Latest / The Antisocial Doctors Podcast / Episode 19: Should We be Deprescribing More SSRIs?

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Episode 19: Should We be Deprescribing More SSRIs? · The Antisocial Doctors Podcast

• 1:27
  Sonia Singh MD: You're listening to The Anti-Social Doctors Podcast, hosted by me, Sonia Singh, a board-certified internal medicine physician with a master's in nutrition and a special interest in health anxiety.
• 1:38
  Rebecca Berens MD: And me, Rebecca Behrens, a board-certified family medicine physician with a special interest in disordered eating.
• 1:43
  Sonia Singh MD: We're also millennial women, anxious moms, and curious humans navigating social media.
• 1:48
  Sonia Singh MD: We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.
• 1:56
  Rebecca Berens MD: This podcast is meant to be the antidote to your doom scrolling, a solve for the anxiety, stress, guilt, shame, and confusion that comes from social media's messaging around health.
• 2:05
  Rebecca Berens MD: In each episode, we discuss a health-related topic trending on social media with curiosity, nuance, evidence, humility, and compassion.
• 2:12
  Sonia Singh MD: This is not your average debunking podcast.
• 2:15
  Sonia Singh MD: We wanna explore not just what is trending on social media, but why.
• 2:18
  Sonia Singh MD: Why are so many people drawn to this?
• 2:20
  Sonia Singh MD: What is the nugget of truth here?
• 2:21
  Sonia Singh MD: What are the facts?
• 2:23
  Sonia Singh MD: What can we learn from this as patients and doctors?
• 2:25
  Sonia Singh MD: No shame, no blame, no snark.
• 2:27
  Rebecca Berens MD: We're so glad you're here
• 2:43
  Sonia Singh MD: Hi, Rebecca
• 2:45
  Rebecca Berens MD: Hi, Sonia
• 2:48
  Sonia Singh MD: How's your week going?
• 2:50
  Rebecca Berens MD: It's going pretty well actually.
• 2:52
  Sonia Singh MD: Okay today we're talking about a topic that I think we actually both have quite a bit of professional and personal experience with, and I'm excited to talk about it.
• 3:00
  Sonia Singh MD: It's very hot right now, I think, on social media and also just in the news in general.
• 3:06
  Sonia Singh MD: I'm gonna start with my patient story here.
• 3:08
  Sonia Singh MD: A few weeks ago, I had a patient message me requesting that I de-prescribe her Lexapro and informing me that she had actually already weaned the medication off herself.
• 3:18
  Sonia Singh MD: The message struck me as odd for a couple of reasons.
• 3:21
  Sonia Singh MD: One, the use of the word de-prescribe, which honestly is not a commonly used word.
• 3:26
  Sonia Singh MD: In medicine we've talked for a long time about polypharmacy and reducing polypharmacy, but specifically talking about de-prescribing feels like it's something that's really blown up suddenly.
• 3:36
  Sonia Singh MD: Yeah.
• 3:36
  Sonia Singh MD: So that word immediately jumped out at me.
• 3:39
  Sonia Singh MD: I was also struck by the fact that she had already weaned it herself, but then was asking me to de-prescribe it as if that was a separate event that happens.
• 3:48
  Sonia Singh MD: I assumed she just meant cancel the prescription or make sure it doesn't get refilled.
• 3:52
  Sonia Singh MD: But again, people don't usually phrase it that way.
• 3:54
  Sonia Singh MD: They might say,"Hey, I just wanted to let you know I stopped taking my antidepressant." Yeah.
• 3:59
  Sonia Singh MD: You don't need to keep refilling it." And then the other reason it struck me as odd is because at our last visit, actually discussed increasing the dose of the medication because she had tremendous benefit from it initially, and then she was going through a period of increased stress, and we thought let's increase the medicine and see if that helps." So it was out of nowhere to me that suddenly she was like, I've weaned off of it completely." Yeah so I'm curious if you've been getting any similar messages from your patients in the recent weeks or months.
• 4:28
  Rebecca Berens MD: I have, and a lot of times, at least for the patients that I've heard it from, it's in the realm of,"I'm afraid of having this in my record,""I'm afraid that I'm gonna be sent to a wellness camp.""I'm afraid I'm not gonna be able to access it sometime in the near future,""My access will be restricted and I don't wanna have to cold turkey stop it." That's a lot of the conversations I've heard from patients around it- rather than"I think this is bad for me and I shouldn't be taking it," which is- has its own set of problems.
• 4:57
  Rebecca Berens MD: But yeah, I think obviously the de-prescribing of SSRIs is a big topic right now, and I think it's affecting patients in a multitude of ways.
• 5:05
  Sonia Singh MD: Yeah the topic today is should we be de-prescribing SSRIs?
• 5:09
  Sonia Singh MD: So what is the claim?
• 5:11
  Sonia Singh MD: I tried to summarize the claims around this.
• 5:12
  Sonia Singh MD: Some of them are extreme, so I'm gonna give you the extreme version and maybe the less extreme version.
• 5:18
  Sonia Singh MD: So I would say the general thought behind this claim is that antidepressants are just over-prescribed, specifically around children and adolescents.
• 5:26
  Sonia Singh MD: And often when I was, when I was looking at all the coverage around this, SSRIs also seem to be lumped in with ADHD meds, antipsychotic, benzos.
• 5:34
  Sonia Singh MD: Things that from a medical perspective are very different.
• 5:36
  Sonia Singh MD: In this episode, we're really gonna focus on SSRIs.
• 5:39
  Sonia Singh MD: But oftentimes I would say in this conversation, all these other psych meds are lumped in with them.
• 5:43
  Sonia Singh MD: Another claim is that too many people who start these antidepressants stay on them for way too long without a clear exit plan.
• 5:51
  Sonia Singh MD: A more cynical view of this would be that doctors and pharmaceutical companies are creating lifelong customers by putting all of these vulnerable people on these meds and then never getting them off.
• 6:01
  Sonia Singh MD: Another claim I would say is that doctors just don't adequately warn patients that these meds are, quote,"addictive." RFK has said that some of these drugs are, quote,"harder to get off of than heroin." Again, in that situation, I think maybe he was talking about benzodiazepines, but it all gets blurred together.
• 6:16
  Sonia Singh MD: Yeah.
• 6:17
  Sonia Singh MD: A less extreme version of this claim would be that patients are just not being adequately informed about what withdrawal from these can look like and what discontinuation syndromes can happen if you stop these suddenly or even if you just try to wean them after being on them for many years.
• 6:31
  Sonia Singh MD: I think there's also a belief that, maybe we're just medicalizing or over-medicalizing normal human suffering, or we're just numbing people out of emotions that they should be having.
• 6:42
  Sonia Singh MD: There's also, I think, a claim around the whole root cause movement that SSRIs don't even work, that for years, doctors were spinning this story of depression and anxiety having to do with chemical imbalances in your brain and that these medicines might help those, and that turns out not to be true.
• 6:59
  Sonia Singh MD: And then there's even been some more kind of outlandish claims about, links to violent behavior.
• 7:04
  Sonia Singh MD: I think RFK said something along the lines of prior to the introduction of Prozac, we had almost none of these- events in this country.
• 7:12
  Sonia Singh MD: He was talking about mass shootings and gun violence.
• 7:14
  Sonia Singh MD: I think there's a multitude of opinions and claims around SSRIs and why we should be de-prescribing them.
• 7:21
  Sonia Singh MD: Does that summarize them for you, or are there others that you think are in there?
• 7:24
  Rebecca Berens MD: Yeah, these are a lot of the things that I've seen and heard from patients about fears about the medicine.
• 7:30
  Rebecca Berens MD: I do think also obviously politically this has become a big concern.
• 7:34
  Rebecca Berens MD: And that's like I said, driving the other side of Some of it may be because they've heard these claims and they're concerned, but there's also genuine concerns about it from a political standpoint, and I think there's also a lot of fear about that being talked about on social media.
• 7:48
  Rebecca Berens MD: So that's like another claim that might be driving people towards this sort of conversation.
• 7:52
  Sonia Singh MD: Yes, like what will happen to people who are using these medicines- Yeah or who do
• 7:56
  Rebecca Berens MD: rely on them?
• 7:57
  Rebecca Berens MD: Yeah, am I gonna be put on a list?
• 7:57
  Rebecca Berens MD: Am I gonna be sent- Yeah to a camp?
• 7:59
  Rebecca Berens MD: Like leg- Right legitimately people are worried about this.
• 8:02
  Sonia Singh MD: Yeah.
• 8:03
  Sonia Singh MD: So let's talk a little bit about why this is so viral, and I'm actually, so excited to cover this topic because I think it's a great example of what we want to accomplish with this podcast, is like really examining not just the claims, but why they have taken hold and what the real context is.
• 8:19
  Sonia Singh MD: And even just the experience of me going through that, like I feel has shifted my thinking on some of this as well.
• 8:24
  Sonia Singh MD: So why is it viral?
• 8:25
  Sonia Singh MD: So I think the first thing is just that anxiety and depression are extremely common conditions, so those are the primary things that we are using SSRIs for.
• 8:33
  Sonia Singh MD: And they've become even more common post-pandemic.
• 8:35
  Sonia Singh MD: So one in five Americans will have an episode of major depression in their lifetime.
• 8:39
  Sonia Singh MD: That's a lot.
• 8:40
  Sonia Singh MD: Most of us have had some relationship with at least somebody struggling with this if we have not struggled with it ourselves.
• 8:46
  Sonia Singh MD: The data shows there was a sharp increase in during the pandemic, so mostly that was driven by younger adults with new diagnoses of depression.
• 8:54
  Sonia Singh MD: One in three Americans will have some form of an anxiety disorder in their lifetime.
• 8:58
  Sonia Singh MD: That's even more than I thought it was going to be.
• 8:59
  Sonia Singh MD: Yeah.
• 8:59
  Sonia Singh MD: Again, that also increased during the pandemic.
• 9:02
  Sonia Singh MD: And then beyond the prevalence of the diseases we treat with SSRIs, it is a big category of drugs, and they are commonly used.
• 9:10
  Sonia Singh MD: One in eight Americans will have been on an SSRI at some point in their lives.
• 9:14
  Sonia Singh MD: That's quite a lot of people.
• 9:15
  Sonia Singh MD: And then, when you have any kind of pharmaceutical, you're going to have people that have had negative experiences with it, and this is just a huge category of drugs with a variety of side effects and potential adverse effects.
• 9:26
  Sonia Singh MD: And so stories of people having a bad experience with one of these meds is not uncommon and they're very easy to find if you Google any names.
• 9:37
  Sonia Singh MD: One thing I would just keep in mind is that those bad experiences, people are likely to be much louder about those than the good ones.
• 9:44
  Sonia Singh MD: And, I think because there's so much stigma around mental health, you're not gonna get a ton of people who are going on the internet just to say,"Hey, I took Zoloft for three months and I felt much better,"
• 9:54
  Rebecca Berens MD: yeah.
• 9:55
  Sonia Singh MD: And then I carried on with my life.
• 9:56
  Sonia Singh MD: And it- it's
• 9:56
  Rebecca Berens MD: Every review thing on the internet.
• 9:58
  Rebecca Berens MD: People don't go leave reviews'cause they're so happy, they go leave
• 10:00
  Sonia Singh MD: reviews-
• 10:00
  Rebecca Berens MD: Yeah,'cause they're so mad.
• 10:02
  Sonia Singh MD: There's a big bias there in terms of what you hear about these meds versus what they're actually doing.
• 10:07
  Sonia Singh MD: But I do think most people have heard some horror story about being put on one of these meds at some point.
• 10:13
  Sonia Singh MD: I think there's also a general backlash against mainstream medicine and distrust of everything that we've been doing for many years.
• 10:21
  Sonia Singh MD: I think a lot of people perceive that doctors were wrong about things during the start of the COVID-19 pandemic, and now that leads them to question what else are they wrong about or what else have they been recommending incorrectly?
• 10:35
  Sonia Singh MD: I think coupled with that is distrust of big pharma driven by vaccine-related fears that started during the pandemic.
• 10:41
  Sonia Singh MD: And lastly, I think these meds still carry a lot of stigma.
• 10:45
  Sonia Singh MD: I think a lot of people still feel shame around talking about being on these meds, thinking about being on these meds, being told that maybe they should try one of these meds.
• 10:54
  Sonia Singh MD: And I think there's a lot of resistance and so when someone is saying to you,"Hey you never needed that,""Nothing was ever wrong with your brain.
• 11:00
  Sonia Singh MD: You never had a chemical imbalance.""You just need sunshine and nutritious food, and the doctor's just trying to make a buck on you," I think that's attractive to a lot of people who, the idea of taking a medication or even the idea of having some kind of mental health diagnosis never really sat right with them and never felt good, or they desperately did not want their son or their daughter or their spouse to go on one of these meds.
• 11:23
  Sonia Singh MD: And so I think for that population, this idea that they're over-recommended and over-prescribed and they're, overused is attractive.
• 11:31
  Sonia Singh MD: And then lastly, and this is the situation I encounter a lot, is that if you have anxiety, which this is one of the evidence-based treatments for anxiety, oftentimes you're going to have anxiety about taking the medication itself.
• 11:42
  Sonia Singh MD: So-
• 11:43
  Rebecca Berens MD: Yeah
• 11:43
  Sonia Singh MD: a lot of the patients that I think have benefited the most from these meds are the same ones that have been most afraid of going on them.
• 11:50
  Sonia Singh MD: And so if you're looking for any reason not to or you're already have that seed of doubt or fear, and then this messaging comes along that says,"Yeah,""These are terrible, and you're gonna get stuck on them for life," it's tempting to hold onto that because it feels like it validates something that you're already feeling.
• 12:06
  Sonia Singh MD: So I would say those are some of the reasons I think it's viral.
• 12:09
  Sonia Singh MD: I'm curious to hear what other thoughts you have.
• 12:12
  Rebecca Berens MD: Yeah.
• 12:12
  Rebecca Berens MD: I think as you said, just mental health conditions in general are very stigmatized and There's a lot of fear around if I'm taking this medicine, it says that there's something deeply wrong with me.
• 12:23
  Rebecca Berens MD: And other people are going to view me differently or I'm not capable of doing the things that I want to do or whatever it is.
• 12:30
  Rebecca Berens MD: That just...
• 12:30
  Rebecca Berens MD: I think that's the, the rhetoric around mental health conditions.
• 12:33
  Rebecca Berens MD: And obviously the field of psychiatry has been pretty harmful to patients in the past, just as medicine in general has been, patients have been institutionalized, they have been you know- Yeah particularly women, just all of their problems blamed on their mental health and not really fully investigated.
• 12:50
  Rebecca Berens MD: So I think that's a- the other sort of fear here.
• 12:53
  Rebecca Berens MD: Yeah.
• 12:53
  Rebecca Berens MD: Once you have this on your chart, everything you go in for is,"Oh, it's just your anxiety," or,"Oh- Yes oh, you're a psych patient," and that is a legitimate concern.
• 13:03
  Rebecca Berens MD: That stigma does still exist, and patients have legitimately experienced that.
• 13:08
  Rebecca Berens MD: And I think that's another reason why people might be concerned about these medications and having these medications on their chart.
• 13:16
  Sonia Singh MD: Yeah.
• 13:16
  Sonia Singh MD: Another common experience that I hear about a lot, especially from women, is them telling me they went to their primary care doctor with some list of complaints- and that they did not believe any of those to be related to depression and anxiety, they all seemed to them something else, and that they were recommended an SSRI.
• 13:34
  Sonia Singh MD: And I think that's a really common experience.
• 13:36
  Sonia Singh MD: And so I think this idea might resonate with a lot of people that like,"Yeah this person tried to give me that med and there was no reason at all." And so maybe this is true that, all these people- Yeah are unnecessarily being medicated, and they don't realize the harms of that.
• 13:50
  Sonia Singh MD: So I can see where that feeling would come from.
• 13:54
  Rebecca Berens MD: Yeah.
• 13:54
  Sonia Singh MD: So let's move on to what is the negative truth here.
• 13:58
  Sonia Singh MD: And the, the...
• 13:58
  Sonia Singh MD: it was good for me to do a deep dive on this so let's just talk a little bit about the ideal use of SSRIs and the evidence base.
• 14:05
  Sonia Singh MD: So the ideal use for most SSRIs is that you initiate it, you titrate the dose over some period of six to 12 weeks, and then if the person has improvement or resolution of their symptoms, you continue for a minimum of six months, and then you consider how they're doing and whether you should taper off.
• 14:22
  Sonia Singh MD: And if you do taper off, you monitor closely for a relapse, and you restart if symptoms reoccur.
• 14:28
  Sonia Singh MD: If somebody has had two or more episodes of depression or they have severe depression, then the recommendation, continue for a minimum of 12 months, and if they've had three or more episodes of depression, then the recommendation is to continue for two years.
• 14:40
  Sonia Singh MD: For anxiety, the evidence base is actually weaker, so guidelines say to continue the med for 6 to 24 months after resolution.
• 14:48
  Sonia Singh MD: That's a very broad range but depends on their individual risk factors and circumstances, with most saying that probably patients with anxiety who are on these meds and benefit from them likely need at least a year of treatment.
• 15:00
  Sonia Singh MD: There is very little evidence evaluating the safety and efficacy of SSRIs being used continuously for longer than two years.
• 15:08
  Sonia Singh MD: Now, it's important to note that this does not mean that is harmful necessarily.
• 15:12
  Sonia Singh MD: It's just that we have not studied it to really say that this is an evidence-based intervention to do for longer than two years.
• 15:20
  Sonia Singh MD: Over 50% of Americans who are taking SSRIs have been taking them for over five years.
• 15:26
  Sonia Singh MD: So it is true that there is a significant number of people who are on these meds that are on them for a longer period than what they were studied to do Again, that, that does not mean that, they're, is evidence that they're harmful or that they are harmful.
• 15:46
  Sonia Singh MD: It's just that we don't know because the studies have not gone beyond that two-year mark.
• 15:50
  Rebecca Berens MD: And is this just based...
• 15:51
  Rebecca Berens MD: Sorry, is this just based on major depressive disorder, generalized anxietiest disorder, or are we including things here like OCD and other- For
• 15:58
  Sonia Singh MD: other indications?
• 15:59
  Sonia Singh MD: That,
• 15:59
  Rebecca Berens MD: that- other anxiety spectrum disorders?
• 16:02
  Sonia Singh MD: That's a good question.
• 16:04
  Sonia Singh MD: You're talking about specifically the 50% that are on it for greater than five years?
• 16:08
  Sonia Singh MD: What are
• 16:08
  Rebecca Berens MD: those diagnoses?
• 16:08
  Rebecca Berens MD: Yeah,'cause I'm just thinking there's a spectrum of anxiety disorders, right?
• 16:11
  Rebecca Berens MD: Yeah.
• 16:11
  Rebecca Berens MD: And obviously OCD is a more significant and life-altering form that people experience.
• 16:18
  Rebecca Berens MD: And so I was just curious if there's been different data for those types of anxiety disorders, or are we only referring here to generalized anxiety disorder?
• 16:26
  Sonia Singh MD: That's a good question.
• 16:27
  Sonia Singh MD: I don't know the breakdown of that number, like what diagnoses that fall into that category.
• 16:33
  Sonia Singh MD: In general, most of the data I'm gonna talk about here are either for anxiety or depression, and the strongest data is really for depression,'cause anxiety is a little bit more heterogeneous.
• 16:42
  Sonia Singh MD: Got it or the spectrum of anxiety disorders is more heterogeneous.
• 16:44
  Sonia Singh MD: So I'll try to annotate, when we're going through which, which things are, relating to depression and which are anxiety.
• 16:50
  Sonia Singh MD: The other thing I want to mention is even though, like I said, the continuing beyond two years is not necessarily an evidence-based practice because we don't have the evidence, there are of course potential harms of long-term use of these medicines.
• 17:04
  Sonia Singh MD: So all of them have some side effects.
• 17:07
  Sonia Singh MD: The most common ones are things like drowsiness dry mouth, weight gain, insomnia, fatigue, nausea, sexual side effects and dysfunction.
• 17:16
  Sonia Singh MD: Most of these will go away upon discontinuation.
• 17:20
  Sonia Singh MD: There is also the risk of drug interactions and being on a bunch of drugs.
• 17:24
  Sonia Singh MD: And the benefit of discontinuing some of these meds when they're no longer leaded, needed is that you just have a lower medication burden, you have less risk of drug-drug interactions.
• 17:33
  Sonia Singh MD: Especially that's relevant in people who are older or who have multiple other medical conditions that they're dealing with.
• 17:38
  Sonia Singh MD: And then the other concern about long-term use is just something called prescribing cascades.
• 17:42
  Sonia Singh MD: So this is when you're doing like a medical whack-a-mole where you put somebody on a medicine and then they have a side effect of that medicine for which you put them on a different medicine, and then you end up on multiple medicines trying to treat one issue that, perhaps that is not the best treatment for anymore'cause now you're taking on risks of two or three meds.
• 17:59
  Sonia Singh MD: When I was reading about this, I kept coming across this statistic over and over saying surveys show that between 30 and 50% of patients on long-term SSRIs have no indication for them.
• 18:10
  Sonia Singh MD: I was really surprised by this.
• 18:12
  Sonia Singh MD: So I tried to go and read the actual study and figure out exactly where that number was coming from.
• 18:17
  Sonia Singh MD: So this was a study of patients in Australia who were on SSRIs for greater than 18 months, so that's what they're referring to as long-term.
• 18:24
  Sonia Singh MD: And what they did was a retrospect review where they had GPs and psychiatrists review the patient's chart and then also look at their current depression and anxiety scores on a validated questionnaire and decide whether they felt ongoing use of the SSRI was appropriate or not.
• 18:40
  Sonia Singh MD: So in that, they felt that 50% of the patients did not meet any current criteria for a DSM diagnosis.
• 18:48
  Sonia Singh MD: They thought 31% of the patients had prescriptions that were inappropriate in some way based on the current or previous data.
• 18:56
  Sonia Singh MD: So I think the important thing to note about this, this stat, 30 to 50%, I saw it in so many places, and it all comes from this one Australian study and nothing else.
• 19:05
  Sonia Singh MD: This was a retrospective review.
• 19:08
  Sonia Singh MD: I I don't know about your documentation, but I see a lot of bad documentation in medicine.
• 19:12
  Sonia Singh MD: Oh, yeah.
• 19:13
  Sonia Singh MD: And I find that often the documentation does not tell the full story of what you are hearing from the patient.
• 19:20
  Sonia Singh MD: And so my strong suspicion is that part of this is maybe that, the data was not really accurately being captured in these records, but also that 50% number comes from them saying that at the time they were reviewing the present day questionnaire results, these people were not complaining of depressive symptoms.
• 19:38
  Sonia Singh MD: They were on the meds.
• 19:39
  Sonia Singh MD: So the first line of the discussion is,"The paucity of syndromal diagnoses and the absence of significant depressive symptoms among a large proportion of our sample, may, of course, be due to the effectiveness of the drug treatments themselves." So they're basically like,"It's possible that all these people are doing fine because they're on the medicine that's making them feel fine." So- I don't think the intention to say, all these people should not be on these...
• 20:05
  Sonia Singh MD: I think the intention was more to be like,"Maybe these people should be reevaluated to see if this can be weaned." Yeah.
• 20:10
  Sonia Singh MD: "Because right now they seem to be stable and doing fine," right?
• 20:13
  Rebecca Berens MD: Yeah.
• 20:13
  Sonia Singh MD: So I think there's a little bit of nuance there in saying that versus saying,"These were all unnecessary prescriptions and they never should have gotten them."
• 20:21
  Rebecca Berens MD: Yeah, and this is if you were to look at a bunch of charts of people who are being treated for high blood pressure, And their numbers are all controlled, and these people are, don't need, they don't even need the meds.
• 20:29
  Rebecca Berens MD: That's it.
• 20:29
  Rebecca Berens MD: They're not hypertensive.
• 20:29
  Rebecca Berens MD: They don't have high blood pressure.
• 20:31
  Rebecca Berens MD: And, patients will say this sometimes too they're like,"Oh, once my blood pressure's normal, can I stop it?" And it's like if you stop it, the blood pressure's gonna come right back up.
• 20:37
  Rebecca Berens MD: Yes.
• 20:37
  Rebecca Berens MD: That's how that works.
• 20:39
  Rebecca Berens MD: So yeah.
• 20:39
  Rebecca Berens MD: I, this is a situation where you can pull out what you want from the study to support the claim you want to make.
• 20:46
  Rebecca Berens MD: And you're really missing a lot of context and nuance, and that's why we're talking about this.
• 20:52
  Sonia Singh MD: Yes, okay.
• 20:53
  Sonia Singh MD: So that's a perfect segue into our next section, which is let's talk about the facts around this, and specifically the context,'cause I this context really changes the way you might think about this topic or approach this topic.
• 21:04
  Sonia Singh MD: And part of the reason the blood pressure example is great, right?
• 21:07
  Sonia Singh MD: Because I think to the patient, maybe the perception is I'm taking this med, it's gonna fix my blood pressure, and then I'm gonna stop taking the med when my blood pressure is fixed.
• 21:15
  Sonia Singh MD: But whether or not you can stop taking the med depends on whether the med has addressed the root cause.
• 21:21
  Sonia Singh MD: The actual driver of the high blood pressure.
• 21:23
  Sonia Singh MD: And we know that, if you remove that med- the physiology of that person is going to return to the way that it was pre-med in the vast majority of cases.
• 21:34
  Rebecca Berens MD: Yeah.
• 21:34
  Sonia Singh MD: Some of these diagnoses are similar.
• 21:36
  Sonia Singh MD: And so I think it's important to think about what are actually the root causes of these conditions?
• 21:41
  Sonia Singh MD: What are the evidence-based treatments, and how many people are actually doing those treatments in the real world and how do they actually play out in humans?
• 21:50
  Sonia Singh MD: Yeah so let's first talk about root causes of anxiety and depression.
• 21:55
  Sonia Singh MD: One day I want us to do an entire series of episodes on root causes because it's such a hot topic, and I think they're so misrepresented in the wellness industry, which wants to make them, super simple and one thing- Yeah and something you just need the right test for and the right supplement for and it's gonna be solved.
• 22:12
  Sonia Singh MD: And it is never like that.
• 22:13
  Sonia Singh MD: So as with most conditions, the root causes of anxiety and depression are multifactorial.
• 22:19
  Sonia Singh MD: They're all these different things layered on top of each other.
• 22:21
  Sonia Singh MD: So they involve this complex interplay of genetic factors, psychological factors, environmental factors, social factors, neurobiological factors.
• 22:28
  Sonia Singh MD: So I'm gonna briefly go through all of those to give you a picture of, how these arise.
• 22:33
  Sonia Singh MD: So genetics is a big one.
• 22:35
  Sonia Singh MD: Heritability for depression is thought to be around 40% and 30% to 50% for anxiety.
• 22:40
  Sonia Singh MD: So this means there's, there seems to be, like, a pretty solid genetic predisposition to developing one of these conditions.
• 22:47
  Sonia Singh MD: There's environmental and psychosocial factors.
• 22:49
  Sonia Singh MD: So adverse childhood experiences, I want everyone to learn about adverse childhood experiences, which are are often abbreviated as ACEs, because if you're ever gonna talk about root causes and you don't talk about ACEs- you're missing a huge part of the puzzle.
• 23:02
  Sonia Singh MD: And this is why my patients sometimes are, taken aback when I'm like,"Tell me about your childhood,""Tell me about the home you grew up in.""Did it feel safe?""Describe your family dynamic," because it is so relevant for people's long-term health.
• 23:12
  Sonia Singh MD: So experiences like abuse, neglect, parental loss, domestic violence, substance abuse, all of these are some of the most potent risk factors that seem to interact with those genetic and epigenetic factors that ultimately cause these conditions.
• 23:26
  Sonia Singh MD: Stressful life events in adulthood are also relevant, so things like job loss, divorces, chronic illness.
• 23:32
  Sonia Singh MD: Those are all contributors as well.
• 23:33
  Sonia Singh MD: Social determinants, so things like lower socio- socioeconomic status, limited education, racism, discrimination, social isolation.
• 23:41
  Sonia Singh MD: And then parenting style has apparently been linked pretty well with anxiety, so an overprotective, overly harsh, or low-warmth parenting style has been associated with a lot of anxiety disorders.
• 23:51
  Sonia Singh MD: Okay.
• 23:52
  Sonia Singh MD: Next let's talk about...
• 23:53
  Sonia Singh MD: these are all things mostly that are happening to you, okay?
• 23:56
  Rebecca Berens MD: Yeah.
• 23:57
  Sonia Singh MD: There is also a category of more modifiable lifestyle and medical factors.
• 24:01
  Sonia Singh MD: Those are things like your sleep quality, whether you're active or sedentary, having a balanced diet or a diet that's high in ultra-processed foods, smoking, substance abuse.
• 24:11
  Sonia Singh MD: Those all also play into your overall vulnerability and risk for these conditions.
• 24:17
  Sonia Singh MD: Having other chronic medical conditions can also increase your risk of anxiety or depression, so cardiovascular disease, diabetes, hypothyroidism, chronic pain.
• 24:24
  Sonia Singh MD: Those are all independently associated with higher depression risk.
• 24:28
  Sonia Singh MD: And other medications and substances can also contribute- Yeah to your anxiety or depression.
• 24:32
  Sonia Singh MD: So that, that category of things that are in your control, again, this flies in the face of sort of this attitude of it's all your choices, it's all willpower- Yeah it's all just making the right you know, eating the right foods and exercising.
• 24:44
  Sonia Singh MD: That is one piece of this puzzle, and there's a whole other, iceberg underneath, underneath all of that.
• 24:51
  Sonia Singh MD: Now, those things that we just talked about the, early life experiences, the adult experiences, the lifestyle factors, other medical factors, those are all playing out in biological ways.
• 25:03
  Sonia Singh MD: So we know- Yeah that there's dysfunction in the serotonergic, noradrenergic, and dopaminergic systems in the brain with these conditions.
• 25:11
  Sonia Singh MD: We know it dysregulates your hypothalamic pituitary adrenal axis, that's your hormones.
• 25:16
  Sonia Singh MD: We know that there's low-grade neuroinflammation associated with some of these conditions.
• 25:21
  Sonia Singh MD: Now, I think there's a corner of medicine and the alternative world that just gets fixated on all of this stuff and the mechanisms.
• 25:28
  Sonia Singh MD: And so they'll say take this supplement,'cause it interacts with this particular neurotransmitter." Or you could even argue that traditional conventional medicine is too focused on this- Yeah this little segment.
• 25:38
  Sonia Singh MD: To me, all of these neurobiological mechanisms are being driven by all I just mentioned before that.
• 25:45
  Sonia Singh MD: Those- Yeah if you're thinking about what was the first thing?
• 25:47
  Sonia Singh MD: What was the root cause?
• 25:49
  Sonia Singh MD: To me, all of the stuff we see that's happening in the brain are symptoms.
• 25:54
  Sonia Singh MD: They're downstream effects of, all of- Yeah these other things that happened so that's a kind of a broad overview of root causes.
• 26:00
  Sonia Singh MD: I wanna let you weigh in if there's anything else you wanna say about root cause with respect to mental illness.
• 26:06
  Rebecca Berens MD: Yeah, no I think this concept of modifiable and not modifiable risk factors I think really gets lost in the mainstream wellness culture talk about root causes, because it's never just one thing.
• 26:18
  Rebecca Berens MD: Never.
• 26:19
  Rebecca Berens MD: It is never.
• 26:20
  Rebecca Berens MD: There and that's the thing.
• 26:20
  Rebecca Berens MD: You even see this sometimes when people are talking about poverty and economic mobility, right?
• 26:26
  Rebecca Berens MD: Where someone's like this person came from nothing, and they were able to do all of this, and you could do that, too.
• 26:32
  Rebecca Berens MD: You don't need any handouts or whatever." But no one is the same.
• 26:36
  Rebecca Berens MD: No one's genetic background or experiences are the same.
• 26:39
  Rebecca Berens MD: There's so many different factors that affect this.
• 26:41
  Rebecca Berens MD: And so ultimately when we're talking about how that influences your health there's a small piece you can control And you do the best you can with the piece you can control, and then you see how things are going, and that's when we use our other tools.
• 26:56
  Rebecca Berens MD: And I feel like the other thing I'm seeing, especially as we talk about these neurobiological mechanisms- Yeah that contribute, is there is a lot of fixation on that, and talking about all these alternative ways of addressing these things.
• 27:07
  Rebecca Berens MD: Yes.
• 27:07
  Rebecca Berens MD: Yet again, don't have a lot of evidence for them yet, which I don't know if we're gonna get into that later or not.
• 27:13
  Sonia Singh MD: We'll talk about it, yes.
• 27:14
  Rebecca Berens MD: But, again we should be looking into other things to see what we can do to approach this problem from different angles, but we also have to take into account the known evidence, the known safety, the known efficacy, and the harm of doing something that doesn't have clear evidence of benefit instead of doing something that has more evidence that it will be beneficial.
• 27:34
  Rebecca Berens MD: So I think that's that's my soapbox on that.
• 27:37
  Sonia Singh MD: Yeah.
• 27:37
  Sonia Singh MD: We're definitely gonna come back to that idea, because I think we could argue that both the medical community and the wellness community, or the alternative medicine community, is too focused on the neurobiological.
• 27:47
  Sonia Singh MD: Yeah.
• 27:47
  Sonia Singh MD: And if their real goal is to address root causes, it, not there.
• 27:52
  Sonia Singh MD: It's not- Yeah.
• 27:52
  Sonia Singh MD: If,
• 27:53
  Rebecca Berens MD: if we're gonna address the root causes, that's not a medical problem.
• 27:56
  Rebecca Berens MD: Yeah.
• 27:56
  Rebecca Berens MD: That's a sociology problem.
• 27:57
  Rebecca Berens MD: Yes.
• 27:57
  Sonia Singh MD: You
• 27:57
  Rebecca Berens MD: know?
• 27:58
  Sonia Singh MD: Yes.
• 27:58
  Sonia Singh MD: Real root causes are, not fun, not easy, often not modifiable.
• 28:03
  Sonia Singh MD: You cannot go back and change, the abusive home that you grew up in.
• 28:07
  Sonia Singh MD: It has happened, you
• 28:08
  Rebecca Berens MD: know?
• 28:08
  Rebecca Berens MD: But you could support families better to avoid future abuse in the, in-
• 28:11
  Sonia Singh MD: You could, yes
• 28:12
  Rebecca Berens MD: for future patients.
• 28:13
  Rebecca Berens MD: Yeah.
• 28:13
  Rebecca Berens MD: But apparently that's not what we're gonna do.
• 28:15
  Rebecca Berens MD: Anyway.
• 28:15
  Sonia Singh MD: Yes.
• 28:15
  Sonia Singh MD: But you can also process the trauma of it.
• 28:18
  Sonia Singh MD: Yeah.
• 28:18
  Sonia Singh MD: There's many ways you can address that.
• 28:19
  Sonia Singh MD: But those are never things...
• 28:20
  Sonia Singh MD: I have never heard a wellness influencer, granted, now I'm trying to detach from a lot of these, a lot of these platforms maybe they're talking about it now.
• 28:28
  Sonia Singh MD: I would be excited if you have heard a wellness influencer talk about adverse childhood events.
• 28:33
  Sonia Singh MD: Because I don't- I
• 28:34
  Rebecca Berens MD: mean, w- I do
• 28:35
  Sonia Singh MD: think there's- don't think it's a
• 28:36
  Rebecca Berens MD: hot topic.
• 28:36
  Rebecca Berens MD: I think there's this now Instagram therapy talk-
• 28:41
  Sonia Singh MD: Okay
• 28:41
  Rebecca Berens MD: form of wellness, where sometimes it's actual therapists and sometimes it's people who read a couple books or took a- Okay online course or something, and now they're, using all this s- therapist speak.
• 28:51
  Rebecca Berens MD: And I, and that's where I think it gets into this sort of, like- in the middle place where they are talking about"This happened to you as a child, and this is why you're having this, and you need to realign your nervous system, and here-" Oh, yes.
• 29:03
  Rebecca Berens MD: Okay"is this thing that will realign
• 29:05
  Sonia Singh MD: your nervous system." So when they can package it into the- Yes course that they can sell you to retrain your vagus nerve- Yes then it's- Yes it's like a good topic.
• 29:12
  Sonia Singh MD: But-
• 29:12
  Rebecca Berens MD: Yeah.
• 29:12
  Rebecca Berens MD: And again there's truth behind that, right?
• 29:14
  Rebecca Berens MD: But let's make sure that we're getting that sort of care from someone who has actual training in it and is using appropriate methods and not just some random thing that some random person on the internet made that- we don't know where that's going.
• 29:30
  Sonia Singh MD: But, so that's a great point.
• 29:31
  Sonia Singh MD: And what's ther- about those people who are selling programs is because they're so effective at communicating and connecting the dots for people and explaining in a non-judgmental validating way- Yeah how those experiences played into that, and I think that's something doctors are terrible at.
• 29:48
  Sonia Singh MD: Like-
• 29:48
  Rebecca Berens MD: Oh, they are.
• 29:49
  Sonia Singh MD: Absolutely we just don't do, we don't do it.
• 29:50
  Sonia Singh MD: We don't get trained to do it, and we don't do it.
• 29:52
  Sonia Singh MD: And so I think then there's this huge gap.
• 29:55
  Sonia Singh MD: So many of those women who I think have walked into a doctor's office with what they perceive as physical, like I-have-something-wrong-with-me right now, and they gave them, an SSRI.
• 30:05
  Sonia Singh MD: In some of those cases that was mo- probably not unreasonable, but they just left this huge gap in communicating to that person, what are the physical symptoms of anxiety and depression?
• 30:17
  Sonia Singh MD: Let's talk about how they can manifest in the body, and let's talk about what testing we've done that makes me believe this is not your thyroid or this is not your cortisol w- that's where the problem really happens,
• 30:27
  Rebecca Berens MD: But I think also to give the physician perspective on this, I think in many cases in these very short PCP visits that people have, there is a discussion of a referral to a mental health professional who could help connect those dots.
• 30:44
  Rebecca Berens MD: Yes.
• 30:44
  Rebecca Berens MD: And that is often perceived as"Oh, you're writing me off.
• 30:47
  Rebecca Berens MD: You think it's all in my head." Yes.
• 30:48
  Rebecca Berens MD: Yes.
• 30:48
  Rebecca Berens MD: When in reality I am not the person with the time or expertise- To explain all of this.
• 30:52
  Rebecca Berens MD: To give you that overview and connect those dots.
• 30:55
  Rebecca Berens MD: So I'm going to refer you to a person who that is their expertise, and they do have the time to really dive deep and explain that to you.
• 31:02
  Rebecca Berens MD: And so they maybe are making an appropriate referral, but that is being perceived as you're dismissing me or you're invalidating me.
• 31:08
  Rebecca Berens MD: It feels writing me off.
• 31:09
  Rebecca Berens MD: Yes.
• 31:10
  Rebecca Berens MD: Yeah.
• 31:10
  Rebecca Berens MD: And and so then I think that happens to you enough times, and then I think a lot of doctors are like I can't do that.
• 31:17
  Rebecca Berens MD: They're getting mad at me, and- Yeah but I really do think that, it- you have to be able to explain the reason for the referral to the patient in a way that doesn't feel invalidating, and a lot of people don't have the time or bandwidth or, education or, skills in that sort of conversation- Yeah to really do that.
• 31:36
  Rebecca Berens MD: And so I do think that's part of the issue as well.
• 31:38
  Sonia Singh MD: I agree.
• 31:40
  Sonia Singh MD: Okay let's move on.
• 31:41
  Sonia Singh MD: So the next topic I wanted to cover is what are the actual evidence-based treatments for anxiety and depression?
• 31:46
  Sonia Singh MD: Because a constant source of outrage for me is when there's all this talk about de-prescribing and I'm like,"That's fine, but what would you like me to do?" Yeah.
• 31:55
  Sonia Singh MD: And what is actually going to help them in an equivalent fashion, okay?
• 32:00
  Sonia Singh MD: So SSRIs are of course one of the evidence-based treatments with response rates of between 30 and 50%.
• 32:07
  Sonia Singh MD: So of note, like these do not work for everybody.
• 32:10
  Sonia Singh MD: It is not the solution for every single person and, a 30% response rate's not great.
• 32:15
  Sonia Singh MD: But it is something.
• 32:15
  Sonia Singh MD: Psychotherapy of some type is also a very evidence-based treatment option.
• 32:20
  Sonia Singh MD: So CBT is the form of therapy, a lot of people don't realize there's so many different forms of therapy.
• 32:24
  Sonia Singh MD: CBT is the form of therapy that has the most data for both anxiety and depression.
• 32:28
  Sonia Singh MD: For depression, acceptance and commitment therapy, which is abbreviated as ACT, I'm sorry, for anxiety, ACT therapy has also been shown to be eq- as beneficial as CBT, and for depression a lot of different therapies have been shown to be effective.
• 32:41
  Sonia Singh MD: CBT, interpersonal therapy, problem-solving therapy, short-term psychodynamic therapy all have been similarly effective.
• 32:47
  Sonia Singh MD: There have actually been a lot of randomized control st- so 101 randomized controlled trials comparing the efficacy of medicine versus therapy.
• 32:56
  Sonia Singh MD: So I think some people have this perceptio- doctors just do medicine.
• 32:59
  Sonia Singh MD: That's all they do.
• 33:00
  Sonia Singh MD: Everyone just gets medicine.
• 33:02
  Sonia Singh MD: That's the treatment for everybody.
• 33:03
  Sonia Singh MD: But this has been studied fairly extensively and what it looks like is that- Medication therapy are about comparable in terms of their effectiveness, so both work similarly well.
• 33:15
  Sonia Singh MD: The combination of both of them together works better than either of them alone.
• 33:19
  Sonia Singh MD: What does therapy actually entail?
• 33:22
  Sonia Singh MD: So in these studies, there's some variability, but usually there's somewhere between eight and 20 sessions of some type of therapy that's of a specific type, and each session lasts, somewhere between 50 and 60 minutes and is delivered over a period of 12 weeks to five months.
• 33:38
  Sonia Singh MD: So we're not talking about going to therapy one time.
• 33:41
  Sonia Singh MD: Or going to a random talk therapist online for a couple sessions is equivalent to taking a med.
• 33:47
  Sonia Singh MD: We're talking about studies in which people did these very structured, over some period of time, therapy sessions.
• 33:54
  Sonia Singh MD: For patients with mild depression, many guidelines actually support just doing psychotherapy before initiating any medication.
• 34:00
  Sonia Singh MD: And another important thing is that psychotherapy has been shown to have more durable longterm benefit than medication.
• 34:07
  Sonia Singh MD: So if you're gonna do just one of them it does appear that psychotherapy the benefit could last longer for you.
• 34:14
  Rebecca Berens MD: But, but-
• 34:15
  Sonia Singh MD: But
• 34:16
  Rebecca Berens MD: you gotta do three to five months of that.
• 34:18
  Rebecca Berens MD: And you feel terrible now and can't do the things you need to do in your life, and so maybe taking your 30 to 50% chance of feeling better much more quickly- With a med?
• 34:29
  Rebecca Berens MD: Reasonable to consider both, right?
• 34:32
  Rebecca Berens MD: Okay, yes.
• 34:32
  Rebecca Berens MD: And as you said, better efficacy with both.
• 34:35
  Sonia Singh MD: Yes, better with both.
• 34:36
  Sonia Singh MD: This is a theme of what you said that I think is gonna come back over and over, which is, I think, both of us being PCPs, this is probably something you see all the time, is that, so the next thing I'm gonna talk about is exercise and then sleep and then diet.
• 34:49
  Sonia Singh MD: There are benefits to all of these with respect to depressive symptoms.
• 34:55
  Sonia Singh MD: When you are seeing somebody with significant depression, it is often so challenging for that person to get to the gym.
• 35:03
  Sonia Singh MD: To get enough sleep or not oversleep, to eat a balanced diet, to not overeat or to just force themself to eat because they have no appetite because they're so depressed.
• 35:11
  Sonia Singh MD: So it's not a one-sided causal relationship where this is the root cause.
• 35:16
  Sonia Singh MD: These are, very much bidirectional in real life.
• 35:18
  Sonia Singh MD: So anyway, I'm gonna talk about some of the data for these other things, because I do think these are the things that are emphasized, by the Make America Healthy Again movement, by the alternative wellness world, that's"Why take this pill when you could just exercise or sleep better or change your diet and that could solve the problem?" Okay?
• 35:36
  Sonia Singh MD: So exercise is the lifestyle intervention that has the most robust evidence for improving depressive symptoms, and specifically aerobic exercise sessions of 30 to 40 minutes three to five times a week seem beneficial for both depression and anxiety.
• 35:50
  Sonia Singh MD: Higher intensity of aerobic exercise was associated with greater improvements of depression, and shorter duration with lower intensity was more associated with anxiety reduction, interestingly.
• 36:00
  Sonia Singh MD: The greatest benefits they've seen for exercise and depression were for younger adults, 18 to 30, so exercise appears to be an effective intervention- Actually, let me talk through the other two, and then I'll talk about my two cents on this as a PCP.
• 36:16
  Sonia Singh MD: But so exercise appears to be an effective intervention.
• 36:18
  Sonia Singh MD: Okay, improving sleep quality, however you want to do that, whether that's CGI or just allowing more time for sleep or whatever, improving sleep quality also seems to improve depressive symptoms.
• 36:29
  Sonia Singh MD: And then in terms of diet, there is some evidence that following a Mediterranean-style diet is associated with reduced risk of depression, so we're not talking about a treatment of depression, but reduced risk, and that it may improve depressive symptoms in patients as an adjunctive treatment.
• 36:44
  Sonia Singh MD: So what that means is those patients are already being treated with the standard first-line treatments, which is therapy and/or medication.
• 36:52
  Sonia Singh MD: And they had further improvement in their symptoms or achieved remission by going on a Mediterranean diet.
• 36:58
  Sonia Singh MD: Important to note that These were two studies that this is based on, 67 and 72 participants, so they're relatively small, and they were not blinded, as people knew that they were on the diet.
• 37:08
  Sonia Singh MD: But here's my take on these three things, the, the exercise, the sleep, the diet.
• 37:12
  Sonia Singh MD: The things I just said do not differ from the recommendations that I would give basically anyone who is trying to be well and live a healthy life.
• 37:21
  Sonia Singh MD: Even with the dietary pattern a whole foods plant-based diet or a Mediterranean are the two diets that seem to have the most data for everything, and this is no exception.
• 37:31
  Sonia Singh MD: I think when there's this belief of why would you take this medicine when you could just do these lifestyle things or make these choices and that would fix it number one, a lot of these things have not been proven to be, like, a monotherapy for depression, so this is not really an alternative to the treatments- that we do have.
• 37:50
  Sonia Singh MD: And, like I said, too, it's challenging to do some of these things when you are deeply depressed or extremely anxious.
• 37:56
  Sonia Singh MD: Yeah and three these are things that we are trying to encourage in every patient, not just these patients with depression.
• 38:03
  Sonia Singh MD: Reviewing the data on exercise specifically made me think about how I could do a better job of really stating that when I'm talking to patients who I'm, initially discussing treatments of anxiety and depression with.
• 38:14
  Sonia Singh MD: I talk about all of these things with all of my patients anyway, but I think putting it in that context and saying it in that- conversation, saying, exercise has been shown comparable benefits to some of these things we're talking about." I think that's helpful, but then again, for a lot of patients, that's gonna feel like you're asking me to do an impossible thing.
• 38:32
  Sonia Singh MD: If I could do that, I would be doing that,
• 38:34
  Rebecca Berens MD: exactly, and it's It's so interesting'cause the...
• 38:37
  Rebecca Berens MD: When people say that on social media I'm like- If the person is coming to the doctor with this complaint, and I'm just like,"Oh, you should just go get some sleep," like how invalidating is that?
• 38:49
  Rebecca Berens MD: Just do you think they didn't know that they need to sleep?
• 38:51
  Rebecca Berens MD: Have you ever
• 38:52
  Sonia Singh MD: thought about getting better sleep?
• 38:54
  Rebecca Berens MD: Yeah.
• 38:54
  Rebecca Berens MD: There's"You should really do some exercise." It's oh, I haven't been hearing that my entire life.
• 38:58
  Rebecca Berens MD: I did think about, I'm so exhausted all the time, I can't even take a shower I'm so depressed, and you want me to go do some exercise.
• 39:05
  Rebecca Berens MD: It's so invalidating and when the influencers say it, I feel like they frame it in such a different way as to where it doesn't sound that way.
• 39:14
  Rebecca Berens MD: But I'm like, if you were to come into the office and I said that to you in that way, I think you would be really annoyed, if not deeply offended, right?
• 39:24
  Rebecca Berens MD: That I would treat your deep concern that you made the time and spent the money to come talk to me about, and I was like,"Oh yeah, you should just go do some exercise." People know that they're supposed to do these things.
• 39:35
  Rebecca Berens MD: If they're coming to ask for help from a doctor, it's because they are struggling and they've already been trying.
• 39:41
  Rebecca Berens MD: And so it just really bothers me when I hear that from them.
• 39:44
  Rebecca Berens MD: 'Cause I'm like, try saying that to someone who is like struggling so much and has- taken the step to try to ask for help, and you just give them this blanket nonsense.
• 39:56
  Sonia Singh MD: And by the way, how much somebody moves their body and the diet they're consuming and how much sleep they're getting has a lot to do with factors around them, like the job that they have- the neighborhood that they live in, their financial situation, when you're talking to somebody with unlimited resources and, a very high level of motivation and support yeah, maybe some of those people would benefit from having a deeper discussion about these topics.
• 40:19
  Sonia Singh MD: But for a lot of patients, even if they know and they want to do it, and maybe they have the energy to do it it's not easy.
• 40:26
  Sonia Singh MD: Yeah.
• 40:26
  Sonia Singh MD: It's not easy to, these things.
• 40:29
  Sonia Singh MD: So-
• 40:29
  Rebecca Berens MD: Yeah
• 40:30
  Sonia Singh MD: so let's move on to another kind of contested hot topic here, which is nutraceuticals and supplements for depression.
• 40:37
  Sonia Singh MD: The supplement that has probably the data is omega-3 supplementation.
• 40:42
  Sonia Singh MD: So specifically, omega-3 supplements with greater than 60% EPA as opposed to predominantly DHA have been studied as adjuncts, for treatment in depression.
• 40:53
  Sonia Singh MD: So again, not as monotherapy, but as something used alongside an antidepressant or psychotherapy.
• 40:59
  Sonia Singh MD: Typically, alongside an antidepressant is what most of the studies were.
• 41:02
  Sonia Singh MD: There have been about 67 randomized controlled trials looking at this overall in the case of depression.
• 41:07
  Sonia Singh MD: But in general, the overall data is still considered to be of relative poor quality due to methodological flaws, heterogeneity.
• 41:16
  Sonia Singh MD: So compared to what we know about SSRIs and therapy, it's really not a replacement or alternative.
• 41:23
  Sonia Singh MD: The data on this is a very small signal compared to the data we have on these other things.
• 41:27
  Sonia Singh MD: Now, I know the retort to this is it's a supplement.
• 41:32
  Sonia Singh MD: It's not patented the same way.
• 41:33
  Sonia Singh MD: There's not as much financial incentive.
• 41:35
  Sonia Singh MD: That's why it's not studied.
• 41:37
  Sonia Singh MD: Big Pharma is driving all of the studies on the pharmaceuticals, so that's why they look so robust.
• 41:41
  Sonia Singh MD: And, maybe we're never gonna get that strong level of data.
• 41:46
  Sonia Singh MD: I get that, but, therapy has also been studied in a pretty robust way.
• 41:50
  Sonia Singh MD: I don't think in this case you can purely blame this on financial incentives and publication.
• 41:57
  Sonia Singh MD: But, there's probably publication bias here with these supplements as well, where if you do a small study and it doesn't really show anything, you're just not gonna bother publishing it.
• 42:04
  Rebecca Berens MD: Yeah.
• 42:04
  Sonia Singh MD: It's something to consider in maybe patients with treatment-resistant depression or patients in who, have a really strong preference, adjust their medications or whatever.
• 42:12
  Sonia Singh MD: It's good to note.
• 42:13
  Sonia Singh MD: But it is certainly not like a,"Oh instead of my Lexapro, I'm gonna take this omega-3 and it's gonna have the same effect." And importantly, the largest trial that we do have to date, which was, over 18,000 participants, which is a lot that was looking at depression prevention in older adults, so that's a little bit different than using it as a treatment.
• 42:32
  Sonia Singh MD: But it did not actually show that it resulted in any prevention of depression, and it actually showed that there was a modest increase in depression risk among the women in the trial.
• 42:41
  Sonia Singh MD: Ooh, interesting.
• 42:41
  Sonia Singh MD: I think a lot of people would say, I hear this all the time about supplements.
• 42:44
  Sonia Singh MD: "Okay, probably, I'll just take it.
• 42:45
  Sonia Singh MD: It can't hurt," but it potentially can.
• 42:47
  Sonia Singh MD: Like, all of these things- Yeah have potential side effects.
• 42:49
  Sonia Singh MD: And
• 42:49
  Rebecca Berens MD: that's, that, this is my soapbox also about supplements, but, it can hurt.
• 42:53
  Sonia Singh MD: Yes,
• 42:53
  Rebecca Berens MD: it can.
• 42:53
  Rebecca Berens MD: It's just whether or not we have the evidence to show how.
• 42:56
  Sonia Singh MD: Yes, it can.
• 42:57
  Rebecca Berens MD: Yeah.
• 42:57
  Sonia Singh MD: So another really hot one in this category S-adenosyl methionine which is abbrevias- abbreviated as SAMe.
• 43:05
  Sonia Singh MD: I don't know if people...
• 43:06
  Sonia Singh MD: Do, have you heard...
• 43:07
  Sonia Singh MD: do people call it SAMmy?
• 43:07
  Rebecca Berens MD: I...
• 43:07
  Rebecca Berens MD: fun fact- SAMe I'm taking, I'm actually taking this, but, Oh, okay that's a conversation for another day.
• 43:12
  Rebecca Berens MD: But yes.
• 43:12
  Rebecca Berens MD: Okay.
• 43:13
  Rebecca Berens MD: SAMe.
• 43:13
  Sonia Singh MD: So SAMe is particularly interesting because it has been studied as a monotherapy.
• 43:18
  Sonia Singh MD: And what I found so fascinating about this, I saw the adverse effects listed are GI symptoms like nausea and diarrhea.
• 43:24
  Sonia Singh MD: It's contraindicated in bipolar disorder because it can induce mania or hypomania.
• 43:29
  Sonia Singh MD: And I was like, this just sounds like SSRIs.
• 43:32
  Sonia Singh MD: Like-
• 43:32
  Rebecca Berens MD: Yeah.
• 43:33
  Rebecca Berens MD: Yeah.
• 43:33
  Sonia Singh MD: It sounds very similar, but yeah.
• 43:36
  Sonia Singh MD: Again, overall data is not super strong.
• 43:39
  Sonia Singh MD: When you look at these studies individually and you're not thinking about it with a broader lens, you're like,"Ooh it's comparable to Lexapro.
• 43:46
  Sonia Singh MD: This looks great." But you have to understand that one study is not really equivalent or- does not make it an alternative to all of those other drugs that we have been studying for years and years.
• 43:58
  Sonia Singh MD: Curcumin, saffron, zinc, folate, all of these kind of fall into this category where there's some small studies, limited evidence.
• 44:04
  Sonia Singh MD: Overall the quality is low to moderate and there's a lot of heterogeneity and publication bias and methodological issues with a lot of these studies.
• 44:13
  Rebecca Berens MD: Yeah.
• 44:13
  Rebecca Berens MD: And I think, I just'cause I did say I don't like supplements and then I said I was taking a supplement- so I'm just gonna talk about that really quick.
• 44:19
  Rebecca Berens MD: The other thing to note here is there are times when, having tried the regular options that are, first line and people are struggling, where you might dip into some of these less well-known or less evidence-based treatments.
• 44:34
  Rebecca Berens MD: Yeah.
• 44:34
  Rebecca Berens MD: But i- with the direction of someone who has evidence and training to be able to fully- Talk you through that explain the risks and pot- and potential risks and benefits, and also make an informed decision together rather than just being like,"Oh, yeah, this influencer is selling this supplement.
• 44:52
  Rebecca Berens MD: I should just take that instead." These are two completely different things.
• 44:55
  Sonia Singh MD: Yes.
• 44:55
  Rebecca Berens MD: And but a- again, we've talked about this before on other episodes.
• 44:58
  Rebecca Berens MD: I don't think that it's...
• 44:59
  Rebecca Berens MD: there's necessarily anything wrong with choosing a treatment that is not a first-line evidence-based treatment.
• 45:06
  Rebecca Berens MD: It's first line'cause it's the first one we recommend, but that doesn't mean it's the right one for everyone.
• 45:10
  Rebecca Berens MD: Yes.
• 45:10
  Rebecca Berens MD: And so we have- Yeah we have levels, right?
• 45:12
  Rebecca Berens MD: But a lot of times when these sorts of supplements get discussed, it's like you could do either conventional medicine or- Yes you could do supplements.
• 45:20
  Rebecca Berens MD: And the truth is you can do both or one or the other, but you should make an informed, educated decision- Yes about that, and you're not likely to have all of the information after watching a few TikTok videos.
• 45:34
  Sonia Singh MD: Yeah.
• 45:35
  Sonia Singh MD: I 100% agree with you, and I really think this is where both sides are at fault.
• 45:40
  Sonia Singh MD: Yeah.
• 45:40
  Sonia Singh MD: Because I do think also as a medical community, a lot of doctors will say,"None of those work.
• 45:45
  Sonia Singh MD: That's all, that's mumbo jumbo.""It's all s- placebo." Yes.
• 45:47
  Sonia Singh MD: "Don't take any of them." And there's a difference between not actively recommending something to somebody, and having a nuanced discussion about the fact that this is not a first line therapy.
• 45:59
  Sonia Singh MD: This is not something that I typically recommend, but in your situation, if you have a strong preference to not do X, Y, and Z, these are things that, we can talk about that have some limited evidence, yeah.
• 46:10
  Sonia Singh MD: And I just, I think that's a lot to ask of doctors, though.
• 46:13
  Sonia Singh MD: It's a lot of CME to keep up on.
• 46:16
  Sonia Singh MD: Yeah.
• 46:16
  Sonia Singh MD: It's a lot of time, and I think time is honestly the biggest factor is you just, the time to read up on some of these things and then have that conversation with the patient most of us are just barely getting done the basic, the most necessary medical care.
• 46:30
  Sonia Singh MD: I do think
• 46:31
  Rebecca Berens MD: that- But I think the thing that's not too much to ask-
• 46:33
  Sonia Singh MD: Yeah
• 46:34
  Rebecca Berens MD: is to say, I don't know much about that.
• 46:36
  Rebecca Berens MD: It's not one of the evidence-based treatments that I'm aware of.
• 46:39
  Rebecca Berens MD: This is what is the first line evidence-based treatment.
• 46:42
  Rebecca Berens MD: This is usually the second line.
• 46:44
  Rebecca Berens MD: I don't know about this thing you're asking me about.
• 46:46
  Rebecca Berens MD: I'd be happy to refer you to someone else- Yeah who may have more specialized expertise in that area." But I think, like you said, what often they say instead is"Oh, I don't know about that.
• 46:55
  Rebecca Berens MD: It must not exist," or,"It must not be real," or,"It must be, quackery- It's garbage or whatever." Yeah.
• 46:59
  Rebecca Berens MD: It's it's really just not helpful.
• 47:01
  Rebecca Berens MD: And it really just creates that divide.
• 47:03
  Rebecca Berens MD: And truly you may not know.
• 47:04
  Rebecca Berens MD: There may be something that you don't know.
• 47:06
  Rebecca Berens MD: Yes, and it would be great if we were better as a profession at admitting openly to patients when there are things we don't know, because I think it would help a lot with building trust.
• 47:16
  Rebecca Berens MD: I think we feel like we have to know everything all the time, and we have to have certainty.
• 47:20
  Rebecca Berens MD: And patients are actually a lot more comfortable with uncertainty when you are indicating that you're on a- Upfront about it, yeah you're on a team.
• 47:27
  Rebecca Berens MD: "I'm hearing you.
• 47:27
  Rebecca Berens MD: I hear what you're saying.
• 47:28
  Rebecca Berens MD: This is not something that I'm an expert in.
• 47:30
  Rebecca Berens MD: Let me get you to someone else who is- Yeah more of an expert in this." Because if we don't do that, then what they do is they find their own quote, unquote,"expert" on the internet, and that person could be selling something, could be telling them very biased things, and it just, it's important for us to be working together.
• 47:49
  Sonia Singh MD: I completely agree.
• 47:51
  Sonia Singh MD: So now that we've talked about the evidence-based treatment options, now let's talk about a very key contextual factor here, which is how many people are actually getting the evidence-based treatment options?
• 48:02
  Sonia Singh MD: So the vast majority of patients with depression and anxiety do not receive any type of treatment.
• 48:08
  Sonia Singh MD: In the United States, only about 28.7% of adults who screen positive for depression end up receiving any treatment at all.
• 48:17
  Sonia Singh MD: Globally, that number is 9%.
• 48:18
  Sonia Singh MD: So I think people have this perception of"Oh my God, everyone in the US is just medicating all of these things." We're still under-treating a ton of depression in the United States.
• 48:27
  Sonia Singh MD: Depression prevalence has been rising.
• 48:29
  Sonia Singh MD: And there has not been a commensurate increase in the treatment rate.
• 48:33
  Sonia Singh MD: So the, the treatment gap has basically widened over time.
• 48:36
  Sonia Singh MD: Among those who do receive treatment we have shifted more towards pharmacotherapy compared to psychotherapy.
• 48:43
  Sonia Singh MD: So psychotherapy declined from 53.7% in 1998 to 43.2% in 2007.
• 48:50
  Sonia Singh MD: And pharmacotherapy has been pretty consistent across that period.
• 48:54
  Sonia Singh MD: For anxiety, only 24% of US adults received any kind of treatment, and as you said it did vary quite a bit depending on the type of anxiety disorder.
• 49:04
  Sonia Singh MD: So panic disorder was most likely to be treated, and specific phobias were least likely to be treated.
• 49:09
  Sonia Singh MD: And we're talking any type of treatment.
• 49:10
  Sonia Singh MD: We're not talking about SSRIs.
• 49:13
  Sonia Singh MD: Now why are so many people untreated?
• 49:16
  Sonia Singh MD: There's a million for this, right?
• 49:18
  Sonia Singh MD: And this is where I think you- if you really care about root causes this is the type of stuff I think we should be thinking about and talking about.
• 49:24
  Sonia Singh MD: So We've talked about what causes the conditions themselves.
• 49:27
  Sonia Singh MD: Why is it that so many people never get any help or treatment for it?
• 49:30
  Sonia Singh MD: Financial barriers is one of the biggest ones.
• 49:33
  Sonia Singh MD: It's often cited as why people chose not to get some treatment, so that could be paying for psychotherapy, paying for meds, paying for the doctor visit to get the meds or to refill the meds.
• 49:43
  Sonia Singh MD: So just underdiagnosis.
• 49:44
  Sonia Singh MD: Again, these are stigmatized conditions, so patients may not always bring them up immediately, or the doctor may not, ask the right questions to elicit it.
• 49:51
  Sonia Singh MD: Demographic disparities, so there are certain ethnic groups less likely to be diagnosed and less likely to be treated.
• 49:58
  Sonia Singh MD: We talked about stigma generally or perceived need.
• 50:00
  Sonia Singh MD: Even if patients screen positive for depression, they may not perceive that they have that or that they need the treatment.
• 50:07
  Sonia Singh MD: And then insurance gaps, which I think also falls in the same category as financial barriers and systemic barriers.
• 50:13
  Sonia Singh MD: So there's a lot of reasons that, people don't end up getting treatment.
• 50:18
  Sonia Singh MD: And so I think when you think about this idea of de-prescribing SSRIs- Yes, there is a group of people that have been on SSRIs for longer than what the evidence tells us, I don't know that we have great data to actually say that those people are being harmed because we just haven't studied it, right?
• 50:42
  Sonia Singh MD: So right now, all of this messaging is focused on oh, this group of people that has just been on it for years, and it's like we gotta get these people off.
• 50:49
  Sonia Singh MD: Meanwhile, like 70 to 80% of the people that have these conditions have never gotten any kind of treatment at all.
• 50:57
  Sonia Singh MD: So to me, this messaging it's similar to the beef that I had with the whole everyone needs to eat more protein idea.
• 51:04
  Rebecca Berens MD: Yes.
• 51:05
  Sonia Singh MD: Where the idea itself is not terrible.
• 51:09
  Sonia Singh MD: It's not applicable to everyone, but it's not terrible, and some people may benefit.
• 51:12
  Sonia Singh MD: But when you think about how that actually plays out in a real set of humans, it's gonna play out in a way that has unintended consequences.
• 51:21
  Sonia Singh MD: To me, this whole push for de-prescribing SSRIs is just further stigmatizing these conditions and the most evidence-based treatments for them.
• 51:29
  Rebecca Berens MD: And the most affordable treatment.
• 51:31
  Rebecca Berens MD: And
• 51:31
  Sonia Singh MD: the most, yes, the most
• 51:32
  Rebecca Berens MD: affordable.
• 51:32
  Rebecca Berens MD: Therapy is not cheap and it's also very time intensive, and- Yes, when do you do it?
• 51:36
  Rebecca Berens MD: if you're an hourly worker, and you don't- Yes get paid when you don't go to work I know.
• 51:42
  Rebecca Berens MD: I,
• 51:42
  Sonia Singh MD: I can barely find time for therapy, so I don't know how somebody with a nine to five can really do that, so it's, the reason that so many doctors, I think, default to pharmacologic therapy is often because we have very little control or ability to affect a lot of the other factors like I can't control whether they can afford a therapist or whether their insurance will cover a therapist.
• 52:08
  Sonia Singh MD: I can't control whether they can exercise or have access to a place to exercise or have time to exercise.
• 52:14
  Sonia Singh MD: I can counsel them on sleep, but if they're just only have six hours or five hours to sleep I can't change that.
• 52:19
  Sonia Singh MD: I can offer them a medication that has a 30 to 50% chance of helping them feel better, you know?
• 52:25
  Sonia Singh MD: And oftentimes as you mentioned that's just the first step in allowing them to make some of these other changes, get out of the toxic relationship or quit the toxic job or, finally have their nervous system quiet a little bit to go to sleep.
• 52:37
  Sonia Singh MD: Like I said before, it's a bidirectional relationship with a lot of these things.
• 52:41
  Sonia Singh MD: It's not as simple as just eat the right foods, just get the sunshine, just move your body and you're gonna be fine.
• 52:47
  Rebecca Berens MD: Yeah.
• 52:47
  Rebecca Berens MD: Not that simple.
• 52:48
  Rebecca Berens MD: If only it were that simple.
• 52:49
  Sonia Singh MD: If only.
• 52:51
  Rebecca Berens MD: Okay.
• 52:51
  Rebecca Berens MD: What can we learn from this as doctors and humans?
• 52:54
  Sonia Singh MD: I think the biggest thing I learned from this is, I do think there's truth in the fact that we should spend more time discussing that these are not meant to be long-term therapies, or they were not studied as long-term therapies.
• 53:12
  Sonia Singh MD: But, the thing I always say to patients is anxiety and depression are chronic conditions they are gonna come and go throughout life.
• 53:17
  Sonia Singh MD: Yeah.
• 53:17
  Sonia Singh MD: In the same way I would counsel someone about GLP-1 use I'm like,"Don't expect that you're gonna go on this once and then it's all gonna be fixed, and then we're never gonna need any treatment again." There is a chance that you will, go on it, feel better, come off of it, and maybe you will need it again, and that's okay, but I do think we can do a better job of perhaps just framing and emphasizing all of the non-pharmacologic things in the discussion so that it doesn't feel like those are left out.
• 53:42
  Sonia Singh MD: Even though those are things that feel implied and are recommended for every patient, incorporating that in the conversation would go a long way in terms of not having the patient leave with the perception that meds are the only option you're offering them,
• 53:56
  Rebecca Berens MD: yeah.
• 53:57
  Rebecca Berens MD: And I think also the, Specifically discussing the evidence of how those things contribute to it.
• 54:02
  Rebecca Berens MD: Sometimes when there's so many things going on in life, it's hard to prioritize what you need to do.
• 54:07
  Rebecca Berens MD: And for a lot of patients, they're working their job, they're struggling to pay bills, they're juggling childcare, they're caring for aging parents.
• 54:15
  Rebecca Berens MD: There's all these things going on, and care of themselves often does take a backseat.
• 54:21
  Rebecca Berens MD: And so maybe having a more concrete conversation about"This is how this could help you with this specific condition that you're experiencing and these symptoms that you're having" allows- Yeah them to maybe reprioritize in a way.
• 54:33
  Rebecca Berens MD: Or just be able to shift their focus a little bit.
• 54:35
  Rebecca Berens MD: 'Cause I think it never feels like a priority until it's on fire,
• 54:38
  Sonia Singh MD: yes,
• 54:38
  Rebecca Berens MD: Yeah.
• 54:39
  Sonia Singh MD: Or I think, for somebody who's really reluctant or like it's just their preference to not be on a medication, saying"Okay.
• 54:44
  Sonia Singh MD: We're gonna talk exercise for your mood, and the data supports aerobic exercise for 30 to 50 minutes three times a week." Yeah.
• 54:51
  Sonia Singh MD: And just being a little bit more concrete and specific about it.
• 54:55
  Rebecca Berens MD: And as you just said, there's lots of things that we could do differently as PCPs.
• 54:59
  Rebecca Berens MD: But I think what I hope that patients might take from this or just like humans in general, understanding that there is a lot behind this that you don't have direct control over.
• 55:09
  Rebecca Berens MD: And of course, we never want to just be like stu- You w- you don't wanna feel stuck of like this is just how it's gonna be because of, X, Y, Z thing.
• 55:16
  Rebecca Berens MD: We can always do things to help ourselves feel better and reach the best health and best abilities and all of that.
• 55:23
  Rebecca Berens MD: But but recognizing that there doesn't need to be blame with it.
• 55:27
  Rebecca Berens MD: Yeah and wherever you're starting from is you didn't get there alone.
• 55:33
  Rebecca Berens MD: You're probably not gonna get out of that alone, but it's not something to feel shame or blame or guilt over, because that feeling will just hold you back.
• 55:41
  Rebecca Berens MD: And that sort of helplessness feeling that people often get that comes right along with depression.
• 55:47
  Rebecca Berens MD: And so getting the support that you need is very important and you can feel better, but it doesn't mean- that it's all your fault that you feel this way.
• 55:57
  Sonia Singh MD: Yeah.
• 55:58
  Sonia Singh MD: I always tell people to me, these are all tools.
• 56:00
  Sonia Singh MD: These are all different tools- Yes in your toolbox.
• 56:02
  Sonia Singh MD: And, we don't hesitate to be like, I can't see that well.
• 56:05
  Sonia Singh MD: I'm gonna wear, I'm gonna start wearing my glasses,""i'm gonna wear glasses." But somehow when it's a medicine and it's for a mental health diagnosis- it feels like there's so much baggage and judgment- Yeah attached to that, and to me, I just try to really normalize and say"Look, this is a tool in your toolbox.
• 56:20
  Sonia Singh MD: You don't have to use it.
• 56:22
  Sonia Singh MD: You can- Yeah if you want to.
• 56:23
  Sonia Singh MD: But it's hard to think about it that way, especially when your thoughts and your per- everything is clouded by anxiety or depression.
• 56:30
  Rebecca Berens MD: Yes.
• 56:30
  Rebecca Berens MD: Yes, absolutely.
• 56:32
  Sonia Singh MD: So the last question we always try to talk about is, like, how do we talk to patients about this?
• 56:36
  Sonia Singh MD: So I wanted to just share for- reasons.
• 56:39
  Sonia Singh MD: One is, we, as we mentioned, I think way more often than not you're gonna hear negative stories about people being on these meds.
• 56:47
  Sonia Singh MD: The number of negative and horror stories about being on an SSRI far outweighs, like, the number of positive stories you hear about them.
• 56:54
  Sonia Singh MD: And the power of that personal narrative is huge.
• 56:58
  Sonia Singh MD: And I th- as doctors we're trained to have this mask and to never reveal things about ourselves'cause it's- it's not about us.
• 57:05
  Sonia Singh MD: But- I think that there's a lot of power in sharing my own personal narrative here and there.
• 57:11
  Sonia Singh MD: And I think about every time in my life, especially as a physician, that another physician revealed to me that they were treated for anxiety or depression or that they were on one of these meds, and I think of all of those times as a tiny gift because it normalized it for me and made it easier for me to make that choice eventually and made me feel less like- Yeah something was wrong with me.
• 57:35
  Sonia Singh MD: So when I was a resident I had pretty profound burnout.
• 57:38
  Sonia Singh MD: I think I I've probably just always been wired to be anxious, but it had never gotten to the point where I needed And I just thought that was my personality.
• 57:47
  Sonia Singh MD: And I'm just like- yes, I stay up really late and work on things and I worry too much about all of my presentations and all of my notes and every- So I did that for a couple of months and then I found myself, I feeling so low and so fatigued and I just felt like a shell of myself.
• 58:02
  Sonia Singh MD: Like I was dragging myself around.
• 58:04
  Sonia Singh MD: I had no appetite.
• 58:05
  Sonia Singh MD: I became skin and bones.
• 58:07
  Sonia Singh MD: I was not socializing.
• 58:09
  Sonia Singh MD: I was just totally isolated, just going to the hospital, coming home, going to sleep.
• 58:13
  Sonia Singh MD: Could barely muster the energy to do my laundry and buy basic food to put in my fridge.
• 58:18
  Sonia Singh MD: And I thought I am burned out from this training.
• 58:23
  Sonia Singh MD: I am burned out from this environment.
• 58:24
  Sonia Singh MD: This environment is causing me to become this really horribly sad human.
• 58:29
  Sonia Singh MD: And so I was like,"Maybe I shouldn't do this," and I tried to quit my residency.
• 58:33
  Sonia Singh MD: And my residency director said, have you ever thought about maybe this being anxiety or depression?
• 58:40
  Sonia Singh MD: Or maybe there's a mental health issue here that is coming out because of the demands of residency." And truthfully, that had not really occurred to me'cause I thought,"Yeah, I'm more anxious, but that's my personality and maybe that just doesn't mesh with this high-stakes, stressful environment." And, I knew the criteria for depression.
• 58:59
  Sonia Singh MD: I could have gone through SIGEIP-CAPS in my mind, and I knew that I checked all all of those boxes.
• 59:05
  Sonia Singh MD: But for some reason, I think, again, maybe'cause of my own, biases and my own, v- vulnerabilities to stigma, like I just, I did not see it that way.
• 59:13
  Sonia Singh MD: But, at that point I was trying to quit a residency that I was halfway through, so I was like if you think I should, go talk to someone about this, then I will go talk to someone about this." And I did, and he suggested to me you might consider going on a tiny dose of a medicine." And again, I was not excited to do that, but I was on the verge of quitting this residency that I had put a year and a half of my life into and a lot of education before that.
• 59:35
  Sonia Singh MD: So I was like,"Okay, I guess I owe it to myself to give try." When I think about my lifestyle before this, I was not sleeping enough as a result of my job.
• 59:45
  Sonia Singh MD: I did not have time to talk to anyone or go to therapy.
• 59:48
  Sonia Singh MD: I, Yeah barely had time to do my laundry and my groceries and sleep.
• 59:51
  Sonia Singh MD: I was not exercising other than going up and down the stairwell of the hospital.
• 59:55
  Sonia Singh MD: I was not socializing.
• 59:56
  Sonia Singh MD: My lifestyle was not healthy.
• 59:58
  Sonia Singh MD: I was eating fries from the cafeteria on a regular basis.
• 1:00:01
  Sonia Singh MD: Yeah.
• 1:00:01
  Sonia Singh MD: I was not doing any of those things.
• 1:00:02
  Sonia Singh MD: But I could not fathom even trying to do any of those things A tiny dose of Lexapro for probably f- four to six months total.
• 1:00:12
  Sonia Singh MD: I can't remember the exact time.
• 1:00:14
  Sonia Singh MD: And it was a night and day difference in terms of how I felt.
• 1:00:19
  Sonia Singh MD: I felt like I had this fog or i was walking through tar all the time, and then slowly it was gone.
• 1:00:25
  Sonia Singh MD: And again, I thought about every person that had ever mentioned that to me before, and I was like,"Oh,""I see why they dropped that nugget."
• 1:00:34
  Rebecca Berens MD: Yeah.
• 1:00:35
  Sonia Singh MD: This was so helpful.
• 1:00:37
  Sonia Singh MD: And I wish desperately that I had a PCP at the time that asked me a couple depression screening questions,'cause I would have screened positive, and had said,"Maybe you should do this thing." So I guess I come from the personal bias of Yeah having had this experience where I felt, I experienced myself, that I did not recognize it in myself, that I did not think I needed that help, that I was not excited to go on the medicine, that I waited way too long before I took it.
• 1:01:03
  Sonia Singh MD: And then I saw how I took it and within a few months, I remember at the time, what was it?
• 1:01:09
  Sonia Singh MD: T80?
• 1:01:10
  Sonia Singh MD: I don't know.
• 1:01:10
  Sonia Singh MD: There were these home workout DVDs that everybody was doing- Yeah.
• 1:01:14
  Sonia Singh MD: in the early 2010s, and I remember I got one of those discs and I started working out every day.
• 1:01:19
  Sonia Singh MD: And I started, going to the farmers market and making my meals, and everything turned around for me very quickly.
• 1:01:24
  Sonia Singh MD: I started making decisions that put me in a better place.
• 1:01:26
  Sonia Singh MD: And eventually, I just relied on those things and I did not need the medicine anymore.
• 1:01:30
  Sonia Singh MD: And I always thought"Oh, if I get postpartum depression or if I go through a really stressful event or whatever, there is a thing that..." And you just don't hear a lot of stories like that on social media- Yeah where somebody experienced a thing, they went on a medicine, they felt better, i did have a little withdrawal when I tapered off of it.
• 1:01:50
  Sonia Singh MD: It was fine.
• 1:01:51
  Sonia Singh MD: It was much better to go through that withdrawal than to continue the path that I was on, which was, very dark.
• 1:01:56
  Sonia Singh MD: So yeah.
• 1:01:56
  Sonia Singh MD: I share that because.
• 1:01:58
  Sonia Singh MD: I know a lot of our audience is other physicians and trainees, and I wanna give the gift that other people gave me to our listeners.
• 1:02:04
  Sonia Singh MD: And so if you're that person and you're hesitant, and you're having some of these thoughts I just wanna share that experience.
• 1:02:12
  Rebecca Berens MD: Yeah.
• 1:02:12
  Rebecca Berens MD: And thank you so much for sharing it, and I think like you said, a lot of people, I feel, I think a lot of physicians feel this need to put on the face of"I'm always fine and everything's great." And, of course, in the context of a patient visit, it's not appropriate for us to start talking about our own stuff.
• 1:02:28
  Rebecca Berens MD: The visit is about them and their, the visit dynamics do limit disclosure in the context of a visit of what we should be doing.
• 1:02:36
  Rebecca Berens MD: But I did have a patient that I saw recently that I was having a day.
• 1:02:40
  Rebecca Berens MD: And I got on the virtual visit and over and over I was like,"I'm sorry, I'm just having a day.
• 1:02:44
  Rebecca Berens MD: Give me a second.
• 1:02:45
  Rebecca Berens MD: I need to just slow down." And she was like,"I'm so glad that doctors are humans too." And like- Yeah like what you just said it, this is the kind of stuff that I think is really important.
• 1:02:55
  Rebecca Berens MD: We are also patients, right?
• 1:02:57
  Rebecca Berens MD: And we deal with all of these things, too, and we shouldn't be expected to do it without the tools that we would offer our patients.
• 1:03:04
  Rebecca Berens MD: And it's actually probably good for our patients to know that we are struggling with these things.
• 1:03:11
  Rebecca Berens MD: And I think, historically, there's been a lot of stigma governmentally of to apply for a medical license you had to say- Yeah if you'd ever been in- Yeah getting any psychiatric treatment.
• 1:03:19
  Rebecca Berens MD: Again this is baked in stigma into the fabric of the society, right?
• 1:03:24
  Rebecca Berens MD: But but it doesn't do anyone any favors to have that, and I think it seems like we're at least moving in a direction of that getting better.
• 1:03:31
  Rebecca Berens MD: And also, I think that's why the influencers are so effective.
• 1:03:34
  Sonia Singh MD: Yes.
• 1:03:34
  Rebecca Berens MD: I 100%
• 1:03:35
  Sonia Singh MD: agree.
• 1:03:36
  Rebecca Berens MD: If they share their stories- Yes.
• 1:03:36
  Rebecca Berens MD: Yes and so if we're not sharing
• 1:03:38
  Sonia Singh MD: our story- It's
• 1:03:38
  Rebecca Berens MD: an unfair
• 1:03:39
  Sonia Singh MD: advantage.
• 1:03:40
  Rebecca Berens MD: Yes.
• 1:03:40
  Rebecca Berens MD: We're giving them an advantage.
• 1:03:41
  Rebecca Berens MD: I over-share a lot of things about myself, here and on the internet, other places.
• 1:03:45
  Rebecca Berens MD: And I'm gonna say it's a good thing.
• 1:03:47
  Rebecca Berens MD: So
• 1:03:48
  Sonia Singh MD: Go
• 1:03:48
  Rebecca Berens MD: for that.
• 1:03:49
  Sonia Singh MD: I just think for a patient to know that about you, it just immediately removes so much of the stigma- Yeah'cause it's like, look, this other person, this high-achieving s person- Yeah who's telling me to do this has been there, and so- Yeah it's if, I think it immediately removes the layer of is this person gonna judge me?
• 1:04:07
  Sonia Singh MD: Is this person gonna say- everything that I do is now anxiety or everything I complain about- Yeah is now anxiety, so I just think...
• 1:04:13
  Sonia Singh MD: And, it certainly influences my practice, yeah.
• 1:04:15
  Sonia Singh MD: 'Cause I've been there.
• 1:04:16
  Sonia Singh MD: And I think just in, in a way it's disclosing my own bias, it's like saying-"Look, I'm coming at it from this perspective."
• 1:04:22
  Rebecca Berens MD: Yeah, which I think is really good also.
• 1:04:24
  Rebecca Berens MD: And I think also it's just there's that hierarchy- in a physician-patient relationship that's sort of- Yes this historical paternalistic hierarchy- that also breaks down when we just act like humans.
• 1:04:36
  Rebecca Berens MD: Yeah.
• 1:04:36
  Rebecca Berens MD: Yes.
• 1:04:36
  Rebecca Berens MD: And talk about our human experiences.
• 1:04:37
  Rebecca Berens MD: And again, it's not always appropriate to be disclosing in the context of a visit, but I think we should do a better job of acknowledging that this is something that a lot of people struggle with in a lot of aspects of, every demographic, every career, everything.
• 1:04:52
  Sonia Singh MD: Yeah.
• 1:04:52
  Rebecca Berens MD: And We should all have the tools available to us.
• 1:04:55
  Sonia Singh MD: Agree.
• 1:04:56
  Sonia Singh MD: Okay, that brings us to the end of the episode.
• 1:04:59
  Sonia Singh MD: So for a summary of this episode and everything we discussed as well as our antidote, which is affirmations for patients around this topic and scripting for clinicians around this topic, you can go to our Substack, which is at antisocialdoctors.com.
• 1:05:16
  Sonia Singh MD: And you can also follow us on Instagram, our handle is@theantisocialdoctors.
• 1:05:21
  Sonia Singh MD: That's right.
• 1:05:22
  Sonia Singh MD: Yeah.
• 1:05:22
  Sonia Singh MD: Okay.
• 1:05:23
  Sonia Singh MD: All right, thanks, Rebecca.
• 1:05:24
  Rebecca Berens MD: Yeah.
• 1:05:24
  Rebecca Berens MD: Thanks so much.
• 1:05:27
  Sonia Singh MD: Hey, guys.
• 1:05:28
  Sonia Singh MD: Last but not least, we have a very important disclaimer.
• 1:05:31
  Sonia Singh MD: This podcast is intended for educational and entertainment purposes only.
• 1:05:35
  Sonia Singh MD: The content shared on this podcast, including but not limited to opinions, research, discussions, case examples, and commentary is not medical advice and should not be considered a substitute for professional medical evaluation, diagnosis, or treatment.
• 1:05:50
  Sonia Singh MD: Listening to this podcast does not establish a physician-patient relationship between you and the hosts.
• 1:05:55
  Sonia Singh MD: We are doctors, but not your doctors.
• 1:05:58
  Sonia Singh MD: Any medical topics discussed are presented for general informational purposes and may not apply to your individual circumstances.
• 1:06:05
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• 1:06:13
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• 1:06:17
  Sonia Singh MD: While the hosts are licensed physicians, the views and opinions expressed are our own and do not represent those of our employers, institutions, organizations, or professional societies with which we are affiliated.
• 1:06:29
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• 1:06:38
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• 1:06:42
  Sonia Singh MD: We, the hosts, make no guarantees about the accuracy, completeness, or applicability of this content, and we disclaim any liability for actions taken or not taken based on the information provided in this podcast.
• 1:06:54
  Sonia Singh MD: By listening to the Anti-Social Doctors podcast, you have agreed to these terms.
• 1:06:58
  Sonia Singh MD: Thanks again for joining us.