December 24, 2025 • 35 mins
Dr. Heather Luing joins Dr. Michael Koren to talk about depression. They discuss what it can feel like, why December is associated with a spike in depression cases, and what's going on inside the body and brain that makes this disorder so challenging. The duo of doctors also explore new and emerging medications in the depression field, including several that target completely new pathways in the brain and may provide relief for people who have not found help with older medications. Dr. Luing also talks about the importance of talk therapy.
The doctors heavily emphasize a relatively new resource for urgent mental help, the 988 Mental Health Crisis Line.
Be a part of advancing science by participating in clinical research.
Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com
Listen on Spotify
Listen on Apple Podcasts
Watch on YouTube
Share with a friend. Rate, Review, and Subscribe to the MedEvidence! podcast to be notified when new episodes are released.
Follow us on Social Media:
Facebook
Instagram
X (Formerly Twitter)
LinkedIn
Want to learn more? Checkout our entire library of podcasts, videos, articles and presentations at www.MedEvidence.com
Music: Storyblocks - Corporate Inspired
Thank you for listening!
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcer (00:00):
Welcome to the MedEvidence Podcast.
This episode is a rebroadcastfrom a live MedEvidence
presentation.
Dr. Michael Koren (00:06):
Heather, I'm super excited that you're here
with me.
By the way, Dr.
Luing is a brilliantpsychiatrist who I'm really
excited to work with.
We've met each other recently.
She's done clinical trials inher practice.
Now she's going to become partof our group.
And I couldn't be happier ormore excited because I can tell
you you just have it.
You have the factor of being atremendous investigator.
(00:27):
So I'm really looking forwardto that.
Dr. Heather Luing (00:28):
I think it's going to be really great.
Dr. Michael Koren (00:30):
Yeah.
And I'm looking forward to oursession today to share with the
audience things aboutdepression.
I know it's it's a topic thatwe don't like to talk about, but
it's an important topic.
And it's actually a topic thatis rich in the research world in
terms of a lot of studies areongoing.
So we'll cover all that.
So these are the objectives fortoday.
And I'll just show them realquickly so everybody can see.
(00:54):
And let me ask you by startingwith this question.
You know, we live in Florida.
What wonderful place, sunnyplace.
It's the holiday season.
Everybody should be happy.
Like, why is there anydepression at all?
Am I crazy or is this the timeof year that we should all just
be joyous?
Dr. Heather Luing (01:11):
It sounds intuitively like it should be.
But the reality is for a lot ofmy patients, this is actually
the hardest time of year.
So I think a lot of peoplestruggle in this season.
And the reality is depressionis at all times highs across the
U.S.
And it started growing duringCOVID and it really hasn't
stopped.
It's continued to increasesteadily, really across all
(01:32):
demographics and age groups,even though some have been
affected more than others.
Interesting.
And how about Florida versusother places?
Yeah, I think that it's prettyconsistent statewide, state to
state.
I don't think there's a hugevariation in Florida.
We do see higher incidence inyounger age groups, so certain
areas might have littledeviations, but it's a serious
(01:54):
problem nationwide.
Okay.
So you we've heard the termmajor depressive disorder.
Why don't you explain toeverybody what that means?
What's major versus minor andhow do you make the diagnosis?
Yeah.
So in psychiatry, we havesomething called the Diagnostic
and Statistical Manual.
So that is really outlines allof our different psychiatric
(02:15):
illnesses.
So I would say major depressivedisorder is probably kind of
what you think about as maybeclinical depression, something
where it rises above the kind ofjust day-to-day up and downs
that the average person hasuntil it becomes more pervasive.
And as you can see, there'sactually really kind of strict
criteria on what qualifies asMDD and what doesn't.
(02:38):
Probably the biggest thing isit has to last at least two
weeks.
So you have to have that lowmood that really becomes
persistent.
Dr. Michael Koren (02:45):
So if you wake up in the morning and you
don't feel like going to work,that doesn't count as
depression?
Dr. Heather Luing (02:50):
Probably not.
Dr. Michael Koren (02:51):
You won't write me a script to get me out
of work?
Dr. Heather Luing (02:53):
No, no, we're not going to do that.
No.
And in fact, staying active anddoing things like work and
being around people can actuallybe helpful.
So most of the time, even ifyou did meet criteria for MDD,
we'd still encourage you to tryto do as much as possible.
So time of the year, we we'retalking a little bit about that,
that it's the winter months.
Is that a factor?
Tell us a little bit about thisconcept of seasonal disorders.
(03:15):
So we used to consider seasonalaffective disorder or SAD as a
separate diagnosis, but underour newest version of the DSM,
it's considered a subtype ofdepression.
So certainly some people aresusceptible to decreases in the
amount of daily sunlight that weget, or even the timing of that
that introduced kind ofinterferes with our circadian
(03:37):
rhythms.
So this seasonal effectivepattern is something that even
in Florida we see, and someindividuals are more susceptible
to it than others.
Dr. Michael Koren (03:46):
Yeah, it's interesting.
Yeah, the celebration ofChristmas actually predates the
birth of Jesus.
A lot of people don't knowthat, but it was a holiday when
people started to recognize,ancient people started to
recognize that the days weregetting longer again.
So that would infer that priorto Christmas that there's a time
where people are gettingnervous that the days are
getting shorter.
Dr. Heather Luing (04:07):
Absolutely.
I mean, I think some of you mayeven kind of feel this, even
when we have the time change andwe fall back by an hour or
spring forward by an hour, somepeople do have a decrease in
energy and and have actualsymptoms related to that.
So it may be relatively mild,but for some people it becomes
more severe.
Dr. Michael Koren (04:24):
So if you live in the southern hemisphere
where everything is flippedduring our winter, there it's
their summer and their days aregetting longer.
Do you see the a flip in termsof the seasonal patterns of
depression?
Dr. Heather Luing (04:36):
Yeah, I believe you do.
Obviously, I've never practicedthere, but but I think that it
really has to do with the timeof daylight you're exposed to.
Interesting.
And about one thing, is thereany chemical issues in terms of
getting sun and vitamin D andmelatonin and those sorts of
things?
Yeah, they think that that maybe somewhat of an influence to
(04:57):
it, but as you'll probably seeon one of the future slides,
just exposing people to acertain type of light that emits
a high voltage of light thatcan be curative even without,
you know, other factors likevitamins.
Dr. Michael Koren (05:12):
Interesting.
All right, so this comes up allthe time.
When should people seek out youknow serious professional help?
So is it when you're get up inthe morning and kind of feeling
cranky? The reason I say that is because when I went to college a generation ago, we had one doctor for the entire campus.
My daughter just graduated theUniversity of Pennsylvania and
(05:39):
they had twenty full-timebehavioral health specialists on
call and 75% of the studentsaccess one during their
undergraduate years.
Dr. Heather Luing (05:52):
Wow.
Dr. Michael Koren (05:52):
So there's a whole change in the paradigm in
terms of when you seek help.
So why don't you give us alittle bit of guidance when you
seek help?
Is it when you kind of feelthose are all the twinges of not
feeling right, or is it whenyou're on the on the ledge?
Dr. Heather Luing (06:05):
Yeah.
Yeah, that's a good question.
You know, I think the realitywith depression is that the
earlier you treat it, the easierit is to treat, the more likely
it is going to be to respond tointerventions.
So I don't think there's reallya too early, and it sounds like
the college students havecaught on to that.
Interesting, they're also thesecond most common demographic
(06:25):
to have this increase indepression symptoms.
So it's great that they areutilizing that.
But in general, if the symptomshave gone on more than a couple
of weeks, that is enough, Ithink, to reach out for some
help or at least try somelifestyle modifications.
And then obviously, if you haveserious suicidal ideations, you
notice you're having someunhealthy coping skills, like
(06:48):
drinking a little too much overthe holidays, those are warning
signs that I think you shouldreach out sooner than later.
Dr. Michael Koren (06:54):
Now, I noticed this 988 number on
texting.
I had no idea about that.
Who who is the person on theother side of that when you text
somebody?
Dr. Heather Luing (07:02):
Yeah, so this is the new national crisis
line.
It's like the 911 for mental orsubstance abuse issues, which
is pretty phenomenal.
So you can use this numberanywhere in the U.S., but 90% of
the time it's going to beanswered by local people in your
community.
So, for example, inJacksonville, MHRC does a lot of
the crisis phone calls.
(07:23):
And it doesn't have to be thatyou're suicidal, it can be any
kind of mental health orsubstance abuse crisis, and they
can guide you to whereresources are in your community.
Dr. Michael Koren (07:32):
Well, out of curiosity from the audience, who
was aware prior to this thatthere was a 988 number?
So maybe a quarter of theaudience.
So that in itself is incredibleinformation.
Thank you.
Dr. Heather Luing (07:44):
Yeah, it's a great resource.
Dr. Michael Koren (07:47):
Okay.
So let's talk about the scienceof mood.
I'm a scientist part-time, whenI'm not practicing medicine.
And explain to people.
It's not just the fact thatyou're, you know, you had you
got a bad hand at work orwhatever the situation may be,
but there's actually somethingthat's more fundamental, more
(08:09):
biological.
So maybe you can helpus understand that.
Dr. Heather Luing (08:11):
I think you highlighted it when we started
that why would I be feeling thisway if everything in my life is
going well?
And I can't tell you how manytimes I hear that from patients,
like, why am I depressed?
You know, I've got a greatspouse, a good job, my kids are
doing well, but I still feelthis way.
And that's because depressiondoesn't just have to do with
things that are going on aroundyou, although, of course,
(08:32):
stressors can make things worse,but it truly is a brain
disorder, and our bodies canaffect our brain as well.
So it could be from anunderlying medical condition
that you're feeling this way.
It could be from parts of yourbrain that aren't functioning
the way that they normally do.
So it truly is a veryscientific phenomenon, and many
(08:53):
things can influence it.
So we talked a little bit aboutseasonality, right?
Light can influence it, hormonelevels, a lot of different
factors.
Dr. Michael Koren (09:01):
Wow.
So obviously you make thediagnosis of depression, and
from what you just said, thereis different scales and
different things that come outof discussion with patients that
ultimately make the diagnosis,and then you take a very
specific stepwise approach tostart treatment.
So once why don't you walk usthrough that?
Dr. Heather Luing (09:23):
It's kind of like building a house, right?
You want to start with a reallygood foundation, a solid
foundation.
And I would say that is yourlifestyle and behavioral
practices, and we'll talk moreabout that.
For some people, that alone isenough to really get the
depression under control.
If it's not, you know, I thinkthe next step is always some
form of psychotherapy.
(09:44):
Having somebody to help guideyou through this, whether it's
like a cognitive behavioralthing where you're working on
how you're thinking isinfluencing how you're feeling,
or maybe you've gone through atrauma and you need some help
processing that.
So adding therapy would be thenext kind of layer of the house.
Medications would, I think,come after that.
If you've tried therapy andyou're still not getting full
(10:06):
effects, then we look atmedications as the next step.
And then finally, we look atsome of our newer and different
types of treatment options.
So things like TMS, ECT, someof the newer medicines like
esketamine.
So those are kind of the finallayer.
But again, like the title ofour presentation, I think there
should be so much hope becausethings have really changed a lot
(10:29):
in the area of psychiatry.
So when I finished residencyand started practicing, it was a
time when all the neurosciencedivisions were closing down at
the pharmaceutical companies,and they really were not
interested in putting kind ofresearch into psychiatry.
But that has changed, andthere's been an explosion of new
treatments, and that's justgoing to continue to grow over
(10:49):
the next few years.
So it really is a time to bevery hopeful about what's on the
horizon.
Dr. Michael Koren (10:54):
Wow.
So I know we have some slidesthat are covering some of these
approaches.
So I'm super interested inlearning more about it.
So I guess you'll start us offwith just the lifestyle
approaches and we'll move onfrom there.
Dr. Heather Luing (11:04):
Yeah, and lifestyle is so important.
So we know that sleep is veryrestorative for the brain.
So having a regular sleepschedule where you're getting
the right amount of sleep.
How many of you are gettingsix, seven, eight hours of sleep
every night?
Okay.
So that's less than half theroom, right?
So half of you need to go homeand work on your sleep.
(11:24):
Yeah, sleep is so healing andrestorative.
So I think that's a greatthing.
Movement or exercise is alsosomething I recommend for all of
my patients.
And it is amazing.
This does not have to beintense exercise.
You don't have to sign up for amarathon, no turkey trots.
Just getting out there andtaking a brisk walk, you know,
walking your dog, riding yourbike, very, very helpful to have
(11:46):
that small amount of aerobicexercise.
Getting good nutrition isdefinitely important, and there
are some micronutrients that areparticularly helpful.
And then having social support.
We know that there's aloneliness epidemic in the US,
and forming those connectionscan really be helpful for mental
health.
Dr. Michael Koren (12:04):
Now, you mentioned something about
nature.
Tell us a little bit more aboutthat.
Is like going to a Jaguars gamecount as nature, or does it
have to be out in the woods?
Dr. Heather Luing (12:13):
It's better than nothing.
Okay.
Um, but I think that if you canimmerse your senses in nature,
that's where the research reallyshows us that there's a
beneficial approach.
So things like listening tobird song has been shown to help
your mental health.
Looking at nature, smelling it,getting the full really
experience is very helpful.
And I encourage all my patientsto make that something in their
(12:36):
life, like a new habit to form.
Dr. Michael Koren (12:38):
So the concepts of Thoreau that talked
about this 200 years ago arejust as relevant now.
Dr. Heather Luing (12:44):
I think so.
Dr. Michael Koren (12:45):
Very cool.
Okay, so I know you have otherslides looking at other elements
of treatment.
Dr. Heather Luing (12:52):
We talked about a little bit about
psychotherapy.
I would say therapy issomething don't be afraid of,
right?
And if you try a therapist andit's not a good fit, try a
different therapist.
They understand you have tohave a good therapeutic bond
between you and the therapist.
And there's all different kindsof therapy.
CBT or cognitive behavioraltherapy really has a lot of good
(13:12):
research behind it.
So it's something we encourage.
And there's actually a specifictype for seasonal affective
disorder.
So if that's something you'redealing with over the winter
months, you can get aspecialized therapy for that.
Dr. Michael Koren (13:23):
Interesting.
Do you always recommendtherapy?
Are there times where that canbe a problem?
Like some people just need toget on drugs, or is it is it
always is there always a part ofit that should be incorporated
with talking to somebody?
Dr. Heather Luing (13:38):
I think we can always learn more about
ourselves, right?
And that's really what therapyis is learning about how you're
thinking, how that'sinfluencing, how you're feeling,
and how to develop differentcoping skills to help you get
through this really stressfullife that we have to deal with.
So I pretty much recommendtherapy across the board.
It really can't hurt you.
So if you have the time and theresources, you know, search out
(13:59):
a therapist.
And really, they're everywhere.
Community mental healthcenters, you should be able to
find somebody.
Telehealth has made things alot more accessible.
So there's a lot of options.
Dr. Michael Koren (14:08):
Yeah, and I want to spend a little bit of
time on telehealth.
In certain areas of medicine,telehealth has taken over more
than others.
And I think it's fair to sayit's taken over more in
psychiatry.
If that's not a true statement,let me know.
But that's my sense.
Dr. Heather Luing (14:21):
That's true, yeah.
But is that the same as beingin the room with the human
being?
What do you think?
I would say it's close.
Dr. Michael Koren (14:27):
Okay.
Dr. Heather Luing (14:28):
I would say it's not really quite the same.
If you have an option ofin-person treatment, I always
think that's a little bit of anedge.
It's preferable.
But if that's not an option foryou, you can't get the time off
work or transportation's aproblem, then telehealth really
does open up access.
So it definitely has a place.
Dr. Michael Koren (14:45):
And how about these bots that have been
promoted as ways of providingpsychotherapy?
What are your opinion on those?
Dr. Heather Luing (14:51):
I think we might be a little early on that.
So I would encourage you tryingto find an actual human being
rather than a bot.
Dr. Michael Koren (14:57):
I like that advice.
So let's talk about medication.
Dr. Heather Luing (15:02):
Yeah, so medications are interesting.
For many, many years, we havekind of hung our hat in
psychiatry on what's called themonoemanergic hypothesis.
That sounds like a lot of bigwords.
How many of you guys have heardof serotonin?
Okay, everybody, right?
And a lot of my patients willcome to me and say, you know, I
(15:22):
think I have a chemicalimbalance or I have a serotonin
deficiency.
The reality is it's not thatsimple.
We really oversimplified thingsa little bit in explaining how
the brain and depression work.
And unfortunately, for myentire career up until a few
years ago, the only meds we hadavailable were those that worked
(15:43):
on monoaminergic brainchemicals like serotonin and
norepinephrine.
For some people, that's great,but about a third of people do
not respond to thesemedications.
And a lot of people get anincomplete response where, yeah,
the depression's better,they're getting out of bed,
they're going to work, butthey're not really enjoying
their life.
It's kind of in black and whiteinstead of color.
(16:03):
So that's really where ourantidepressant treatments have
been for many years.
Now we have had some recentadvances, and we have a lot of
chemicals that are in researchright now that work in different
ways.
And so I think again, it's avery hopeful time when it comes
to med management, but we've hada lot of unmet need.
Dr. Michael Koren (16:24):
The seasonal preventive strategies.
One of the things I was curiousabout and wondering about is is
somebody that tends to havethat the type of patient that
may get on preventative medicinecome October.
Is that something that you doin for some patients?
Dr. Heather Luing (16:41):
Yeah, absolutely.
For some people that can bevery helpful.
And you know, like I said atthe beginning, the sooner we
treat depression, the easier itis to treat.
So if you can nip it in the budlike that, a lot better than it
getting to December and youhaving a hard time getting out
of bed.
Dr. Michael Koren (16:54):
Because we we like to promote preparedness
for the cold and flu season atMedEvidence.
And we always tell peoplestarting in August that prepare
to get your flu shot and yourRSV, et cetera, for the coming
season.
It's probably similar inpsychiatry.
Dr. Heather Luing (17:09):
Yeah, I think so.
And you know, that could bethings beyond medicine, right?
Maybe it's increasing yourlifestyle interventions.
You're gonna get outside andwalk and get some sunlight,
things like that.
You could definitely dopreventatively.
Dr. Michael Koren (17:21):
Fascinating.
This light therapy I findreally super interesting.
So why don't you walk usthrough this?
Dr. Heather Luing (17:27):
Yeah, so you have to have a certain type of
light.
So they make these light boxes.
You don't look directly intothe light, so you want to have
your eyes open, but kind oflooking to the side, and you'll
have a period of time that isspecified to how much light
exposure you need.
Now, certain disorders, forexample, bipolar disorder, you
got to be very careful with thelight because it can be too
(17:49):
much.
It's something that has to betailored to the individual.
Dr. Michael Koren (17:52):
Interesting.
And how does light therapystack up against medications?
Dr. Heather Luing (17:56):
I think for seasonal affective disorder,
very well.
It's really the kind ofstandard treatment for that
particular type of depression.
Dr. Michael Koren (18:03):
Interesting.
Okay, TMS.
This sounds really fascinating.
So I'm real curious to learnmore about this.
Dr. Heather Luing (18:12):
Yeah, I think TMS is the best kept secret in
psychiatry.
Dr. Michael Koren (18:15):
Really?
Dr. Heather Luing (18:16):
Yeah.
And so it has been FDA approvedin the US for about 17 years,
but I bet most of you have neverheard of it.
So and I think it's somethingthat I love talking about
because so many people don'tknow about it and it's such a
great treatment option.
So what it is is it's anon-invasive type of brain
stimulation.
So what we do is we applymagnetic pulses to a certain
(18:37):
part of your brain that indepressed individuals is
hypoactive.
So it kind of goes to sleep onthe job.
What these magnetic pulses dois help to wake it up so that it
starts communicating with therest of the brain and forming
those neuronal connections thatare so important.
Dr. Michael Koren (18:53):
Interesting.
So what kind of device do youhave to use for this?
Dr. Heather Luing (18:56):
So TMS machine, it kind of has a chair
that looks a little bit like adental chair.
You just kind of recline backin that chair, and then there's
a magnet that fits over yourhead, kind of like this.
And you just sit there and ittaps away for about 19 minutes.
And you do this for a series oftreatments.
So you come in five days aweek, Monday through Friday, for
(19:16):
30 treatments, and then you doa six-treatment taper.
Dr. Michael Koren (19:19):
Now the last bullet point here talks about
minimal systemic side effects.
Are there anything inparticular you're worried about
as a side effect?
Dr. Heather Luing (19:27):
Yeah, it's pretty amazing in that it's a
very effective treatment, butvery few side effects.
So most common is a little bitof scalp tenderness under where
the magnet sits.
So kind of thing when you'rebrushing your hair in the
morning, you're like, oh, that'sa little tender and occasional
headaches.
And that's pretty much it.
There's no anesthesia, nodowntime.
You can drive, you can go towork, you can do all your normal
activities.
Dr. Michael Koren (19:46):
Pretty cool.
So you get into more detailsabout what to expect.
Dr. Heather Luing (19:51):
Yeah, so you kind of see an example of one of
the types of TMS machinesthere.
You're gonna feel a tappingsensation, you'll hear that too,
right over your scalp.
And most sessions take about 19minutes.
We do have some newer protocolsthat are being studied, uh
Theta Bursts, which are down tothree minutes.
They really compress the pulsesdown.
And there's even someaccelerated TMS protocols that
(20:14):
have been in the news quite abit in the last year where you
can compress TMS down to a fewdays instead of going over
several weeks.
Dr. Michael Koren (20:21):
Interesting.
And which companies manufacturethis machine out of curiosity?
Dr. Heather Luing (20:25):
That particular one is a Neurostar.
There's about eight of thesefigure eight machine companies
that are on the market.
So there's they're all prettysimilar when you come to the
inside.
The magnet itself is the same.
It's just kind of the outsideof the machine that's different.
Dr. Michael Koren (20:40):
One not better than the other,
particularly?
Dr. Heather Luing (20:41):
No, they're comparable.
The FDA has has cleared them.
Dr. Michael Koren (20:44):
Interesting.
All right.
So beyond TMS.
Dr. Heather Luing (20:48):
Yeah, so we have other types of
neurostimulation.
So again, this is kind of yourlast layer of treatment.
You've tried lifestyle, you'vetried therapy, you've tried
meds, but you're still notgetting resolution.
VNS or vagus nerve stimulationis another really exciting type
of neurostimulation.
You can see from the picturethere, this is a small implanted
(21:09):
device.
It goes about under yourcollarbone.
It's about the size of aquarter, and it connects to the
vagus nerve, which is one of thelargest nerves in our body.
And what it'll do is every fewseconds it will stimulate that
nerve, and that has been shownto improve depression.
So it's interesting.
This was actually FDA approvedmaybe close to 17 years ago now,
(21:30):
too.
But CMS or Medicare did notpick it up to pay for it, and so
insurance doesn't pay for it.
And because of that, thisrecover trial has been going on
for the last four years or so.
And that is just an additionaltrial to demonstrate efficacy,
not only for major depressivedisorder, but also bipolar
depression.
Dr. Michael Koren (21:50):
That's so interesting.
So here in Jacksonville, we'veactually done a number of
studies of vagus nervestimulators for other diseases.
Right.
And we did studies with similardevices to treat hypertension,
high blood pressure, and itworked.
Dr. Heather Luing (22:04):
Yeah.
And we did studies in heartfailure using these type of
devices, and it's actuallyapproved, and CMS covers it for
heart failure.
Yeah, that's fascinating.
I think they also use it forclotting disorders and some GI.
Dr. Michael Koren (22:16):
Yeah, but it's the f this is the first
time I've actually heard thatone of the positive side effects
of this may be less depression.
Dr. Heather Luing (22:23):
Yeah.
Dr. Michael Koren (22:23):
Have people looked at that in the heart
failure population?
Dr. Heather Luing (22:26):
Yeah, I think that's kind of how they
discovered it initially.
Dr. Michael Koren (22:29):
Interesting.
Dr. Heather Luing (22:29):
Yep.
Dr. Michael Koren (22:30):
Fascinating.
Okay, emergent research, rapidacting treatment.
So tell us more about this.
Dr. Heather Luing (22:35):
Yeah, so we've again moved beyond this
monoaminergic hypothesis asketamine was our first
FDA-approved treatment thatlooks at targeting the glutamate
system.
And so because glutamate worksa lot quicker than serotonin,
we're getting improvementswithin 24 hours for many
patients.
And so that's really exciting.
(22:56):
You can also doketamine-assisted psychotherapy.
Now, ketamine itself is not FDAapproved, so that is an
off-label treatment, butsometimes combining the therapy
with the actual medication canbe really impactful.
Dr. Michael Koren (23:10):
So when when I think of ketamine, I think of
being in almost a state ofanesthesia.
How does it work in in theoutpatient setting in a
psychiatrist's office?
I'm really curious about that.
Dr. Heather Luing (23:19):
Much lower doses, yes.
We definitely don't want anyoneunder anesthesia in their
psychiatrist's office.
But low doses actually give aprofound relaxation.
For some people, a little bitof a dissociative effect, and
that can be dose-dependent.
With esketamine, which is theFDA-approved nasal spray, it's a
fairly mild dissociation.
But you do stay for a couplehours in the doctor's office for
(23:43):
your treatment.
Dr. Michael Koren (23:44):
So that's interesting.
Do people fall asleep duringthis?
Is that a problem?
Dr. Heather Luing (23:47):
Sometimes it's one of those known side
effects.
Yeah, I have one lady, she'sbeen doing it in our clinic for
I think about five years, andshe sleeps every single session
the entire time.
But I think she just reallylikes a good nap.
Dr. Michael Koren (24:00):
So well, you talked about sleep being
important for depression, sothere you go.
That's right.
I love that.
Okay.
And uh psychedelics, we'veactually had a few MedEvidence
podcasts on psychedelics.
And we're excited that peopleare actually looking at it
scientifically for the firsttime.
Dr. Heather Luing (24:18):
Right.
There's been a lot of feararound it that I think was
somewhat unfounded.
So, you know, it's kind of onthe horizon, nothing here yet,
but a lot of studies going on.
Dr. Michael Koren (24:29):
When when these studies are done, you have
to have a very specificfacility to actually do the work
in clinical research.
I recently was exposed to thatwhen I was visiting one of our
sister sites in Chicago.
And they had this whole setupwith you kind of look like a
hippies den from the 1960s.
But it was a a very specificroom that you needed to perform
(24:52):
these studies.
Is that the general sense thatthat's how we're gonna be
treating these peopleclinically?
You were gonna get in yourVolkswagen bus and and and give
the therapy in that?
Dr. Heather Luing (25:02):
I don't think it has to be quite like that.
But you know, there are somereally important considerations
with psychedelic research andsafety is one of them for sure.
But also having a goodenvironment where it doesn't
feel too sterile, you feel likeyou're comfortable enough to
really relax and have thatexperience is important.
Dr. Michael Koren (25:18):
Interesting.
All right, new and emergingmedications.
So walk us through some ofthese.
Dr. Heather Luing (25:24):
Yeah, and I'm not gonna go through all these
details.
I can tell you that the nicething about these is these are
all novel mechanism of action.
So we don't have anythingcurrently on the market that
treats depression in this way.
And that's so important becauseif you're one of those people
who doesn't respond to theserotonergic agents, this is
like a potential lifeline,right?
(25:45):
These are some new ways totreat depression that we haven't
had access to before.
So really exciting for some ofthese, we're utilizing your
endogenous opioid system.
And that always sounds weird topeople, right?
Because we're in an opioidcrisis.
Opiates seem like they shouldbe bad.
But the reality is we havenatural opiate systems within
our body that some of thesemedications can stimulate in
(26:07):
ways that can help depression.
Um, some of them also are veryhelpful for other things like
anxiety, insomnia, so thingsthat a lot of my patients suffer
from, some of these medicationsare going to specifically
target in the studies.
Dr. Michael Koren (26:19):
So that's so interesting.
So one of the things that we'vebeen taught in medicine is that
although opioids give youeuphoria in the short term, they
actually cause depression inthe long term.
Is that is that inaccurate or?
Dr. Heathe (26:34):
A lot of times, when you're bringing in an unnatural
opiate, something that's notnaturally in our system, you can
really deplete yourneurotransmitters and kind of
exhaust the system.
With this, it's a very carefulmodulation of your natural
system.
And so you don't have that kindof exhaustion of the system
that leads to those depressivesymptoms.
Dr. Michael Koren (26:52):
Interesting.
And are any of these trialsongoing in our community now?
Dr. Heather Luing (26:56):
The first one I'm actually a site PI for
currently.
So that one is ongoing.
Dr. Michael Koren (27:01):
Is that enrolling now?
Dr. Heather Luing (27:02):
It is currently enrolling.
Dr. Michael Koren (27:03):
And just give everybody a sense for the type
of patient that would getinvolved in something like that.
Dr. Heather Luing (27:08):
Yeah, it these are mostly major
depressive disorder studies.
So for these studies, you wantsomebody who either hasn't tried
antidepressants yet, or maybethey've tried one or maybe two
for some studies in the currentepisode of depression.
If you're somebody who's triedthree, four, five, you know, in
a fairly recent period, that'sprobably not gonna meet the
criteria for the study.
Dr. Michael Koren (27:29):
And how do these new drugs are anticipated
to interact with the serotonininhibition concept?
Totally different.
So they're not gonna beinfluencing those systems to any
meaningful amount.
And do when you do thesestudies, do they have to be on a
baseline of an SSRI or notnecessarily?
Dr. Heather Luing (27:46):
No, I don't think most of these, there may
be there may be one in therethat's or two that's an
adjunctive trial.
So for those, you would need tobe on an antidepressant
already.
But some of these arestandalone, so you'd get washed
off if you were already on anantidepressant.
You'd need to stop that for aweek or two before you started
this study.
Dr. Michael Koren (28:04):
Are there any of these mechanisms that you're
particularly excited about?
Dr. Heather Luing (28:07):
I think we're excited about all of them.
Okay.
There's really a lot of different ways
that we can target depression.
And now that the companies arereally putting the investment
into finding newer, safer ways,I think we're in a time of great
advancement in psychiatry.
Dr. Michael Koren (28:23):
Yeah, I mentioned in the beginning that
I was super excited to beworking with you.
We actually did some studies indepression 20 years ago, I
guess during the last phase ofinvestment.
And one of the frustratingthings is that people who are in
the studies were getting betterregardless of what the
treatment was.
And I guess is the whole socialinteraction thing, the
Hawthorne effect, et cetera.
(28:44):
So is that still relevant forstudies that we're doing today?
Is that people who get intostudies just get better?
Dr. Heather Luing (28:51):
It it is relevant.
The placebo response is huge inpsychiatry studies in general,
but particularly depressiontrials.
And so we try to minimize that.
So if you come into adepression trial and we're not
just quite as warm and fuzzy asmaybe we would when you come in
ordinarily to see us, it'sbecause we just try to minimize
things that can confound it andcause that placebo response.
(29:13):
So we try to keep itprofessional and really.
Dr. Michael Koren (29:16):
On the other hand, that's good for the
patients.
If you we like to talk aboutthe fact that one of the
advantages of doing research isthe fact that regardless of what
the study assignment is, peopletend to get better.
Dr. Heather Luing (29:26):
Right.
Dr. Michael Koren (29:27):
That's true for psychiatry, it's true for
cardiology.
Dr. Heather Luing (29:29):
Oh, yes.
When I'm not wearing myresearcher hat, I love the
placebo effect.
It's fantastic, right?
The key is just to get youbetter no matter what.
But when you're in research,you have to be careful about
that.
Dr. Michael Koren (29:40):
But uh again, I think it's yeah, in my
perspective at least, any of thetherapies that we use should be
effective enough that they'regiving you that result on top of
the benefits from just comingin.
Dr. Heather Luing (29:52):
Yeah, they have to be, and the FDA requires
that, and that's that's goodfor patients.
Dr. Michael Koren (29:56):
It reminds me uh of the vagal nerve
stimulator device.
So and this was superinteresting.
So we were treating thesepeople that had refractory
hypertension.
Some people were on like fivedifferent drugs for blood
pressure.
And in order to do the study,you had to bring them to the OR.
You had to put a pacemaker-likedevice in, which is the pulse
generator, and then a wire thatgoes up to the neck where the
(30:17):
carotid artery and the vagusnerve are most prominent.
And we found a couple ofinteresting things.
One, when we put them to sleep,using ketamine, their blood
pressure dropped tremendously.
Number one.
And then number two, is duringthe course of the study, the
people in the placebo group hada huge drop in their blood
pressure during the course oftime just being involved in the
(30:38):
study.
And so the first studiesactually turned out to be null
studies.
They didn't prove theirhypothesis because everybody did
so well.
So it was literally a 40-pointdrop in blood pressure in the
placebo group and a 50-pointdrop in the vagus stimulating
group.
But because the placebopatients did so well, they had a
hard time proving their point.
Dr. Heather Luing (31:00):
Well, it shows the mind-body connection,
right?
Dr. Michael Koren (31:02):
Exactly.
So it's fascinating.
And again, I would argue that'sa reason people should check
out research.
Good things happen.
Dr. Heather Luing (31:09):
Yes.
Dr. Michael Koren (31:10):
Well, there you go.
Why clinical research matters.
Dr. Heather Luing (31:13):
Yeah, absolutely.
Dr. Michael Koren (31:14):
So give us your perspective on that.
Dr. Heather Luing (31:15):
Any medication or procedure that we
have today started in research.
So it's really our way ofmoving medicine forward, and I
think because of that plays suchan important role.
Dr. Michael Koren (31:27):
And we now have a plan to really expand
what you're doing.
Yeah, we're super excited tohave somebody uh of your caliber
as part of the team, and we'regonna get the word out about
some of these great trials.
Dr. Heather Luing (31:40):
There's so much need, and I think the
wonderful thing about clinicalresearch too is it kind of takes
away the barriers thatsometimes people have with
insurance or maybe lack ofinsurance, and it allows people
to really anyone can have accessto looking at.
Dr. Michael Koren (31:53):
Yeah, and and expand on that a little bit
because I've talked to thepsychiatrist, and it seems in
this kind of managed care era,insurance companies say, well,
we'll give you psychotherapy butfive sessions, regardless of
what kind of progress you make.
And it it's become very, verychallenging.
So comment a little bit more onthat.
Is that still a big problem?
Dr. Heather Luing (32:11):
It's a huge problem.
I think it's the mostfrustrating thing about being a
psychiatrist today.
Yeah, because you know whatwould help your patient, but
maybe they can't access itbecause of the limitations on
insurance.
So I think a good psychiatricoffice is going to really
advocate for you and try to helpyou to get that approved.
But again, clinical research,even if you don't have
insurance, you can stillparticipate.
Dr. Michael Koren (32:33):
That's great.
Okay.
So how do you help a friend ora family member?
Dr. Heather Luing (32:38):
I think the most important thing is to talk
about it.
You know, we've traditionallyhad kind of a taboo or stigma
against mental health and mentalillness in the US, and that's a
problem.
It just makes the problem worsefor everyone.
So being open yourself to justtalking about this thing, if you
notice somebody who doesn'tseem to be doing well, ask them
about it.
And it's been shown in researchthat talking about things, even
(33:01):
suicide, doesn't make it worse.
It actually makes it better.
Helping out in practical ways,however you can, and then
encouraging them to getprofessional help if they need
it.
Dr. Michael Koren (33:12):
Again, that 988 number, I think, is really a
very important public healthmessage that everybody should
know that number, committed tomemory.
And and even just remindingpeople that may be in a
depressed state that if it getsto a certain point, yeah, you
have that resource out there.
Dr. Heather Luing (33:26):
Yeah.
And the 988, it's not kind oflike calling 911 where you're
gonna have police responding,that sort of thing.
It's really more of a mentalhealth focus.
Dr. Michael Koren (33:34):
So fabulous.
And building your personalmental wellness plan.
I'm super interested in yourperspective on this.
Dr. Heather Luing (33:43):
Really focus on some of those lifestyle
things that are the foundation.
So sleep, exercise, nutrition,time in nature, and that social
connectivity.
Those are really impactfulthings to add, whether you're
gonna be doing therapy andmedication or you're just gonna
be doing those alone.
It can be life-changing.
So make it kind of a new habitor routine.
(34:03):
And there really are resourcesfor everybody.
So if you don't have insurance,there are community mental
health centers in every countyacross the U.S.
So there's always helpavailable.
And of course, if you do haveinsurance, you can check with
your insurance plan and they cantell you who's in network.
Dr. Michael Koren (34:21):
And how how does it work nowadays?
Can people refer themselves topsychiatrists or do they have to
generally go through theirprimary physicians?
What's what's the traffic ofthis these days?
Dr. Heather Luing (34:31):
I would say 90% of the time you can
self-refer.
If you can't, you probablyalready know that your plan has
that limitation, but most peoplecan.
Dr. Michael Koren (34:39):
And the the other question that I hear that
comes up a lot is there's ashortage of psychiatrists around
the country, and I assume alsohere in Northeast Florida, how
long does it take to get in tosee you?
Dr. Heather Luing (34:50):
I mean, we can get somebody in usually the
same week, if not the next week.
So I don't think that that'sgonna be a barrier.
But also the majority of mentalhealth problems are treated by
primary care in the U.S.
So if you run into anydifficulty seeing a
psychiatrist, then start withyour primary care provider.
Dr. Michael Koren (35:06):
Excellent.
So I think we're up totake-home messages, so go ahead
with that.
Dr. Heather Luing (35:11):
Yeah, I think the the thing I really want to
emphasize is hope.
I want everybody to leave herefeeling like no matter what
you're going through from amental health standpoint, that
there is hope available andreaching out for resources when
you need them.
They're there for you.
Announcer (35:25):
Thanks for joining the MedEvidence Podcast.
To learn more, head over toMedEvidence.com or subscribe to
our podcast on your favoritepodcast platform.
Welcome to the MedEvidence Podcast.
This episode is a rebroadcastfrom a live MedEvidence
presentation.
Dr. Michael Koren (00:06):
Heather, I'm super excited that you're here
with me.
By the way, Dr.
Luing is a brilliantpsychiatrist who I'm really
excited to work with.
We've met each other recently.
She's done clinical trials inher practice.
Now she's going to become partof our group.
And I couldn't be happier ormore excited because I can tell
you you just have it.
You have the factor of being atremendous investigator.
(00:27):
So I'm really looking forwardto that.
Dr. Heather Luing (00:28):
I think it's going to be really great.
Dr. Michael Koren (00:30):
Yeah.
And I'm looking forward to oursession today to share with the
audience things aboutdepression.
I know it's it's a topic thatwe don't like to talk about, but
it's an important topic.
And it's actually a topic thatis rich in the research world in
terms of a lot of studies areongoing.
So we'll cover all that.
So these are the objectives fortoday.
And I'll just show them realquickly so everybody can see.
(00:54):
And let me ask you by startingwith this question.
You know, we live in Florida.
What wonderful place, sunnyplace.
It's the holiday season.
Everybody should be happy.
Like, why is there anydepression at all?
Am I crazy or is this the timeof year that we should all just
be joyous?
Dr. Heather Luing (01:11):
It sounds intuitively like it should be.
But the reality is for a lot ofmy patients, this is actually
the hardest time of year.
So I think a lot of peoplestruggle in this season.
And the reality is depressionis at all times highs across the
U.S.
And it started growing duringCOVID and it really hasn't
stopped.
It's continued to increasesteadily, really across all
(01:32):
demographics and age groups,even though some have been
affected more than others.
Interesting.
And how about Florida versusother places?
Yeah, I think that it's prettyconsistent statewide, state to
state.
I don't think there's a hugevariation in Florida.
We do see higher incidence inyounger age groups, so certain
areas might have littledeviations, but it's a serious
(01:54):
problem nationwide.
Okay.
So you we've heard the termmajor depressive disorder.
Why don't you explain toeverybody what that means?
What's major versus minor andhow do you make the diagnosis?
Yeah.
So in psychiatry, we havesomething called the Diagnostic
and Statistical Manual.
So that is really outlines allof our different psychiatric
(02:15):
illnesses.
So I would say major depressivedisorder is probably kind of
what you think about as maybeclinical depression, something
where it rises above the kind ofjust day-to-day up and downs
that the average person hasuntil it becomes more pervasive.
And as you can see, there'sactually really kind of strict
criteria on what qualifies asMDD and what doesn't.
(02:38):
Probably the biggest thing isit has to last at least two
weeks.
So you have to have that lowmood that really becomes
persistent.
Dr. Michael Koren (02:45):
So if you wake up in the morning and you
don't feel like going to work,that doesn't count as
depression?
Dr. Heather Luing (02:50):
Probably not.
Dr. Michael Koren (02:51):
You won't write me a script to get me out
of work?
Dr. Heather Luing (02:53):
No, no, we're not going to do that.
No.
And in fact, staying active anddoing things like work and
being around people can actuallybe helpful.
So most of the time, even ifyou did meet criteria for MDD,
we'd still encourage you to tryto do as much as possible.
So time of the year, we we'retalking a little bit about that,
that it's the winter months.
Is that a factor?
Tell us a little bit about thisconcept of seasonal disorders.
(03:15):
So we used to consider seasonalaffective disorder or SAD as a
separate diagnosis, but underour newest version of the DSM,
it's considered a subtype ofdepression.
So certainly some people aresusceptible to decreases in the
amount of daily sunlight that weget, or even the timing of that
that introduced kind ofinterferes with our circadian
(03:37):
rhythms.
So this seasonal effectivepattern is something that even
in Florida we see, and someindividuals are more susceptible
to it than others.
Dr. Michael Koren (03:46):
Yeah, it's interesting.
Yeah, the celebration ofChristmas actually predates the
birth of Jesus.
A lot of people don't knowthat, but it was a holiday when
people started to recognize,ancient people started to
recognize that the days weregetting longer again.
So that would infer that priorto Christmas that there's a time
where people are gettingnervous that the days are
getting shorter.
Dr. Heather Luing (04:07):
Absolutely.
I mean, I think some of you mayeven kind of feel this, even
when we have the time change andwe fall back by an hour or
spring forward by an hour, somepeople do have a decrease in
energy and and have actualsymptoms related to that.
So it may be relatively mild,but for some people it becomes
more severe.
Dr. Michael Koren (04:24):
So if you live in the southern hemisphere
where everything is flippedduring our winter, there it's
their summer and their days aregetting longer.
Do you see the a flip in termsof the seasonal patterns of
depression?
Dr. Heather Luing (04:36):
Yeah, I believe you do.
Obviously, I've never practicedthere, but but I think that it
really has to do with the timeof daylight you're exposed to.
Interesting.
And about one thing, is thereany chemical issues in terms of
getting sun and vitamin D andmelatonin and those sorts of
things?
Yeah, they think that that maybe somewhat of an influence to
(04:57):
it, but as you'll probably seeon one of the future slides,
just exposing people to acertain type of light that emits
a high voltage of light thatcan be curative even without,
you know, other factors likevitamins.
Dr. Michael Koren (05:12):
Interesting.
All right, so this comes up allthe time.
When should people seek out youknow serious professional help?
So is it when you're get up inthe morning and kind of feeling
cranky? The reason I say that is because when I went to college a generation ago, we had one doctor for the entire campus.
My daughter just graduated theUniversity of Pennsylvania and
(05:39):
they had twenty full-timebehavioral health specialists on
call and 75% of the studentsaccess one during their
undergraduate years.
Dr. Heather Luing (05:52):
Wow.
Dr. Michael Koren (05:52):
So there's a whole change in the paradigm in
terms of when you seek help.
So why don't you give us alittle bit of guidance when you
seek help?
Is it when you kind of feelthose are all the twinges of not
feeling right, or is it whenyou're on the on the ledge?
Dr. Heather Luing (06:05):
Yeah.
Yeah, that's a good question.
You know, I think the realitywith depression is that the
earlier you treat it, the easierit is to treat, the more likely
it is going to be to respond tointerventions.
So I don't think there's reallya too early, and it sounds like
the college students havecaught on to that.
Interesting, they're also thesecond most common demographic
(06:25):
to have this increase indepression symptoms.
So it's great that they areutilizing that.
But in general, if the symptomshave gone on more than a couple
of weeks, that is enough, Ithink, to reach out for some
help or at least try somelifestyle modifications.
And then obviously, if you haveserious suicidal ideations, you
notice you're having someunhealthy coping skills, like
(06:48):
drinking a little too much overthe holidays, those are warning
signs that I think you shouldreach out sooner than later.
Dr. Michael Koren (06:54):
Now, I noticed this 988 number on
texting.
I had no idea about that.
Who who is the person on theother side of that when you text
somebody?
Dr. Heather Luing (07:02):
Yeah, so this is the new national crisis
line.
It's like the 911 for mental orsubstance abuse issues, which
is pretty phenomenal.
So you can use this numberanywhere in the U.S., but 90% of
the time it's going to beanswered by local people in your
community.
So, for example, inJacksonville, MHRC does a lot of
the crisis phone calls.
(07:23):
And it doesn't have to be thatyou're suicidal, it can be any
kind of mental health orsubstance abuse crisis, and they
can guide you to whereresources are in your community.
Dr. Michael Koren (07:32):
Well, out of curiosity from the audience, who
was aware prior to this thatthere was a 988 number?
So maybe a quarter of theaudience.
So that in itself is incredibleinformation.
Thank you.
Dr. Heather Luing (07:44):
Yeah, it's a great resource.
Dr. Michael Koren (07:47):
Okay.
So let's talk about the scienceof mood.
I'm a scientist part-time, whenI'm not practicing medicine.
And explain to people.
It's not just the fact thatyou're, you know, you had you
got a bad hand at work orwhatever the situation may be,
but there's actually somethingthat's more fundamental, more
(08:09):
biological.
So maybe you can helpus understand that.
Dr. Heather Luing (08:11):
I think you highlighted it when we started
that why would I be feeling thisway if everything in my life is
going well?
And I can't tell you how manytimes I hear that from patients,
like, why am I depressed?
You know, I've got a greatspouse, a good job, my kids are
doing well, but I still feelthis way.
And that's because depressiondoesn't just have to do with
things that are going on aroundyou, although, of course,
(08:32):
stressors can make things worse,but it truly is a brain
disorder, and our bodies canaffect our brain as well.
So it could be from anunderlying medical condition
that you're feeling this way.
It could be from parts of yourbrain that aren't functioning
the way that they normally do.
So it truly is a veryscientific phenomenon, and many
(08:53):
things can influence it.
So we talked a little bit aboutseasonality, right?
Light can influence it, hormonelevels, a lot of different
factors.
Dr. Michael Koren (09:01):
Wow.
So obviously you make thediagnosis of depression, and
from what you just said, thereis different scales and
different things that come outof discussion with patients that
ultimately make the diagnosis,and then you take a very
specific stepwise approach tostart treatment.
So once why don't you walk usthrough that?
Dr. Heather Luing (09:23):
It's kind of like building a house, right?
You want to start with a reallygood foundation, a solid
foundation.
And I would say that is yourlifestyle and behavioral
practices, and we'll talk moreabout that.
For some people, that alone isenough to really get the
depression under control.
If it's not, you know, I thinkthe next step is always some
form of psychotherapy.
(09:44):
Having somebody to help guideyou through this, whether it's
like a cognitive behavioralthing where you're working on
how you're thinking isinfluencing how you're feeling,
or maybe you've gone through atrauma and you need some help
processing that.
So adding therapy would be thenext kind of layer of the house.
Medications would, I think,come after that.
If you've tried therapy andyou're still not getting full
(10:06):
effects, then we look atmedications as the next step.
And then finally, we look atsome of our newer and different
types of treatment options.
So things like TMS, ECT, someof the newer medicines like
esketamine.
So those are kind of the finallayer.
But again, like the title ofour presentation, I think there
should be so much hope becausethings have really changed a lot
(10:29):
in the area of psychiatry.
So when I finished residencyand started practicing, it was a
time when all the neurosciencedivisions were closing down at
the pharmaceutical companies,and they really were not
interested in putting kind ofresearch into psychiatry.
But that has changed, andthere's been an explosion of new
treatments, and that's justgoing to continue to grow over
(10:49):
the next few years.
So it really is a time to bevery hopeful about what's on the
horizon.
Dr. Michael Koren (10:54):
Wow.
So I know we have some slidesthat are covering some of these
approaches.
So I'm super interested inlearning more about it.
So I guess you'll start us offwith just the lifestyle
approaches and we'll move onfrom there.
Dr. Heather Luing (11:04):
Yeah, and lifestyle is so important.
So we know that sleep is veryrestorative for the brain.
So having a regular sleepschedule where you're getting
the right amount of sleep.
How many of you are gettingsix, seven, eight hours of sleep
every night?
Okay.
So that's less than half theroom, right?
So half of you need to go homeand work on your sleep.
(11:24):
Yeah, sleep is so healing andrestorative.
So I think that's a greatthing.
Movement or exercise is alsosomething I recommend for all of
my patients.
And it is amazing.
This does not have to beintense exercise.
You don't have to sign up for amarathon, no turkey trots.
Just getting out there andtaking a brisk walk, you know,
walking your dog, riding yourbike, very, very helpful to have
(11:46):
that small amount of aerobicexercise.
Getting good nutrition isdefinitely important, and there
are some micronutrients that areparticularly helpful.
And then having social support.
We know that there's aloneliness epidemic in the US,
and forming those connectionscan really be helpful for mental
health.
Dr. Michael Koren (12:04):
Now, you mentioned something about
nature.
Tell us a little bit more aboutthat.
Is like going to a Jaguars gamecount as nature, or does it
have to be out in the woods?
Dr. Heather Luing (12:13):
It's better than nothing.
Okay.
Um, but I think that if you canimmerse your senses in nature,
that's where the research reallyshows us that there's a
beneficial approach.
So things like listening tobird song has been shown to help
your mental health.
Looking at nature, smelling it,getting the full really
experience is very helpful.
And I encourage all my patientsto make that something in their
(12:36):
life, like a new habit to form.
Dr. Michael Koren (12:38):
So the concepts of Thoreau that talked
about this 200 years ago arejust as relevant now.
Dr. Heather Luing (12:44):
I think so.
Dr. Michael Koren (12:45):
Very cool.
Okay, so I know you have otherslides looking at other elements
of treatment.
Dr. Heather Luing (12:52):
We talked about a little bit about
psychotherapy.
I would say therapy issomething don't be afraid of,
right?
And if you try a therapist andit's not a good fit, try a
different therapist.
They understand you have tohave a good therapeutic bond
between you and the therapist.
And there's all different kindsof therapy.
CBT or cognitive behavioraltherapy really has a lot of good
(13:12):
research behind it.
So it's something we encourage.
And there's actually a specifictype for seasonal affective
disorder.
So if that's something you'redealing with over the winter
months, you can get aspecialized therapy for that.
Dr. Michael Koren (13:23):
Interesting.
Do you always recommendtherapy?
Are there times where that canbe a problem?
Like some people just need toget on drugs, or is it is it
always is there always a part ofit that should be incorporated
with talking to somebody?
Dr. Heather Luing (13:38):
I think we can always learn more about
ourselves, right?
And that's really what therapyis is learning about how you're
thinking, how that'sinfluencing, how you're feeling,
and how to develop differentcoping skills to help you get
through this really stressfullife that we have to deal with.
So I pretty much recommendtherapy across the board.
It really can't hurt you.
So if you have the time and theresources, you know, search out
(13:59):
a therapist.
And really, they're everywhere.
Community mental healthcenters, you should be able to
find somebody.
Telehealth has made things alot more accessible.
So there's a lot of options.
Dr. Michael Koren (14:08):
Yeah, and I want to spend a little bit of
time on telehealth.
In certain areas of medicine,telehealth has taken over more
than others.
And I think it's fair to sayit's taken over more in
psychiatry.
If that's not a true statement,let me know.
But that's my sense.
Dr. Heather Luing (14:21):
That's true, yeah.
But is that the same as beingin the room with the human
being?
What do you think?
I would say it's close.
Dr. Michael Koren (14:27):
Okay.
Dr. Heather Luing (14:28):
I would say it's not really quite the same.
If you have an option ofin-person treatment, I always
think that's a little bit of anedge.
It's preferable.
But if that's not an option foryou, you can't get the time off
work or transportation's aproblem, then telehealth really
does open up access.
So it definitely has a place.
Dr. Michael Koren (14:45):
And how about these bots that have been
promoted as ways of providingpsychotherapy?
What are your opinion on those?
Dr. Heather Luing (14:51):
I think we might be a little early on that.
So I would encourage you tryingto find an actual human being
rather than a bot.
Dr. Michael Koren (14:57):
I like that advice.
So let's talk about medication.
Dr. Heather Luing (15:02):
Yeah, so medications are interesting.
For many, many years, we havekind of hung our hat in
psychiatry on what's called themonoemanergic hypothesis.
That sounds like a lot of bigwords.
How many of you guys have heardof serotonin?
Okay, everybody, right?
And a lot of my patients willcome to me and say, you know, I
(15:22):
think I have a chemicalimbalance or I have a serotonin
deficiency.
The reality is it's not thatsimple.
We really oversimplified thingsa little bit in explaining how
the brain and depression work.
And unfortunately, for myentire career up until a few
years ago, the only meds we hadavailable were those that worked
(15:43):
on monoaminergic brainchemicals like serotonin and
norepinephrine.
For some people, that's great,but about a third of people do
not respond to thesemedications.
And a lot of people get anincomplete response where, yeah,
the depression's better,they're getting out of bed,
they're going to work, butthey're not really enjoying
their life.
It's kind of in black and whiteinstead of color.
(16:03):
So that's really where ourantidepressant treatments have
been for many years.
Now we have had some recentadvances, and we have a lot of
chemicals that are in researchright now that work in different
ways.
And so I think again, it's avery hopeful time when it comes
to med management, but we've hada lot of unmet need.
Dr. Michael Koren (16:24):
The seasonal preventive strategies.
One of the things I was curiousabout and wondering about is is
somebody that tends to havethat the type of patient that
may get on preventative medicinecome October.
Is that something that you doin for some patients?
Dr. Heather Luing (16:41):
Yeah, absolutely.
For some people that can bevery helpful.
And you know, like I said atthe beginning, the sooner we
treat depression, the easier itis to treat.
So if you can nip it in the budlike that, a lot better than it
getting to December and youhaving a hard time getting out
of bed.
Dr. Michael Koren (16:54):
Because we we like to promote preparedness
for the cold and flu season atMedEvidence.
And we always tell peoplestarting in August that prepare
to get your flu shot and yourRSV, et cetera, for the coming
season.
It's probably similar inpsychiatry.
Dr. Heather Luing (17:09):
Yeah, I think so.
And you know, that could bethings beyond medicine, right?
Maybe it's increasing yourlifestyle interventions.
You're gonna get outside andwalk and get some sunlight,
things like that.
You could definitely dopreventatively.
Dr. Michael Koren (17:21):
Fascinating.
This light therapy I findreally super interesting.
So why don't you walk usthrough this?
Dr. Heather Luing (17:27):
Yeah, so you have to have a certain type of
light.
So they make these light boxes.
You don't look directly intothe light, so you want to have
your eyes open, but kind oflooking to the side, and you'll
have a period of time that isspecified to how much light
exposure you need.
Now, certain disorders, forexample, bipolar disorder, you
got to be very careful with thelight because it can be too
(17:49):
much.
It's something that has to betailored to the individual.
Dr. Michael Koren (17:52):
Interesting.
And how does light therapystack up against medications?
Dr. Heather Luing (17:56):
I think for seasonal affective disorder,
very well.
It's really the kind ofstandard treatment for that
particular type of depression.
Dr. Michael Koren (18:03):
Interesting.
Okay, TMS.
This sounds really fascinating.
So I'm real curious to learnmore about this.
Dr. Heather Luing (18:12):
Yeah, I think TMS is the best kept secret in
psychiatry.
Dr. Michael Koren (18:15):
Really?
Dr. Heather Luing (18:16):
Yeah.
And so it has been FDA approvedin the US for about 17 years,
but I bet most of you have neverheard of it.
So and I think it's somethingthat I love talking about
because so many people don'tknow about it and it's such a
great treatment option.
So what it is is it's anon-invasive type of brain
stimulation.
So what we do is we applymagnetic pulses to a certain
(18:37):
part of your brain that indepressed individuals is
hypoactive.
So it kind of goes to sleep onthe job.
What these magnetic pulses dois help to wake it up so that it
starts communicating with therest of the brain and forming
those neuronal connections thatare so important.
Dr. Michael Koren (18:53):
Interesting.
So what kind of device do youhave to use for this?
Dr. Heather Luing (18:56):
So TMS machine, it kind of has a chair
that looks a little bit like adental chair.
You just kind of recline backin that chair, and then there's
a magnet that fits over yourhead, kind of like this.
And you just sit there and ittaps away for about 19 minutes.
And you do this for a series oftreatments.
So you come in five days aweek, Monday through Friday, for
(19:16):
30 treatments, and then you doa six-treatment taper.
Dr. Michael Koren (19:19):
Now the last bullet point here talks about
minimal systemic side effects.
Are there anything inparticular you're worried about
as a side effect?
Dr. Heather Luing (19:27):
Yeah, it's pretty amazing in that it's a
very effective treatment, butvery few side effects.
So most common is a little bitof scalp tenderness under where
the magnet sits.
So kind of thing when you'rebrushing your hair in the
morning, you're like, oh, that'sa little tender and occasional
headaches.
And that's pretty much it.
There's no anesthesia, nodowntime.
You can drive, you can go towork, you can do all your normal
activities.
Dr. Michael Koren (19:46):
Pretty cool.
So you get into more detailsabout what to expect.
Dr. Heather Luing (19:51):
Yeah, so you kind of see an example of one of
the types of TMS machinesthere.
You're gonna feel a tappingsensation, you'll hear that too,
right over your scalp.
And most sessions take about 19minutes.
We do have some newer protocolsthat are being studied, uh
Theta Bursts, which are down tothree minutes.
They really compress the pulsesdown.
And there's even someaccelerated TMS protocols that
(20:14):
have been in the news quite abit in the last year where you
can compress TMS down to a fewdays instead of going over
several weeks.
Dr. Michael Koren (20:21):
Interesting.
And which companies manufacturethis machine out of curiosity?
Dr. Heather Luing (20:25):
That particular one is a Neurostar.
There's about eight of thesefigure eight machine companies
that are on the market.
So there's they're all prettysimilar when you come to the
inside.
The magnet itself is the same.
It's just kind of the outsideof the machine that's different.
Dr. Michael Koren (20:40):
One not better than the other,
particularly?
Dr. Heather Luing (20:41):
No, they're comparable.
The FDA has has cleared them.
Dr. Michael Koren (20:44):
Interesting.
All right.
So beyond TMS.
Dr. Heather Luing (20:48):
Yeah, so we have other types of
neurostimulation.
So again, this is kind of yourlast layer of treatment.
You've tried lifestyle, you'vetried therapy, you've tried
meds, but you're still notgetting resolution.
VNS or vagus nerve stimulationis another really exciting type
of neurostimulation.
You can see from the picturethere, this is a small implanted
(21:09):
device.
It goes about under yourcollarbone.
It's about the size of aquarter, and it connects to the
vagus nerve, which is one of thelargest nerves in our body.
And what it'll do is every fewseconds it will stimulate that
nerve, and that has been shownto improve depression.
So it's interesting.
This was actually FDA approvedmaybe close to 17 years ago now,
(21:30):
too.
But CMS or Medicare did notpick it up to pay for it, and so
insurance doesn't pay for it.
And because of that, thisrecover trial has been going on
for the last four years or so.
And that is just an additionaltrial to demonstrate efficacy,
not only for major depressivedisorder, but also bipolar
depression.
Dr. Michael Koren (21:50):
That's so interesting.
So here in Jacksonville, we'veactually done a number of
studies of vagus nervestimulators for other diseases.
Right.
And we did studies with similardevices to treat hypertension,
high blood pressure, and itworked.
Dr. Heather Luing (22:04):
Yeah.
And we did studies in heartfailure using these type of
devices, and it's actuallyapproved, and CMS covers it for
heart failure.
Yeah, that's fascinating.
I think they also use it forclotting disorders and some GI.
Dr. Michael Koren (22:16):
Yeah, but it's the f this is the first
time I've actually heard thatone of the positive side effects
of this may be less depression.
Dr. Heather Luing (22:23):
Yeah.
Dr. Michael Koren (22:23):
Have people looked at that in the heart
failure population?
Dr. Heather Luing (22:26):
Yeah, I think that's kind of how they
discovered it initially.
Dr. Michael Koren (22:29):
Interesting.
Dr. Heather Luing (22:29):
Yep.
Dr. Michael Koren (22:30):
Fascinating.
Okay, emergent research, rapidacting treatment.
So tell us more about this.
Dr. Heather Luing (22:35):
Yeah, so we've again moved beyond this
monoaminergic hypothesis asketamine was our first
FDA-approved treatment thatlooks at targeting the glutamate
system.
And so because glutamate worksa lot quicker than serotonin,
we're getting improvementswithin 24 hours for many
patients.
And so that's really exciting.
(22:56):
You can also doketamine-assisted psychotherapy.
Now, ketamine itself is not FDAapproved, so that is an
off-label treatment, butsometimes combining the therapy
with the actual medication canbe really impactful.
Dr. Michael Koren (23:10):
So when when I think of ketamine, I think of
being in almost a state ofanesthesia.
How does it work in in theoutpatient setting in a
psychiatrist's office?
I'm really curious about that.
Dr. Heather Luing (23:19):
Much lower doses, yes.
We definitely don't want anyoneunder anesthesia in their
psychiatrist's office.
But low doses actually give aprofound relaxation.
For some people, a little bitof a dissociative effect, and
that can be dose-dependent.
With esketamine, which is theFDA-approved nasal spray, it's a
fairly mild dissociation.
But you do stay for a couplehours in the doctor's office for
(23:43):
your treatment.
Dr. Michael Koren (23:44):
So that's interesting.
Do people fall asleep duringthis?
Is that a problem?
Dr. Heather Luing (23:47):
Sometimes it's one of those known side
effects.
Yeah, I have one lady, she'sbeen doing it in our clinic for
I think about five years, andshe sleeps every single session
the entire time.
But I think she just reallylikes a good nap.
Dr. Michael Koren (24:00):
So well, you talked about sleep being
important for depression, sothere you go.
That's right.
I love that.
Okay.
And uh psychedelics, we'veactually had a few MedEvidence
podcasts on psychedelics.
And we're excited that peopleare actually looking at it
scientifically for the firsttime.
Dr. Heather Luing (24:18):
Right.
There's been a lot of feararound it that I think was
somewhat unfounded.
So, you know, it's kind of onthe horizon, nothing here yet,
but a lot of studies going on.
Dr. Michael Koren (24:29):
When when these studies are done, you have
to have a very specificfacility to actually do the work
in clinical research.
I recently was exposed to thatwhen I was visiting one of our
sister sites in Chicago.
And they had this whole setupwith you kind of look like a
hippies den from the 1960s.
But it was a a very specificroom that you needed to perform
(24:52):
these studies.
Is that the general sense thatthat's how we're gonna be
treating these peopleclinically?
You were gonna get in yourVolkswagen bus and and and give
the therapy in that?
Dr. Heather Luing (25:02):
I don't think it has to be quite like that.
But you know, there are somereally important considerations
with psychedelic research andsafety is one of them for sure.
But also having a goodenvironment where it doesn't
feel too sterile, you feel likeyou're comfortable enough to
really relax and have thatexperience is important.
Dr. Michael Koren (25:18):
Interesting.
All right, new and emergingmedications.
So walk us through some ofthese.
Dr. Heather Luing (25:24):
Yeah, and I'm not gonna go through all these
details.
I can tell you that the nicething about these is these are
all novel mechanism of action.
So we don't have anythingcurrently on the market that
treats depression in this way.
And that's so important becauseif you're one of those people
who doesn't respond to theserotonergic agents, this is
like a potential lifeline,right?
(25:45):
These are some new ways totreat depression that we haven't
had access to before.
So really exciting for some ofthese, we're utilizing your
endogenous opioid system.
And that always sounds weird topeople, right?
Because we're in an opioidcrisis.
Opiates seem like they shouldbe bad.
But the reality is we havenatural opiate systems within
our body that some of thesemedications can stimulate in
(26:07):
ways that can help depression.
Um, some of them also are veryhelpful for other things like
anxiety, insomnia, so thingsthat a lot of my patients suffer
from, some of these medicationsare going to specifically
target in the studies.
Dr. Michael Koren (26:19):
So that's so interesting.
So one of the things that we'vebeen taught in medicine is that
although opioids give youeuphoria in the short term, they
actually cause depression inthe long term.
Is that is that inaccurate or?
Dr. Heathe (26:34):
A lot of times, when you're bringing in an unnatural
opiate, something that's notnaturally in our system, you can
really deplete yourneurotransmitters and kind of
exhaust the system.
With this, it's a very carefulmodulation of your natural
system.
And so you don't have that kindof exhaustion of the system
that leads to those depressivesymptoms.
Dr. Michael Koren (26:52):
Interesting.
And are any of these trialsongoing in our community now?
Dr. Heather Luing (26:56):
The first one I'm actually a site PI for
currently.
So that one is ongoing.
Dr. Michael Koren (27:01):
Is that enrolling now?
Dr. Heather Luing (27:02):
It is currently enrolling.
Dr. Michael Koren (27:03):
And just give everybody a sense for the type
of patient that would getinvolved in something like that.
Dr. Heather Luing (27:08):
Yeah, it these are mostly major
depressive disorder studies.
So for these studies, you wantsomebody who either hasn't tried
antidepressants yet, or maybethey've tried one or maybe two
for some studies in the currentepisode of depression.
If you're somebody who's triedthree, four, five, you know, in
a fairly recent period, that'sprobably not gonna meet the
criteria for the study.
Dr. Michael Koren (27:29):
And how do these new drugs are anticipated
to interact with the serotonininhibition concept?
Totally different.
So they're not gonna beinfluencing those systems to any
meaningful amount.
And do when you do thesestudies, do they have to be on a
baseline of an SSRI or notnecessarily?
Dr. Heather Luing (27:46):
No, I don't think most of these, there may
be there may be one in therethat's or two that's an
adjunctive trial.
So for those, you would need tobe on an antidepressant
already.
But some of these arestandalone, so you'd get washed
off if you were already on anantidepressant.
You'd need to stop that for aweek or two before you started
this study.
Dr. Michael Koren (28:04):
Are there any of these mechanisms that you're
particularly excited about?
Dr. Heather Luing (28:07):
I think we're excited about all of them.
Okay.
There's really a lot of different ways
that we can target depression.
And now that the companies arereally putting the investment
into finding newer, safer ways,I think we're in a time of great
advancement in psychiatry.
Dr. Michael Koren (28:23):
Yeah, I mentioned in the beginning that
I was super excited to beworking with you.
We actually did some studies indepression 20 years ago, I
guess during the last phase ofinvestment.
And one of the frustratingthings is that people who are in
the studies were getting betterregardless of what the
treatment was.
And I guess is the whole socialinteraction thing, the
Hawthorne effect, et cetera.
(28:44):
So is that still relevant forstudies that we're doing today?
Is that people who get intostudies just get better?
Dr. Heather Luing (28:51):
It it is relevant.
The placebo response is huge inpsychiatry studies in general,
but particularly depressiontrials.
And so we try to minimize that.
So if you come into adepression trial and we're not
just quite as warm and fuzzy asmaybe we would when you come in
ordinarily to see us, it'sbecause we just try to minimize
things that can confound it andcause that placebo response.
(29:13):
So we try to keep itprofessional and really.
Dr. Michael Koren (29:16):
On the other hand, that's good for the
patients.
If you we like to talk aboutthe fact that one of the
advantages of doing research isthe fact that regardless of what
the study assignment is, peopletend to get better.
Dr. Heather Luing (29:26):
Right.
Dr. Michael Koren (29:27):
That's true for psychiatry, it's true for
cardiology.
Dr. Heather Luing (29:29):
Oh, yes.
When I'm not wearing myresearcher hat, I love the
placebo effect.
It's fantastic, right?
The key is just to get youbetter no matter what.
But when you're in research,you have to be careful about
that.
Dr. Michael Koren (29:40):
But uh again, I think it's yeah, in my
perspective at least, any of thetherapies that we use should be
effective enough that they'regiving you that result on top of
the benefits from just comingin.
Dr. Heather Luing (29:52):
Yeah, they have to be, and the FDA requires
that, and that's that's goodfor patients.
Dr. Michael Koren (29:56):
It reminds me uh of the vagal nerve
stimulator device.
So and this was superinteresting.
So we were treating thesepeople that had refractory
hypertension.
Some people were on like fivedifferent drugs for blood
pressure.
And in order to do the study,you had to bring them to the OR.
You had to put a pacemaker-likedevice in, which is the pulse
generator, and then a wire thatgoes up to the neck where the
(30:17):
carotid artery and the vagusnerve are most prominent.
And we found a couple ofinteresting things.
One, when we put them to sleep,using ketamine, their blood
pressure dropped tremendously.
Number one.
And then number two, is duringthe course of the study, the
people in the placebo group hada huge drop in their blood
pressure during the course oftime just being involved in the
(30:38):
study.
And so the first studiesactually turned out to be null
studies.
They didn't prove theirhypothesis because everybody did
so well.
So it was literally a 40-pointdrop in blood pressure in the
placebo group and a 50-pointdrop in the vagus stimulating
group.
But because the placebopatients did so well, they had a
hard time proving their point.
Dr. Heather Luing (31:00):
Well, it shows the mind-body connection,
right?
Dr. Michael Koren (31:02):
Exactly.
So it's fascinating.
And again, I would argue that'sa reason people should check
out research.
Good things happen.
Dr. Heather Luing (31:09):
Yes.
Dr. Michael Koren (31:10):
Well, there you go.
Why clinical research matters.
Dr. Heather Luing (31:13):
Yeah, absolutely.
Dr. Michael Koren (31:14):
So give us your perspective on that.
Dr. Heather Luing (31:15):
Any medication or procedure that we
have today started in research.
So it's really our way ofmoving medicine forward, and I
think because of that plays suchan important role.
Dr. Michael Koren (31:27):
And we now have a plan to really expand
what you're doing.
Yeah, we're super excited tohave somebody uh of your caliber
as part of the team, and we'regonna get the word out about
some of these great trials.
Dr. Heather Luing (31:40):
There's so much need, and I think the
wonderful thing about clinicalresearch too is it kind of takes
away the barriers thatsometimes people have with
insurance or maybe lack ofinsurance, and it allows people
to really anyone can have accessto looking at.
Dr. Michael Koren (31:53):
Yeah, and and expand on that a little bit
because I've talked to thepsychiatrist, and it seems in
this kind of managed care era,insurance companies say, well,
we'll give you psychotherapy butfive sessions, regardless of
what kind of progress you make.
And it it's become very, verychallenging.
So comment a little bit more onthat.
Is that still a big problem?
Dr. Heather Luing (32:11):
It's a huge problem.
I think it's the mostfrustrating thing about being a
psychiatrist today.
Yeah, because you know whatwould help your patient, but
maybe they can't access itbecause of the limitations on
insurance.
So I think a good psychiatricoffice is going to really
advocate for you and try to helpyou to get that approved.
But again, clinical research,even if you don't have
insurance, you can stillparticipate.
Dr. Michael Koren (32:33):
That's great.
Okay.
So how do you help a friend ora family member?
Dr. Heather Luing (32:38):
I think the most important thing is to talk
about it.
You know, we've traditionallyhad kind of a taboo or stigma
against mental health and mentalillness in the US, and that's a
problem.
It just makes the problem worsefor everyone.
So being open yourself to justtalking about this thing, if you
notice somebody who doesn'tseem to be doing well, ask them
about it.
And it's been shown in researchthat talking about things, even
(33:01):
suicide, doesn't make it worse.
It actually makes it better.
Helping out in practical ways,however you can, and then
encouraging them to getprofessional help if they need
it.
Dr. Michael Koren (33:12):
Again, that 988 number, I think, is really a
very important public healthmessage that everybody should
know that number, committed tomemory.
And and even just remindingpeople that may be in a
depressed state that if it getsto a certain point, yeah, you
have that resource out there.
Dr. Heather Luing (33:26):
Yeah.
And the 988, it's not kind oflike calling 911 where you're
gonna have police responding,that sort of thing.
It's really more of a mentalhealth focus.
Dr. Michael Koren (33:34):
So fabulous.
And building your personalmental wellness plan.
I'm super interested in yourperspective on this.
Dr. Heather Luing (33:43):
Really focus on some of those lifestyle
things that are the foundation.
So sleep, exercise, nutrition,time in nature, and that social
connectivity.
Those are really impactfulthings to add, whether you're
gonna be doing therapy andmedication or you're just gonna
be doing those alone.
It can be life-changing.
So make it kind of a new habitor routine.
(34:03):
And there really are resourcesfor everybody.
So if you don't have insurance,there are community mental
health centers in every countyacross the U.S.
So there's always helpavailable.
And of course, if you do haveinsurance, you can check with
your insurance plan and they cantell you who's in network.
Dr. Michael Koren (34:21):
And how how does it work nowadays?
Can people refer themselves topsychiatrists or do they have to
generally go through theirprimary physicians?
What's what's the traffic ofthis these days?
Dr. Heather Luing (34:31):
I would say 90% of the time you can
self-refer.
If you can't, you probablyalready know that your plan has
that limitation, but most peoplecan.
Dr. Michael Koren (34:39):
And the the other question that I hear that
comes up a lot is there's ashortage of psychiatrists around
the country, and I assume alsohere in Northeast Florida, how
long does it take to get in tosee you?
Dr. Heather Luing (34:50):
I mean, we can get somebody in usually the
same week, if not the next week.
So I don't think that that'sgonna be a barrier.
But also the majority of mentalhealth problems are treated by
primary care in the U.S.
So if you run into anydifficulty seeing a
psychiatrist, then start withyour primary care provider.
Dr. Michael Koren (35:06):
Excellent.
So I think we're up totake-home messages, so go ahead
with that.
Dr. Heather Luing (35:11):
Yeah, I think the the thing I really want to
emphasize is hope.
I want everybody to leave herefeeling like no matter what
you're going through from amental health standpoint, that
there is hope available andreaching out for resources when
you need them.
They're there for you.
Announcer (35:25):
Thanks for joining the MedEvidence Podcast.
To learn more, head over toMedEvidence.com or subscribe to
our podcast on your favoritepodcast platform.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.