18.2 How We Should Be Practicing Psychiatry with Cara Hoepner, PMHNP

[00:00:00] Some of my favorite bits of the outline that you sent me about this interview, in terms of how you practice is your ability to kind of balance or address, you know, the biologic, the psychologic, the social, environmental components of illness and treatment.

[00:00:17] Somebody get this guy some help!

[00:00:27] Disclaimer, this podcast is for informational purposes only. The information provided in this podcast and related materials are meant only to educate. This information is not intended as a substitute for professional medical advice.

[00:00:35] While I am a medical doctor and many of my guests have extensive medical training and experience, nothing stated in this podcast nor materials related to this podcast, including recommended websites, texts, graphics, images, or any other materials, should be treated as a substitute for professional, medical, or psychological advice, diagnosis, or treatment.

[00:00:48] All listeners should consult with a medical professional, licensed mental health provider, or other healthcare provider if seeking medical advice, diagnosis, or treatment.

[00:00:54] Tell us more about kind of this general approach and what distinguishes, you know, your practice and the way that you practice.

[00:01:02] So I'm looking at everything in this person's world. In fact, my first question for them is not like, what would you like to leave? Like, what would you like to resolve or leave behind?

[00:01:15] But if you were feeling fantastic, if you were at a new baseline and feeling great, what would you be doing more of in your life?

[00:01:22] And so I start on a positive. And I want to know what do they want to achieve in their life. And that's actually how I measure progress. It's not just symptoms reduction.

[00:01:31] It's what they are achieving with their relationships, with their work, with their, like, with the things that are meaningful to them.

[00:01:39] And because not everyone gets a hundred percent symptoms reduction. And a lot of people do.

[00:01:46] I would say that two thirds of my practice is at a new baseline, not asking for any additional work, no side effects. So that's my goal.

[00:01:53] And, but my goal also is for them to be living a full life. And I'm looking at people's, and this, and it really varies depending on the individual, because everybody has different things that they want to work with.

[00:02:04] But I'm looking at their sleep, diet, exercise, or movement, meditation, or breath work, or it's like some kind of an in-board process.

[00:02:14] I'm interested in people really cleaning up their lifestyle. There's a study from the National Health Service, you know, because they've got a captive audience, right?

[00:02:24] And they've just, they've got data on all these people and they can mine it.

[00:02:26] And so they looked at a number of health practices and people who were practicing, you know, achieving goals in these practices to a varying degree.

[00:02:37] And the people who were just kind of doing it, the people who were moderately doing well with, you know, eating and exercise and sleep had a 41% reduced risk of depression.

[00:02:50] Like that's huge. So it's, and I, I've saved a lot of, you know, inspiring literature like this for my clients to try to like move them into like to, to motivate them to want to do more with lifestyle.

[00:03:02] I do use medicines. I have an armamentarium that's large enough that I've had people who've failed 40 medicines come to see me and I still find solutions for them.

[00:03:11] So it's, I really, I really rely on that toolkit. I'm different from a lot of folks in my community in that I will almost never use an SSRI or SNRI.

[00:03:22] If someone begs me for it, if they're like, oh, I took this before it worked out really well, no side effects. I'm like, okay, we can do that. But that's maybe once a year.

[00:03:30] I can treat OCD to near remission without an SSRI. I don't know why people think they need one.

[00:03:35] There there's all of these algorithms that tell you what to do. And then you make these assumptions, but you, you don't have to have those assumptions. There's plenty, plenty else out there.

[00:03:42] I'm still using, I'm still using calcium channel blockers and bipolar disorder. I use LL purinol. I use, you know, branch chain amino acids for mania. I use height of thyroid. I use things that other, some, some providers have never heard of, you know,

[00:03:56] but it's, but I fortunately came into this field long enough ago that what was available to study was very high quality.

[00:04:06] And right now there's just so much noise and so much media and so much marketing.

[00:04:10] It's interesting because I went to a, oh, it was actually an APA last year and Mike Gitlin, Mark Fry and Sue McElroy were on a panel on genetics.

[00:04:22] And I read everything that they had published back in like 2002. They were like rock stars to me. I was just so excited to see them on a panel.

[00:04:30] And so I got up and I asked them, I said, what's going on that I go to a meeting and I never hear about, and I'm named five drugs I use all the time.

[00:04:37] And they're like, well, you know, there wasn't enough data and we've kind of forgotten about that now.

[00:04:43] So what you'll find are 60% of people living with bipolar illness, taking second generation antipsychotics chronically.

[00:04:50] These are drugs that cause a 20 to 40% risk of charter dyskinesia, a disfiguring movement disorder.

[00:04:57] And they also cause cortical thinning. I have 11 papers on that.

[00:05:00] The last one I collected is in children from Israel with eight to 11% brain volume loss.

[00:05:07] I will not keep a patient on one of them. I also don't treat primary psychotic disorders, by the way.

[00:05:11] So I can treat without these and I won't use them for more than six months.

[00:05:16] So I am very, very concerned about long-term side effects and concerned about people's health in that regards.

[00:05:21] You and I have talked about finding these root causes or these root triggers of any sort of mental illness or mental health decompensation.

[00:05:31] Things that may have more of a medical biologic basis.

[00:05:34] I mean, that is our first job, right?

[00:05:37] To ensure that what we're seeing that we're not missing or their other providers haven't missed something medical that could be triggering their symptoms.

[00:05:46] What kind of things do you see most commonly when somebody comes to you with depression, anxiety, OCD, where there is some other medical root cause, root trigger of that?

[00:06:00] Oh, terrible sleep.

[00:06:02] Number one, sleep, sleep.

[00:06:04] Matthew Walker likes to say sleep is the foundation of health.

[00:06:07] Like we have many pillars of health, but sleep is absolutely number one.

[00:06:11] And then I go looking for the root cause of that.

[00:06:13] Is it hyperthyroidism, arrhythmia?

[00:06:16] Is it lack of ability to conduct lacunia genesis overnight due to hypoglycemia and then getting a norepinephrine spike?

[00:06:25] Is it hypercortisolemia?

[00:06:27] Are they snoring?

[00:06:29] Which then causes the right atrium of the heart to make atrial natriotic peptide, which is a diuretic, which makes them whiz.

[00:06:36] So like they're waking up in the middle of the night to pee, but really their problem is apnea.

[00:06:41] Is there PTSD giving them a 40 to 80% risk of apnea?

[00:06:47] Right?

[00:06:47] So I look at sleep really deeply and in a lot of detail, and I run sleep studies on many, many, many people.

[00:06:54] I would say another thing that is absolutely root cause is metabolics.

[00:06:59] 80% of my practice lives with ADHD, and people with ADHD often eat a lot of carbohydrate.

[00:07:05] They also skip meals.

[00:07:06] They're often hypoglycemic.

[00:07:08] They're metabolically inflexible after a time, depending on how old they are and how long this has been going on.

[00:07:13] I run into a lot of cardiometabolic.

[00:07:16] I pull minimum 12 tubes of blood out of people after their first visit, so I get a lot of data.

[00:07:24] And I see a lot of cardiometabolic disease in young people.

[00:07:27] And the way that they're managing glucose is absolutely impacting their anxiety, their depression, their sleep, their cognition.

[00:07:37] I think that's one of the biggest problems I run into, especially considering that in America, like the way that we encourage people to eat.

[00:07:49] The latest CDC data says that 6.83% of our population is metabolically healthy.

[00:07:55] That's going by the normal random labs.

[00:07:57] If you were to go by what a functional medicine practitioner considers healthy, it's probably 2%.

[00:08:02] So we're not a healthy country, and you can't separate mental health from that.

[00:08:08] Yeah, and we don't have healthy systems in place.

[00:08:11] I mean, having kids changed my life, obviously.

[00:08:15] I think anybody would tell you that, that having kids changes their lives.

[00:08:19] It changed my life in terms of how I look at the food that we eat.

[00:08:24] Because when you start buying food for your children, whose brains are very, very early in their development,

[00:08:30] I'm very cognizant of looking at all of the ingredients that are in all of these different foods,

[00:08:37] and you look at something that appears so innocent.

[00:08:40] You hear that yogurt has probiotic properties, and then you look at the amount of sugar that is added to so much of the yogurt or so many of these foods,

[00:08:53] and it's absolutely insane to give these things to your children.

[00:08:59] So that has really changed my whole perspective on even my own diet, and what I'm very, very much more aware of looking at packaging.

[00:09:11] Sugar's not the enemy.

[00:09:12] It is added sugar to me that is a huge enemy.

[00:09:16] And when you think about what this stuff does in your gut, and what it does to your proteins and your peptides,

[00:09:23] and how your immune system is just attacking all of this extra sugar that's latching on places where it's not supposed to be,

[00:09:32] that stuff doesn't just stay in your gut.

[00:09:34] Your body's a connected entity, and if you have gut inflammation, that gut inflammation is going to turn into some degree of neuroinflammation.

[00:09:43] We say leaky gut, leaky brain.

[00:09:46] Absolutely.

[00:09:47] I'm curious to hear more about mast cell-mediated comorbidities.

[00:09:52] I have this patient, and I've recognized the same pattern in other patients and have not been successful in treating their condition,

[00:09:59] but it is primarily female.

[00:10:03] Come to me, typically either postpartum or kind of postmenopausal, but not in that immediate time frame.

[00:10:12] Not one to six months after, but maybe even second pregnancy and within nine months to a year.

[00:10:22] I think the number one symptom is chronic insomnia.

[00:10:29] Not responsive to several different types of sleep medications, severe anxiety, a lot of rumination, a lot of contamination type concerns in terms of the OCD.

[00:10:45] And maybe they've had anxiety in the past, but it has not.

[00:10:49] They've never had the severity of symptoms that they have now.

[00:10:55] And by the way, I don't treat mast cell activation.

[00:10:57] It's not in my scope of practice.

[00:10:59] No.

[00:11:00] But I have it.

[00:11:01] I have it.

[00:11:02] Yeah.

[00:11:03] And I have a lot of patients that have it.

[00:11:05] And so I've gotten pretty deep into it, and I do a lot of education on it for clients, but I don't actually make the recommendations.

[00:11:13] I will often tell them, you might mention these four things to your functional medicine doctor because people are stuck.

[00:11:20] A lot of docs, as you know, have habits, and they're using the same five tools every day.

[00:11:24] And sometimes that doesn't work for an individual patient.

[00:11:26] Yeah, I actually got it from mycotoxin toxicity in my home, and the majority of people who are, well, not everyone who's exposed to mold is sensitive and is going to become sick from it.

[00:11:37] But those of us who do, the majority of us do wind up with MCAS.

[00:11:43] So the mast cells are on alert, and they're spewing histamine and also cytokines.

[00:11:50] So when you notice that people can't sleep, it's specifically 3 a.m.

[00:11:54] They wake up at 3 a.m.

[00:11:56] That's when you get a big histamine dump, and they can't go back to sleep.

[00:11:59] The way that I, because I had an atypical case of MCAS, they didn't have typical symptoms.

[00:12:04] I actually wound up diagnosing it myself.

[00:12:07] And I ran a blood test.

[00:12:09] My histamine was sky high.

[00:12:10] And I thought, oh, and I added 3 grams of quercetin and instantly slept amazingly.

[00:12:15] Like, I'm talking within 3 or 4 days.

[00:12:18] So it's, in fact, I was a complete responder to quercetin.

[00:12:22] I no longer use that.

[00:12:23] But interestingly, when I first figured out I had MCAS, I looked at the supplements that I take and drugs that I take.

[00:12:30] And I ran Medline searches on all of them and found out that 12 of them improve mast cell function.

[00:12:36] And so people are probably already using some things that help, and you can capitalize on that, in addition to adding medicines and supplements that are really heavy hitters for mast cell.

[00:12:48] A lot of people use H1 blockers, like Claritin, Zerotac, Allegra.

[00:12:53] You're blocking histamine.

[00:12:54] You're not preventing its production.

[00:12:57] I've never used the blockers for my own health.

[00:13:00] Some people have to for symptoms relief, but using them chronically inhibits the production of DAO, which is an enzyme that the body makes to break down histamine.

[00:13:09] And so you're working against yourself there.

[00:13:12] And what else can you use?

[00:13:14] I mean, there's supplements.

[00:13:15] There's also practices.

[00:13:17] Mast cell activation, POTS.

[00:13:19] They're, some of us consider them limbic system disorders.

[00:13:23] It's connected with inflammation, vagus nerve function.

[00:13:26] People who've done programs like DNRS, Dynamic Noreware Training System, Gupta Program, Primal Trust, which capitalize on, you know, training HRV, training the vagus nerve and calming the limbic system.

[00:13:41] Some people have complete resolution of their MCAS and POTS doing that.

[00:13:46] So it's not.

[00:13:47] Do you know of any like residential treatment programs that, that specialize in that?

[00:13:53] Or where do you send patients when, when you see them and you suspect MCAS?

[00:13:58] It's not, it's not something that you send to residential because it's such a long-term process.

[00:14:03] It took me three years to figure mine out.

[00:14:05] And I would say that's short.

[00:14:07] And it's still not figured out because I keep getting, I keep growing ectopic tissue and I've had my second cardiac ablation now.

[00:14:16] So heart stuff is part of mine and that's still there.

[00:14:19] And even though I have no other symptoms that has come back now.

[00:14:24] So how do you balance?

[00:14:27] Because, you know, I think that, that at least the, some of the patients that I've seen, they have taken measures to, and a lot of people will not believe that it is mycotoxin related.

[00:14:38] A lot of providers will tell them that that is not the source of your symptoms.

[00:14:42] But then I do also see obsessive compulsive symptoms that are then interfering with the ability to get treated.

[00:14:49] Right.

[00:14:50] And the OCD gets worse because of the inflammation.

[00:14:53] Exactly.

[00:14:54] But, but even after moving homes and changing cars and cleaning, and then that's another thing, the cleaning aspect can then induce its own mass cell activation symptoms as well.

[00:15:08] Right.

[00:15:08] Like cleaning products.

[00:15:10] Yeah.

[00:15:11] Oh, well, you don't clean with that.

[00:15:13] You, you learn from like, I, I hired experts to teach me exactly what to do and you don't use traditional cleaning products.

[00:15:21] In fact, cleaning is not what you do.

[00:15:23] Right.

[00:15:24] You throw things out and you remove mold.

[00:15:26] If you, if you clean mold, if you pissed it off, like if you use bleach, it will spore.

[00:15:30] It'll make more.

[00:15:31] You don't want to, to hurt it.

[00:15:34] You don't want to harm it or try to kill it.

[00:15:36] You want to remove it.

[00:15:37] And there are techniques for that.

[00:15:39] It's extremely time consuming when people are very, very sick, they can't do it.

[00:15:43] And they end up, I got rid of 98% of my belongings.

[00:15:48] And I had some things professionally claimed by people with experience in this.

[00:15:52] And, you know, and when I, when I move homes, uh, I have to own two homes or rent two homes for a period of like two months.

[00:16:00] So I pay a lot of extra money in rent, mortgage, et cetera, because I am testing the new one before I move in.

[00:16:08] So there's a lot of additional expense and time and effort.

[00:16:13] If somebody is sensitive to mold.

[00:16:16] MCAS comes from lots of things other than mold.

[00:16:18] Like actually, um, mast cell dysfunction is inherent in ADHD.

[00:16:23] I've got a whole lecture on that from AppSard from two years ago, actually.

[00:16:27] And so that makes 50% of these folks hypermobile.

[00:16:30] They don't all have, uh, Ehlers-Danlos syndrome, but they're 50% are hypermobile.

[00:16:34] Um, it also really contributes to why so many people with ADHD have apnea because they don't have the connective tissue to support the airway.

[00:16:42] You were asking about comorbidities that I see that impact people's mental health.

[00:16:46] Mass cell dysfunction ends up impacting many areas of mental health.

[00:16:50] Yeah.

[00:16:51] And how do you balance, you know, not, uh, not furthering the, the OCD, which can get to delusional, uh, a place of, you know, I'm, I'm, I am directly harming all these people around me.

[00:17:03] And even though you've removed all of these different, uh, potential, uh, triggers, not to say there are not other environmental triggers that may trigger those, uh, MCAS symptoms.

[00:17:13] But, and again, I'm not saying that I believe this, but typically what is taught in psychiatric practice is to not feed into the rituals to provide reassurance without kind of feeding into them.

[00:17:25] But also you and I have a, again, like I mentioned early, a vitally important task as a provider to ensure that what we're seeing does not have a, a medical cause.

[00:17:36] But how do you kind of play that balancing act?

[00:17:43] I'm not sure that I thought about it that way.

[00:17:46] Interestingly, one thing I do is I tell my patients who have mold or MCAS problems to stay off of the forums.

[00:17:55] Because that's where the fear mongering happens.

[00:17:57] That's where all the negativity, the crazy, like some guy sleeping in a plastic bag.

[00:18:01] So he doesn't like detox onto his sheets.

[00:18:04] I mean, I mean, like, you know, um, I, I do have patients who have gone out and lived in the desert in a tent.

[00:18:11] You know, I have a guy who built himself a tiny house and I have somebody else who moved into an airstream.

[00:18:16] I mean, I do have these people who have taken extreme measures and whose entire life is about this now.

[00:18:22] Don't know what to do about that.

[00:18:24] Yeah.

[00:18:24] Yeah.

[00:18:25] Also, interestingly, my wife and I were talking about this one day.

[00:18:30] Just in general, talking about, um, mold and, and what the, you know, effective of mold is as a mycotoxin versus just as something that a lot of people don't have this, uh, kind of immune system reaction to.

[00:18:44] Within hours, she was getting pop-ups on her phone for these websites talking about mold, kind of leading you to these message boards.

[00:18:55] Um, that was really a little disconcerting for that to happen just from us having a conversation.

[00:19:01] And again, I think we all realized that, you know, our phones listen to what we're doing and then target advertising and marketing efforts to us.

[00:19:10] But I can imagine that that probably plays into this problem societally and take something that has a, a biologic basis, but then adds this intense psychological comorbidity on top of it.

[00:19:23] Mm-hmm.

[00:19:24] I think that there, there is a culture around it.

[00:19:26] It's just like, I mentioned the website, uh, surviving antidepressants.org.

[00:19:31] Great place to get some information.

[00:19:33] Um, but there are also like, there are people on there that are quite positive and there are people where there's a lot of fear mongering and negativity, and you're going to find that in any forum.

[00:19:41] And so when I do recommend a forum to a client, this is always a caveat that I mentioned that there, there people form communities.

[00:19:52] They call it a community.

[00:19:53] They're not meeting face to face.

[00:19:54] They're not sharing emotions.

[00:19:55] They're not seeing each other's eyes.

[00:19:58] Right.

[00:19:58] But form these communities around these topics.

[00:20:01] Um, and I think a lot of misinformation gets spread that way.

[00:20:05] And a lot of fear.

[00:20:05] I think that our phones are slowly killing us in this, in this way of, um, creating this false sense of what our lives should look like promoting all of the positive.

[00:20:17] And I think that really does feed back to our minds in this comparison way of look at what these other people are doing in their ability to survive out here.

[00:20:27] But the problem is that we are aware of all the great things that are going on in people's lives directly via social media.

[00:20:34] But then you look at the news and you, you, you look at so many alternative forms of media.

[00:20:40] You watch videos of, for example, a car accidents or major, you know, accidents happening.

[00:20:46] And you think, oh, that doesn't feed back because consciously I realized that I'm not there.

[00:20:52] But I truly believe that our subconscious logs all that information.

[00:20:57] And then if you're driving down the road and you, you notice your mind kind of thinking about the possibility of veering off the road or thinking about somebody.

[00:21:08] For example, like having a seizure and veering into you and your kids when you're in the car.

[00:21:14] You think, oh my gosh, I must be crazy that I would have that thought.

[00:21:18] But it's really your mind feeding back the stuff that it knows is possible that could threaten your survival.

[00:21:25] And your mind thinks it's helping your survival and making you aware of something.

[00:21:29] And if it was just one incident or one example, then it would, that would be fine.

[00:21:33] But when you're getting fed hundreds, if not thousands of these examples every single day, your mind is firing off all of these false threats to your survival.

[00:21:45] And that directly feeds back to the amount of information that you are exposing yourself to and the types of information that you're exposing yourself to.

[00:21:54] It allows our minds to connect more things together and make more relationships between what may seemingly be unrelated objects or ideas.

[00:22:05] And that's good for innovation, but it's also, again, drives that survival sense of our brain, that limbic system to recognize so many more things that could hurt us.

[00:22:16] And so many more things that it thinks we should be doing that we're not doing that would be pro-survival.

[00:22:23] And all of that can leave you feeling overwhelmed or guilty and shameful that I'm not doing more.

[00:22:31] That's a big thing that I try to talk to my patients about.

[00:22:35] And in the context of that OCD discussion, I mean, it's such a hard thing to get my patients to be open to, though.

[00:22:43] Hey, you might feel a lot better if you turn your phone off between the hours of 1 to 5 p.m., if you can, obviously.

[00:22:51] And go without that information.

[00:22:53] Go outside.

[00:22:54] Be in nature.

[00:22:56] Breathe.

[00:22:57] Meditate.

[00:22:59] Defuse your thoughts, etc., etc.

[00:23:01] Something else that you do that I think is worth mentioning, you use a lot of anti-inflammatory agents or anti-inflammatory recommendations, which I think is so important.

[00:23:12] Recommendation, not agents.

[00:23:13] Not agents.

[00:23:13] Well, actually, you know, N-acetylcysteine is anti-inflammatory.

[00:23:17] Yeah.

[00:23:18] Yeah, yeah.

[00:23:18] But if somebody says you use anti-inflammatory agents, I'm thinking menocycline, infliximab, aspirin, celecoxib.

[00:23:28] No.

[00:23:29] Because honestly, if someone has chronic inflammation, they actually need to be able to...

[00:23:36] I'm not going to go down the rabbit hole, but they do need to be able to maintain an active immune system in order to deal with that.

[00:23:43] And you can make them worse.

[00:23:44] I learned this from...

[00:23:46] And I have an omia.

[00:23:47] So sometimes I can't come up with the names that I want, but I will think of his name.

[00:23:51] And...

[00:23:52] That's the first time you've not been able to come up with somebody's name in the nearly two hours I've been talking to you.

[00:23:57] It happens to me all the time.

[00:23:59] In his studies with infliximab, anybody who had a high sensitivity CRP level of five or greater, they were able to get them better if it was less.

[00:24:08] They couldn't.

[00:24:09] So that's one thing.

[00:24:10] And he says in clinical practice, he would go with a cutoff of three.

[00:24:12] And CRP is a proxy for interleukin-6.

[00:24:15] You can't measure interleukin-6 directly.

[00:24:17] It's offered by the labs, but from a practical standpoint, you'd have to stick the person six times a day.

[00:24:22] And if they're female and ovulating, you would have to stick them 30 days a month to get it accurate.

[00:24:29] So we use CRP as a proxy.

[00:24:31] For it to work, it has to be high enough and it should be acute inflammation.

[00:24:35] So those interventions are not ready for prime time.

[00:24:38] And every year when I see this person whose name I can't come up with, every year when I see him, I ask him his opinion.

[00:24:44] And for the past 10 years, he's been telling me the same thing.

[00:24:47] And he's a leader in that field.

[00:24:49] But in terms of reducing inflammation in general, diet, sleep, exercise, meditation, lifestyle.

[00:24:58] I was going to say the first.

[00:24:59] There's a lot of supplements that help, but it's not, you know.

[00:25:02] But the first thing to do is to identify things that you can remove from a person's life that are contributing to their inflammation.

[00:25:11] Things like sugar, processed food, alcohol, kind of systematically working with their diet to find any potential food allergens.

[00:25:19] And then you can look at some of those other things.

[00:25:22] What I wanted to ask you about is because I didn't see it in your outline is my whole philosophy around my practice and what I would consider to be how successful my patients are really changed with utilizing the anti-inflammatory agent at the low doses of lithium.

[00:25:42] Linked to GSK3 beta inhibition, which causes all of this downstream anti-inflammatory response, but without knocking out the immune system.

[00:25:50] It actually seems to optimize immune system function.

[00:25:55] And then neuroinflammation is something that's so important to consider in terms of your treatment.

[00:26:01] I'm going to take a lot away from this conversation and the outline that you sent me about some of your common practices.

[00:26:08] I want to hear more about what you know about low-dose lithium.

[00:26:12] Well, low-dose lithium has been shown, like even at just five milligrams a day, to be preventive of Alzheimer's dementia.

[00:26:19] It is, well, higher-dose lithium is an antiviral.

[00:26:22] We know that if you've got lithium in the water of a municipality, that people there are less likely to be violent.

[00:26:29] There are fewer suicides.

[00:26:30] This has been shown over and over again in big population studies.

[00:26:34] Lithium.

[00:26:34] Groana Moncrief doesn't believe it.

[00:26:37] Well, she doesn't believe that depression is a physiologic process either.

[00:26:42] And she's very vocal about that.

[00:26:45] Yeah.

[00:26:46] Not that we all have to agree on everything.

[00:26:48] We need to be able to have conversations about our disagreements to, again, the pursuit of the scientific truth of things.

[00:26:57] To your point about the antiviral, I never had any cold sore outbreaks until I got to medical school.

[00:27:03] I started having one or two a year, especially if my lip would ever get burnt.

[00:27:07] It was going to happen within the next few days.

[00:27:10] I started taking five milligrams within a couple of months, started taking 10 milligrams of a supplement at 10 milligrams.

[00:27:18] And I knew about the ability for lithium to directly inhibit DNA replication of HSV.

[00:27:25] And within probably three to six months, I stopped having cold sores.

[00:27:30] I've been on it for three years and I haven't had a cold sore.

[00:27:34] You're using five or two milligrams of orotate?

[00:27:36] Orotate, yeah.

[00:27:37] Yeah.

[00:27:38] In the literature, that's not the doses that are preventing HSV replication.

[00:27:43] They're all bipolar doses.

[00:27:46] But personally, that carries a lot of weight with me when I take something and it has an effect on me that's very objective, right?

[00:27:55] I should probably use more lithium.

[00:27:58] I do use nutritional lithium.

[00:27:59] Lithium orotate.

[00:28:00] I'm using it predominantly in clients who have a feeling of anxiety that's fussy, that's edgy.

[00:28:09] And it's got an edge of negativity or irritability to it, especially irritable people.

[00:28:14] This is my number two.

[00:28:16] My number one intervention for irritability is high-dose omega-3 fatty acids.

[00:28:22] And my number two is nutritional lithium because it works and it has these additional benefits.

[00:28:28] I'm not giving it to people to boost their immune system because it's not.

[00:28:31] So I do care a lot about physical illness.

[00:28:35] I ask a lot about it.

[00:28:36] I do a lot of testing around it.

[00:28:37] I do tons of referrals.

[00:28:38] It is not my job to treat directly there.

[00:28:41] It is not in my scope of practice.

[00:28:43] I'm very aware of the medical legal aspects of what I do.

[00:28:47] And so I don't reach out and like I will educate people about, you know, mast cell activation syndrome, for instance, and some of the agents that are used.

[00:28:56] I'll even give them handouts on it.

[00:28:57] I will not make recommendations.

[00:29:00] And with all of those kind of ancillary benefits of it, yeah, I'm right there with you.

[00:29:05] I need a primary reason that I feel comfortable using it, whether it be suicidality or even impulsivity in addiction.

[00:29:15] I've had some success with that.

[00:29:17] There's a psychiatrist in New York, Sadir Gad, who's on the airwaves talking about this a lot and has had a lot of success promoting his recovery center up there to the, I don't know who determines this,

[00:29:32] but some New York state organization ranks the top recovery centers in the state every year.

[00:29:39] And so with his rates of remission, he's been, you know, ranked in that top 1%.

[00:29:46] How about relapse?

[00:29:48] Are they able to track relapse?

[00:29:49] Are they able to track the success of their clients after they leave?

[00:29:52] I think the data goes out to 12 months.

[00:29:55] I'd have to look at what he sent me again.

[00:29:57] But if you just look up low-dose lithium, I think it's called Low-Dose Lithium in the Addiction Setting by GADH, Sadir Gad.

[00:30:05] His research is in there.

[00:30:09] And I'd say that the research itself, there are some holes that you could poke in it.

[00:30:13] But it's a, again, it's an interesting, there's very few articles on lithium use and addiction.

[00:30:19] There's one by somebody named Sartori for alcoholism that goes back to 1987.

[00:30:23] I'm going to grab a book, actually.

[00:30:24] I have a lithium book over here.

[00:30:26] Yeah, let me find it.

[00:30:28] If I have it, if somebody didn't take it, which happens.

[00:30:35] I think it disappeared.

[00:30:36] But it's by Dean Greenblatt.

[00:30:39] And he's an expert in eating disorders.

[00:30:43] Trying to think what else he has.

[00:30:44] True, true expertise in eating disorders.

[00:30:47] And, well, anyway, he runs a functional medicine academy for psychiatry.

[00:30:51] And he has been a proponent of nutritional lithium forever.

[00:30:54] And he wrote this really nice book on it and on how he uses it.

[00:30:57] That might be one of the reasons why I can't keep a job at the recovery center is because the risk management, they see lithium or not lithium.

[00:31:07] And they do not have an appreciation for the dosage used in terms of predicting the risk of it.

[00:31:14] I have had one, maybe two out of probably 500 patients that have had any impact on their thyroid.

[00:31:24] Other than that, there have been maybe some nuisance side effects.

[00:31:29] I had one woman who came to see me for suicidality.

[00:31:34] And unfortunately, I do have limitations in terms of time that I have to spend with a patient.

[00:31:40] And I do hope to get rid of that limitation at some point in my career.

[00:31:44] Probably the most interesting response that I've had to 150 milligrams of lithium carbonate is a female kind of late 30s who came to see me and had her husband actually drive her to the appointment because she was having those visions, those images pop in of driving off the road.

[00:32:04] Oh, she's having intrusive suicidal thoughts.

[00:32:07] Yes. And so her husband drove her and she comes to see me and, you know, they're they're, you know, saying she hasn't had great responses to SRIs in the past.

[00:32:16] And I said, look, I really want to start you on this low dose of lithium as a primary measure to address the suicidality.

[00:32:24] And this has good evidence and it's really safe.

[00:32:27] And so, you know, I ended up seeing her two to three weeks later and she comes back.

[00:32:35] She's like, you know what?

[00:32:36] I didn't tell you this last time, but for the last 20 plus years, every single month, like clockwork, I have a week before I start my period that you can ask my mother, you can ask my husband.

[00:32:51] I am highly emotional.

[00:32:53] I'm having a lot of crying spells.

[00:32:56] I am so irritable.

[00:32:57] It's not enjoyable for anybody to be around me.

[00:33:00] And I feel all this shame and this guilt.

[00:33:02] She goes, I didn't have that this month.

[00:33:04] I'm like, okay, that's interesting.

[00:33:06] But, you know, there, there are some placebo responses.

[00:33:10] That is something more objective that maybe doesn't fall into one person or have you been able to replicate this?

[00:33:16] So this is, this is one person that that has stayed over time too.

[00:33:21] We are now five or six months removed.

[00:33:24] And I've only seen her a couple of times because she's like, this is amazing.

[00:33:28] I don't, I feel so much better and so much more consistent.

[00:33:33] That, that is one of the most interesting, I have not had the same response, but I have, I do have some people on it for things like impulsivity, suicidality, that also have the comorbid PMDD symptoms.

[00:33:47] So I'm really curious to see throughout my course of my career, if I do find more patient characteristics or patterns of who does respond to that.

[00:33:59] I've had other females tell me that it made changes to their cycle that either they started a few days early or it pushed.

[00:34:08] So it, it has this impact on the menstrual cycle.

[00:34:13] I don't fully understand it yet.

[00:34:15] And that's not why I'm using it, but I have seen that as a kind of secondary downstream response.

[00:34:22] And I haven't heard, or I haven't been able to find any literature on that phenomenon specifically.

[00:34:27] So I'm going to run a really fast query on it.

[00:34:30] Okay.

[00:34:32] Drum roll.

[00:34:34] What do you use to query?

[00:34:36] Perplexity AI.

[00:34:38] I've used a number of AI tools for medical queries.

[00:34:42] Most of them come up with stuff that just doesn't exist at all, or that doesn't say what they say it does.

[00:34:48] Perplexity is almost always right.

[00:34:50] Sometimes it does make mistakes.

[00:34:52] When I point it out, it apologizes and produces a better result.

[00:34:56] Yeah, it's great.

[00:34:59] So lithium levels may fluctuate during the menstrual cycle.

[00:35:03] Let's see.

[00:35:03] Pilot study on lithium carbonate for premenstrual tension.

[00:35:05] Lithium genealate ineffective.

[00:35:08] Well, all right.

[00:35:09] The thing about studies too is like methodology.

[00:35:13] Despite some statistics and significant improvements recorded by symptom rating instruments.

[00:35:18] We don't have a rating instrument for this exactly.

[00:35:21] Benefits not of clinical value.

[00:35:22] You know what?

[00:35:24] This is a problem.

[00:35:25] This is what I was saying before about like, before I use a tool, what do I do?

[00:35:29] I want to read a number of studies.

[00:35:30] I want to talk to my colleagues.

[00:35:32] I want to talk on my list serves about it.

[00:35:34] I want to get a real world impression of what something does.

[00:35:39] Like you're giving me really valuable real world information.

[00:35:41] I'm going to check that out.

[00:35:42] If nobody's publishing on it yet, it doesn't mean it's not there.

[00:35:45] My number one tool for hypervigilance is lamotrigine.

[00:35:49] I can get it to work and get an usually a hundred percent response 90% of the time, not a single paper on it.

[00:35:57] Yeah.

[00:35:58] Everything we do is published.

[00:36:00] Right.

[00:36:01] I know.

[00:36:02] I know.

[00:36:02] And that, and that stuff, when you see it that directly, and I am, I am so cognizant of the risk of my own bias and of the risk of somebody having a placebo response.

[00:36:13] That example, you cannot correlate that with a placebo response.

[00:36:18] I really, really asked a lot of questions of my patient on the couple of follow-ups I've had about other changes that she may have made.

[00:36:27] And there was really not anything else.

[00:36:30] And it was such a direct within a few days to a week, you know, had that response, which I do have patients who have, you know, what, what is called a lithium super responder.

[00:36:41] Most of them, I would say are more of a three month response where they look back and it's almost like an occult improvement.

[00:36:50] It's a, I always use.

[00:36:51] The fan response.

[00:36:52] That's a Yanis Rubikowski's term.

[00:36:55] Oh, I got Yanis Rubikowski coming on in a couple of weeks here.

[00:36:59] I love him.

[00:37:00] He presented at APA on the long-term ancillary benefits of lithium and sent me that PowerPoint.

[00:37:08] And I read, I mean, I've got a stack of those printed out on my desk for patients to take because the reality is I am a younger psychiatrist.

[00:37:19] I have not been in independent practice for a decade.

[00:37:23] I've been seeing patients at this point for a decade.

[00:37:25] So I understand that some of my patients may have a bias that, well, I don't, I don't, I don't know that you've been around long enough.

[00:37:34] And so I try to supplement with, you know, Hey, this is not just little old Ethan short from a Louisville, Kentucky saying this, this is coming from people who have a lot more cloud, a lot more respect nationally, internationally in the field.

[00:37:49] And that's where I get my information of.

[00:37:52] And that really is besides what I see directly in my patients.

[00:37:55] It is like you're talking about with your listservs.

[00:37:58] It's let's talk to the actual experts, the people that psychiatrists and psychiatric practitioners have the most faith in.

[00:38:08] Not the ones that are just promoted from the business side of things, but the ones that folks like you and me have the most respect for that make the most sense logically, critical thinking wise, and in their understanding of the available research out there.

[00:38:24] It's interesting because the only time that I have to listen to podcasts is when I'm doing other things.

[00:38:30] And so it amazes me that people will sit in front of a screen and watch.

[00:38:33] It's one of the reasons why I don't mind traveling.

[00:38:35] If I have to travel throughout the state for work or something, I really don't mind it because it gives me plenty of time to catch up on Carlet Psychiatry and David Pewter's podcast.

[00:38:48] Don't know that one.

[00:38:49] No.

[00:38:50] What podcasts do you like to listen to?

[00:38:52] I listen to, you know what, I do so many that I would have to get out my podcast app to tell you, but I definitely listen to Carlot and I listen to, there's another one called Psychopharmacology Updates that I find worthwhile.

[00:39:10] And Peter Atiyah's podcast.

[00:39:13] He's much more allopathic than functional medicine in the topics that he discusses, but I find a lot of value in his discussion of cardio metabolics in particular.

[00:39:23] Found My Fitness, Rhonda Patrick.

[00:39:25] I do listen to some Dave Asprey and some Chris Cressor.

[00:39:30] And let me see what else.

[00:39:32] Ben Greenfield sometimes.

[00:39:33] What do you listen to when you're like, I'm tired of thinking about psychiatry and mental health.

[00:39:38] And medicine?

[00:39:39] I'm never tired of it.

[00:39:41] I'm never tired of it.

[00:39:43] What do you listen to when you're not listening to a medical podcast?

[00:39:47] Music.

[00:39:49] Okay.

[00:39:49] What's your favorite kind of music?

[00:39:52] Well, like last night I was listening to Etta James and Jim Christie.

[00:39:57] I tend to listen to anything from the teens through the late 40s.

[00:40:02] And sometimes I get into the 70s or 80s, but usually earlier stuff.

[00:40:06] My dad was a trumpet player.

[00:40:08] He played big band when he was young.

[00:40:10] Yeah.

[00:40:10] Cool.

[00:40:11] My wife and I went to a, there's a music festival here in Louisville this weekend called Bourbon and Beyond.

[00:40:18] And so we, we went last night.

[00:40:21] We saw Maren Morris.

[00:40:23] She's a big Maren Morris fan.

[00:40:25] Then we saw Matchbox 20.

[00:40:28] And then it was, oh, there was somebody else before Sting came on.

[00:40:35] Oh, wow.

[00:40:36] Yeah.

[00:40:37] It was, it turned out to be a pretty good time.

[00:40:39] That must've been really fun.

[00:40:40] Yeah.

[00:40:41] Yeah.

[00:40:42] We had to leave about halfway through Sting because we had our two babies at home that we had to get home.

[00:40:48] Oh, you have two small people.

[00:40:50] Yeah.

[00:40:51] I've got, yeah.

[00:40:52] I actually, today is my daughter's first birthday.

[00:40:55] Oh my gosh.

[00:40:56] Congratulations.

[00:40:58] Yeah.

[00:40:58] So we went out and got some coffee this morning and we're going to have a very small first birthday party at the park on Sunday.

[00:41:06] Oh, that's sweet.

[00:41:08] Where are you located physically?

[00:41:10] Louisville, Kentucky.

[00:41:12] Okay.

[00:41:13] As we call it here, Louisville.

[00:41:15] That's the, that's our hallway.

[00:41:17] That's how we know if somebody's not from Louisville is when they say Louisville.

[00:41:21] But I usually try to help people out who aren't from here and say Louisville, Kentucky.

[00:41:25] We have one here at Louisville.

[00:41:27] Thanks again for watching and or listening.

[00:41:30] If you're passionate about the subjects that I discuss on the channel, do me a favor and like, comment, subscribe.

[00:41:39] Do whatever you can to make your voice heard that these are problems that must be addressed in our society.

[00:41:48] If you have any questions, comments, or concerns, I want to hear them.

[00:41:53] Feel free to reach out on social media or email us at renegadesyke at gmail.com.

[00:42:00] And if you'd like to be a guest of the show or you have a connection to somebody that you think would be a good guest, let us know.

[00:42:09] Thanks again for listening.

[00:42:19] Disclaimer.

[00:42:19] This podcast is for informational purposes only.

[00:42:21] The information provided in this podcast and related materials are meant only to educate.

[00:42:24] This information is not intended as a substitute for professional medical advice.

[00:42:27] While I am a medical doctor and many of my guests have extensive medical training and experience,

[00:42:30] nothing stated in this podcast nor materials related to this podcast, including recommended websites, texts, graphics, images, or any other materials,

[00:42:36] should be treated as a substitute for professional, medical, or psychological advice, diagnosis, or treatment.

[00:42:39] All listeners should consult with a medical professional, licensed mental health provider,

[00:42:43] or other healthcare provider if seeking medical advice, diagnosis, or treatment.