Finding Peaks

Finding Peaks


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

May 26, 2022


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

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https://youtu.be/tM-U-QhmYbA

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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


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