Episode notes:



This episode is sponsored by the Iodine's smart app START. For a free download go to www.iodine.com/mentalpod

Check out Dr. Watkins new blog/podcast Your Mental Health First

Episode Transcript:



Paul G: Welcome to Episode 240 with my guest, Dr. Melanie Watkins. I’m Paul Gilmartin. This is the Mental Illness Happy Hour, a place for honesty about all the battles in our heads from medically-diagnosed conditions, past traumas and sexual dysfunction to everyday compulsive negative thinking.

This show is not meant to be a substitute for a professional mental counseling. It’s not a doctor’s office. I’m not a therapist. It’s more like a waiting room that doesn’t suck, and the website for this show is mentalpod.com, all kinds of stuff there. You can check out the forum. You can fill out surveys to help us get to know you. Maybe your survey will get read on the air.

You can support the show financially through the website. You can re-blog, guest blogs, buy coffee mugs and tee-shirts, all kinds of different things.

What else I want to tell you? Oh, I wanted to remind you about the two upcoming live events that I have. One is in Los Angeles on Saturday, September 19th, and that’s at LA Podfest, and I’m going to be recording comedienne Jackie Kashian, and if you can’t make it to the Podfest, you can still pay and watch the interview live and watch a video stream of it, and it will be available too for up to a month afterwards. You can get $5 off if you go to lapodfest.com and use the offer code MENTAL and that will get you $5 off, so they’ll take it from $25 to $20, and there is a ton of other great podcasts that you can watch for that $20, WTF With Marc Maron, Paul F. Tomkins’ new podcast, Walking The Room, they’re getting together for an episode, Never Not Funny with Jimmy Pardo, The Dork Forest with Jackie Kashian, and the list goes on and on, so that’s the LA event.

The Brooklyn one is Sunday, September 27th, at 7 p.m. My guest is writer/performer Lane Moore who’s very funny. She’s written for The Onion, and she sings in a band and has a pretty crazy story, and she’s a workaholic. I’m really looking forward to having somebody talk about workaholism, and the tickets for that, it’s at The Bell House, and the tickets for that, you can go to thebellhouseny.com, and the tickets are $20 at the door or $15 in advance. I really hope to see you guys out there with both of them.

Is there something else I wanted to share with you, guys? I had two just angering hockey experiences this week. The first one happened on Sunday night. I play pick-up hockey on Sunday nights, which means it’s not a league, it’s just a group of guys who get together, you split it and often decides one side wears dark jerseys, the other wears light jerseys and you have fun. It’s usually pretty low key, but there is this guy that’s been playing there lately who’s a really good hockey player, but just has anger issues, and he’s just this mean shit to people and slams his stick against the boards a lot, and he’s made a couple of snide comments towards me when I’ve picked his pocket and stolen the puck from him. But that didn’t bother me so much, but what bothered me on Sunday as we’re walking out to our car and I think he had had a frustrating night at playing hockey, and he looks at me getting in my car and he goes, “Pfft, pretty ass.” 00:04:00 And I go, “Well, you know, I’d get the last laugh when I’m filling up at the gas station.” And he goes, “Yeah, and it hurts America.”

And his kid was with him. He and his kid get in his truck that looked like it was something out of the movie Transformers. That thing couldn’t have gotten more than a mile per gallon, and with his kid in the cab of the truck lays rubber, a 35-year-old man with his child laying rubber. Oh my God.

And he had a story, but that’s not even worth telling, but one of my teams played for a championship on Tuesday night and we lost in overtime, but I didn’t want to go play this team because there are a couple of guys on there that they’re dangerous, those are super emotionally unstable. Between the two of them, they probably have been kicked out 35 times from games like forced off the ice, like you have to leave and then they’re suspended.

I don’t know why they keep getting allowed to come back, but I keep voicing a complaint saying, “They’re going to seriously hurt somebody,” and one of the guys did just fucked my neck up. There are a lot of times when you’re playing hockey where you’ll pass the puck or you’ll take the shot, and for a second afterwards, you’re bent over and you’re totally vulnerable. Your neck is exposed, you’re in an awkward position, and sure enough, this guy just took a run at me while I was bent over after making a pass and just my neck went crunch, crunch, crunch, and my neck hurt for like three fucking days, but who knows, if he would have hit me harder, it might have paralyzed me. I don’t know, but why…

I shouldn’t ask why because I’ve been that guy before. I haven’t tried… yes, I have tried to hurt people, that’s that. I’ve never tried to certainly to paralyze somebody, but I have tried to. I don’t hit guys when they’re in vulnerable positions. I think that’s what really pissed me off. If you’re going to hit me, do it face to face. Give us both an equal chance to hit other. I think that’s what made me so fucking angry, and then the fact that we lost and the fact that it bothered me that we lost. It bothers me. Oh God, I need to double up on therapy.

Let’s read a couple of surveys. Do I talk too much about hockey, on this? This is from the Struggle in the Sense survey. This was filled out by Daniel and it’s about his ADHD. He writes today, “I’m going to focus on the professor’s lecture when movies out there are similar to Blade Runner. Class is over already?” That one made me laugh.

About his OCD, “Driving down the road and I realized my tongue is sore because for the hour and a half I’ve been driving, I’ve been ‘jumping’ the patches and shadows on the road with my tongue.”

Snapshot from his life, “I’m lying in bed thinking there will be a home invasion. I have cancer or I am going to die in my sleep. I then realized that I haven’t checked the door lock in about 15 minutes. I get up to check the already locked door, but I’m not convinced it is properly locked. I unlocked the door and locked it again and then checked to make sure it is fully in the lock position five times. I then returned to bed. Once I get there, I get up again and repeat the process. This lasted for about an hour. At least now the worry about the home invasion is gone and I’m just left with the fear of cancer.”

This is the same survey filled out by Akara, and the snapshot from her, she lives with depression, anxiety, alcoholism and living with an abuser, and a snapshot from her life she writes, “Sitting in work at my desk working on another pointless spreadsheet when all of a sudden, it feels like an invisible dome has come down around me and is filling with water and I can’t breathe. But everyone continues talking and laughing around me, how can they not see that I’m drowning? Before I know what I’m doing, I grabbed my lighter out of my purse and ran to the bathroom, heat the lighter up and placed three quick small burns down my arm. I feel better for about two seconds before I realized I just did the very thing I promised myself I wouldn’t. Then I sit on the bathroom floor and cried for failing myself again before I remembered that I have to go back out to my desk and pretend to function like a normal human being. So I washed my face and wiped my eyes and go back to my desk. I laughed at everyone’s jokes and join in on the conversation all the while my arm is on fire under my sleeve reminding me just how much of a pathetic piece of shit I am.”

You are not a pathetic piece of shit. What you are is you are a sensitive person living in a world that has a lot of insensitivity, and that’s what you are experiencing. You are not a piece of shit. We are normal people reacting to an abnormal world.

This last one is by a woman who calls herself “Moe,” and she struggles with depression, and I really relate to this one so much, she writes, “Explaining to my friend that I had to cancel an invitation with them because I needed to manage my depression. My anxiety kicks in and I need to make sure they don’t feel bad so I cannot feel bad about trying to not feel bad.”

Voice over inserts:

“My God, somebody does what I’ve been doing.”

“You are ashamed.”

“You have boundary issues.”

“I feel guilty for hating my mom.”

“I will be high by 4 p.m.”

“You feel hopeless.”

“I will be in hell by 4:50.”

“Personally, it’s not easy, but I deserved it. I think I’m just addicted to lie.”

“I rub my body in mud and I lay in the swamp. I didn’t move for six hours.”

“I look forward to and dreaded each meal at the same time.”

“I think I desperately, desperately wanted to talk about it, but I didn’t really know how to start the conversation.”

“And that’s when I called the suicide hotline.”

“A good and great life experiences if you are alive at the end of it.”

“That is when I first felt love when I first felt…”

“Reaching out to the people and sharing with the other people.”

“This intimate connection where people do suffer each other without wanting something in return.”

“Yeah, I just… I surrender.”

“I think I was 28 and that was the first time I ever experienced that, and it was amazing.”

Paul G: I’m here with Dr. Melanie Watkins who is a board-certified psychiatrist out of the Bay Area, Walnut Creek specifically, right?

Dr. Watkins: Yes.

Paul G: And I put some questions out there to listeners, Twitter people, Facebook people, and I said, “I’m finally going to record a psychiatrist, and what are the questions that you’d like to ask her?” And I’m just going to go through them, and if I have any of my own, I’ll toss some in there, but I have the feeling they are going to… I’ll add enough of my own personal shit in here in between. What does she recommend when patients do not respond to a dozen different meds?

Dr. Watkins: Well, it depends if they’re also in therapy. So if they’re trying medication after medication and they haven’t had any therapy, then I usually refer patients a therapy because I think the medications can be very powerful and very effective, but if they aren’t having the regular therapy and a consistent relationship with someone who can help them do the inner work that needs to be done, all the medications in the world aren’t going to be very effective.

Paul G: And the other thing that I would imagine too is if there is an addiction that’s not being treated.

Dr. Watkins: Yes.

Paul G: My psychiatrist refused to treat me until I got sober.

Dr. Watkins: Yeah.

Paul G: And I am so grateful he did. He said, “I’m wasting your money if you’re going to continue drinking. The meds aren’t going to do anything if you’re drinking yourself into a stupor every night.”

Dr. Watkins: Yeah, that’s a very honest psychiatrist, and that’s true because many of the medications that we prescribe, if you add alcohol to the mix, alcohol is a CNS depressant, and so you’re going to be basically negating the effects of the antidepressants or other medications. So really treating the addiction first is a good call.

Paul G: Are you saying I’m a psychiatrist?

Dr. Watkins: [Laughs]

Paul G: That’s all I need. I’m printing up my diploma.

Dr. Watkins: Hey, after 13 years of training yourself.

Paul G: When did you get your board certification issued?

Dr. Watkins: Oh, yeah.

Paul G: Because you look very young.

Dr. Watkins: Oh, thank you. I’ll take that as a compliment. You know, it’s funny, but I used to get a little bit offended when people say, “Oh, you’re too young to be a psychiatrist,” but then as I get older, I said, “Hey, I want to hear that.” So I was board certified in 2009.

Paul G: Awesome. Can I give you more water?

Dr. Watkins: Yes, you did. Thank you.

Paul G: Okay.

Dr. Watkins: Thank you.

Paul G: I apologize if it’s a little warm in here. We might have visitors outside, so I’m keeping the door closed. I would like to know why they generally cannot show an ounce of empathy.

Dr. Watkins: Oh.

Paul G: I’m trusting that’s somebody that has had a bad experience with a psychiatrist.

Dr. Watkins: It sounds like it. You know you have the right to choose your psychiatrist, especially outpatients, so just because you started off with a particular psychiatrist doesn’t mean that you have to continue with him or her. Sometimes it’s not a good fit, but it doesn’t necessarily mean that the treatment isn’t appropriate. It’s just a matter of finding someone who you can really connect with.

So I know sometimes it can be difficult at county clinics or in certain settings to get a new psychiatrist, but you can always put in a request if it’s a group of psychiatrist there at the clinic or outpatient practice.

Paul G: I would imagine too when you’re in a county situation where the doctors are just swamped.

Dr. Watkins: Yes.

Paul G: There is compassion fatigue, and catch that doctor on another day as first patient of the day, maybe things will look different, but if you’re seeing them maybe at 4 o’clock, and I don’t know, what do you think/

Dr. Watkins: Yes, I agree. Psychiatrist have stressors too, and sometimes at busy county clinics, sometimes patients are double booked because they know that some patients are going to be no shows or show up late, and so the psychiatrists, we have our stressors too, we’re human, and I think you’re totally right that sometimes some days are better than others.

Paul G: “Bipolar personality disorder, and borderline personality disorder is notoriously complex to medicate, with lots of patch work, a bit of everything. Our personality disorder is not responsive to drugs.”

I think maybe answer that in two ways, first, about personality disorders in general and then about borderline personality disorder.

Dr. Watkins: Okay, so personality disorder, so we usually don’t make the diagnosis of a personality disorder until after a patient is 18 years old, and with patients with personality disorders can sometimes have a maladaptive way doing the world and sometimes themselves.

Usually for borderline personality disorder, we recommend a form of treatment called DBT (dialectical behavioral therapy), which was created by Marsha Linehan.

Paul G: Who herself has borderline personality.

Dr. Watkins: Yes.

Paul G: She didn’t come out with that until a couple of years ago.

Dr. Watkins: Yes, yes.

Paul G: Which I thought was awesome that she shared that.

Dr. Watkins: I’m really, really glad that she disclosed that too, and it can work wonders to have the individual therapy and the group therapy and talk about ways in which they can learn how to deal with crisis, learn how to self-soothe and so forth. We do sometimes use medication for personality disorders such as borderline personality disorder, but it’s more for the impulsivity and irritability and sometimes the depression that can go along with it. So sometimes we might use a little bit of Depakote or an SSRI completely off label, but sometimes we’ll do that to help the patient.

Paul G: And what do you mean when you say completely off label?

Dr. Watkins: So there’s no FDA-approved medication treatment for personality disorders, so what we do is sometimes target the symptoms. So if patients are having worsening depression and anxiety as a result of their personality disorder, sometimes we’ll treat that, or if they’re having irritability, impulsivity or self-harm behaviors, sometimes we see self-injurious behaviors with borderline personality disorders, so sometimes we’ll give medication to help target those behaviors, but really the therapy is very, very important in treating that disorder.

Paul G: Learning the tools to cope with expressing their emotions.

Dr. Watkins: Yes.

Paul G: Recognize that other people around them are maybe having a different experience than they are.

Dr. Watkins: Yes, yes. “I want these people to be close to me, but I keep pushing them away is what happens, and how do I deal with that?” You know?

Paul G: Yeah, yeah. I think you answered both of those. “What’s opinion regarding the claim that borderline is less a personality disorder and more a form of CPTSD? They do seem similar,” this person writes.

Dr. Watkins: Ha.

Paul G: Complex post-traumatic stress disorder, what is complex post-traumatic stress disorder?

Dr. Watkins: You know I’m not an expert in PTSD, so I know generally about post-traumatic stress disorder, and I can speak about that, but there could be some overlap, and that’s something to think about. Because many patients with borderline personality disorder do experience some trauma, and whether they have experienced that trauma directly or they perceive it as a trauma, the way in which they look at their past experiences impacts their current relationships now, and so that is interesting to think about the overlap with PTSD and borderline personality disorder.

Paul G: And correct me if I’m wrong, but the most common emotional injury to people with borderline personality disorder is some type of abandonment.

Dr. Watkins: Abandonment.

Paul G: Childhood abandonment.

Dr. Watkins: Yes, neglect, abandonment.

Paul G: And it doesn’t physically have to, and I’m talking to listeners now, it doesn’t have to be a physical abandonment, “We left you in this warehouse and we went away.” It could be you were sexually abused or you were told you were a piece of shit or something where you’re very being was negated.

Dr. Watkins: Yes, yes, exactly, and it can be doubly hard for these folks because they not only are experiencing that abandonment, but oftentimes other people aren’t really validating the abandonment that they’re experiencing, and so sometimes then too they’ll start acting out wanting that validation and support like, “Look at me, listen to me, I’m feeling this pain.” I mean, they may not be saying that, but that’s kind of what they’re wanting people to realize and then they act in ways that can be very uncomfortable for the people around them. So the very people that they want to love them and support them, they indirectly push away, and so this can be really difficult for them because they want that closeness and that security, but they sometimes, unfortunately, act in ways that can be off-putting to others, and so in therapy, we try to help patients with that.

Paul G: That seems like a vicious cycle for that person who’s suffering to get into because they become their own worst enemy and they don’t know it, and I guess that’s why DBT must be helpful is it not only helps them express themselves, but from what I understand, the loved ones of people with borderline personality disorder often learn DBT to help learn how to communicate with that person so they don’t feel panicked and abandoned a lot.

Dr. Watkins: Yes.

Paul G: Is that correct?

Dr. Watkins: Yes, yes. So when I have patients who have borderline personality disorder in my office, the first thing that I’m thinking is validation, validation, validation, and being very sincere in saying that, “I know you’re going through a difficult time.” Now, other people may not believe that it’s difficult. They may, from the outside, see it a certain way, but that person feels it so intensely, and so before even starting to talk about what we can do, I’m going to validate their experience of what they’ve been through first, and that helps establish the trust because they want, they really, really deep down want someone who validates what they’re experiencing.

Paul G: And what they want is so pure and so beautiful.

Dr. Watkins: Yes, yes.

Paul G: They want to be loved, they want to be seen. They want what we all want.

Dr. Watkins: We all want those things.

Paul G: They just want it so, so desperately, you know?

Dr. Watkins: Yes.

Paul G: I’ve learned so much about that disorder doing this show, and what’s interesting too is now I’ll see people out and about where I’m like, “Oh, I think that person has borderline personality disorder,” which is probably terrible of me as an armchair person kind of, and I would never say it to somebody, “Oh, you clearly have borderline personality disorder.”

Dr. Watkins: Oh no.

Paul G: But one of the TV shows I watch, it’s a reality show called Naked and Afraid. Have you ever seen?

Dr. Watkins: I’ve heard of it.

Paul G: Well, there’s a woman on that who I swear has to have borderline personality disorder because you could see her going through the motions of trying to win the love of the people on her team, and one of them in particular was just a dick to her and just negated her, and you could see the pain on her face.

Dr. Watkins: Yes.

Paul G: And then he negated her pain again.

Dr. Watkins: Oh.

Paul G: And then she went and she took their survival tools and she threw them in the river, and I was like, “That is somebody acting out.”

Dr. Watkins: Right.

Paul G: “Who reached out for love and acceptance and had their toes stepped on.”

Dr. Watkins: Yes, yes.

Paul G: And it broke my heart because I was like, “I can’t imagine how terrified she must feel right now.” And I can’t imagine how frustrated those guys must be that she just threw their fucking tools in the river.

Dr. Watkins: Yes, yes. So, Paul, you get it, you get it, and sometimes I have to talk with patients in my office who complain about a boss or an ex-wife or a coworker, “Why can’t I reason with this person? Why can’t I connect with them? What’s going on?” And the more and more they describe them, I start to think, “Oh, it sounds like that person has a personality disorder,” and so then I have to do a lot of education and talk with them about how best they can communicate with the person.

Paul G: Yeah.

Dr. Watkins: Yeah.

Paul G: What’s so funny how it always just all comes back to communication.

Dr. Watkins: Communication.

Paul G: And validating our feelings.

Dr. Watkins: [Agrees]

Paul G: How does someone know when it’s time to adjust meds, and two, what changes, good and bad, might be coming with Obamacare? And let’s do the first one first, how do you know when it’s time to change your meds? I’ve changed mine. I’ve probably taken 15 different SSRIs in the last twelve years.

Dr. Watkins: Oh, my goodness.

Paul G: Yeah.

Dr. Watkins: Yeah

Paul G: And even done some atypical ones. I just did Abilify and almost had to be hospitalized.

Dr. Watkins: Oh.

Paul G: It started out great. I think I might have been a little hypomania, and then it turned into nothing, but pure anxiety, insomnia and suicidal thoughts.

Dr. Watkins: Oh no.

Paul G: And I was only on 4 milligrams for a month.

Dr. Watkins: Oh.

Paul G: And then I weaned myself off of it over a two-week period, but those feelings stayed for probably a month or two months, and I am still now almost eight months later, not able to sleep like I used to be able to sleep.

Dr. Watkins: Oh.

Paul G: Have you heard of horror stories with Abilify?

Dr. Watkins: I haven’t heard of a story like that, but I tell everyone, all my patients, I tell them, “You know, I don’t know every possible experience that can happen with this. We’re going to call this a medication trial.” So I let them know that chances are we might have to try a couple of different medications in different combinations. Sometimes I really luck out and the first medication works great. But sometimes we do have to try some different combination.

So how do I make that decision? Well, first of all, if they’re starting a new medication and they really can’t tolerate it, usually in the first couple of days, there might be a little bit of nausea, dizziness and headache. The first few days tend to be the worst, particularly with an SSRI.

Paul G: Dry mouth.

Dr. Watkins: Dry mouth.

Paul G: Low libido.

Dr. Watkins: So if they can tolerate that and get through those initial days, then they tend it to do a little bit better and we can see how they do over time, but if it’s really intolerable, they’re vomiting every day, they really can’t tolerate it, then of course, we stop the medication and we talk about something else.

Now, if they’ve been on the medication for a while and it has worked really well for them, but it’s not working as well anymore, the most obvious thing for me as a psychiatrist is to increase the dosage a bit. So I’ll get folks who come to me from primary care docs and I’ll increase their Prozac from 20 to 40 and it’s like, “Oh, Dr. Watkins is so wonderful.” And it’s something that simple, okay?

Now, sometimes the patient has been on the max dosage of medication for a pretty long time, that’s when we might have to consider an adjunct, so something like a little low dose of Abilify, which I’m sorry, Paul, about your experience, but sometimes we’ll do that, a little augmentation. Sometimes we’ll add a little Lithium or a little bit of Wellbutrin, and sometimes a little thyroid augmentation too. So we can be creative and make some changes.

Sometimes it may not be the accurate diagnosis, so let’s say I’m treating someone for depression and they’re not tolerating the medication well and now they’re starting to have a little bit of case of hypomania or mania, then I have to switch them over to a mood stabilizer or something else.

So your psychiatrist really has many, many options for you, and we’re always thinking about what a patient can tolerate that’s going to be the most efficacious with the lowest risk of side effects, because we really want you to be in a regimen that you can be on for a while and be stable.

So it is hard each time to try to change a medication for patient and have to go through the whole discussion about risks and benefits and so forth. So I really, really try to think about, “Hmm, well, this patient is having difficulty with sleep and they having difficulty with anxiety and their appetite isn’t so good. Hmm, maybe I’ll try this medication versus that.” So I really try to hear their whole story before selecting a medication and try to target several different concerns at once with a medication.

Paul G: I’ll get emails occasionally from people that will ask me questions about meds, and of course, I always say, “I’m not even a therapist, let alone a psychiatrist. Stay in contact with the person who is prescribing.” You almost can’t give them too much information.

Dr. Watkins: Yes.

Paul G: That is hugely important, that they know everything that is going on with you, but a lot of people are like me where you’re like, “Oh, I’ve got to spend another $200 to go see.” But sometimes I’ll shoot my psychiatrist an email.

Dr. Watkins: Yes, yes.

Paul G: So if your psychiatrist is open to email and you don’t abuse it.

Dr. Watkins: Yeah.

Paul G: And I’m not sure where that line is. I know I don’t come anywhere close.

Dr. Watkins: Good, good.

Paul G: But stay in contact with the person that’s prescribing.

Dr. Watkins: Yes, that is so important. I laugh with my patients. I say, “You know, I just assume no news is good news, so if I don’t hear from you until the next appointment, I’m assuming, ‘Hey, they’re doing great with the medications. See you at the next appointment.’”

So it saddens me when a patient comes in and says, “Yeah, Dr. Watkins, I stopped that medication two weeks ago. I couldn’t take it anymore.” “Well, why didn’t you call me? Why didn’t you email me?”

Paul G: A psychiatrist does the same thing.

Dr. Watkins: Oh, we want to hear from our patients. With really good psychiatrist, we want to hear from our patients and we know that most patients won’t abuse that, and if it turns out that it’s a little bit more than what we feel comfortable with, we’ll just ask you to come in, you know?

Paul G: [Agrees]

Dr. Watkins: But most of us are pretty reasonable and if you want to shoot us an email or call, we can address your concerns pretty quickly.

Paul G: How was the advertising of pills on television for any disorders change the public’s perception of mental illness in general? Well, that’s a broad question, but I think an interesting one.

Dr. Watkins: It is. It is. I remember when there were commercials for Wellbutrin before it was generic, and I would have patients specifically ask for, “That medication that’s going to make me feel well. You know, you saw the commercials.” I was like, “Oh, okay, okay.”

Paul G: “I want to play tennis better.”

Dr. Watkins: I thought I was having fun doing something while the rambling was to possible side effects in monotone where they’re playing tennis and having fun.

Paul G: “I want to fuck my wife on a tire swing.”

Dr. Watkins: Well, my son is 21 and he’s so funny. He’s like, “Mom, I think after that, I’ll just keep the problem that I started off with. I’d rather not have those side effects.”

Paul G: The side effects listing, thank God that that is legally mandated.

Dr. Watkins: Yes, I know. It’s very important for patients to know about potential side effects, definitely, but I will say that it has made the general public more aware of some of the medications that we prescribe and what’s available to them. Although I will say with some medications like Zyprexa, sometimes there will be folks who might see a commercial about Zyprexa that’s not necessarily from the pharmaceutical company, but maybe from a legal office and there will be concerns about, “Have you ever had diabetes as a result…,” you know, that kind of thing, and that can be off-putting to some of my patients because I’ll talk with them about a medication that I’m recommending and they’ll say, “But won’t I get diabetes or won’t I have this problem or that problem?” And it really can be great in terms of getting the dialogue going, but also it can make them even more concerned about taking the medication. Because all medications have some possible risk of side effects, but I want my patients to make an informed decision and I’ll talk about what’s common, what isn’t so common, what’s very, very rare, and they can talk about what they feel like they could live with.

Paul G: Yeah, because ultimately it’s their decision.

Dr. Watkins: Yeah, it’s their choice.

Paul G: Yeah.

Dr. Watkins: It’s their choice.

Paul G: You know the other thing I always like to say to people who are really stuck in ruts that my view is that meds should be the last house on the block. You should try to exercise, the support groups…

Dr. Watkins: Yes.

Paul G: The processing of the emotions, the meditation, eating right, all of that stuff, and if you still need stuff, then I think meds are definitely worth it. They’ve absolutely saved my life. That being said, there are times that people say, “Well, I’ve tried all of those things, but I still don’t want to take meds,” and they’re sleeping 16 hours a day and they’re feeling suicidal.

Dr. Watkins: Yeah.

Paul G: And I’ll say to them, “What are the side effects of not taking meds?”

Dr. Watkins: Yes, good point.

Paul G: Sleeping 16 hours a day.

Dr. Watkins: [Agrees]

Paul G: Losing job after job.

Dr. Watkins: Yes.

Paul G: Unable to have a stable relationship in your life.

Dr. Watkins: [Agrees]

Paul G: Well, isn’t that a side effect?

Dr. Watkins: Yes.

Paul G: So that’s something to consider.

Dr. Watkins: Yes, it is.

Paul G: Are people with personality disorders a lost cause as far as changing who they are even if they want to, and does medication help? We talked or touched on it a little bit, but expand on that.

Dr. Watkins: Yeah, that’s an interesting question because sometimes they may not have the insight. So, for example, I don’t mean they don’t want to change at all. I mean, they might not have the insight they may not want to change. There are two parts to that. There are some people, let’s say, who have narcissistic personality disorder, they may not even care about how their behavior is affecting their functioning. They might be the CEO of a company and they have a lot of people working under them and they’re very successful, but they may not really care that they have narcissistic personality. So it’s working for them, you know?

Paul G: Right, yeah.

Dr. Watkins: Or some of that anti-social personality disorder who might be charming and able to get their needs met and they have a certain way of looking at the world, it may not be a problem to them. So it really depends on what the personality disorder is, how much insight they have and their motivation and willingness to change. But like I said before, we do know that medications don’t tend to work too well to primarily treat a personality disorder. That person ultimately has to be willing to do the work, to go to therapy and work through that.

Paul G: And find coping skills.

Dr. Watkins: And find coping skills, but unfortunately, there are a lot of people out there with personality disorders whom it’s working for them in some level and they don’t really feel a desire to change.

Paul G: Have you come across somebody who has narcissistic personality disorder that wanted to change?

Dr. Watkins: No, never.

Paul G: Have any of your colleagues come across somebody who…

Dr. Watkins: No, no, no. I haven’t heard of anyone, and the patients who do come in, they might come in for another reason. Let’s say, their wife has finally gotten them to come in, and the whole approach about it will be, “Oh, well, the wife told me to come in here, and yeah, but…,” and they’ll go on and on and on in a very narcissistic way about why they’re there and not really be willing to look into what’s going on for them internally, so there’s kind of this block there, and the psychiatrist will try to work with patients who have narcissistic personality disorder where we’ve been kind of feed in, gently feed into the narcissism because if you try to come across as expert to a narcissist, it’s going to shut the relationship down. So sometimes you do have to say, “Yeah, you have a good point. Yeah, you’re right about that,” and then try to work with them, but it’s extremely hard because they’re not coming in because they see that they have a problem. Usually, it’s the folks around them that are concerned and they will then say, “It’s the other people’s problem not mine.”

Paul G: They’re coming in to get the heat off.

Dr. Watkins: Yes, exactly.

Paul G: Yeah. You see a lot of people come in to support groups for addictions, and those people almost never get any kind of sobriety because you have to want it for yourself.

Dr. Watkins: You have to want it, yeah.

Paul G: Because there are a lot of work involved. There’s a lot of humbling information that you need to process and chew on and, yeah. Oh, this is a good question. Is the thinking still that if you’ve had recurrent episodes of major depression, are lifelong antidepressants needed?

Dr. Watkins: Yes. So, our top patients who come in with their first depressive episode, they may not need to be in medication long term. Particularly with young people who come in, they have all the criteria for MDD, and I’ll tell them, “Let’s get us a trial. Let’s see how you do for nine months to a year, and then we’ll reassess,” and usually I’ll also have them in therapy at the same time. It’s very, very important.

But for some patients who have been hospitalized multiple times, have had suicide attempts, who have a strong family history, I will tell them that it may be in their best interest to be on medication long term, and I think that the risk of them not doing so well, not being on medication really needs to be discussed because those patients are at such high risk of having bad outcomes in terms of relapse, future suicide attempts, et cetera. So I think folks in those situations will probably benefit from being on lifelong therapy.

Paul G: Should you change meds after several years of use if the depression is stable for a long time?

Dr. Watkins: Well, if it’s working and things are stable…

Paul G: Oh, they added, “thinking about titrating off.”

Dr. Watkins: Ah, so it’s definitely important to be in discussion with your psychiatrist about that.

Paul G: Yeah. I actually almost died from trying to go off my meds on my own. My psychiatrist had strongly urged me not to do it, but I thought, “Oh, you know, I’ve got this new diet.” I was probably depressed because I was eating too much white flour, and I thought, “If I start feeling worse in the first three months, then I’ll know it’s the depression, and I’ll go back on my meds.” I didn’t realize that it can take longer than that for the depression to come back. So when it came back at five months, I thought it was reality and I thought my life really was meaningless and futile, and I was starting to think about suicide, and then one day it occurred to me, “Oh my God, this is the darkness,” and I got back on my meds and three days later I felt fine and that’s why I started this podcast.

Dr. Watkins: Oh, really?

Paul G: Yes, because I thought, “If I’ve been in therapy and psychiatric care for ten years and I was fooled by it, think about somebody out there who doesn’t even believe in mental illness, how much is their up against in trying to feel better?”

Dr. Watkins: Yes.

Paul G: But the reason I bring that up is because there is this thing in us, those of us who have to take meds, that we are looking for any excuse to get off them constantly, constantly. So what would you say to this person who wants to titrate off?

Dr. Watkins: Well, first of all, I ask them why. Sometimes the medication has been so helpful for the patient and they want to get off of it. The first question is why is that? Is it stigma? Is someone telling you that you don’t need those meds anymore? Are you having any problems with side effects of the medication? So the first question to answer is, why, and why now? So what else is going on in your life right now that makes you think this is a good time to do that?

Then also too, really exploring the history and letting patients know, like I’ll read out loud to them their initial psychiatric evaluation. So for every patient that comes to my office, I have dictated psychiatric evaluation and years and years have passed and they forget sometimes how difficult and bad life was for them when they first came in, and I have to read it out loud. The patient was experiencing this, and then I’m going all the way down, they’re like, “Oh okay, that’s why I need to stay on my medication.” “Yes, that’s why.”

Paul G: My psychiatrist will do that. I see him every six months, and sometimes more if needed, but he will do that every time I go in, he will read out loud where I was the previous time I was in there.

Dr. Watkins: Yeah.

Paul G: And it always shocks me because I always forget.

Dr. Watkins: Yes.

Paul G: Oh, my God, that’s right. I had lost hope six months ago.

Dr. Watkins: Yeah, yes, and that can be very, very powerful. So it really is worth a discussion with your psychiatrist about that, and so please, please don’t stop your medications suddenly without being in touch with your mental health provider.

Paul G: Here’s another person that had a bad experience, why do so many psychiatrists seem to suck and diagnose and treat mental health problems like they’re troubleshooting a computer without giving regard to the fact that the person is a human individual?

Dr. Watkins: Oh, I’m really sorry to hear that person had that experience with their psychiatrist. There are others to choose from too. I just really want to emphasize that. Just because you have an initial bad experience with a psychiatrist, it doesn’t mean you’re stuck with that psychiatrist for life or it doesn’t mean that, “Oh, you know, I’m done with mental health treatment. I never want to do that again.”

There are some psychiatrists who are more warm than others. There are some who spend a little more time with patients than others, and sometimes it takes a few tries to find someone who’s a good fit.

Paul G: Yeah. This is a good follow up from a different person. Does she feels psychiatrists get adequate training and talk therapy when compared to clinical psychologists?

Dr. Watkins: So that is a good question, so when I was in training, I actually had supervision from both psychologist and psychiatrist.

Paul G: Oh, that’s great.

Dr. Watkins: Yeah, so I learned a lot about psychodynamics, psychotherapy, CBT, and I actually did a little bit extra on top of my psychiatric training because that was so important to me. So I really believe in treating the whole person. One of my former supervisors said, “You know, I refused to be a psychiatrist from the wrist down, so I’m not going to spend all day writing scripts for people. It’s very important to have a real relationship with that patient.”

Also, I do a little bit of what we call supportive therapy every time a patient comes in to the office. I don’t want to just talk about medication. That’s not fun for me. That’s not great for the patients. So that’s very, very important. In the past, it used to be that psychiatrists were required to have what we call supervision or what I like to call theravision because sometimes it ends up being a little bit of therapy along with supervision.

But now it’s optional, and so that unfortunate because for the psychiatrist to be on the couch, so to speak, and have that experience with someone who’s dedicated to helping them work through all of their stuff that shows up in the room with the patient, it’s so important. So I had several years of that. I’d meet with my psychiatrist when I was a resident at 6 a.m. once a week.

Paul G: Wow.

Dr. Watkins: He was so wonderful. He just really made a bid difference in my life and helped me out so much during that time as I was learning how to be there and present for my patients while also keeping in mind I have my own stuff, and so it’s optional now, and I really, really think that it should be mandatory again to have that.

Paul G: I agree.

Dr. Watkins: Yeah.

Paul G: I agree.

Dr. Watkins: It’s a different experience being on the couch versus being on the chair.

Paul G: Yeah. I have yet to have an experience with a psychiatrist where I felt this alone would be enough.

Dr. Watkins: Yeah.

Paul G: I wish you would live in Los Angeles. I swear to God I would switch psychiatrist. You’re very warm.

Dr. Watkins: Oh, thank you.

Paul G: You’re very warm. I’m curious to know about avoidant personality disorder. It’s rarely discussed. What do you know about it?

Dr. Watkins: Well…

Paul G: Or would you prefer to avoid talking about it?

Dr. Watkins: I avoid talking about it. You know we usually talk primarily about and will cover the Cluster B personality disorders that we’ve described before, the borderline personality disorder, anti-social personality disorder, narcissistic personality disorder, and sometimes histrionic personality disorder.

Paul G: Why do they call them Cluster Bs?

Dr. Watkins: Because it’s Cluster A, Cluster B, and Cluster C, so it’s just the way that we categorize the personality disorders.

Paul G: Okay.

Dr. Watkins: And clusters have something in common with each other, so we don’t really talk so much about dependent or avoidant personality disorder because I just think the other ones are ones that we deal with all the time. With family members and coworkers and employees and so forth, we talk about that more. But as far as avoidant personality disorder and dependent personality disorder, these two can affect functioning, so if someone is avoidant or shy or reserved, that may be keeping them from being to live the fullest life that they could live.

Or I had a patient with severe dependent personality disorder who is often admitted to the psychiatric unit, and it became very difficult for the staff to find that balance between being there for her and helping her to get better, but also pushing her to be more independent and be more functioning so that she wouldn’t have to keep coming back to the hospital because it wasn’t the best place for her to get treatment for her personality disorder.

But that was primary and she felt so much support and love from the staff so she would sometimes say that she’s having suicidal thoughts and that she needed to go to the hospital and she would come and get all of this great support from the nurses, the OT staff, the psychiatrists and then we’ll start trying to push her to take care of her ADLs or activities of daily living and trying to get her to do things, and then she’d resist that and then kind of regress a bit, and we’d get into this whole dynamic, and so sometimes that can be very difficult.

She really would have benefited much more from having regular ongoing therapy with a therapist who could find that balance with her, be there for her, validate her, support her, but also push her a bit, but being in a psychiatric unit, that wasn’t really the best place for her.

Paul G: Yeah, one of the surveys we have for the show is the Being Hospitalized survey, and people’s experiences are never somewhere in the middle. They either feel that their hospitalization saved their life or it was one of the worst experiences they’ve ever had, and it seems almost completely dependent on the amount of compassion and attention that they received in the facility. Is it money?

Dr. Watkins: Oh.

Paul G: Is it bad staff members? Is it a culture of arrogance? What makes it a bad situation that when I read these terrible surveys?

Dr. Watkins: Hmm, well, there are many, many factors. Sometimes, even though the doctor may really want this and the rest of the staff really wants this for the patient to be able to stay in the hospital longer to get the treatment that they need and deserve, there are so many factors that play and it’s very hard to explain to folks and families how the systems work.

So for example, there might be pressure from the insurance company or utilization review who’s looking at the acuity of the hospital stay and saying, “Okay, this patient no longer meets criteria for acute in-patient treatment. You need to discharge them.” Even though the doctor may not feel fully ready to discharge the patient, we act as part of this larger system, and so it’s very important to, for me in working with my patients, try to come up with an appropriate after-care plan and do everything I can to try to help them get the services they need after their discharge from the hospital because the hospital length of stay is getting shorter and shorter and shorter.

Well, that’s almost like with anything in medicine. It used to be when women had a vaginal delivery, they would stay in the hospital a lot longer, and now it’s kind of like a drive-through deliveries, to joke about that.

Paul G: And they’d give you…

Dr. Watkins: And basically…

Paul G: They’d give you a C-section on Uber.

Dr. Watkins: I mean, there are so many factors there. There’s money and there is business and there is insurance and there are so many factors with it. Yeah, and so I think that can also to taint 00:47:34 the hospital stay. So I see patients who have all kinds of diagnoses in the hospital, and so for some of my patients who have severe mental illness, who have schizophrenia, sometimes too their stay can be very difficult if they’re requiring intramuscular injections or other treatment that can be very traumatic to them and that can be very hard and also them not even wanting to be in the hospital or having the insight to know why they’re in the hospital, and so that’s one end of the spectrum.

Then you have someone who’s, let’s say, pretty high functioning and they have a job and they have resources and they have insurance, and you really want to be able to spend lots of time with them, but the doctor, I mean, over the years, I went from seeing about eight patients per day in the in-patient unit, and now I average twelve to thirteen, but there has been sometimes I’ve seen sixteen.

Yeah, yeah, so things have really, really changed, so obviously, that decreases the amount of time i can spend with that patient. I used to love family meetings. When I first started out of residency, I thought, “Oh, this is so fun. I get to educate the family and talk with them how they can be supportive and come up with a good after-care plan,” and as time went on, I had this yucky feeling inside because I dreaded the family meetings. Like when a family would show up and want to talk with me, I just kind of tense up.

Paul G: Why?

Dr. Watkins: Because I knew that I wasn’t going to be able to give them the time that I wanted because I had so many patients to see, and that frustrated me so much, and so now that the compromise that I make is I tell them like, “Let’s set up a time where you can come back like maybe tomorrow or something. We could talk on the phone in a conference call with the social worker, and I can talk with you about the overall plan.”

But I don’t have the flexibility in my day that I used to have where I could kind of put some things on hold and meet with the family while they’re there and then get back to my work. Now, it’s just so busy.

Paul G: And is it because that scheduling is dictated to you or you have built your schedule up that you’ve packed your schedule that tight?

Dr. Watkins: No, no. Some of this just comes from the general hospital systems administrators who have determined, “You know we have these many beds. We have these many doctors and these are the number of patients that need to be seen in a day.” So if I were to create more time to do the family meetings but then I have sixteen patients to see, I could potentially be there until 10 o’clock at night.

There is a saying in medicine, “the longer you stay, the longer you stay.” So for your own mental health, you have to have a cut off at some point.

Paul G: What does that mean “the longer you stay, the longer you stay?”

Dr. Watkins: There is always more work to do, always more things that come up.

Paul G: I see.

Dr. Watkins: So let’s say I finish my work for the day at 6 o’clock. I’m getting out of the door and something has happened with a patient, and the nurse is saying, “Oh, Dr. Watkins, can you take care of this?” Well, technically, it should be the doctor who’s on for the next shift, but, “Oh, it’s my patient. I’m still here. Okay, I can take care of this, no problem.” So you find yourself kind of getting caught in this, you know?

Paul G: I see.

Dr. Watkins: Yeah, so it’s hard to find that end point because you know you need to fair to your family and be able to get home and be there for them, but yeah, the longer you stay, the longer you stay.

Paul G: Yeah. Maybe this sounds like an obvious question, but Dr. Watkins is African-American. Have you encountered racism as a psychiatrist, and how have you handled it?

Dr. Watkins: Yes. So it’s interesting because in my private practice in Walnut Creek, when people look me up online, they can see that I’m an African-American female and so if they have any racism, sexism, atheism concerns, they’re just not going to call me.

Paul G: Right.

Dr. Watkins: So that kind of eliminates those people right there.

Paul G: The beauty of the internet.

Dr. Watkins: But in the hospital setting, you know there has been some situations where someone will say that they don’t want a doctor of a certain culture or background, and sometimes for some patients, it might be there’s some paranoia or something else going on, and so I’ve kind of looked at the situation for the patient and try to meet them where they’re at, okay?

Paul G: [Agrees]

Dr. Watkins: So for example, if a man, if a white man in his 80s calls me “colored,” I’m not going to be offended because that’s the time that he grew up in, right?

Paul G: [Agrees]

Dr. Watkins: So I meet people where they’re at, but as far as blatant racism, I haven’t really had any situations I couldn’t handle or something that was so off-putting that I wasn’t able to do my job, nothing like that, but there are subtle racisms and things that come up, and also with sexism, it’s funny. When I was in residency, people had no idea what I look like, and so randomly, the psychiatric resident was assigned to a patient in our continuity clinic, and so I remember this patient came in and I came out to greet him, and he’s like, “You’re Dr. Watkins? You’re Dr. Watkins?” And so I’m thinking, I didn’t say this, but I’m thinking, “I think they don’t expect me to be so young, black female.” Because I look nothing like it, right? 00:52:45.

But it’s funny because it has also worked in another way though. I’ve had some patients who come in who have said, “I wanted a doctor who’s very different from me. I wanted a doctor of color because I think that doctor has probably been through some stuff.”

Paul G: And do you feel like that’s true?

Dr. Watkins: I do feel like that’s true.

Paul G: Right.

Dr. Watkins: Because they know that to be at this position in my life at this time and to have the level of success and so forth that I have, that yeah, I’ve dealt with some stuff to be here, and so some people will actually find that really helpful to know that this psychiatrist doesn’t have this perfect, pristine life where everything has been easy for her.

Paul G: One of the things I think is so often discounted in the discussions of mental illness is the generational effects of institutional racism. Because I have you here and you’re African-American and you’re a psychiatrist and race is such an important issue, especially in the media in this last year.

Dr. Watkins: Yes.

Paul G: There’s finally some awareness and people are no longer able to say, “Oh, we’ve got a black President.” There’s no racist anymore. What are your thoughts being in the position you’re in as a clinician and a black woman?

Dr. Watkins: Yeah. Well, one of the things I feel very strongly about is educating more people of color to become therapists, psychiatrists, psychologists, because there is such stigma and I think that we need more people out there of color to be available to people of color so that they can feel a little more comfortable in getting the treatment that they need.

Gosh, if I had a dollar for every time I heard a friend or relative or someone say, “Oh, well, I’m just going to pray on it. I’m going to pray on it. I’m praying. Yeah, I’m talking with God. I’m talking with the Lord about it,” and it’s good to do that. Prayer is very important, and it can be very helpful to feel like you can give this to a higher power, but then it’s almost like using that instead of getting the treatment that you need.

So having someone who has that cultural connection because when I hear another person of color saying something like that, I get it because I grew up in that same environment, and I get that. I know what it’s like to go to the pastor, go to the church and pray on it, but there are sometimes so many barriers because the person of color might be looking at a therapist of a different background and thinking, “Oh, this person will have no idea where I’m coming from. They won’t get it,” and that can be a big challenge. So I think encouraging more people of color to go into mental health fields is important. I think that’s going to help.

Also, what’s going on in the media, what’s going on as far as police violence and stuff, this impacts people in so many ways. I had a teen recently who was placed on a 5150. So here in California, it’s a legal psychiatric hold and someone called the police because she had some behavioral concerns. She had no psychiatric history, and when I met with her and talked with her about why she was on this hold, she was like, “Ask the police. I don’t care about them. They don’t care about us.”

Paul G: You can say fuck here.

Dr. Watkins: Yeah, yeah.

Paul G: Or maybe you don’t personally.

Dr. Watkins: I don’t even…

Paul G: But I’m just letting you know you can.

Dr. Watkins: Okay.

Paul G: Okay.

Dr. Watkins: So the officers thought that she was someone who might be manic or acting bizarrely, and she was basically trying to fight back against the police because she has seen all of the violence in the media and all that’s going on and she’s a young person of color who is like, “I’m standing up for myself,” and by me being a person of color, I was able to connect with her in a way and I said, “I hear what you’re saying. I hear that this was so angry. It’s such a difficult situation. We’re so angry about it, and you want to get back at them.” But I said, “You know, we have to choose our battles wisely. Your ultimate goal is safety here, okay? Your ultimate goal is to be able to get to the situation and then afterwards, you can use some of that frustration, and who knows, maybe you’ll become an advocate of some sort, or maybe you’ll be a therapist or a lawyer or whatever, and make change in a different way. But you against the police, you’re little…”

Paul G: It’s not going to turn out well.

Dr. Watkins: It’s not going to turn out well, okay?

Paul G: Yeah.

Dr. Watkins: And so she was really able to get that, and I was able to share with her, I don’t do a lot of disclosure, but in this particular situation I thought it could be helpful, and I think it was, so I told her, “You know, my son is 21, 6’2, with big Afro. I had to have to talk with him very early on how to communicate with the police if you’re ever pulled over or if they ever approach you, you’d be respectful, you stay calm. You hear what they have to say. If you’re in a car, your hands at 10 and 2 o’clock.” You know?

Paul G: [Agrees]

Dr. Watkins: Yeah, and so this was an important discussion I had to have with him that perhaps other people aren’t having with their children, and this is something that this patient was really able to take in, and we often talk about coping skills and strategies and so forth, but she didn’t need to be at a psychiatric unit. She didn’t need to be on a psychiatric hold, but this was those larger racial issues that are playing out in people’s lives.

Paul G: And that’s the thing I could tell as somebody from the white community that we never even consider, that we need to hear about, that we need to go, “You know, my parents didn’t have to have that talk with me to keep your hands at 10 and 2.”

Dr. Watkins: Yeah.

Paul G: It breaks my heart that that is a conversation that a parent has to have with their child. It’s like…

Dr. Watkins: It’s the world that we live unfortunately, and so Jonathan feels very empowered that way that he knows how to conduct himself if this happens, and the ultimate goal is safety, and later on, if we need to do something else, we can go that route, but in the moment, the ultimate goal is safety. It’s sad, but it’s true, that many people of color have to have these conversations with their children.

Paul G: A lot of people I think are like me in that we’re opposed to racism and we think we know the effects of racism, but we don’t really know because we don’t live it. We see it. We see it in the news. Maybe we have a person of color who’s a friend that shares their stories with us.

Dr. Watkins: Yes.

Paul G: But we don’t hear the day-to-day thing that a conversation that you had with your son, the conversation with the woman who wanted to confront the police, and I think until we can have those dialogues every day, the people who are in denial that there’s still institutional racism are never going to change.

Dr. Watkins: Yeah.

Paul G: Because a lot of those or some of those people I think are ignorant, some of them are mean, and some of them are just ignorant, some are both, but the meanness, I don’t think there’s anything we can do to change those people really.

Dr. Watkins: Yeah, right, right.

Paul G: But the ignorance, I think there’s stuff that we can do, and I’m just kind of thinking out loud here, but there needs to be a way that we can see the minutiae of racism.

Dr. Watkins: Yeah.

Paul G: The non-dramatic racism that takes its toll. I guess as the cops would call it the cumulative PTSD.

Dr. Watkins: Yes.

Paul G: And that’s what I guess I was looking to make a point on earlier when I talked about 400 years of institutional racism, the collective PTSD of that.

Dr. Watkins: Yes, yes, right, and this young person who told me about the situation there in the psychiatric unit, I totally got where she was coming from because she has felt with these little micro aggressions and such, she’s felt it, felt it, felt it for so long and they caught her at a point where she’s just like, “I can’t take this anymore. I’m going to stand up for myself.” And she wasn’t really thinking clearly about these people have guns, these people have batons, these people can arrest you, that kind of thing, and so yeah, I think that over the years that just builds up, builds up, builds up and so people wonder, “Well, why do people do this? Why do some black women go off on me and do this and that or whatever? Why do, you know?”

But you have to understand where someone is coming from. When you’re treated a certain way for so long, you get to a point where it’s just like, “F- it!” Like you know?

Paul G: Yeah. You know I’ve noticed the times when I lose my temper, as the listeners know, usually when I’m playing ice hockey. It’s never, almost never about the person that pissed me off.

Dr. Watkins: Yes.

Paul G: It’s about the phone call I’d had with my mom where she emasculated me.

Dr. Watkins: Yes.

Paul G: Or I perceived it as a certain way, or my fear that my job is going, you know?

Dr. Watkins: Yeah.

Paul G: A thousand other things, and I guess the challenge for both of us, for people who are experiencing racism and people who are not interested enough in it, is to remember not to treat everybody else as the person that wronged you.

Dr. Watkins: Yes.

Paul G: Do you know what I mean?

Dr. Watkins: Yes.

Paul G: And that’s so hard when you’re having a shitty day.

Dr. Watkins: Yes.

Paul G: Are you okay on time?

Dr. Watkins: Yes.

Paul G: Okay. Should the crap shoot of meds in the beginning be free? I’m not going to be on them until I die. Perhaps the Big Pharma can front the cost of the first six to ten weeks. I don’t see the patient’s value with using the wrong drug for two weeks.

Well, my psychiatrist when he gives me a new one almost always gives me like four or five bottles of samples to start out on.

Dr. Watkins: Yes, yes, yes. Yeah, I’m very similar to your psychiatrist. So I try to do everything in my power to help the patient out with the finances because it’s an expensive to see the psychiatrist and then also to add on the cost of medication. I don’t want there to be another barrier, so we get creative.

So sometimes it’s providing samples, sometimes there are pharmaceutical copay cards, sometimes there are online programs based on income. Especially with the newer medications, if it turns out that the patient meets less than a certain income level, they might be able to qualify for some meds that would be covered, and most of these companies allow each psychiatrist to have three patients or so in one of their patient assistance programs. They are called different names with different companies.

But yeah, I do everything that I can to decrease the cost. One of the resources that I’ve been using a lot over the last two months is goodrx.com.

Paul G: I was just going to say that one. I’ve heard some great things about them.

Dr. Watkins: It is great. So you can present that. So there are a couple of points to do this. So they actually have cards that you can get, or you can go to the website, or you can use your app, and you present the information to the pharmacist, much like an insurance card, and then the pharmacist will run it and chances are you’ll pay a lot less than you would otherwise. So that’s a really good resource.

Two, sometimes I have my patients put in different zip codes because sometimes it might be cheaper in Oakland versus Walnut Creek for whatever reason or a different pharmacy. So we get creative. Sometimes Costco and Wal-Mart are good places to get prescriptions, that might be a little less expensive than other places, and then also too, if the psychiatrist is comfortable, you can ask him or her to write for a different dosage of medications. So let’s say I want a patient to be on, let’s see, a 20 milligrams. Sometimes if I write for 40s, and then have them split it in half, they’ll save money that way. So there are many ways to be creative. I don’t want patients to let that be a barrier to them in getting their medications, so there’s always a way.

Paul G: And numbing with vodka is always a good or cheap alternative route.

Dr. Watkins: No. Oh, no.

Paul G: No, it works. You’ve just got to stick with it. I swear to God, I wish you’d live in Los Angeles. You see, I would so fire my psychiatrist. How to handle a true sociopath as a family member?

Dr. Watkins: Oh.

Paul G: I want to cut them off from me, but I want my nieces and my life, they need me and I need them. Well, that’s a tough one.

Dr. Watkins: Yes. Oh, my goodness. Yeah, if you have someone in the family who has a severe personality disorder, yet there are other relatives that you still want to be in contact with, well, first of all, it might be an issue of safety. I don’t know what level of sociopathy this person has, but obviously if they’re dangerous, you want to do what you can to advocate for your family so you want to make sure that they are safe. If they’re younger than 18 and you’d think that it’s a danger issue then you’d want to maybe get the authorities involved and call CPS. Now, that’s if they’re at risk of being harmed.

Now, if they’re more of someone who’s just very difficult to deal with and it’s not clear that it’s exactly that, then you can talk about having good communication and good boundaries. So you can just be very clear and say, “You know, I know that we don’t have relationship, but it’s very important to me to be able to communicate with nieces and nephews. How do you feel about that? Can we talk about how that might be possible?” Maybe you can meet somewhere in a public place and they can spend some time that way versus going up to that person’s house and having to kind of be in their environment. But it can be pretty tricky sometimes when people have severe issues to maintain relationships.

But also too, as the children get older, they’ll have more insight and more awareness and understanding. I often say that you as the co-parent or the other relative, you don’t have to be the one to say something negative about that toxic person or whatever, like that kid is going to ultimately come up to their own conclusions and they’re going to kind of realize what’s going on. Your best route is to be there to validate and support that kiddo and help them to assert themselves, have good boundaries, good communication.

So there’s nothing you can really do to change that so-called toxic person, but you can be there for that young person, and they’ll kind of get the gist of what’s going on as they get older. They’ll start to realize, “Wait a minute, you know, my dad is not like other, you know.” Yeah, they’ll pick up, and then also you’re too encouraging them to get into therapy and being there for them as a responsible adult who’s empathetic and there for them and can validate what they’re experiencing.

Paul G: That’s awesome. At what point does the doctor recommend some sort of in-house treatment or hospitalization aside from being suicidal?

Dr. Watkins: Hmm.

Paul G: That’s an interesting one.

Dr. Watkins: Yeah, so I had a patient recently who I really, really, really want to go to what we call partial hospitalization or intensive outpatient. So I’ve tried several medications for her, SSRIs, SNRIs, mood stabilizers, atypical and she’s still functioning, but she has a lot of anhedonia. She doesn’t want to do some of the things that used to make her very happy. She’s anxious about starting school soon, and so I said, “Gosh, you know, maybe PHP or IOP (intensive outpatient) might be a good option.”

Because what’s nice is it’s not putting a patient in the hospital where they’re in a locked unit and it’s a different environment being in a locked unit versus being in a place where you can come and go. So PHP is usually 9 to 3 or so Monday through Friday and there’s intensive group and the psychiatrist is available every day, and there can be medication changes that can be monitored and supervised, and for folks who work during the day or at school during the day, they could do intensive outpatient in the evening, and that may be three evenings a week, and then the person goes back home, spends the night home and comes back later on the week.

So yes, I wish more people knew about that because when I bring it up to patients or to parents, they’re always kind of, “Oh, I didn’t know about that.” Because sometimes people think it’s just either “I’m seeing the doctor in the clinic or I’m on the psych unit at a hospital.”

Paul G: Yeah.

Dr. Watkins: Yeah, so there are other options.

Paul G: Yeah, and as well with addiction treatments, there’s in-patient and outpatient.

Dr. Watkins: Yes.

Paul G: Let’s see…

Dr. Watkins: Yeah, there are alternatives to people. A lot of people know about residential 28-day programs, but PHP and IOP, if the insurance covers it, it’s something to look into.

Paul G: Could you explain the different categories of meds that are applied, that are prescribed? You talked about SSRIs, and then another one.

Dr. Watkins: Oh, SNRIs.

Paul G: SNRIs.

Dr. Watkins: Yeah. So specific names of, or…

Paul G: Yes, you can say, “Okay, this is one category and this would include drugs like this and this and this, and they’re used to treat such and such.”

Dr. Watkins: Oh okay.

Paul G: Kind of give a sense of your palette as a..

Dr. Watkins: What I have to choose from, right?

Paul G: Yes.

Dr. Watkins: Okay. So the SSRIs…

Paul G: And what the names stand for as well.

Dr. Watkins: Sure. Yeah, so selective serotonin re-uptake inhibitors, so SSRIs, so the first one that came out was Prozac back in 1987 or so, and these are medications that we use for depression. They’re called antidepressants, so we use them for depression, for anxiety, for OCD, for PTSD.

Before the SSRIs, there were these older medications called tricyclic antidepressants, so these are medications like Elavil or Pamelor. So these may have been antidepressants that maybe your parents were on with the older medications. They tend to have a lot of side effects and can be very dangerous when overdosed.

So when the SSRIs came out, it’s like, “Wow, this is great. We have medications that patients can take once a day that have minimal side effects.”

Paul G: At least compared to the previous generation.

Dr. Watkins: Compared to the previous ones, right. Compared to the previous ones. So those have been around for a while, and now we also have what are called SNRIs, and these are medications like Cymbalta and Effexor, which we use for depression and anxiety, okay?

Paul G: And what is SNRIs before?

Dr. Watkins: Oh, so they’re workable serotonin and norepinephrine, but serotonin and norepinephrine reuptake inhibitors.

Paul G: Okay.

Dr. Watkins: And so those medications we use for depression and anxiety. So then we have what are called the mood stabilizers, so we use these for patients who have bipolar disorder, but we also use them off label, kind of going back again to off label, for irritability, impulsivity and such.

Paul G: And some examples of those would be?

Dr. Watkins: Impulse control disorders or…

Paul G: I mean the meds.

Dr. Watkins: Oh, the medications.

Paul G: Yeah.

Dr. Watkins: Oh, okay. So Depakote, Tegretol, Trileptal, Lamictal, and Lithium on occasions like that.

Paul G: I’m on Lamictal.

Dr. Watkins: Yeah, yeah. Lamictal is a good medication. It takes a little while to get up to therapeutic dosage. So you start off very low at 25 milligrams and you slowly titrate upwards.

Paul G: I started out at 5,000 and working my way down just because I’m different.

Dr. Watkins: Oh, my goodness.

Paul G: I didn’t realize that at the time, but a lot of the meds that I’ve been on, I would experience hypomania for the first month. Is that pretty common?

Dr. Watkins: Yeah, so feeling kind of activated or revved up. So the irony with some of these medications is that one of the potential side effects is having worsening anxiety. So some of my patients will say, “Well, why do you have me on the medication that can make my anxiety worse when it’s trying to treat my anxiety?”

So for some of those patients, sometimes if they have no substance use history, I’ll give them a little low dose benzodiazepine, a long-acting one like Klonopin. I might give them a teeny, teeny, tiny amount, maybe 0.25 twice a day while the SSRI is building up in their system, and I told them it’s short term and then taper them off of that once we’re at the three- to six-week mark.

Paul G: I see.

Dr. Watkins: Just to kind of help with that revved up feeling, so they’re the mood stabilizers. Okay, so the next category would be the antipsychotics, and I hate that they’re called that. I really hate that name because it’s so off-putting because we use them for bipolar disorder, we use them for depression augmentation like Abilify, and sometimes we do use them off label, like sometimes some folks might take a little low dose Seroquel for a PTSD, and so these are medications like Abilify, Zyprexa, Risperdal and Seroquel.

Then there are the older antipsychotics which we still prescribe like Haldol and Thorazine, Stelazine and so forth. So I tend to use those more so in the hospital, but they’re fine in outpatient, I call it Outpatient Land, Outpatient Land as well. But that’s the next category.

Then there are other medications that we use that don’t really quite fit into any particular large group, so there are medications like BuSpar, which is only…

Paul G: Which I take.

Dr. Watkins: Okay, yes, yes.

Paul G: Yeah.

Dr. Watkins: So that one is usually taken for…

Paul G: And norepinephrine.

Dr. Watkins: And norepinephrine, that’s a TCA, a tricyclic antidepressant.

Paul G: Okay.

Dr. Watkins: And so BuSpar is usually taken three times a day or twice a day, and it’s only approved for anxiety, but it’s kind of have its own kind of category. Yeah, a little different. We have other medications too like trazodone and Remeron, which can be helpful for sleep as well as depression. So if I have a patient who because of their depression has low appetite and not sleeping well, I might give them a little Remeron which might help put on some weight and also help them sleep better, and sleep is so important as you know. You have to be sleeping well.

Paul G: Yeah.

Dr. Watkins: Yeah.

Paul G: If that’s off, that’s what we’re so horrible about that coming off Abilify, I would lay down at 2 o’clock in the morning and I wouldn’t fall asleep until 8 in the morning.

Dr. Watkins: Oh.

Paul G: And then when I would wake up, it was just thoughts of “I don’t want to be here. I don’t want to be alive.”

Dr. Watkins: Oh.

Paul G: Not like I’m actively going to go kill myself, but I just actively don’t want to be alive.

Dr. Watkins: Yeah.

Paul G: But thankfully, I have had enough laps around the track with mental health to realize this is going to pass. It’s not going to last forever.

Dr. Watkins: Yes.

Paul G: And that would be the other thing I would pass along to anybody who’s new to getting treatment for mental health is be compassionate and patient with the process. It is so counterproductive to say, “I should be in this other place now,” instead of just saying, “Okay, I’m in this place right now, what are we going to do?”

Dr. Watkins: Yes.

Paul G: Can you talk about that?

Dr. Watkins: Yeah, so oftentimes, patients when they first come in, they have their own idea of what looking better would feel like. Sometimes they don’t, but sometimes those who do, they’ll say, “Yeah, I want to be able to do this and do that, and this is what I’m struggling with.” And we have to be realistic as far as the time frame. So it’s not going to be just like that, the patient is going to start feeling better, and so for some of our medications, it can take a little while for them to what we call “separate from placebo.” So in studies where they’ve compared placebos to some of our FDA-approved treatments, there is a certain amount of time to when the data starts to separate and you can see, “Wow, this person is really responding to medication versus the sugar pill.”

So we have that give that time. Now, sometimes I have patients who come in who’ll just say, “I don’t know what, but I’m not feeling like myself, and this is not how I want to be living.” We talk about, “Well, what can we work on? Do you want something that’s going to help you with your energy and with your focus and concentration, and you want to be able to work and have good relationships with your spouse and not be so irritable and cranky and restless.”

So we work together on what’s realistic, and then also too, again, I just emphasize the therapy because the medication while can be so helpful, if they’re not getting their regular therapy, they’re going to really miss out on getting better that much more quickly and also really looking at the root of what’s going on.

Sometimes patients will come in and see me who’ve never had any mental health treatment and they’re starting off with a psychiatrist, and I’ll ask them, “Oh, I’m curious why you chose to start off with a psychiatrist.” And they’ll say, “Well, I want to get better soon. I don’t want to do that other work. The therapy is going to take too long.”

Paul G: So you’re a proponent of therapy first and if you’re still not getting to where you’d like to be, then…

Dr. Watkins: Yes, yes, I tell patients, “Just because you’re coming to my office does not mean you’re leaving with a script.”

Paul G: Good for you.

Dr. Watkins: And I find too that sometimes initially I’ll think that they may not need medication and then they’re seeing a therapist, and the therapist, I really love therapist who stay in contact with me. I mean, some will kind of keep me hanging, and others will give me updates on all our mutual patients, and I just love that, and so they’ll me, “You know, this is what I’m seeing in Johnny, and what do you think about medication at this point?” And I’ll say, “Thank you. Thank you for telling me this. Sure, sure, you know I’ll have my receptionist reach out to Johnny and we’ll get him back in, and we can talk about that.”

So that’s another reason why the therapy is so important because it’s another set of eyes looking at that person, another set of ears listening to that person, and it’s someone who can advocate for them and let me know what’s going on because, as you say, you’re seeing your psychiatrist maybe once every six months or maybe once every three months, but that therapist is seeing the patient much more frequently and they can keep us informed as to what they’re seeing and we can make a decision from there.

Paul G: Is it common for depression to get worse when taking a new medication before it gets better?

Dr. Watkins: It depends because sometimes what we’ll do is we’ll keep the patient on their current medication and do what we call a cross-titration, so we’ll be starting them on the new medication while they’re still on the old medication, and so sometimes that can be helpful so that levels aren’t dipping. Serotonin levels aren’t dipping while we’re trying to get someone onto the next medication.

So it depends if they’re starting brand new with the medication versus they’re currently on a medication that’s lost some efficacy and now they want to start something new. So it really depends, but I like the cross-titration approach, unless the medication is really intolerable like we were talking about….

Paul G: Like Abilify.

Dr. Watkins: Right, right. Just toss the medication under a psychiatrist’s care.

Paul G: Yeah.

Dr. Watkins: And we’ll talk about what to do next.

Paul G: Yeah. Did we cover all of the categories?

Dr. Watkins: Well, there are other medications that we use that don’t really fit into a particular category, and some are off label usage, and I’m kind of reluctant to talk about just because they aren’t FDA approved, and a legal disclaimer here, I don’t want anyone to believe this is any kind of psychiatric advice specifically to them.

Paul G: Okay.

Dr. Watkins: Just talk with your psychiatrist or therapist about it. But there may be other medications that the psychiatrist might prescribe, depending on what’s going on, like there are medications that I prescribe sometimes for my patients who have alcohol abuse or alcohol dependence that are very specific to that diagnosis, and also medications for patients that have opiate abuse or opiate dependence specific to that diagnosis. So there’s a long list of options, but I just told you about the most common ones.

Paul G: Okay.

Dr. Watkins: Yeah.

Paul G: Long term effect of SSRIs and what’s your point of view on the state of the pharmaceutical industry? It’s a two-part, or…

Dr. Watkins: Yeah, so I don’t know of any concerning data as far as long-term use of SSRIs. I’ve had many patients who have been in SSRIs for a long time and sometimes they might need augmentation or they might need to switch for whatever reason, but nothing as far as any long-term effects that are concerning with this class of medication that I know of.

As far as the pharmaceutical industry, things have really changed over the years with the pharmaceutical industry. If I were a psychiatrist in my 60s, I would probably be talking with you about all of the relationships that were had in the past with pharmaceutical companies, and that’s really changed now. I mean, in the past, sometimes there would be gifts or freebies and so forth. Pretty outrageous stories that some older psychiatrists have told me about that I don’t really feel comfortable with. Nowadays, it’s a bit of a challenge because I do maintain these relationships with the pharmaceutical reps because I rely on their samples to help my patients, you know?

Paul G: [Agrees]

Dr. Watkins: And also too, they’re the ones who know about the latest medications that are out and they’re able to arrange dinners so that I’m able to go to the dinner sometimes and get more education about it, but it gets a little tricky and sticky if there is something that’s an inappropriate. So it’s actually not the case anymore where pharmaceutical reps can give us Post Its or pens or anything like that, which I think is a good thing, but we do rely on them in many ways to be able to maintain that connection so that we can get some of the resources for our patients.

I tell my patients too, just because the medication is new doesn’t mean that it’s going to be more effective than what we currently have. So I tell them I’d rather when my colleagues try out these newer medications and let me know about their experience before I try them on my own patients. So I’m very honest enough and upfront with them about that. But sometimes my patients will say, “Well, you know, Doc, I really want to try this new medication.” And I’ll say, “Okay, but the caveat is that I don’t have any data. I mean, there is a pharmaceutical data, but I don’t have any personal data on any of my patients who tried this new drug. So just with that caveat, then okay, I’ll give you the samples.”

So I try to have appropriate boundaries with them, but I do rely on them to help out my patients, but it’s a bit of an issue. It’s a big topic of discussion in psychiatry and other fields.

Paul G: Any benefits seen in taking 5-HTP for anxiety or depression over SSRIs?

Dr. Watkins: So sometimes patients will ask, “Well, what do you think about SAMe or St. John’s wort or some – what we call complementary or alternative medications?” And I will them that that’s not my area of expertise, and the caveat that some of these supplements or alternative therapies aren’t regulated. So I don’t know if we’re really comparing apples to apples when a patient brings in a medication from Whole Foods or somewhere else or a supplement that I don’t really know what the contents are and how it’s manufactured. I just don’t know, and so I’ll tell them that I don’t want them to use those medications in combination with what I’m prescribing because sometimes that isn’t safe for someone to use St. John’s wort along with an SSRI, but usually what I’ll do is I’ll refer them to another psychiatrist who specializes in that.

We do have some great ones in the Bay Area for patients who really want to go that route, and so if they want to perhaps try out some of the other remedy, like melatonin. I prescribe melatonin. I mean, I prescribe some things that patients can get over the counter, but as far as the more in-depth conversation about those things, really they should be talking with someone who knows all the data about it because I just don’t know.

Paul G: I should probably bring mine. I just started taking an over-the-counter sleep thing that’s finally helping me get to sleep, but I should probably let my psychiatrist know.

Dr. Watkins: You should definitely let your psychiatrist know, and as a psychiatrist, I’m open when patients bring in something to me and they say, “Oh, I tried this out and it really worked for me.” I do tell them that I want them to tell me, but often they just start taking something without me knowing about it, but I’m not primitive and I’ll say, “Well, let me look into that. Okay, we can learn together. Let me look into that and see what we can do. Maybe it is safe too, but let me talk about it with some colleagues and get back to you.”

Paul G: You’re going to get some new patients.

Dr. Watkins: Oh.

Paul G: And sadly, they’re my listeners, so I apologize for that. You are awesome.

Dr. Watkins: Okay.

Paul G: I’m curious about the link between thyroid problems and depression.

Dr. Watkins: Yes, so sometimes we will do a little thyroid augmentation, so even if after we’ve checked TFTs, what we call thyroid function test, which I highly, highly, highly encourage people to talk with their psychiatrist about this, so when you first come in and see the psychiatrist, get your thyroid tested. Get a CBC to make sure you don’t anemia because we know…

Paul G: What’s CBC?

Dr. Watkins: Oh, a complete blood count.

Paul G: Okay.

Dr. Watkins: So that’s testing for hemoglobin, white blood cell count, and platelets, and if someone has anemia, that can mimic depression. They’re feeling sluggish, lethargic, low energy, and so that’s really easy to treat. So we want to treat what’s easy to treat, and also too, if their thyroid hormone is off and they have hypothyroidism, that can really mimic depression as well if they’re feeling sluggish or holding on to weight. That’s something too that’s pretty easy to treat with some Synthroid or some other medication. So that’s the number one thing is when you get this out with a psychiatrist, they should be getting some lab work done because we’re MDs so we want to rule out any medical reasons why the person may not be feeling fully like themselves.

So after the TFTs are done, the thyroid function tests, we’re looking at the TSH and the free T4 and T3 and so forth, and so sometimes we can diagnose hypothyroidism and then that can be treated, and usually a psychiatrist will refer out to their primary care doc or an endocrinologist if it’s pretty involved. Sometimes as a favor I might write a Synthroid prescription, but it’s more of a primary care or endocrinology kind of thing.

Paul G: ...Like a physical illness that typically worsens if not treated does a mental illness proceed to advance and worsen as well as we age?

Dr. Watkins: Yes. So, dementia and schizophrenia are two of the most common conditions that we know can worsen with age. And so, dementia is something that is progressive and we have medications that can slow the progression. Medications like Aricept and Namenda, but they don’t cure the dementia, and the person still has dementia but it is thought to slow the progression of the disease and we know that the older, the longer they are alive their dementia is going to worsen. Schizophrenia, so over time if it is untreated schizophrenia can worsen so that’s why it’s so important when patients have that diagnosis, that they have good support and they are taking medications regularly because we know that it can make a difference, especially early on. So right now there’s a big movement to identify young people who have what we call nuance at psychosis. So we are trying to screen young people who might be in their late teens or so, and if they have some of the prodromal symptoms of schizophrenia we are trying to target them and get them treatment early on because we know over time things can get worse if they are not getting treatment.

Paul G: I am going to apologize right now to the person that has to transcribe this episode. Try to spell some of this shit. I’ve been doing this show for four years, and I hear a lot of terms. There’s probably been a dozen here, where I’m just like “alright let it go Paul.” No idea. It would slow it down too much to keep asking what the hell that thing is. What is the best way to find the right meds?

Dr. Watkins: Well, start off finding the right psychiatrist. So, I say that to say that I’ve had some patients who come to me who are on so many medications I’ve actually taken away medications and they have gotten better, because people don’t think about what we call drug-drug interactions. So, sometimes if patients are on so many medications it’s hard to sort out “Wait a minute, why are they taking this one, or why are they taking that one?” So, your psychiatrist should be able to tell you, why this particular medication was prescribed. Even if it’s off label use, they should be able to tell you “This is why I chose this medication for you.” But sometimes I have patients where you know the psychiatrist just goes “We will add some Abilify, Seroquel, and add some Neurontin and doing a little of this and little that…” And It is like “Whoa, what are we treating here?” And so sometimes taking away some medications doing a taper can actually be helpful. You really want, and this is something I talk with folks about to in NAMI (National Alliance of Mental Illness), you really want a psychiatrist, you really want someone who enjoys what they do, who has time for you, and who has appropriate boundaries though OK? Very, very important, someone who’s knowledgeable. And there is different ways in which you can find a good psychiatrist. Sometimes it’s word of mouth, and I wish more people would talk about these things but most of the referrals that I get are word of mouth. Someone had a good experience with me and they told someone else. You know, that kind of thing. But really to be on the right regimen, you have to start off with the right psychiatrist. That’s very important.

Paul G: And a lot of it is hit or miss. Every person reacts differently to different meds, so what may save one’s person life might be a nightmare for another person, and it is not necessarily the psychiatrist’s fault that you had a terrible reaction to that med, correct?

Dr. Watkins: Yes. That is so true, so true. So, I had a therapist who called me who was questioning why I chose the specific medication for a patient and I had to talk with her about “Well this is all things that we tried. This is where we are at now. It wasn’t that I just came up with it. These are the experiences she had before with these other medications and this is why I chose this one…” And it’s a trial. We are just going to see how she does with this, and so um, yeah some medications work well for some patients versus others. One of the questions that we ask when we do an intake is family history. So sometimes if there is a relative that’s done really well with let’s say Wellbutrin. That might be the medication for the patient for their depression. But if the patient has more of an anxious kind of depression, Wellbutrin can be a little bit stimulating, a little bit activating for the patient and maybe it may not be a good choice for them. So, we really have to get that history, and look at the whole picture of what’s going on with the patient to determine the right medications to start off with, but even, you know, making that decision it still may not be the best medication for the patient and we have to do a few trials.

Paul G: And I think that’s where the patients, as a patient, is so key. I can tell you there have been dozens and dozens of times where I’m just at this super low point where my meds have to be changed and I’m on something new, and it’s going to be eight weeks before I know if it even works. And sometimes “Nope, that one didn’t work.” Got to try another one and it’s another two months waiting to see if this one’s going to work

Dr. Watkins: Very frustrating

Paul G: And you don’t want to add on top of that this feeling that this shouldn’t be happening. You just have to, you just have to you know, take naps, do nice things for yourself. We are almost done, we are almost done I appreciate you hanging in here as long as you had. Thoughts on… Does marijuana have a place in psychiatric treatment?

Dr. Watkins: No, not at this time, no especially for young people. So, unfortunately, now with cannabis and young people it’s become a big problem particularly where I live and probably all over now but young people are using marijuana to self medicate, for anxiety, to help them sleep. Sometimes they use it socially. So instead of judgments, I just start off with teens “Oh, I understand you like to smoke weed?” I just kind of talk to them casually “So tell me why you do that? Are you alone? Are you with people?” That says so much about what’s going on. You know, sometimes its social pressure. They don’t even like it, but they are doing it because they are messing around with friends and they are passing around the stuff and you know they feel some pressure so we can talk about that. We can talk about what can happen if they continue to use it for people who are using it alone we can talk about that “So what do you do you taking it at night or morning? Let’s talk about that.” You know, so it is an opportunity to really explore how they are using it and then sometimes I am able to use that information to get them to consider some other options. Therapy or medications if indicated, but I think it’s really important to talk about why are they using it versus judging them “You shouldn’t do that.” You know? And then you kind of open up the discussion for some conversation about the possible consequences. You know, letting them know “You have a choice, right because you’re choosing to do this now but let me tell you from a psychiatrist perspective what can happen if you continue to use this.”

Paul G: Long term effect of depression…

Dr. Watkins: It’s a CNS (Central Nervous System) depressant, for many patients and for young people whose brains are still developing OK? This is why young people have to pay more for car insurance who are under twenty five. Right? They’ve done studies on this. Young brain still developing. You don’t want to expose your brain to something that can potentially have some long term consequences while it’s still developing and so it’s very hard to talk with young people about this, because you know, at times they feel invincible and “Oh, it is not a big deal.”, and you kinda have to…

Paul G: “I am never going to live to see thirty. You know who gives a shit?”

Dr. Watkins: But we do know that for patients who have prodromal symptoms of psychosis kind of

Paul G: What does prodromal mean?

Dr. Watkins: Prodromal is kind of like, slowly what’s happening before the psychosis. It’s all the kind of subtle things that family members might kind of see but just kind of dismiss you know. So maybe the patients, you know, on the internet for six hours, and they are talking very fast and they are not sleeping very much and you know putting it all together there’s something brewing here that needs to be addressed but they may not see it as a mental health issue. And so, these are kind of the pre-symptoms, and for young people, if they are using cannabis on top of some other things that are going on, it really increases the risk of something more chronic happening in the future.

Paul G: Final question. The safety in taking anti-depressants during pregnancy?

Dr. Watkins: That’s a big discussion. So there are several of my colleagues who actually specialize in reproductive psychiatry so I’d suggest that you can Google reproductive psychiatry in your area and see if there’s someone who specializes in that. Now, I have a general understanding of that. I started off in OB/GYN before I became a psychiatrist, and the take home messages we look at with some benefits. Right? So if I have a patient who is so overwhelmed by their anxiety, they are barely functioning, they are anxious about what’s going to happen with the baby, what’s going to happen with their marriage, you know? And it’s really affecting all aspects of their life. I am probably going to encourage them more to consider staying on the SSRI versus someone who is not as anxious and has a great therapist, and doesn’t have a family history, and they’ve had a couple of deliveries before that have been just fine. You know we might have a discussion about weekly therapy, and then let’s talk about the medications that are indicated. But the worst thing is for someone to suddenly stop medication because they want to become pregnant. They really should have a discussion with their psychiatrist about that, and the psychiatrist can help you make an informed decision.

Paul G: And aren’t the majority of meds safe to be on during pregnancy or?

Dr. Watkins: No. There are some that are actually dangerous. For example medications like Depakote and Lithium can cause birth defects for some fetuses, so that’s why it’s really important to have a conversation with a psychiatrist about this. Now, some are safer in pregnancy, but yeah, there is definitely a role for some discussion on that. And as part of my intake, some of my patient’s chuckle when I ask them this, but I ask all of my patients of reproductive ages their birth control method. And so sometimes they ask me “Why are you asking me that? Aren’t you a psychiatrist?” And I say “Well, some of these medications can potentially impact the fetus and I want you to talk with me about your child. Do you plan to have children? What’s your birth control method? Let’s talk about that.” Because if a patient is doing really well in a medication for a while and then becomes pregnant; we need to talk about what we’re going to do about that.

Paul G: Are SSRIs safe during pregnancy?

Dr. Watkins: We don’t really use the term “safe”, because we don’t really have a lot of long-term studies. We know which medications can be safer, and so I have like my go to list of the ones that tend to be safer during pregnancy and also breastfeeding. That’s an important question for patients. Do they plan to breastfeed? Are they going to pump and dump, what are they going to do after the pregnancy. And but again, that’s a discussion they really should have with their psychiatrists about looking at all the options, and maybe therapy weekly therapy with a therapist who is in contact with a psychiatrist who can let the psychiatrist know if something is brewing. That might be fine with some patients. Some patients, the psychiatrists are going to feel more strongly that they pro