 Welcome Dr. Mike to the Psych2Go YouTube channel. Thank you so much for having me. Hello to Monica, hello to all the Psych2Goers. I'm excited to chat mental health. This is something I chat with not only with my patients, but with my friends all the time because it's a topic I get so passionate about. Yeah, we absolutely love you. We love how you make medical education so interesting and accessible. As a family medicine provider, most people think that, you know, we manage only physical complaints, but the reality is not only do we manage a lot of mental health issues and well-being, but we also see the mental health issues start popping up as physical health complaints initially, and then only upon further investigation figuring out that there's way more that needs to be discussed before we start making a diagnosis. Yeah, this really leads into the question of relationship between mental and physical health issues. A common question that we get from the community is what is that direct relationship between mental and physical health? Yeah, so it happens in multiple pathways. First, our bodies are so interconnected through the neurological system. Any implication that plays a role into how your brain is perceiving the outside world is gonna change how your body reacts to the outside world. A simple way of seeing this is if you're in a stressed out state, high anxiety state, your blood pressure starts to go up, and that's a physical manifestation of something that's happening on the mental side of your body. Another way the body connects is through a neuroendocrine pathway where the body actually starts signaling through different hormones how your physical body should react, again, to your mental health state. And that plays out in a lot of different roles when it comes to chronic stress states or chronic anxiety or chronic depression states because that's when you start seeing weight gain become an issue, joint pain become an issue, lack of motivation and things that you might relate to being more physical health bound but are actually related more to the mental health side of things. Right, when you think of more common things like diet and exercise, how can that play a role in all these kind of neuroendocrine pathways and things that you just described? Yeah, so because the body's so connected and it's so reactive to each different aspect of life because the body's all about maintaining homeostasis which is sort of a balanced state within the body. So if you have a release of too much hormone, the body will then counteract its initial release and decrease the amount of hormone being produced. And that sort of pathway that homeostasis pathway happens in many ways. Whether we're talking about blood pressure, pulse, even your environment, like if it's too hot, you start sweating or if you see a lie and you need to release a lot of adrenaline. That sort of homeostasis is all about balance and it's best balance when you're experiencing both ends of the spectrum and when your mental health is in a state where you're only on one end of the spectrum, the negative end of the spectrum where you're not feeling well or you're feeling down, the body starts taking a toll on it because the blood pressure starts to suffer. The foods that you're eating start to become foods that spike your insulin, causing you to crash more often throughout the day, have less energy levels throughout the day. And all of that is gonna impact your motivation levels. And once your motivation levels start dropping, it's harder to go to the gym. It's harder to create social connections and loneliness takes a huge toll on us both physically and mentally. So it's really like this cascading pathway where it may start with not feeling great and feeling down then it goes to not eating healthy foods and eating a lot of junk foods that make you crash and not have motivation. Then to putting on weight, to having joint pains, to having less social connection. And that could further put you back into that cycle of not feeling great, of having anxious thoughts, depressive thoughts. And really that's what a doctor should focus on when they're seeing you in the office or in a hospital setting. Because when we look at patients and we look at the issues that they bring forth to us, it's about understanding them as a whole person. It's very easy to just look at the end of that spectrum and say, oh well, you know, you don't have many social connections, let's find you a social group to join. Or you're not eating healthy foods, here's a list of healthy foods. I am technically providing you a solution, but it's not the solution to the actual problem because the problem started much earlier in that pathway. And that's what a good doctor does, that's what a good clinician does, is try and figure out where that pathway starts. So we address that goal earlier on so that pathway doesn't even get a chance to form. And to me, that's the beauty of medicine. That's where like I get to play detective to figure out why it's happening. Yes, we're talking about mental health causing these physical manifestations, but that's not always the case. Sometimes it is a physical issue that's causing the patient symptoms. So that sort of touch and go balance, understanding the person in front of you, gaining trust with them. That's the beauty of medicine. That's why I enjoy being in a room with a patient. I think it's sort of similar to that biopsychosocial approach to medicine and really contrasting it to more like disease models of medicine. And I think medicine as a whole is going more towards the biopsychosocial approach, which is absolutely wonderful. We have to treat people, patients as a whole rather than just kind of isolated parts. Yeah, and that's why earlier in my career when I was a resident, I started seeing a lot of physical complaints come in and being an osteopathic physician. I was doing some manipulation. I was getting them physical therapy, perhaps medications on board when they needed to or injections. And then I realized like, I feel like I'm missing part of the spectrum here because I'm doing what the textbooks told me to do. You know, if a patient comes in with disease X, the treatment for disease X is Y. And I would prescribe Y. And then the patients would maybe get better or not get better at all. And then I would feel frustrated that I'm not helping this person, even though I'm following what the textbook told me to do. And that's when I began to realize that like the whole mantra of medicine being an art as much as the science is so true. But it's not because like the treatments are all that different. And some people may have a different choice of treatment but it's because of the diagnosis being so subjective because patients view the world through their own lens. And then you have to view the patient through your own lens. And that's the art because only through properly understanding the patient and what symptoms they're experiencing and why they're experiencing them. Can you make the right diagnosis then come to the correct treatment? The treatment is really the science but the diagnosis is where the art form kicks in. Right. Yeah, with diagnoses sometimes being sort of subjective there's often a lot of comorbidities, right? So I'm wondering how can for example, depression affect the body differently compared to, I don't know, anxiety or even different subtypes of depression. That's an important point you raised because depression has different subtypes. A lot of times my patients who do suffer with generalized anxiety disorder end up having symptoms of depression. And again, it's very easy to start saying, oh, they're feeling down. They lost motivation and things they once enjoyed. They're not sleeping well and diagnosed them with major depressive disorder. When the reality is they're actually suffering from generalized anxiety disorder from constant nervousness, constant catastrophic thinking like even jitteriness from this hyperarousal state that needs to be addressed. And then the depressive symptoms start to wane. So it's really understanding like what is the source of the symptoms before jumping to following a checklist of, oh, the patient has XYZ and that's exactly the diagnosis. No, like what caused those things to happen? Is it from that true depressive state or is there something else going on? And why is that important? A, therapy tends to change depending on which diagnosis your patient falls into. B, medications change. There are certain medications that we use for both depression and anxiety that can be sort of an upper for a patient. So if you have a patient who's struggling to get out of bed, struggling to be motivated, maybe we use a medication that will give them a little boost of energy and make them feel a little bit more motivated to do things. And on the other hand, even in a similar class of medications, there's ones that make them a little bit calmer, a little bit more relaxed. And for patients who have high anxiety states, maybe that's the optimal play. And while we know that these options exist, we also know that they act differently on different patients because the psychiatric world of medicine is not the most well understood part of medicine. Biggest class of medications we probably use in mental health are called SSRIs. And these medications, we have theories as to why they work and none of them are quite fully proven yet. And the reality is that we see the evidence that they work. We see that they're well tolerated in patients with certain side effects differing on which medication you choose. And you try and choose the best one for your individual patient. But the reality is we don't fully understand them yet. And I think that's like the world that I'm really excited about because I think there is a lot of future in pharmacology and understanding how the body works because that whole idea of homeostasis is what really makes it all tricky. You know, you give a patient one medication, are they getting better because you're increasing neurotransmitters or are you treating them because their neurotransmitters are going up and then their body through homeostasis is down regulating the receptors that those neurotransmitters bind to. So by flooding the neurotransmitters, that's not what's helping them. It's the body's reaction to that flooding and actually decrease sort of reactivity to those neurotransmitters. Maybe that's why they're healthy. And that's what I'm so excited about, to figure out future and how that applies to each individual patient because no one patient is the same as the other. And that's why we start with small dosages. We work our way up. We have a lot of education before we start medications. So that's why when I'm in my practice and I see a 15 minute appointment for a patient who's, you know, worried about their depressive or anxiety symptoms and they've never been seen before. There's no way I can spend 15 minutes. I'm gonna be late. I'm gonna be 45 minutes with that patient to understand what they're going through, what their troubles are, what have they tried, what do they wanna try, lay out all the options, talk about the dangers of the medications, like not abruptly discontinuing and stopping medicines because that can cause a lot of problems and really having an open line of dialogue because that's the only way to go when it comes to mental health. Right. And with starting so many perhaps different treatment options, how do you know which one's actually doing, like, you know, causing the effect? Yeah. Part of disentangle, I think. I guess like the way that I do it is first I have a patient that's coming in with depressive or anxiety symptoms, figuring out severity and length of time of how long they've been feeling these symptoms is the first thing that we have to establish. Then figuring out what the patient is open to or wants to do because some patients may just want to have that one visit, make sure their blood pressure is okay, share what is going on in their lives and that's it. Some patients want to be more aggressive and want to take medications. Some people rush to medications and maybe that's not the best route for them based on our conversation. So I try and decide like, is this gonna be a patient that wants treatment A and then do they want treatment in the form of cognitive behavioral therapy or medications or both or maybe just learn about those options and then do some bibliotherapy where I give them some books to read or pamphlets to read on the subject and then we have a follow-up appointment and then from there, it's really a feeling out process. Unless it's severe depression, my general policy is to get patients to do cognitive behavioral therapy first, the conditions that I mentioned and then if that's not working or we feel like we can add some extra benefit, then we get medications on board. But again, it's patient dependent, it's what they want, it's what they're comfortable with because everything has side effects, everything has time commitments, prices, costs, insurances, our healthcare system, especially when it comes to the mental health side of things, is a disaster. There's no other word for it. It's an absolute disaster. Like I have to tell my patients with major depressive disorder, which means that they have low motivation levels to tell them that they have to get motivated to call 20 different offices and see which one is gonna have availability. Which one is gonna be able to take their insurance? Which one has availability within the next six months? And it's like a recipe for disaster because that patient is already struggling to brush their teeth in the morning or take a shower. How can I expect for them to make all these calls? And that's where we have the introduction of interdisciplinary teams where we have social workers, counselors on staff that can actually help patients with things like this, give them some assistance in finding availability or perhaps be an interim counselor while they are waiting for their appointments that are booked super far down the line. That has been probably the biggest change that I've noticed over the last five, 10 years in medicine of working as interdisciplinary teams, whether it's mental health related or even something like dietitians or nutritionists because we need that. We can't handle everything as primary care physicians. This is like physically impossible, especially with the time constraints we have. Yeah, there's a lot of barriers it seems, even trying to access mental health in the first place, not even like when you're already in touch with the GP. And so I think it leaves a lot of people wondering whether their feelings of stress might just be the usual normal feeling of stress or whether it could be something more that warrants a medical professional. So what are your thoughts on whether someone can tell if they should be reaching out to someone or if it's kind of short-term and manageable on their own? My first thought is if you're considering it, do it because the worst case scenario in that is that you go and you realize like you're glad you did it, but you don't really need it. That's literally the worst case scenario. And if that's the worst case scenario, you might as well go and like have the relationship with your GP that you're sharing what's going on in your life. But for me, it starts with exactly that, like having a GP, having a primary doctor because you have a primary doctor, you're already seeing them regularly and you're having what we call touch points in medicine where you're interacting with your patient. In those moments, you can catch that the patient is feeling a little bit off. You can catch that something's going on in their life that they may need some help, whether it's counseling related, medication related or even physical health related. So to me, like if you have a primary care doctor and you're considering that should I go, I'm kind of feeling off, that's it, that's the sign. You're telling yourself to trigger, go and allow someone with an objective perspective to take a look and see if you can benefit from some kind of help. And sometimes patients come in and they speak with me and I feel like they're doing a great job coping where I say, look, I think you're doing a great job. Why don't you take a look, read this book. I think it's gonna help you a lot. There's some exercises and stuff to do in it. It can reconnect in a period of two to four weeks. See how you're doing. If you're not benefiting greatly from this and you could use more, we can escalate treatment. But it's really about that experimentation and figuring out what works best because there's no one size fits all answer. There's no score where you're like, if I feel like a five out of 10, that means I need to go see a doctor. It just doesn't exist, unfortunately, because mental health is a very subjective space and it's a subjective space with a lot of outside influence. You could feel okay one day but then your partner can be unfaithful to you the next day and your whole mental state can change and that's understandable. So at what point does it become a disorder versus a totally normal human reaction to someone breaking your trust or having a death in the family and you're grieving? There's a lot of misunderstanding that comes with that. I have young patients that come to my office believing that they themselves are depressed because they read it online or they see their favorite social media start to talk about it and when I start talking to them, they tell me that they had a death in the family recently like a week before, two weeks before. And I asked them like, if there was a person sitting next to you who recently lost a family member and they were down about it, would you tell them that they're depressed or there's something wrong with them? Say, no, absolutely not. And I ask them like, why are you feeling that way about yourself? And they sort of start to realize that, oh, this is normal, this is part of life is being sad, part of life is experiencing the whole range of emotions and it's really about that balance. Like when does that balance get thrown off? Medically, the definition of the balance being thrown off is that it starts impacting your work, it starts impacting your ability to have relationships, family, social, romantic and if those things are suffering, that's when it starts getting labeled quote unquote diagnosis or disorder and doctors technically can put that as a code because we love our codes in medicine and our nomenclature when in reality, like that means nothing, the human in front of you is everything. Hey, Psych2Goers, I hope you enjoyed this part one interview with Dr. Mike. If you want part two of this video, don't forget to share this video to create awareness on how physical health may impact one's mental health.