MedEvidence! Truth Behind the Data
Welcome to the MedEvidence! podcast, hosted by Dr. Michael Koren. MedEvidence, where we help you navigate the real truth behind medical research with both a clinical and research perspective. In this podcast, we will discuss with physicians with extensive experience in patient care and research. How do you know that something works? In medicine, we conduct clinical trials to see if things work! Now, let's get to the Truth Behind the Data. Contact us at www.MedEvidence.com
MedEvidence! Truth Behind the Data
'Tis the Season... to Talk About Depression
Dr. Heather Luing joins Dr. Michael Koren to talk about depression. They discuss what it can feel like, why December is associated with a spike in depression cases, and what's going on inside the body and brain that makes this disorder so challenging. The duo of doctors also explore new and emerging medications in the depression field, including several that target completely new pathways in the brain and may provide relief for people who have not found help with older medications. Dr. Luing also talks about the importance of talk therapy.
The doctors heavily emphasize a relatively new resource for urgent mental help, the 988 Mental Health Crisis Line.
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Music: Storyblocks - Corporate Inspired
Thank you for listening!
Welcome to the MedEvidence Podcast. This episode is a rebroadcast from a live MedEvidence presentation.
Dr. Michael Koren:Heather, I'm super excited that you're here with me. By the way, Dr. Luing is a brilliant psychiatrist who I'm really excited to work with. We've met each other recently. She's done clinical trials in her practice. Now she's going to become part of our group. And I couldn't be happier or more excited because I can tell you you just have it. You have the factor of being a tremendous investigator. So I'm really looking forward to that.
Dr. Heather Luing:I think it's going to be really great.
Dr. Michael Koren:Yeah. And I'm looking forward to our session today to share with the audience things about depression. I know it's it's a topic that we don't like to talk about, but it's an important topic. And it's actually a topic that is rich in the research world in terms of a lot of studies are ongoing. So we'll cover all that. So these are the objectives for today. And I'll just show them real quickly so everybody can see. And let me ask you by starting with this question. You know, we live in Florida. What wonderful place, sunny place. It's the holiday season. Everybody should be happy. Like, why is there any depression at all? Am I crazy or is this the time of year that we should all just be joyous?
Dr. Heather Luing:It sounds intuitively like it should be. But the reality is for a lot of my patients, this is actually the hardest time of year. So I think a lot of people struggle in this season. And the reality is depression is at all times highs across the U.S. And it started growing during COVID and it really hasn't stopped. It's continued to increase steadily, really across all demographics and age groups, even though some have been affected more than others.
Dr. Michael Koren:Interesting. And how about Florida versus other places?
Dr. Heather Luing:Yeah, I think that it's pretty consistent statewide, state to state. I don't think there's a huge variation in Florida. We do see higher incidence in younger age groups, so certain areas might have little deviations, but it's a serious problem nationwide.
Dr. Michael Koren:Okay. So you we've heard the term major depressive disorder. Why don't you explain to everybody what that means? What's major versus minor and how do you make the diagnosis?
Dr. Heather Luing:Yeah. So in psychiatry, we have something called the Diagnostic and Statistical Manual. So that is really outlines all of our different psychiatric illnesses. So I would say major depressive disorder is probably kind of what you think about as maybe clinical depression, something where it rises above the kind of just day-to-day up and downs that the average person has until it becomes more pervasive. And as you can see, there's actually really kind of strict criteria on what qualifies as MDD and what doesn't. Probably the biggest thing is it has to last at least two weeks. So you have to have that low mood that really becomes persistent.
Dr. Michael Koren:So if you wake up in the morning and you don't feel like going to work, that doesn't count as depression?
Dr. Heather Luing:Probably not.
Dr. Michael Koren:You won't write me a script to get me out of work?
Dr. Heather Luing:No, no, we're not going to do that. No. And in fact, staying active and doing things like work and being around people can actually be helpful. So most of the time, even if you did meet criteria for MDD, we'd still encourage you to try to do as much as possible.
Dr. Michael Koren:So time of the year, we we're talking a little bit about that, that it's the winter months. Is that a factor? Tell us a little bit about this concept of seasonal disorders.
Dr. Heather Luing:So we used to consider seasonal affective disorder or SAD as a separate diagnosis, but under our newest version of the DSM, it's considered a subtype of depression. So certainly some people are susceptible to decreases in the amount of daily sunlight that we get, or even the timing of that that introduced kind of interferes with our circadian rhythms. So this seasonal effective pattern is something that even in Florida we see, and some individuals are more susceptible to it than others.
Dr. Michael Koren:Yeah, it's interesting. Yeah, the celebration of Christmas actually predates the birth of Jesus. A lot of people don't know that, but it was a holiday when people started to recognize, ancient people started to recognize that the days were getting longer again. So that would infer that prior to Christmas that there's a time where people are getting nervous that the days are getting shorter.
Dr. Heather Luing:Absolutely. I mean, I think some of you may even kind of feel this, even when we have the time change and we fall back by an hour or spring forward by an hour, some people do have a decrease in energy and and have actual symptoms related to that. So it may be relatively mild, but for some people it becomes more severe.
Dr. Michael Koren:So if you live in the southern hemisphere where everything is flipped during our winter, there it's their summer and their days are getting longer. Do you see the a flip in terms of the seasonal patterns of depression?
Dr. Heather Luing:Yeah, I believe you do. Obviously, I've never practiced there, but but I think that it really has to do with the time of daylight you're exposed to.
Dr. Michael Koren:Interesting. And about one thing, is there any chemical issues in terms of getting sun and vitamin D and melatonin and those sorts of things?
Dr. Heather Luing:Yeah, they think that that may be somewhat of an influence to it, but as you'll probably see on one of the future slides, just exposing people to a certain type of light that emits a high voltage of light that can be curative even without, you know, other factors like vitamins.
Dr. Michael Koren:Interesting. All right, so this comes up all the time. When should people seek out you know serious professional help? So is it when you're get up in the morning and kind of feeling cranky? The reason I say that is because when I went to college a generation ago, we had one doctor for the entire campus. My daughter just graduated the University of Pennsylvania and they had twenty full-time behavioral health specialists on call and 75% of the students access one during their undergraduate years.
Dr. Heather Luing:Wow.
Dr. Michael Koren:So there's a whole change in the paradigm in terms of when you seek help. So why don't you give us a little bit of guidance when you seek help? Is it when you kind of feel those are all the twinges of not feeling right, or is it when you're on the on the ledge?
Dr. Heather Luing:Yeah. Yeah, that's a good question. You know, I think the reality with depression is that the earlier you treat it, the easier it is to treat, the more likely it is going to be to respond to interventions. So I don't think there's really a too early, and it sounds like the college students have caught on to that. Interesting, they're also the second most common demographic to have this increase in depression symptoms. So it's great that they are utilizing that. But in general, if the symptoms have gone on more than a couple of weeks, that is enough, I think, to reach out for some help or at least try some lifestyle modifications. And then obviously, if you have serious suicidal ideations, you notice you're having some unhealthy coping skills, like drinking a little too much over the holidays, those are warning signs that I think you should reach out sooner than later.
Dr. Michael Koren:Now, I noticed this 988 number on texting. I had no idea about that. Who who is the person on the other side of that when you text somebody?
Dr. Heather Luing:Yeah, so this is the new national crisis line. It's like the 911 for mental or substance abuse issues, which is pretty phenomenal. So you can use this number anywhere in the U.S., but 90% of the time it's going to be answered by local people in your community. So, for example, in Jacksonville, MHRC does a lot of the crisis phone calls. And it doesn't have to be that you're suicidal, it can be any kind of mental health or substance abuse crisis, and they can guide you to where resources are in your community.
Dr. Michael Koren:Well, out of curiosity from the audience, who was aware prior to this that there was a 988 number? So maybe a quarter of the audience. So that in itself is incredible information. Thank you.
Dr. Heather Luing:Yeah, it's a great resource.
Dr. Michael Koren:Okay. So let's talk about the science of mood. I'm a scientist part-time, when I'm not practicing medicine. And explain to people. It's not just the fact that you're, you know, you had you got a bad hand at work or whatever the situation may be, but there's actually something that's more fundamental, more biological. So maybe you can help us understand that.
Dr. Heather Luing:I think you highlighted it when we started that why would I be feeling this way if everything in my life is going well? And I can't tell you how many times I hear that from patients, like, why am I depressed? You know, I've got a great spouse, a good job, my kids are doing well, but I still feel this way. And that's because depression doesn't just have to do with things that are going on around you, although, of course, stressors can make things worse, but it truly is a brain disorder, and our bodies can affect our brain as well. So it could be from an underlying medical condition that you're feeling this way. It could be from parts of your brain that aren't functioning the way that they normally do. So it truly is a very scientific phenomenon, and many things can influence it. So we talked a little bit about seasonality, right? Light can influence it, hormone levels, a lot of different factors.
Dr. Michael Koren:Wow. So obviously you make the diagnosis of depression, and from what you just said, there is different scales and different things that come out of discussion with patients that ultimately make the diagnosis, and then you take a very specific stepwise approach to start treatment. So once why don't you walk us through that?
Dr. Heather Luing:It's kind of like building a house, right? You want to start with a really good foundation, a solid foundation. And I would say that is your lifestyle and behavioral practices, and we'll talk more about that. For some people, that alone is enough to really get the depression under control. If it's not, you know, I think the next step is always some form of psychotherapy. Having somebody to help guide you through this, whether it's like a cognitive behavioral thing where you're working on how you're thinking is influencing how you're feeling, or maybe you've gone through a trauma and you need some help processing that. So adding therapy would be the next kind of layer of the house. Medications would, I think, come after that. If you've tried therapy and you're still not getting full effects, then we look at medications as the next step. And then finally, we look at some of our newer and different types of treatment options. So things like TMS, ECT, some of the newer medicines like esketamine. So those are kind of the final layer. But again, like the title of our presentation, I think there should be so much hope because things have really changed a lot in the area of psychiatry. So when I finished residency and started practicing, it was a time when all the neuroscience divisions were closing down at the pharmaceutical companies, and they really were not interested in putting kind of research into psychiatry. But that has changed, and there's been an explosion of new treatments, and that's just going to continue to grow over the next few years. So it really is a time to be very hopeful about what's on the horizon.
Dr. Michael Koren:Wow. So I know we have some slides that are covering some of these approaches. So I'm super interested in learning more about it. So I guess you'll start us off with just the lifestyle approaches and we'll move on from there.
Dr. Heather Luing:Yeah, and lifestyle is so important. So we know that sleep is very restorative for the brain. So having a regular sleep schedule where you're getting the right amount of sleep. How many of you are getting six, seven, eight hours of sleep every night? Okay. So that's less than half the room, right? So half of you need to go home and work on your sleep. Yeah, sleep is so healing and restorative. So I think that's a great thing. Movement or exercise is also something I recommend for all of my patients. And it is amazing. This does not have to be intense exercise. You don't have to sign up for a marathon, no turkey trots. Just getting out there and taking a brisk walk, you know, walking your dog, riding your bike, very, very helpful to have that small amount of aerobic exercise. Getting good nutrition is definitely important, and there are some micronutrients that are particularly helpful. And then having social support. We know that there's a loneliness epidemic in the US, and forming those connections can really be helpful for mental health.
Dr. Michael Koren:Now, you mentioned something about nature. Tell us a little bit more about that. Is like going to a Jaguars game count as nature, or does it have to be out in the woods?
Dr. Heather Luing:It's better than nothing. Okay. Um, but I think that if you can immerse your senses in nature, that's where the research really shows us that there's a beneficial approach. So things like listening to bird song has been shown to help your mental health. Looking at nature, smelling it, getting the full really experience is very helpful. And I encourage all my patients to make that something in their life, like a new habit to form.
Dr. Michael Koren:So the concepts of Thoreau that talked about this 200 years ago are just as relevant now.
Dr. Heather Luing:I think so.
Dr. Michael Koren:Very cool. Okay, so I know you have other slides looking at other elements of treatment.
Dr. Heather Luing:We talked about a little bit about psychotherapy. I would say therapy is something don't be afraid of, right? And if you try a therapist and it's not a good fit, try a different therapist. They understand you have to have a good therapeutic bond between you and the therapist. And there's all different kinds of therapy. CBT or cognitive behavioral therapy really has a lot of good research behind it. So it's something we encourage. And there's actually a specific type for seasonal affective disorder. So if that's something you're dealing with over the winter months, you can get a specialized therapy for that.
Dr. Michael Koren:Interesting. Do you always recommend therapy? Are there times where that can be a problem? Like some people just need to get on drugs, or is it is it always is there always a part of it that should be incorporated with talking to somebody?
Dr. Heather Luing:I think we can always learn more about ourselves, right? And that's really what therapy is is learning about how you're thinking, how that's influencing, how you're feeling, and how to develop different coping skills to help you get through this really stressful life that we have to deal with. So I pretty much recommend therapy across the board. It really can't hurt you. So if you have the time and the resources, you know, search out a therapist. And really, they're everywhere. Community mental health centers, you should be able to find somebody. Telehealth has made things a lot more accessible. So there's a lot of options.
Dr. Michael Koren:Yeah, and I want to spend a little bit of time on telehealth. In certain areas of medicine, telehealth has taken over more than others. And I think it's fair to say it's taken over more in psychiatry. If that's not a true statement, let me know. But that's my sense.
Dr. Heather Luing:That's true, yeah.
Dr. Michael Koren:But is that the same as being in the room with the human being? What do you think?
Dr. Heather Luing:I would say it's close.
Dr. Michael Koren:Okay.
Dr. Heather Luing:I would say it's not really quite the same. If you have an option of in-person treatment, I always think that's a little bit of an edge. It's preferable. But if that's not an option for you, you can't get the time off work or transportation's a problem, then telehealth really does open up access. So it definitely has a place.
Dr. Michael Koren:And how about these bots that have been promoted as ways of providing psychotherapy? What are your opinion on those?
Dr. Heather Luing:I think we might be a little early on that. So I would encourage you trying to find an actual human being rather than a bot.
Dr. Michael Koren:I like that advice. So let's talk about medication.
Dr. Heather Luing:Yeah, so medications are interesting. For many, many years, we have kind of hung our hat in psychiatry on what's called the monoemanergic hypothesis. That sounds like a lot of big words. How many of you guys have heard of serotonin? Okay, everybody, right? And a lot of my patients will come to me and say, you know, I think I have a chemical imbalance or I have a serotonin deficiency. The reality is it's not that simple. We really oversimplified things a little bit in explaining how the brain and depression work. And unfortunately, for my entire career up until a few years ago, the only meds we had available were those that worked on monoaminergic brain chemicals like serotonin and norepinephrine. For some people, that's great, but about a third of people do not respond to these medications. And a lot of people get an incomplete response where, yeah, the depression's better, they're getting out of bed, they're going to work, but they're not really enjoying their life. It's kind of in black and white instead of color. So that's really where our antidepressant treatments have been for many years. Now we have had some recent advances, and we have a lot of chemicals that are in research right now that work in different ways. And so I think again, it's a very hopeful time when it comes to med management, but we've had a lot of unmet need.
Dr. Michael Koren:The seasonal preventive strategies. One of the things I was curious about and wondering about is is somebody that tends to have that the type of patient that may get on preventative medicine come October. Is that something that you do in for some patients?
Dr. Heather Luing:Yeah, absolutely. For some people that can be very helpful. And you know, like I said at the beginning, the sooner we treat depression, the easier it is to treat. So if you can nip it in the bud like that, a lot better than it getting to December and you having a hard time getting out of bed.
Dr. Michael Koren:Because we we like to promote preparedness for the cold and flu season at MedEvidence. And we always tell people starting in August that prepare to get your flu shot and your RSV, et cetera, for the coming season. It's probably similar in psychiatry.
Dr. Heather Luing:Yeah, I think so. And you know, that could be things beyond medicine, right? Maybe it's increasing your lifestyle interventions. You're gonna get outside and walk and get some sunlight, things like that. You could definitely do preventatively.
Dr. Michael Koren:Fascinating. This light therapy I find really super interesting. So why don't you walk us through this?
Dr. Heather Luing:Yeah, so you have to have a certain type of light. So they make these light boxes. You don't look directly into the light, so you want to have your eyes open, but kind of looking to the side, and you'll have a period of time that is specified to how much light exposure you need. Now, certain disorders, for example, bipolar disorder, you got to be very careful with the light because it can be too much. It's something that has to be tailored to the individual.
Dr. Michael Koren:Interesting. And how does light therapy stack up against medications?
Dr. Heather Luing:I think for seasonal affective disorder, very well. It's really the kind of standard treatment for that particular type of depression.
Dr. Michael Koren:Interesting. Okay, TMS. This sounds really fascinating. So I'm real curious to learn more about this.
Dr. Heather Luing:Yeah, I think TMS is the best kept secret in psychiatry.
Dr. Michael Koren:Really?
Dr. Heather Luing:Yeah. And so it has been FDA approved in the US for about 17 years, but I bet most of you have never heard of it. So and I think it's something that I love talking about because so many people don't know about it and it's such a great treatment option. So what it is is it's a non-invasive type of brain stimulation. So what we do is we apply magnetic pulses to a certain part of your brain that in depressed individuals is hypoactive. So it kind of goes to sleep on the job. What these magnetic pulses do is help to wake it up so that it starts communicating with the rest of the brain and forming those neuronal connections that are so important.
Dr. Michael Koren:Interesting. So what kind of device do you have to use for this?
Dr. Heather Luing:So TMS machine, it kind of has a chair that looks a little bit like a dental chair. You just kind of recline back in that chair, and then there's a magnet that fits over your head, kind of like this. And you just sit there and it taps away for about 19 minutes. And you do this for a series of treatments. So you come in five days a week, Monday through Friday, for 30 treatments, and then you do a six-treatment taper.
Dr. Michael Koren:Now the last bullet point here talks about minimal systemic side effects. Are there anything in particular you're worried about as a side effect?
Dr. Heather Luing:Yeah, it's pretty amazing in that it's a very effective treatment, but very few side effects. So most common is a little bit of scalp tenderness under where the magnet sits. So kind of thing when you're brushing your hair in the morning, you're like, oh, that's a little tender and occasional headaches. And that's pretty much it. There's no anesthesia, no downtime. You can drive, you can go to work, you can do all your normal activities.
Dr. Michael Koren:Pretty cool. So you get into more details about what to expect.
Dr. Heather Luing:Yeah, so you kind of see an example of one of the types of TMS machines there. You're gonna feel a tapping sensation, you'll hear that too, right over your scalp. And most sessions take about 19 minutes. We do have some newer protocols that are being studied, uh Theta Bursts, which are down to three minutes. They really compress the pulses down. And there's even some accelerated TMS protocols that have been in the news quite a bit in the last year where you can compress TMS down to a few days instead of going over several weeks.
Dr. Michael Koren:Interesting. And which companies manufacture this machine out of curiosity?
Dr. Heather Luing:That particular one is a Neurostar. There's about eight of these figure eight machine companies that are on the market. So there's they're all pretty similar when you come to the inside. The magnet itself is the same. It's just kind of the outside of the machine that's different.
Dr. Michael Koren:One not better than the other, particularly?
Dr. Heather Luing:No, they're comparable. The FDA has has cleared them.
Dr. Michael Koren:Interesting. All right. So beyond TMS.
Dr. Heather Luing:Yeah, so we have other types of neurostimulation. So again, this is kind of your last layer of treatment. You've tried lifestyle, you've tried therapy, you've tried meds, but you're still not getting resolution. VNS or vagus nerve stimulation is another really exciting type of neurostimulation. You can see from the picture there, this is a small implanted device. It goes about under your collarbone. It's about the size of a quarter, and it connects to the vagus nerve, which is one of the largest nerves in our body. And what it'll do is every few seconds it will stimulate that nerve, and that has been shown to improve depression. So it's interesting. This was actually FDA approved maybe close to 17 years ago now, too. But CMS or Medicare did not pick it up to pay for it, and so insurance doesn't pay for it. And because of that, this recover trial has been going on for the last four years or so. And that is just an additional trial to demonstrate efficacy, not only for major depressive disorder, but also bipolar depression.
Dr. Michael Koren:That's so interesting. So here in Jacksonville, we've actually done a number of studies of vagus nerve stimulators for other diseases.
Dr. Heather Luing:Right.
Dr. Michael Koren:And we did studies with similar devices to treat hypertension, high blood pressure, and it worked.
Dr. Heather Luing:Yeah.
Dr. Michael Koren:And we did studies in heart failure using these type of devices, and it's actually approved, and CMS covers it for heart failure.
Dr. Heather Luing:Yeah, that's fascinating. I think they also use it for clotting disorders and some GI.
Dr. Michael Koren:Yeah, but it's the f this is the first time I've actually heard that one of the positive side effects of this may be less depression.
Dr. Heather Luing:Yeah.
Dr. Michael Koren:Have people looked at that in the heart failure population?
Dr. Heather Luing:Yeah, I think that's kind of how they discovered it initially.
Dr. Michael Koren:Interesting.
Dr. Heather Luing:Yep.
Dr. Michael Koren:Fascinating. Okay, emergent research, rapid acting treatment. So tell us more about this.
Dr. Heather Luing:Yeah, so we've again moved beyond this monoaminergic hypothesis as ketamine was our first FDA-approved treatment that looks at targeting the glutamate system. And so because glutamate works a lot quicker than serotonin, we're getting improvements within 24 hours for many patients. And so that's really exciting. You can also do ketamine-assisted psychotherapy. Now, ketamine itself is not FDA approved, so that is an off-label treatment, but sometimes combining the therapy with the actual medication can be really impactful.
Dr. Michael Koren:So when when I think of ketamine, I think of being in almost a state of anesthesia. How does it work in in the outpatient setting in a psychiatrist's office? I'm really curious about that.
Dr. Heather Luing:Much lower doses, yes. We definitely don't want anyone under anesthesia in their psychiatrist's office. But low doses actually give a profound relaxation. For some people, a little bit of a dissociative effect, and that can be dose-dependent. With esketamine, which is the FDA-approved nasal spray, it's a fairly mild dissociation. But you do stay for a couple hours in the doctor's office for your treatment.
Dr. Michael Koren:So that's interesting. Do people fall asleep during this? Is that a problem?
Dr. Heather Luing:Sometimes it's one of those known side effects. Yeah, I have one lady, she's been doing it in our clinic for I think about five years, and she sleeps every single session the entire time. But I think she just really likes a good nap.
Dr. Michael Koren:So well, you talked about sleep being important for depression, so there you go. That's right. I love that. Okay. And uh psychedelics, we've actually had a few MedEvidence podcasts on psychedelics. And we're excited that people are actually looking at it scientifically for the first time.
Dr. Heather Luing:Right. There's been a lot of fear around it that I think was somewhat unfounded. So, you know, it's kind of on the horizon, nothing here yet, but a lot of studies going on.
Dr. Michael Koren:When when these studies are done, you have to have a very specific facility to actually do the work in clinical research. I recently was exposed to that when I was visiting one of our sister sites in Chicago. And they had this whole setup with you kind of look like a hippies den from the 1960s. But it was a a very specific room that you needed to perform these studies. Is that the general sense that that's how we're gonna be treating these people clinically? You were gonna get in your Volkswagen bus and and and give the therapy in that?
Dr. Heather Luing:I don't think it has to be quite like that. But you know, there are some really important considerations with psychedelic research and safety is one of them for sure. But also having a good environment where it doesn't feel too sterile, you feel like you're comfortable enough to really relax and have that experience is important.
Dr. Michael Koren:Interesting. All right, new and emerging medications. So walk us through some of these.
Dr. Heather Luing:Yeah, and I'm not gonna go through all these details. I can tell you that the nice thing about these is these are all novel mechanism of action. So we don't have anything currently on the market that treats depression in this way. And that's so important because if you're one of those people who doesn't respond to the serotonergic agents, this is like a potential lifeline, right? These are some new ways to treat depression that we haven't had access to before. So really exciting for some of these, we're utilizing your endogenous opioid system. And that always sounds weird to people, right? Because we're in an opioid crisis. Opiates seem like they should be bad. But the reality is we have natural opiate systems within our body that some of these medications can stimulate in ways that can help depression. Um, some of them also are very helpful for other things like anxiety, insomnia, so things that a lot of my patients suffer from, some of these medications are going to specifically target in the studies.
Dr. Michael Koren:So that's so interesting. So one of the things that we've been taught in medicine is that although opioids give you euphoria in the short term, they actually cause depression in the long term. Is that is that inaccurate or?
Dr. Heather Luing:A lot of times, when you're bringing in an unnatural opiate, something that's not naturally in our system, you can really deplete your neurotransmitters and kind of exhaust the system. With this, it's a very careful modulation of your natural system. And so you don't have that kind of exhaustion of the system that leads to those depressive symptoms.
Dr. Michael Koren:Interesting. And are any of these trials ongoing in our community now?
Dr. Heather Luing:The first one I'm actually a site PI for currently. So that one is ongoing.
Dr. Michael Koren:Is that enrolling now?
Dr. Heather Luing:It is currently enrolling.
Dr. Michael Koren:And just give everybody a sense for the type of patient that would get involved in something like that.
Dr. Heather Luing:Yeah, it these are mostly major depressive disorder studies. So for these studies, you want somebody who either hasn't tried antidepressants yet, or maybe they've tried one or maybe two for some studies in the current episode of depression. If you're somebody who's tried three, four, five, you know, in a fairly recent period, that's probably not gonna meet the criteria for the study.
Dr. Michael Koren:And how do these new drugs are anticipated to interact with the serotonin inhibition concept?
Dr. Heather Luing:Totally different. So they're not gonna be influencing those systems to any meaningful amount.
Dr. Michael Koren:And do when you do these studies, do they have to be on a baseline of an SSRI or not necessarily?
Dr. Heather Luing:No, I don't think most of these, there may be there may be one in there that's or two that's an adjunctive trial. So for those, you would need to be on an antidepressant already. But some of these are standalone, so you'd get washed off if you were already on an antidepressant. You'd need to stop that for a week or two before you started this study.
Dr. Michael Koren:Are there any of these mechanisms that you're particularly excited about?
Dr. Heather Luing:I think we're excited about all of them.
Dr. Michael Koren:Okay.
Dr. Heather Luing:There's really a lot of different ways that we can target depression. And now that the companies are really putting the investment into finding newer, safer ways, I think we're in a time of great advancement in psychiatry.
Dr. Michael Koren:Yeah, I mentioned in the beginning that I was super excited to be working with you. We actually did some studies in depression 20 years ago, I guess during the last phase of investment. And one of the frustrating things is that people who are in the studies were getting better regardless of what the treatment was. And I guess is the whole social interaction thing, the Hawthorne effect, et cetera. So is that still relevant for studies that we're doing today? Is that people who get into studies just get better?
Dr. Heather Luing:It it is relevant. The placebo response is huge in psychiatry studies in general, but particularly depression trials. And so we try to minimize that. So if you come into a depression trial and we're not just quite as warm and fuzzy as maybe we would when you come in ordinarily to see us, it's because we just try to minimize things that can confound it and cause that placebo response. So we try to keep it professional and really.
Dr. Michael Koren:On the other hand, that's good for the patients. If you we like to talk about the fact that one of the advantages of doing research is the fact that regardless of what the study assignment is, people tend to get better.
Dr. Heather Luing:Right.
Dr. Michael Koren:That's true for psychiatry, it's true for cardiology.
Dr. Heather Luing:Oh, yes. When I'm not wearing my researcher hat, I love the placebo effect. It's fantastic, right? The key is just to get you better no matter what. But when you're in research, you have to be careful about that.
Dr. Michael Koren:But uh again, I think it's yeah, in my perspective at least, any of the therapies that we use should be effective enough that they're giving you that result on top of the benefits from just coming in.
Dr. Heather Luing:Yeah, they have to be, and the FDA requires that, and that's that's good for patients.
Dr. Michael Koren:It reminds me uh of the vagal nerve stimulator device. So and this was super interesting. So we were treating these people that had refractory hypertension. Some people were on like five different drugs for blood pressure. And in order to do the study, you had to bring them to the OR. You had to put a pacemaker-like device in, which is the pulse generator, and then a wire that goes up to the neck where the carotid artery and the vagus nerve are most prominent. And we found a couple of interesting things. One, when we put them to sleep, using ketamine, their blood pressure dropped tremendously. Number one. And then number two, is during the course of the study, the people in the placebo group had a huge drop in their blood pressure during the course of time just being involved in the study. And so the first studies actually turned out to be null studies. They didn't prove their hypothesis because everybody did so well. So it was literally a 40-point drop in blood pressure in the placebo group and a 50-point drop in the vagus stimulating group. But because the placebo patients did so well, they had a hard time proving their point.
Dr. Heather Luing:Well, it shows the mind-body connection, right?
Dr. Michael Koren:Exactly. So it's fascinating. And again, I would argue that's a reason people should check out research. Good things happen.
Dr. Heather Luing:Yes.
Dr. Michael Koren:Well, there you go. Why clinical research matters.
Dr. Heather Luing:Yeah, absolutely.
Dr. Michael Koren:So give us your perspective on that.
Dr. Heather Luing:Any medication or procedure that we have today started in research. So it's really our way of moving medicine forward, and I think because of that plays such an important role.
Dr. Michael Koren:And we now have a plan to really expand what you're doing. Yeah, we're super excited to have somebody uh of your caliber as part of the team, and we're gonna get the word out about some of these great trials.
Dr. Heather Luing:There's so much need, and I think the wonderful thing about clinical research too is it kind of takes away the barriers that sometimes people have with insurance or maybe lack of insurance, and it allows people to really anyone can have access to looking at.
Dr. Michael Koren:Yeah, and and expand on that a little bit because I've talked to the psychiatrist, and it seems in this kind of managed care era, insurance companies say, well, we'll give you psychotherapy but five sessions, regardless of what kind of progress you make. And it it's become very, very challenging. So comment a little bit more on that. Is that still a big problem?
Dr. Heather Luing:It's a huge problem. I think it's the most frustrating thing about being a psychiatrist today. Yeah, because you know what would help your patient, but maybe they can't access it because of the limitations on insurance. So I think a good psychiatric office is going to really advocate for you and try to help you to get that approved. But again, clinical research, even if you don't have insurance, you can still participate.
Dr. Michael Koren:That's great. Okay. So how do you help a friend or a family member?
Dr. Heather Luing:I think the most important thing is to talk about it. You know, we've traditionally had kind of a taboo or stigma against mental health and mental illness in the US, and that's a problem. It just makes the problem worse for everyone. So being open yourself to just talking about this thing, if you notice somebody who doesn't seem to be doing well, ask them about it. And it's been shown in research that talking about things, even suicide, doesn't make it worse. It actually makes it better. Helping out in practical ways, however you can, and then encouraging them to get professional help if they need it.
Dr. Michael Koren:Again, that 988 number, I think, is really a very important public health message that everybody should know that number, committed to memory. And and even just reminding people that may be in a depressed state that if it gets to a certain point, yeah, you have that resource out there.
Dr. Heather Luing:Yeah. And the 988, it's not kind of like calling 911 where you're gonna have police responding, that sort of thing. It's really more of a mental health focus.
Dr. Michael Koren:So fabulous. And building your personal mental wellness plan. I'm super interested in your perspective on this.
Dr. Heather Luing:Really focus on some of those lifestyle things that are the foundation. So sleep, exercise, nutrition, time in nature, and that social connectivity. Those are really impactful things to add, whether you're gonna be doing therapy and medication or you're just gonna be doing those alone. It can be life-changing. So make it kind of a new habit or routine. And there really are resources for everybody. So if you don't have insurance, there are community mental health centers in every county across the U.S. So there's always help available. And of course, if you do have insurance, you can check with your insurance plan and they can tell you who's in network.
Dr. Michael Koren:And how how does it work nowadays? Can people refer themselves to psychiatrists or do they have to generally go through their primary physicians? What's what's the traffic of this these days?
Dr. Heather Luing:I would say 90% of the time you can self-refer. If you can't, you probably already know that your plan has that limitation, but most people can.
Dr. Michael Koren:And the the other question that I hear that comes up a lot is there's a shortage of psychiatrists around the country, and I assume also here in Northeast Florida, how long does it take to get in to see you?
Dr. Heather Luing:I mean, we can get somebody in usually the same week, if not the next week. So I don't think that that's gonna be a barrier. But also the majority of mental health problems are treated by primary care in the U.S. So if you run into any difficulty seeing a psychiatrist, then start with your primary care provider.
Dr. Michael Koren:Excellent. So I think we're up to take-home messages, so go ahead with that.
Dr. Heather Luing:Yeah, I think the the thing I really want to emphasize is hope. I want everybody to leave here feeling like no matter what you're going through from a mental health standpoint, that there is hope available and reaching out for resources when you need them. They're there for you.
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