Episode 54
Exploring Depression: Therapy, Medication, and Lifestyle Changes

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Description

In this exciting episode, we are joined by renowned Dr. Ilardi, to discuss his knowledge on treating Major Depressive Disorder with therapy, medication, and lifestyle changes.

Talking Points

1. Going over different perspectives on how to treat depression
   
2. Reviewing how meds for depression work in the brain 
   
3. Explaining some simple lifestyle changes that can help immensely 
   
4. Clarifying how the environment that contributed to the depression needs to be changed in a positive manner in order for any treatment to be successful
   

Quotes

“I feel like, depression is so much more treacherous than we give it credit for being. It is so much harder to fix, it is fixable, completely fixable, but it is so much harder to get it right and keep somebody well. We do our patients a grave disservice by being very cavalier and saying things like, these meds are like magic. When really, the meds are helpful but they’re not all that for so many patients. But if we are willing to really take it seriously, like you all do at Peaks, that’s what I get really excited about.”

-Dr. Stephen Ilardi, Ph.D. Professor, Clinical Neuroscientist

Episode Transcripts

Episode 54 Transcripts

empathy is knowing your own darkness

without that connection you don’t have

anything what’s the opposite of

addiction just freedom

hello everyone

welcome to

another special episode of finding peaks

this is a special episode we got a

special guest with us today and i’m

excited

to be a part of this group dynamic uh

today and we’re gonna also have an

additional episode uh coming soon as

well too or thereafter however it works

out in the time frame of things but

again welcome my name is brandon burns

chief executive officer for peaks

recovery centers you all know me your

favorite host trying to disrupt an

industry provide quality of care vision

insights for family systems

seeking treatment so that we can empower

you all to make best possible decisions

for your loved one for yourself and so

forth joined today as always by the

great clinton nicholson chief operating

officer great lpclic

all things clinical

to join us today the heavy-hitting dr

ryan md board-certified addictionologist

with us today uh at peaks recovery

centers and then our

what’s that chief medical officer i am

so sorry chief medical officer wow that

wouldn’t make any sense

we’ll rewind the tape we’ll fix it

special guest today dr stephen elardy

clinical psychologist researcher

professor university of kansas and

author of the depression cure the book

and joining us here today to talk about

depression major depressive disorders

all of its variations some anxiety maybe

we’ll tackle some sud along the way

welcome

hey thank you so much for having me it’s

a pleasure to be here um

i i’m in such a gas company i didn’t

realize the great yeah the great the

chief medical officer yeah

favorite podcast host or whatever you

know it’s like

i this is like some pretty pretty high

cotton that is pretty impressive i i so

i’m honored to be yeah trying to give

you some highlights too because you run

your own podcast as well too you know

that’s a new thing okay it’s it’s i

dabble i don’t know maybe some folks out

there could identify with this i get

bored really easily

so like you know i’ve done nba

consulting i’ve

i’ve written blogs for espn i’ve

done a podcast now youtube channel

um

you know it it this is new train for me

though so being on camera it’s like

not nervous at all

well now you know you can come on and

say you were the greatest host and mean

it when you say it and just really give

yourself all the credit i’m taking notes

they’re the mental notes right now but

yeah absolutely absolutely the viewers

at home are like yeah i think he is the

best host

that’s gonna be in my bag

so yeah thank you for being here excited

about this group and this bunch that we

have to really talk about

major depressive disorder

the symptomology of it and so forth and

the potential for the cure for it and

the remission of symptoms and so forth

and

as the viewers know we’ve done some

episodes with you know for example uh dr

ashley johnson a do psychiatrist with

colorado recovery services

here in town doing tms services and a

lot of great psychiatric work and what

the reason for highlighting that is

because in those episodes we talked

about medication um the benefits of it

also its limitations and the excitement

around new opportunities like tms and

sitting here with uh you know dr o’lardy

and certainly uh dr ryan johnson here we

want to uh i think reintroduce that as a

topic and highlight it through a

different lens

and have a really good conversation

about it the pros of it the cons of it

uh in that regard and a little bit more

of a backdrop and we were talking about

this earlier as well too you know when

you go to each and every single

addiction treatment center’s website it

says we treat dual diagnosis we can

treat this thing called major depressive

disorder

and generally out of that i think it’s

something like here’s depression and six

months ago you know the pot smoking was

taking place or the drug use and so

forth and somehow our industry keeps

trying to make it about this thing over

here and i think what that’s led to from

an industry standard is uh limitations

about how we treat major depression

major depression so certainly here at

peaks we’re trying to you know work

alongside you know individuals like you

to really advance new insights education

and

ultimately see

as an outcome a reduction in symptoms

around major depressive disorder and do

more than just med management certainly

meds are important but you have a

great deal of analogies and insights

into this so i’m just going to let you

fire away and then we’re just going to

wrap around and talk about it with you

okay well thanks yeah so the first thing

i want to say is somebody earlier this

morning when i was getting to know the

staff at peaks

mentioned you know the common thread

that runs through

everything that takes place at peaks

is you’re dealing first and foremost

with human suffering

whether or not somebody is battling

clinical depression whether they’re

battling a substance use disorder

whether they’re battling

associated anxiety or any of the other

so-called dual diagnoses

they’re suffering

and there’s a through line that really

connects substance use disorders and

depression and that is reduced

activity in the brain’s reward circuits

and probably a lot of the audience have

heard of brain chemical dopamine which

is the go-to signaling molecule in those

reward circuits

when we’re depressed

there’s a syndrome that goes along with

it our fancy we got a fancy word you

ready you know it the audience may not

and had anhedonia from the latin

no hedonic no no pleasure right

um

the dopamine-based reward circuits in

clinical depression don’t fire so the

person now doesn’t enjoy their normal

activities the way they used to they

don’t have sex drive anymore they don’t

enjoy food anymore

and

the person who is battling substance use

disorder

when they stop using what we typically

find is their dopamine reward circuits

are very blunted

they they’ve been kind of kicked into

artificially high modes of activity with

whatever they were using

and now they’re

in this state maybe they’ve gotten

through withdrawal

but they’re they’re in recovery and they

often have a lot of craving

and the reward circuits are throbbing in

anticipation like

what is out there for me

and they’re going through day-to-day

life often feeling like things are kind

of

blunted things are kind of dim and pale

and life doesn’t have the vivid colors

well guess what that’s exactly what my

depressed patients say

and we see the same kinds of underlying

neurological deficits in both and what

is exciting to me

is

many of the same strategies that can

help

with that suffering and loss of pleasure

and depression can also help in

addiction so to bring it back around

full circle

what about the role of medication what

about their old drugs well it sounds

kind of ironic and i don’t know if you

want to go down this rabbit hole but the

idea of using drugs to treat substance

use disorder strikes some people as

counterintuitive

right yeah

and yet there’s a really compelling

rationale for it in all kinds of ways

and we can talk about that in a bit but

one of the things the drugs can do

is to help those reward circuits that

have been kind of fried

in the grip of addiction in the grip of

substance use disorder to help them

normalize more quickly so the person can

enjoy the things respond to the rewards

that we’re supposed to

rather than this artificial sort of

reward

well when it comes to depression

you hear a lot about serotonin

you don’t hear nearly as much about

dopamine but dopamine function is

crucial

in depression well why do we hear so

much more about serotonin because most

of the depression drugs target serotonin

why are the depression drugs not

as effective as we wish they were i mean

they certainly help a lot of people

don’t get me wrong millions of lives

have been improved

but they’re not the game changers for

many people that we need them to be that

we want them to be why not in part

because when you give a drug like our

ssris or sssnris to ramp up serotonin

signaling very often you’re

simultaneously pushing down on the

dopamine system that’s why we have

sexual side effects it’s one of the

most common side effects right you’re

pushing down on the on the reward

circuitry well that’s not really what we

want

in depression so we need to augment that

effect with other things and you know

because we’ve talked about it a lot

that i’m a big big proponent of the idea

that there is no magic bullet in

depression there’s no single thing

fancy word monotherapy there’s no

monotherapy approach there’s no magic

drug that’s going to completely cure

forever a person’s depression most of

the time there are you know rare

exceptions but

um the drugs have a place they have a

role but we have to augment it we have

to do all the things we can’t just rely

on the one thing we can’t rely on the

monotherapy

so that’s that’s just the first premise

i wanted to put out there

i know there are a lot of different so

i’m curious now too you know and um

certainly we’re presenting to the team

earlier which is so grateful for it was

so uh informed on educational but why

why how are we in a situation which i

mean maybe it’s just speaking science or

we just don’t have the application for

it yet but why don’t we have drugs that

do the dopamine thing rather than the

serotonin we do okay so the one that

probably a lot of the audience have

heard of is is the generic is bupropion

the the trade name is either depending

on whether you’re taking it for smoking

cessation or depression the trade name

is wellbutrin for depression or or zyban

for smoking cessation same drug

um

and

the problem is that depression is often

and by often i mean over half the time

accompanied by a lot of anxiety

and if you give a drug like wellbutrin

it’s like oh okay so we’re going to ramp

up dopamine that’s good we’re going to

ramp up rewards signaling that’s good

occasionally a patient will even have

spontaneous orgasm

on wealthy trend okay um side effects of

podcast

we will circle back around

there was a grey’s anatomy episode by

the way for interesting yeah um

so

it’s no joke it can ramp up reward

signaling

but it can also ramp up anxiety okay

because the circuits are kind of

cross-wired a little bit which it’s a

long story we don’t have to go into but

so um well what else can we use well

stimulants

right adhd meds like um like adderall

like methylphenidate ritalin like

vivants all these drugs also ramp up

dopamine can they be helpful in

depression yes

absolutely

are they commonly used no why because

well they’re controlled substances a

have a high addiction potential or at

least moderate addiction potential be

but c they also ramp up anxiety

and so a lot of prescribers are very

loath to use them even though we’ve got

these dopamine deficits

in depression

that if anything a lot of times the

medications that we’re throwing at

depression can make worse

so then it’s like all right well what

can we do that’s non-pharmacological to

ramp up dopamine

and it turns out thank god there are

lots of things like physical activity

like

ambient sunlight exposure which is about

and light is a drug literally photons of

light are drugs

that hit specialized receptors in the

back of the eye in the retina that have

a broadband connection

to the center of the brain the

hypothalamus

and they

not only

renormalize our body clock which gets

out of sync and depression

not only regulate our sleep regulate our

hormones but kick up dopamine signaling

so we’ve probably all had this

experience when we go out on a bright

sunny day like we happen to be enjoying

today

if we go on a long hike or something

regardless of the activity level we feel

energized we feel stimulated and often

we have better focus because of that

sort of stimulant-like effect

when people are depressed though what do

they do they they don’t go outside they

crawl into a cave their brain is giving

them a signal to shut down pull away

withdrawal

and

part of

effective clinical work with depressed

populations is validating for them like

look

your brain is telling you that you’re

sick your brain is telling you just like

when you have the flu

get away from everybody crawl into a

cave lick your wounds

rest tight for a couple weeks till you

heal

and when you have the flu that’s great

listen to the brain when you have

depression that’s the last thing in the

world you want to do because that’s

going to make it worse

and so a lot of

the threading the needle with depressed

patients is validating yes of course you

feel like shutting down yes of course

you don’t want to be around other people

yes of course you have no energy and you

have no initiative and you’re suffering

and you’re hurting

but we have to partner together to help

you not listen to these signals from

your brain that are actually broken

signals right now

and if we can

if we can pull off that particular

clinical trick then we’re actually

ramping up dopamine signaling and that’s

the part that i think so many people

don’t get they’re like well wait a

minute if you have a brain chemistry

problem the only possible way to fix it

is to throw drugs at it or to you know

put some powerful magnets on the brain

and call it tms or you know do

electroshock there if you’re something

very somatic

but what we know from the realm of

neuroscience the realm that i’m trained

in is experience changes the brain

and

activity changes the brain and the food

we eat changes the brain and our ambient

light exposure changes the brain so all

the things

we think of as like oh my grandma could

have told me

to go get some fresh air my grandma

could have told me oh go get some oh be

active

but grandma didn’t know that this is

like powerful powerful psychoactive sort

of intervention

yeah so what i’m hearing though is that

at least one of the primary barriers is

that all of the things that you need or

at least

a good um

a good chunk of the things that you need

to get better or at least to start to

overcome depression are things that your

brain are telling you to not engage in

exactly right and that’s part of the

tragedy right of depression absolutely

and you know just to build on that a

little bit so imagine i’m depressed

and my doctor gives me an antidepressant

let’s say

um lexapro sure it’s one that a lot of

people have heard of acetal frame

and

um

one of the things it’s doing

is it’s eventually going to kick up

activity in my serotonin circuits what

does that do well

it’s going to help put the brakes

a bit on my stress response circuits

which is good because they tend to be

way too active in depression

but they’re also going to do this really

cool magical thing called

neuroplasticity they’re going to

increase the brain’s ability

to make new connections and new

associations and by the way that ability

is really compromised in the presence so

when people are depressed they cannot

easily learn new things they can’t

easily acquire new

associations and new parts of their

repertoire they’re kind of

closed sure and so you give them a drug

like lexapro is like oh this is amazing

this is going to kick up

the brain’s growth hormone it’s called

bdnf if folks want to look it up and now

they’re going to have greater

neuroplasticity here’s the problem

most patients with depression who get

treatment all they get is the drug and

it’s like here take this drug

and good luck with that go back to your

life

and well in a lot of cases their life

has some toxic elements to it so we’re

sending them to an environment that’s

negative

or at least that has some prominent

negative features sometimes by the way

is a side effect of the depression

because when we’re depressed we’re not

at our best and we can actually have a

sort of corrosive effect on some

relationships because we’ve been shut

down because we’ve been withdrawing and

we’ve been ghosting people and we’ve

been not responding to them

and now we give them the drug okay great

i got more plasticity but i’m going back

to a life that has a lot of negative

elements and now i’m

making those associations so it’s like

oh

the drug is making me more responsive to

my environment and i’ve done nothing to

fix my environment

yeah

hey

maybe that’s a reason why these drugs

are not more effective than they

actually turn out to be maybe these

drugs have the potential to be a lot

more effective

if we could attend to the

neuroplasticity angle and provide a

supportive context so provide

a beautifully healing support of milieu

yeah this sounds like an ad i love it

and i’m thinking about going you know

for the for the viewers out there that

can’t see you know your slides in your

presentation right i’m thinking of the

pie chart right where 76 roughly 76 77

of the time they’re just getting that

you know mono therapeutic approach

through medications most patients with

depression if they get treatment all

they’re getting is meds all they’re

getting is meds that is wild

when it’s such a complex issue as we’ll

get into certainly here around your web

analogy and so forth and then i think

out of that as well too it’s somewhere

you know 4.8 to 5.6 percent somewhere

and they’re just received psychotherapy

alone

and then 18 roughly of the popular

population receives both psychotherapy

and medication as a management

at the same time in lieu of that pie

chart and that incredible data right we

have more depression anxiety and so

forth than ever before

and then we have these medications and

no wonder we’re arriving at sort of a

frustration here in american culture

there’s such

a belief in

the med only a sort of approach yet it’s

not really resolving the problem and

it’s kind of like you know for me i i

just i want to shake the tree of

american culture and say let’s wake up

to this and let’s put

all these other benefits like you were

talking about the light and all of these

natural things and also how through

psychotherapy maybe it’s a residential

program maybe it’s ambulatory you know

uh you were saying something uh

wonderful earlier as well too like how

can we be you know the frontal lobe how

can we be the how can we do that for you

as you get well in the process yeah

should we unpack that a little bit yes

please so

so

i

that’s like page 9 15 100. it’s all over

the book so

yeah please unpack it okay so

um

depression hits so many different

circuits in the brain and takes them

offline or or just compromises them so

they don’t work as well and one of the

most important to me

is this set of circuits in the frontal

cortex and they lateralize to the left

so it’s really cool people are always

fascinated by left brain right brain and

a lot of the popular ideas about what

that is are are off-base but

one of them to put it gently but one of

the ways that lateralization matters is

the left frontal cortex has circuits

that help us go after the things that we

want and initiate

sort of pull the trigger if i can you

can i use that metaphor yes i’m in

colorado with that yeah

pull the trigger on

our

um the things we want to do so if i’m

sitting on the couch i am sitting you

know if i’m sitting on a couch and i’m

like oh i should get up

and i should get out it would help me to

get up and go for a brisk walk outside

maybe walk the dog whatever

um if i’m depressed

my left frontal cortex takes that

impulse

and it’s like

flatline like oh i should do that i got

nothing

it’s like i’ve fallen and i can’t get up

it’s like i’m sitting and i can i and

and what our depressed patients tell us

all the time

is i know the things that will help me

and i can’t make myself do

them when i started crafting the

therapeutic lifestyle change program for

depression what several colleagues told

me is yes we see the research we see the

science we see the evidence we know

these things will help but they’re all

the things people can’t do when they’re

depressed right

and and my gentle pushback was

friendly amendment these are things they

cannot initiate often when they’re

depressed but if they have someone to

partner with them to provide them that

spark of initiative that their left

frontal cortex is not giving

then they can do them so let’s take

exercise for example so what is the

antidepressant dose of exercise luckily

it’s very low

the the most robustly established

antidepressant what do i mean by

antidepressant as effective as the

average drug for the average patient

three times a week

i’ll say it again because it’s low 30

minutes of brisk aerobic walking three

times a week

that’s been tested in head-to-head

trials against zoloft sertraline

twice now at my alma mater duke

university

and found to be every bit as effective

in the short term more effective

at preventing recurrence

and it’s super low dose but

patients with depression usually have

trouble making themselves do it so what

do we do we partner with them we say you

know would you let us play the role of

your left frontal cortex would you let

us

schedule the exercise with you

or with your trainer would you let us

then give you a little prompt a little

tickler a little reminder what do you

call it tickler that’s fine i think that

works yeah

i don’t know i’m looking at the

millennial in the room

no

yeah i’m in between is there a cooler

i’m on the latter end of the millennial

spectrum right now i’ve got to have a

cooler word yeah i’m the

i don’t oh

i don’t have a cooler word than tickler

yeah

um so a little tickler

a half hour before the workout like hey

you know we just just took a little

reminder we you know we’re mrs jones you

know we’re going to be meeting in a half

hour

and it’s like oh now the trainer is

playing the role of the left frontal

cortex giving that signal that spark

that the depressed person is not getting

on their own so what do we find people

with depression can exercise people with

depression can enjoy exercise people

with depression can benefit enormously

but they cannot make themselves do it

usually

so we have to let go of the judgment we

have to let go of the nagging we have to

let go of the self-blame

and just be freaking realist about it

it’s like

let’s validate for people that are

suffering with depression it’s like yes

depression is taking you away from your

best self

it’s robbing you of capabilities that

you normally have

and there’s no judgment

but we’re going to partner with you

to help you do the things that you need

to do

to get well

because when you’re well you’ll be able

to initiate all the things again

hopefully yeah if you could before you

you got depressed then you’ll be able to

again yeah yeah absolutely and i think

that’s the that’s the that’s a special

sauce in the tlc model because you know

at peaks recovery certainly we have an

opportunity to front line with

medications and do what we can there and

i hope that the viewers watching this as

well too can hear all the things that

doctors are trying to roll through in

their heads as prescribers or even

mid-level providers as they go through

this because i mean that’s back to my

point about the dopamine medication it’s

like don’t we have these things you know

it was kind of rhetorical right we do

have these things but why don’t we throw

that at them you know in that sort of

way because it comes with all these

consequences a med and then a med to

manage the symptoms of the med and you

know potentially all of this you know

fallout

and then on the other side of that we

have psychotherapy you know but the med

is going to take time to ramp up and the

depressed patient is having difficulty

just sitting in that environment and it

feels like as the next sensible thing

and why this tlc model is so fascinating

uh is because now we can do so much more

with the time that we have them within

these residential settings and

differently than the challenges of your

you know your research studies where

they had to kind of go home come back

report that sort of thing and you’ve got

them yeah

and you can provide a level of support

and a level of for one of the better

word stress management sure that you

know is just going to be so

incredibly beneficial for many patients

and so with the integration i mean

when you talk about depression i just

keep having this

this idea of like paralysis right it’s

like almost like a neural paralysis

where things just are stuck like you

can’t

move in any way shape or form

neurologically to a certain degree and

then you have something you introduce

medication which gives you

neuroplasticity right so you’ve got some

room to maneuver at that point but then

that desire to

to actually make those changes and push

forward and push through that paralysis

requires almost like

neural like a neural partner right like

somebody to come and partner with you in

order to push you along and so then you

have these all of a sudden though you’ve

got all of the major components

especially in something like a

residential program where you can really

come at it from all these different

angles and like you said do all the

things right exactly right and then we

have iop right where we get to help them

make those habits lifelong habits and

and change the environment they’re in

and i think that’s what’s exciting about

this yes that’s a really important point

too right because we were talking about

this earlier but

so much of the if we if we zoom out to

landscape of mental health and treating

depression what we see

is it’s challenging to treat depression

in the short term

in the first couple months

but we have the tools if we’re willing

to do all the things we’ve got the tools

it’s like we’ve got this in the great

majority of cases

the bigger challenge is treating it in

the long term

very similar case i would say i think

you’d agree with substance use disorders

where absolutely you know the short-term

outcomes are better generally than the

long-term outcomes and yet we’re playing

the long game

we want our patients to thrive in the

long term and so that means now how can

we pivot from this very cocoon like can

i use that word this oasis like

environment of 45 days where i’m going

to be

really well cared for

but everything in my environment is

controlled and now i’ve got to pivot

back out to the real world my life as it

exists outside

how do i take all of these new tools and

skills and associations and generalize

them out to my life in the world and

that that is

i mean

it’s like you’re speaking my love

language now because because i mean i’m

so excited about this this 45-day

residential i mean

that’s miraculous that that exists

but then to be able to take that and

take it out into somebody’s you know

real world life is is so important

absolutely

yeah

um

yeah so well there are a lot of

different directions we can go yeah with

this yeah one of the one of the

challenges of integrated care and i

don’t know if uh if there’s you know a

tone you can put on it or give us some

insights or just a general conversation

but you go to integrate the care and

major depressive patient and sud patient

are sitting next to each other and say

i’m not like that person and i’m not

like that person and why are we in the

same room together and you’re treating

something different but it reminds you

know going back to that you know the the

dopamine you know uh reward circuits you

remember reward circuits in scenario

that’s the that’s the intersection

that’s the bridge well the two two

bridges one is profound suffering yeah

profound suffering

and you know i i don’t know if you all

find this but i find that when people

are suffering

a lot of the superfluous things in life

get stripped away and people get very

real

because it’s like you know i mean like i

worked for three months on a brain tumor

clinic

with patients that

for the most part had about a year to

live

and it was the most existentially

profound experience professionally of my

life because people just get so most

people not everyone but most people just

get very dialed in to what’s important

and what’s not

and i feel like a lot of sud patients

get that way

i mean they’ve been to the brink a lot

absolutely right they’ve been to the

brink

a lot of depressed patients have been

suicidal they’ve been to the brink some

of them made a town some of them made

serious attempts

and then you know now they’re at this

moment where they’re like i you know

i can’t take much more of this i need

some relief and they’re coming to you

and they’re desperate

and your sud patients are coming to you

and they’re desperate

so

they’re experiencing the suffering

and

they have

compromised reward circuits and you know

for those who want to take the deep dive

there’s a dopamine receptor subtype that

helps coordinate

activity in the these circuits are

called d2 receptors

and long story short

people with sud have low levels of d2

receptors so the reward circuits don’t

work correctly they don’t get high on

life but they get way way way too much

reward from substances of abuse

people with depression also low d2

receptors also wonky reward circuitry so

they’re kindred

yeah and by the way there’s a lot of

overlap because a lot of people with

depression self-medicate

and a lot of addicts become depressed

and a lot of those who are not addicts

but just sud you know abuse folks get

depressed so and i think both of those

worlds those uh people suffering from

either sud or depression feel isolated

they feel like they feel completely

disconnected and brilliant and again

yeah earlier in the day we talked about

the idea of you know the opposite of

addiction being connection and so the i

and we were talking about the opposite

of suffering is also connection yeah so

it’s interesting you get it’s this

ironic thing again where you have two

people sitting next to each other who

feel so far apart but they’re actually

so close together and one of the actual

things that would make them feel even

better was is to find that connection

with each other and to share that so

it’s just this kind of i i don’t know i

think that we we live in a world of

irony a lot of times in what we do

there’s so many levels of irony that we

are dealing with and it’s just really

interesting to hear them point it out

that way and uh sort of have a different

angle and a different lens to look at it

through that’s a great connection i love

that

yeah just this idea that whether

somebody’s sud or depressed

they’re experiencing the sense of

alienation absolutely the sense of

isolation and

often just profound disconnection yeah

often also i hadn’t thought about this

but profound

self-loathing

absolutely that’s literally a symptom of

depression

is self-deprecation self-loathing but so

common in sud as well because people

have made really bad decisions often and

they’re beating themselves up and

they’re seeing the fallout absolutely

and i think we as a you know peaks we’ve

really we we work really hard to try to

get rid of this idea of

uh substance use disorder and mental

health disorder being different they are

so the same you know they are so

intertwined it’s it’s again it goes it

goes back to suffering and it goes back

to this connection it goes back to

self-loathing it goes back to

this a sort of neural paralysis that you

exist in and and the treatment again is

uh is

there’s so much overlap and can be so

similar for both sides exactly and it’s

um

yeah so it’s just it’s great to hear i

don’t know some affirmation for that to

be quite honest yeah well i get really

excited about it and you know the other

thing i just want if it’s okay to circle

back to something you said earlier just

about

um okay so you’ve got 45 days if if

somebody’s coming residential if they’re

doing intensive outpatient it’s a little

bit different but

when somebody’s suffering they want

relief immediately

if we use a standard anti-depressant so

the typical treatment that the majority

of patients are going to get one

antidepressant standard off the shelf

garden variety anti-depressant they’re

told usually like two to six weeks

depending if you’re lucky two weeks if

you’re not so lucky maybe four to six

weeks four kicks in and we see anxiety

three weeks depression four weeks is

typical okay there you go yeah

you know and there are exceptions or you

know uh

so

what what are we at that’s faster

well you know there’s a lot of

excitement around

more i think of them maybe you all don’t

as a little bit more extreme

interventions um some folks obviously

have heard for decades about

electroshock that we now call

electroconvulsive therapy it’s faster

has re there are reasons why it’s not a

go-to intervention for most people but

it is faster

tms transcranial magnetic stimulation

is faster for some people the effects

are not as robust yet as i would like

them to be but there’s there’s still it

can be faster well guess what this is

where i get super excited

light therapy bright light therapy not

just for somebody who has winter onset

depression not just for somebody who has

seasonal depression or sad some people

have heard

for any depression

effects can kick in within five to seven

days

it’s fast acting

now i’ve got a nutritional intervention

that can kick in within seven days

acetyl l-carnitine

and acetyl-carnitine is like it’s a

nutrient

that

our bodies mostly have to i say a

nutrient it’s it’s a a nutrient that our

bodies make out of substrate that we get

from our diet how about that and the

more we age

the crappier our body isn’t making it so

if you look at people who are depressed

in their teens and 20s their levels of

acetyl-carnitine are usually sort of

okay they’re lower than we would want

them to be but they’re okay and and

what it means is if their levels are low

the powerhouse the mitochondria of their

brain cells are not as efficient and so

literally their brain is getting a bit

underpowered

and the circuits that they need

uh get fatigued more quickly

so they can’t fire as efficiently okay

so we can supplement with

acetyl-l-carnitine and the best research

is two thousand milligrams a day divided

dose so a thousand milligrams twice a

day

and not only in the best

meta-analysis studies of studies does

acetyl-l-carnitine

outperform placebo

with an effect size that’s roughly on

par with medication

has no common side effects

and effects kick in typically within

about a week

and were you saying that’s more

important with age more important with

the thank you right it’s yeah so for

those of us who are of a certain age

on the wrong side 40 how about the wrong

side of 40

yeah

there’s some really nice signal in the

in the research that says that

middle-aged and older depressed

individuals really respond right and

younger individuals are less likely to

have that i haven’t heard of that before

so yeah it’s a pretty cool little little

tidbit

and there are other things as well but i

guess my point is

that

even if we don’t want to go to something

as extreme as electro-convulsive therapy

to get that really fast effect because

we’re we’re all impatient we’re

americans

we’re not saying right of course we’re

impatient but people are suffering

people’s lives are hanging in the

balance of course we’re impatient

we don’t have to wait four weeks

we have things already in the toolkit

that can get this recovery going and get

it going pretty quickly

and i think a lot of people don’t

realize that can i give you one more

please okay

we did we did not rehearse this we don’t

script this i’m totally going off script

now ladies and gentlemen

and brandon is he bold

i’m open to it okay

martin luther said sin boldly so here we

go um

good intro

it’s a little reformation yeah the

viewers at home are like

come on sin boldly where is he taking

this

yeah

you you’ll edit that out yeah um

there is a

novel

integrative intervention

called

chronotherapy

have you heard of it i’m not familiar

okay it involves three things the first

of which is going to blow your mind yeah

you want to know how to get

an immediate antidepressant effect with

someone even if they’re severely

depressed it will warning disclaimer it

will only last for about 12 hours

keep the person up for 36 straight hours

i kid you not

acute sleep

deprivation 36 hours of continuous

wakefulness has a profound acute

antidepressant effect why do we not use

it aside from the obvious people don’t

like staying up 36 hours

because

as soon as the person goes to sleep when

they wake up the next day they’re right

back where they started there’s zero

enduring effect

but proof of concept

sleep deprivation strategically employed

antidepressant we can build on that

second

component

circadian

circuit reset

most people with depression have a body

clock that is out of sync with the

ambient world around them

the most common form of circadian phase

shifting

is the person’s body clock

thinks that it is a couple hours maybe

three hours later than it really is

so we say it’s phase advanced so they

wake up let’s say they’re wake time

what’s the wait time in the room here

six a.m is that yeah say six it’s great

okay yeah so their wake time is 6 a.m

but they’re wide awake at 3 a.m because

their body clock is telling them oh it’s

we call this by the way terminal

insomnia because it’s at the terminus of

their sleep cycle interesting okay

so we want to phase shift them

three hours

right and that will help a lot it will

help with their sleep which has

antidepressant therapeutic effects the

final thing is the use of bright light

therapy which we’ve talked about before

so you combine all three

there is a center for chronotherapy in

chicago

that’s a residential

facility

we really should talk about this is

pretty cool because you guys could do

this

um where they have

patients come in and they’re like okay

we’re going to combine these three

things

so we’re going to keep you up 36

straight hours

and then we’re going to

let you sleep for a while

actually it’ll be more than 36 or eight

hours it’ll be we’re basically going to

shift their body clock about four hours

every day

until we’ve run all the way through

the the clock if you think if you do the

math in your head it’s like five or six

days

and we’re going to hit them with a

massive dose of therapeutic bright light

as soon as they wake up

to give a signal of circadian reset to

be like okay hey you know what

um it’s now 8 am but your brain thinks

it’s noon hey it’s now noon or 8 am but

your brain thinks it’s four in the

afternoon and then the next day eight

in the evening and after a week you’ve

run the entire cycle your back around

where you started

and you can get them entrained

perfectly to the world around them you

get the acute benefit of sleep

deprivation it doesn’t go away because

you’re continually keeping the brain off

balance and you have the antidepressant

effect of the bright light

and you can now connect with people

because they’re up at the same time

exactly yeah and at the center for

chronotherapy in chicago

they um you know they try to use the

milieu of it right so they have like

activities for folks when it’s four in

the morning and they’re all up and they

and they shine pretty bright light out

in the patient day room where they’re

all hanging out

so it’s a it’s a but it’s a very fast

acting

very powerful oh by the way it’s been

used in bipolar depression

and patients with bipolar are

exquisitely sensitive to light

exquisitely sensitive to changes in

circadian rhythm exquisitely sensitive

to sleep deprivation

and

it has a roughly 50 percent acute

response rate in bipolar depression in a

week

which is

far higher

than any in a week any current

therapeutic medication that we have for

bipolar depression

so there’s some all kinds of really cool

exciting potentials i would say

and not to veer off script here but uh

on the manic side of bipolar disorder

wasn’t there a light benefit or an

anti-light benefit yeah because yeah

thank you so bipolar patients i don’t

know if you guys have ever experimented

with this but bipolar patients

exquisitely sensitive to light

and very sensitive to um

time change

you know going on and off of daylight

savings time can often be a trigger for

depression or mania

but it’s recently been discovered that

when a patient with bipolar is manic

or

mixed where there’s sort of

simultaneously manic and some depressive

symptoms

if you use polarized wraparound goggles

or lenses polarized in the sense that

they’re that deep amber

okay kind of like if folks know the rock

star bono of youtube

he has glaucoma

and has to filter out that light for

medical reasons for it’s the same basic

principle

um

patients with mania who filter out

probably most people know about blocking

blue light like at night it’s blue light

is very stimulating

patients with mania where they block out

blue light 24 7 and then stay out of

direct sunlight

it has enormous potential to break a

manic episode

and can be used in tandem with

anti-manic medication

to potentiate the effect to quicken the

effect to speed it up to make it more

robust

and in some cases i’m not recommending

this at all but in some cases it’s been

used without medication for patients

as you probably know sometimes when

patients are manic they they do

everything against medical advice

because they have impaired judgment

and they will not take them in

but sometimes they will agree to wear

the cool bono glasses

right sounds like a fantastic

alternative

um

so i feel like we’re just scratching the

tip of the iceberg

on leveraging

the neurological power

of lifestyle based intervention

these things are like drugs and their

effects on the brain

absolutely yeah

powerful stuff so dr ryan yeah you got

the challenging job we got to keep him

up for 36 hours

you get hazardous duty pay for that

right

i love the idea i think we need a little

more robust nursing staff

you’d have to definitely make some new

hires for sure

no but i’m curious dr reddit i mean

there’s somebody who you know you live

in the trenches with this right i’ve

seen i and i’ve

you know being in rounds with you and um

with working with the clinical team the

medical team even our residential team

and and seeing people struggle and

really trying to get a hold on what is

going to be the best approach to help

stabilize them to help keep them engaged

to help

i mean we’re not even at symptom

reduction yet at that point right but uh

but listening to this and listening to

this sort of approach and which does

feel integrative it actually has a

genuinely holistic feel to it i’m just

curious what your response is

i love it um i mean i think it has the

potential

now to fix them while they’re with us

but more importantly to set them up for

success in the future um

when he spoke

earlier today steve you talked about a

spider web

yeah

do you want to yeah go ahead and talk

about this

[Laughter]

he talked about depression be having a

lot of different attachments and

basically every every

thing you can pull off so a medication

you’re pulling off a big string you’re

pulling off another string with light

therapy with exercise with connectedness

with nutrition what am i missing

uh habits of healthy sleep habits of

healthy sleep i mean you’re just pulling

more off of that

brain axis and yeah

and i think the more we more of those

strings we can pull off

the better people are going to do i love

the analogy i think it’s great for thank

you yeah

yeah metaphor metaphor analogy

yes yes

so

yeah i i mean i a patient

actually actually

many years ago said to me you know i

just feel like i’m caught in this web

um and it always stayed with me that

that image of like being trapped in this

web and then when i started thinking

about how depression involves all these

different layers of dysregulation

molecular

neurochemical

hormonal

cognitive affective potential and we

haven’t even talked about like the

attentional biases people when they’re

depressed

the brain only wants to go to negative

things people when they’re depressed

they they don’t want to be around other

people so there’s the social withdrawal

piece there’s the i mean there’s so many

different layers and it’s like this web

and our typical approach like we talked

about earlier is monotherapy we’re going

to do the one thing we’re looking for

the one magic

stone that we can throw at the web and

bring the whole thing down

and sometimes we get lucky sometimes we

get lucky and the one thing really does

bring it down for some people some for

some time

but god it just makes so much more sense

to think about like what if i have a

whole pocket full of stones or you know

like a shotgun or something where i can

just blast this thing

and i feel like

how about this

depression is so much more treacherous

than we give it credit for being it’s so

much harder to fix it is fixable

it’s completely fixable but it’s so much

harder to to get it well and keep

somebody well

and we do our patients a grave

disservice by

being very cavalier and very oh yeah

yeah we got this our these meds are like

magic these it’s like the meds you know

they’re helpful but they’re not all that

for so many patients but if we’re

willing to really take it seriously like

you all do at peaks that’s what i get

really excited about yeah i’m going to

send you so many patients yeah

[Laughter]

love it also would love to figure out a

you know path forward to you know we

have a setting in which

you know it’s a little bit different

than the ambulatory stylus setting in

which we could approach you know maybe a

project of research or something around

it to really ignite this and

locate its value proposition because

this is exciting stuff and

i don’t want to insist that we’re the

only treatment center thinking of this

in america but

i think our industry is sort of missing

this opportunity to really

bring in all of these things at the same

time but to do that we have to

responsibly think about integration of

care we cannot just talk about drugs in

these settings that’s a really visionary

a rich genuinely visionary sort of

approach because i mean here’s what i’m

thinking and maybe

you all tell me if i’m too naive about

this because you know the biz way better

than i do

my feeling is

if you could get

some sort of

funding sponsorship

to pay for the research to

like legitimately show with a carefully

controlled conducted research study

that this kind of multi-pronged

approach this

doing all the things approach

is highly effective

now you’ve got this

publication that you can

take to all the industry people all the

leaders all the you know and say

don’t just take our word for it like we

you know

we have

independent verification that what we’re

doing is working

and we’d like we’d like to make this the

gold standard yeah but to do it right

it’s going to take some money

some money some time a lot of time

to get it right why did you point to me

because

when i when i hear all the things i

think that is your

you are mr all the things that yes wait

doctor

he’s director of all things

chief of all things at peace recovery

centers there

there’s so much to expand on to talk

about to be excited about on this i do

you know while we got the the sort of

the medi the met the strict medical lens

here before we invite the the clinical

side of things into this you know the

anti-ruminating you know uh

psychotherapy psychotherapy approaches

and so forth into this i i did want to

touch base you know chris burns one of

the host president founder of peace

recovery centers is often talking about

the vulnerable population

and what i what i would like to talk

about is that you know it really uh

struck me as kind of obvious for myself

when you were talking about it earlier

with our team but

you know i wake up in the morning and i

get the sunshine i think this is a

beautiful day look at this mountain

that’s in front of me pike’s peak

america’s mountain man so beautiful you

know we live among nature we get to see

deer running across the highway we get

it all here in you know colorado uh in

that regard and so

you know you get this high on life sort

of experience when your dopamine levels

are up and that’s my common experience

and why it resonates with me so much

with those lower dopamine levels that’s

the vulnerable person we’re talking

about right because they’re taking the

drug and they take it and all of a

sudden it’s the mountain they’re high on

life this is what this guy brandon was

experiencing when he was talking to me

about looking at the mountain that i

don’t experience

yeah exactly right so that’s that’s

that’s one of the real

under

appreciated and i think misunderstood

elements of the

the brain of the person vulnerable to

addiction vulnerable to substance use

disorder is

they’re very often genetically

predisposed to those low d2 receptor

levels so in other words genetically

predisposed to not

be able

as much to get high in life

and to have the drug be able to hack

into their reward circuits the drug

takes over and says

this is what you’ve been missing yeah

this is now your home

now you’re in a space where you feel on

top of the world

by the way fun side note psilocybin

actually does not light up the brain’s

reward circuit or lsd or any of those

it really does i didn’t get that message

when i was doing it

it could be i mean obviously it could be

really

yeah i mean depending on your own

experience it certainly can have a

reward component by the way

a lot of

folks probably know psilocybin is now

being actively investigated

as a

supercharging agent for effective

psychotherapy for depression

so

you know it increases plasticity it

opens people up to reconceptualizing

their stuckness

and under expert therapeutic guidance it

can be a

catalyst

for a lot of healing for a lot of you

know sort of rapid response so i think

it’s been a little bit overhyped

oversold but i’m not in any way opposed

to that kind of research and work i just

want to

basically i’m just giving like a public

service announcement for magic mushrooms

they are being actively investigated at

some of the leading research centers in

the world as a

legitimate psychiatric

agent

but they don’t they’re not a drug of

addiction typically yeah um but yeah

like alcohol how about i mean there’s a

very common drug of addiction

um

you know

can i say this we were out to dinner

last night there may have been a glass

or two of alcohol consumed

um in a very responsible manner and

um

a little bit of dopaminergic reward

which you know all drugs of addiction do

but if somebody has high d2 receptor

levels they just walk away they’re just

like oh yeah that was fine whatever

um

and so i feel like once we start viewing

addiction through this lens of these are

our

brothers and sisters our fellow

travelers

who are laboring right now with the

burden of reward circuits that don’t get

lit up the way they’re supposed to

when they hug a friend when they see the

beauty of nature when they have an uh a

professional accomplishment when they

have sex when they do anything

except for using and when they’re using

then it lights everything up and that’s

a tragedy and you know it’s like if we

can have that viewpoint for me at least

i’ll just speak to myself judgment melts

away

and compassion

seems to be the only sane response

yeah you know um so yeah i just i

i love the work you’re doing um i i love

i love the compassion i love the sanity

i love the

you know the community absolutely um

yeah

so

well i think that’s beautiful and

exactly what we’re you know what we’re

coming to here when we apprecia we can

all appreciate that decisions are being

made around alcohol use drug use and so

forth

but at the level of decision making

they

those who suffer from addiction

don’t know

that that is the underlying thing within

their being right that’s going to get

ignited and that experience is going to

happen making them most vulnerable or

susceptible to