Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital
Guest: Dr. Melissa Kahler, UnityPoint Clinic Family Medicine - Westdale
Dr. Arnold: This is LiveWell Talk on mental health, taking care of the entire you. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health-St. Luke's Hospital. For years, physicians have treated patients for their physical health yet mental health is just as important. Joining me to talk about this topic today is Dr. Melissa Kahler from UnityPoint Clinic Family Medicine - Westdale. That's a long title to say. Do you say that every day you go to work that you're Dr. Melissa Kahler from UnityPoint Family Medicine - Westdale?
Dr. Kahler: No I don’t. (laughing)
Dr. Arnold: That's a big title. Thanks for taking the time to talk about this. Welcome.
Dr. Kahler: Thanks for having me.
Dr. Arnold: This is a moot question, but tell us why mental health is just as important as physical health.
Dr. Kahler: There are lots of reasons. I mean, we know our brains and bodies are so interconnected. You really can't treat one without treating the other. We know that patients with mental health concerns have a higher risk of chronic physical disease and also vice versa. We know that patients with chronic heart disease, diabetes, who've had a stroke, that they're at a higher risk for having mental health disease also. So they're very intertwined.
Dr. Arnold: I'm a big advocate for mental health. I think it's unfortunate, you know, we do not stigmatize people if they require insulin for their diabetes, then why are we, we have a tendency to stigmatize patients that require an antidepressant for their depression. And I don't think we should. And you know, we'll talk about more of that a little bit later as well. The mental health issue obviously influences physical health to a significant degree that's understandable. But what percentage of your patients do you think have a component of chronic mental health diagnosis?
Dr. Kahler: So we know that over a lifetime, probably about 50% of people will be diagnosed with a mental health illness. I mean, I treat it in my practice every day. I would hate to throw out a number but I mean I would say at least 20% of my patients on a daily basis either have a current diagnosis or have had within the last few years of some sort of mental health illness.
Dr. Arnold: Do you find patients reluctant to talk about it? Do they talk about other things that perhaps reflect mental health? But let me think of something here that maybe fatigue, maybe they which really fatigue, it's not really fatigue. It's loss of interest and apathy in some way. Is that how it subliminally presents in the clinic?
Dr. Kahler: Oftentimes, and I think things with like fatigue or other kind of vague symptoms, people just don't realize that that really is and can be a symptom of underlying mental health illness.
Dr. Arnold: And I think that the reluctancy of people to be labeled, a mental illness. Does lead to perhaps indirect increase utilization of health care that is not being used appropriately. For example we don't see this very often in this community, which is a good thing, but the schizophrenic homeless patient. That is if we were just treating their schizophrenia well we wouldn't have to treat their pneumonias if they acquire or the hypothermia they acquire from being homeless so there is an influence there. Do you always start out with a medication when a patient presents they have symptoms of depression, let's say? Do you start with a medication first? Is it always a pill?
Dr. Kahler: It is not always a pill. I mean we know that there's lots of different ways to treat it. So I usually kind of start out talking about a healthy lifestyle because we know a healthy lifestyle influences our mental health as well. So getting enough sleep, eating healthy, exercising regularly. Those are all things that can help our brains too. And then I often talk about counseling and or medication, you know, if symptoms are not controlled or if they're significant enough that we need some other treatment.
Dr. Arnold: And is it, in a primary care practice, Dr. Kahler, or is it mostly depression that you see or adjustment disorder, etc? I mean, I don't think paranoid schizophrenia is walking in your clinic on a normal day. It will, I mean I'm sure you have had that happen, but that's not as common.
Dr. Kahler: Yeah, so most of what I treat is depression, anxiety disorders, ADHD is considered mental health too, so we treat quite a bit of that. PTSD and eating disorders. I mean, I would say those are kind of my, the top ones, but mostly depression and anxiety.
Dr. Arnold: Have you observed some stigma that patients maybe have relayed to you that they've experienced because they have a mental health disease?
Dr. Kahler: Definitely, yeah I think patients feel alone or lonely. They feel like if they talk to their parents or their friends or their spouse about it, that they'll think they're crazy or not normal. I mean to which I tell patients, everyone's a little bit crazy and no one's normal. You know, this is our normal. But yeah, I see a lot of stigma.
Dr. Arnold: It's interesting. I have a friend that's a surgeon, but when he was in medical school, he had just a really bad case of hiccups and they use Thorazine, which you can use. Right? And he had a dystonic reaction from it. So his chart said allergy: Thorazine. Which is a medication used to treat bipolar disorder and significant mental illness. So that was on the old paper chart. And he felt he was treated differently until he would explain, no, I'm allergic Thorazine because they used it for hiccups. But he said the way that he could perceive the clinician treating him differently on that first encounter because of that and once that was cleared up, it was a different experience. Which I find that really enlightening, that perhaps as physicians also, even though we're advocates, even though we know it should be treated, that perhaps we have our own internal bias or a prejudgment on these conditions and you have to fight against that. Is that something that you've experienced?
Dr. Kahler: I hope we don't. I mean I think, you know, even since I've done my training 12 to 15 years ago, I think we're talking about it more, we realized that it's a more common condition then and you know, what we've previously realized and I mean I feel really comfortable talking about it.
Dr. Arnold: That's great. They'll say that the cases of just, let's say mental illness are going up. It's trending up, the incidents. I hope part of that is now more people are coming forward and getting treated. It's really the same number of people have it. It's just more of those patients are being treated than in the past. Which I hope that's true. What are some common medications that you've used and when you start those medications, how long does it take to see a response? I mean, certainly it's not a happy pill where you take it and you feel better the next day. But what is in your judgment, how long should a patient be on a medication where you expect to see a change?
Dr. Kahler: So generally our first line of medications for both depression and anxiety are SSRIs and there's six to eight ones that we use pretty regularly. And you're right, I mean, I tell patients, even though you really want to feel better tomorrow or the next day, this is going to take a while. It works on the chemical level in your brain. So over four weeks where you should be noticing some change and by six weeks we should be noticing kind of the full effects of the medication.
Dr. Arnold: Do you then continue that for a period of time? Okay, if I get put on a medication for mental health, am I on it the rest of my life or is there a time in the future where you might reassess that and try coming off of it and see how they do?
Dr. Kahler: Definitely. So, especially if it's the first time it's been diagnosed and treated usually I'll tell patients we should stay on this for six months to twelve months and then kind of take a look at it. You know, if there's no big stressors going on, if life is pretty stable, you're feeling really well, we can taper off of it and see how it goes. If people need to be on it subsequent times, usually by the third time or so I would tell a patient, you're probably just going to feel better on it. And at that point I would just recommend that we just stay on it long term.
Dr. Arnold: I guess I can remember a time when it was essentially Prozac was the only SSRI and you know, and now we have a selection of them. The side effect profiles have become smaller which is a benefit. I do know that my psychiatry colleagues, when the newer anti-psychotics came out that had less side effects, the paranoid patients thought they were being given sugar pills because their side effects went away. So they knew when they took their old medication, Hey, I have to take my medication because if I don't, I'm going to decompensate. But then they get this new medication and they don't have the same side effects they're like, Oh my gosh, someone's exchanging my pills. So sometimes when we try to make things better, there are unintended consequences of that. I'm going to go on a limb here and say family medicine, you probably provide a lot of mental health because we have a deficit of psychiatrists.
Dr. Kahler: Yes, we do. I mean, I feel like that's a big part of my practice and I feel like I'm also pretty passionate about it, so I probably kind of have more of that patient population. But I think all of us treat it a lot.
Dr. Arnold: That's understandable. And you know, I think St. Luke's, Unity Point Health, we are one of the leaders in the state as far as mental illness. We have our partnership with the Abbe Center. At one time and I think we're still there. We were only like two or three beds away from being the largest mental health care provider inpatient side in the state. I think one of the Cherokee may have like two beds more than us, you know, so some of those big institutions that exist in the past are gone. You know, the movie One Flew Over the Cuckoo's Nest, which that was not an inspirational movie from that standpoint because they stigmatize mental health and mental health hospitals. Which when you see the homeless population in some of the bigger cities grow, you wonder how much of this is mental illness? And if we were just treating their mental illness, how that would be less. What advice do you have for the patient that might feel, I don't know how to phrase this, but sometimes I think patients confuse that they're having anxious symptoms but they're depressed, they don't have anxiety. How do you sort through that in your practice?
Dr. Kahler: That's a good question. And I think sometimes anxiety can cause depression or vice versa. So sometimes we see both of them together. The good thing is that they're both treated in about the same way. We treat them both with SSRIs. We also do a couple of different screening questionnaires with patients pretty frequently. So all patients that come into our clinic once a year, they have a screening questionnaire called the PHQ-2. So that's a screening for depression. And it asks, the two questions are: over the last two weeks, have you felt depressed, down or hopeless? And the second question is: over the last two weeks, have you had little interest or pleasure in things that you normally would enjoy? So everybody gets that who walks into our clinic, which I think is also good for stigma. If people answer those questions, they know that it's a safe place to talk about these things that if they answer positively, we do the longer questionnaire with them. So the longer questionnaire is called the PHQ-9 and it has more symptoms of depression. And there's also another questionnaire that I often will do if there's not a previous diagnosis called the GAD-7. Which is seven questions more about anxiety symptoms. So often it's interesting to do both of those and look at those scores side-by-side. I would say often people have some symptoms of both and maybe don't realize.
Dr. Arnold: The classic one that I've seen, usually friends cause we're getting to this age, is the 55 year old that worked out their whole career. They have a lot of high stress job, but they work out, they get 55 their knee gets replaced and now they don't play racketball anymore. And also they develop the symptoms of anxiety. And you know, I've reassured them. They're like, why is this happening to me now? Well, it was probably happening to your whole life. It's just you were treating it with exercise and the release of endorphins and you know, and now that's changed. And that can be happening and it can be frustrating. I think patients feel, why is this happening to me now? You know and they start off with that stigma as well, what did I do? How did this happen? Well, nothing happened. You know? It's okay to have a mental illness.
Dr. Kahler: And I reassure patients all the time, you know, this is not something you've caused. This is not something you've done. You know, some of it is situational and stressors and some of it is genetic. And some of it's a chemical imbalance in your brain. There's so many different things that can cause this, it doesn't mean there's anything wrong with you. It just means we need to get you feeling better.
Dr. Arnold: I think I would fail that questionnaire for about the five days after every time Notre Dame loses a football game.
Dr. Kahler: (Laughing) So at least it's just five days and not most over the last two weeks.
Dr. Arnold: I haven't reached the threshold for medication yet. Right? Okay. That's good. So do you always recommend counseling with the medication? Do they go hand in hand? Or sometimes do you say do the medication and follow ups with you can treat this and we don't need a counselor?
Dr. Kahler: I almost always recommend counseling along with medication. And some people are very open to that and some not, in which case, you know, we'll start medication and follow up and see how things are going. And I think there's kind of that stigma with counseling too. Like, you know I don't need to see a counselor. I don't need to talk about it. But our brains are so complex in how we process things and our self talk. We know that counseling helps and we know that medication helps and we know that both together is more help than one or the other by themselves.
Dr. Arnold: I know people have this question. Let's say you have a family member that dies and obviously there's a grieving process there. At what point would a patient or a person say this is pathologic? It's gone. How would someone differentiate that?
Dr. Kahler: It can be tough. I mean we always kind of give them the short term to grieve. I mean functioning in daily life is not going to be the same. But I would say if that persists, like especially if they're not going to work or not doing things that they would normally do on a daily basis then that's when we really need to look at other treatment and maybe it's starting to get in the way.
Dr. Arnold: Is there a time in there? If I recall it's less than six months, it's not something you need to intervene on. But then I've always thought, well, why do we want this patient to suffer for six months? Let's treat it now.
Dr. Kahler: Yeah, there's not a specific time frame that I usually kind of go by. It's really just how they're functioning.
Dr. Arnold: What about postpartum depression? Do you see a lot of that?
Dr. Kahler: We do and I mean, I think we're seeing more of that too because we're asking about it and because we're kind of looking for it. But yeah, we know that that's pretty common also. And you know I don't deliver babies, but I do see the babies in follow-ups. So we always take time to ask mom how she's doing. And follow up on that too.
Dr. Arnold: I think that's a condition that's overlooked or explained away perhaps, might be the way they handle that. So we talked about counseling. Where do I go for counseling? You don't see billboards with counseling advertisements. So tell us what services you use or resources you use for that.
Dr. Kahler: Yeah, so there's lots of different resources. We now have a counselor in our office three full days a week. And I know a lot of the UnityPoint Clinics have somebody there at least part time. So I think that makes it really easy for patients. They're already comfortable coming in our office. They can schedule with her just like they would schedule with me, you know, with our same schedulers. So there's not kind of that you have to make a different call or go to a different place. So that's been a really great asset for us. We also are associated with Abbe Center, so they have walk-in hours where you can speak with the nurse triage and get set up with a counselor there.
Dr. Arnold: The counseling, how often is that?
Dr. Kahler: So it really depends. I mean, some people it's once a week at least, kind of acutely. Some people it's once a month. So it really varies on what services were needed.
Dr. Arnold: Do you make that referral? Like I would make to physical therapy to say, see and treat, you know, see the patient, develop a treatment plan.
Dr. Kahler: No usually, you don't need a referral from us for counseling. So we would give them the phone number or the hours to stop in at the Abbe Center. But then they're kind of on their own to make that. If I do see a patient in my clinic and we're getting them set up with our counselor, I can put on their checkout to schedule an appointment with her, which is pretty handy.
Dr. Arnold: When we started, we talked about mental health advocacy and the Make It OK campaign to reduce that stigma is coming up. I know you mentioned that you're on the leadership panel for that. Can you talk a little bit about the Make It OK campaign?
Dr. Kahler: Yeah. So it's just about mental health awareness and just making it okay to talk about it and to get it treated and so you can be your best and you can feel the best that you can feel. I've also noticed just recently, maybe it's because I'm on this committee and so I'm a little more aware, I've seen posters up in my kids' schools and just community wide and not necessarily about this campaign, but about mental health resources that are out there. So, I think we're getting better as a community and as providers of talking about it and making it okay. So this campaign will well hopefully just kind of progress that.
Dr. Arnold: Yeah, I think directionally we are, and the one I always go back to, and you've probably had some of these patients that, you know, in the 1950s you didn't talk about someone having cancer. You know, there was like we can't talk about that. And that's gone away. I mean that just blows my mind that at one time you would not talk about something like that. Just like socially taboo to discuss cancer. But now we have all sorts of visibility to cancer and the treatments and the progress we're making. So maybe someday we can hopefully feel that mental health will be the same.
Dr. Kahler: I agree. I read a good story. It was after Kate Spade committed suicide a couple of years ago. I just read an article about how we have celebrities who have Parkinson's disease or pancreatic cancers and they're kind of the big cheerleaders and advocates for these conditions. But yet celebrities are not saying, hey I struggle with depression, or hey I struggle with anxiety and let's make it okay. So hopefully within the next few years we start to see that too.
Dr. Arnold: Well for physicians which that's a different animal. And I admit that ahead of time, you know, there's questionnaires, that's do you have a mental illness that would impair you from practicing or have you ever been treated for a mental illness? So right away it's like you wonder about the trepidation to get assistance when you might have to fill out a questionnaire, be asked that in the future and who knows how that'll be interpreted, the yes.
Dr. Kahler: I think people just in general might be worried, you know what if my insurance is going to see this, you know, what if that diagnosis is on there too. So hopefully those are all barriers that we can overcome.
Dr. Arnold: Well, at one time, nicotine dependence was considered a mental health issue by some insurance carriers and people complained and it was taken out of the mental health realm. So if you didn't have mental health benefits, then they wouldn't cover nicotine treatment and errors, curtailment and cessation. And then so the people were complaining because they didn't want the stigma, mental health. And I was like, well we just facilitated that stigma by moving it away from that. You know it is a mental health. You're addicted to it. But instead it was like, okay, well we'll move it out of that. And so I think right there was an opportunity for medicine and healthcare in general to have held our ground and said, no, we're not going to move it. And there's nothing wrong with having a mental illness.
Dr. Kahler: Right. This is okay, let's just treat it.
Dr. Arnold: Really great information today. Thanks so much for taking the time to talk about this. Again that was Dr. Melissa Kahler from UnityPoint Clinic Family Medicine - Westdale. If you have a topic you'd like to suggest for our talk on podcast, shoot us an email at firstname.lastname@example.org. Let me encourage you, tell your family, friends, neighbors, strangers about our podcast. Until next time, be well.