WEBVTT 00:00:00.000 --> 00:00:10.020 Welcome to today's episode of Medically Speaking. I'm super excited to have a great guest with us 00:00:10.020 --> 00:00:15.560 today. We have Dr. Allure with us today from our behavioral health team and today we're going to 00:00:15.560 --> 00:00:20.420 talk about mental illness and some of the treatments and the opportunities that we have 00:00:20.420 --> 00:00:25.580 in our community to improve some of the care and some of the latest treatment modalities that are 00:00:25.580 --> 00:00:29.980 available. We're going to touch on some of the inpatient treatment options as well as outpatient 00:00:29.980 --> 00:00:35.820 treatment options, and just mental health in general. Interestingly, the month of May is Mental 00:00:35.820 --> 00:00:41.180 Health Awareness Month, so I think the timing is just about right. So with that, I'd like to 00:00:41.180 --> 00:00:46.040 maybe introduce Dr. Allure and welcome him to the podcast. And Dr. Allure, maybe just tell us a 00:00:46.040 --> 00:00:51.060 little bit about yourself and your background. Yeah, thank you, Dr. Logan, for giving me this 00:00:51.060 --> 00:01:03.860 opportunity to speak in this podcast. So I'm Dr. Lohr. I joined Self-Regional Health in October 00:01:03.860 --> 00:01:09.140 last year as a staff psychiatrist and a medical director for the Psychiatric Services. 00:01:09.140 --> 00:01:16.820 So since then, I'm excited to be here, looking forward for our vision of 00:01:16.820 --> 00:01:25.020 high quality accessible care in this regional health system and which is serving the seven 00:01:25.020 --> 00:01:34.020 county area so awesome yeah well thank you so we have really seen growth I guess in mental health 00:01:34.020 --> 00:01:38.320 illness and not something to kind of growth you necessarily want to have but we certainly want to 00:01:38.320 --> 00:01:45.040 be here to help folks and maybe you can tell me a little bit about some of the services that we 00:01:45.040 --> 00:01:50.620 offer at self regional just in general and in some of your experiences here so 00:01:50.620 --> 00:01:56.320 far yes a little bit of work my background is I I grew up on and raised 00:01:56.320 --> 00:02:01.800 in India and went to medical school in South India and after that I was trained 00:02:01.800 --> 00:02:06.640 in Thomas Jefferson University in Philadelphia Pennsylvania then spent 00:02:06.640 --> 00:02:11.740 significant amount of time in the rural Missouri for seven years you know 00:02:11.740 --> 00:02:17.560 completing the Delta waiver programs and see you know what type of the services 00:02:17.560 --> 00:02:22.780 there is a community need for those kind of behavioral health services and you 00:02:22.780 --> 00:02:27.880 know how to improve the services how to engage in the community stakeholders and 00:02:27.880 --> 00:02:31.760 improving the bringing the highly accessible care to the rural area so 00:02:31.760 --> 00:02:40.740 with that our self regional health as a both inpatient and outpatient services 00:02:40.740 --> 00:02:45.580 Inpatient currently has 17, 36-bedded, 00:02:45.580 --> 00:02:50.540 and currently admitting age group of 18 to 65 00:02:50.540 --> 00:02:52.860 for the patients suffering from depression 00:02:52.860 --> 00:02:56.240 with suicidal thoughts, schizophrenia, 00:02:56.240 --> 00:02:59.440 and other related psychosis, bipolar disorders, 00:02:59.440 --> 00:03:04.440 dual diagnosis, and patients who are just feeling 00:03:04.440 --> 00:03:08.660 unsafe at home and having the underlying 00:03:08.660 --> 00:03:15.440 mental health you know diagnosis these are the common admitting diagnosis and 00:03:15.440 --> 00:03:20.120 admitting problems on our inpatient at self regional health so and in the 00:03:20.120 --> 00:03:25.640 outpatient we are treating the patients with the depression anxiety comorbid 00:03:25.640 --> 00:03:32.000 substance use disorders PTSD and other trauma related disorders and bipolar 00:03:32.000 --> 00:03:36.500 disorders even schizophrenia we just now added addiction medicine as a 00:03:36.500 --> 00:03:42.160 a co-located and collaborative care model into that and to bringing whole spectrum of 00:03:42.160 --> 00:03:49.760 services to the our outpatient at Western Carolina Psychiatric Services. Okay let's talk about the 00:03:49.760 --> 00:03:54.980 inpatient side maybe a little more detail then we can dive into the outpatient world a little bit 00:03:54.980 --> 00:04:03.080 more too. So like what's the typical path if someone does have a mental illness and they need 00:04:03.080 --> 00:04:05.900 to be admitted to an inpatient psychiatric unit. 00:04:05.900 --> 00:04:11.320 How is that decision made, and what's the usual process to get plugged into the system? 00:04:11.320 --> 00:04:19.400 When the patient has severe depression or is not able to do significant impairment in 00:04:19.400 --> 00:04:23.840 their activities of daily living, it could be social functioning in terms of relationships. 00:04:23.840 --> 00:04:30.260 Or if they're students, they're struggling with academics due to academic stresses, or 00:04:30.260 --> 00:04:36.620 Or if they're working in some kind of job here they're struggling at the job. 00:04:36.620 --> 00:04:40.800 So these kind of significant impairment with underlying depression, if they continue to 00:04:40.800 --> 00:04:48.400 have thoughts of self-harm or suicidal thoughts, then that's a reason for, you know, to visiting 00:04:48.400 --> 00:04:50.500 our emergency room. 00:04:50.500 --> 00:04:55.840 And we have a trained behavioral health assessment team. 00:04:55.840 --> 00:04:57.500 We go by BHAT. 00:04:57.500 --> 00:05:00.260 They are essentially a mental health screeners. 00:05:00.260 --> 00:05:02.720 They are the conduit between the emergency physicians 00:05:02.720 --> 00:05:06.860 and the inpatient psychiatrist who provide the care. 00:05:06.860 --> 00:05:09.200 They go and evaluate, assess the need 00:05:09.200 --> 00:05:11.100 and the level of care they need 00:05:11.100 --> 00:05:12.900 in terms of medication management 00:05:12.900 --> 00:05:14.680 or inpatient level of care 00:05:14.680 --> 00:05:17.100 or even outpatient level of care. 00:05:17.100 --> 00:05:20.880 They discuss with the on-call psychiatrist 00:05:20.880 --> 00:05:24.900 who is an MDR devo and come up with a plan for them 00:05:24.900 --> 00:05:29.340 admitting or discharging or even transferring if we are not able to 00:05:29.340 --> 00:05:35.460 provide any care at the inpatient level so and the another condition is first is 00:05:35.460 --> 00:05:39.360 depression second is severe psychosis having you know various types of 00:05:39.360 --> 00:05:44.420 perceptual disturbances the auditory and visual hallucinations various delusions 00:05:44.420 --> 00:05:51.340 and even agitations from the agitation irritability from the underlying mental 00:05:51.340 --> 00:05:58.020 illness and bipolar disorders are the indications for admissions. Yeah, so I know you know I'm an 00:05:58.020 --> 00:06:04.940 ER physician too in my background working in the ER and taking care of mental illness problems over 00:06:04.940 --> 00:06:10.120 the years. I have seen a lot of improvement I think in some of the services that we offer on 00:06:10.120 --> 00:06:15.920 the inpatient side and I think you just hit on it that behavioral health assessment team, that 00:06:15.920 --> 00:06:21.780 BHAT team. They are really key to the whole process. You know, as an ER physician, you know, 00:06:21.780 --> 00:06:28.160 I'm really good at identifying medical issues and really kind of ruling some things out. But once 00:06:28.160 --> 00:06:32.480 you've kind of ruled out those like medical reasons for the way someone's thought processes 00:06:32.480 --> 00:06:39.860 may be going on, it's awesome to be able to have the resources here in our local community to kind 00:06:39.860 --> 00:06:45.000 of take that next step if we need to, say, be admitted for further inpatient treatment. 00:06:45.000 --> 00:06:51.280 Absolutely. So in the medical primary, if there is any underlying medical disorders or neurological 00:06:51.280 --> 00:06:57.700 disorders are involved, our emergency room physicians are excellent, and they're very good 00:06:57.700 --> 00:07:05.620 in what they do in clearing them and finding the way to get them this type of care and the level 00:07:05.620 --> 00:07:12.860 of care they need. As I said, our vision continues to be the same high-quality accessible care 00:07:12.860 --> 00:07:17.300 in our regional health system and our seven-county service area. 00:07:17.300 --> 00:07:18.360 Yeah, absolutely. 00:07:18.360 --> 00:07:24.460 So, yeah, kind of rule out the medical non-mental health issues. 00:07:24.460 --> 00:07:27.920 And once those are kind of ruled out, then the behavioral health assessment team 00:07:27.920 --> 00:07:32.740 and you and your expertise kind of identify kind of next steps 00:07:32.740 --> 00:07:34.240 for those individual patients. 00:07:34.240 --> 00:07:40.000 So I really like that model, and I think it seems to be working pretty well for us here. 00:07:41.380 --> 00:07:48.120 So, all right, so let's say that someone does have, like, say, let's just use an example, severe depression, and they're thinking of harming themselves. 00:07:48.120 --> 00:07:49.420 What's the process? 00:07:49.420 --> 00:07:54.260 And, like, how long does someone usually stay in the hospital, and what happens in the hospital when they're there? 00:07:54.260 --> 00:08:00.280 I'm glad we're having these conversations, you know, as you already said, the May is the Mental Health Awareness Week. 00:08:00.280 --> 00:08:19.260 And the CDC and SAMHSA, with the multiple efforts in the past, like five years ago, they created 988 Suicide Prevention Hotline or Suicide and Life Crisis Hotline, where the patients themselves can call the 911. 00:08:19.260 --> 00:08:31.280 It's a private and confidential conversation to express, you know, what they're feeling inside and connect with the resources and telling them, you know, to guide them in the process. 00:08:31.280 --> 00:08:43.820 And the family members can also call to guide them and, you know, to provide them with the resources and telling, you know, even connecting them with the 911 calls has been very helpful. 00:08:43.820 --> 00:08:50.300 It created some somewhat dent in the suicide rates nationally and also in the state of South Carolina, too. 00:08:50.300 --> 00:08:59.100 And when they come in, there is a thorough assessment for suicide risk and safety assessment that they receive. 00:08:59.100 --> 00:09:08.280 They receive a PHQ, patient health questionnaire, nine questionnaire in the ER and also Columbia suicide severity scale. 00:09:08.280 --> 00:09:16.240 also uh um you know the provided to them and they we had team you know the evaluates ed physician 00:09:16.240 --> 00:09:21.760 does that as well there are multiple eyes and multiple hands who are involved in the care 00:09:21.760 --> 00:09:29.360 when the patient comes to the er okay so um let's say the patient gets admitted to the hospital 00:09:29.360 --> 00:09:34.420 and for let's just say severe depression like what what's the treatment that they get while 00:09:34.420 --> 00:09:39.700 in the hospital so traditionally the treatment has been for years the 00:09:39.700 --> 00:09:47.980 medication management then then then came like antidepressants like SSRIs 00:09:47.980 --> 00:09:53.740 which act on the serotonin receptors and norepinephrine SNRIs and atypical 00:09:53.740 --> 00:09:59.020 antidepressants like ibuprofen and remeron and medication has been the 00:09:59.020 --> 00:10:05.080 mainstay and again to supplement that in kind of like a severe cases of major 00:10:05.080 --> 00:10:11.680 depression is psychotherapy and medication management combined are very 00:10:11.680 --> 00:10:17.440 helpful like cognitive behavioral therapy and interpersonal therapy and 00:10:17.440 --> 00:10:22.600 supportive psychotherapy and you know a little bit more advanced psychotherapy 00:10:22.600 --> 00:10:27.640 like psychodynamic psychotherapy would be very helpful but when they usually 00:10:27.640 --> 00:10:31.960 when they get admitted to inpatient floor with this when they're danger to 00:10:31.960 --> 00:10:37.120 themselves or others and they receive thorough psychiatric evaluation and we 00:10:37.120 --> 00:10:42.740 have groups we have individual therapy and recreational activities you know 00:10:42.740 --> 00:10:47.140 where they learn the coping skills and relaxation techniques they get a full 00:10:47.140 --> 00:10:51.900 comprehensive services when they are on the inpatient floor and the psychiatrist 00:10:51.900 --> 00:10:56.440 visit with them every day wrong and assess the need they work with a in a 00:10:56.440 --> 00:11:01.620 social worker on the unit identify and provide the resources for them when they are stable and 00:11:01.620 --> 00:11:08.640 ready to be discharged. That's great. Okay, so let's say that that same patient now is ready 00:11:08.640 --> 00:11:13.680 to go home and they are no longer thought to be a threat to themselves or not want to hurt 00:11:13.680 --> 00:11:18.560 themselves anymore. But you know, the treatment doesn't necessarily end at that point, right? 00:11:18.560 --> 00:11:24.260 Because things, as you know, we all know, life stresses can come back or whatever that was that 00:11:24.260 --> 00:11:30.060 kind of may have triggered that episode may still be out there right so what 00:11:30.060 --> 00:11:33.560 happens when the patient leaves like what are the resources that patients can 00:11:33.560 --> 00:11:38.000 can follow up with when they leave the hospital so I work closely with the our 00:11:38.000 --> 00:11:42.140 unit social workers you know who reach out to the our community mental health 00:11:42.140 --> 00:11:48.480 resources like Beckman mental health and our Western Carolina Psychiatric 00:11:48.480 --> 00:11:57.420 associates and we find a therapist a counselor with the LPC level and also 00:11:57.420 --> 00:12:03.900 you know the psychiatrist or psychiatric providers to you know to continue the 00:12:03.900 --> 00:12:08.460 psychotropic medication management and continue the psychotherapy for them 00:12:08.460 --> 00:12:12.260 wherever they are depending upon the zip code are the counties where they live in 00:12:12.260 --> 00:12:16.980 you know try to connect with them and make the appointment date before they 00:12:16.980 --> 00:12:22.720 leave and make sure the family is also on board with this or they're aware of the discharge plans 00:12:22.720 --> 00:12:29.120 and aftercare plan. So it's really a on the outpatient setting well inpatient too for that 00:12:29.120 --> 00:12:35.020 matter it's a combination of like sometimes medications to to help kind of stabilize the 00:12:35.020 --> 00:12:42.280 the brain chemistry we can think of it that way and then as well as as counseling and following 00:12:42.280 --> 00:12:46.820 up with the mental health specialists like the psychiatrist and or counselors and whatnot in the 00:12:46.820 --> 00:12:51.640 outpatient to try to deal with those ongoing stressors in a way that's more healthy maybe 00:12:51.640 --> 00:12:55.920 we could say that way yeah because there's always going to be like stress right yes something all 00:12:55.920 --> 00:13:02.640 the time improving you know the identifying each uh when they are in the inpatient unit 00:13:02.640 --> 00:13:08.900 psychiatric inpatient unit we have a team interdisciplinary team i would say 00:13:08.900 --> 00:13:14.740 our multidisciplinary team because you have a recreation therapist you have a psychiatric 00:13:14.740 --> 00:13:23.320 social worker, psychiatric nurse, psychiatrist, and we have the other therapist as well, so 00:13:23.320 --> 00:13:32.080 we have, and the bonus is, like, we also have the clinical pharmacist, which is trained 00:13:32.080 --> 00:13:38.960 in psychopharmacology, it's very, very rare to have a clinical psychopharmacologist, which 00:13:38.960 --> 00:13:43.840 did a residency, and helping us out with, and explaining the family and the patient 00:13:43.840 --> 00:13:49.940 about adherence to medications and, you know, about the medications prescribed, how do you 00:13:49.940 --> 00:13:53.120 take them, you know, where do you get them, arranging the medications. 00:13:53.120 --> 00:13:56.420 It's a very comprehensive multidisciplinary team. 00:13:56.420 --> 00:14:01.480 You know, we all visit with the patients every Wednesday, and we make the treatment very 00:14:01.480 --> 00:14:02.240 individualized. 00:14:02.240 --> 00:14:08.920 Again, every patient has different needs because their backgrounds are different, you know, 00:14:09.260 --> 00:14:15.900 They grew up in a different, you know, different types of families, you know, without trauma. 00:14:15.900 --> 00:14:22.840 So when we make the treatment, we identify, ask them to state what are the two important things you would like to work on 00:14:22.840 --> 00:14:25.060 and you would like to continue to work on after discharge. 00:14:25.060 --> 00:14:33.840 So then they come up and they learn the coping skills and we make the treatment when suitable for that patient. 00:14:33.840 --> 00:14:35.020 So individualized. 00:14:35.660 --> 00:14:45.200 The same one, when they're leaving, we find a similar therapist and a psychiatrist so that they can continue their care. 00:14:45.200 --> 00:14:49.480 So preventing here, you're also thinking a bigger picture is you are preventing suicide. 00:14:49.480 --> 00:14:54.740 The patient came here for help, and we are providing their psychiatric evaluation. 00:14:54.740 --> 00:15:04.600 You assess the safety and risk, and you address what is driving them to experience these kind of thoughts. 00:15:05.660 --> 00:15:10.800 and you're mitigating the risk, then they continue to get outpatients. 00:15:10.800 --> 00:15:12.760 Yeah, no, that's great. 00:15:12.760 --> 00:15:16.040 You know, another thing that comes to mind that is challenging 00:15:16.040 --> 00:15:21.960 is there's a lot of situations where someone has some type of mental illness, 00:15:21.960 --> 00:15:26.300 whether it be depression or some type of chronic psychotic disease 00:15:26.300 --> 00:15:28.040 or something like schizophrenia or something else, 00:15:28.040 --> 00:15:32.060 and then folks want to try to help themselves a lot, 00:15:32.060 --> 00:15:46.040 And a lot of times people end up getting on substances of some sort, whether it be like using excessive alcohol or perhaps drugs, marijuana, who knows, all types of different medications that people are, I say, illegal drugs. 00:15:46.040 --> 00:15:54.300 We'll say it that way, that people can get on and kind of end up with that dual diagnosis where you've got like a mental illness and also a substance use problem. 00:15:54.300 --> 00:15:56.900 How do we address that situation? 00:15:56.900 --> 00:15:59.140 Yeah, that is very important. 00:15:59.140 --> 00:16:04.700 AND THIS IS ONE OF THE IDENTIFIED COMMUNITY MENTAL HEALTH NEEDS. 00:16:04.700 --> 00:16:12.700 SO WE ARE ABOUT TO MARK ON THE SECOND 2024 COMMUNITY HEALTH NEEDS ASSESSMENT FROM THE 00:16:12.700 --> 00:16:13.940 SOUTH REGION. 00:16:13.940 --> 00:16:22.900 SO ACCORDING TO THE 2022 REPORT, OUR NEEDS IS STILL LIKE PATIENTS WHO ARE SUFFERING FROM 00:16:22.900 --> 00:16:27.140 dual diagnosis primary mental health secondary substance use disorders and 00:16:27.140 --> 00:16:32.800 who has solely just without any mental health we have substance use disorders 00:16:32.800 --> 00:16:37.240 prevalent one is opiate use disorders stimulant use disorders like cocaine use 00:16:37.240 --> 00:16:42.100 disorders alcohol is disorder is a big one again so when they come in we assess 00:16:42.100 --> 00:16:47.500 first thorough psychiatric evaluation I'm getting a detail the history of the 00:16:47.500 --> 00:16:54.380 drinking, detail a history of the underlying past psychotic disorders like depression or 00:16:54.380 --> 00:17:03.060 schizophrenia or bipolar disorder or anxiety or panic disorders and starting the medication 00:17:03.060 --> 00:17:09.860 first model where you also treat the primary mental health with the psychotropic like antidepressant 00:17:09.860 --> 00:17:14.600 and anxiety or mood stabilizer depending upon the primary mental health diagnosis and the 00:17:14.600 --> 00:17:20.440 secondary substance use disorders like we have naltrexone for all of all you know we have 00:17:20.440 --> 00:17:27.800 gabapentin we have topiramate we have disulfiram you know that model has also helped us to treat 00:17:27.800 --> 00:17:35.880 both mental health and the secondary substance use disorders as well and they also go into crisis 00:17:35.880 --> 00:17:43.160 just like who patients who do not have the um the substance use disorders the the plain mental 00:17:43.160 --> 00:17:49.480 health and i would say you know it's pretty hard because there are like 40 to 60 percent of the 00:17:49.480 --> 00:17:55.560 mental health disorders like are comorbid with substance use disorders it's very difficult to 00:17:55.560 --> 00:18:02.120 tease out okay this which came first you know and there is a um that's the reason why we have you 00:18:02.120 --> 00:18:07.320 know we have to make sure that in all the dual diagnosis is treated and mental health is treated 00:18:07.320 --> 00:18:12.040 and when they are stable and ready to be discharged again individualized treatment plans 00:18:12.920 --> 00:18:19.320 they go to substance use follow-up where we have in town is a greenwood cornerstone and abbeville 00:18:19.320 --> 00:18:24.840 cornerstone and for the patient residents living in there where the intensive outpatient program 00:18:24.840 --> 00:18:29.560 for drug and alcohol referral we provide we provide the psychotropic medicate medication 00:18:29.560 --> 00:18:35.240 support and they can go to attend the groups there in the intensive outpatient three times a week 00:18:35.240 --> 00:18:42.440 three days a week and they interact with the therapist and counselor there so you are taking a 00:18:42.440 --> 00:18:47.720 full a full comprehensive approach for the recovery is not just treating mental illness 00:18:47.720 --> 00:18:54.360 and discharging them your take addressing all the issues so um it's been working and um um 00:18:54.360 --> 00:19:01.640 and because this is a huge need in the community so yeah absolutely you know we just um our self 00:19:01.640 --> 00:19:07.000 regionals just received a nice grant from the state to start a medication assisted treatment 00:19:07.000 --> 00:19:12.640 for opiate abuse disorder and maybe you could talk about that unit a little bit kind of what 00:19:12.640 --> 00:19:19.100 some of the goals of that area are this is exactly the right time again so the grant for the medical 00:19:19.100 --> 00:19:25.580 stabilization unit and the continuity of care in terms of partial hospital program or intensive 00:19:25.580 --> 00:19:30.140 outpatient program for the patients with the substance use disorder mainly opioid use disorder 00:19:30.140 --> 00:19:35.960 because this is a continue to be one of the cause and which is driving the increased rates of 00:19:35.960 --> 00:19:43.000 national suicide, you know, again, South Carolina ranks 29th in the state for the suicide rates, 00:19:43.000 --> 00:19:53.140 deaths by suicide, and it's still, like, the number of suicide deaths are, like, 00:19:53.140 --> 00:19:58.280 one percentage point higher than the national average still. Our neighboring Georgia is a 00:19:58.280 --> 00:20:05.280 little bit less, you know, but we continue to, again, this is a public health problem. Suicide 00:20:05.280 --> 00:20:11.120 is a public health problem so the illicit opiates and even the prescription opiates they continue to 00:20:11.120 --> 00:20:17.200 drive these rates of suicide so when you when you look at the rates of suicide nationally they're 00:20:17.200 --> 00:20:22.400 actually they're increased a little bit you know i would say not very significant but they're 00:20:22.400 --> 00:20:29.920 increased um now cdc they started and samsung reviewing what exactly happened we are coming 00:20:29.920 --> 00:20:35.600 out of COVID the last three years and increased access to these prescription and illicit opioids 00:20:35.600 --> 00:20:43.200 like fentanyl. So that was the reason why it really made sense to start this medical stabilization 00:20:43.200 --> 00:20:49.240 unit at Self Regional. And when they are stable or when they started on buprenorphine, which is 00:20:49.240 --> 00:20:55.140 a standard of care for opioid use disorder, you initiate the buprenorphine induction. And 00:20:55.140 --> 00:21:00.180 you know when they are stable within three to four days you find the right dose of buprenorphine 00:21:00.180 --> 00:21:09.980 which is an opioid antagonist combination so we you know we try we transition them to outpatient 00:21:09.980 --> 00:21:17.960 level of care that's the reason why we are on board like dr amber gasper she's and she's very 00:21:17.960 --> 00:21:22.660 interested in addiction medicine she has been doing that and we're transferring the patients 00:21:22.660 --> 00:21:27.720 there so they're receiving the care for the opiate use disorder yeah i think that's a neat 00:21:27.720 --> 00:21:32.780 program that i think is going to grow with a little bit of time as people more folks learn 00:21:32.780 --> 00:21:39.100 about it but the ability to kind of come in and get detoxed in a way um it's kind of i think how 00:21:39.100 --> 00:21:42.660 maybe the community might think about i'm going to go get go through so you don't go through such 00:21:42.660 --> 00:21:47.200 severe opiate withdrawal which can be very severe not necessarily life-threatening but you feel 00:21:47.200 --> 00:21:54.060 terrible when folks are going through that in a way to kind of get off the opiates for folks that 00:21:54.060 --> 00:21:58.720 are ready to make that change in their life and want to get back on track to come in the hospital 00:21:58.720 --> 00:22:03.380 a couple days intense treatment and then transition to the outpatient setting I think it's a really 00:22:03.380 --> 00:22:10.980 neat model I'm pretty excited about yeah I think we started working and we started in early March 00:22:10.980 --> 00:22:15.900 and the patients have started coming in and we're getting the referrals from outside sources and 00:22:15.900 --> 00:22:21.820 within the hospital in-house uh it's just a the awareness again the community awareness is so 00:22:21.820 --> 00:22:28.780 important in this recovery of these patients and reducing the deaths from the illicit words and 00:22:28.780 --> 00:22:35.100 also prescription opiates so much so absolutely so let's touch on um just for a second like other 00:22:35.100 --> 00:22:39.260 community resources of course self-regional we have outpatient treatments and inpatient 00:22:39.260 --> 00:22:44.540 hospital stuff but what are some of the other community resources that our patients can tap into 00:22:44.540 --> 00:22:50.100 So we have Beckman Mental Health, you know, they have from the state department of mental health 00:22:50.100 --> 00:22:56.560 sponsored and contracted state, the agencies, they also treat this for the, they've been very 00:22:56.560 --> 00:23:01.360 helpful with the severely mentally ill, you know, they don't have acute facility, they do have 00:23:01.360 --> 00:23:07.540 outpatient, they provide the medication management, and they provide the counseling services and 00:23:07.540 --> 00:23:12.760 psychotherapy, and they do provide the DBT, dialectical behavioral therapy, the standard of 00:23:12.760 --> 00:23:16.200 care for patients with borderline personality disorder 00:23:16.200 --> 00:23:18.440 in the region, so that has been helpful. 00:23:18.440 --> 00:23:21.520 They have the multiple locations to the county areas 00:23:21.520 --> 00:23:24.940 we are, which are our service area, so in this, 00:23:24.940 --> 00:23:29.100 so they can be able to connect with their individual 00:23:29.100 --> 00:23:33.220 psychotherapist and provide the telephone consultation, 00:23:33.220 --> 00:23:37.380 they have the TPT groups, and that is one thing. 00:23:37.380 --> 00:23:41.700 The second is we have the Greenwood Cornerstone 00:23:41.700 --> 00:23:44.860 drug and alcohol intensive outpatient program 00:23:44.860 --> 00:23:47.240 where there are groups that, you know, 00:23:47.240 --> 00:23:49.300 three times a week, three days a week. 00:23:49.300 --> 00:23:52.680 So that are also helpful in this community. 00:23:52.680 --> 00:23:57.680 So with that, each county has their own like the, 00:23:57.680 --> 00:24:03.800 just like Beckman, they have the Abbeville Mental Health 00:24:03.800 --> 00:24:06.520 and the Abbeville, for the residents of Abbeville County, 00:24:06.520 --> 00:24:08.360 but Newberry and Edgeville, 00:24:08.360 --> 00:24:10.440 they have Edgeville County Mental Health. 00:24:10.440 --> 00:24:13.820 And so there is a best view behavioral health 00:24:13.820 --> 00:24:17.060 for the patients in Newbury and other side 00:24:17.060 --> 00:24:19.960 near the Lexington, which is nice. 00:24:19.960 --> 00:24:21.940 You're trying to improve the access. 00:24:21.940 --> 00:24:24.440 The goal here is to improve the access 00:24:24.440 --> 00:24:25.840 to mental health services, 00:24:25.840 --> 00:24:27.660 which can reduce the suicide rate. 00:24:27.660 --> 00:24:32.220 Again, why the South Carolina is on 29 in the suicide rates 00:24:32.220 --> 00:24:37.160 and is because there is a 74% less access 00:24:37.160 --> 00:24:40.540 our mental health provider in the state of South Carolina. 00:24:40.540 --> 00:24:45.140 So, and again, in terms of behavioral health expenditure 00:24:45.140 --> 00:24:48.980 is still, we are in the 25th percentile. 00:24:48.980 --> 00:24:52.980 So what the state has spent in terms of the, 00:24:52.980 --> 00:24:57.280 invested in behavioral health is less than 25th in the state. 00:24:57.280 --> 00:25:02.280 So that's again, there is always a need for the inpatient, 00:25:04.340 --> 00:25:09.740 patient looking for the bed for the inpatient level of care, there is always a patient who is 00:25:09.740 --> 00:25:15.900 waiting for an appointment to see a licensed or qualified psychiatrist and a 00:25:15.900 --> 00:25:24.000 psychiatric provider in the state. Absolutely. So there have been some advances in some of the 00:25:24.000 --> 00:25:27.740 treatment for outpatient depression. I thought maybe we could just touch on those for just one 00:25:27.740 --> 00:25:32.880 second. Let's talk a little bit about, I guess, treatment for depression and some of the more 00:25:32.880 --> 00:25:38.880 the newer treatment options for severe depression on the outpatient side yeah so historical 00:25:38.880 --> 00:25:46.800 perspective in the treatment of depression is very important so when we you know the dsm the 00:25:46.800 --> 00:25:53.740 diagnostical and statistical manual now in the edition five and the text version um that all 00:25:53.740 --> 00:25:59.340 the device that they have gone through a lot of formulation because of the emerging research and 00:25:59.340 --> 00:26:04.600 The evidence they have gathered, there are a lot of, we never used to call the alcohol use disorder, 00:26:04.600 --> 00:26:09.700 it's just alcohol dependence, cocaine use, cocaine dependence. 00:26:09.700 --> 00:26:11.360 And those words are gone. 00:26:11.360 --> 00:26:15.760 There is a change in the language, obviously, because of the evidence and the research that's indicated. 00:26:15.760 --> 00:26:26.200 And so then also, in an attempt to de-stigma, lessen the stigma and improve the awareness and bring them to the care. 00:26:26.780 --> 00:26:29.680 And you're also following the harm reduction model 00:26:29.680 --> 00:26:31.480 in treating this addiction. 00:26:31.480 --> 00:26:35.160 So in our outpatient, traditionally we have treated 00:26:35.160 --> 00:26:40.160 with antidepressants, like SSRIs and SNRIs. 00:26:40.160 --> 00:26:43.180 We have atypical antidepressants. 00:26:43.180 --> 00:26:45.180 I use antipsychotics, mood stabilizer, 00:26:45.180 --> 00:26:50.180 like lithium, Depakote, and other augmentation strategies. 00:26:50.180 --> 00:26:54.260 So when there's increasingly, there is a nearly 00:26:54.260 --> 00:26:55.900 at least one third of the patients, 00:26:55.900 --> 00:26:59.280 don't respond to antidepressant it's surprising when two or more 00:26:59.280 --> 00:27:05.620 antidepressants they don't work as they should when they fail to respond to the 00:27:05.620 --> 00:27:09.760 antidepressant so they started the psychiatrist started looking at other 00:27:09.760 --> 00:27:14.860 interventional modalities for the treatment of depression and other 00:27:14.860 --> 00:27:20.560 depressive disorders so there was a ECT electroconvulsive therapy and it's not 00:27:20.560 --> 00:27:27.100 available at a self regional it's available in Greenville Columbia so now 00:27:27.100 --> 00:27:34.640 we have the first the first for the first time in 2019 they found out 00:27:34.640 --> 00:27:40.840 ketamine has been you know they evidence showed the ketamine is is helpful in 00:27:40.840 --> 00:27:45.500 depression especially those with the treatment resistant depression we call 00:27:45.500 --> 00:27:56.080 as TRD, when they fail to respond to or more types of antidepressants, then they can benefit 00:27:56.080 --> 00:27:57.660 from the ketamine treatment. 00:27:57.660 --> 00:28:02.580 Again, the ketamine, again, sounds like it's more, it's a very counterintuitive, because 00:28:02.580 --> 00:28:08.220 it used to be a special K, it has a street value, it used to be a street drug, it is 00:28:08.220 --> 00:28:09.880 closely related to PCP, 00:28:09.880 --> 00:28:11.780 phencyclidine, and 00:28:11.780 --> 00:28:14.320 the ketamine is more, is already 00:28:14.320 --> 00:28:16.180 used in our operating 00:28:16.180 --> 00:28:18.360 rooms as a dissociative anesthetic, 00:28:18.360 --> 00:28:20.100 and they 00:28:20.100 --> 00:28:22.000 found that our 00:28:22.000 --> 00:28:23.660 increasing understanding 00:28:23.660 --> 00:28:25.360 based on the research, 00:28:25.360 --> 00:28:28.100 that it is not only serotonin, 00:28:28.100 --> 00:28:30.300 norepinephrine, GABA, 00:28:30.300 --> 00:28:32.080 and the 00:28:32.080 --> 00:28:33.940 dopamine, it's also there is 00:28:33.940 --> 00:28:35.140 fourth receptors there 00:28:35.140 --> 00:28:38.120 in the brain, which is altering 00:28:38.120 --> 00:28:40.620 and causing neuroplasticity changes in the brain 00:28:40.620 --> 00:28:43.360 and affecting our learning and our experiences 00:28:43.360 --> 00:28:45.760 and try to improve the depressive symptoms. 00:28:45.760 --> 00:28:47.220 That was the glutamate. 00:28:47.220 --> 00:28:52.400 So ketamine is an NMDA receptor antagonist. 00:28:52.400 --> 00:28:53.420 You know, it's a blocker 00:28:53.420 --> 00:28:57.520 and improves the glutaminergic neurotransmission in the brain. 00:28:57.520 --> 00:29:00.020 It is another fourth pathway for the depression. 00:29:00.020 --> 00:29:01.380 We started exploring. 00:29:01.380 --> 00:29:04.760 Our understanding in the depression has gotten much, much better, 00:29:04.760 --> 00:29:06.200 especially in the last 20 years. 00:29:07.020 --> 00:29:16.320 More so with the last 10 years when they had three or four randomized control studies for ketamine and esketamine. 00:29:16.320 --> 00:29:24.120 It's derivative is very helpful in changing the brain chemistry and neurocircuitry to improve the depressive symptoms. 00:29:24.120 --> 00:29:33.260 Those with the acute symptoms and those with the treatment-resistant depression, two or more antidepressants fail to respond, so then is option. 00:29:33.260 --> 00:29:37.500 The patients do stop taking the medications because they have the side effects. 00:29:37.500 --> 00:29:40.300 You know, they just don't tolerate. 00:29:40.300 --> 00:29:43.160 So now comes the ketamine. 00:29:43.160 --> 00:29:50.900 It's one of the, it comes, there are centers in the nation where they receive the IV ketamine infusion. 00:29:50.900 --> 00:29:55.680 We call it treatment, KTCs, ketamine treatment centers. 00:29:56.820 --> 00:30:05.800 There was also use of ketamine in ketamine-assisted psychotherapy, just like the mushrooms, psilocybin-assisted 00:30:05.800 --> 00:30:11.600 psychotherapy, LSD, the hallucinogen-assisted psychotherapies, so much understanding in 00:30:11.600 --> 00:30:13.780 terms of psychedelics. 00:30:13.780 --> 00:30:20.200 Just like that, the S-ketamine also has been FDA approved for treatment-resistant depression 00:30:20.200 --> 00:30:24.980 and treatment-resistant, the major depression with suicidal ideation. 00:30:24.980 --> 00:30:27.120 There are two indications for esketamine. 00:30:27.120 --> 00:30:29.880 One is treatment-resistant depression. 00:30:29.880 --> 00:30:35.460 The second is major depression with suicidal ideation and behaviors. 00:30:35.460 --> 00:30:37.040 Gotcha. 00:30:37.040 --> 00:30:43.680 So, yeah, I'm just going to summarize that up in, I think, a simple way to think about it. 00:30:43.680 --> 00:30:46.800 So if someone has, like, they've been on some antidepressants 00:30:46.800 --> 00:30:51.300 and they're still suffering with depression and they feel like it's not getting better 00:30:51.300 --> 00:30:54.480 or they can't tolerate it very well and they've tried a couple different ones. 00:30:54.620 --> 00:30:58.260 So it's just not getting better despite treatment. 00:30:58.260 --> 00:31:01.580 Or if someone has severe depression with suicidal thoughts. 00:31:01.580 --> 00:31:06.920 And then they would potentially be a candidate for the esketamine or the Spravada treatment. 00:31:06.920 --> 00:31:08.760 Is that basically kind of the idea? 00:31:08.760 --> 00:31:14.700 And it works in the brain a little bit differently than some of the other antidepressants that are currently available. 00:31:14.700 --> 00:31:18.180 And can sometimes help when other things don't, essentially. 00:31:18.180 --> 00:31:20.960 And then, so the Spravada treatment. 00:31:20.960 --> 00:31:23.180 Tell me a little bit specifically about Spravada. 00:31:23.340 --> 00:31:27.860 Like, how do we administer it, and, like, how often do you have to take it and all those type things? 00:31:27.860 --> 00:31:39.580 The esketamine, or the Spravato, the commercial name, is approved for both with and without antidepressant combination therapy in conjunction with antidepressant. 00:31:39.580 --> 00:31:45.440 But just in January this year, they approved as a standalone treatment for treatment-resistant depression, which is nice. 00:31:46.140 --> 00:31:49.260 So you have this treatment-resistant depression. 00:31:49.260 --> 00:31:56.040 You don't need to be in the major depression where you have the suicidal thoughts. 00:31:56.040 --> 00:31:57.600 You can use it as a standalone. 00:31:57.600 --> 00:32:04.200 It is the first time the FDA has approved a single standalone treatment without any other medications. 00:32:04.200 --> 00:32:11.060 But when you refer to treatment-resistant depression, there are prior trials of two or more antidepressants. 00:32:11.060 --> 00:32:13.920 And then you define the treatment-resistant depression. 00:32:13.920 --> 00:32:15.760 It comes in as a nasal spray. 00:32:16.140 --> 00:32:23.740 um it's just like our flonase okay it's kind of it each um each spray is one dose okay 00:32:23.740 --> 00:32:32.700 uh this is just like our flonase nasal inhaler like uh it contains 28 milligrams of ketamine 00:32:32.700 --> 00:32:38.220 okay so it is only administered at the very licensed facility and credentialed under the 00:32:38.780 --> 00:32:40.600 which is REMS certified. 00:32:40.600 --> 00:32:44.420 REMS is Risk Evaluation and Mitigation Strategy. 00:32:44.420 --> 00:32:47.880 So all the facilities, like medical offices, 00:32:47.880 --> 00:32:50.940 psychiatric outpatients, or even the inpatients, 00:32:50.940 --> 00:32:54.900 so they have to be certified by REMS. 00:32:54.900 --> 00:32:58.660 So it is a process wherein you identify the risk 00:32:58.660 --> 00:33:00.980 and you are able to mitigate them, 00:33:00.980 --> 00:33:03.680 identify the risk and mitigate this 00:33:03.680 --> 00:33:05.780 in terms of, like, elevated blood pressure, 00:33:06.600 --> 00:33:12.520 dissociation and the patient tend to disconnect from the surroundings and then sedation and 00:33:12.520 --> 00:33:18.120 elevated blood pressures you should be able to manage but with western carolina center 00:33:18.120 --> 00:33:24.920 you know with the staff education and we should we are in the process of getting the 00:33:24.920 --> 00:33:30.440 western carolina psychiatric associates enrolled into this program so that we can we can start 00:33:30.440 --> 00:33:35.800 these services we are already in the process yeah starting this yeah great so yeah so we're in the 00:33:35.800 --> 00:33:42.760 process of of getting approval to administer the uh spravato the s ketamine treatment um in our 00:33:42.760 --> 00:33:50.200 outpatient western carolina psychiatric offices um our office um sometime soon any idea when we 00:33:50.200 --> 00:33:55.720 anticipate like getting through that approval process uh our hope is that uh as early as uh 00:33:55.720 --> 00:34:01.880 early june the first week of june uh you should be ready to this should be available 00:34:02.600 --> 00:34:08.600 for the patient to access again the patient selection um which patient is going to benefit 00:34:08.600 --> 00:34:15.080 is the key for the better outcomes or the good outcomes um so who has not responded to those 00:34:15.080 --> 00:34:22.360 antidepressant and you know this four-week treatment this is a twice weekly uh inhalations 00:34:22.360 --> 00:34:30.580 nasal spray they come to the check-in and you have a space for the monitoring and after the 00:34:30.580 --> 00:34:33.300 administered, they have to be in the office for two hours. 00:34:33.300 --> 00:34:35.400 There's a space, they monitor. 00:34:35.400 --> 00:34:38.280 At the end of 40 minutes, they check the blood pressure, 00:34:38.280 --> 00:34:40.780 make sure that blood pressure is not elevated 00:34:40.780 --> 00:34:42.860 and evaluated by the provider 00:34:42.860 --> 00:34:44.540 before they are ready to go home. 00:34:44.540 --> 00:34:48.660 We advise caution against driving and operating machinery 00:34:48.660 --> 00:34:51.320 because of the mild cognitive impairment and sedation 00:34:51.320 --> 00:34:53.840 that comes with this dose administration. 00:34:53.840 --> 00:34:57.820 So the initiation phase is for first four weeks, 00:34:57.820 --> 00:35:02.000 twice a week in the clinic, two hours monitored 00:35:02.000 --> 00:35:04.780 for the blood pressure and sedation and dissociation. 00:35:04.780 --> 00:35:09.660 And we'd have the family member pick them up and go home. 00:35:09.660 --> 00:35:11.100 - So twice a week for four weeks. 00:35:11.100 --> 00:35:11.940 - Four weeks, yes. 00:35:11.940 --> 00:35:15.760 - And then like, how long does it work? 00:35:15.760 --> 00:35:19.600 - It is, you see the results as early as first 24 hours 00:35:19.600 --> 00:35:20.880 relief from the depression. 00:35:20.880 --> 00:35:21.720 - Wow. 00:35:21.720 --> 00:35:25.000 - How it changes the glutamate, 00:35:26.000 --> 00:35:28.900 the neurocircuit in the brain, you get 24 hours, 00:35:28.900 --> 00:35:31.840 and you see more effect by the end of the fourth week. 00:35:31.840 --> 00:35:32.680 Okay. 00:35:32.680 --> 00:35:37.260 So, again, if the psychiatrist, after evaluation, 00:35:37.260 --> 00:35:40.260 thinks that the patient needed to enter the maintenance phase 00:35:40.260 --> 00:35:44.900 and they're continuing on the esketamine spray, they can. 00:35:44.900 --> 00:35:50.060 Again, that would be tapered along once weekly to, again, 00:35:50.060 --> 00:35:53.300 once to two-weekly or biweekly spray. 00:35:53.780 --> 00:35:56.580 and it's just one dose, two nostrils. 00:35:56.580 --> 00:36:00.420 You close one nostril when the patient 00:36:00.420 --> 00:36:02.860 is using the other nostril. 00:36:02.860 --> 00:36:07.860 So the two doses each visit with 56 milligrams 00:36:07.860 --> 00:36:13.180 of esketamine should help the relief from the depression. 00:36:13.180 --> 00:36:15.800 This is very important because they have been struggling 00:36:15.800 --> 00:36:18.300 going through the, one of the things, 00:36:18.300 --> 00:36:20.400 challenges, treatment challenges we have 00:36:20.400 --> 00:36:26.600 outpatient treatment of depression is trial and error you try this you know even though it is 00:36:26.600 --> 00:36:32.200 guided by precision medicine now with the genetic testing where we take a buccal swab and send them 00:36:32.200 --> 00:36:38.600 to testing for the you know their dna and type how the medication interacts but still they are 00:36:38.600 --> 00:36:44.680 just guiding but they don't replace the you know the psychiatrist the decision making processor 00:36:44.680 --> 00:36:50.040 So this one is one of the tools available, and this is a new medication. 00:36:50.040 --> 00:36:52.560 And you have to be very careful at the same time. 00:36:52.560 --> 00:36:56.900 It's a Class III scheduled, controlled medication. 00:36:56.900 --> 00:37:02.840 That's why the facility or the medical offices or the outpatient need to be REM certified. 00:37:02.840 --> 00:37:03.780 Right, right. 00:37:03.780 --> 00:37:07.460 So, again, help me with this. 00:37:07.460 --> 00:37:11.160 So someone gets treated, you say it's twice a week for four weeks, 00:37:11.260 --> 00:37:13.460 and then they go, if they're doing well, 00:37:13.460 --> 00:37:14.580 onto a maintenance phase. 00:37:14.580 --> 00:37:16.260 Is that something you have to take the rest of your life, 00:37:16.260 --> 00:37:18.420 or once a week rest of your life, or is it, 00:37:18.420 --> 00:37:19.660 how does that transition? 00:37:19.660 --> 00:37:21.980 There's no studies with the long-term use. 00:37:21.980 --> 00:37:26.240 Again, we are treating the treatment-resistant depression 00:37:26.240 --> 00:37:28.060 or we are treating the major depression 00:37:28.060 --> 00:37:29.140 with suicidal thoughts. 00:37:29.140 --> 00:37:31.700 So for the treatment-resistant depression, 00:37:31.700 --> 00:37:34.060 there are some studies, some evidence 00:37:34.060 --> 00:37:36.500 to beyond four weeks they can benefit. 00:37:36.500 --> 00:37:39.220 Again, the psychiatrist evaluates the patient. 00:37:39.700 --> 00:37:41.300 Again, each and every patient is different. 00:37:41.300 --> 00:37:46.640 There are no guidelines of continuation beyond the initiation phase. 00:37:46.640 --> 00:37:50.680 Weak evidence, but there's some evidence with the treatment-resistant depression, 00:37:50.680 --> 00:37:54.060 but not with a major depressive disorder with so subtle thoughts. 00:37:54.060 --> 00:37:59.460 First four weeks, at the end of the four weeks, you see the maximum benefit 00:37:59.460 --> 00:38:01.400 in terms of the relief from the depression. 00:38:01.400 --> 00:38:02.780 This is acute relief. 00:38:03.820 --> 00:38:12.640 One of the analogy I remember is in a patient who presents with the acute asthmatic attack 00:38:12.640 --> 00:38:16.720 and you give the albuterol spray and then they get relief from the wheezing 00:38:16.720 --> 00:38:18.380 and they start breathing better. 00:38:18.380 --> 00:38:19.940 It's a similar thing. 00:38:19.940 --> 00:38:24.480 Patient enters the emergency room, they're in crisis, having the suicidal thoughts, 00:38:24.480 --> 00:38:30.120 having this access to esketamine is a relief from the suicidal thoughts. 00:38:30.580 --> 00:38:37.720 It's amazing how the ketamine works on the brain neurocircuitry to relieve those suicidal thoughts. 00:38:37.720 --> 00:38:50.860 It's still unknown, but it has a rapid resolution of symptoms is one of the key words I would like to use in terms of both depressive symptoms and the suicidal thoughts. 00:38:50.860 --> 00:38:51.340 Yeah. 00:38:51.340 --> 00:38:54.040 Well, we're excited to be able to offer that here real soon. 00:38:55.020 --> 00:39:04.160 Anything you want to close with or our listeners, anything you want to share with the community about any of our services or really anything about mental health at all? 00:39:04.160 --> 00:39:15.920 We are accepting new patients, you know, for the Western Carolina Psychiatric Associates with this addition of Spravato and REMS certified. 00:39:15.920 --> 00:39:24.240 And we are accepting the patients with the depression, trauma, children's, you know, and adolescents. 00:39:25.020 --> 00:39:27.460 We and in the inpatient wise which you know 00:39:27.460 --> 00:39:34.420 We are treating the patients with the dual diagnosis and the mental health conditions that I had mentioned earlier in the talk. So 00:39:34.420 --> 00:39:41.860 And we are looking forward for the other new modalities of the treatment like transcranial magnetic stimulation. Yeah, so 00:39:41.860 --> 00:39:47.900 We're just taking one day at a time. Yeah, and it's really exciting to be here in this community and 00:39:47.900 --> 00:39:54.200 We as a our goal is I in a high quality accessible care in the region 00:39:54.340 --> 00:40:07.660 Yeah. Dr. Lohr, thank you so much for spending some time with me today, and we're certainly glad you're here, and we appreciate your leadership and helping us really develop our behavioral health services for the community. So thank you so much. 00:40:07.660 --> 00:40:08.180 Thank you. 00:40:08.180 --> 00:40:13.420 And thank you all for joining us for today's Medically Speaking, and we'll see you next time. Thank you.