2026-01-30--t09-26-40pm--696a9a9c73207785e83335fe--matthew-stack

The conversation involves technical issues with audio equipment and a discussion on treatment-resistant depression. They mention using neurofeedback and transcranial magnetic stimulation for depression, highlighting the importance of ruling out physical conditions like hypothyroidism and substance use disorders. Personal anecdotes about patients experiencing neurological changes and delirium are shared, emphasizing the complexity of mental health issues. Challenges accessing treatment, such as lack of transportation, are also mentioned. Even before you say go, I mean, it still is, yeah, all right. You know, for me, a lot of it is, you know, I sort of have in my mind differentials, and, you know, I kind of try to screen for those through history, just by taking a good history. And so, well, let me ask you this, Adam, I mean, are you able to hear me okay? Because my, I don't know, I can't tell if, you know, how there's the line, my gain looks real small, but I don't know if I need to do anything about that. I mean, I've turned my gain, yeah, I've turned my gain up on my microphone here, my gain is decent. But I don't, well, and I mean, there's like, what I observe is there's a difference, quite a difference in the amplitude of your voice, the little lines and the amplitude of my voice. I don't know if that makes any difference. But louder than, right, exactly. Yeah, so I guess I'll just turn my gain up a little bit. Let me see if I need to do anything different back here. Actually, I got to, I dropped my glasses, just a second. Yeah, that would be my luck. Here's the gain. So, let me just turn that up a little bit. Yes. Yeah, he did, and I am hearing you through my speakers, and I don't have his headphones. And I'm trying to think if I have any here. You want to give me like two minutes and I'll look? Okay, let me just look real quick. So, so, so, so, yeah, actually I found some. My little closet is not very big here. Yeah, make sure it's, yes, yep, I'll double check on that. Okay, let's see here. Yeah, yep, and I'm hearing you through the earphones. But let me make sure I'm still on the Yeti mic. Okay, yeah, I'll see what mic I'm on here. Yep, that's, yeah, that's not the right one. I'll change it here. So, I just, I just put it back on the Yeti, which is my main microphone. All right, so hopefully that'll help. Can you hear me okay? Oops, I just, I think I just lost you. So, I gotta, in taking you off the microphone, I think I might have taken you off the audio too. So, let me, so, microphone is Yeti, speakers is Logitech headset. Okay, microphone should be Yeti and then the speakers are the Logitech headset. I can't hear them. Well, hopefully, hopefully we're getting it figured out. Right, well, you, you're, you, you made a good, I saw your checklist. I thought that was a nice checklist. You put, you posted, no, you posted it, you know, you posted it on the Google Drive. It was a nice, it was a nice checklist of all the stuff we need to do for each session, which, yeah, we'll need to revive it. I thought it was a good checklist. Yeah. Yeah. Yep. Yep. Yeah, I did want to ask you too, Adam, I mean, before I respond to that, I also thought it would be relevant for us to talk today about treatment-resistant depression a little bit. Is that okay if we talk about that too? And like, what do you do when you have somebody who you've already tried the SSRIs with and they're not responding? Okay. Okay. Sure. Well, and I, the only reason I thought of that is because I guess I don't, I don't think I have enough in terms of the issue of like differentials to do like 20 minutes or however long we want to do it. I mean, you might, you might, you might have, I mean, it sounds like you've done your research and, you know, have some good material. I just don't have 20 minutes on differentials. Yes. Sure. Yeah, absolutely. Okay. Yes. Okay. If I did, I don't, if I did, I don't remember it. Okay. Okay. All right. Yes. Uh-huh. Uh-huh. Uh-huh. Uh-huh. Uh-huh. One more. Uh-huh. Right. Uh-huh. Uh-huh. Uh-huh. Well, yeah, and there's no, yeah, yeah, I was just going to say like, unlike diabetes, I mean, with diabetes, you know, you can do an A1C, right, you know, or a fasting glucose. There's really no lab test for depression, so it's not, it's not straightforward like that in terms of being able to do a lab test and say, oh, yeah, they have depression. Yeah. Yeah, the only, the only thing that I know of is, it really has to do more with the frontal lobe and the balance between the left frontal lobe and the right frontal area, premotor, premotor cortex. And there's like an asynchrony between the left premotor cortex and the right, usually with their left being more depressed and the right being more, having, having higher waves. So higher waves would be like the high beta waves, and the lower waves would be like theta waves, and so there would be like an imbalance between those. And actually, interestingly, when they do transcranial magnetic stimulation, oftentimes it's on the left prefrontal cortex. The large magnets are usually put here on the left prefrontal cortex to stimulate that part of the brain. Yep. Yep. And so that, that would be the main neurofeedback or EEG. And I'm not, I'll be honest, I'm not an expert at using neurofeedback for depression. You know, with PTSD, which I have used it for, we tend to focus more on the posterior brain, like the parietal lobes. And so we tend not to do as much in the, in the prefrontal cortex. So I do more of my work in the parietal, kind of backward, the, no, I mean, there's a little, there's some literature on that. And, and it's, it's more, I mean, sort of what it's more recognized for is ADHD and PTSD. And, and I mean, actually, there's some evidence that it has helped with seizures as well. I mean, they've actually, that's kind of, that's kind of one of the early findings that they realized neurofeedback is helpful is they actually could help people with seizures. Yeah. Yeah. Yeah. But I mean, in terms of kind of, if you want to think about, like, neuromodulation, I think we would think more about transcranial magnetic stimulation rather than the neurofeedback for depression. Yeah. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. Right. Yes. I think those are good. Those are good questions. Yeah. Mm-hmm. Mm-hmm. Right. Yeah. I think in my, I think that, you know, what you've mentioned so far is excellent. I, I tend to like have a mental list, I guess, in the back of my mind that I sort of think through as I'm seeing patients. And then I ask questions in my, you know, review of systems and history to kind of rule some of these things out. And so, you know, you mentioned the TSH, so I almost always, you know, want to make sure that they're not hypothyroid. I think I'm, I remember one time we saw a lady on the psychiatric hospital who was brought in by ambulance, and she actually looked like she had a stroke. I mean, she had been on the couch for three days. She had been, you know, soiling herself, lethargic, unresponsive. And she looked like she had a stroke, but actually it was, she was in a myxedema coma. She was so profoundly hypothyroid, you know. And so, of course, you know, she, that's what she got was a thyroid replacement, you know. And she got, started to help her. But I think it was months. I think it was months. Yeah. And, and, you know, I mean, right, right. Yeah, that's right. Yeah. I mean, it was months. And I think, I think it was one of those situations where she didn't have much family involvement. There wasn't a lot of people checking in on her and, you know, social, not a lot of social support. You know, somebody caring to recognize, you know, what's going on. I guess another that's in the back of my mind so often is, you know, just substance use disorders. And you kind of alluded to that as well, especially, you know, alcoholism, alcohol use disorder. You know, I mean, alcohol is a depressant in the brain. And so that's in the differential for me, you know, neurological conditions, other neurological conditions. You know, one thing I observed is that my father, to my knowledge, had never been depressed in his life, as far as I know. And then he had a stroke. And then he developed depression. You know, and so is, you know, is there something neurologically going on like early dementia, that's those neurological changes in the brain are, I mean, not not I mean, it's, I think it's a combination of what neurologically is happening in the brain, but also the psychosocial impact of the disease can also contribute to depression as well. Yep. Yes. Wow. Yeah. Wow. Yeah. Yes. Okay. Yep. Well, and just for our listeners who may not be as familiar, you know, the TMS being the transcranial magnetic stimulation. Yep, yep. Yes. Yes. Yes. Yes. Yes. Yeah, I had a lady that, you know, I had, I mean, she'd been on SNRIs, I had augmented with bupropion, I had augmented with a little bit of atypicals, I don't know, in fact, you know, nothing was helping. So I referred her to transcranial magnetic stimulation, but it was 40 minutes away was the closest place. And, you know, she didn't have good transportation, and she didn't have anybody to take her five days a week. You know, and so she ended up not not being able to do it. Yeah. Yep. Yes. Right. Right. Yes. Yes. Yeah, that's for sure. Yeah. Mm hmm. Mm hmm. Yes. Yes. Well, and I actually had a similar experience with my mother-in-law. I mean, she was always a very sharp woman. I mean, you know, she played Jeopardy and beat most people, you know, answering the Jeopardy questions. But she ended up going and she had aortic stenosis and passed out. So she went in for the valve replacement surgery for aortic stenosis. And when she came out of that, she was different. And they did MRIs on her at first, and they didn't notice anything. But the way that she acted, she looked like she had a frontal lobe stroke. Because like, she was very disinhibited and, you know, difficulty with initiation, and she was repetitive and all kind of frontal lobe type things. But anyways, she went into a delirium. And I always thought of delirium as something that was, you know, days, but she was in a delirium for months. She was like six months. You know, and sometimes she was hallucinating and agitated. But like you said, sometimes she was lethargic. And, you know, looked like she was depressed. But it was all this ongoing, difficult delirium. Yes. Yep. Yes. Yep. Yep. I guess the other things that I think about, you know, I think about anxiety disorders, because there's such a interplay between anxiety disorders and depression. So often people that are depressed are more anxious, and people that are chronically anxious, can become depressed, as well. So I think about anxiety disorders. And certainly, I have people with PTSD that, you know, have depressive symptoms, or people with OCD, obsessive compulsive disorder, that are so paralyzed with their OCD, that they end up having depression symptoms. But really, it's the primary issue is the OCD. Unfortunately, Prozac can help with both. Right. Yeah, that might be part of it. Yeah. You know, just the frustration of that. I think that's part of it. Yeah. Yes. Yep. I think probably another thing that I think about is, you know, and this becomes especially important when we start thinking about antidepressant therapy is, of course, really not bipolar. Are they in a depressed phase of bipolar disorder? And you want to obviously, you want to make sure you know that when you start in antidepressant therapy, because you could make a manic, you know, you're gonna Yeah, so you want to, you know, make sure they're on a mood stabilizer first, you know, before you start the antidepressant. Okay. Yep. Yes. Yes. Yes. Right. Mm hmm. Yep. Yeah. Well, the only the only other one that I think about is is really what I would call family system dysfunction. I mean, there are there are, you know, family systems that are that are so painful for people to be in that, like you were saying that learned helplessness, you know. And I remember, for example, a woman that I originally started seeing her for vaginal yeast infections. And then that led to realizing that she had diabetes. So we started to treat her diabetes. And then, you know, she was chronically kind of down and blue. And so we started to treat her for depression. But it turned out as I got to know her and she got to trust me and everything that she was in a domestic violence relationship. And very, very controlling, angry husband. And it was it was interesting because, you know, she I had her on antidepressants and then she started to feel better and she started to go to counseling and she started to, you know, speak up and eventually realized she didn't want to live with this man anymore. And when she was less depressed, and she ended up separating herself and when she was less depressed and she ended up separating from him. And then for about six months after that, I got phone calls about once a month from this guy to my office, mad at me because I yeah, because I gave him I gave him this pill. I gave his wife this pill that that made her like this, you know, so you said that Prozac that you gave my wife is causing all this problem. You know, so Prozac was the problem. Anyways, but you know that. Okay. Well, I mean, part of it, I think just, you know, providing that good care like we like we've talked about in previous broadcasts, I built that relationship with her. And as a primary care provider and treated her medical conditions well, and it helped her well with her other medical conditions. And so I think we had built that trust that and I had known her for some time. And then I started to hear stories about her husband calling her at work and coming to her work and being outside her work waiting for her, you know, in kind of a sounded like a threatening way or intimidating way. And I mean, these stories started to come out. And that's, yeah, I mean, obviously, that was began to make me realize there was more going on. So, yeah, I think it was just mostly the fact that we had built that relationship and she trusted me. Yeah. Yeah. Yeah. Mm hmm. Yes. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Yes. Yeah, for sure. And I think medication should pretty much always be on the differential, you know, medication side effects for most, most conditions. Mm hmm. Yes. Yeah. Yeah. Well, I've had, I've had, I mean, I've had, you know, several people come in on Topamax complaining of mental fog, you know, lack of mental sharpness. And, you know, we've, oftentimes, it was, you know, my being used for migraines, and they've gone, you know, tapered down and stopped it. And it really, their mental fog cleared up. I mean, so it did seem like that was contributing to it. Yeah. Yep. Right. Mm hmm. Mm hmm. Well, I mean, you know, primarily, you'd be looking for hypothyroidism, you know, so a low, a low T4 and an elevated TSH. You know, the pituitary is trying to crack the whip on the thyroid gland to get working, you know. Yeah. Mm hmm. Yes. Yep. Yes. Right. Yeah. Right. Right. Well, and especially if there's, if there's something that might affect the absorption as well, you know, of the B12. Yeah, so. Mm hmm. Mm hmm. Not really. I have not found, I have not found it, I guess I would say, to be real high yield in terms of diagnosing depression. I mean, a lot of times I will, I will get, I will get labs. I mean, I pretty much always get thyroid. And frankly, a lot of my colleagues that I worked with, the psychiatric AAPs, a lot of people get vitamin D. And I don't know if that's because it makes a lot of difference or just because it's a real easy thing to say, oh, you got this problem, here's, here's something to help, you know, and give 50,000 units, international units of ergo calciferol once a week, you know, that it's easy to, you know, feel like you're doing something. But I actually have had some people, I've had some people come back and say, well, I feel better with, you know, that vitamin D tablet. So, right. Yeah. Well, and almost everybody in Michigan, you know, we're in Michigan, again, of course, and almost everybody I test is vitamin D deficient in Michigan. But I mean, mostly the labs that I do, I get in part because I'm anticipating treatment, and I want to know what renal function is, I want to know what liver function is, because it may guide my treatment decisions a little bit. And so, like, for example, if I end up thinking I might have to give like an atypical as an augmentation, I want to know what their lipids and their blood sugar are. For example, yeah. Or if I'm, if I'm, you know, if I'm worried that I might end up having to give a person lithium, you know, because they've been on so many antidepressants already, and they haven't helped much, or I worry a little bit about, you know, bipolar for them or suicidality. I want to know what their thyroid is in their renal function, because of thinking about starting them on lithium. So, it really guides my therapy decisions as much as it, I'm looking at it from a diagnostic standpoint. Yeah. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Yes. And I mean, I think that's really important, because if you just think about it, from a practical standpoint, what does it mean to our brain to have our oxygen level drop, you know, into the 80s 100 times a night? You know, I mean, how does that affect, you know, our cognitive functioning? And so, I mean, sleep apnea is really an important differential, I think, to evaluate for. Yeah. Mm hmm. Okay. Wow. Yes, yes. Well, now, Adam, though, you got me curious. So, I need to know more about why did your wife find sleep apnea to be attractive? Oh, okay. Okay. Okay. I gotcha. Yeah. Oh, actually, yeah, absolutely. Absolutely. Because, I mean, I have a, I have a, I, oh, I think she's 12. I have a 12-year-old girl that has sleep apnea, or had sleep apnea, and it was from her tonsils, adenoids, and, you know, a lot of times, people can have a, well, actually, she, no, she's someone that I'm seeing for ADHD, and her mom did, her mom did not want to do psychostimulants, and so we're, we're doing neurofeedback for the ADHD. Yeah. Yeah. Yeah. Yes, it was. And, you know, there's, again, you know, probably a correlation between sleep apnea and ADHD in terms of how can your brain function in terms of paying attention in school in the morning if you, your oxygen went down to 80 multiple times during the night, you know. Yes. Yes. Yes. Yes. No. Well, I mean, I, I think that's good to keep in mind. I mean, I, I just saw a lady the other day, a young, young woman, you know, and probably has PTSD, probably bipolar, and, you know, I was trying to help her with those, but she had this chronic pain all the time, and so I was going to do some labs anyways, so I, you know, I threw in, you know, rheumatoid factor and ANA and, you know, a few other, you know, rheumatological tests, ANA, CRP, you know, all those, and anyway, she came back positive for rheumatoid arthritis, you know, and, of course, you know, she's seen her primary, or, you know, saw her primary care doctor, and then they referred her to rheumatology, but, so I don't know, I mean, I don't know if there is a correlation. I mean, if it's just, she just happens to have both, you know, mood disorders and this rheumatological condition, or if maybe they're correlated with each other for her. Yeah. Mm-hmm. Mm-hmm. Mm-hmm. Yeah. Well, I think I would still probably, I mean, base that still more on both history and other symptoms, like you were mentioning, you know. I mean, do they have a history that might be suggestive of exposure, you know, to ticks, for example? And, you know, do they have the myalgias, the arthralgias that you might expect with, like, a Lyme disease? You know, yeah, those other symptoms. I don't think I would order anything like, you know, testing for that without those other factors being in place. Yep. Yep. Yep. Yep. Yep. No, I think that was good. No, I mean, my computer says 57 minutes. So, I mean, I think that's, and I know some of that was organizational. Get my headphones and stuff like that. But I think this is a good topic. And I don't know that we necessarily need to do the other stuff now. I mean, I think you're right that that could be its own topic. You know, what do we do you know, what do we do when the primary care providers tried an SSRI? They've a couple SSRIs and the person's not responding, you know, what do we do then? That could be its own topic. So, yeah, sure. Yeah. In my, what I have seen is that primary care providers vary in their comfort and their confidence about their own ability in that regard. And I've seen, I know some primary care doctors that are superb with, you know, antidepressants and depressant treatment. And so, like, I've seen some doctors, you know, they try a couple SSRIs, they don't work, they switch them to an SNRI. They're comfortable with that. I've seen primary care doctors augment with Welbutrin. I've seen primary care doctors augment with Mirtazapine and feel fairly comfortable with that. And I've seen some primary care doctors augment even with the atypicals, like a little bit of Abilify and have some comfort with that. There's other doctors that, you know, won't touch that with a 10-foot pole. And if they try Prozac and Prozac doesn't work, they send them to psychiatry, you know. Or maybe Prozac and Lexapro and then it doesn't work. So, okay, you're going to go see the psychiatrist, you know. So, I think that just varies with the – yeah. I think that's very true because, I mean, actually, good point. When I think about it, the ones that I know that would do Prozac and then Refer are, you know, folks that lived in areas that had large psychiatry practices, you know. And, I mean, I think I've shared that, you know, my first five years were on the Navajo Indian Reservation and, you know, there wasn't a psychiatrist for 90 miles, you know. And so, our doctors had to figure out what to do. You know, our family practice doctors prescribed lithium, you know. Yep. Yep. Right. Well, and like I shared before, I mean, I think it's okay for primary care doctors to be as confident and as competent in managing psychiatric conditions as they would want to be like other disorders. So, they want to be confident in managing diabetes. They want to be confident and competent in managing high blood pressure. You don't – they're not sending every person with diabetes to the endocrinologist, you know. And they're going to start Metformin and they're going to start, you know, GLP-1 and they're going to start Atlantis and they're going to, you know, do these different things. And then, you know, if they still can't get them under control, they'll send them to the endocrinologist. But that's not going to be their initial knee jerk reaction is give them – yeah. Yes. Sure. Yeah. Well, I mean, I think it's important – I mean, you know, so some of the things I was thinking about with that topic, I think primary care providers need to be reminded of, you know, what is a treatment – an adequate trial of something. And an adequate trial isn't, you know, two weeks. Oh, this Prozac isn't working. It's been two weeks, so we'll stop it and switch them to something else, right? No. And the idea that, you know, if – when you first see them back, what you're checking for is to make sure they're not suicidal and they're not having bad side effects. And if they're not suicidal and they're not having bad side effects, then you go up on the medicine. And an adequate trial is higher doses for six to eight weeks. And I get lots of people that they've been on multiple antidepressants, and I'm not sure that they had really good trials of them. Yeah. So, I mean, that's a topic that I think is relevant. I think it's relevant to talk about the fact that, you know, there's probably going to be 30 or 40 percent of people that don't respond initially to the antidepressants that you give them. And so the whole idea of sometimes you need to augment, you know, and how do you augment safely? And I think that's good. Okay. Yeah. Yes. Right, right. No, I think that's good. And I know the psychiatrist that I work with in Flint, you know, if he has somebody that he's tried a number of things on and they don't seem to be getting better, that's one of the things that he does is he kind of doubles down on getting a better history and he also starts to think about, you know, inflammatory conditions. And he usually orders an inflammatory screen for those people. Yeah. Yes. Yeah. Well, so, I mean, I think talking about, you know, some things that, I mean, I think primary care providers could, in my opinion, you know, like if they have somebody on Lexapro and the person's not adequately responding and the person's a smoker, I mean, I think it's within the scope of practice for them to add a little bit of Welbutrin, you know, or, you know, I like, like with older people that aren't eating very much, I mean, I like to give a little bit of mirtazapine if they're having insomnia. I think that's within the scope of practice of primary care doctors to augment in that way. Yeah. Yeah. Yeah. Yeah. Yeah. And so, I mean, that's kind of how I augment is I augment by tailoring to, is there some other use of this augmenting medicine? You know, so they're a smoker and they have a little ADHD, so I'll augment with Welbutrin, or they're older and not sleeping and not eating, so I give mirtazapine or they're, I had one guy that, you know, he was, you know, he couldn't believe it. I think he was kind of skeptical, but he was on Paxil and Welbutrin from somebody else. And I said, well, let's just give you a little tiny bit of Abilify. Oh my gosh, he came back like the next week and just could not believe it how much better he said. I said, he felt better almost within just a couple days he started to feel better with Abilify, you know. Yeah. Yes, they do. Yes, they do. Yeah. Yeah. So. Yes. Well, and I probably also, I probably would also want to just, you know, and obviously primary care doctors aren't going to be doing this, but just mention, you know, the idea that you can augment, I mean, refer for augmenting with the neuromodulations or the transcranial magnetic stimulation to have that be on their radar. You can augment with, I mean, ketamine, you know, is for some people, that's a different pathway that helps. And then for people that you just can't find help with any other way, I mean, ECT is highly effective. And so, you know, keeping in mind when does this person need to be referred for ECT? So, yeah. Yeah. Wow. Yes. Right. Yeah. Prior to the, yeah. Wow. Yes. Yep. Yep.