Podcasts about snris

Vilazodone (brand name Viibryd) is an antidepressant with a unique pharmacologic profile compared to most other agents in the SSRI class. While not a first-line choice for every patient, understanding its mechanism, adverse effects, and interaction profile is essential for optimizing therapy and preventing downstream prescribing problems. Mechanism of ActionVilazodone is classified as a selective serotonin reuptake inhibitor (SSRI) and a partial agonist at the 5-HT1A receptor. The SSRI activity increases synaptic serotonin by blocking the serotonin transporter, while partial agonism at 5-HT1A receptors may contribute to antidepressant effects and potentially reduce certain SSRI-associated adverse effects (though clinical evidence for this benefit is mixed). Adverse Effects GI effects – diarrhea, nausea, and vomiting are frequent early in therapy. Taking the medication with food can help minimize these. Insomnia – often dose-related; morning dosing may help. Sexual dysfunction – may be slightly lower than with some SSRIs but still present. Serotonin syndrome – rare but serious, particularly if combined with other serotonergic drugs. Discontinuation syndrome – abrupt cessation can lead to dizziness, irritability, and flu-like symptoms. Drug InteractionsVilazodone is primarily metabolized by CYP3A4. This means: CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin, ritonavir) can increase vilazodone concentrations, potentially worsening side effects—dose reductions may be required. CYP3A4 inducers (e.g., carbamazepine, rifampin, St. John's Wort) can lower drug levels, reducing effectiveness. Other serotonergic agents (e.g., triptans, SNRIs, MAOIs, tramadol, linezolid) increase the risk of serotonin syndrome. Antiplatelets and anticoagulants – SSRIs can impair platelet aggregation, increasing bleeding risk when combined with aspirin, NSAIDs, or warfarin. Prescribing Cascade ExamplesVilazodone's adverse effects can easily lead to unnecessary prescriptions if side effects aren't recognized: GI upset → Acid suppression therapy – Diarrhea or nausea prompts the addition of proton pump inhibitors or antiemetics, instead of adjusting vilazodone dose or timing. Insomnia → Hypnotic initiation – Trouble sleeping results in adding zolpidem or trazodone, without reassessing morning dosing or vilazodone's role. Sexual dysfunction → PDE5 inhibitor prescription – Erectile dysfunction leads to sildenafil use, when the root cause is vilazodone's serotonergic activity. Vilazodone's combination of SSRI and 5-HT1A partial agonist activity makes it somewhat distinct, but its side effect profile and interactions require the same careful monitoring as other antidepressants. Healthcare professionals can play a key role in catching early signs of adverse effects, preventing prescribing cascades, and ensuring drug–drug interactions are managed appropriately.

In this episode of our pharmacology podcast, we take a deep dive into the pharmacology of levomilnacipran (Fetzima), a unique serotonin-norepinephrine reuptake inhibitor (SNRI) approved for the treatment of major depressive disorder (MDD) in adults. Designed for pharmacy students, clinicians, and anyone interested in psychopharmacology, this episode breaks down what makes levomilnacipran different from other antidepressants and how to use it effectively in clinical practice. We explore levomilnacipran's mechanism of action, which features a greater affinity for norepinephrine reuptake inhibition compared to serotonin—an uncommon trait among SNRIs. This pharmacologic profile gives it a distinctive effect on energy, motivation, and physical symptoms of depression. Listeners will also learn about its pharmacokinetics, including once-daily dosing, renal elimination, and metabolism via the CYP3A4 pathway—making drug interactions an important consideration. The episode also covers levomilnacipran side effects, including common adverse reactions like nausea, dry mouth, constipation, and increased heart rate or blood pressure. We'll also highlight rare but serious risks like serotonin syndrome and urinary hesitation. Because levomilnacipran drug interactions can impact safety and efficacy, we review important combinations to avoid, such as CYP3A4 inhibitors (e.g., ketoconazole), serotonergic drugs, and blood pressure-altering agents. For pharmacists and prescribers, this is a key segment to help guide safer medication use and monitoring. Finally, we wrap up with clinical pearls for starting, titrating, and monitoring levomilnacipran therapy—including renal dose adjustments and differences with duloxetine. Whether you're studying for boards or optimizing your patient's antidepressant regimen, this episode delivers a concise, evidence-based overview of levomilnacipran pharmacology in a digestible, podcast-friendly format.

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

Summary In this episode of the Pain Exam Podcast, Dr. David Rosenblum provides a comprehensive review of herpes zoster and postherpetic neuralgia (PHN), focusing on pathophysiology, diagnosis, and treatment options. Dr. Rosenblum explains that postherpetic neuralgia affects approximately 25% of patients with acute herpes zoster, causing debilitating unilateral chronic pain in one or more dermatomes. He discusses the three phases of herpes zoster: acute (up to 30 days), subacute (up to 3 months), and postherpetic neuralgia (pain continuing beyond 3 months). Dr. Rosenblum identifies risk factors for developing PHN, including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. He details the pathophysiology involving peripheral and central sensitization, and explains different phenotypes of PHN that can guide treatment approaches. For treatment, Dr. Rosenblum reviews various options including antiviral medications (which should be started within 72 hours of onset), corticosteroids, opioids, antidepressants (particularly tricyclics and SNRIs), antiepileptics (gabapentin and pregabalin), topical agents (lidocaine and capsaicin), and interventional procedures such as epidural injections and pulsed radiofrequency. He emphasizes that prevention through vaccination with Shingrix is highly effective, with 97% effectiveness in preventing herpes zoster in patients 50-69 years old and 89% effectiveness in those over 70. Dr. Rosenblum mentions that he's currently treating a patient with trigeminal postherpetic neuralgia and is considering a topical sphenopalatine ganglion block as a minimally invasive intervention before attempting more invasive procedures. Chapters Introduction to the Pain Exam Podcast and Topic Overview Dr. David Rosenblum introduces the Pain Exam Podcast, mentioning that it covers painful disorders, alternative treatments, and practice management. He explains that this episode focuses on herpes zoster and postherpetic neuralgia as board preparation for fellows starting their programs, with ABA boards coming up in September. Dr. Rosenblum notes that he's not only preparing listeners for boards but also seeking the latest information to help treat his own patients with this notoriously difficult disease. Upcoming Conferences and Educational Opportunities Dr. Rosenblum announces several upcoming conferences including Aspen in July, Pain Week in September, and events with NYSIP and the Latin American Pain Society. He mentions he'll be teaching ultrasound and regenerative medicine at these events. Dr. Rosenblum invites listeners to sign up at nrappain.org to access a community discussing regenerative medicine, ultrasound-guided pain medicine, regional anesthesia, and board preparation. He also offers ultrasound training in New York and elsewhere, with upcoming sessions in Manhattan on July 12th and October 4th, plus private shadowing opportunities. Overview of Postherpetic Neuralgia Dr. Rosenblum defines postherpetic neuralgia as typically a unilateral chronic pain in one or more dermatomes after acute herpes zoster infection. He states that the incidence of acute herpes zoster ranges between 3-5 patients per thousand person-years, and one in four patients with acute herpes zoster-related pain will transition into postherpetic neuralgia. Dr. Rosenblum emphasizes that while this condition won't kill patients, it can be extremely debilitating and significantly reduce quality of life. Treatment Options Overview Dr. Rosenblum reviews treatment options according to the WHO pain ladder, including tricyclics like nortriptyline and antiepileptic drugs such as gabapentin. He explains that if pain is not significantly reduced, interventional treatments like epidural injections with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion are options. For postherpetic neuralgia specifically, Dr. Rosenblum notes that preferred treatments include transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Phases of Herpes Zoster and Definitions Dr. Rosenblum outlines the three phases during herpes zoster reactivation: acute herpes zoster-related pain (lasting maximum 30 days), subacute herpes zoster-related pain (pain after healing of vesicles but disappearing within 3 months), and postherpetic neuralgia (typically defined as pain continuing after 3 months). He mentions that acute herpes zoster pain often begins with prodromal pain starting a few days before the appearance of the rash. Incidence and Risk Factors Dr. Rosenblum states that the incidence of herpes zoster ranges between 3-5 patients per 1,000 person-years, with approximately 5-30% of cases leading to postherpetic neuralgia. He identifies risk factors including older age, female sex, immunosuppression, prodromal pain, severe rash, and greater acute pain severity. Dr. Rosenblum describes the clinical manifestations as a mosaic of somatosensory symptoms including burning, deep aching pain, tingling, itching, stabbing, often associated with tactile and cold allodynia. Impact on Quality of Life Dr. Rosenblum emphasizes that postherpetic neuralgia can be debilitating, impacting both physical and emotional functioning and causing decreased quality of life. He notes that it leads to fatigue, insomnia, depression, anorexia, anxiety, and emotional distress. Dr. Rosenblum stresses the importance of exploring methods for prevention of postherpetic neuralgia and optimizing pain treatment for both subacute herpes zoster-related pain and postherpetic neuralgia. Literature Review and Pathophysiology Dr. Rosenblum mentions that he's discussing a literature review from 2024 that updates previous practical guidelines published in 2011. He explains the pathophysiology of postherpetic neuralgia, which involves sensitization of peripheral and sensory nerves from damage. Dr. Rosenblum describes how inflammatory mediators reduce the stimulus threshold of nociceptors and increase responsiveness, resulting in pathological spontaneous discharges, lower thresholds for thermal and mechanical stimuli, and hyperalgesia. Central Sensitization and Nerve Damage Dr. Rosenblum explains that central sensitization results from peripheral nociceptor hyperactivity leading to plastic changes in the central nervous system, involving amplification of pain signals and reduced inhibition. He describes how nerve damage in postherpetic neuralgia patients results from neuronal death due to severe inflammatory stimuli or secondary to neuronal swelling. Dr. Rosenblum notes that motor defects occur in 0.05% of patients with herpes zoster, observed as abdominal pseudohernias or motor weakness of limbs limited to the affected myotome. Different Phenotypes and Classification Dr. Rosenblum discusses different phenotypes of postherpetic neuralgia and how phenotyping can determine treatment. He explains that there are several ways to classify the phenotypes, with one categorizing patients into three subtypes: sensory loss (most common), thermal gain, and thermal loss with mechanical gain. Dr. Rosenblum describes the mechanistic categorization, including the irritable nociceptive phenotype characterized by preserved sensation, profound dynamic mechanical allodynia, reduced pressure pain threshold, and relief with local anesthetic infiltration. Deafferentation Phenotype Dr. Rosenblum explains that a deafferentation phenotype may arise from destruction of neurons by the virus in the dorsal root ganglion. This phenotype is characterized by sensory loss, including thermal and vibratory sensation without prominent thermal allodynia. He notes that mechanical allodynia can occur secondary to A-beta fibers activating spinothalamic pathways (known as phenotypic switches), along with pressure hyperalgesia and temporal summation suggesting central sensitization. Dr. Rosenblum mentions that in one study, this phenotype was present in 10.8% of individuals, and for those with deafferentation pain, gabapentinoids, antidepressants, and neuromodulatory therapies like repetitive transcranial magnetic stimulation may be beneficial. Diagnosis and Physical Examination Dr. Rosenblum discusses the diagnosis of herpes zoster and postherpetic neuralgia, emphasizing the importance of physical examination. He explains that diagnosis is based on the rash, redness, papules, and vesicles in the painful dermatomes, with healing vesicles showing crust formation. Dr. Rosenblum notes that the rash is generally unilateral and does not cross the midline of the body. In postherpetic neuralgia patients, he mentions that scarring, hyper or hypopigmentation is often visible, with allodynia present in 45-75% of affected patients. Sensory Testing and Assessment Dr. Rosenblum explains that in patients with postherpetic neuralgia, a mosaic of somatosensory alterations can occur, manifesting as hyperalgesia, allodynia, and sensory loss. These can be quantified by quantitative sensory testing, which assesses somatosensory functions, dermal detection thresholds for perception of cold, warmth, and paradoxical heat sensations. He notes that testing can provide clues regarding underlying mechanisms of pain, impaired conditioned pain modulation, temporal summation suggesting central sensitization, and information about the type of nerve damage and surviving afferent neurons. Prevention Through Vaccination Dr. Rosenblum discusses prevention of acute herpes zoster through vaccination, noting that the risk increases with reduced immunity. He highlights studies evaluating Shingrix, a vaccine for herpes zoster, which showed 97% effectiveness in preventing herpes zoster in patients 50-69 years old with healthy immune systems and 89% effectiveness in patients over 70. Dr. Rosenblum states that Shingrix is 89-91% effective in preventing postherpetic neuralgia development in patients with healthy immune systems and 68-91% effective in those with weakened or underlying conditions. Treatment Objectives Dr. Rosenblum outlines the treatment objectives for herpes zoster and postherpetic neuralgia. For acute herpes zoster, objectives include relieving pain, reducing severity and duration of pain, accelerating recovery of epidermal defects, and preventing secondary infections. For postherpetic neuralgia, the objectives are pain alleviation and improved quality of life. Dr. Rosenblum lists available treatments including psychotherapy, opiates, antidepressants, antiepileptics, NMDA antagonists, topical agents, and interventional treatments such as epidurals, pulsed radiofrequency, nerve blocks, and spinal cord stimulation. Antiviral Medications Dr. Rosenblum emphasizes that antiviral drugs should be started within 72 hours of clinical onset, mentioning famciclovir, valacyclovir, and acyclovir. He notes there is no evidence for effectiveness after 72 hours in patients with uncomplicated herpes zoster. Dr. Rosenblum provides dosing information: for immunocompetent patients, famciclovir 500mg and valacyclovir 1000mg three times daily for seven days; for immunocompromised patients, famciclovir 1000mg three times daily for 10 days, while acyclovir should be given IV in the immunocompromised. Benefits of Antiviral Therapy Dr. Rosenblum explains that antiviral medication accelerates the disappearance of vesicles and crusts, promotes healing of skin lesions, and prevents new lesions from forming. By inhibiting viral replication, he notes that antiviral therapy likely reduces nerve damage, resulting in reduced incidence of postherpetic neuralgia, and should be started as soon as possible. Corticosteroids and Opioids Dr. Rosenblum discusses the use of corticosteroids, noting that when added to antiviral medications, they may reduce the severity of acute herpes zoster-related pain, though increased healing of skin lesions was not observed in one study. He mentions that a Cochrane review found oral corticosteroids ineffective in preventing postherpetic neuralgia. Regarding opioids, Dr. Rosenblum states they are commonly used alongside antivirals for controlling acute herpes zoster pain, with tramadol having a number needed to treat (NNT) of 4.7 and strong opioids having an NNT of 4.3 for 50% pain reduction. Methadone and Antidepressants Dr. Rosenblum discusses methadone as an NMDA receptor antagonist used in acute and chronic pain management, though he notes there are no randomized controlled trials determining its efficacy in acute herpes zoster pain or postherpetic neuralgia. He explains that methadone can modulate pain stimuli by inhibiting the uptake of norepinephrine and serotonin, resulting in decreased development of hyperalgesia and opioid tolerance, but has side effects including constipation, nausea, sedation, and QT prolongation that can trigger torsades de pointes. Dr. Rosenblum identifies antidepressants as first-line therapy for postherpetic neuralgia, including tricyclics and SNRIs, with tricyclics having an NNT of 3 and SNRIs an NNT of 6.4 for 50% pain reduction. Antiepileptics and Pharmacological Treatment Summary Dr. Rosenblum discusses antiepileptics like gabapentin and pregabalin for postherpetic neuralgia. He cites two trials measuring gabapentin's effect, concluding it was effective compared to placebo with a pooled NNT of 4.4, while pregabalin had an NNT of 4.9. Dr. Rosenblum summarizes that pharmacological treatment is well established for subacute herpes zoster pain, though new high-quality evidence has been lacking since the last update in 2011. Topical Agents Dr. Rosenblum discusses local anesthetic topical agents including lidocaine and capsaicin creams and patches. He notes that 8% capsaicin provided significant pain reduction during 2-8 weeks, while 5% lidocaine patches provided moderate pain relief after eight weeks of treatment. Dr. Rosenblum also mentions acute herpes zoster intracutaneous injections, citing a study where single intracutaneous injection with methylprednisolone combined with ropivacaine versus saline alone showed significant difference in VAS score at 1 and 4 weeks post-intervention favoring the intervention group. Intracutaneous Injections Dr. Rosenblum discusses the effect of repetitive intracutaneous injections with ropivacaine and methylprednisolone every 48 hours for one week. He cites a randomized control trial comparing antivirals plus analgesics to antivirals plus analgesics and repeat injections, finding the intervention group had significantly shorter duration of pain, lower VAS scores, and lower incidence of postherpetic neuralgia (6.4% vs 28% at 3 months). Dr. Rosenblum notes that a potential side effect of cutaneous methylprednisolone injection is fat atrophy, though this wasn't reported in the study. Summary of Local Anesthetics Dr. Rosenblum summarizes that there are no new studies reporting the efficacy of capsaicin 8% for postherpetic neuralgia, but it remains widely used in clinical practice and is approved in several countries. He notes that lidocaine patches can reduce pain intensity in patients with postherpetic neuralgia but may be more beneficial in patients with allodynia. Dr. Rosenblum adds that intracutaneous injections may be helpful for short periods, while repetitive injections with local anesthetics may reduce VAS scores for up to six months but can cause subcutaneous fat atrophy. Interventional Treatments: Epidural and Paravertebral Injections Dr. Rosenblum discusses interventional treatments, noting that previous guidelines found epidural injection with corticosteroids and local anesthetic as add-on therapy superior to standard care alone for up to one month in managing acute herpes zoster pain. He mentions a randomized controlled trial showing no difference between interlaminar and transforaminal epidural steroid injections for up to three months after the procedure. Dr. Rosenblum adds that previous guidelines reported high-quality evidence that paravertebral injections of corticosteroids or local anesthetic reduces pain in the active phase of herpes zoster. Comparative Studies on Injection Approaches Dr. Rosenblum discusses a trial comparing efficacy of repetitive paravertebral blocks with ropivacaine versus dexmedetomidine to prevent postherpetic neuralgia, which showed significantly lower incidence of zoster-related pain one month after therapy in the dexmedetomidine group, with effects still significant at three months. He also mentions a study comparing steroid injections administered via interlaminar versus transforaminal approaches, finding both groups had significantly lower VAS scores at 1 and 3 months follow-up compared to baseline, though this could align with the natural course of herpes zoster. Timing of Interventions and Continuous Epidural Blockade Dr. Rosenblum cites a retrospective study showing that transforaminal epidural injections administered for acute herpes zoster-related pain were associated with significantly shorter time to pain relief compared to those performed in the subacute phase. He also mentions a randomized controlled trial finding that continuous epidural blockade combined with opioids and gabapentin reduced NRS pain scores more than analgesic drug treatments alone during three-day follow-up, though both studies were low-quality. Interventions for Postherpetic Neuralgia Dr. Rosenblum discusses interventions specifically for postherpetic neuralgia, citing a small randomized controlled trial that demonstrated decreased NRS pain scores six months post-treatment for repeat versus single epidural steroid injections (15mg vs 5mg dexamethasone) administered over 24 days. The trial also found increased likelihood of complete remission during 6-month follow-up in the group receiving repeat epidural dexamethasone, though this was low-quality evidence. Summary of Epidural and Paravertebral Injections Dr. Rosenblum summarizes that epidural or paravertebral injections of local anesthetic and/or glucocorticoids could be considered in treating acute herpes zoster-related pain. For subacute postherpetic neuralgia pain, he notes low-quality evidence supporting epidural injections, while for postherpetic neuralgia, evidence supports continuous epidural infusion, though also of low quality. Dr. Rosenblum emphasizes that none of the included studies for postherpetic neuralgia investigating epidural or paravertebral injections resulted in decreased pain compared to standard therapy. Pulsed Radiofrequency (PRF) Evidence Dr. Rosenblum discusses pulsed radiofrequency (PRF), noting that previous guidelines indicated moderate quality evidence that PRF of the intercostal nerve reduces pain for 6 months in patients with postherpetic neuralgia, and very low-quality evidence that PRF to the dorsal root ganglion (DRG) reduces pain for 6 months. He mentions that multiple studies have been published since then assessing PRF efficacy. PRF Studies for Acute Herpes Zoster Dr. Rosenblum discusses a randomized controlled trial with 60 patients comparing high-voltage bipolar PRF of the cervical sympathetic chain versus sham, with treatment repeated after three days in both groups. He reports that VAS scores in the PRF group at each post-interventional point (1 day, 2 days, 1 month, 2 months, 3 months) were significantly lower than in the sham group, and at 3 months, the incidence of postherpetic neuralgia was 16.7% in the PRF group compared to 40% in the sham group. PRF for Trigeminal Neuralgia Dr. Rosenblum cites another randomized controlled trial evaluating high-voltage long-duration PRF of the Gasserian ganglion in 96 patients with subacute herpes-related trigeminal neuralgia, which found decreased VAS pain scores at all post-interventional time points (3, 7, 14 days and 1, 3, and 6 months) compared to the sham group. He also mentions a randomized comparative effectiveness study in 120 patients with subacute trigeminal herpes zoster, comparing a single application of high-voltage PRF to the Gasserian ganglion versus three cycles of conventional PRF treatment, finding significantly lower mean VAS pain scores for up to six months in the high-voltage PRF group. PRF Compared to Other Interventions Dr. Rosenblum discusses a randomized controlled trial comparing PRF to short-term spinal cord stimulation, which found decreased pain and improved 36-item short-form health survey scores in both groups at six months. He also mentions a randomized controlled trial in 72 patients where PRF of spinal nerves or peripheral branches of cranial nerves combined with five-day infusion of IV lidocaine resulted in greater pain reduction, less rescue analgesia, and reduced inflammatory cytokines at two months compared to PRF with saline infusions. Dr. Rosenblum notes a major limitation of this study was not accounting for the high natural recovery rate. Summary of PRF and Final Recommendations Dr. Rosenblum summarizes that PRF provides significant pain relief lasting over three months in patients with subacute herpes zoster and postherpetic neuralgia. He notes that since few studies have compared PRF versus sham, it's not possible to calculate an accurate number needed to treat. Dr. Rosenblum mentions there are no comparative studies comparing PRF to the intercostal nerves versus PRF of the DRG, but both preclinical and clinical studies suggest superiority of the DRG approach. He adds that evidence for spinal cord stimulation for postherpetic neuralgia is of low quality, and more research is needed given its invasive nature. Sympathetic Blocks and Conclusion Dr. Rosenblum notes there is low-quality evidence for using sympathetic blocks to treat acute herpes zoster-related pain, but no evidence for their use in postherpetic neuralgia. He mentions that risks of treatment with intrathecal methylprednisolone are unclear and therefore not recommended. Dr. Rosenblum concludes by praising the comprehensive article he's been discussing and mentions it provides insight for treating his patients, including a recent case of trigeminal postherpetic neuralgia. Personal Clinical Approach and Closing Dr. Rosenblum shares that he doesn't currently perform PRF in his practice, partly because it's not standard of care and not well reimbursed, creating barriers to implementation. However, he notes that PRF is a very safe procedure as it doesn't involve burning tissue. For his patient with trigeminal neuralgia pain, Dr. Rosenblum plans to try a topical sphenopalatine ganglion block as the least invasive intervention before considering injecting the trigeminal nerves at the foramen, in addition to pharmacotherapy. He concludes by thanking listeners, encouraging them to check the show notes and links, mentioning institutional memberships and shadowing opportunities, and asking listeners to rate and share the podcast. Q&A No Q&A session in this lecture Pain Management Board Prep   Ultrasound Training REGISTER TODAY!   Create an Account and get Free Access to the PainExam- NRAP Academy Community Highlights     David Rosenblum, MD, currently serves as the Director of Pain Management at Maimonides Medical Center and AABP Integrative Pain Care.  As a member of the Department of Anesthesiology, he is involved in teaching, research, CME activities, and was key faculty in developing the anesthesiology residency's regional anesthesia block rotation, as well as institutional wide acute and chronic pain management protocols to ensure safe and effective pain management. He currently is a managing partner in a multi-physician private pain practice, AABP Integrative Pain Care, located in Brooklyn, NY. He is one of the earliest interventional pain physicians to integrate ultrasound guidance to improve the safety and accuracy of interventional pain procedures.   Awards New York Magazine: Top Doctors: 2016, 2017, 2018, 2021, 2022, 2023, 2024, 2025 Schneps Media: 2015, 2016, 2017, 2019, 2020 Top Doctors New York Metro Area (digital guide): 2016, 2017, 2018, 2019, 2020, 2021, 2022, 2023 2025 Schneps Media - Brooklyn Courier Life: 2021, 2022, 2023   Dr. Rosenblum written several book chapters on Peripheral Neuromodulation, Radiofrequency Ablation, and Pharmacology.  He has published numerous noteworthy articles and most recently is developing the ASIPP Guidelines for Peripheral Neuromodulation in the treatment of chronic pain. He has been named several times in NY Magazine's Best Pain Management Doctor List, Nassau County's Best Pain Physician, has appeared on NY1 News, and has made several appearances on XM Radio's Doctor Talk. He currently is lecturing on a national and international level and has partnered with the American Society of Interventional Pain Physicians (ASIPP), American Society of Pain and Neuroscience (ASPN), IASP Mexican Chapter, Eastern Pain Association (EPA), the North American Neuromodulation Society (NANS), World Academy of Pain Medicine United, as well as various other organizations, to support educational events and develop new courses. Since 2008, he has helped over 3000 physicians pass the Pain Management Boards, and has been at the forefront of utilizing ultrasound guidance to perform pain procedures.  He now hosts the PainExam podcast, AnesthesiaExam Podcast, PMRExam Podcasts and uses this platform to promote the safe and effective use of ultrasound in the performance of various procedures such as Peripheral Nerve Stimulation, Caudal Epidurals, Selective Nerve Root Blocks, Cluneal Nerve Blocks, Ganglion impar Blocks, Stellate Ganglion Blocks, Brachial Plexus Blocks, Joint Injections and much more!   Doctor Rosenblum created the NRAP (Neuromodulation Regional Anesthesia and Pain) Academy  and travels to teach various courses focused on Pain Medicine, Regenerative Medicine, Ultrasound Guided Pain Procedures and Regional Anesthesia Techniques.  Dr. Rosenblum is persistent when it comes to eliminating pain and has gained a reputation among his patients for thinking "outside the box" and implements ultrasound guidance to deposit medications, biologics (PRP, Bone Marrow Aspirate, etc.) and Peripheral Nerve Stimulators near pain generators. He is currently treating patients in his great neck and Brooklyn office.  For an appointment go to AABPpain.com or call Brooklyn     718 436 7246 Reference Adriaansen, E. J., Jacobs, J. G., Vernooij, L. M., van Wijck, A. J., Cohen, S. P., Huygen, F. J., & Rijsdijk, M. (2025). 8. Herpes zoster and post herpetic neuralgia. Pain Practice, 25(1), e13423.

In this podcast episode Dr. Dee talks about how the Western approach to health issues, especially mental health, is to treat the symptoms but it fails to address the root cause what is going on in the body and brain. Most doctors continue to try different SSRIs and SNRIs to help relieve symptoms for their patients, but this does not address the underlying cause of these symptoms, which is brain health. Dr. Dee explores how to improve brain health so that the symptoms go away AND you are healthier in the process.

In this episode of the HealthspanMD Podcast, Dr. Robert Todd Hurst, MD, FACC, FASE is joined by concierge psychiatrist Dr. Mona Amini, MD, MBA. They dive into one of the most overlooked components of longevity: mental health. Discussing the limitations of traditional psychiatry, the stigma still surrounding mental health, and why a customized, integrative approach is the key to lasting wellness. From supplements and sleep to trauma and therapy, this conversation is packed with powerful insights to help you or someone you love take the next step toward mental and physical well-being.  Dr. Mona Amini, MD, MBA is a board-certified psychiatrist practicing concierge psychiatry in Phoenix, Arizona. Known for her vibrant presence and trailblazing approach, Dr. Mona integrates lifestyle, supplementation, and holistic therapies alongside traditional treatment to create individualized care plans. With a strong focus on breaking mental health stigma and bringing humanity back into psychiatry, she's transforming how we think about mental wellness.  Key Time Stamps  00:00 – Introduction to today's topic and guest  02:00 – Why traditional psychiatry fails patients & Dr. Mona's path away from it  05:10 – The power of getting to know your patients on a deeper level   10:50 – Mental health stigma and the role of social media  13:05 – The connection between cardiology and mental health symptoms  15:15 – How Dr. Mona builds trust with hesitant patients  19:40 – Advice for finding the right mental health provider  23:40 – Every path to a healthy life is unique  27:00 – Are SSRIs and SNRIs overprescribed?  31:00 – How looking at all aspects of life are critical to health  34:25 – How supplements and deficiencies impact mental health  38:30 – Healing is hard, and the patient gets to choose the next step  40:45 – The spectrum of clients Dr. Mona sees  43:55 – Dr. Mona's best patient  46:00 – How a major depressive disorder doesn't have to be a lifetime diagnosis  46:50 – What to expect from a concierge psychiatry intake with Dr. Mona  48:20 – How to connect with Dr. Mona  This information is for educational purposes only and is not medical advice. Don't make any decisions about your medical treatment without first talking to your doctor.  Connect with Dr. Mona Amini and Mon'Vie Mind Wellness here:  http://www.monaaminimd.com  https://www.instagram.com/mona.amini.md/#  https://www.facebook.com/monaaminimd  http://www.linkedin.com/in/monaaminimd  https://www.youtube.com/@monaaminimd  https://www.tiktok.com/@notyourtypicalpsych  Connect with HealthspanMD:  https://www.linkedin.com/company/healthspanmd/   https://www.facebook.com/healthspanmd   https://www.instagram.com/healthspanmd/  https://quiz.healthspanmd.com/  

Dr. Casey Grover breaks down psychiatric medications and their role in addiction treatment, explaining how different medications work, when they're most appropriate, and which ones to avoid. He provides a practical overview based on his extensive experience treating patients with substance use disorders.• Psychiatric medications get developed through research on brain receptors and undergo rigorous testing before FDA approval• Medications often have "off-label" uses that weren't originally intended but provide benefits in certain situations• Antidepressants like SSRIs and SNRIs serve as the foundation for treating depression in people with addiction• Using non-addictive options like hydroxyzine, clonidine, and buspirone is crucial when treating anxiety in recovery• Trazodone and mirtazapine are preferred for sleep issues over benzodiazepines and "Z-drugs" that can create dependence• ADHD treatment requires careful consideration when patients have stimulant use disorder histories• Benzodiazepines should be avoided when possible as they paradoxically worsen anxiety over time• Medication selection should consider urgency of conditions, past medication responses, and potential side effects• Some psychiatric conditions may improve with therapy allowing medication reduction, while others require long-term treatmentThank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Remember, treating addiction saves lives.To contact Dr. Grover: ammadeeasy@fastmail.com

Can medication truly transform the landscape of pediatric mental health, or are we oversimplifying the complexities of growing minds? In this episode of Pediatric Meltdown, Dr. Lia Gaggino welcomes Dr. Jess Pierce, a hospital-based child psychiatrist whose expertise bridges the worlds of pediatrics and mental health, especially for children in rural areas. Unraveling the fascinating history of psychopharmacology and delving into the mechanisms of action for the antidepressants, this episode offers a roadmap for pediatricians navigating the maze of SSRIs, SNRIs, risks like serotonin syndrome, and difficult conversations about side effects. The nuances matter and Dr. Pierce guides us skillfully.Discover why family history, patient buy-in, and transparent communications are pivotal to successful treatment—and why prescribing for young people demands a delicate blend of science, art, and empathy. This conversation will change the way you see—and approach—medication and the treatment of kids' mental health.[00:08:51] Exploring Pediatric Psychopharmacology's RootsTracing the unexpected origins of antidepressants, including how tuberculosis and hypertension treatments led to modern psychopharmacologyThe monoamine hypothesis: understanding the neurotransmitter focus in early depression treatmentsThe move beyond serotonin, dopamine, and norepinephrine: new research on neurobiology, neurogenesis, and stress responseProzac's arrival and its impact in reshaping the treatment landscape for pediatric mental health[08:52- 18:06 ] SSRIs in Practice: Similarities, Differences, and SelectionAll SSRIs share rapid absorption, high protein binding, and similar side effect profiles—but key differences can matterImportant reasons to avoid Paxil and to use Lexapro over Celexa, particularly due to side effect burdensNuanced considerations: matching specific SSRIs to individual patient needs, such as Prozac's activating profile for low-energy depressionPractical dosing strategies: the art of balancing “start low and go slow” with the urgency to help suffering children[18:07- 27:59] Navigating Risks, Side Effects, and Patient MonitoringThe truth behind the Black Box Warning: clarifying risks of suicidal ideation vs. the dangers of untreated depressionWhy regular, open conversations with families about medication side effects—especially sexual side effects in teens—build trust and adherenceRecognizing and managing serotonin syndrome: how to spot symptoms and when emergency intervention is neededIdentifying high-risk drug interactions, including situations with migraine or neurology medications[28:00-45:19 ] From SNRIs to the Five-Step Prescribing Approach and BeyondHow SNRIs differ from SSRIs in action, side effects, and indication—especially in pain syndromes or where activating effects are desiredThe use of Wellbutrin as an alternative with fewer sexual side effects, and cautions for seizure-prone populationsStrategic guidelines: the five-step approach to medication choice, considering patient history, family response, symptoms, buy-in, and comorbiditiesCritical cautions with genetic testing and the limitations of using these results to guide first-line medication choices[45:20-1:00:00] Dr Lia's TakeAwaysResources Mentioned:Dr. Pierce's PPT on Pediatric Psychopharmacology Hello! Here's the link to the slides: Psychopharm...

Send Me a Message! After years of trying a myriad of psychiatric medications—SSRIs, SNRIs, NDRI's, Tricyclics (TCA), mood stabilisers, antipsychotics, stimulants, benzodiazepines, and everything in between—I've reached a breaking point. Nothing has truly worked, my anxiety has never been worse, and the side effects are piling up. My body's jittery, my mind's exhausted, and I'm stuck somewhere between sedation and overstimulation.In this episode, I open up about my plea for a full medication reset. I am wanting to strip things back and start again—clean slate, clean brain. But getting support for that? A whole other battle. This episode is about what it's like to fight for your own mental clarity when everything you've tried has left you feeling worse.--Follow my journey living with mental illness and the hard-fought lessons learned along the way. Lived experience is the driving force of this podcast, and through this lens, my stories are told. This is a raw, honest, and authentic account of how multiple psychological disorders have shaped my past and continue to influence my future.Support the showTo support the show, CLICK HEREYou can follow me on Instagram: @elliot.t.waters

In today's episode, we're going to talk about a substance that has been around for centuries but is currently gaining some attention in the health and wellness community: methylene blue. You might have heard of it as a chemical used in labs or even in aquariums as a disinfectant or anti-fungal, but what is it actually? We'll break it all down, talk about its potential benefits, and explore the side effects. We'll also get into why some people respond to methylene blue and others don't. So, let's jump right in! What is Methylene Blue? So, first things first, what exactly is methylene blue? Well, it's a synthetic dye that was first created back in the late 1800s. It was first synthesized in 1876 by a German chemist named Heinrich Caro. It was initially used as a dye for fabrics, but it didn't take long for scientists to realize that it had some remarkable medicinal properties. One of the first medical uses of methylene blue was as a treatment for malaria. In fact, it was the first synthetic drug used to treat the disease. Malaria, caused by a parasite spread by mosquitoes, was a major health crisis, particularly in tropical regions. Methylene blue was used as an antimalarial treatment because of its ability to interfere with the parasite's life cycle. In addition to treating malaria, methylene blue was also used as a diagnostic tool. It was used in medical imaging and as a staining agent in laboratories. Its bright blue color made it easy to see in different biological samples, which helped researchers track the progress of diseases and study cellular structures. Later, in the 20th century, methylene blue found other uses in medicine, such as in the treatment of methemoglobinemia, a condition where the blood can't effectively carry oxygen. It was found to be effective in treating this condition by helping to restore the blood's ability to carry oxygen. How Does Methylene Blue Work? Methylene blue boosts mitochondrial function by enhancing cytochrome c oxidase, a key enzyme involved in energy production. This helps cells produce more ATP, increasing overall energy and vitality. Additionally, it affects nitric oxide (NO) levels in the body, influencing blood vessel dilation and oxygen delivery. Let's talk a little science here.  Because methylene blue can inhibit nitric oxide synthase (NOS), particularly endothelial NOS (eNOS), it may reduce nitric oxide production and cause vasoconstriction (narrowing of blood vessels). While this may help manage conditions like sepsis or shock, it can also limit nitric oxide's vasodilatory benefits. The compound also supports nitric oxide recycling by enhancing mitochondrial function, indirectly benefiting blood flow and oxygen delivery. The Potential Benefits of Methylene Blue So, what are the potential benefits of methylene blue? Well, let's break them down. Cognitive Function: One of the most exciting areas of research is methylene blue's potential to improve cognitive function. Some studies suggest that it can enhance memory, focus, and even slow down the progression of neurodegenerative diseases like Alzheimer's. Its ability to improve mitochondrial function means your brain cells could be getting more energy, which could lead to better cognitive performance. Anti-Aging: As we mentioned earlier, its antioxidant properties can help protect cells from oxidative stress, which plays a big role in the aging process. By mitigating this stress, methylene blue may have anti-aging effects on both the brain and the body. Mental Clarity and Mood: Some users report improvements in mood and mental clarity after using methylene blue. This could be linked to its effects on mitochondrial health and energy production, but there's still much more research to be done. Cellular Health and Longevity: Beyond just improving cognitive function, methylene blue is also being studied for its broader impact on overall cellular health. The idea is that by improving mitochondrial function and reducing oxidative stress, it could help to slow down the aging of all types of cells in your body, potentially promoting longevity. So, yeah, sounds pretty cool, right? But, like anything, it's not all sunshine and rainbows. Let's talk about some potential side effects and who may not respond well to methylene blue. The Side Effects of Methylene Blue and Why Some Don't Respond to Methylene Blue As promising as methylene blue sounds, there are some side effects that come with it. For one, high doses of methylene blue can be toxic, so it's important to be cautious with its use. Some people may experience symptoms like nausea, dizziness, or headaches. Additionally, it can cause skin discoloration—yep, your skin might turn a bit blue, though it's temporary. Now, one of the more interesting things about methylene blue is that not everyone responds to it the same way. Some people see significant benefits, while others might not feel much of anything. There are a few reasons for this. First, individual genetics can play a big role. People have different levels of mitochondrial efficiency and varying abilities to process certain compounds, which means that some might not experience the same boost in energy or mental clarity that others do. Secondly, the dosage matters. Methylene blue has a pretty narrow therapeutic window, meaning too little might not have much effect, and too much can lead to toxicity. Finding the right dose is key, and that's where a healthcare provider or a practitioner familiar with it comes in handy. Lastly, if someone has certain conditions, like serotonin syndrome or G6PD deficiency, they should avoid methylene blue, as it can exacerbate those conditions. For example, methylene blue can increase serotonin levels, which could lead to serotonin syndrome in some individuals, a potentially life-threatening condition. What About Methylene Blue Dosing High doses of methylene blue can affect several systems in the body and potentially lead to significant side effects or toxicity. Here's an overview of the areas where high doses can have an impact: 1. Kidneys Renal toxicity: High doses of methylene blue may cause oxidative stress in kidney cells, leading to kidney damage or acute kidney injury (AKI), especially in individuals with pre-existing kidney issues. Hemolysis risk: Methylene blue, particularly at higher doses, can cause hemolysis (destruction of red blood cells), leading to the release of hemoglobin, which can overwhelm the kidneys and cause kidney damage. 2. Central Nervous System Confusion and agitation: Large doses of methylene blue can cause neurotoxicity, leading to symptoms like confusion, agitation, and even delirium. Headaches: A common side effect at higher doses, possibly due to its effects on blood flow and serotonin levels. Seizures: There is a risk of seizures at high doses, especially if the person is already predisposed to neurological issues or is combining methylene blue with other medications that affect the central nervous system. 3. Cardiovascular System Hypertension (High Blood Pressure): Methylene blue can potentially increase blood pressure due to its ability to inhibit nitric oxide production, leading to vasoconstriction (narrowing of blood vessels). This is more pronounced at higher doses. Arrhythmias: High doses may also lead to heart arrhythmias (irregular heartbeats) due to its influence on vascular tone and nitric oxide pathways. 4. Serotonin Levels Serotonin Syndrome: High doses of methylene blue can elevate serotonin levels in the brain. This could potentially lead to serotonin syndrome, a life-threatening condition characterized by symptoms such as agitation, high body temperature, rapid heart rate, and muscle rigidity. This is especially a concern if methylene blue is combined with other serotonergic drugs, like SSRIs, SNRIs, or MAO inhibitors. 5. Gastrointestinal System Nausea and vomiting: High doses of methylene blue can irritate the stomach and cause gastrointestinal discomfort, including nausea, vomiting, and abdominal pain. Diarrhea: Some people may also experience diarrhea as a side effect of higher doses. 6. Skin and Mucous Membranes Discoloration: Methylene blue is known to stain skin and mucous membranes. High doses can cause blue discoloration of the skin, tongue, and urine, though this is not harmful and is usually temporary. 7. Liver Liver toxicity: There is some evidence that high doses of methylene blue might place extra strain on the liver, as it is metabolized by the liver. In extreme cases, this could lead to hepatotoxicity (liver damage), though this is rare and more likely with prolonged use. Where Can I Buy Methylene Blue? Alright, so when you're buying methylene blue, it's super important to get it from a trusted source. Why? Because if you're getting a product that's low quality, it could have impurities or the wrong concentration, and that totally messes with the health benefits. Methylene blue is used in everything from research to nootropics, and its effectiveness really depends on how pure and potent it is.  That's why you want to go with a reputable retailer—like MitoZen, which Chase Hughes actually mentioned on Joe Rogan's podcast. They've got strict standards for quality, so you can trust you're getting the real deal, the right dosage, and none of those unwanted side effects from shady products. Thanks for listening to The Peptide Podcast. If you found this episode helpful, be sure to subscribe and leave a review. And as always, have a happy, healthy week.

In this episode we look at pharmacological treatments frequently used for children, particularly neurodivergent children. We discuss the evidence, the pros, the cons, the side effects and the stigma associated with medication for children.References cited:Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2022). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & therapeutics, 230, 107940.Boland, H., DiSalvo, M., Fried, R., Woodworth, K. Y., Wilens, T., Faraone, S. V., & Biederman, J. (2020). A literature review and meta-analysis on the effects of ADHD medications on functional outcomes. Journal of Psychiatric Research, 123, 21-30.https://doi.org/10.1016/j.jpsychires.2020.01.006Garland, E. J., Kutcher, S., Virani, A., & Elbe, D. (2016). Update on the use of SSRIs and SNRIs with children and adolescents in clinical practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(1), 4.Hetrick, S. E., McKenzie, J. E., & Merry, S. N. (2010). The use of SSRIs in children and adolescents. Current Opinion in Psychiatry, 23(1), 53-57.Catalá-López, F., Hutton, B., Núñez-Beltrán, A., Page, M. J., Ridao, M., Macías Saint-Gerons, D., ... & Moher, D. (2017). The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: a systematic review with network meta-analyses of randomised trials. PloS one, 12(7), e0180355.Dalsgaard, S., Nielsen, H. S., & Simonsen, M. (2014). Consequences of ADHD medication use for children's outcomes. Journal of health economics, 37, 137-151. https://doi.org/10.1016/j.jhealeco.2014.05.005

On this Real Life Pharmacology Podcast episode, we cover medications 181-185. Proscar is the brand name for finasteride. This medication can be helpful in shrinking the size of the prostate but it does typically take a while to work (months). Sinemet is a combination of carbidopa and levodopa. Levodopa is converted in the central nervous system to dopamine to help alleviate a shortage of dopamine in the brain. Risedronate is a bisphosphonate medication that can be used in the treatment of osteoporosis. Albuterol (Ventolin) is a short-acting beta-agonist that is used to relieve symptoms of acute respiratory distress most often associated with an asthma exacerbation. Tramadol is classified as an opioid analgesic. It also has activity similar to SNRIs as it has the ability to increase serotonin and norepinephrine in the brain.

This episode launches the first part of a 3-part mini-series on IBS-C, shedding light on the complexities of this widespread condition that affects millions of people across the U.S. It stresses the importance of a holistic, patient-centered approach to managing IBS-C. We explore the various medications used to treat IBS-C, including both over-the-counter options and prescription drugs, offering a comprehensive review. Our expert guest, Dr. Justin Brandler, a neurogastroenterologist at Virginia Mason Franciscan Health, provides valuable insights into the mechanisms and effectiveness of these treatments.Dr. Brandler simplifies the intricate science and treatment of IBS into easy-to-understand concepts. He likens his role in treating IBS to that of both a plumber and an electrician. As a disorder of gut-brain interaction (DGBI), IBS affects how the brain and spinal cord process signals, influencing gastrointestinal symptoms.Different patients respond to different treatment approaches. Dr. Brandler discusses medications that target the "plumbing" aspect of IBS, including pharmaceutical options like linaclotide, tenapanor, and lubiprostone, as well as over-the-counter treatments such as magnesium oxide, senna, and bisacodyl. He also covers treatments that address the altered brain-gut connection in IBS, highlighting various neuromodulators, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), and their role in adjusting the nervous system to help alleviate IBS symptoms.We explore essential tips for making the most of your medical appointments, such as organizing a concise summary of your medical history and symptoms to ensure clear and effective communication, including outlining your goals. Preparing ahead of time can help your healthcare providers deliver the best possible care and make the right referrals for your needs.This podcast was sponsored by Ardelyx.Resources: Living your BEST IBS Life: Practical Tools to Beat the Battle with your Bowels by Justin Brandler, MD via IFFGDMechanisms of Action Considerations in the Management of IBS-CLearn more about Kate and Dr. Riehl:Website: www.katescarlata.com and www.drriehl.comInstagram: @katescarlata @drriehl and @theguthealthpodcastOrder Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS. The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Send us a textWhat if we told you that understanding the science behind depression treatment could change the way you approach mental health? Join us as we unravel the complexities of neurotransmitters and mood disorders, exploring both historical insights and modern-day treatments. From Joseph Schildkraut's catecholamine hypothesis to the permissive hypothesis by Arthur Prang and Alec Coppen, we cover the intriguing developments in understanding chemical imbalances. We discuss the vital role of antidepressants like SNRIs and SSRIs and tackle the challenges posed by age-related changes in the brain. With a deep dive into these scientific concepts, you'll gain a clearer picture of how medication manages neurotransmitter levels and why it's just one piece of the puzzle.But medication isn't the complete answer to mental health. In our conversation, we emphasize the need for a holistic approach, where therapy, personal effort, and lifestyle changes are paramount to healing. Learn how self-care practices, such as massage therapy and chiropractic care, can significantly enhance mental well-being. And don't miss the heartwarming story of Paul Myers and Brian Harris—a powerful testament to human connection and the support systems essential for recovery. Stay tuned for our exciting holiday special announcement, promising an episode full of fun and spontaneity!FIND ME:My Website: https://motorcityhypnotist.com/podcastMy social media links: Facebook: https://www.facebook.com/motorcityhypnotist/YouTube: https://www.youtube.com/channel/UCCjjLNcNvSYzfeX0uHqe3gATwitter: https://twitter.com/motorcityhypnoInstagram: motorcityhypnoFREE HYPNOSIS GUIDEhttps://detroithypnotist.convertri.com/podcast-free-hypnosis-guidePlease also subscribe to the show and leave a review.(Stay with me as later in the podcast, I'll be giving away a free gift to all listeners!)Change your thinking, change your life!Laugh hard, run fast, be kind. David R. Wright MA, LPC, CHTThe Motor City Hypnotist

Depression is one of the most researched mood disorders, but if we look a bit deeper into how depression is able to develop, it is more nuanced than we think. This means, treating depression isn't a one size fits all solution. It is agreed upon that depression is a chemical imbalance and can be treated with SSRIs or SNRIs, etc., which can work for some, but this doesn't always work for everyone. Understanding what happens in the body and brain when it comes to nervous system outputs and how we are wired, as well as our connection to nature and sunlight, we can start to understand the complexities of depression, and find ways to treat it at an individual level. In today's episode, Elisabeth and Jennifer are joined by Matt Bush to talk about depression, chronic fatigue and functional freeze, and how they are all interlinked with one another. They discuss myths about depression and how pharmaceuticals aren't the only, or best, way to treat depression. Also, how we may become wired toward depression at a young age by witnessing and mimicking caregivers in their own depressive states and how social connection, nature, and neurodrills that produce domaine, can help rewire the brain. Depression can look and feel insidious, but its main function is to be protective. If we reframe the way we look at depression, we can be effective in healing it.  Join us to learn about this and more! Topics discussed in this episode:   Different levels of freeze responses The overlap of functional freeze and burnout Chronic fatigue as a protective output What is depression? Some myths about depression Are pharmaceuticals necessary to treat depression? How depression can be wired into us by mimicking our primary caregivers Social connection as a way to rewire depression Dopamine's role in the correlation between addiction and depression How neurodrills can rewire and change brain chemistry Nature as a healing tool The socioeconomic and cultural impact on the nervous system   Learn more about the Neuro-Somatic Intelligence Coaching program and sign up for the spring cohort now! https://www.neurosomaticintelligence.com   Get started training your nervous system with our FREE 2-week offer on the Brain Based Membership site: https://www.rewiretrial.com   Connect with us on social media: @trauma.rewired   Join the Trauma Rewired Facebook Group! https://www.facebook.com/groups/761101225132846   FREE 1 Year Supply of Vitamin D + 5 Travel Packs from Athletic Greens when you use my exclusive offer: https://www.drinkag1.com/rewired   This episode was produced by Podcast Boutique https://www.podcastboutique.com Trauma Rewired podcast  is intended to educate and inform but does not constitute medical, psychological or other professional advice or services. Always consult a qualified medical professional about your specific circumstances before making any decisions based on what you hear.  We share our experiences, explore trauma, physical reactions, mental health and disease. If you become distressed by our content, please stop listening and seek professional support when needed. Do not continue to listen if the conversations are having a negative impact on your health and well-being.  If you or someone you know is struggling with their mental health, or in mental health crisis and you are in the United States you can 988 Suicide and Crisis Lifeline.  If someone's life is in danger, immediately call 911.  We do our best to stay current in research, but older episodes are always available.  We don't warrant or guarantee that this podcast contains complete, accurate or up-to-date information. It's very important to talk to a medical professional about your individual needs, as we aren't responsible for any actions you take based on the information you hear in this podcast. We  invite guests onto the podcast. Please note that we don't verify the accuracy of their statements. Our organization does not endorse third-party content and the views of our guests do not necessarily represent the views of our organization. We talk about general neuro-science and nervous system health, but you are unique. These are conversations for a wide audience. They are general recommendations and you are always advised to seek personal care for your unique outputs, trauma and needs.  We are not doctors or licensed medical professionals. We are certified neuro-somatic practitioners and nervous system health/embodiment coaches. We are not your doctor or medical professional and do not know you and your unique nervous system. This podcast is not a replacement for working with a professional. The BrainBased.com site and Rewiretrail.com is a membership site for general nervous system health, somatic processing and stress processing. It is not a substitute for medical care or the appropriate solution for anyone in mental health crisis.  Any examples mentioned in this podcast are for illustration purposes only. If they are based on real events, names have been changed to protect the identities of those involved.  We've done our best to ensure our podcast respects the intellectual property rights of others, however if you have an issue with our content, please let us know by emailing us at traumarewired@gmail.com  All rights in our content are reserved

Learn the skills to regulate your emotions, join the membership: https://courses.therapyinanutshell.com/membership Morning depression is a common experience where symptoms of depression, such as fatigue, hopelessness, brain fog, and difficulty getting out of bed, are at their worst upon waking. This is largely influenced by biological factors, including the cortisol awakening response, where stress hormones spike in the morning, causing a sense of overwhelm or shutdown. Misalignment of the circadian rhythm, due to genetics, sleep disorders, or inconsistent schedules, can exacerbate these symptoms. Additional contributors include inflammation, which peaks for some people in the morning, and underlying conditions like sleep deprivation, insomnia, or physical illnesses such as low thyroid function or anemia. Treatment focuses on resetting the circadian rhythm and managing cortisol through light therapy, melatonin microdosing, consistent sleep hygiene, and gradually building a positive morning routine. Simple actions like taking one step out of bed, drinking water, or practicing gratitude can help counteract the depressive freeze response. Talk therapy and medication, particularly SNRIs, can also provide significant relief. By addressing these biological and behavioral factors, individuals can create mornings that feel manageable and even uplifting. Small changes, taken one step at a time, can lead to meaningful improvements. Check out the transcript: https://therapyinanutshell.com/morning-depression/ Looking for affordable online counseling? My sponsor, BetterHelp, connects you to a licensed professional from the comfort of your own home. Try it now for 10% off your first month: https://betterhelp.com/therapyinanutshell Learn more in one of my in-depth mental health courses: https://courses.therapyinanutshell.com Support my mission on Patreon: https://www.patreon.com/therapyinanutshell Sign up for my newsletter: https://www.therapyinanutshell.com Check out my favorite self-help books: https://kit.co/TherapyinaNutshell/best-self-help-books  Therapy in a Nutshell and the information provided by Emma McAdam are solely intended for informational and entertainment purposes and are not a substitute for advice, diagnosis, or treatment regarding medical or mental health conditions. Although Emma McAdam is a licensed marriage and family therapist, the views expressed on this site or any related content should not be taken for medical or psychiatric advice. Always consult your physician before making any decisions related to your physical or mental health. In therapy I use a combination of Acceptance and Commitment Therapy, Systems Theory, positive psychology, and a bio-psycho-social approach to treating mental illness and other challenges we all face in life. The ideas from my videos are frequently adapted from multiple sources. Many of them come from Acceptance and Commitment Therapy, especially the work of Steven Hayes, Jason Luoma, and Russ Harris. The sections on stress and the mind-body connection derive from the work of Stephen Porges (the Polyvagal theory), Peter Levine (Somatic Experiencing) Francine Shapiro (EMDR), and Bessel Van Der Kolk. I also rely heavily on the work of the Arbinger Institute for my overall understanding of our ability to choose our life's direction. And deeper than all of that, the Gospel of Jesus Christ orients my personal worldview and sense of security, peace, hope, and love https://www.churchofjesuschrist.org/comeuntochrist/believe If you are in crisis, please contact the National Suicide Prevention Hotline at https://suicidepreventionlifeline.org or 1-800-273-TALK (8255) or your local emergency services. Copyright Therapy in a Nutshell, LLC

An alarming number of individuals find themselves dependent on antidepressants and psychiatric medications, desperately seeking guidance on how to safely discontinue their use. The general medical community has failed to assist people in safely getting off these drugs. The dependency can create severe withdrawal symptoms. Most doctors have no clue how to get their patients off safely keeping them in a cycle of drug dependency. The worst of prescribers will frame the withdrawal symptoms as worsening "depression" and justification for staying on drugs. On Episode 154 of the Radically Genuine Podcast Dr. Roger McFillin dives into the topic of deprescribing and tapering off psychiatric drugs with a pharmacist. Dr. Shawn Gill, PharmD, is a pharmacist, writer, podcaster, and entrepreneur dedicated to sparking change in healthcare through deprescribing. He is the founder of Deprescribe Solutions, an independent consulting practice focused on reversing early-stage chronic conditions in mental health, hypertension, and type 2 diabetes. He hosts the "Deprescribe" podcast and writes the Substack newsletter "B.U.D.S," where he explores topics in health, deprescribing, parenting, and personal growth. Chapters00:00 The Silent Epidemic of Over-Prescription03:06 The Role of Pharmacists in Mental Health06:11 Understanding Compounding Pharmacy09:01 Polypharmacy: A Growing Concern11:58 The Dangers of SSRIs and SNRIs15:12 The Ethics of Prescribing Practices18:01 Navigating Withdrawal and Tapering20:57 Hyperbolic vs. Linear Tapering24:14 Protracted Withdrawal: Understanding the Risks26:49 Preventing Dependency: Education and Awareness29:58 The Future of Mental Health TreatmentResources: Systematic review detailing the relationship between SERT occupancy and SSRI dosing.- This is a great systematic review that breaks down the hyperbolic nature of SSRIs. It also elucidates on the potential pharmacology and mechanism behind protracted withdrawal, which we touched upon. RELEASE Clinical Trial - RCT which will be investigating hyperbolic tapering vs. linear tapering. The trial will begin in 2025.Outro Health - Fantastic organization trying to scale and make hyperbolic tapering accessible to the US. Dr. Sean Gill SubstackDeprescribe Podcast w/ Dr. Sean Gill RADICALLY GENUINE PODCASTDr. Roger McFillin / Radically Genuine WebsiteYouTube @RadicallyGenuineDr. Roger McFillin (@DrMcFillin) / XSubstack | Radically Genuine | Dr. Roger McFillinInstagram @radicallygenuineContact Radically GenuineConscious Clinician CollectivePLEASE SUPPORT OUR PARTNERS15% Off Pure Spectrum CBD (Code: RadicallyGenuine)10% off Lovetuner click here—-----------FREE DOWNLOAD! DISTRESS TOLERANCE SKILLS

Can stress rewire your brain and alter your body's health? Join us on this gripping episode of Kore Kast as we uncover the deep-seated effects of trauma on our brains and bodies. You'll discover how traumatic experiences can trigger your body's stress response, affecting crucial regions like the amygdala, hippocampus, and prefrontal cortex. These changes can disrupt your emotional regulation, memory, and decision-making abilities. We'll also highlight how imbalances in key neurotransmitters such as serotonin and dopamine can pave the way for mental health challenges like depression and anxiety. Beyond the mental sphere, trauma has tangible physical repercussions, manifesting as chronic pain, fatigue, and gastrointestinal issues, while also compromising your immune system and heightening vulnerability to illnesses and autoimmune diseases. In the next segment, we turn our focus to hope and healing, exploring effective treatments for PTSD. Learn about groundbreaking psychotherapies, including cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy, which empower individuals to process trauma and build resilient coping mechanisms. Additionally, we'll discuss how medications like SSRIs and SNRIs can aid in managing anxiety and depression. You'll hear about the transformative power of lifestyle changes such as regular exercise, mindfulness practices, and social support in promoting emotional well-being. Discover how physical activity can release endorphins, enhance cognitive function, improve sleep, and foster a sense of accomplishment and community. Tune in for a comprehensive guide on navigating the path to recovery and reclaiming your life from the grips of trauma.Support the Show.https://www.kore-fit.comhttps://www.korecandlecompany.com

Depression is one of the most researched mood disorders, but if we look a bit deeper into how depression is able to develop, it is more nuanced than we think. This means, treating depression isn't a one size fits all solution. It is agreed upon that depression is a chemical imbalance and can be treated with SSRIs or SNRIs, etc., which can work for some, but this doesn't always work for everyone. Understanding what happens in the body and brain when it comes to nervous system outputs and how we are wired, as well as our connection to nature and sunlight, we can start to understand the complexities of depression, and find ways to treat it at an individual level. In today's episode, Elisabeth and Jennifer are joined by Matt Bush to talk about depression, chronic fatigue and functional freeze, and how they are all interlinked with one another. They discuss myths about depression and how pharmaceuticals aren't the only, or best, way to treat depression. Also, how we may become wired toward depression at a young age by witnessing and mimicking caregivers in their own depressive states and how social connection, nature, and neurodrills that produce domaine, can help rewire the brain. Depression can look and feel insidious, but its main function is to be protective. If we reframe the way we look at depression, we can be effective in healing it.  Join us to learn about this and more! Topics discussed in this episode:   Different levels of freeze responses The overlap of functional freeze and burnout Chronic fatigue as a protective output What is depression? Some myths about depression Are pharmaceuticals necessary to treat depression? How depression can be wired into us by mimicking our primary caregivers Social connection as a way to rewire depression Dopamine's role in the correlation between addiction and depression How neurodrills can rewire and change brain chemistry Nature as a healing tool The socioeconomic and cultural impact on the nervous system   Learn more about the Neuro-Somatic Intelligence Coaching program and sign up for the spring cohort now! https://www.neurosomaticintelligence.com   Get started training your nervous system with our FREE 2-week offer on the Brain Based Membership site: https://www.rewiretrial.com   Join the Next Level Neuro Mentorship Program: https://www.nextlevelneuro.com/a/2147666262/2U4AvzLR   REWIRE RETREAT  https://www.thenatureofmindbody.com/book-online   Contact us about private Rewire Neuro-Somatic Coaching: https://brainbased-wellness.com/rewire-private-neuro-somatic-coaching/   Connect with us on social media: @trauma.rewired   Join the Trauma Rewired Facebook Group! https://www.facebook.com/groups/761101225132846   FREE 1 Year Supply of Vitamin D + 5 Travel Packs from Athletic Greens when you use my exclusive offer: https://www.drinkag1.com/rewired   This episode was produced by Podcast Boutique https://www.podcastboutique.com Trauma Rewired podcast  is intended to educate and inform but does not constitute medical, psychological or other professional advice or services. Always consult a qualified medical professional about your specific circumstances before making any decisions based on what you hear.  We share our experiences, explore trauma, physical reactions, mental health and disease. If you become distressed by our content, please stop listening and seek professional support when needed. Do not continue to listen if the conversations are having a negative impact on your health and well-being.  If you or someone you know is struggling with their mental health, or in mental health crisis and you are in the United States you can 988 Suicide and Crisis Lifeline.  If someone's life is in danger, immediately call 911.  We do our best to stay current in research, but older episodes are always available.  We don't warrant or guarantee that this podcast contains complete, accurate or up-to-date information. It's very important to talk to a medical professional about your individual needs, as we aren't responsible for any actions you take based on the information you hear in this podcast. We  invite guests onto the podcast. Please note that we don't verify the accuracy of their statements. Our organization does not endorse third-party content and the views of our guests do not necessarily represent the views of our organization. We talk about general neuro-science and nervous system health, but you are unique. These are conversations for a wide audience. They are general recommendations and you are always advised to seek personal care for your unique outputs, trauma and needs.  We are not doctors or licensed medical professionals. We are certified neuro-somatic practitioners and nervous system health/embodiment coaches. We are not your doctor or medical professional and do not know you and your unique nervous system. This podcast is not a replacement for working with a professional. The BrainBased.com site and Rewiretrail.com is a membership site for general nervous system health, somatic processing and stress processing. It is not a substitute for medical care or the appropriate solution for anyone in mental health crisis.  Any examples mentioned in this podcast are for illustration purposes only. If they are based on real events, names have been changed to protect the identities of those involved.  We've done our best to ensure our podcast respects the intellectual property rights of others, however if you have an issue with our content, please let us know by emailing us at traumarewired@gmail.com  All rights in our content are reserved  

Title: 110 | Postpartum Anxiety Treatments Part 2  Welcome to the New Mom Naturopath Podcast! Today's episode dives deep into the often-overlooked challenges of postpartum anxiety. Many new moms experience a range of symptoms from rapid heartbeat and nausea to irritability and intrusive thoughts. Understanding these signs and knowing when to seek help is crucial for your health and well-being. Coaching with me:  Feeling like this podcast series was just enough to get you above water? Still feeling overwhelmed. Like there is too much to do. You are losing patience with your baby. FInding it hard to enjoy this time without a little one. Perhaps you feel you have lost touch with who you were pre-pregnancy with? I can help you manage the stress of becoming a mom. That is what my coaching program is all about: Finding who you are again in the chaos of postpartum. Hurry up prices are going up soon!  Click here to schedule a 30-minute call with me!   Today we are expanding on Monday Episode, and we are talking about:   Medication Options: Discuss the role of medications like SSRIs and SNRIs in managing postpartum anxiety, their effects, and what to expect when starting them. Supplements and Herbs: Examine the potential benefits of using supplements like lavender and fish oil to support mental health during the postpartum period. What we Covered in Monday's Episode: Click here to Listen to it!  Symptoms of Postpartum Anxiety: Explore the emotional and physical symptoms that can impact new moms, from constant worry and panic to difficulty concentrating and a lack of connection with the baby. Risk Factors: Understand the factors that increase the likelihood of experiencing postpartum anxiety, including personal and family history, previous losses, and the stresses of caring for multiple children. Non-Medication Based Treatments: Discover the benefits of counseling, where you can learn coping skills, improve communication, and focus on self-care. We'll discuss what to expect in therapy sessions and how to differentiate normal stress from anxiety. Self-Care Treatments: Learn grounding exercises and the importance of nutrition, sun exposure, and maintaining social connections. Practical tips for self-care routines will also be shared   Coaching with me:  Feeling like this podcast series was just enough to get you above water? Still feeling overwhelmed. Like there is too much to do. You are losing patience with your baby. FInding it hard to enjoy this time without a little one. Perhaps you feel you have lost touch with who you were pre-pregnancy with? I can help you manage the stress of becoming a mom. That is what my coaching program is all about: Finding who you are again in the chaos of postpartum. Hurry up prices are going up soon!  Click here to schedule a 30-minute call with me!     How to Connect with me:  Here is the link to the facebook group: https://www.facebook.com/groups/newmomnaturopath  Link to coaching call: Click here to schedule a 30-minute call with me!   Link to my instagram page: https://www.instagram.com/drkailyngalloway/ My resources Page: New Mom Naturopath Resource Page  

Show Notes:  Title: 109 | Treatments for Postpartum Anxiety - Part 1  Welcome to the New Mom Naturopath Podcast! Today's episode dives deep into the often-overlooked challenges of postpartum anxiety. Many new moms experience a range of symptoms from rapid heartbeat and nausea to irritability and intrusive thoughts. Understanding these signs and knowing when to seek help is crucial for your health and well-being. What We'll Cover: Symptoms of Postpartum Anxiety: Explore the emotional and physical symptoms that can impact new moms, from constant worry and panic to difficulty concentrating and a lack of connection with the baby. Risk Factors: Understand the factors that increase the likelihood of experiencing postpartum anxiety, including personal and family history, previous losses, and the stresses of caring for multiple children. Non-Medication Based Treatments: Discover the benefits of counseling, where you can learn coping skills, improve communication, and focus on self-care. We'll discuss what to expect in therapy sessions and how to differentiate normal stress from anxiety. Self-Care Treatments: Learn grounding exercises and the importance of nutrition, sun exposure, and maintaining social connections. Practical tips for self-care routines will also be shared. Come back to Thursdays episode where we will talk about:  Medication Options: Discuss the role of medications like SSRIs and SNRIs in managing postpartum anxiety, their effects, and what to expect when starting them. Supplements and Herbs: Examine the potential benefits of using supplements like lavender and fish oil to support mental health during the postpartum period. Call to Action: Subscribe for more insights: Stay connected with us for more valuable discussions on navigating motherhood. Share your thoughts: We love hearing from you! Please leave a review for us, I want to hear your feedback so I can improve the show and make it more of what you need.  Join our community: Check out our social media or visit our website for additional resources and support.Here is the link to the facebook group: https://www.facebook.com/groups/newmomnaturopath  Coaching with me:  Feeling like this podcast series was just enough to get you above water? Still feeling overwhelmed. Like there is too much to do. You are losing patience with your baby. FInding it hard to enjoy this time without a little one. Perhaps you feel you have lost touch with who you were pre-pregnancy with? I can help you manage the stress of becoming a mom. That is what my coaching program is all about: Finding who you are again in the chaos of postpartum. Hurry up prices are going up soon!  Click here to schedule a 30-minute call with me!     How to Connect with me:  Here is the link to the facebook group: https://www.facebook.com/groups/newmomnaturopath  Link to coaching call: Click here to schedule a 30-minute call with me!   Link to my instagram page: https://www.instagram.com/drkailyngalloway/ My resources Page: New Mom Naturopath Resource Page

In this episode, Dr. Rena Malik, MD delves into the complex and often misunderstood topic of menopause. She explains the different stages: premenopause, perimenopause, menopause, and postmenopause, highlighting the range of symptoms women may experience, from hot flashes and mood swings to sleep disturbances and genitourinary issues. Dr. Malik discusses how these symptoms arise due to declining estrogen levels and provides detailed information on various treatment options, including hormonal replacement therapies and non-hormonal alternatives. Listeners will gain a comprehensive understanding of menopause, its impact on different aspects of health, and the available strategies to manage symptoms and improve quality of life. Additionally, Dr. Malik emphasizes the importance of individualized treatment plans, noting the various forms of estrogen administration, such as transdermal gels, oral tablets, and vaginal rings, each with its own benefits and considerations. She also addresses the risks and benefits associated with hormone therapy, citing the outcomes of notable studies like the Women's Health Initiative. For women who cannot or prefer not to use hormone therapy, Dr. Malik discusses alternative treatments, including SSRIs, SNRIs, and other medications. By demystifying menopause and its treatments, this episode empowers women to make informed decisions about their health during this significant life transition. ▶️Chapters: 00:00 Menopause 03:44 Menopausal symptoms and treatment 09:46 Hormone therapy benefits and risks in women 10:49 Benefits of Progesterone Let's Connect!: WEBSITE: http://www.renamalikmd.com YOUTUBE: https://www.youtube.com/@RenaMalikMD INSTAGRAM: http://www.instagram.com/RenaMalikMD TWITTER: http://twitter.com/RenaMalikMD FACEBOOK: https://www.facebook.com/RenaMalikMD/ LINKEDIN: https://www.linkedin.com/in/renadmalik PINTEREST: https://www.pinterest.com/renamalikmd/ TIKTOK: https://www.tiktok.com/RenaMalikMD ------------------------------------------------------ DISCLAIMER: This podcast is purely educational and does not constitute medical advice. The content of this podcast is my personal opinion, and not that of my employer(s). Use of this information is at your own risk. Rena Malik, M.D. will not assume any liability for any direct or indirect losses or damages that may result from the use of information contained in this podcast including but not limited to economic loss, injury, illness or death. Learn more about your ad choices. Visit megaphone.fm/adchoices

Hello, friends! In today's episode, we tackle two profound listener questions that may resonate with many of you: How Do You Feel About Antidepressants and Anti-Anxiety Medications? A listener asks about the use of antidepressants and anti-anxiety medications, expressing concerns about addiction and the potential difficulty of getting off these meds. Dr. Duff shares his positive personal experience with Lexapro, explaining the various classes of medications, including SSRIs, SNRIs, and benzodiazepines. He emphasizes the importance of evaluating both the benefits and potential side effects of these medications, as well as considering the cost of not using them. Dr. Duff also addresses misconceptions about feeling disconnected from reality due to medication and discusses the concept of psychological and physiological dependence. Dealing with a Hurtful Partner: Another listener seeks advice on how to help their partner understand the impact of their hurtful behavior, which includes yelling and mocking. Dr. Duff offers empathetic support, acknowledging the listener's heartbreak. He outlines the importance of healthy conflict resolution, setting personal boundaries, and recognizing signs of potential abuse. Dr. Duff encourages open communication and suggests resources for improving relationship dynamics, while also addressing the need for safety and support when dealing with ongoing hurtful behavior. As always, you can send me questions to duffthepsych@gmail.com and find the full show notes for this episode at http://duffthepsych.com/episode403

Episode 171: Postpartum Blues, Depression, and PsychosisFuture Dr. Nguyen defines and explains the difference between baby blues, depression, and psychosis. Dr. Arreaza added comments about screening and management of these conditions. Written by Vy Nguyen, OMSIII, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.Pregnancy is one of the most well-celebrated milestones in one's life. However, once the baby is born, the focus of the family and society quickly shifts to the new member. It is important to continue to care for our mothers and offer them support physically and mentally as they begin their transition into their role. Peripartum mood disorders affect both new and experienced mothers as they navigate through the challenges of motherhood. The challenges of motherhood are not easy to spot, and they include sleep deprivation, physical exhaustion, dealing with pain, social isolation, and financial pressures, among other challenges. Let's focus on 3 aspects of the postpartum period: Postpartum Blues (PPB), Post-partum Depression (PPD) and Post-partum Psychosis (PPP). By the way, we briefly touched on this topic in episode 20, a long time ago. Postpartum blues (PPB) present as transient and self-limiting low mood and mild depressive symptoms that affect more than 50% of women within two or three days of childbirth and resolve within two weeks of onset. Symptoms vary from crying, exhaustion, irritability, anxiety, appetite changes, and decreased sleep or concentration to mood lability. Women are at risk for PPB.Several factors are thought to contribute to the increased risk of postpartum blues including a history of menstrual cycle-related mood changes, mood changes associated with pregnancy, history of major depression, number of lifetime pregnancies, or family history of postpartum depression. Pathogenesis of PPB: While pathogenesis remains unknown, hormonal changes such as a dramatic decrease in estradiol, progesterone, and prolactin have been associated with the development of postpartum blues. In summary, PPB is equivalent to a brief, transient “sad feeling” after the delivery. Peripartum depression (PPD) occurs in 20% of women and is classified as depressive symptoms that appear within six weeks to 1 year after childbirth. Those with baby blues have an increased risk of developing postpartum depression. About 50% of “postpartum” major depressive episodes begin before delivery, thus the term has been updated from “postpartum” to “peripartum” depressive episodes. Some risk factors include adolescent patients, mothers who deliver premature infants, and women living in urban areas. Interestingly, African American and Hispanic mothers are reported to have onset of symptoms within two weeks of delivery instead of six like their Caucasian counterparts. Additional risks include psychological risks such as a personal history of depression, anxiety, premenstrual syndrome, and sexual abuse; obstetric risks such as emergency c-sections and hospitalizations, preterm or low birth infant, and low hemoglobin; social risks such as lack of social support, domestic violence in form of spousal physical/sexual/verbal abuse; lifestyle risks such as smoking, eating sleep patterns and physical activities. Peripartum depression can present with or without psychotic features, which may appear between 1 in 500 or 1 in 1,000 deliveries, more common in primiparous women. Pathogenesis of PPD: Much like postpartum blues, the pathogenesis of postpartum depression is unknown. However, it is known that hormones can interfere with the hypothalamic-pituitary-adrenal axis (HPA) and lactogenic hormones. HPA-releasing hormones increase during pregnancy and remain elevated up to 12 weeks postpartum. The body receptors in postpartum depression are susceptible to the drastic hormonal changes following childbirth which can trigger depressive symptoms. Low levels of oxytocin and prolactin also play a role in postpartum depression causing moms to have trouble with lactation around the onset of symptoms. The USPSTF recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. Edinburgh Postnatal Depression Scale (EPDS) can be used in postpartum and pregnant persons (Grade B recommendation).Postpartum psychosis (PPP) is a psychiatric emergency that often presents with confusion, paranoia, delusions, disorganized thoughts, and hallucinations. Around 1-2 out of 1,000 new moms experience postpartum psychosis with the onset of symptoms as quickly as several days and as late as six weeks after childbirth. Given the high risk of suicide and harm, individuals with postpartum psychosis require immediate evaluation and treatment. Postpartum psychosis is considered multifactorial, and the single most important risk factor is first pregnancy with family or personal history of bipolar 1 disorder. Other risk factors include a prior history of postpartum psychosis, family history of psychosis, history of schizoaffective disorder or schizophrenia, or discontinuation of psychiatric medications. Studies show that patients with a history of decreased sleep due to manic episodes are twice as likely to have postpartum psychosis at some point in their lives. However, approximately 50% of mothers who experience psychosis for the first time do not have a history of psychiatric disorder or hospitalization. Evaluation.Symptoms of postpartum blues should not meet the criteria for a major depressive episode and should resolve in 2 weeks. The Edinburg Postpartum Depression Scale which is a useful tool for assessing new moms with depressive symptoms. Postpartum depression is diagnosed when the patient presents with at least five depressive symptoms for at least 2 weeks. According to the DSM5, postpartum depression is defined as a major depressive episode with peripartum onset of mood symptoms during pregnancy or in the 4 weeks following delivery. Symptoms for diagnosis include changes in sleep, interest, energy, concentration, appetite, psychomotor retardation or agitation, feeling of guilt or worthlessness, and suicidal ideation or attempt. These symptoms are not associated with a manic or hypomanic episode and can often lead to significant impediments in daily activities. Peripartum-onset mood episodes can present with or without psychotic features. The depression can be so severe that the mother commits infanticide. Infanticide can happen, for example, with command hallucinations or delusions that the infant is possessed.While there are no standard screening criteria in place of postpartum psychosis, questionnaires mentioned earlier such as the Edinburg Postpartum Depression Scale can assess a patient's mood and identify signs of depression and mania. It is important after a thorough history and physical examination to order labs to rule out other medical conditions that can cause depressive and psychotic symptoms. Disorders like electrolyte imbalance, hepatic encephalopathy, thyroid storm, uremia, substance use, infections, and even stroke can mimic a psychiatric disorder. So, How can we treat patients who are diagnosed with a peripartum mood disorder?Management.On the spectrum of peripartum mood disorders, postpartum blues are the least severe and should be self-limiting by week 2. However, patients should be screened for suicidal ideation, paranoia, and homicidal ideation towards the newborn. Physicians should provide validation, education, and resources especially support with sleep and cognitive therapy and/or pharmacotherapy can be recommended if insomnia persists. Regarding postpartum depression, the first-line treatment includes psychotherapy and antidepressants. For those with mild to moderate depression or hesitant to start on medications, psychosocial and psychotherapy alone should be sufficient. However, for those with moderate to severe symptoms, a combination of therapy and antidepressants, such as selective serotonin reuptake inhibitors, is recommended. Once an effective dose is reached, patients should be treated for an additional 6 to 12 months to prevent relapse. In severe cases, patients may need to be hospitalized to treat their symptoms and prevent complications such as self-harm or infanticide.Most SSRIs can be detected in breast milk, but only 10 percent of the maternal level. Thus, they are considered safe during breastfeeding of healthy, full-term infants. So, you mentioned SSRIs, but also SNRIs, bupropion, and mirtazapine are reasonable options for treatment. In patients who have never been treated with antidepressants, zuranolone (a neuroactive steroid) is recommended. Zuranolone is easy to take, works fast, and is well tolerated. Treatment with zuranolone is consistent with practice guidelines from the American College of Obstetricians and Gynecologists.While there are no current guidelines to manage postpartum psychosis, immediate hospitalization is necessary in severe cases. Patients can be started on mood stabilizers such as lithium, valproate, and lamotrigine, and atypical antipsychotics such as quetiapine, and olanzapine, to name a few. Medications like lithium can be eliminated through breast milk and can expose infants to toxicity.The use of medications such as SSRIs, carbamazepine, valproate, and short-acting benzodiazepines are relatively safe and can be considered in those with plans to breastfeed. Ultimately, it is a decision that the patient can make after carefully discussing and weighing the pros and cons of the available medical management. While the prognosis of peripartum mood disorders is relatively good with many patients responding well to treatments, these disorders can have various negative consequences. Individuals with a history of postpartum blues are at increased risk of developing postpartum depression. Similarly, those with a history of postpartum psychosis are at risk of experiencing another episode of psychosis in future pregnancies. Additionally, postpartum depression can have a detrimental effect on mother-infant bonding and affect the growth and development of the infant. These children may have difficulties with social interactions, cognitive development, and depression. In summary, following the birth of a baby can pose new challenges and often is a stressful time for not only the mother but also other family members. Validation and reassurance from primary care physicians in an empathetic and understanding manner may offer support that many mothers may not have in their close social circle. As the first contact, primary care physicians can identify cues and offer support promptly that will not only improve the mental well-being of mothers but also that of the growing children.___________________________Conclusion: Now we conclude episode number 171, “Postpartum blues, depression, and psychosis.” These conditions may be more common than you think. So, be alert during your prenatal and postpartum visits and start management as needed. Psychotherapy and psychosocial therapy alone may be effective but do not hesitate to start antidepressants or antipsychotics when necessary. Make sure you involve the family and the patient in the decision-making process to implement an effective treatment.This week we thank Hector Arreaza and Vy Nguyen. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Raza, Sehar K. and Raza, Syed. Postpartum Psychosis. National Library of Medicine. Last updated Jun 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK544304/Balaram, Kripa and Marwaha, Raman. Postpartum Blues. National Library of Medicine. Last updated Mar 6, 2023. https://www.ncbi.nlm.nih.gov/books/NBK554546/Mughal, Saba, Azhar, Yusra, Siddiqui, Waquar. Postpartum Depression. National Library of Medicine. Last updated Oct 7, 2022. https://www.ncbi.nlm.nih.gov/books/NBK519070/Royalty-free music used for this episode: Good Vibes by Simon Pettersson, downloaded on July 20, 2023, from https://www.videvo.net/royalty-free-music/.

In this episode of Quah (Q & A), Sal, Adam & Justin coach four Pump Heads via Zoom. Mind Pump Fit Tip: BUILD MUSCLE to drastically improve your health! (1:45) Risk vs. reward when it comes to kids and contact sports. (15:19) Dispelling misinformation on Sal's tattoo. (19:25) Adam at his lowest weight since competing days. (20:42) Educating the audience on the accuracy of body fat tests. (27:55) The Happy Drops from Organifi are CRUSHING! (32:04) A wedding reception gone TERRIBLY wrong. (36:43) That one-time Justin got stuck on a rollercoaster. (37:47) Adam's embarrassing text. (39:08) Highlighting how we misunderstand studies or data. (43:06) Storytelling and teaching lessons. (46:05) How to get 10 clients in 10 days. (50:40) Shout out to Hippy Feet socks! (51:23) #ListenerLive question #1 – What sort of training/conditioning would you suggest aiding with dance lifts? (57:23) #ListenerLive question #2 – Would you have any suggestions on how to program for 75 Hard to finish strong and not be worn out or injured? (1:09:21) #ListenerLive question #3 – How do I work on body parts that are lagging? (1:24:10) #ListenerLive question #4 – I've had a string of injuries, any advice on how to remedy this? (1:37:52) Related Links/Products Mentioned Ask a question to Mind Pump, live! Email: live@mindpumpmedia.com See and hang out with Mind Pump, LIVE! Saturday, June 15 · 1pm PDT Bellagio Las Vegas. Click the link here for more details. Visit Organifi for the exclusive offer for Mind Pump listeners! **Promo code MINDPUMP at checkout for 20% off. May 10-12th, Mother's Day Weekend - Buy 1 Get 1 Free Organifi Harmony Plus Free Shipping ** Exclusively for Mind Pump Listeners, NCI is offering access to their free guide on learning to find, close and retain 10 clients in 10 days.  May Promotion: MAPS Strong | MAPS Powerlift 50% off! ** Code MAY50 at checkout ** Trends in nutrition, lifestyle, and metabolic disease in the United States from 1900 onwards Effects of macronutrient intake in obesity: a meta-analysis of low-carbohydrate and low-fat diets on markers of the metabolic syndrome Strength Of Grip Declines In Young Adults Mind Pump #1877: Obesity, It's Not Your Genetics Guardian Caps: Are the soft-shelled football helmet covers effective at limiting head injuries? Mind Pump #2320: Throw Away The Scale! An 8-Week Randomized, Double-Blind Trial Comparing Efficacy, Safety, and Tolerability of 3 Vilazodone Dose-Initiation Strategies Following Switch From SSRIs and SNRIs in Major Depressive Disorder The wedding menu that put 80 guests in hospital and left more than 100 people vomiting is revealed - as one attendee says men and women were given different food, but all ended up sick Giving Birth Later in Life Linked to Longer Life | TIME Children's Books by Andy Frisella The Very Hungry Caterpillar book hand2mind Numberblocks Friends One to Five Figures, Toy Figures Collectibles, Small Cartoon Figurines for Kids, Mini Action Figures, Character Figures, Play Figure Playsets, Imaginative Play Toys All Hippy Feet Products - American Made & Eco-Friendly Body Brokers | Rotten Tomatoes California fails to track how billions are spent to fight homelessness Visit Seed for an exclusive offer for Mind Pump listeners! **Promo code 25MINDPUMP at checkout for 25% off your first month's supply of Seed's DS-01® Daily Synbiotic** Improve Your Overhead Press & Build Your Shoulders with Unilateral Kettlebell Carries – Mind Pump TV Chaos Band Training: How To, Benefits, Variations - Muscle & Fitness Using The Earthquake Bar | Westside Barbell Mind Pump #2290: Becoming A Better Man With Jason Khalipa Mind Pump #2220: How To Stay Consistent With Your Workouts Ask Mind Pump Mind Pump #2322: Why Your Butt Won't Grow Mind Pump #1872: Eight Benefits Of Lifting With Light Weight Sore muscles…what does it mean? – Mind Pump Blog Mind Pump #2312: Five Steps To Bounce Back From Overtraining MAPS Prime Pro Webinar Mind Pump Podcast – YouTube Mind Pump Free Resources People Mentioned Drew Canole (@drewcanole) Instagram Mark Hyman, M.D. (@drmarkhyman) Instagram Mike Matthews (@muscleforlifefitness) Instagram Andy Frisella (@andyfrisella) Instagram Joe DeFranco (@defrancosgym)  Instagram James Smith (@smittydiesel)  Instagram Jason Khalipa (@jasonkhalipa) Instagram  

In this episode Dr. Sand leads us on a conversation about how three popular classes of antidepressant medications affect our gastrointestinal tract! SSRIs, TCAs, and SNRIs. This has definitely changed how we view the guts of these patients and may change your mind on how we're using them! Rebecca Sand ND, LAc, MSOM - ⁠⁠https://www.drrebeccasand.com/⁠⁠Ilana Gurevich ND, FABNG, LAc, MSOM - ⁠https://www.openwellnesspdx.com Ami Kapadia, MD, ABFM, ABIHM - ⁠⁠https://www.amikapadia.com/⁠⁠

In this episode, we review the high-yield topic of ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ ⁠from the Psychiatry section. Follow ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Medbullets⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets Linkedin: https://www.linkedin.com/company/medbullets

Just because your doctor might have advised you that hormone replacement therapy might not be an option for you, this does not mean your doctor won't be able to prescribe you other medications that can help. Here is your summary of non-hormonal prescription options for managing menopause symptoms after cancer treatment which includes a variety of medications such as gabapentin, pregabalin, clonidine, oxybutynin and antidepressants like SSRIs, and SNRIs, which can help alleviate symptoms like hot flushes, mood swings, anxiety, sleep and bladder and vaginal problems. Episode Highlights:00:00 Intro.05:18 Antidepressants can help with menopausal symptoms after cancer.06:58 Antidepressant effectiveness varies; talk to your doctor.11:43 Prescribable non-hormonal vaginal options for comfort.About Dani:The Menopause and Cancer Podcast is hosted by Dani Binnington, menopause guide, patients advocate for people in menopause after a cancer diagnosis, and founder of the online platform Healthy Whole Me. There is lots of information out there about the menopause but hardly any if you have had a cancer diagnosis as well. Many people say to me they have no idea what their options are, who to ask for help, and that they feel really isolated in their experiences. I started this podcast because there was nothing out there when I was thrown into surgical menopause at the age of 39, which followed on from my cancer diagnosis aged 33.Through the episodes, I want to create more awareness, share information from our fabulous guest experts, doctors and other specialists in the cancer and menopause field. And of course, I will share stories from the people in our community.So that together we can work towards a better menopause experience. For all of us.More educated, better informed and less alone.Connect with Dani:Instagram @healthywholeme Facebook: @healthywholeme Website: menopauseandcancer.org Join Dani's private Facebook group: https://www.facebook.com/groups/menopauseandcancerchathubFor oodles of inspiration, healthy recipes, yoga classes and all round positivity go to her website: https://www.healthywholeme.com/Mentioned in this episode:Subscribe to the Menopause and Cancer YouTube Channel here: https://www.youtube.com/@MenopauseandCancer

Happy New Year 2024! To celebrate the new year, Spotify sent me a bunch of data points about 2023. I was particularly interested in one question: which conversation moved people the most? I already knew which episode people played the most. (That's episode 17 with Bernardo Kastrup.) But to listen is one thing. To share with friends and family is another. The most shared episode was my conversation with Helen Fisher, titled "A Cultural Biology of Sex, Love, and Monogamy". It was one of my favourite conversations, too. Fisher offered a sweeping take on romantic love, combining fascinating anthropology with practical tips about maintaining passion in relationships. She even convinced my parents to re-design their TV arrangement... Perhaps it deserves one more share. So here you go! ___ ORIGINAL SHOW NOTES Why do we love? And how much does our culture shape the way we do so? In this episode, Ilari talks with Helen Fisher about the powers that drive and shape our romantic relationships. Ilari and Professor Fisher discuss: Is romantic love a modern invention? Is monogamy a social invention?  Do men care more about sex? Do women care more about romance? Why agriculture, especially with the plough, caused havoc in romantic relationships. Why divorces might be on the decline. A science-based guide for maintaining romantic relations (based on couples who are still in love after 25 years) Why (certain) antidepressants can kill the sex drive and blunt romantic love (to read more, see the end of the notes) How common is polygamy or polyandry? Where in the world do we find most "free love"? Why did homosexuality evolve? Names mentioned Irenäus Eibl-Eibesfeldt (as recounted by Alison Gopnik in her The Gardener and the Carpenter) Bill Jankowiak Robert Sternberg (see episode 7) Anderson Thompson Bertrand Russell  Technical terms and ethnic groups mentioned Ventral tegmental area VTA Hypothalamus Dopamine, testosterone, oxytocin, vasopressin, serotonine Monogamy (serial or lifelong; social or biological) Polygamy (several wives) and polyandry (several husbands)  Tlingit (the polyandrous Inuit society with wealthy women) Oneida community (in New York State) Dig Deeper Antidepressants: To read more about the possible effects of SSRIs on sex drive and romantic love, see ⁠Tocco and Brumbaugh (2019)⁠. Below is a list of possible alternatives or complements to SSRIs (please consult with your doctor in all matters related to pharmaceuticals): Fisher herself suggested that SNRIs could be less risky than SSRIs. Theoretically, dopamine reuptake inhibitors, such as bupropion, could also counter the risks associated with SSRIs (for a review, see ⁠Zisook et al. 2006⁠). For alternative or complementary oral treatments of depression, see research on supplementation with a high dosage of Omega 3 (EPA and DHA, not ALA) (for a review, see ⁠Bhat & Ara 2015⁠). Polyamory: In the episode, Professor Fisher suggests that many Amazonian tribes have informal polyandry, i.e. women have many partners, albeit only one formal husband. However, there are ⁠non-academic sources⁠ suggesting that formalised polyandry is common in the Zo'é community in Amazon. For some of these photos of Zo'é and other Amazonian tribes, many of whom exhibit remarkably liberal attitudes to sex, see the ⁠recent Amazonia exhibition⁠ in the London Science Museum.

The power of repetition is undeniable. A lie, repeated often enough, can become the accepted truth. This "illusion of truth effect" applies to all areas of life, including healthcare. In the case of medications like SSRIs and SNRIs, which are commonly prescribed for depression and anxiety, the illusion of truth can have serious consequences.  The illusion of truth can lead patients to underestimate risks. They may see these medications advertised as safe and effective, without fully understanding the potential downsides. This can lead them to blindly accept the doctor's recommendations without questioning or seeking further information. Don't let the illusion of truth cloud your judgment—ask questions. This is where informed consent becomes crucial.Can Antidepressants Induce Suicide, Violence & Bizarre Behavior?Note: This podcast episode is designed solely for informational and educational purposes, without endorsing or promoting any specific medical treatments. We strongly advise consulting with a qualified healthcare professional before making any medical decisions or taking any actions.*If you are in crisis or believe you have an emergency, please contact your doctor or dial 911. If you are contemplating suicide, call 1-800-273-TALK to speak with a trained and skilled counselor.RADICALLY GENUINE PODCASTDr. Roger McFillin / Radically Genuine WebsiteYouTube @RadicallyGenuineDr. Roger McFillin (@DrMcFillin) / X (Twitter)Substack | Radically Genuine | Dr. Roger McFillinInstagram @radicallygenuineContact Radically Genuine—-----------FREE DOWNLOAD! DISTRESS TOLERANCE SKILLS—----------ADDITIONAL RESOURCES2:30 - What Is Cognitive Ease and How It Blocks Your Critical Thinking - Learning Mind3:00 - Thinking, Fast and Slow: Daniel Kahneman3:30 - Science and Its Skeptics | The New Yorker7:30 - Newsom Admits to Cleaning Up SF For Major Summit, CA Reps Respond - California Family Council9:30 - How Fox News and CNN Have Changed in the Last Decade11:00 - Study shows that repeated statements are more often judged to be true, regardless of a person's age or prior knowledge | Vanderbilt University13:30 - How to survive the medical misinformation mess - Ioannidis - 2017 - European Journal of Clinical Investigation - Wiley Online Library26:30 - Role of antidepressants in the treatment of adults with anorexia nervosa - PMC35:00 - Vaccines for preventing influenza in healthy adults (Review) - Cochrane Review39:30 - Decline in Seasonal Influenza Vaccine Effectiveness With Vaccination Program Maturation: A Systematic Review and Meta-analysis48:00 - Just-world hypothesis - The Decision Lab

Join L. Joseph Parker, a research physician, as we explore the intricacies of depression treatment. We'll delve into the prevailing theories about serotonin, the delayed effects of SSRIs and SNRIs, and the emerging neuroplastic theory of depression. Discover how ketamine offers rapid relief and its potential synergy with traditional antidepressants. We'll also discuss the risks and benefits of these treatments and the importance of investing in further research to address this critical issue. L. Joseph Parker is a research physician. He discusses the KevinMD article, "Can ketamine and SSRIs offer a complete depression treatment?" Our presenting sponsor is Nuance, a Microsoft company. Together, Microsoft and Nuance are leveraging their rich digital technology and advanced AI capabilities to tackle some of health care's biggest challenges. AI-driven technology promises to revolutionize patient and provider experiences with clinical documentation that writes itself. The Nuance Dragon Ambient eXperience, or DAX for short, is a voice-enabled solution that automatically captures patient encounters securely and accurately at the point of care. DAX Copilot combines proven conversational and ambient AI with the most advanced generative AI in a mobile application that integrates directly with your existing workflows. Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 85 percent of patients say their physician is more personable and conversational. Discover AI-powered clinical documentation that writes itself. Visit https://nuance.com/daxinaction to see a 12-minute DAX Copilot demo. VISIT SPONSOR → https://nuance.com/daxinaction SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended GET CME FOR THIS EPISODE → https://earnc.me/a1978F Powered by CMEfy.

Dennis discusses MDMA therapy for PTSD with guest Emily, a pharmacist. They explore how MDMA is being researched as a treatment for combat-related PTSD, especially when conventional medications like SSRIs and SNRIs fall short. MDMA offers a unique approach by providing stimulating effects while fostering empathy and helping patients reprocess traumatic memories. Emily emphasizes the importance of integration in therapy. Clinical trials have shown promising results, with 67% of participants achieving remission from PTSD. The episode also touches on the challenges and progress in getting MDMA therapy approved and accessible to patients. Thank you to Delta Development Team for in part, sponsoring this podcast. deltadevteam.com For more content go to www.prolongedfieldcare.org Consider supporting us: patreon.com/ProlongedFieldCareCollective

Menopausal vasomotor symptoms occur in about 80% of women and have a significant impact on quality of life. Hormone replacement therapy works well; however, it is often underused. Join host, Geoff Wall, as he evaluates Fezolinetant, a new medication to treat 'hot flashes.' The GameChangerHRT is vastly underused in menopausal women. Gabapentin and SNRIs may help with some vasomotor symptoms. Fezolinetant is effective for hot flashes and seems to be well tolerated. HostGeoff Wall, PharmD, BCPS, FCCP, BCGPProfessor of Pharmacy Practice, Drake UniversityInternal Medicine/Critical Care, UnityPoint Health ReferenceLederman S, Ottery FD, Cano A, et al. Fezolinetant for treatment of moderate-to-severe vasomotor symptoms associated with menopause (SKYLIGHT 1): a phase 3 randomised controlled study. Lancet. 2023 Apr 1;401(10382):1091-1102. doi: 10.1016/S0140-6736(23)00085-5. Epub 2023 Mar 13. PMID: 36924778.https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00085-5/fulltext Pharmacist Members, REDEEM YOUR CPE HERE! Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)CPE Information Learning ObjectivesUpon successful completion of this knowledge-based activity, participants should be able to:1. Discuss the pros and cons of hormone replacement therapy in women with vasomotor symptoms.2. Discuss the role of fezolinetant for treatment of vasomotor symptoms.  0.05 CEU/0.5 HrUAN: 0107-0000-23-365-H01-PInitial release date: 11/27/2023Expiration date: 11/27/2024Additional CPE details can be found here.Follow CEimpact on Social Media:LinkedInInstagramDownload the CEimpact App for Free Continuing Education + so much more!

High Yield Psychiatric Medications Antidepressants Review for your PANCE, PANRE, Eor's and other Physician Assistant exams. Review includes SSRI's, SNRIs, TCAs, MAOIs, Atypical antidepressants, Serotonin modulators. TrueLearn PANCE/PANRE SmartBank:https://truelearn.referralrock.com/l/CRAMTHEPANCE/Discount code for 20% off: CRAMTHEPANCEIncluded in review: Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Desvenlafaxine, Duloxetine, Levomilnacipran , Milnacipran, Venlafaxine, Amitriptyline, Clomipramine, Doxepin, Imipramine, Trimipramine, Desipramine, Nortriptyline, Protriptyline, Tranylcypromine, Isocarboxazid, Phenelzine Selegiline, Bupropion, Mirtazapine, Trazodone

A few weeks ago, MS3 Bilal Rana hosted an episode on Mood Disorders. This is a two-part follow-up to that episode, with a packed and powerful review of the pharmacology of mood disorders – what are the drugs we use to treat mood disorders, and how do they work? In part 1, we cover SSRIs, SNRIs, TCAs, atypical antidepressants, MAU inhibitors. Let's go!

Physician Assistant and prior C&P examiner Leah Bucholz discusses Erectile Dysfunction as it relates to PTSD in VA disability.Leah discusses the relationship between erectile dysfunction (ED) and mental health disorders like PTSD, depression, and anxiety in the context of VA disability. She explains that ED can be service-connected either directly (primary) or secondarily due to other service-connected disabilities, such as mental health disorders. Leah emphasizes the importance of supporting VA disability claims with peer-reviewed literature, citing several studies from the Journal of Sexual Medicine that establish a significant link between PTSD in veterans and sexual dysfunction. She also mentions that medications used for treating mental health disorders, such as SSRIs and SNRIs, can contribute to ED. While not an expert on VA disability ratings, Leah briefly touches on them, explaining that ED generally receives a special monthly compensation, and the rating can vary based on specific conditions like testicular atrophy or physical deformities.If you would like more information on our services including Independent Medical Opinion Letters often referred to as nexus letters and records review, please check us out here: https://www.prestigeveteranmctx.com/#veterans #va #medical

This episode is sponsored by Charm Economics.  In this podcast episode, Dr. Robert McCarron discusses the urgent need for improved mental health training for primary care physicians and specialists. As the founding director of the UC Davis Train New Trainers Primary Care Psychiatry Fellowship, Dr. McCarron aims to expand access to mental healthcare delivery, emphasizing the importance of addressing both physical and emotional pain in patients. The episode covers three key components of treatment: therapy, medication, and whole person care. Dr. McCarron advocates for empowering patients in decision-making and planting the seed for treatment, rather than pushing them into therapies they may not be ready for. He provides an overview of commonly used antidepressants like SSRIs and SNRIs and highlights the challenges of finding therapists due to the shortage of psychiatrists and insurance complexities.  His training program equips primary care providers with brief psychotherapy skills, such as cognitive behavioral therapy and motivational interviewing, to initiate treatment while patients wait for specialized care, ensuring better mental health support overall. Looking for something specific? Here you go! [00:05:00] Introduction to the Train New Trainers Primary Care Psychiatry Fellowship program. [00:06:00] The importance of training primary care providers in addressing mental health issues. [00:10:00] Approaching patients with stigma against mental illness and behavioral health conditions. [00:13:00] Integrative or whole person care as an essential component of treatment. [00:19:00] Overview of different antidepressant medications (SSRIs, SNRIs, Wellbutrin, Remeron). [00:22:00] Challenges in finding a therapist and the need for increased mental health resources in primary care. [00:23:00] Mini therapies and training primary care providers to address mental health. Bio/links! Dr. Robert McCarron, D.O., is a board-certified psychiatrist and internist, having completed a dual residency in internal medicine and psychiatry at Rush University. As the founding training director of the combined internal medicine/psychiatry residency program at the University of California, Davis School of Medicine, he received a prestigious 2.6 million dollar grant from the California Department of Mental Health. This grant aims to establish a comprehensive "Med Psych" curriculum that can be adopted by other primary care practitioner training programs, reflecting his dedication to enhancing mental health training in primary care. With a focus on unexplained physical complaints, depression, anxiety in primary care, and metabolic syndrome, Dr. McCarron has published extensively in these areas. He holds significant leadership roles, including the immediate past president of the Central California Psychiatric Society and the Association of Medicine and Psychiatry. Additionally, he serves as the Medicine/Psychiatry Section editor for Current Psychiatry and an Associate Editor for The Primary Care Companion to the Journal of Clinical Psychiatry. Dr. McCarron's contributions to various psychiatric associations and assemblies underscore his commitment to advancing general medical and psychiatric research, patient care, and medical education in California and beyond. Find Dr. McCarron on his LinkedIn.  Did ya know…  You can also be a guest on our show? Please email me at brad@physiciansguidetodoctoring.com to connect or visit www.physiciansguidetodoctoring.com to learn more about the show! Socials: @physiciansguidetodoctoring on FB  @physicianguidetodoctoring on YouTube @physiciansguide on Instagram and Twitter

Drs. Hope Rugo and Kristin Rojas discuss advances in the management of menopausal symptoms, fertility preservation, and bone health for women on endocrine therapy for breast cancer. TRANSCRIPT Dr. Hope Rugo: Hello. I'm Dr. Hope Rugo, your guest host of the ASCO Daily News Podcast today. I'm a professor of medicine and director of breast oncology and clinical trials education at the University of California San Francisco's Comprehensive Cancer Center. And I'm also an associate editor of the ASCO Educational Book.   In patients with hormone receptor positive breast cancer, the most common subset of the most common cancer in women worldwide, adjuvant endocrine therapy significantly reduces the risk of recurrence and death. However, prolonged estrogen suppression associated with the use of endocrine therapy can cause life-altering menopausal symptoms, bone loss, and fertility concerns. These issues impact the use of endocrine therapy and potentially breast cancer outcome.    Today, we'll be discussing mitigation strategies to manage the side effects of endocrine therapy, which we hope will improve our patient's quality of life and adherence to treatment with Dr. Kristin Rojas, who addressed these issues in a recently published article in the 2023 ASCO Educational Book. Dr. Rojas is an assistant professor of surgery and a breast surgical oncologist and gynecologic surgeon at the University of Miami Sylvester Comprehensive Cancer Center.    Our full disclosures are available in the transcript of this episode, and disclosures of all guests on the podcast can be found in our transcripts at asco.org/DNpod.    Dr. Rojas, thank you for being on the podcast today.   Dr. Kristin Rojas: Thanks, Dr. Rugo, thank you so much for having me. Thank you to ASCO as well. It's truly an honor to be here with you today.  Dr. Hope Rugo: Your excellent article provides an updated overview of the existing approaches and a little forward thinking for improving the quality of life of breast cancer patients who are receiving estrogen deprivation therapy, a really broad term we use for all the hormone therapy we use in ovarian function suppression in the treatment of breast cancer. And then you had a very nice session education session at the ASCO Annual Meeting discussing these issues. Can you briefly discuss the educational session, your speakers and topics, and then we'll get more into the details of this important topic?   Dr. Kristin Rojas: At our educational session at ASCO this year, I chaired the session and presented on managing the sexual side effects and menopausal symptoms of estrogen suppression. And I had two wonderful colleagues with me: Dr. Matteo Lambertini, who shared guidelines regarding bone-targeted agents and managing bone health during endocrine suppression. And then we also had Dr. Terri Woodard, who is a reproductive endocrinologist from MD Anderson, who spoke on managing fertility concerns, which is a very important topic right now.   Dr. Hope Rugo: Yeah, that's great. And it was such a fabulous session. Our listeners can view it online at asco.org if you missed this session. But let's talk a little bit about what was in your article and what was discussed. First, I think the physical and psychological effects of cancer care we know are critical components of survivorship care. Can you tell me a little bit more about that and how we need to understand that as oncologists?  Dr. Kristin Rojas: So, as you know, as treatment continues to improve, our cancer outcomes are improving and the population of survivors continues to grow. So, I think that for many breast cancer patients, or having the diagnosis of breast cancer, becomes more of a chronic illness and less a life-threatening issue for some. I think that the conversation is now changing from “Will you live?” to “How will you live?” And I was thrilled to see that other big organizations, along with ASCO, are prioritizing managing these important symptoms in survivorship. Because I think that, as most patients will be on some form of estrogen suppression, managing the toxicity of these therapies, as you pointed out, probably does influence treatment adherence, which directly translates to an oncologic improvement. So, it's not just managing these soft symptoms, it actually will have a direct influence on probably overall survival along with disease-free survival.  Dr. Hope Rugo: Yeah, I think that's incredibly important and it's not just about doing the exam and finding out symptoms that might signify recurrence, it's really trying to address the effects of the treatment patients have gotten of chemo and their ongoing treatment with endocrine therapy that's so incredibly important. And now, of course, in medical oncology, we're adding on more agents which add to symptoms. That'll be the topic of next year's ASCO educational session. What do you do with the CDK4/6 inhibitors and managing those. But in more than 80% of women who are on the antiestrogen or various, I'm going to call hormone therapies, for early-stage breast cancer, vasomotor symptoms are a big issue. They're typically more severe in younger patients because of course they have estrogen and we take it away. So, how do we mitigate this problem in patients that can result in poor sleep and impact many aspects of one's psychosocial status? And these issues, not sleeping, of course, you make everything worse.  Dr. Kristin Rojas: Yeah, that's a really important point. And you're right, this is a really common symptom experienced by the majority of patients on endocrine suppression. And not only those patients, but patients with triple negative disease who are put into menopause from chemotherapy, etc., along with women with cancer of other disease sites. And so, as the director of our program at the Sylvester Comprehensive Cancer Center, the program is called MUSIC, which stands for Menopause Urogenital Sexual Health and Intimacy Clinic.    This is a very common symptom that patients often report. And one of the important things about this that I've realized is that hot flashes or vasomotor symptoms can actually have a pretty varied presentation. So, it's not just intense sweating. Sometimes these patients can present with palpitations, panic attacks, and they don't even realize that they're hot flashes. This is an effect of estrogen suppression and it's a central mechanism. So, it's probably related to hypothalamic dysregulation regarding how our body senses temperature changes, but it results in widespread flushing and sweating and those other aspects I told you about.   So, we've known for a long time that there are some behavioral modifications that can help with vasomotor symptoms or hot flashes. But now, we actually do have some pretty effective pharmacologic therapies for these patients as well, for whom behavioral modifications aren't completely helping the issue. Or, as you said, when patients are being woken up all night long with these hot flashes, it totally disrupts how their day goes and disrupts coping with their disease and all the other aspects of their treatment.   So, there's some effective treatments that we have. One of those being cognitive behavioral therapy has been shown to be helpful. The data on acupuncture is mixed, but I'm hopeful about this. And then the pharmacologic therapies we have. Traditionally or historically, clonidine, which is an alpha agonist, has been used along with gabapentin. But I think when choosing a medication to prescribe to a patient for hot flashes, you have to take into account the side effect profile. Clonidine does have some issues with blood pressure rebound, and gabapentin is really only effective in large doses, which can be very sedating for patients.    In the MUSIC Sexual Health After Cancer program, we typically stick to low dose SSRIs or SNRIs. I usually go with venlafaxine at a really low dose of 37.5 milligrams, and I can titrate up. I have patients take it at night in case they feel a little foggy when they first start it. But more recently, we've started using oxybutynin, which is an anticholinergic medication originally FDA approved for overactive bladder. I use the XL formulation, or you can do 2.5 or 5 milligrams BID. And this, in a study a few years ago, was shown to significantly reduce hot flashes and improve quality of life in a placebo-controlled trial.   So, important aspects of side effects of these medications with SSRIs or SNRIs working in the MUSIC Sexual Health After Cancer Program, sexual health concerns are often an issue, so those drugs can be libido zappers sometimes. But, the biggest side effect I've come across with oxybutynin for patients is dry mouth, and usually that resolves after a little while. So, we've had a lot of success in managing patients' hot flashes with these medications.  Dr. Hope Rugo: That's great and incredibly helpful. And I will say that as we're talking about these issues on this podcast, this is really important for all of our staff and our clinics because most of us don't have a fabulous clinic like the one you've started. But we are managing this with our staff, our APPs, and other areas that our patients are seeing. If everybody has this education, it will really help in the management of symptoms. And I just want to point out that venlafaxine was the first drug to be studied in this area really successful, but that we can use a whole host of different antidepressants. If people have side effects from one another, one may work really well, and generally low doses work well. The oxybutynin was such a very cool study. I think that's a great additional option.    In addition to hot flashes, we also see genitourinary syndrome of menopause, and that's part of what you deal with every day in your clinic, GSM. And this can be not just vaginal dryness, which is bad enough, but also increased infections, painful sex, recurrent bladder infections and also reduced libido, which is a really big issue, we just don't talk about very much. What's the most effective and safe treatment for GSM? And we use a lot of low dose vaginal estrogen and a variety of delivery mechanisms. What are the risk and benefits when patients really need something more?   Dr. Kristin Rojas: GSM, or genitourinary syndrome of menopause, is this newer umbrella term for what we used to call vaginal atrophy. And you're right, it encompasses not only dryness, but all the other changes that can happen to the vulvovaginal mucosa along with anatomic changes to the pelvic floor. This is critically important, I think, that we address these issues or these potential side effects at the time of endocrine therapy prescription because what we have found in our program is that while hot flashes might get better, these symptoms do not get better. And left untreated, they get worse.   And one of the surprising findings that we have presented earlier at another conference this year was that almost half of our patients, when they had their pelvic exam in the program, were also found to have vaginal stenosis. So narrowing and shortening of the vagina, making penetrative sex actually impossible. So it's really not just dryness, but a host of these other symptoms that go along with that. I like to break this down in a really simple way because I know that a lot of providers may be intimidated when patients might bring this up. But I think about it this way. Number 1, eliminate irritants. Number 2, moisturize. Number 3, lubricate. And 4, address the pelvic floor.   Oftentimes when patients present in the MUSIC program, they've been putting a lot of over the counter topical therapies on the vulva and the vagina using intravaginal washes. One of the biggest offenders of some of these symptoms is artificial fragrance, which we can actually develop an allergic reaction to, which manifests as burning and stinging. So these patients may also report burning and stinging in addition to dryness. These offenders can be in all kinds of products. So not only feminine washes, which I don't recommend in our program, but things like bath bombs, bubble bath, toilet paper. And so we kind of go through an inventory of everything that's touching the delicate tissues of the vulva and the vagina and try to back off those products.   The second thing is moisturization. It's important to talk to patients about the difference between moisturization, which I say is for maintenance, and lubricants, which are for PRN use sexual activity. But I tell patients, "lubricants for love." That's how I differentiate the use of these two different types of products because they have different properties. Usually after eliminating irritants, our first step is to start with a non-hormonal moisturizer because there's some really good high-tech non-hormonal moisturizers out there, specifically those containing hyaluronic acid, which pulls moisture from the environment and holds it on the skin. And by using this first—this is my personal opinion—but I think by improving the mucosa a little bit and kind of improving the dryness, maybe even the elasticity a little bit, I think that when patients do have persistent symptoms after using regularly these non-hormonal moisturizers at least three times a week, that adding in a low dose vaginal hormone at that time, instead of putting it on completely atrophic mucosa, you're putting it on kind of like a pretreated mucosa, which I think might decrease systemic absorption.   I'm so glad you brought up vaginal estrogen. I could give an entire talk just on that, so I'd be happy to do that next year for ASCO if anybody wants. But it is very controversial. Historically, there have not been studies showing an increased risk of recurrence with the use of local estrogen therapy, so estrogen in the vulva and the vagina. However, there was a recent study that came out this year that was a large analysis of breast cancer patients receiving different types of hormone therapy. And in a subset analysis of the group who got local vaginal estrogen, just in those patients on aromatase inhibitors, there was a slightly, but statistically significant–according to their analysis–increase in the risk of recurrence. I think there's some issues with this analysis because it was a large study and there's a lot of recall bias and measuring this in patients is really challenging. But I think it's still important to mention because a lot of patients are going to read about those things, these types of studies.   The way I approach it is to start with the lowest dose and I start with infrequent dosing. If patients have persistent symptoms, I start them with once a week or twice a week, which is different from the original pharmacokinetic studies of higher dose estrogens, which showed a bump in their serum estradiol when they used it every night for two weeks. So I actually do the opposite and taper them up. I'll do once a week to twice a week. And usually, patient symptoms are resolved at that point.   But I do want to point out, that's a great option for patients on tamoxifen because mechanistically, as you know, it probably doesn't matter if they have a little bump in their serum estrogen. But for the patients on aromatase inhibitors, we actually have a new kid on the block, a vaginal androgen called prasterone or DHEA. I dose this in the same way, titrate it up. But this can be really helpful for patients on aromatase inhibitors because the ALLIANCE trial showed that for those patients on AIs that their systemic estrogen levels do not increase. And so that's kind of how I manage that discussion. I do think it takes some multidisciplinary collaboration, so I always involve my medical oncology colleagues on this.    Lastly, lubricants. So, everyone seems to be really into using water-based lubricants, but I try to tell patients, unless you're depending on condoms for STD or contraception protection, silicone-based lubricants that are like preservative-free and don't have a lot of those gimmicks or additives, are great—they stay slippery for longer—and there's some really great brands out there. And then for patients who still have persistent pain with sex, we address the pelvic floor, which is either through the use of dilators, referring them to pelvic floor physical therapy, or other sexual devices that we use in the MUSIC program.  Dr. Hope Rugo: This is really helpful, and I think that for many of us in practice, we really want to get the specifics of what you use. I think this prasterone, the idea of DHEA is really very interesting and something that personally I haven't used, but we did use in the distant past before there was an FDA-approved version.   So I guess I have several questions just to ask about the details. So one is, when you prescribe this, do you find it's generally covered by insurance? And when you say low dose, do you mean just try it once a week? And then do you use the estrogen tablets, the brand names are often Yuvafem or Vagifem, we often use those twice a week. How often do you use them and do you use the estrogen ring also? What are the absolute specifics of what you're recommending to these women? And do you feel like sometimes in patients who are developing these symptoms that early use can help avoid the more severe symptoms and therefore reduce the exposure?   And lastly, just to say, that paper which was so interesting about the slightly increased risk of recurrence, I felt was so flawed in terms of what people were using and if they were taking their hormone therapy and risk of recurrence, the risk of the cancer itself, that I really felt like I couldn't make anything out of it in terms of the risk to patients. But I'm really interested in your specific recommendations.  Dr. Kristin Rojas: Thanks for asking about specifics. And I'm happy to give our treatment algorithms here, which we also discussed in our session and we listed in our EdBook manuscript. We do pelvic exams in the MUSIC program and I often find that there's very specific points in the vestibule or the opening of the vagina that are tender and have pain, specifically, what's known as the posterior fourchette, which is the kind of connection between the right and the left side towards the posterior aspect. So, I usually start with a 1% estradiol cream and have patients tap it to the outside and then bring in a dilator and have patients use not only a silicone lubricant, but put some of the estradiol cream on the dilator. And so that brings the product up to the top of the vagina for patients that have some of those anatomic changes that I discussed.   So this is 1 option, and we really don't have a lot of issues with insurance authorization for the cream, just every once in a while. We can also use a 4 microgram or a 10 microgram dose of estradiol, which is a tablet, which are newer options. This is in contrast to the old pharmacokinetic studies that use 25 micrograms. So this is much, much lower. I do run into some prior authorization issues with those because there tend to be newer versions of this. But as you mentioned, the estradiol ring, which I do think is a great option and when you calculate it out, releases a very low dose of estradiol every day. And it's good for patients who want a more low maintenance regimen. The only challenge I've had with that is it's a large rigid ring. And for patients who already have those anatomic changes, it can be really hard to place that in the vagina.   And so, just like you said, early prevention and treatment of these issues can prevent not only anatomic changes, but even potentially the need for exposure for larger doses of hormones. For all of those options, I tend to do it once or twice a week and then can move up. But we sometimes get kind of creative in how we use these options in terms of placing them on the dilator, placing them externally. For patients that have recurrent urinary tract infections, I also have them kind of tap some of the estradiol cream around the urethra as well to improve the urethral and potentially bladder microbiome and decrease risk of recurrent UTIs.  Dr. Hope Rugo: That's really interesting, and I think those specifics are incredibly helpful. We also will check, although I have to say there's no data to support it, the serum estradiol levels in patients who are using more than our minimal amount. We have plenty of studies that have shown that there really isn't systemic estrogen if people are using very low doses. But we will check sometimes, just sometimes people use these topical creams where they get premenopausal levels of estrogen, which of course we don't want. So, this is an incredibly helpful and useful discussion.    One of the other things that happens for these patients and our younger patients, which breast cancer is still increasing in small numbers in younger patients every year, and many of these patients have hormone receptor positive disease. And it just breaks your heart to see a 38-year-old who is planning to get pregnant next month with their new partner who develops a hormone receptor positive breast cancer. and we want to give people all the options they possibly can. We are strong proponents for harvesting eggs and either freezing eggs or embryos before you start treatment. And we figure we always have 2 weeks for breast cancer. We also use ovarian function suppression during chemo just for whatever help it might have.   But then after patients have finished their treatment and they're on hormone therapy, it's a really big issue for women about when they can have a child because we don't want to wait until they're 45. So, you had noted in your article that some women could take a break from endocrine therapy after 18 to 24 months to try and conceive. Can you tell me a little more about that?  Dr. Kristin Rojas: Sure. Well, this aspect of our discussion was very well presented by my colleague, Dr. Terri Woodard from MD Anderson, a reproductive endocrinologist, and she also put together the aspect of this for our manuscript. She talks about how fertility counseling and referral is probably underutilized, but definitely indicated for most of these patients who are of pregnancy age or premenopausal status. And observational data for a long time didn't show that pregnancy after treatment worsened oncologic outcomes. However, patients as well as many providers had reservations.   So, it's been very helpful that we now have a prospective, large, international trial known as the POSITIVE trial, the early results of which came out earlier this year, which showed that women, after 18 to 24 months, could interrupt endocrine therapy and did not have a worsened short-term oncologic outcome. And those are women with early-stage breast cancer. However, there is a concern that many patients do take longer to get pregnant in that age group or after treatment, potentially if they've received chemo. There is a concern about the duration of time that they're not on endocrine therapy afterwards, which might be further clarified in later analyses. So that's my takeaway from that study, which did show us that very helpful, reassuring information. But I think we're still waiting for the long-term data and it's definitely still a very important patient-centered discussion.   Dr. Hope Rugo: This is a really excellent point, and I think that one of the things of a trial like this, which is sort of a registry study, is that we're always going to speak with our feet to some degree. So, if patients have very, very high risk of recurrence and highly proliferative disease, we might not want them to stop at 18 months because their risks are so high early. So, it has to be a risk versus benefit discussion for individual patients, of course. But I think this data was incredibly reassuring.   It was interesting there were some patients who hadn't restarted their endocrine therapy. In the paper in the New England Journal, it told us that some of those patients were still trying to conceive. But one of the things that's going to be really important for these patients is to really make a big effort on the part of our clinical practices to get patients to restart their hormone therapy. It's very hard to do that, as you can imagine, in that setting.    Another area here is monitoring bone health. And I know that's not part of the MUSIC clinic per se because you're really focusing on GSM and other areas that we've just discussed, which are so incredibly important. And it's funny, bone health is silent, right? So, although some patients don't want to take aromatase inhibitors because they're worried about losing further bone density, they don't feel it. So that's, of course, a different kind of a toxicity. But we know that by suppressing ovarian function in young women, we cause a lot of bone loss, and in older women, already in menopause, that this continuous loss of bone increases the risk of fractures, which can be a huge impact on quality of life and even survival in some cases. So, we're really interested in trying to prevent bone demineralization and reducing the risk of fractures. I believe that Matteo Lambertini from Italy discussed this in your paper and that there's a lot of discussion about use of denosumab and zoledronate. I wonder if you could just comment a little bit on that in our last couple of minutes.  Dr. Kristin Rojas: Well, as you said, my colleague Dr. Lambertini put this aspect of our paper together, but he did put together a very nice summary of bisphosphonates and denosumab and separated their use by premenopausal and postmenopausal patients because the data surrounding those patient populations is slightly different or nuanced. But as you mentioned, it is important to monitor these patients' bone density. We have our standard recommendations such as a calcium-enriched diet, resistance and weight-bearing exercise, and vitamin D for patients, for those patients with a vitamin D deficiency or at risk of bone density loss. And so these pharmacologic agents can also help decrease bone mineral density loss and potentially decrease or likely decrease bone recurrences, which, as we know, influences survival. I think he provides a very nice summary of that, as you mentioned.  Dr. Hope Rugo: I think that's so incredibly important. And thank you for really emphasizing the weight-bearing exercise and checking vitamin D and making sure patients are taking vitamin D and at least some calcium. And then, of course, our institution, we work closely with our endocrinologists specializing in bone as well, when issues come up about risk of osteonecrosis of the jaw, and we require dental clearance for everybody starting medication just to make sure that we've reduced risk to the patient. And then when we're trying to think about stopping denosumab and should we bridge with zoledronate to reduce the risk of fracture, we also talk to our bone doc. So it's really important.   And in our last just 1 minute, I know you were thinking of saying something about measuring estrogen in the blood in patients who are using vaginal estrogens. Do you do that?   Dr. Kristin Rojas: Yeah, great question. I'm glad you brought that up. We actually don't routinely do this in the MUSIC program, but it is an important aspect to think about today, because I don't know about where you are, but here in South Florida we have a lot of patients who are receiving therapies outside of the FDA-approved space and these are typically marketed as bioidentical hormones, which is a marketing term. Oftentimes, they'll get either transdermal formulations or pelleted hormone therapy that can result in really high superphysiologic testosterone or estrogen levels. And so we typically, for those patients, do try to get them off those non FDA-approved therapies because the safety of those is unknown.   Dr. Hope Rugo: That's really interesting and so helpful. Yes, I know this whole idea of bioidentical hormones drives me crazy, but I think that's great that you brought that up, actually. We do measure it. Who knows? I think if you're really worried, measuring “Yeah, everybody's hot flashes went away,” it's probably worthwhile checking.   This was such a fabulous conversation. I learned so much. We really appreciate your contribution to the educational manuscript, to the educational program, and your fabulous insights with us today. Thank you so much for participating on the ASCO Daily News Podcast. I think everyone will find this very helpful.   Dr. Kristin Rojas: Thank you so much for having me.   Dr. Hope Rugo: And thank you to you, our listeners, for joining us today. You'll find a link to Dr. Rojas and her colleagues' article in the transcript of this episode and in the 2023 ASCO Educational Book, which features practice-changing oncology research and a wide range of compelling studies on quality and equitable cancer care.    Finally, if you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. Thanks again.    Disclaimer:   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.    Follow today's speakers:   Dr. Hope Rugo  @hoperugo  Dr. Kristin Rojas  @kristinrojasmd    Follow ASCO on social media:    @ASCO on Twitter    ASCO on Facebook    ASCO on LinkedIn      Disclosures:   Dr. Hope Rugo:  Honoraria: Puma Biotechnology, Mylan, Samsung Bioepis, Chugai Pharma, Blueprint MedicinesConsulting or Advisory Role: Napo PharmaceuticalsResearch Funding (Inst.): OBI Pharma, Pfizer, Novartis, Lilly, Genentech, Merck, Odonate Therapeutics, Daiichi Sankyo, Sermonix Pharmaceuticals, AstraZeneca, Gilead Sciences, Ayala Pharmaceuticals, Astellas Pharma, Seattle Genetics, Macrogenics, Boehringer Ingelheim, Polyphor  Dr. Kristin Rojas:   Honoraria: Pacira Pharmaceuticals  Consulting or Advisory Role: Roche Diagnostics, Merck  Research Funding (Inst): Bristol Myers Squibb Foundation       

Hi! I've been in the hospital with pneumonia! But enjoy this banger of an encore about: Serotonin! Dopamine! Norepinephrine! Neurotransmitters: what's their deal? Dr. Crystal Dilworth, aka Dr. Brain, stops by to have a spirited discussion about how chemical messengers change our moods and behaviors. We chat about depression, anxiety, what chemicals drive us to get off the couch, how antidepressants work, ADHD, addiction, the microbiome, new habits, quitting smoking, starting meditation, Oreos vs. cocaine, SSRIs vs. SNRIs, what it's like to hold a human brain in your hands and if she would donate hers to science. Also: what's up with "lizard brains?"Visit Dr. Dilworth's websiteFollow Dr. Dilworth on Instagram & TwitterA donation went to The Geena Davis Institute: seejane.orgMore episode sources and linksSmologies (short, classroom-safe) episodesOther episodes you may enjoy: Attention-Deficit Neuropsychology (ADHD) Part 1 with Dr. Russell Barkley, Attention-Deficit Neuropsychology (ADHD) Part 2, LIFE ADVICE: For anyone who needs some hacks, Dolorology (PAIN), Eudemonology (HAPPINESS), Chronobiology (CIRCADIAN RHYTHMS) Encore + 2023 Updates, FIELD TRIP: An Airport Full of Neuroscientists, Oneirology (DREAMS), Thanatology - NEW Interview (DEATH, GRIEF & MOURNING), Neuropathology (CONCUSSIONS), Molecular Biology (PROTEINS + SCIENCE COMMUNICATION), Awesomeology (GRATITUDE FOR LITTLE THINGS), Oikology (DECLUTTERING), Philematology (KISSING), Traumatology (PTSD), Victimology (CRIME VICTIMS), Personality Psychology (PERSONALITIES), Somnology (SLEEP),  Fearology (FEAR) Pt. 1, Fearology (FEAR) Pt. 2, Sports & Performance Psychology (ANXIETY & CONFIDENCE)Sponsors of OlogiesTranscripts and bleeped episodesBecome a patron of Ologies for as little as a buck a monthOlogiesMerch.com has hats, shirts, masks, totes!Follow @Ologies on Twitter and InstagramFollow @AlieWard on Twitter and InstagramEditing by Mercedes Maitland of Maitland Audio Productions, Jarrett Sleeper of MindJam Media, and Steven Ray Morris Transcripts by Emily White of The WordaryWebsite by Kelly R. DwyerTheme song by Nick Thorburn

Dr. Carrie Jones rejoins the Evolution of Medicine podcast to discuss the functional medicine approach to depression, anxiety and attention issues. She is an avid educator who specializes in stress and endocrine health. A recent systematic review found that the serotonin theory of depression is scientifically unsupported,  which raises the question: What does this mean for patients who use either SSRIs or SNRIs? Dr. Jones explains how she answers this for concerned patients and discusses her approach to resolving mood issues by looking for root causes. Other topics discussed in this conversation include rising mental health issues amongst teenagers in particular, group care, and mental health lifestyle factors, such as balancing neurotransmitters, stress management, social connection, nutrition, gut health and physical activity. Tune in and listen to the whole conversation to learn about the following from Dr. Jones: Examples of how blood sugar dysregulation can harm sleep quality and mental health Problems that can arise when supporting only one neurotransmitter Specific nutrients she uses for patients with mood dysregulation The potential for technology, especially continuous glucose monitors, to empower patients in their health journeys And much, much more!  

Physician Assistant and prior C&P examiner Leah Bucholz discusses Erectile Dysfunction as it relates to PTSD in VA disability.Leah discusses the relationship between erectile dysfunction (ED) and mental health disorders like PTSD, depression, and anxiety in the context of VA disability. She explains that ED can be service-connected either directly (primary) or secondarily due to other service-connected disabilities, such as mental health disorders. Leah emphasizes the importance of supporting VA disability claims with peer-reviewed literature, citing several studies from the Journal of Sexual Medicine that establish a significant link between PTSD in veterans and sexual dysfunction. She also mentions that medications used for treating mental health disorders, such as SSRIs and SNRIs, can contribute to ED. While not an expert on VA disability ratings, Leah briefly touches on them, explaining that ED generally receives a special monthly compensation, and the rating can vary based on specific conditions like testicular atrophy or physical deformities.If you would like more information on our services including Independent Medical Opinion Letters often referred to as nexus letters and records review, please check us out here: https://www.prestigeveteranmctx.com/#veterans #va #medical

In this episode, we will discuss the most important updates from the American Diabetes Association's 2023 Standards of Care in Diabetes. Key Concepts The first-line therapy for type II diabetes is based on whether the primary goal of therapy is cardiorenal benefit (reduced risk of ASCVD, heart failure, or CKD) or glycemic and weight goals. For cardiorenal benefit, GLP1 receptor agonists and SGLT2 inhibitors are heavily emphasized. For glycemic control and weight gain, GLP1 receptor agonists (or GLP1/GIP in the case of tirzepatide) have a very favorable effect on weight loss and glycemic control. While metformin is still mentioned, it is no longer the sole, first-line therapy for type II diabetes. For patients with diabetes and a high risk of ASCVD (20% or higher), high-intensity statins, ezetimibe, and/or PCSK9 inhibitors are recommended to achieve an LDL less than 70 mg/dL. In patients with a history of ASCVD events, these same therapies are used to achieve a recommended LDL goal of less than 55 mg/dL. Among selected patients with diabetes and CKD with albuminuria, finerenone (a new mineralocorticoid receptor antagonist) is recommended to improve renal and cardiovascular outcomes. A variety of different therapies are now recommended for neuropathic pain, including gabapentinoids, SNRIs, TCAs, and several antiseizure medications (lamotrigine, lacosamide, oxcarbazepine, and valproic acid). A wide variety of other new recommendations are discussed in the episode, including NASH/NAFLD, obesity and weight management, special populations, diabetes technology, and health behavior changes. References American Diabetes Association. Standards of Care in Diabetes-2023. Diabetes Care. 2023; 46(1): S1-S292. https://diabetesjournals.org/care/issue/46/Supplement_1

Hello and welcome back everybody. We are on Week 3 of the Sexual Health and Anxiety Series. At first, we talked with the amazing Lauren Fogel Mersy about sexual anxiety or sexual performance anxiety. And then last week, I went into depth about really understanding arousal and anxiety, how certain things will increase arousal, certain things will decrease it, and teaching you how to get to know what is what so that you can have a rich, intimate, fulfilling life.  We are now on Week 3. I have to admit, this is an episode that I so have wanted to do for quite a while, mainly because I get asked these questions so often and I actually don't know the answers. It's actually out of my scope. In clinical terms, we call it “out of my scope of practice,” meaning the topic we're talking about today is out of my skill set. It's out of my pay grade. It's out of my level of training.  What we're talking about this week is the sexual side effects of antidepressants or anxiety medications, the common ones that people have when they are anxious or depressed. Now, as I said to you, this is a medical topic, one in which I am not trained to talk about, so I invited Dr. Sepehr Aziz onto the episode, and he does such a beautiful job, a respectful, kind, compassionate approach to addressing sexual side effects of anxiety medication, sexual side effects of depression medication. It's just beautiful. It's just so beautiful. I feel like I want to almost hand this episode off to every patient when I first start treating them, because I think so often when we're either on medication or we're considering medication, this is a really common concern, one in which people often aren't game to discuss. So, here we are. I'm actually going to leave it right to the doctor, leave it to the pro to talk all about sexual side effects and what you can do, and how you may discuss this with your medical provider. Let's do it. Kimberley: Welcome. I have been wanting to do this interview for so long. I am so excited to have with us Dr. Sepehr Aziz. Thank you so much for being here with us today. Dr. Aziz: Thanks for having me. Kimberley: Okay. I have so many questions we're going to get through as much as we can. Before we get started, just tell us a little about you and your background, and tell us what you want to tell us. Dr. Aziz: Sure. Again, I'm Dr. Sepehr Aziz. I go by “Shepherd,” so you can go ahead and call me Shep if you'd like. I'm a psychiatrist. I'm board certified in general adult psychiatry as well as child and adolescent psychiatry by the American Board of Psychiatry and Neurology. I completed medical school and did my residency in UMass where they originally developed mindfulness-based CBT and MBSR. And then I completed my Child and Adolescent training at UCSF. I've been working since then at USC as a Clinical Assistant Professor of Psychiatry there. I see a lot of OCD patients. I do specialize in anxiety disorders and ADHD as well. Kimberley: Which is why you're the perfect person for this job today. Dr. Aziz: Thank you.  WHAT ARE THE BEST MEDICATIONS FOR PEOPLE WITH ANXIETY & OCD (IN GENERAL)? Kimberley: I thank you so much for being here. I want to get straight into the big questions that I get asked so regularly and I don't feel qualified to answer myself. What are the best medications for people with anxiety and OCD? Is there a general go-to? Can you give me some explanation on that? Dr. Aziz: As part of my practice, I first and foremost always try to let patients know that the best treatment is always a combination of therapy as well as medications. It's really important to pursue therapy because medications can treat things and they can make it easier to tolerate your anxiety, but ultimately, in order to have sustained change, you really want to have therapy as well. Now, the first-line medications for anxiety and OCD are the same, and that's SSRIs or selective serotonin reuptake inhibitors. SNRIs, which are selective norepinephrine reuptake inhibitors, also work generally, but the best research that we have in the literature is on SSRIs, and that's why they're usually preferred first. There are other medications that also might work, but these are usually first-line, as we call it. There are no specific SSRIs that might work better. We've tried some head-to-head trials sometimes, but there's no one medication that works better than others. It's just tailored depending on the patient and the different side effects of the medication. SSRI'S VS ANTIDEPRESSANTS DEFINITION Kimberley: Right. Just so people are clear in SSRI, a lot of people, and I notice, use the term antidepressant. Are they synonymous or are they different? Dr. Aziz: Originally, they were called antidepressants when they first were released because that was the indication. There was an epidemic of depression and we were really badly looking for medications that would work. Started out with tricyclic antidepressants and then we had MAOIs, and then eventually, we developed SSRIs. These all fall under antidepressant treatments. However, later on, we realized that they work very well for anxiety in addition to depression. Actually, in my opinion, they work better for anxiety than they do for depression. I generally shy away from referring to them as antidepressants just to reduce the stigma around them a little bit and also to be more accurate in the way that I talk about them. But yes, they're synonymous, you could say.  BEST MEDICATION FOR DEPRESSION Kimberley: Sure. Thank you for clearing that up because that's a question I often get. I know I led you in a direction away but you answered. What is the best medication for people with depression then? Is it those SSRIs or would you go-- Dr. Aziz: Again, these are first-line medications, which means it's the first medication we would try if we're starting medication, which is SSRIs. Other medications might also work like SNRIs again. For depression specifically, there are medications called serotonin modulators that are also effective such as vortioxetine or nefazodone, or vilazodone. But SSRIs are generally what people reach for first just because they've been around for a long time, they're available generic, they work, and there's no evidence that the newer medications or modulators work better. They're usually first line. Kimberley: Fantastic. Now you brought up the term “generic” and I think that that's an important topic because the cost of therapy is high. A lot of people may be wondering, is the generic as good as the non-generic options? Dr. Aziz: It really depends on the medication and it also depends on which country you're in. In the US, we have pretty strict laws as to how closely a generic has to be to a regular medication, a brand name medication, and there's a margin of error that they allow. The margin of error for generics is, I believe, a little bit higher than for the brand name. However, most of the time, it's pretty close. For something like Lexapro, I usually don't have any pressure on myself to prescribe the brand name over the generic. For something like other medications we use in psychiatry that might have a specific way that the brand name is released, a non-anxiety example is Concerta, which is for ADHD. This medication uses an osmotic release mechanism and that's proprietary. They license it out to one generic company, but that license is expiring. All those patients who are on that generic in the next month or two are going to notice a difference in the way that the medication is released. Unless you're a physician privy to that information, you might not even know that that's going to happen. That's where you see a big change. Otherwise, for most of the antidepressants, I haven't noticed a big difference between generic and brand names.   Kimberley: Right. Super helpful. Now you mentioned it depends on the person. How might one decide or who does decide what medication they would go on? Dr. Aziz: It's really something that needs to be discussed between the person and their psychiatrist. There are a number of variables that go into that, such as what's worked in a family member in the past, because there are genetic factors in hepatic metabolism and things like that that give us some clue as to what might work. Or sometimes if I have a patient with co-occurring ADHD and I know they're going to be missing their medications a lot, I'm more likely to prescribe them Prozac because it has a longer half-life, so it'll last longer. If they miss a dose or two, it's not as big of a deal. If I have a patient who's very nervous about getting off of the medication when they get pregnant, I would avoid Prozac because it has a long half-life and it would take longer to come off of the medication. Some medications like Prozac and Zoloft are more likely to cause insomnia or agitation in younger people, so I'll take that into consideration. Some medications have a higher likelihood of causing weight loss versus weight gain. These are all things that would take into consideration in order to tailor it to the specific patient. Kimberley: Right. I think that's been my experience too. They will usually ask, do you have a sibling or a parent that tried a certain medication, and was that helpful? I love that question. I think it informs a lot of decisions. We're here really. The main goal of today is really to talk about one particular set of side effects, which is the sexual side effects of medication. In fact, I think most commonly with clients of mine, that tends to be the first thing they're afraid of having to happen. How common are sexual side effects? Is it in fact all hype or is it something that is actually a concern? How would you explain the prevalence of the side effects? Dr. Aziz: This is a really important topic, I just want to say, because it is something that I feel is neglected when patients are talking to physicians, and that's just because it can be uncomfortable to talk about these things sometimes, both for physicians and for patients. Oftentimes, it's avoided almost. But because of that, we don't know for sure exactly what the incidence rate is. The literature on this and the research on this is not very accurate for a number of reasons. There are limitations. The range is somewhere between 15 to 80% and the best estimate is about 50%. But I don't even like saying that because it really depends on age, gender, what other co-occurring disorders they have such as depression. Unipolar depression can also cause sexual dysfunction. They don't always take that into account in these studies. A lot of the studies don't ask baseline sexual function before asking if there's dysfunction after starting a medication, so it's hard to tell. What I can say for sure, and this is what I tell my patients, is that this sexual dysfunction is the number one reason why people stop taking the medication, because of adverse effects.  WHAT MEDICATIONS ARE MORE PRONE TO SEXUAL SIDE EFFECTS?  Kimberley: Right. It's interesting you say that we actually don't know, and it is true. I've had clients say having anxiety has sexual side effects too, having depression has sexual side effects too, and they're weighing the pros and cons of going on medication comparative to when you're depressed, you may not have any sexual drive as well. Are some medications more prone to these sexual side effects? Does that help inform your decision on what you prescribe because of certain meds? Dr. Aziz: Yeah. I mean, the SSRIs specifically are the ones that are most likely to cause sexual side effects. Technically, it's the tricyclics, but no one really prescribes those in high doses anymore. It's very rare. They're the number one. But in terms of the more commonly prescribed antidepressants and anti-anxiety medications among the SSRIs and the SNRIs and the things like bupropion and the serotonin modulators we talked about, the SSRIs are most likely to cause sexual dysfunction. Kimberley: Right. Forgive me for my lack of knowledge here, I just want to make sure I'm understanding this. What about the medications like Xanax and the more panic-related medications? Is that underneath this category? Can you just explain that to me? Dr. Aziz: I don't usually include those in this category. Those medications work for anxiety technically, but in current standard practice, we don't start them as an initial medication for anxiety disorders because there's a physical dependency that can occur and then it becomes hard to come off of the medication. They're used more for panic as an episodic abortive medication when someone is in the middle of a panic attack, or in certain cases of anxiety that's not responding well to more conventional treatment, we'll start it. We'll start it on top of or instead of those medications. They can cause sexual side effects, but it's not the same and it's much less likely.  SEXUAL SIDE EFFECTS OF MEDICATION FOR MEN VS WOMEN  Kimberley: Okay. Very helpful. Is it the same? I know you said we don't have a lot of data, and I think that's true because of the stigma around reporting sexual side effects, or even just talking about sex in general. Do we have any data on whether it impacts men more than women? Dr. Aziz: The data shows that women report more sexual side effects, but we believe that's because women are more likely to be treated with SSRIs. When we're looking at the per capita, we don't have good numbers in terms of that. In my own practice, I'd say it's pretty equal. I feel like men might complain about it more, but again, I'm a man and so it might just be a comfort thing of reporting it to me versus not reporting. Although I try to be good about asking before and after I start medication, which is very important to do. But again, it doesn't happen all the time. Kimberley: Yeah, it's interesting, isn't it? Because from my experience as a clinician, not a psychiatrist, and this is very anecdotal, I've heard men because of not the stigma, but the pressure to have a full erection and to be very hard, that there's a certain masculinity that's very much vulnerable when they have sexual side effects—I've heard that to be very distressing. In my experience. I've had women be really disappointed in the sexual side effects, but I didn't feel that... I mean, that's not really entirely true because I think there's shame on both ends. Do you notice that the expectations on gender impacts how much people report or the distress that they have about the sexual side effects?  Dr. Aziz: Definitely. I think, like you said, men feel more shame when it comes to sexual side effects. For women, it's more annoyance. We haven't really talked about what the sexual side effects are, but that also differs between the sexes. Something that's the same between sexes, it takes longer to achieve orgasm or climax. In some cases, you can't. For men, it can cause erectile dysfunction or low libido. For women, it can also cause low libido or lack of lubrication, which can also lead to pain on penetration or pain when you're having sex. These are differences between the sexes that can cause different reporting and different feelings, really. Kimberley: Right. That's interesting that it's showing up in that. It really sounds like it impacts all the areas of sexual playfulness and sexual activity, the arousal, the lubrication. That's true for men too, by the sounds of it. Is that correct?  Dr. Aziz: Yeah.  Kimberley: We've already done one episode about the sexual performance anxiety, and I'm sure it probably adds to performance anxiety when that's not going well as well, correct? Dr. Aziz: It's interesting because in my practice, when I identify that someone is having sexual performance anxiety or I feel like somebody, especially people with anxiety disorders, if I feel like they have vulvodynia, which means pain on penetration—if I see they have vulvodynia and I feel that this is because of the anxiety, oftentimes the SSRI might improve that and cause greater satisfaction from sex. It's a double-edged sword here. COMMON SEXUAL SIDE EFFECTS OF ANTIDEPRESSANTS Kimberley: Yeah. Can you tell me a little more about What symptoms are they having? The pain? What was it called again? Dr. Aziz: Vulvodynia. Kimberley: Is that for men and women? Just for women, I'm assuming. Dr. Aziz: Just from vulva, it is referring to the outside of the female genitalia. Especially when you have a lack of lubrication or sometimes the muscles, everyone with anxiety knows sometimes you have muscle tension and there are a lot of complex muscles in the pelvic floor. Sometimes this can cause pain when you're having sex. There are different ways to address that, but SSRIs sometimes can improve that.  Kimberley: Wow. It can improve it, and sometimes it can create a side effect as well, and it's just a matter of trial and error, would you say? Dr. Aziz: It's a delicate balance because these side effects are also dose-dependent. It's not like black or white. I start someone on 5 milligrams, which is a child's dose of Lexapro. Either they have sexual side effects or don't. They might not have it on 5, and then they might have it a little bit on 10, and then they get to 20 and they're like, “Doctor, I can't have orgasms anymore.” We try to find the balance between improving the anxiety and avoiding side effects. SEXUAL SIDE EFFECTS TREATMENT Kimberley: You're going right into the big question, which is, when someone does have side effects, is it the first line of response to look at the dose? Or how would you handle a case if someone came to you first and said, “I'm having sexual side effects, what can we do?”  Dr. Aziz: Again, I'm really thorough personally. Before I even seem to start a medication, I'll ask about libido and erectile dysfunction and ability to climax and things like that, so I have a baseline. That's important when you are thinking about making a change to someone's medications. The other thing that's important is, is the medication working for them? If they haven't seen a big difference since they started the medication, I might change the medication. If they've seen an improvement, now there's a pressure on me to keep the medication on because it's working and helping. I might augment it with a second medication that'll help reverse the sexual side effects or I might think about reducing the dose a little bit while maintaining somewhere in the therapeutic zone of doses or I might recommend, and I always recommend non-pharmacological ways of addressing sexual side effects. You always do that at baseline. Kimberley: What would that be? Dr. Aziz: There's watchful waiting. Sometimes if you just wait and give it some time, these symptoms can get better. I'm a little more active than that. I'll say it's not just waiting, but it's waiting and practicing, whether that's solo practice or with your partner. Sometimes planning sex helps, especially if you have low libido. There's something about the anticipation that can make someone more excited. The use of different aids for sex such as toys, vibrators, or pornography, whether that's pornographic novels or imagery, can sometimes help with the libido issues and also improve satisfaction for both partners. The other thing which doesn't have great research, but there is a small research study on this, and not a lot of people know about this, but if you exercise about an hour before sex, you're more likely to achieve climax. This was specifically studied in people with SSRI-related anorgasmia. Kimberley: Interesting. I'm assuming too, like lubricants, oils, and things like that as well, or? Dr. Aziz: For lubrication issues, yes. Lubricants, oils, and again, you really have to give people psychoeducation on which ones they have to use, which ones they have to avoid, which ones interact with condoms, and which ones don't. But you would recommend those as well. Kimberley: Is it a normal practice to also refer for sex therapy? If the medication is helping their symptoms, depression, anxiety, OCD, would you ever refer to sex therapy to help with that? Is that a standard practice or is that for specific diagnoses, like you said, with the pain around the vulva and so forth? Dr. Aziz: Absolutely. A lot of the things I just talked about are part of sex therapy and they're part of the sexual education that you would receive when you go to a sex therapist. I happen to be comfortable talking about these things, and I've experienced talking about it. When I write my notes, that would fall under me doing therapy. But a lot of psychiatrists would refer to a sex therapist. Hopefully, there are some in the town nearby where someone is. It's sometimes hard to find someone that specializes in that. Kimberley: Is there some pushback with that? I mean, I know when I've had patients and they're having some sexual dysfunction and they do have some pushback that they feel a lot of shame around using vibrators or toys. Do you notice a more willingness to try that because they want to stay on the meds? Or is it still very difficult for them to consider trying these additional things? Are they more likely to just say, “No, the meds are the problem, I want to go off the medication”? Dr. Aziz: It really depends on the patient. In my population that I see, I work at USC on campus, so I only see university students in my USC practice. My age group is like 18 to 40. Generally, people are pretty receptive. Obviously, it's very delicate to speak to some people who have undergone sexual trauma in the past. Again, since I'm a man, sometimes speaking to a woman who's had sexual trauma can be triggering. It's a very delicate way that you have to speak and sometimes there's some pushback or resistance. It can really be bad for the patient because they're having a problem and they're uncomfortable talking about it. There might be a shortage of female psychiatrists for me to refer to. We see that. There's also a portion of the population that's just generally uncomfortable with this, especially people who are more religious might be uncomfortable talking about this and you have to approach that from a certain angle. I happen to also be specialized in cultural psychiatry, so I deal with these things a lot, approaching things from a very specific cultural approach, culturally informative approach. Definitely, you see resistance in many populations. Kimberley: I think that that's so true. One thing I want to ask you, which I probably should have asked you before, is what would you say to the person who wants to try meds but is afraid of the potential of side effects? Is there a certain spiel or way in which you educate them to help them understand the risks or the benefits? How do you go about that for those who there's no sexual side effects, they're just afraid of the possibility? Dr. Aziz: As part of my practice, I give as much informed consent to my patients as I can. I let them know what might happen and how that's going to look afterwards. Once it happens, what would we do about it if it happened? A lot of times, especially patients with anxiety, you catastrophize and you feel this fear of some potential bad thing happening, and you never go past that. You never ask yourself, okay, well now let's imagine that happens. What happens next? I tell my patients, “Yeah, you might have sexual dysfunction, but if that happens, we can reduce the medications or stop them and they'll go away.” I also have to tell my patients that if they search the internet, there are many people who have sexual side effects, which didn't go away, and who are very upset about it. This is something that is talked about on Reddit, on Twitter. When my patients go to Dr. Google and do their research, they often get really scared. “Doctor, what if this happens and it doesn't go away?” I always try to explain to them, I have hundreds of patients that I've treated with these medications. In my practice, that's never happened. As far as I know from the literature, there are no studies that show that there are permanent dysfunctions sexually because of SSRIs.  Now, like I said, the research is not complete, but everything that I've read has been anecdotal. My feeling is that if you address these things in the beginning and you're diligent in asking about the side effects of baseline sexual function beforehand and you are comfortable talking with your patients about it, you can avoid this completely. That's been my experience. When I explain that to my patients, they feel like I have their back, like they're protected, like I'm not just going to let them fall through the cracks. That has worked for me very well. Kimberley: Right. It sounds like you give them some hope too, that this can be a positive experience, that this could be a great next step. Dr. Aziz: Yeah, absolutely. Kimberley: Thank you for bringing up Dr. Google, because referring to Reddit for anything psychologically related is not a great idea, I will say. Definitely, when it comes to medications, I think another thing that I see a lot that's interesting on social media is I often will get dozens of questions saying, “I heard such and such works. Have your clients taken this medication? I heard this medication doesn't work. What's your experience?” Or if I've told them about my own personal experience, they want to know all about it because that will help inform their decision. Would you agree, do not get your information from social media or online at all? Dr. Aziz: I have patients who come to me and they're like, “My friend took Lexapro and said it was the worst thing in the world, and it may or not feel any emotions.” I'm explaining to them, I literally have hundreds of patients, hundreds that I prescribe this to, and I go up and down on the dose. I talk to them about their intimate lives all day. But for some reason, and it makes sense, the word of their friend or someone close to them, really, carries a lot of weight. Also, I don't want to discount Reddit either, because I feel like it's as a support system and as a support group. I find other people who have gone through what you've gone through. It's very strong. Even pages like-- I don't want to say the page, but there's a page that's against psychiatry, and I peruse this page a lot because I have my own qualms about psychiatry sometimes. I know the pharmaceutical companies have a certain pressure on themselves financially, and I know hospitals have a certain pressure on themselves. I get it. I go on the page and there's a lot of people who have been hurt in the past, and it's useful for patients to see other people who share that feeling and to get support. But at the same time, it's important to find providers that you can trust and to have strong critical thinking skills, and be able to advocate for yourself while still listening to somebody who might have more information than you. Kimberley: I'm so grateful you mentioned that. I do think that that is true. I think it's also what I try to remember when I am online. The people who haven't had a bad experience aren't posting on Reddit. They're out having a great time because it helped, the medication helped them, and they just want to move on. I really respect those who have a bad experience. They feel the need to educate. But I don't think it's that 50% who gave a great experience are on Reddit either. Would you agree? Dr. Aziz: Right. Yeah. The people who are having great outcomes are not creating a Reddit page to go talk about it, right? Kimberley: Yeah. Thank you so much for answering all my questions. Is there a general message that you want to give? Maybe it's even saying it once over on something you've said before. What would be your final message for people who are listening? WHEN SSRIs IMPACTS YOUR SEX LIFE: ADVICE FROM DR AZIZ Dr. Aziz: I just want to say that when SSRI's impact your sex life, it's really important for psychiatry, and especially in therapy, that you feel comfortable sharing your experiences in that room. It should be a safe space where you feel comfortable talking about your feelings at home and what's going on in your intimate life and how things are affecting you. Your feelings, positive or negative towards your therapist or your psychiatrist, whether things they said made you uncomfortable, whether you feel they're avoiding something, that room should be a safe space for you to be as open as possible. When you are as open as possible, that's when you're going to get the best care because your provider, especially in mental health, needs to know the whole picture of what's going on in your life. Oftentimes, we are just as uncomfortable as you. And so, again, a lot of providers might avoid it because they're afraid of offending you by asking about your orgasms. As a patient, you take the initiative and you bring it up. It's going to improve your care. Try not to be afraid of bringing these things up. If you do feel uncomfortable for any reason, always let your provider know.  I always tell my patients, I have a therapist. I pay a lot of money to see my therapist, and sometimes I tell him things I hate about him. He's a great therapist. He's psychoanalytic. Every time I bring something up, he brings it back to something about my dad. He's way older than me. But he's a great therapist. Every time I've brought something like that up, it's been a breakthrough for me because that feeling means something. That would be my main message to everyone listening. Kimberley: Thank you. I'm so grateful for your time and your expertise. Really, thank you. Can you tell us where people can get in touch with you, seek out your services, read more about you? Dr. Aziz: Sure. I work for OCD SoCal. I'm on the executive board, and that's the main way I like to communicate with people who see me on programs like this. You can always email me at S, like my first name, Aziz, that's A-Z-I-Z, @OCDSoCal.org. If you're a USC student, you can call Student Health and request to see me at the PBHS clinic. That's the Psychiatry and Behavioral Health Services clinic on campus at USC. Kimberley: They're lucky to have you. Dr. Aziz: Thank you. Kimberley: Yes. I love that you're there. Thank you so much for all of your expertise. I am so grateful. This has been so helpful.

The following question refers to Section 4.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by medicine resident Dr. Ahmed Ghoneem, and then by expert faculty Dr. Noreen Nazir. Dr. Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Question #21 Ms. J is a 57-year-old woman with a past medical history of myocardial infarction resulting in ischemic cardiomyopathy, heart failure with reduced ejection fraction, and major depressive disorder who presents today for follow-up. She reports feeling extremely overwhelmed lately due to multiple life stressors. She is on appropriate cardiovascular GDMT agents and is not prescribed any medications for her mood disorder. True or false: in addition to psychotherapy for stress management, it is appropriate to consider Ms. J for anti-depressant SSRI pharmacotherapy at this time to improve cardiovascular outcomes. A True B False Answer #21 Explanation The correct answer is FALSE. An ESC class 3 recommendation states that SSRIs, SNRIs, and tricyclic antidepressants are not recommended in patients with heart failure and major depression; this is based on data suggesting potential lack of SSRI efficacy for reducing depression or cardiovascular events, as well as safety data indicating an association between SSRI use and increased risk of CV events and all-cause as well as cardiovascular mortality among HF patients. Mental health disorders are associated with worse outcomes in patients with ASCVD and appropriate treatment effectively reduces stress symptoms and improves quality of life. Nonpharmacologic modalities of treatment (exercise therapy, psychotherapy, collaborative care) should be considered before pharmacotherapy to improve cardiovascular outcomes in patients with heart failure. Of note, the ESC suggests SSRI treatment be considered for patients with coronary heart disease (without HF) and moderate-to-severe major depression based on data that SSRI treatment is associated with lower rates of CHD readmission (RR 0.63), all-cause mortality (RR 0.56), and the composite endpoint of all-cause mortality/MI/PCI (HR 0.69) vs. no treatment. This is a class 2a recommendation. ESC also gives a class 2a recommendation to consider referral to psychotherapeutic stress management for individuals with stress and ASCVD to improve CV outcomes and reduce stress symptoms. The ACC/AHA guidelines do not provide focused recommendations regarding mental health considerations in patients with elevated cardiovascular risk. Main Takeaway It is important to consider mental health treatment in patients with ASCVD as mental disorders are associated with increased CVD risk and poor patient prognosis, and data support that mental health interventions can improve overall and CVD outcomes, as well as improve quality of life. Guideline Loc. Section 4.4 CardioNerds Decipher the Guidelines - 2021 ESC Prevention Series CardioNerds Episode Page CardioNerds Academy Cardionerds Healy Honor Roll CardioNerds Journal Club Subscribe to The Heartbeat Newsletter! Check out CardioNerds SWAG! Become a CardioNerds Patron!

This episode discusses some strategies for starting antidepressants in the elderly, the important role of titrating doses, the efficacy of SSRIs, the side effects and drug–drug interactions of different medications, and clinical tips for using SSRIs and SNRIs in this population. Faculty: Lauren Gerlach, D.O. Host: Richard Seeber, M.D. Learn more about our memberships here Earn 1.25 CME: Updates on Geriatric Psychopharmacology Using SSRIs and SNRIs in the Geriatric Population

In this episode, we review the high-yield topic of Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) from the Psychiatry section. Follow Medbullets on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets --- Send in a voice message: https://anchor.fm/medbulletsstep1/message

There are very few people in the world who are truly altruistic, and even fewer brands. But one fragrance company is creating breakthroughs in depression research and pioneering new treatments to end the suffering of millions. We talk to Audrey Gruss, founder of Hope Fragrances and Hope for Depression Research, about:Her inspiring career path to Director of Advertising and Creative Services Worldwide for Elizabeth Arden, in a time when men ruled the industry.Shocking facts about depression: Over 20 million adults have depression in the U.S. each year and over 350 million globally. And according to Audrey, “50% of the people who need antidepressants, who take this type of antidepressant [SSRIs like Prozac and Lexapro, and SNRIs ] do not respond to them."Hope for Depression Research: A foundation that Audrey founded in 2006 in memory of her late mother, Hope, who suffered from clinical depression. While researching her mother's illness, she discovered that the funding towards depression research was limited and so she decided to assemble a task force of the top leading neuroscientists in the world. By allowing them to share information in real-time, HDRF has made incredible discoveries into the origins, diagnosis, treatment and prevention of depression and its related mood and other emotional disorders, with the ultimate goal of finding a cureThe Hope Fragrance Collection: In 2017, Audrey created a line of luxury perfumes, body care and candles, that donates 100% of its profits to Hope for Depression Research.The future of depression research and treatment.

Join Dr. Danielle Belardo and her expert of the week, clinical psychologist Dr. Jonathan Stea, for a highly requested and informative episode about all things mental health. With the rise of pseudo-psychology circulating on social media, Dr. Stea has been on a mission to drown out the mental health misinformation noise by amplifying scientific communication in a digestible, creative way. Tune in to hear how Dr. Stea answers some important questions surrounding depression, anxiety, and much more.    Danielle and Jonathan discuss:    What depression and anxiety are and how they are diagnosed   Evidence-based therapies to treat depression, anxiety, and other disorders  Pharmaceutical treatment options including SSRIs and SNRIs and their effectiveness  The impact of exercise on mental health     Jonathan N. Stea, Ph.D., R. Psych., is a registered and practicing clinical psychologist and Adjunct Assistant Professor at the University of Calgary. Clinically, he specializes in the assessment and treatment of concurrent addictive and psychiatric disorders. He is interested in topics related to science communication and health misinformation in popular media, especially with respect to addiction and mental health. He is a coalition member of Science Up First which distributes and amplifies best-in-class, science-informed content surrounding COVID-19 and the COVID-19 vaccine. He is the co-editor of the forthcoming book Investigating Psychology: Pseudoscience, Fringe Science, and Controversies out in 2023.    Thank you so much for taking the time to contribute to a generation that values fact over fiction! Be sure to rate, review, and follow on your favorite podcast app and let us know which not-so-wellness trend you'd like to hear debunked. Follow your host on Instagram @daniellebelardomd and the podcast @wellnessfactvsfiction. Follow Jonathan @jonathanstea and Science Up First @ScienceUpFirst. 

Join Dr. Danielle Belardo and her expert of the week, clinical psychologist Dr. Jonathan Stea, for a highly requested and informative episode about all things mental health. With the rise of pseudo-psychology circulating on social media, Dr. Stea has been on a mission to drown out the mental health misinformation noise by amplifying scientific communication in a digestible, creative way. Tune in to hear how Dr. Stea answers some important questions surrounding depression, anxiety, and much more.  Danielle and Jonathan discuss:   What depression and anxiety are and how they are diagnosed   Evidence-based therapies to treat depression, anxiety, and other disorders  Pharmaceutical treatment options including SSRIs and SNRIs and their effectiveness  The impact of exercise on mental health    Jonathan N. Stea, Ph.D., R. Psych., is a registered and practicing clinical psychologist and Adjunct Assistant Professor at the University of Calgary. Clinically, he specializes in the assessment and treatment of concurrent addictive and psychiatric disorders. He is interested in topics related to science communication and health misinformation in popular media, especially with respect to addiction and mental health. He is a coalition member of Science Up First which distributes and amplifies best-in-class, science-informed content surrounding COVID-19 and the COVID-19 vaccine. He is the co-editor of the forthcoming book Investigating Psychology: Pseudoscience, Fringe Science, and Controversies out in 2023.  Thank you so much for taking the time to contribute to a generation that values fact over fiction! Be sure to rate, review, and follow on your favorite podcast app and let us know which not-so-wellness trend you'd like to hear debunked. Follow your host on Instagram @daniellebelardomd and the podcast @wellnessfactvsfiction. Follow Jonathan @jonathanstea and Science Up First @ScienceUpFirst.  Learn more about your ad choices. Visit megaphone.fm/adchoicesSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.