that drugs are your [00:43:30] only option and you're committing to taking that path.
[00:43:32] Stephanie: It can be a point of entry for diagnosis, for referrals, for other types of evaluations as to what could be contributing to psychological distress. So let's talk about some of those alternatives, some of the [00:43:45] things you educate patients on and where you tend to refer people.
[00:43:48] Michael: When I'm doing an initial evaluation with a patient, I like to think very broadly in terms of what might this patient benefit from.
[00:43:58] Michael: And as I said, sometimes that [00:44:00] might include medication, but not always. And there there are definitely situations where medication would not be. Appropriate at all and were, it would really be wrong to do so. 'cause keep in mind you have people who are coming in with, and I'll give some good [00:44:15] examples, situations where someone might be going through a period of bereavements or maybe a significant stressor like a divorce or a job loss where they're having some feelings of sadness or [00:44:30] anxiety that are relatively appropriate given what's going on in their lives.
[00:44:36] Michael: But something that might very well be. A time limited thing that's, unless they're [00:44:45] severely impaired by their symptoms, that's not necessarily something where medication would be warranted. So that's something where I might recommend that they meet with a therapist, and I would say they can definitely feel free to come back if things worsen or they don't [00:45:00] improve.
[00:45:01] Michael: Well often big piece of what we do, 'cause keep in mind we have our medical training. So we think a lot about are there medical things going on that could be causing these symptoms that are happening? 'cause there's many [00:45:15] medical problems or medication side effects that can cause psychiatric symptoms. So we do think about that.
[00:45:22] Michael: So sometimes we may do something as simple as ordering some basic labs if they haven't had that done. One good example [00:45:30] being thyroid disease, either hypothyroidism or hyperthyroidism is something that can cause a whole variety of psychiatric symptoms. So that's a common lab we will check, but we'll do some other basic labs as well.
[00:45:44] Michael: Sometimes if they [00:45:45] have more complex medical issues going on, they might, we might recommend that they talk to their primary care doctor if, if I see they're on medication that seems. Potentially problematic to me, medications that might be [00:46:00] causing or exacerbating some of their psychiatric symptoms. Then I might say to the patient, you should talk to your other doctor about this.
[00:46:07] Michael: Or I might talk to that other doctor myself and say, Hey, are there other alternatives we can consider?
[00:46:14] Stephanie: [00:46:15] Sorry, can I ask you about that? Yeah. So you're saying medications for non-psychiatric conditions that could have psychiatric effects? Yes. What would be some examples?
[00:46:23] Michael: Some common ones would be steroids.
[00:46:25] Michael: So steroids are commonly prescribed in a variety of, often for [00:46:30] anti-inflammatory conditions or for inflammatory conditions. Steroids are really notorious for causing a lot of bad psychiatric effects.
[00:46:38] Stephanie: I have to ask, uh, is flu Joe Cortisone considered a steroid?
[00:46:43] Michael: Technically yes, but not the type of [00:46:45] steroid we're thinking about.
[00:46:46] Michael: So, okay, we're talking about things like prednisone would be a good example of that. So some people will take prednisone or similar steroids chronically for an inflammatory condition. So often people like lupus being a good example, [00:47:00] some people may take them as small pulses for certain inflammatory conditions.
[00:47:06] Michael: But either way, steroids, whether they be taken chronically or as small pulses can cause a whole variety of psychiatric side effects. [00:47:15] Other things would be, we talked about pain, medications, anything that has potentially sedating side effect can be problematic. So things like muscle relaxants, anti-seizure medications, I had mentioned that.
[00:47:29] Michael: So those would be some [00:47:30] common examples. Often, I often find that hormonal based medications can be challenging, so birth control pills, and that's I think, a particularly challenging one because it, it can be quite [00:47:45] variable from person to person and from formulation to formulation. But I've had many patients who have found that they felt much worse emotionally on a given.
[00:47:57] Michael: Birth control pill, but they may do very well on a [00:48:00] different form. So that would be another good example.
[00:48:02] Stephanie: Well, thank you for mentioning that. So for listeners, I did bring this up with Dr. Fra. Before we started recording, we decided we weren't gonna spend the whole episode talking about that issue. It's one of my pet issues, the issue of young women being put on birth [00:48:15] control.
[00:48:16] Stephanie: From a young age, often just to manage painful periods, acne or just because they don't want to menstruate. I mean, who, who would choose that if there were no side effects to the alternative, but then it causing psychiatric issues with then, which then get [00:48:30] medicated and then years and years pass. And these girls think that they have this chronic condition called depression and anxiety.
[00:48:35] Stephanie: So it's one of my pet issues. And you said you didn't have a ton of experience with it, but I am glad to, to notice that you've had that. It's like, of course taking drugs that affect your [00:48:45] hormones are going to affect your emotions.
[00:48:46] Michael: Right? Right. I think that goes without saying. And I mean, if I had a patient coming in and let's say a young woman and she told me that she's having some psychiatric symptoms that.
[00:48:59] Michael: [00:49:00] Very much correlate with when she started an oral contraceptive. I, and to me it seems like kind of a no-brainer, but I guess not everyone would approach it this way. I, I would say to, to this person, it's, I think the first step is you should talk to your whomever's, prescribing your OB whomever, [00:49:15] see if there's something else that you can try.
[00:49:18] Michael: And I would not be inclined to start them on medication until that other piece has been addressed
[00:49:24] Stephanie: Well, and one of the reasons that it's not necessarily so obvious in all cases is [00:49:30] particularly the girls who start early, because we're we're talking about young women potentially within a year or two of the onset of menses.
[00:49:37] Stephanie: And at that point it hasn't stabilized yet in terms of their cycles may not be regular, which may actually be the reason they might be taking these drugs because their cycles were [00:49:45] irregular. But that's normal at the beginning. And then they also haven't had a chance to grow into themselves, go as going through puberty and all the new emotions that come with that.
[00:49:54] Stephanie: So if a young woman starts taking birth control. Before she [00:50:00] knows herself very well, then she may not connect the dots. Right. It, it may be in Dr. RA's office that those dots get connected for her that like, wait a minute. Okay. You started menstruating at 12, you started birth control at 13 and six [00:50:15] months later is when you started taking that antidepressant.
[00:50:18] Stephanie: But it's, so I do think we ought to talk about it and that sometimes doctors may need to read the patient's timeline a little bit more carefully to kind of put the pieces together. 'cause not everyone realizes [00:50:30] how connected these things are.
[00:50:31] Michael: Yeah. No, I think those are good points. And yeah, I'll say this, obviously I'm not a, I'm not an ob gyn and I only treat adults.
[00:50:39] Michael: I don't treat anyone under 18. But, so I can, you know, my ability to comment is [00:50:45] somewhat limited. But I will say this, I do think there is, and not just hormones, but I think medication in general, I think one has to be mindful in terms of prescription too. People who are not yet [00:51:00] in adulthood. 'cause, and you highlighted this, there's a lot of maturation that's happening in adolescence your teen years, even young adulthood.
[00:51:13] Michael: And I think there are [00:51:15] dangers that can happen if you are suppressing or masking certain things. So I think there may be very good, legitimate reasons for an adolescent girl to be on a birth control pill. Uh, again, [00:51:30] it depends on patient to patient and what their needs are. But I think you highlight one of the downsides that can come with being too quick to prescribe something that while may provide some benefit, may not be.
[00:51:44] Michael: A [00:51:45] hundred percent medically warranted.
[00:51:47] Stephanie: So you were talking about what else you do besides prescribing some of the things that you evaluate, like thyroid, any other sort of alternatives or adjunctive care.
[00:51:58] Michael: Another big one that I think [00:52:00] often gets missed is sleep disorders. We'll see people come in, they're chronically fatigued, they can't focus in the daytime, they're cranky and ask them questions about their sleep.
[00:52:11] Michael: And it turns out they're getting very poor sleep. And yes, [00:52:15] insomnia can be a symptom of depression and anxiety, but you know, many people have insomnia or just sleep disturbance. In the absence of those diagnoses, so I, I do like to ask a lot of questions about sleep and [00:52:30] if it's clear that they're having some sort of issue with sleep, and that could be insomnia, it could be just poor quality potential sleep apnea.
[00:52:39] Michael: Sleep apnea is one that I think gets missed a lot, and so I will [00:52:45] consider interventions for that. It might be something as simple as discussing sleep hygiene with them. I might refer them to sleep medicine to get a consultation and a potential sleep study. CBT for insomnia [00:53:00] is something that has really kind of exploded over the past few years.
[00:53:04] Michael: That's something that I think can be a good intervention for people. So you definitely don't wanna miss anything sleep related, so I'll definitely talk about that with patients.
[00:53:13] Stephanie: I'm always so shocked [00:53:15] to find out how. Uncommon it is, I guess, to be aware of sleep hygiene, especially light exposure, especially now that we're all surrounded by LEDs all the time.
[00:53:27] Stephanie: Yeah. Which for those who aren't [00:53:30] completely red pilled on this issue, like I am, like the long and short of it is that LEDs are not great for your circadian health. They're on the cool blue bright end of the spectrum and they have this rapid vibrating thing that's not so great for your brain. So I recently [00:53:45] actually swapped out all of our lights for halogen and incandescent and, and I am, I'm a big sleep nerd, so I have my amber tinted glasses, the blocked blue light at night.
[00:53:55] Stephanie: I have some prescription ones on the way and, and it's like, to me, this stuff is so [00:54:00] obvious 'cause I've been studying it forever, but you know, whenever someone comes to me with insomnia and I do an inventory, it's like they don't know about this stuff.
[00:54:08] Michael: Right. Yeah. I think, I mean obviously there are many elements to sleep hygiene, but the effects of.[00:54:15]
[00:54:15] Michael: Screen use and light, I think is something we've been learning much more about. We're really learning the negative effects. So I think anyone who works in mental health, when you're talking to your patients about your sleep, you need to ask them about, [00:54:30] especially at the end of the day, what sort of light are they getting exposed to?
[00:54:34] Michael: What devices are they on? How close are they doing it to bedtime? And I mean, you hear people, they'll sit and they'll scroll on their phone for an hour before bedtime, and I can't think of [00:54:45] anything worse for them to be doing before bedtime for many reasons.
[00:54:49] Stephanie: See, at least when I scroll on my phone before bed, I'm doing it through my blue blocking class.
[00:54:53] Michael: Okay. Okay. So that, that's not
[00:54:54] Stephanie: as bad. A book is better, but, but
[00:54:56] Michael: yeah, I mean, if one is going to scroll, then that at least [00:55:00] mitigates some of the negative effects.
[00:55:01] Stephanie: I can't believe that it took me until this far into the interview to even think of asking you this, but it occurred to me. Weight loss drugs.
[00:55:09] Stephanie: That's something I have not learned about yet. And if anyone has recommendations for [00:55:15] either an expert on sleep hygiene as we were just discussing, or an expert on weight loss drugs, please drop them in the comments. Let me know. 'cause I'd love to interview someone on that. But there are many things that people who have expertise on weight loss drugs could inform us about.
[00:55:28] Stephanie: But in your domain, [00:55:30] psychiatry, I mean, I'm sure you've seen an uptick in the number of patients on these drugs, and I've heard that they have psychological impacts. What are you noticing?
[00:55:38] Michael: I'm noticing a lot, and it kind of cuts both ways. I mean, in terms of positive effects, [00:55:45] I mean, it kind of goes without saying that when people, especially people who have contended with obesity or just being overweight for a while, if they're able to make progress with losing weight, feeling healthier in a general sense, feeling [00:56:00] more.
[00:56:00] Michael: Confident about their bodies, feeling they're taking control of their health. That can have a positive effect on one's emotional health. So that's something I've definitely seen. And that's not to say, to be very clear, people are not going to go [00:56:15] from. Depressed to non-depressed simply because of taking a weight loss drug.
[00:56:19] Michael: But it can, I've seen it. It enhances people's sense of self-esteem and maybe even self-efficacy. So I think those are the positive effects. Thankfully, [00:56:30] in terms of my patient population, I haven't personally seen a lot in terms of negative effects, but I have heard anecdotally of some cases where individuals can feel depressed on these medications.
[00:56:43] Michael: I don't quite know the [00:56:45] mechanism for how this would happen, but it's something I've heard. And then other things you need to consider are, from what we know about these drugs, I mean obviously they're new and we've had very few people who have taken them. [00:57:00] Long term. And so we don't really know what are the effects gonna be for people who are using them long term and for those who are using them short term.
[00:57:09] Michael: The challenge with that is that a lot of people find that they may [00:57:15] end up back at square one once they stop using the drugs, which obviously can be very demoralizing and frustrating. And so then it brings up a whole question of what, so really is there any benefit that comes from these drugs if they're only gonna get a [00:57:30] temporary improvement in terms of their weight situation?
[00:57:33] Michael: But there has been some, some data that has come out in terms of these drugs helping with other conditions beyond diabetes and weight loss. I've seen some reports that maybe they help with [00:57:45] alcohol yeast disorder. I'm, I've seen some evidence that they might help to prevent dementia in older age. So there may actually be a whole variety of additional positive effects that we see.
[00:57:58] Michael: But I think a lot of it is. [00:58:00] Speculative and we don't have a lot of data to support it. So there there's, long story short, there's a lot of question marks in terms of what are we going to see in terms of both positive and negative effects with more frequent use of these [00:58:15] medications.
[00:58:15] Stephanie: That makes sense. I don't know the mechanism of action of these drugs or if there are multiple mechanisms of action depending on the drug.
[00:58:26] Stephanie: What you say makes sense. I mean, losing weight sounds [00:58:30] in and of itself, mood boosting if that's been a struggle. But it's my understanding, and I'm not sure like the chemistry if this is very anecdotal, but that part of how these drugs operate is by stopping the [00:58:45] craving. For food and that people have noticed similarly that they stop craving all kinds of other things, like you say, like addictions and, or maybe they're shopping less.
[00:58:55] Stephanie: But then I've heard that by that same mechanism they kind of lose their [00:59:00] lust for life, if you will. Their Jo Div.
[00:59:03] Michael: Yeah, I can see that being possible. That last part I haven't heard specifically, but it kind of makes sense that would happen, but yes, in terms of what patients have [00:59:15] described to me in terms of their experience with this medication, yeah, they will describe much reduced cravings, so they will be eating a lot less.
[00:59:25] Michael: And I think there's also a sort of, physically there's a effect that's going on in the GI [00:59:30] system. 'cause patients will describe, they, they feel. Satisfied with a very small amount of food and in a negative sense. I hear a lot of people describing stomach upsets, bloating, pain, et cetera. So it's definitely doing a lot in [00:59:45] terms of the GI system, but you know, it stands to reason that if something is going on that's interfering with cravings, desire, our ability to enjoy things that might.[01:00:00]
[01:00:00] Michael: Not be limited to just food and it can go to a whole variety of things and potentially some negative things such as alcohol, but it stands to reason that it could happen with with other things as well. We were talking [01:00:15] earlier about naltrexone and obviously that has a very different mechanism of action, but we were talking about how that can help to suppress cravings.
[01:00:25] Michael: But when I've had patients of my own who take naltrexone, I [01:00:30] wouldn't say this is a common thing, but some have told me that they maybe feel a little bit flat or numb or that they, their excitement about things might be a little bit dulled. So in essence, I think it shows that it's kind of difficult [01:00:45] to suppress your craving and desire for some things and ability to enjoy some things, but not other things.
[01:00:52] Michael: I'm gonna. Bring up a different topic, like are you very familiar with use of ketamine for treatment of depression?
[01:00:59] Stephanie: [01:01:00] I interviewed Karen King. She does ketamine assisted psychotherapy.
[01:01:04] Michael: Okay. Okay. Okay, cool. Yeah, I mean, so you're probably, and I don't know if I would say it's a hundred percent analogous, but it makes me think of when ketamine is used for treatment of depression.[01:01:15]
[01:01:15] Michael: It's a very, what's happening pharmacologically is very different than with conventional oral antidepressants. 'cause with ketamine, it's a very quick, almost instantaneous response and it's often associated with this sort [01:01:30] of unusual dissociative sensory experience. But it almost sounds like there's a little bit of overlap between what someone might experience with treatment with ketamine and what you had with a stellate ganglion block.
[01:01:44] Stephanie: [01:01:45] Interesting. I just recorded a panel earlier today, which of course these episodes are gonna come out at different times, but I did a round table on psychedelics and Christianity, and we ended up talking about [01:02:00] ketamine and an anesthesia.
[01:02:04] Michael: Sure. You're aware of that. Psychedelic drugs in a general sense, are being studied for potential therapeutic use and depression, anxiety, other things.
[01:02:14] Michael: [01:02:15] So psilocybin is one that I think is one of the more promising ones, but also things like M-D-M-A-L-S-D Ayahuasca have also been studied. So none of these are approved yet for [01:02:30] treatment of psychiatric diagnosis. But it's interesting to see what will come of that. And I think at least from what we know of studies that exist, there is something about psychedelics and.
[01:02:44] Michael: How they [01:02:45] put someone into a different state. That's at least for some may be therapeutic.
[01:02:50] Stephanie: You are in Chicago. I don't know off the top of my head how ketamine is classified in the United States and if that's one of [01:03:00] these drugs that varies from state to state. Like for example, psilocybin is not legal in the United States, but it's decriminalized.
[01:03:09] Stephanie: Oregon and Colorado, which doesn't mean it's legal, it just means you won't, you get like a slap on the [01:03:15] wrist. You get like the same as a parking ticket basically in Oregon. Right. And then there in these states, are these kind of quasi-legal, like therapeutic settings? And I don't know, I need to interview someone on that, but what's the status of ketamine in Illinois?
[01:03:29] Michael: I mean, ketamine, [01:03:30] it's a, I mean, I always forget the different like categories of controlled medications, but it's just keep in mind ketamine ha was first used as an anesthetic many decades ago. I forgot when it came out. Maybe in in the fifties or something. So it's a drug with a [01:03:45] legitimate medicinal purpose.
[01:03:46] Michael: And it's really only in maybe the past decade or two that we learned that it had potential therapeutic effect for depression specifically. So it's legal from the standpoint of if it's administered [01:04:00] by a physician. So obviously if you got it on the streets, which you know people do sometimes that would not be.
[01:04:07] Michael: Legal, but in terms of use for anesthetic procedures, prescription and administration by [01:04:15] physicians for depression, legal here,
[01:04:17] Stephanie: what about ketamine assisted psychotherapy?
[01:04:21] Michael: That I'm not aware of in terms of whether or not it would be legal here.
[01:04:26] Stephanie: When you talk about its treatment for depression, I'm most [01:04:30] familiar with it as a depression treatment in the sense of ketamine assisted psychotherapy where there's a patient is taking ketamine with a psychotherapist with the goal of treating depression.
[01:04:42] Stephanie: Although I've heard of things that sound [01:04:45] kind of illegitimate to me, like I've heard of, there's a service, and I'm probably not getting this description correctly, but a service that essentially sends like males, ketamine to the patient, and [01:05:00] then there's like a therapist. Supposedly remotely available, but it's really just the patient sort of self-administering.
[01:05:06] Michael: Oh yeah.
[01:05:07] Stephanie: Ketamine as, and it's supposed to treat their depression. But I, it doesn't sound very ethical to me.
[01:05:14] Michael: No, it sounds [01:05:15] totally sketchy and I'm, I can't imagine that being legal anywhere. Yeah, I mean, I think, 'cause in my experience, most places, at least here in Chicago, that offer ketamine are not doing it in the context of [01:05:30] ketamine assisted psychotherapy.
[01:05:32] Michael: So you're really just administered on its own and it can be given there. There's different forms of KE ketamine most commonly given via iv, although sort of the one version of ketamine that's been approved by the [01:05:45] FDA is administered as a nasal spray. But in my experience, those are given for, again, you come to a clinic, it's given you're monitored for a few hours and that's it.
[01:05:56] Stephanie: And that's as a depression treatment,
[01:05:58] Michael: correct? [01:06:00] Correct.
[01:06:00] Stephanie: Monitored. So, well, I guess that's the thing with ketamine, because it's a dissociative,
[01:06:07] Michael: yeah,
[01:06:07] Stephanie: it's not like with with psilocybin or MDMA where someone might wanna talk to the [01:06:15] therapist. It's my understanding that the state that a patient goes into when they're on ketamine, they don't really wanna talk.
[01:06:20] Stephanie: So is that what you, why monitoring?
[01:06:22] Michael: That's my under. Well, they're monitoring because I mean, there are cardiopulmonary effects that can happen as a side effect of [01:06:30] ketamine or excessive sedation. Sometimes people may have dissociative episodes or they might have brief hallucinations that might upsetting.
[01:06:39] Michael: So they do need to be medically monitored for a certain period of time after they're given it. [01:06:45] Obviously everyone's different. I would say that many patients after getting a dose of ketamine might not necessarily be in a place where they would want to. Engage in psychotherapy. I imagine some might, and I imagine it's dependent on the dose of [01:07:00] the ketamine that they're getting and the sort of their individual response to it.
[01:07:04] Michael: 'cause some of the other psychedelics that I've mentioned have been studied in the use of psychedelic assisted therapy. I forget which one's been studied the best. I think [01:07:15] maybe MDMA.
[01:07:16] Stephanie: Probably MDMA for PTSD?
[01:07:18] Michael: Yes, exactly. Yes. That's what I'm thinking
[01:07:20] Stephanie: of. I think MAPS says that's the one that's closest to getting FDA approval because of their work.
[01:07:25] Michael: Right, right. Yeah. There's some promising data with respect to that, but it [01:07:30] says the reason other drugs with psychedelic effects could have potential value. But going back to your original question, I'm not aware of ketamine being used in that context. In in terms of whether it's legal. I [01:07:45] imagine it's legal just as long provided that it's being given in the same way that it's given when not with psychotherapy.
[01:07:53] Michael: So something where they're just getting it in a random office or you're getting it sent to you, that I, I can't imagine that being [01:08:00] seen as legal.
[01:08:00] Stephanie: So what kind of depression or history would you need to see in a patient to think that referring them to a place that administers ketamine might be a good treatment for them for their depression?
[01:08:12] Michael: Yeah, good question. Yeah, it's not a [01:08:15] first line treatment, so long story short, this would be for people with pretty treatment resistant depression where they've tried a number of different agents from different classes and either they got no [01:08:30] benefits or they had very problematic side effects. So that's what I would think of where really we really, we've exhausted all of the other sort of conventional options, but they're still not getting better.
[01:08:43] Stephanie: Why do you suppose [01:08:45] it works for some people with treatment depression, treatment resistant depression?
[01:08:49] Michael: I mean, it does have a different mechanism of action. So we were talking earlier about different neurotransmitters and we were talking about glutamate in particular. And so ketamine [01:09:00] specifically, it's therapeutically, it's main mechanism of action is on glutamate.
[01:09:05] Michael: And very, when we think of conventional antidepressants, oral antidepressants, virtually none of them have any significant effects on glutamate. [01:09:15] And so it may be that someone who does well with ketamine, they may simply be a person where, you know, based on their. Genetic profile based on the physiology of what's going on in their brain.
[01:09:28] Michael: They may be someone who [01:09:30] simply happens to do better with a glutamate based antidepressant.
[01:09:33] Stephanie: And I know I'm probably oversimplifying things because when I listen to experts talk about neurotransmitters, it's really not so straightforward as like serotonin makes you happy and dopamine makes you motivat.
[01:09:44] Stephanie: Like it's [01:09:45] not that simple. These things do lots of things, as you pointed out in the brain and body. That being said, I am gonna dumb it down. Glutamate. All I know is that it's excitatory. So if ketamine acts on glutamate, it must [01:10:00] temporarily stop. It must temporarily inhibit glutamate, right?
[01:10:06] Michael: It's a antagonist at the glutamate receptor.
[01:10:08] Michael: And this is yet another example of how we. Don't fully know how these medications [01:10:15] work. And it also illustrates, I had discussed earlier the concept of how there's often downstream effects. And so the ketamine, its initial effect may be to, it hits the glutamate receptor on the [01:10:30] neurons, but several steps beyond that.
[01:10:32] Michael: There are likely other effects on other neurotransmitters. Could be serotonin, could be dopamine. We honestly don't know fully what that is, but that's, we're suspecting that the [01:10:45] mechanism of action is not just the effect on the glutamate, but some other downstream effects that we haven't fully elucidated yet.
[01:10:52] Stephanie: Would part of it also be the rebound in the sense that, 'cause I mean, here's how I'm thinking [01:11:00] of it. As someone who doesn't really understand these things, I'm thinking, here's someone already in a low energy state, depression, low energy, low mood, low motivation, low appetite for life. Then they take a drug that suppresses them even further in [01:11:15] the sense that ketamine makes them still and tranquil and dissociative.
[01:11:19] Stephanie: So in that sense, it would be considered a depressive, but it's not. It's a dissociative. And so ketamine suppresses activity further. Is there a rebound effect [01:11:30] where after using ketamine glutamate goes up,
[01:11:34] Michael: there might be, we don't know. I, but I think that's a, I think that's an interesting question. I think it's definitely possible, and it seems a little bit analogous to what we were talking about earlier with [01:11:45] the the low dose naltrexone.
[01:11:46] Stephanie: Okay, interesting. Well, fun times with drugs. Talking about drugs on the podcast, and it's the episode right after the one where I talk to a bunch of Christians about why they're opposed to psychedelics.
[01:11:59] Michael: Goodness. [01:12:00]
[01:12:01] Stephanie: Well, some of them are all
[01:12:02] Michael: sorts
[01:12:02] SKOT: of
[01:12:02] Michael: viewpoints on these topics.
[01:12:03] Stephanie: Well, Dr. Michael Ziffra, this has been such a pleasure talking with you.
[01:12:06] Stephanie: Tell us where listeners can find.
[01:12:09] Michael: Sure they can find me a couple different places. Probably the best places on Substack. [01:12:15] You can go to Michael Ziffra, MD. substack.com or you can look up the name of my series of essays is Wise Mind in Anxious Times. I'm also very active on Twitter slash [01:12:30] x and you can find me there.
[01:12:31] Michael: My handle there is my FRA md.
[01:12:34] SKOT: Alright, well thank you so much for joining uss. Been a pleasure. Thanks.
[01:12:39] Stephanie: Thank you for listening to you Must Be some kind of Therapist. If you enjoyed [01:12:45] this episode. Kindly take a moment to rate, review, share or comment on it using your platform of choice. And of course, please remember, podcasts are not therapy and I'm not your therapist.
[01:12:58] Stephanie: Special thanks to Joey [01:13:00] Rero for this awesome theme song, half Awake and to Pods by Nick for production. For help navigating the impact of the gender craze on your family, be sure to check out my program for parents, ROGD, [01:13:15] repair. Any resource you heard mentioned on this show plus how to get in touch with me can all be found in the notes and links below Rain or shine.
[01:13:25] Stephanie: I hope you'll step outside to breathe the air today [01:13:30] in the words of Max Airman. With all its sham, drudgery and broken dreams, it is still a beautiful [01:13:45] [01:14:00] world.