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Dr Weis (Host): . All right, well, welcome back to another Get Wise with Weiss podcast. I am very happy today to have a special guest, Dr. Arismendez, who is one of our family medicine practitioners. And, think you're about to join us in our brand new primary care clinic on I 40. Is that correct?

Dr Shyla Arismendez: Yeah.

Dr Weis (Host): Yeah. So we're excited. We have eight practitioners there. Yeah. Beautiful. I guess the old Zachary building we're on the ground floor. It's been freshly renovated and gorgeous space.

Dr Shyla Arismendez: Yeah. Super pretty.

Dr Weis (Host): When did that actually open up?

Dr Shyla Arismendez: We're supposed to move in next week, so the 19th should be the first time that we see patients.

Dr Weis (Host): Fantastic. We are very excited. Very excited. So, yeah, this time of year, obviously a lot of people find this to be a very joyful, happy time of year, but that's not true for everybody. And this can be a rough time of year. I know some of the previous podcasts we've talked about, mental health challenges. But wanted to get your perspective as a primary care physician is, how do you identify those people that may be struggling this time of year. So, is it important for primary care doctors to look for depression or anxiety in their patients?

Dr Shyla Arismendez: Oh yeah, absolutely. There's lots of stigma around mental health. Nobody wants to be thought of as the person who doesn't have their life together or whatever. But, what we really find is that if you've got a mind, you've got mental health that needs addressing, you know, whether that's just that you have to find what works for you in your daily life and you keep functioning. Or whenever things start piling on and it gets a little hard, then you need a little extra help. And that's all it is, is hey, mental health is finding the wellness within you.

No different than if you have physical health. And we really find that, there's strong correlations between mental health and physical health. You can't really separate the two. It's very hard to have pristine condition, operating physical health, whenever you are not having very good mental health. It shows up in some way, one way or another. Whether that's just experiencing chronic pain and not processing it very well, or just occasionally having little panic attacks are feeling like sometimes your heart's just racing or you feel a little more stressed out than normal.

Or even just, your sleep isn't very great. It impacts so many different parts of our physical health, and so having part of our primary practice is looking for mental health, mental wellness, to make sure that your physical health can be good as well.

Dr Weis (Host): Fantastic. You brought up some really important points there. First, I like the idea if you've got a mind, then you may be vulnerable to a mental health condition. So very important. I've done primary care for a number of years, and, people come in if I say, well, you feel. They're like, don't know, so that was not usually a very good screening tool was to ask someone, do you feel depressed? So do we have more formal tools now that we use to look for these conditions that may be pretty subtle, depression, anxiety?

Dr Shyla Arismendez: Yeah, so some basic screeners we've got are, a PHQ screener. There's just a basic quick two question, one that we can ask real quick just to see if there's anything that kind of raises some red flags and maybe we need to do the longer one. And that's called a PHQ nine. It's nine questions that we ask you of some common findings we see in depression and that can kind of clue us in.

And then we've got the GAD seven, which is a an anxiety questionnaire that is seven questions, and clues us into, could you have something going on with anxiety? And, these are screeners, they're not fully diagnostic. We definitely need to explore further into those once we get. Those questions. So filling those questions out and being truly honest with those doesn't mean that you're going to end up with a diagnosis or be told you have something wrong with you. But it definitely clues us in if there is something going on.

Dr Weis (Host): No great point. If, you look at like the PHQ nine questionnaire, a lot of those questions, of those nine questions, a lot of them are what we would call somatic complaints, right? Or bodily complaints. And you made a great point of, hey, there's a connection between the body and the. And so you look at those questions and ask, how are you sleeping? What's your energy level? Are you able to maintain your attention? If you're watching tv, you're going, well, gosh, those are more physical.

And that's the, thing is, when we look at the responses that people have to those. We realized that, people who have depression or anxiety, it basically manifests itself a lot of times as physical, conditions. So as you're pointing out chronic pain, things like that, right? You as a doctor, I mean, when you look at that, someone says, well, I'm not sleeping very well and I'm not eating very well. And boy, I kind of feel fatigued, how do you separate that from maybe a physical condition versus a mental health condition?

Dr Shyla Arismendez: Right. Of course all of those sort of things that come up would trigger me to wanna get, a screening tool in place just to see. But we also ask lots of other questions like, how long has this been going on? Are there any changes that have happened around this time? You know, how are you feeling during this time? Because some people don't really recognize that they're feeling stressed until you ask that question. So, looking into it and exploring it more and let's also look for some other symptoms.

There are things like thyroid disorders that can present with either anxiety or depression, fatigue, all those things. We can do lab tests if we feel that's warranted. There's lots of investigation that can go on for all these things, but certainly a lot of overlap between depression, anxiety, all these symptoms as well as, other mental health conditions that can overlap with these things as well. So there's definitely a lot more questioning an investigation to go into it, that we kind of sort through all this stuff.

Dr Weis (Host): Great, fantastic. I think that's important. These are, we're call screening tools. We're screening, looking for red flags, if you will. Right. And as you said, the doctor then has to kind of go delve further into, okay, could there be a physical condition? I think, you know, a thyroid, ailment is a perfect example. A thyroid being the gland that kind of run tells us how fast or slow we run. And can manifest a lot of these things. But I think that's important is that the doctor's job is to then tease these things out, further. So now we hear a lot about anxiety versus depression, right? And, when people talk about anxiety, what kind of symptoms are they experiencing? .

Dr Shyla Arismendez: So the main categories we would kind of see in the actual disorders would be generalizing, anxiety disorder versus panic disorder. And a lot of times people have both. but panic would be more of, this sudden onset fear of something happening or an overwhelming sense of anxiety, stress, something you don't feel like you can really control. Sometimes you may not notice that that's what you're feeling mentally, but your body all of a sudden starts getting very tight. You start feeling very sweaty. You could have chest pain and palpitations where you feel like your heart is racing out of your chest.

You can start feeling like the room is closing in around you. you can feel short of. . it's a really common cause of people going to the ER because, a lot of times it can feel like a heart attack and it's, very sudden overwhelming and, usually goes away on its own after a little while. But like I said, you don't always know that you're stressed and sometimes there's not really a clear trigger for why you're feeling. and so that would be kind of like a panic attack.

Dr Weis (Host): It is a true attack, I mean, that my experience is, wait, it comes outta nowhere. People have trouble explaining what is going on and I've had literally patients tell me they had an impending sense of doom, right? I said something, terrible wrong, and your points will take a lot of people go in the emergency room, just because it is such a fearful event in that sense now, so, I used to get anxious when I went to take test, is that an anxiety disorder or, it just seems like certain things would make me feel anxious, but you talked about generalized anxiety?

Dr Shyla Arismendez: Right. Yeah. so everybody experiences stress, anxiety, that's fight or flight, that's, we all know about that basic instincts. It's physiologic. We do it as part of our Basic protective instincts. but when we start to worry about it is whenever you're worrying all the time, you're worried about a lot of different things. You're worried about a lot of things that are outta your control. Worry to the point where you're not sleeping well or you're not eating well, or you're getting really irritable with people for no clear reason.

It's, whenever it's been not going on, usually we would like to say at least six months because sometimes you can have a clear trigger, a big change in your life that would incite this event and it would be appropriate to be stressed and you might have a very strong stress response to it. But that's usually pretty self-limited. It's when we start seeing that it's impacting your life for a long time. And it is definitely something that is distressing you. It's not something that you feel like you're functioning well. It's impairing your relationships, your job, things like that. And so that's when we would start looking into generalized anxiety disorder.

Dr Weis (Host): Yeah. Fantastic. I mean, clearly the operative term there is generalized, right? In a sense of just. , as you point out, it affects every aspect of your life, right? It's not, focused on particular events, it's just there all the time. So let's say that you have a patient that, manifests those kind of symptoms, and just based on your assessment, you believe that they have either depression or generalized anxiety. by the way, my understanding is that in many ways those are almost one in the same thing, or two sides of the same coin. Do they come have a similar, chemical imbalance or?

Dr Shyla Arismendez: Very similar. a lot of times almost every patient that has depression, has anxiety, and vice versa. Every so often we'll see a patient that just really doesn't have depression, they're not really feeling sad or they're not having those symptoms where they don't feel like they can get out of bed or lack of motivation, but they are definitely anxious or vice versa, where they're having depressive symptoms but they don't feel very anxious. They just feel pretty, flat or whatever.

That's the occasional patient, but for almost every other patient, it's going to be that those two come together. So you have depression and anxiety and it's very hard to tease out between the two once you do have them both. The good thing is, is that we treat them pretty much with the same medicines, the same routine is pretty much all the same. So, what we would look at is what seems to be most prominent with you, what seems to be most distressing and go from there.

Dr Weis (Host): What kind of medications do you consider in patients that now you've made the diagnosis of a major depressive disorder or generalized anxiety disorder. What are some of the tools you have in terms of medications?

Dr Shyla Arismendez: So, there are lots. I wouldn't want anyone to ever feel discouraged if they try one medicine and feel like it didn't work and there's no hope because this medicine didn't work or I didn't like the side effects, any of that, because we have a lot of medicines. However, just at baseline we start out with a class of drugs called SSRIs. And that's selective serotonin re-uptake inhibitors. That's what SSRIs are. The reason why we start with those is because we have the most evidence for those they're. The oldest drugs really, I mean, not the oldest, but we have a lot of good evidence and good efficacy with them.

They work, but they do come with some side effects, so we have a lot to choose from within that class. And if we see that depression is more the depressing concern more so than anxiety. We might start out with the medication such as sertraline or fluoxetine. Some names that people might recognize are Prozac or zoloft.

Dr Weis (Host): Yeah. Paxil Lexapro. Boy, like you said, there's, yeah, there's a whole, bunch of them in terms of, you know, I think that's been my experience is, the reason there's so many in that category is because, as you point out, not, each drug is right for every person. Right. And sometimes it takes a little bit of trial and error to see which one works best for a given person.

Dr Shyla Arismendez: And we do have Lexapro, it's Escetalopram. That one's a little bit newer within that class, and so it's a little bit cleaner in terms of side effects versus some of the other ones. But, what I've really seen with that one is that it works. Very, very well for anxiety. But we do see that there are some people that need a little bit more of a boost from depression with that one. And so it doesn't always work as great with depression. But for some people it does. So, like I said, very much trial and error. And even just within that one class of drugs, there are so many options.

Dr Weis (Host): So let's say you start a patient on one of those drugs, which you said is really the foundation of how we treat these conditions, the anxiety and the depression. How fast can I expect to see a difference in my symptoms?

Dr Shyla Arismendez: Yeah. So, the frustrating thing about treating depression anxiety is that we don't necessarily have quick fixes. These medications. Ideally take four to six weeks to really start noticing the biggest effect and to see, you know, are we really getting anywhere with this? Around two weeks or so, you might start noticing more side effects, but you may not notice any actual improvement. So it does take a little while to, see are we actually getting somewhere with this medication?

Dr Weis (Host): Yeah, obviously for years, we didn't have these drugs for a long time, and they were a major breakthrough when they came out. But we know you used to see a lot of people for anxiety. They were on things like Valium or Xanax or Klonopin. This, category of drugs called the benzodiazepines. Why don't we use those anymore? Is there a problem with using those?

Dr Shyla Arismendez: Those medications are super effective in treating anxiety. They're quick, they work fast. Pretty much everybody feels relief from them. However, one, they are very addictive. We have to be very careful if and when we use them. very, very careful with the addictive properties. There are also some more evidence showing that if you've been on benzodiazepines for a very long time, you could have a higher risk for dementia when you get older. They cause problems if you take too much of them, you could potentially have what's called respiratory depression, where you don't breathe as well.

That would be in higher doses. You can have withdrawal from them if you've been on a long time and you just stop taking them suddenly. Or let's say you ran outta medicines and you forgot about them, you could have withdrawals from them. That would be a whole spectrum of symptoms from just having some intolerance and filling a little jittery all the way to having like seizure. And withdrawals from those so all around just not our favorite thing to use anymore now that we've got so many other medicines.

Dr Weis (Host): Absolutely. I think that's the important thing is they were the best we had for a long time. Right. But we got so many better drugs, particularly drugs nowadays that fix the problem. I think that, that whole category, the Valiums and Xanax, you get like, you point out a bit of a roller coaster ride. You take it, you feel good for a little while, and then the symptoms come back and you get that up and down. Because they're not fixing the problem. They're in many ways masking it. And so I think these, SSRIs you point out really just foundational drugs in terms of helping people with this. Let's say someone you just can't quite get someone to that point where they're content that, that's been fixed. Do we use add-on drugs or are there other things we do that can help that person who's just, not quite getting enough effect out of that first dose?

Dr Shyla Arismendez: Right. So if we've, given it a good six weeks or so with the medicine and a patient's tolerating the medicine side effect wise, but not really seeing much effect, then we kind of look into what parts of this do you feel like is working? What do you feel is not working? We can try out a different drug within the class of SSRIs, or we can switch over to other classes, or we could do something that's called augmenting therapy. And what that is, is if we feel like you're getting some benefit, and you like it, you like the medicine, and you don't really wanna make a switch, but you feel like you need a little bit more, we can try augmenting with a different medicine.

So there's a medication called Wellbutrin or Bupropion, which works in a different way, works more with norepinephrine and that one can kind of help with, increasing your energy a little bit more, kind of perking you up a bit when you've got a lot of that, fatigue and slowed thought and everything with depression. So that's a good one. That's a common one we would augment with if you feel like you're happy with what you have. So that's an option we have. But another option is, just switching class of medication completely.

The, I think more popular. class of drugs I would see now is the SNRIs, which is serotonin, norepinephrine, reuptake inhibitors. Big word for it works for both serotonin and norepinephrine. So, having both of those effects we see really good improvement with depression, anxiety because, know, you're getting kind of leveled out with the serotonin. You're getting that nice perk, you're feeling a lot better with the norepinephrine. And then it tends to, be Pretty well-tolerated side effects wise. So lots of people are liking that. It's getting a lot more popular in these last few years I feel like. So those are medications like Duloxetine, which is Cymbalta or venlafaxine. which is Effexor. So those are some options too. Make those changes.

Dr Weis (Host): Yeah. And you've talked about some big words like the norepinephrine, serotonin, these basically chemical messengers in our brain. So these, and I think what we've realized now is that depression is not a willpower thing. It's not just. Just need to snap out of it kind of, kind of situation. These are chemical imbalances in the brain and these medicines are addressing those. And so that's what people need to realize that it's not a willpower thing. These are, particularly when you get into panic attacks and all, there's nothing you can do to control of that.

It just, it happens. So, great. How about in terms you obviously got medications, but how about lifestyle changes or lifestyle modifications that could help in terms of, lifting the mood or, relieving anxiety?

Dr Shyla Arismendez: Yeah, so baseline for anybody I feel like, even if you don't have any struggles with depression or anxiety or any sort of mental health aspect, I think just counseling in general is good because we're humans and we're all operating in this thing we call life and there's no manual for that. And we've all gotta learn how to interact with our daily life. And if you're ever questioning is this the right way to handle this? Or how do I process these thoughts? Counseling's a great option. It just, somebody who is trained in thinking essentially. How do you, manage your lifestyle, your thoughts, your behaviors, things you can do to actually do better in life.

And so if you've got depression, anxiety, any other mental health disorder counseling should definitely be part of your, therapy, because it just helps so much with learning, things you can do yourself. to, help control your thoughts more, things like, deep breathing and stopping to think about what you're feeling, what you're thinking.

Dr Weis (Host): I think a lot of the counseling is in many ways it teaches coping skills, if that kind of thing. And then, boy, your point is excellent. There have been incredible studies on the value of meditation and daily meditation. And again, we're not talking about, sitting in a lotus position for two hours. I mean, when we're talking about meditation, it can be 10 to 15 minutes of essentially just focusing your attention on just your breathing. Right. But it clears the mind. and there's been great data on the fact that that alone can help in terms of relaxation. And just learning to better Manage your own feelings and, physical being in those times of stress, relaxation therapy, things like that. So, lots of tools out there beyond just the medications.

Dr Shyla Arismendez: Right. And they're so much more accessible now than it used to be. You, I mean, a quick YouTube search will find good guided meditation. Just, two minutes even of just sitting there and having somebody walk you through, let's just, think about your draw, are you clenching it, release that pressure, things like that. And it really helps you be more in tune with your body.

Dr Weis (Host): Good point. I mean, like you said, YouTube, apps you can download on your phone right now can walk you through meditations. Yeah. Just, the resources are endless at this point, like the modern era and the internet. Stuff like that. So, but again, I think it's many ways to help address people individually. There's just so many tools and a lot of times it is just literally trying to find the right, grouping of tools that help that person, whether it be medication or some of these lifestyle changes and can really make a big difference.

So, Let's say you have someone that gets past the holidays, maybe that's a bad time for them, as you point out, there's maybe triggers during the holidays that lead to some of this. Do people need to stay on these drugs indefinitely? What do you do with the medications after maybe they say, well, I kind of feel a lot better at this point?

Dr Shyla Arismendez: You know, that's a kind of complicated question, but everybody's different. When it comes to mental health. These drugs, the treatment, everything, everybody's different. There's absolutely nothing wrong with having to be on medicine for the rest of your life, and that's okay. There are some people that can experience some clear triggers. They know what they are, they get into counseling where they start learning themselves a lot better and they really beef up their mental health and wellness and they feel pretty good and they know what they need to do and how to work through all of these things.

And eventually they can come off medications. But for a lot of people, it's very hard to really dig into your mind and, figure out what are your triggers, what are the things that are hard? And sometimes there's not a clear trigger. There's not a clear reason. And for a lot of people it really is just chemical imbalance and for a lot of people you do need to be on medicines for a long time. So it's really just a trial and error of, if you feel like you're doing really good, you feel like you're in a good place, a lot's changed in your life and you just really feel very healthy.

And you're ready to start weaning off of it, we can kind of taper down your dosing so that you don't, just an abrupt stopping of the medicine. Cause we don't want you to feel bad coming off of it automatically, but, we can start working on that and see how you do. And, if you are able to do good off of it, then that's awesome. We'll celebrate together. But if you're not, there's nothing wrong with that either. We'll just keep on going.

Dr Weis (Host): Absolutely. No, that's very important. I think I've had patients who are going through major life stressors, things like, losing a loved one. Yeah. Maybe having a disruption of a relationship or a divorce, changing jobs, moving to new cities. I mean, these are all major stressors in people's lives. And in many ways, these medicines can be used almost like a crutch in someone who's broken their leg just gets you past the healing part of it. And I've had patients that six months down the road say, you know what, those stressors are gone and I think I can go alone at this point.

And then I said, yeah, the people that really, have that struggle their whole life and that these medicines become vital to their function. But you made a very good point, is what you don't wanna do is stop any of these medicines abruptly. Because they are changing chemicals in the brain. And when you stop it, all of a sudden you'll get a sudden fallback to baseline or something that, and people will feel that. So it has to be done under doctor's supervision to reduce that drug and then eventually eliminate it. So, well, fantastic. We hit a lot of topics today.

And I really appreciate your insight. I think what I heard in many ways you say is first it's very important that people are open with their physicians. what they're feeling, particularly when we give 'em these questionnaires, it allows us to maybe get that insight and maybe something's going on. And then second, once we identify it, it's very treatable. so, any other things that you wanna bring up in terms about this topic before we close out today?

Dr Shyla Arismendez: Oh, I would just say that, If you are struggling in any sort of way, please do not feel ashamed. Do not feel like there's something wrong with you. Come and talk with us. We are happy to help. We definitely can help you. And the other thing would be that, even if you're not struggling, if you just are thinking, what can I do just to feel a little bit better with my mental health? There's lots of things you can do to kind of help prevent, having some, derailing whenever something bad does happen. You can certainly work on coping mechanisms and learning how to deescalate when you're feeling really stressed out, deep breathing, all that good stuff. You can also work on practicing mindfulness, that mindfulness and meditation aren't the same thing.

They occur together a lot, but mindfulness is. Just paying attention to your mind. What are you thinking? Where are you at in this moment? And that's something that can be done in an instant when you're just sitting driving, be thinking, where am I at right now? Where's my mind? What am I thinking about? And then you can think about your body and you think like am I feeling tense? Am I feeling sick to my stomach? Am I feeling headaches? Anything like that? And then once you start, Practicing that mindfulness, you start finding, this mind body connection. You start learning your whole self all over and that just makes it so much easier to just feel mentally stronger moving forward.

Dr Weis (Host): Fantastic. Outstanding. Great points. So once again, thank you so much for being on a podcast. Really appreciate all your insight and to this very important topic, particularly this time of year. Well then we will, finish out there and we will see everyone on the next edition of Get Wise With Weiss. Thank you.