Medically Speaking #15

Welcome to today's episode of Medically Speaking. I'm super excited to have a great guest with us today. We have Dr. Allure with us today from our behavioral health team and today we're going to talk about mental illness and some of the treatments and the opportunities that we have in our community to improve some of the care and some of the latest treatment modalities that are available. We're going to touch on some of the inpatient treatment options as well as outpatient treatment options, and just mental health in general. Interestingly, the month of May is Mental Health Awareness Month, so I think the timing is just about right. So with that, I'd like to maybe introduce Dr. Allure and welcome him to the podcast. And Dr. Allure, maybe just tell us a little bit about yourself and your background. Yeah, thank you, Dr. Logan, for giving me this opportunity to speak in this podcast. So I'm Dr. Lohr. I joined Self-Regional Health in October last year as a staff psychiatrist and a medical director for the Psychiatric Services. So since then, I'm excited to be here, looking forward for our vision of high quality accessible care in this regional health system and which is serving the seven county area so awesome yeah well thank you so we have really seen growth I guess in mental health illness and not something to kind of growth you necessarily want to have but we certainly want to be here to help folks and maybe you can tell me a little bit about some of the services that we offer at self regional just in general and in some of your experiences here so far yes a little bit of work my background is I I grew up on and raised in India and went to medical school in South India and after that I was trained in Thomas Jefferson University in Philadelphia Pennsylvania then spent significant amount of time in the rural Missouri for seven years you know completing the Delta waiver programs and see you know what type of the services there is a community need for those kind of behavioral health services and you know how to improve the services how to engage in the community stakeholders and improving the bringing the highly accessible care to the rural area so with that our self regional health as a both inpatient and outpatient services Inpatient currently has 17, 36-bedded, and currently admitting age group of 18 to 65 for the patients suffering from depression with suicidal thoughts, schizophrenia, and other related psychosis, bipolar disorders, dual diagnosis, and patients who are just feeling unsafe at home and having the underlying mental health you know diagnosis these are the common admitting diagnosis and admitting problems on our inpatient at self regional health so and in the outpatient we are treating the patients with the depression anxiety comorbid substance use disorders PTSD and other trauma related disorders and bipolar disorders even schizophrenia we just now added addiction medicine as a a co-located and collaborative care model into that and to bringing whole spectrum of services to the our outpatient at Western Carolina Psychiatric Services. Okay let's talk about the inpatient side maybe a little more detail then we can dive into the outpatient world a little bit more too. So like what's the typical path if someone does have a mental illness and they need to be admitted to an inpatient psychiatric unit. How is that decision made, and what's the usual process to get plugged into the system? When the patient has severe depression or is not able to do significant impairment in their activities of daily living, it could be social functioning in terms of relationships. Or if they're students, they're struggling with academics due to academic stresses, or Or if they're working in some kind of job here they're struggling at the job. So these kind of significant impairment with underlying depression, if they continue to have thoughts of self-harm or suicidal thoughts, then that's a reason for, you know, to visiting our emergency room. And we have a trained behavioral health assessment team. We go by BHAT. They are essentially a mental health screeners. They are the conduit between the emergency physicians and the inpatient psychiatrist who provide the care. They go and evaluate, assess the need and the level of care they need in terms of medication management or inpatient level of care or even outpatient level of care. They discuss with the on-call psychiatrist who is an MDR devo and come up with a plan for them admitting or discharging or even transferring if we are not able to provide any care at the inpatient level so and the another condition is first is depression second is severe psychosis having you know various types of perceptual disturbances the auditory and visual hallucinations various delusions and even agitations from the agitation irritability from the underlying mental illness and bipolar disorders are the indications for admissions. Yeah, so I know you know I'm an ER physician too in my background working in the ER and taking care of mental illness problems over the years. I have seen a lot of improvement I think in some of the services that we offer on the inpatient side and I think you just hit on it that behavioral health assessment team, that BHAT team. They are really key to the whole process. You know, as an ER physician, you know, I'm really good at identifying medical issues and really kind of ruling some things out. But once you've kind of ruled out those like medical reasons for the way someone's thought processes may be going on, it's awesome to be able to have the resources here in our local community to kind of take that next step if we need to, say, be admitted for further inpatient treatment. Absolutely. So in the medical primary, if there is any underlying medical disorders or neurological disorders are involved, our emergency room physicians are excellent, and they're very good in what they do in clearing them and finding the way to get them this type of care and the level of care they need. As I said, our vision continues to be the same high-quality accessible care in our regional health system and our seven-county service area. Yeah, absolutely. So, yeah, kind of rule out the medical non-mental health issues. And once those are kind of ruled out, then the behavioral health assessment team and you and your expertise kind of identify kind of next steps for those individual patients. So I really like that model, and I think it seems to be working pretty well for us here. 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. What's the process? And, like, how long does someone usually stay in the hospital, and what happens in the hospital when they're there? I'm glad we're having these conversations, you know, as you already said, the May is the Mental Health Awareness Week. 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. 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. 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. It created some somewhat dent in the suicide rates nationally and also in the state of South Carolina, too. And when they come in, there is a thorough assessment for suicide risk and safety assessment that they receive. They receive a PHQ, patient health questionnaire, nine questionnaire in the ER and also Columbia suicide severity scale. also uh um you know the provided to them and they we had team you know the evaluates ed physician does that as well there are multiple eyes and multiple hands who are involved in the care when the patient comes to the er okay so um let's say the patient gets admitted to the hospital and for let's just say severe depression like what what's the treatment that they get while in the hospital so traditionally the treatment has been for years the medication management then then then came like antidepressants like SSRIs which act on the serotonin receptors and norepinephrine SNRIs and atypical antidepressants like ibuprofen and remeron and medication has been the mainstay and again to supplement that in kind of like a severe cases of major depression is psychotherapy and medication management combined are very helpful like cognitive behavioral therapy and interpersonal therapy and supportive psychotherapy and you know a little bit more advanced psychotherapy like psychodynamic psychotherapy would be very helpful but when they usually when they get admitted to inpatient floor with this when they're danger to themselves or others and they receive thorough psychiatric evaluation and we have groups we have individual therapy and recreational activities you know where they learn the coping skills and relaxation techniques they get a full comprehensive services when they are on the inpatient floor and the psychiatrist visit with them every day wrong and assess the need they work with a in a social worker on the unit identify and provide the resources for them when they are stable and ready to be discharged. That's great. Okay, so let's say that that same patient now is ready to go home and they are no longer thought to be a threat to themselves or not want to hurt themselves anymore. But you know, the treatment doesn't necessarily end at that point, right? Because things, as you know, we all know, life stresses can come back or whatever that was that kind of may have triggered that episode may still be out there right so what happens when the patient leaves like what are the resources that patients can can follow up with when they leave the hospital so I work closely with the our unit social workers you know who reach out to the our community mental health resources like Beckman mental health and our Western Carolina Psychiatric associates and we find a therapist a counselor with the LPC level and also you know the psychiatrist or psychiatric providers to you know to continue the psychotropic medication management and continue the psychotherapy for them wherever they are depending upon the zip code are the counties where they live in you know try to connect with them and make the appointment date before they leave and make sure the family is also on board with this or they're aware of the discharge plans and aftercare plan. So it's really a on the outpatient setting well inpatient too for that matter it's a combination of like sometimes medications to to help kind of stabilize the the brain chemistry we can think of it that way and then as well as as counseling and following up with the mental health specialists like the psychiatrist and or counselors and whatnot in the outpatient to try to deal with those ongoing stressors in a way that's more healthy maybe we could say that way yeah because there's always going to be like stress right yes something all the time improving you know the identifying each uh when they are in the inpatient unit psychiatric inpatient unit we have a team interdisciplinary team i would say our multidisciplinary team because you have a recreation therapist you have a psychiatric social worker, psychiatric nurse, psychiatrist, and we have the other therapist as well, so we have, and the bonus is, like, we also have the clinical pharmacist, which is trained in psychopharmacology, it's very, very rare to have a clinical psychopharmacologist, which did a residency, and helping us out with, and explaining the family and the patient about adherence to medications and, you know, about the medications prescribed, how do you take them, you know, where do you get them, arranging the medications. It's a very comprehensive multidisciplinary team. You know, we all visit with the patients every Wednesday, and we make the treatment very individualized. Again, every patient has different needs because their backgrounds are different, you know, They grew up in a different, you know, different types of families, you know, without trauma. So when we make the treatment, we identify, ask them to state what are the two important things you would like to work on and you would like to continue to work on after discharge. So then they come up and they learn the coping skills and we make the treatment when suitable for that patient. So individualized. The same one, when they're leaving, we find a similar therapist and a psychiatrist so that they can continue their care. So preventing here, you're also thinking a bigger picture is you are preventing suicide. The patient came here for help, and we are providing their psychiatric evaluation. You assess the safety and risk, and you address what is driving them to experience these kind of thoughts. and you're mitigating the risk, then they continue to get outpatients. Yeah, no, that's great. You know, another thing that comes to mind that is challenging is there's a lot of situations where someone has some type of mental illness, whether it be depression or some type of chronic psychotic disease or something like schizophrenia or something else, and then folks want to try to help themselves a lot, 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. 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. How do we address that situation? Yeah, that is very important. AND THIS IS ONE OF THE IDENTIFIED COMMUNITY MENTAL HEALTH NEEDS. SO WE ARE ABOUT TO MARK ON THE SECOND 2024 COMMUNITY HEALTH NEEDS ASSESSMENT FROM THE SOUTH REGION. SO ACCORDING TO THE 2022 REPORT, OUR NEEDS IS STILL LIKE PATIENTS WHO ARE SUFFERING FROM dual diagnosis primary mental health secondary substance use disorders and who has solely just without any mental health we have substance use disorders prevalent one is opiate use disorders stimulant use disorders like cocaine use disorders alcohol is disorder is a big one again so when they come in we assess first thorough psychiatric evaluation I'm getting a detail the history of the drinking, detail a history of the underlying past psychotic disorders like depression or schizophrenia or bipolar disorder or anxiety or panic disorders and starting the medication first model where you also treat the primary mental health with the psychotropic like antidepressant and anxiety or mood stabilizer depending upon the primary mental health diagnosis and the secondary substance use disorders like we have naltrexone for all of all you know we have gabapentin we have topiramate we have disulfiram you know that model has also helped us to treat both mental health and the secondary substance use disorders as well and they also go into crisis just like who patients who do not have the um the substance use disorders the the plain mental health and i would say you know it's pretty hard because there are like 40 to 60 percent of the mental health disorders like are comorbid with substance use disorders it's very difficult to tease out okay this which came first you know and there is a um that's the reason why we have you know we have to make sure that in all the dual diagnosis is treated and mental health is treated and when they are stable and ready to be discharged again individualized treatment plans they go to substance use follow-up where we have in town is a greenwood cornerstone and abbeville cornerstone and for the patient residents living in there where the intensive outpatient program for drug and alcohol referral we provide we provide the psychotropic medicate medication support and they can go to attend the groups there in the intensive outpatient three times a week three days a week and they interact with the therapist and counselor there so you are taking a full a full comprehensive approach for the recovery is not just treating mental illness and discharging them your take addressing all the issues so um it's been working and um um and because this is a huge need in the community so yeah absolutely you know we just um our self regionals just received a nice grant from the state to start a medication assisted treatment for opiate abuse disorder and maybe you could talk about that unit a little bit kind of what some of the goals of that area are this is exactly the right time again so the grant for the medical stabilization unit and the continuity of care in terms of partial hospital program or intensive outpatient program for the patients with the substance use disorder mainly opioid use disorder because this is a continue to be one of the cause and which is driving the increased rates of national suicide, you know, again, South Carolina ranks 29th in the state for the suicide rates, deaths by suicide, and it's still, like, the number of suicide deaths are, like, one percentage point higher than the national average still. Our neighboring Georgia is a little bit less, you know, but we continue to, again, this is a public health problem. Suicide is a public health problem so the illicit opiates and even the prescription opiates they continue to drive these rates of suicide so when you when you look at the rates of suicide nationally they're actually they're increased a little bit you know i would say not very significant but they're increased um now cdc they started and samsung reviewing what exactly happened we are coming out of COVID the last three years and increased access to these prescription and illicit opioids like fentanyl. So that was the reason why it really made sense to start this medical stabilization unit at Self Regional. And when they are stable or when they started on buprenorphine, which is a standard of care for opioid use disorder, you initiate the buprenorphine induction. And you know when they are stable within three to four days you find the right dose of buprenorphine which is an opioid antagonist combination so we you know we try we transition them to outpatient level of care that's the reason why we are on board like dr amber gasper she's and she's very interested in addiction medicine she has been doing that and we're transferring the patients there so they're receiving the care for the opiate use disorder yeah i think that's a neat program that i think is going to grow with a little bit of time as people more folks learn about it but the ability to kind of come in and get detoxed in a way um it's kind of i think how maybe the community might think about i'm going to go get go through so you don't go through such severe opiate withdrawal which can be very severe not necessarily life-threatening but you feel terrible when folks are going through that in a way to kind of get off the opiates for folks that are ready to make that change in their life and want to get back on track to come in the hospital a couple days intense treatment and then transition to the outpatient setting I think it's a really neat model I'm pretty excited about yeah I think we started working and we started in early March and the patients have started coming in and we're getting the referrals from outside sources and within the hospital in-house uh it's just a the awareness again the community awareness is so important in this recovery of these patients and reducing the deaths from the illicit words and also prescription opiates so much so absolutely so let's touch on um just for a second like other community resources of course self-regional we have outpatient treatments and inpatient hospital stuff but what are some of the other community resources that our patients can tap into So we have Beckman Mental Health, you know, they have from the state department of mental health sponsored and contracted state, the agencies, they also treat this for the, they've been very helpful with the severely mentally ill, you know, they don't have acute facility, they do have outpatient, they provide the medication management, and they provide the counseling services and psychotherapy, and they do provide the DBT, dialectical behavioral therapy, the standard of care for patients with borderline personality disorder in the region, so that has been helpful. They have the multiple locations to the county areas we are, which are our service area, so in this, so they can be able to connect with their individual psychotherapist and provide the telephone consultation, they have the TPT groups, and that is one thing. The second is we have the Greenwood Cornerstone drug and alcohol intensive outpatient program where there are groups that, you know, three times a week, three days a week. So that are also helpful in this community. So with that, each county has their own like the, just like Beckman, they have the Abbeville Mental Health and the Abbeville, for the residents of Abbeville County, but Newberry and Edgeville, they have Edgeville County Mental Health. And so there is a best view behavioral health for the patients in Newbury and other side near the Lexington, which is nice. You're trying to improve the access. The goal here is to improve the access to mental health services, which can reduce the suicide rate. Again, why the South Carolina is on 29 in the suicide rates and is because there is a 74% less access our mental health provider in the state of South Carolina. So, and again, in terms of behavioral health expenditure is still, we are in the 25th percentile. So what the state has spent in terms of the, invested in behavioral health is less than 25th in the state. So that's again, there is always a need for the inpatient, patient looking for the bed for the inpatient level of care, there is always a patient who is waiting for an appointment to see a licensed or qualified psychiatrist and a psychiatric provider in the state. Absolutely. So there have been some advances in some of the treatment for outpatient depression. I thought maybe we could just touch on those for just one second. Let's talk a little bit about, I guess, treatment for depression and some of the more the newer treatment options for severe depression on the outpatient side yeah so historical perspective in the treatment of depression is very important so when we you know the dsm the diagnostical and statistical manual now in the edition five and the text version um that all the device that they have gone through a lot of formulation because of the emerging research and The evidence they have gathered, there are a lot of, we never used to call the alcohol use disorder, it's just alcohol dependence, cocaine use, cocaine dependence. And those words are gone. There is a change in the language, obviously, because of the evidence and the research that's indicated. And so then also, in an attempt to de-stigma, lessen the stigma and improve the awareness and bring them to the care. And you're also following the harm reduction model in treating this addiction. So in our outpatient, traditionally we have treated with antidepressants, like SSRIs and SNRIs. We have atypical antidepressants. I use antipsychotics, mood stabilizer, like lithium, Depakote, and other augmentation strategies. So when there's increasingly, there is a nearly at least one third of the patients, don't respond to antidepressant it's surprising when two or more antidepressants they don't work as they should when they fail to respond to the antidepressant so they started the psychiatrist started looking at other interventional modalities for the treatment of depression and other depressive disorders so there was a ECT electroconvulsive therapy and it's not available at a self regional it's available in Greenville Columbia so now we have the first the first for the first time in 2019 they found out ketamine has been you know they evidence showed the ketamine is is helpful in depression especially those with the treatment resistant depression we call as TRD, when they fail to respond to or more types of antidepressants, then they can benefit from the ketamine treatment. Again, the ketamine, again, sounds like it's more, it's a very counterintuitive, because it used to be a special K, it has a street value, it used to be a street drug, it is closely related to PCP, phencyclidine, and the ketamine is more, is already used in our operating rooms as a dissociative anesthetic, and they found that our increasing understanding based on the research, that it is not only serotonin, norepinephrine, GABA, and the dopamine, it's also there is fourth receptors there in the brain, which is altering and causing neuroplasticity changes in the brain and affecting our learning and our experiences and try to improve the depressive symptoms. That was the glutamate. So ketamine is an NMDA receptor antagonist. You know, it's a blocker and improves the glutaminergic neurotransmission in the brain. It is another fourth pathway for the depression. We started exploring. Our understanding in the depression has gotten much, much better, especially in the last 20 years. More so with the last 10 years when they had three or four randomized control studies for ketamine and esketamine. It's derivative is very helpful in changing the brain chemistry and neurocircuitry to improve the depressive symptoms. Those with the acute symptoms and those with the treatment-resistant depression, two or more antidepressants fail to respond, so then is option. The patients do stop taking the medications because they have the side effects. You know, they just don't tolerate. So now comes the ketamine. It's one of the, it comes, there are centers in the nation where they receive the IV ketamine infusion. We call it treatment, KTCs, ketamine treatment centers. There was also use of ketamine in ketamine-assisted psychotherapy, just like the mushrooms, psilocybin-assisted psychotherapy, LSD, the hallucinogen-assisted psychotherapies, so much understanding in terms of psychedelics. Just like that, the S-ketamine also has been FDA approved for treatment-resistant depression and treatment-resistant, the major depression with suicidal ideation. There are two indications for esketamine. One is treatment-resistant depression. The second is major depression with suicidal ideation and behaviors. Gotcha. So, yeah, I'm just going to summarize that up in, I think, a simple way to think about it. So if someone has, like, they've been on some antidepressants and they're still suffering with depression and they feel like it's not getting better or they can't tolerate it very well and they've tried a couple different ones. So it's just not getting better despite treatment. Or if someone has severe depression with suicidal thoughts. And then they would potentially be a candidate for the esketamine or the Spravada treatment. Is that basically kind of the idea? And it works in the brain a little bit differently than some of the other antidepressants that are currently available. And can sometimes help when other things don't, essentially. And then, so the Spravada treatment. Tell me a little bit specifically about Spravada. Like, how do we administer it, and, like, how often do you have to take it and all those type things? The esketamine, or the Spravato, the commercial name, is approved for both with and without antidepressant combination therapy in conjunction with antidepressant. But just in January this year, they approved as a standalone treatment for treatment-resistant depression, which is nice. So you have this treatment-resistant depression. You don't need to be in the major depression where you have the suicidal thoughts. You can use it as a standalone. It is the first time the FDA has approved a single standalone treatment without any other medications. But when you refer to treatment-resistant depression, there are prior trials of two or more antidepressants. And then you define the treatment-resistant depression. It comes in as a nasal spray. um it's just like our flonase okay it's kind of it each um each spray is one dose okay uh this is just like our flonase nasal inhaler like uh it contains 28 milligrams of ketamine okay so it is only administered at the very licensed facility and credentialed under the which is REMS certified. REMS is Risk Evaluation and Mitigation Strategy. So all the facilities, like medical offices, psychiatric outpatients, or even the inpatients, so they have to be certified by REMS. So it is a process wherein you identify the risk and you are able to mitigate them, identify the risk and mitigate this in terms of, like, elevated blood pressure, dissociation and the patient tend to disconnect from the surroundings and then sedation and elevated blood pressures you should be able to manage but with western carolina center you know with the staff education and we should we are in the process of getting the western carolina psychiatric associates enrolled into this program so that we can we can start these services we are already in the process yeah starting this yeah great so yeah so we're in the process of of getting approval to administer the uh spravato the s ketamine treatment um in our outpatient western carolina psychiatric offices um our office um sometime soon any idea when we anticipate like getting through that approval process uh our hope is that uh as early as uh early june the first week of june uh you should be ready to this should be available for the patient to access again the patient selection um which patient is going to benefit is the key for the better outcomes or the good outcomes um so who has not responded to those antidepressant and you know this four-week treatment this is a twice weekly uh inhalations nasal spray they come to the check-in and you have a space for the monitoring and after the administered, they have to be in the office for two hours. There's a space, they monitor. At the end of 40 minutes, they check the blood pressure, make sure that blood pressure is not elevated and evaluated by the provider before they are ready to go home. We advise caution against driving and operating machinery because of the mild cognitive impairment and sedation that comes with this dose administration. So the initiation phase is for first four weeks, twice a week in the clinic, two hours monitored for the blood pressure and sedation and dissociation. And we'd have the family member pick them up and go home. – So twice a week for four weeks. – Four weeks, yes. – And then like, how long does it work? – It is, you see the results as early as first 24 hours relief from the depression. – Wow. – How it changes the glutamate, the neurocircuit in the brain, you get 24 hours, and you see more effect by the end of the fourth week. Okay. So, again, if the psychiatrist, after evaluation, thinks that the patient needed to enter the maintenance phase and they're continuing on the esketamine spray, they can. Again, that would be tapered along once weekly to, again, once to two-weekly or biweekly spray. and it's just one dose, two nostrils. You close one nostril when the patient is using the other nostril. So the two doses each visit with 56 milligrams of esketamine should help the relief from the depression. This is very important because they have been struggling going through the, one of the things, challenges, treatment challenges we have outpatient treatment of depression is trial and error you try this you know even though it is guided by precision medicine now with the genetic testing where we take a buccal swab and send them to testing for the you know their dna and type how the medication interacts but still they are just guiding but they don't replace the you know the psychiatrist the decision making processor So this one is one of the tools available, and this is a new medication. And you have to be very careful at the same time. It's a Class III scheduled, controlled medication. That's why the facility or the medical offices or the outpatient need to be REM certified. Right, right. So, again, help me with this. So someone gets treated, you say it's twice a week for four weeks, and then they go, if they're doing well, onto a maintenance phase. Is that something you have to take the rest of your life, or once a week rest of your life, or is it, how does that transition? There's no studies with the long-term use. Again, we are treating the treatment-resistant depression or we are treating the major depression with suicidal thoughts. So for the treatment-resistant depression, there are some studies, some evidence to beyond four weeks they can benefit. Again, the psychiatrist evaluates the patient. Again, each and every patient is different. There are no guidelines of continuation beyond the initiation phase. Weak evidence, but there's some evidence with the treatment-resistant depression, but not with a major depressive disorder with so subtle thoughts. First four weeks, at the end of the four weeks, you see the maximum benefit in terms of the relief from the depression. This is acute relief. One of the analogy I remember is in a patient who presents with the acute asthmatic attack and you give the albuterol spray and then they get relief from the wheezing and they start breathing better. It's a similar thing. Patient enters the emergency room, they're in crisis, having the suicidal thoughts, having this access to esketamine is a relief from the suicidal thoughts. It's amazing how the ketamine works on the brain neurocircuitry to relieve those suicidal thoughts. 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. Yeah. Well, we're excited to be able to offer that here real soon. 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? We are accepting new patients, you know, for the Western Carolina Psychiatric Associates with this addition of Spravato and REMS certified. And we are accepting the patients with the depression, trauma, children's, you know, and adolescents. We and in the inpatient wise which you know We are treating the patients with the dual diagnosis and the mental health conditions that I had mentioned earlier in the talk. So And we are looking forward for the other new modalities of the treatment like transcranial magnetic stimulation. Yeah, so We're just taking one day at a time. Yeah, and it's really exciting to be here in this community and We as a our goal is I in a high quality accessible care in the region 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. Thank you. And thank you all for joining us for today's Medically Speaking, and we'll see you next time. Thank you.