In this episode, we talk with Sandra Alexander, your physician assistant. She's going to share some alternative options that are different ways to look at treating depression and anxiety in addition to the typical anti-depressants that are commonly prescribed.
Dr. Mona Gupta (00:00):
Are you ready? Hi everyone. This is Mona Gupta. That's me. I am a psychiatrist in Raleigh, North Carolina, and I'm here with Sandra Alexander and she's a physician assistant. However, we both work together at Gupta psychiatry and, um, we're doing our first ever podcast to talk about subjects that are kind of in the news or, um, on people's minds. And we're gonna try to answer questions if you send questions in, but today we're gonna start with a topic, um, that a lot of people, a lot of patients ask us. Um, and I'm surprising Sandra with the question, so let's see how she answers it. So, um, the question I wanna ask you is a lot of patients will come in and they say things like, you know, are there any options outside of regular antidepressants? I don't wanna take Prozac. I don't wanna take Effexor. I don't wanna take Wellbutrin. And I always tell them there's nothing wrong with these medications, but what are some other options? So I'd like to throw that question to you, and then we can kind of start the discussion.
Sandra Alexander (00:55):
Well, you know what, my background, I'm always trying to think from the neurochemical, the neuro transmission side of what's going on with the brain. So then I try to pair, you know, a lot of people want that holistic approach or they want other approaches. So, um, I'm always thinking serotonin is dropping depression. Dopamine is not high enough depression.
Dr. Mona Gupta (01:14):
So serotonin is low.
Sandra Alexander (01:16):
Yeah.
Dr. Mona Gupta (01:17):
So dopamine is,
Sandra Alexander (01:18):
It can be low or, or is not transmitting or, um, different things. So, uh, everybody traditionally they're trained, you know, SSRI, Selecto serotonin reuptake inhibitors, but they come, they come with their drawbacks. Um, so
Dr. Mona Gupta (01:33):
SSRIs are
Sandra Alexander (01:35):
Prozac, Lexapro select Zoloft. Okay. And it, they, they grip 'em all together. Yeah. This is the common one. So that's why mostly primary care doctors, uh, will talk with them about the kind of stuff. But, um, sometimes we get, think outside the box mm-hmm <affirmative> um, and I always think of dopamine as the chemistry of happy. Right. Um, so improving that dopamine, improving that dopamine transmission. So getting it to the front of the brain cognition and motivation,
Dr. Mona Gupta (01:59):
You have a really, really great rep who's called dopamine chocolate, cuz you know, chocolate can
Sandra Alexander (02:04):
Increase dopamine, however, like male lip, as you say chocolate. Yeah. So
Dr. Mona Gupta (02:08):
Actually, you know, the thing with chocolate is, is, you know, around your period, right before your period, your dopamine is kind of waning. So ch women crave chocolate. So that's a little thing,
Sandra Alexander (02:16):
You know? Yeah. And progesterone pull serotonin down. Right. So when it drops makes sense. Right. So yeah. So there's that relationship, but it, I always think, you know, dopamine to the front of the brain cognition, motivation, parts of depression. If we break it down, you know, you lose your motivation, you have this brain fog, um, memory can be affected your, those emotional behaviors that you commonly not enjoying things you used to enjoy. There's low moods. That's the doesn't mean in the middle of the brain. So
Dr. Mona Gupta (02:42):
Let's talk about depression just to break it down. I know we're gonna get into the actual treatments, but depression, when you think of major depression, which is what we call it in the DSM, which is our Bible and psychiatry. Um, it's our, it's what we have to go by. Yeah. Um, the depression, the symptoms of depression, I would, you know, I think it's a cheating thing to call it. Ciggy caps. Have you ever gone by that? Yeah,
Sandra Alexander (03:03):
But
Dr. Mona Gupta (03:03):
It's good for us to kind of go through them. So people understand. So it's two weeks of five of these symptoms and what are they?
Sandra Alexander (03:11):
Uh, so sleep disturbances, you can be too much sleep, uh, to little sleep. The interest is your eye that ciggy caps mm-hmm <affirmative> uh, guilt or worthlessness energy, uh, concentration mm-hmm <affirmative> uh,
Dr. Mona Gupta (03:24):
Appetite,
Sandra Alexander (03:24):
Appetite. Thank you. Psychomotor sluggishness. But that's,
Dr. Mona Gupta (03:28):
It could be fast too. It could be both, you know? Yeah. Um, and then the other S a suicide
Sandra Alexander (03:33):
Suicidality. Yeah. Um,
Dr. Mona Gupta (03:34):
So those, that's our cheat sheet, how to say it, but you know, in layman's terms, it's like not wanting to do anything low motivation feeling like, you know, you find no joy anymore. I think that's a big one, not finding joy, you know, in the little things. Right. Um, so I know I just wanted to break down what depression can look like. Right. And depression can look like different in so many people. So your depression and my depression could be completely different. Now treatment of depression is very similar though. Yeah. So even if you're an anxious, depressed, or, um, a very sluggish depressed, there might be different medications that go for you, but in general, they're in this family.
Sandra Alexander (04:09):
Yeah. And that's where that serotonin bouncing comes into effect where we think of our SSRIs classically, but dopamine is that, that chemistry of happy, that, that feeling good, that energy, that good memory, that good concentration, that feeling present. And so I try to think of things other than the medications that work on serotonin and it can help that chocolate keep saying chocolate, you're gonna get me stuck on it. But, um,
Dr. Mona Gupta (04:31):
Wellbutrin is great cuz it's like dopamine. Um, it works on dopamine. Correct. So, yeah. So, um, a lot of times I use it for someone who has low energy, however, there are other options.
Sandra Alexander (04:42):
Yeah. So, I mean there's vitamins and supplements. Mm-hmm <affirmative> um, so vitamin D um, D three bioavailability makes a, a big part of it, um, can help make, um, dopamine there's B12, folate. There's a supplement out there called Enseal cystine mm-hmm <affirmative> that has been shown, um, we've seen
magnesium play effect on, but
Dr. Mona Gupta (05:01):
These seems
Sandra Alexander (05:02):
Huge. Yeah. Yeah. And it works on NM D a yeah. Um, so, so that antagonist so downstream, it has the benefit Tomine as well. Um, and of course there's a whole bunch of magnesiums, but that's a whole nother podcast.
Dr. Mona Gupta (05:13):
Yeah. That is <laugh> what magnesium should I use now? That's a whole different ballgame.
Sandra Alexander (05:18):
Yeah. And I I've been studying that lately, trying to figure out what my recommendation's going to be and that kind of stuff and what crosses the blood brain barrier. And that, that can be, that'll
Dr. Mona Gupta (05:26):
Be next one.
Sandra Alexander (05:27):
Yeah. That can be 18 minutes all in itself on my opinions on that. But, um, there's those vitamins and supplements that we can use. There's the medications we can use, but there's the non-medication, um, things that we can use too, like transcranial magnetic stimulation that you offer. Right. Um, and we
Dr. Mona Gupta (05:41):
Offer, honestly, at this
Sandra Alexander (05:43):
Process we offer, I apologize. Yeah.
Dr. Mona Gupta (05:45):
So we offer, and what's great about transcranial magnetic stimulation is not too many side effects, you know? Um, you have to be cleared for it, but once you're cleared for it, I mean, it's it, the thing is it's time intensive for a month, you know? But then after that, I mean the benefits keep going. Some people don't wanna be on medications. They don't wanna be on daily medications. So that could be an option. It also could be a supplement. Right, right. Uh, ECTs another one, which is a little harder that's for, I think, a more serious patient or someone who's chronic basically really struggling. Yeah. Cuz you have memory deficits on what whatnot with
Sandra Alexander (06:16):
It. Yeah. And I picture that the person that can't even do their daily tasks, they're not, they're not showering. They're not eating, they're not, they're not doing their daily tasks functioning. Yeah. They're not function. That's the extreme patient that that I think is, but
Dr. Mona Gupta (06:28):
It does work and it's safe in pregnancy. So it's actually a very safe, um, uh, treatment. Uh, but TMS is a lot lighter. Like I think of it as you can think of it as E CT light, except it's not E CT light. It has nothing to do with EC T it's just, if people were worried, I mean, doesn't have the memory issues, doesn't have the downtime, you can get up, get up and go right after your treatment. It's about 10, 15 minutes and you're out of here.
Sandra Alexander (06:50):
It reminds me of like sitting it, not that everybody hates going to the dentist, but it reminds me of like a dental chair with a helmet. Yeah. Um, and that that's fast
Dr. Mona Gupta (06:57):
And it's tailored to the patient, you know, it's gonna be prescribed to the patient where in the brain, they need
Sandra Alexander (07:01):
It. And that's where we can come after the, the, the neuro transmission, we can improve the signaling that people are getting, um, with magnets. It's pretty
Dr. Mona Gupta (07:09):
Amazing. It sounds crazy. But it, it really does work. Now the other, uh, the other couple of treatments coming out are, or will be coming out. One is psilocybin that's for depression, PTSD it'll have different. Um, but it's a little more complicated and it's not out here in North Carolina yet, but do you wanna talk about that at all?
Sandra Alexander (07:27):
So, yeah, so hallucinogens in general, uh, you know, with my background in addiction, it made me really hesitant stop and thinking about this,
Dr. Mona Gupta (07:35):
But oh, me too, honestly, nervous, you know, I was like, ah, do we really wanna get people high? But thinking about it old is new, new is old. Like it just,
Sandra Alexander (07:42):
Well, I mean, if you think about it, the chemistry of high is dopamine and Norine right. Mm-hmm <affirmative> so that chemistry high. So if you can do it in a known product, in a known dosage, in a
Dr. Mona Gupta (07:53):
Controlled setting,
Sandra Alexander (07:54):
Controlled setting, scheduled setting, and you can actually work on the chemistry and the neuro transmission and neuro transmission repair, um, we can actually benefit the patient, um, long term, not having to necessarily be on as much medication or on medication with actual neuro pathway repair.
Dr. Mona Gupta (08:13):
Some people get off medications, which this is people's dream. And it's honestly, I think our dream being that we are, you know, on the addiction side of things, you know, that's part of our, uh, part of our love in psychiatry, which not a lot of people do like, but we love. And I feel like, um, you know, we are always looking for ways to, for people to come off of things. So we're always trying to get people on less medications. And I think in general medicine, we try to do that, but we find that to be really our purpose. So trying something like psilocybin, which you think, oh my God, that's shrooms or mushrooms. Like we're giving people mushrooms, like, you know, but honestly in a controlled setting, it can make a huge difference.
Sandra Alexander (08:51):
Yeah. And, and it's not, you know, addiction by definition to me was taking something that wasn't prescribed taking somebody else's button from the street. So we're not getting somebody addicted to this. Right. But we're actually fixing things with this and we're fixing it in a controlled manner and in a medically protected environment. Um, and repairing the brain when substances are used illicitly, it's not on a schedule, it's not known doses. You don't know what else is in it. And people obviously keep going back to it. Cause they thought they got a benefit from it. Now we actually take advantage of that benefit that you can get from it in a scheduled way, um, and repair the brain. Um, so we
Dr. Mona Gupta (09:27):
Don't have psilocybin as of yet in North Carolina. Right. And I think it'll be 2023 before we're gonna be talking about that and able to do it. Yeah. But we do have ketamine. Right. So I'll let you talk about ketamine. We can kind of have a discussion about it.
Sandra Alexander (09:41):
So that,
Dr. Mona Gupta (09:42):
So what is ketamine for?
Sandra Alexander (09:43):
So ketamine is for treatment resistant, depression and treatment resistant depression with suicidality mm-hmm <affirmative>. So, um, those also
Dr. Mona Gupta (09:49):
Acute suicidality
Sandra Alexander (09:51):
And acute. Yeah. So those really severe lows. Um, and I mean every life is worth saving, um, and using a treatment that profoundly can have a difference in even potentially the first visit and turning those things around is huge. And of course, you know, statistically, we have to do a scheduled environment and that type of stuff, but it works in the NM D a receptor. It has downstream effects on glutamate, which is the stimulus center of the brain to release more, uh, uh, it releases, it goes to APA and goes to, uh, mTOR. Anyways, I can go in the whole science of it, sorry, I'm a nerd. Um, but, uh, it, it can improve dopamine pathway. It's like fill in the potholes.
Dr. Mona Gupta (10:32):
I think that a lot of people call it neuroplasticity or like helping neuroplasticity. So you wanna talk about that just in layman's terms kind of,
Sandra Alexander (10:38):
Uh, if you wanna go with that one
Dr. Mona Gupta (10:40):
More like, you know, I just think helps the neurons fire that's I keep it real simple. It helps the neurons fire. We've got, um, patients who have been struggling for years with depression, which in itself can cause kind of a depressed state in the brain where they're not firing as strong their D rates aren't as like,
Sandra Alexander (10:56):
And that's what those tentacles and
Dr. Mona Gupta (10:57):
Yes. And so the tentacles can work again, you know, and it's pretty amazing cuz they chose pretty quickly. You know, they have, um, pet scans that show the differences. They have a lot of different, um, functional MRIs that are showing differences and there's studies going on right now. So we are learning more every single day. What's great is that companies like Jansen were able to approve S bravado, which is a nasal form of S ketamine, uh, um, ISER of it. And, um, that was able to kind of make it mainstream because a lot of people were nervous. Like people like us in the addiction world, we were like, ah, we don't wanna be like getting people high, but because it was approved and it was approved in such a fast manner by the FDA because there's such a need because the suicidality was, you know, becoming a real problem and still is, um, it, I think that that gave us the backing that, that gave me the backing to be like, okay, let's do this. And then as I did more, I was able to add ketamine, uh, intramuscular and IV at infusions at our facilities. And I feel like don't you feel like patients are getting outcomes like so quickly. And it's, it's amazing.
Sandra Alexander (12:04):
I have seen, I mean, you see so significant low, um, that you start to see the improvement quickly, um, low, low, I mean with the right patient in the protective environment, the risks are relatively low. Um, we have to rule out some medical conditions. We, you know, we're monitoring when nursing and medical staff and
Dr. Mona Gupta (12:22):
I mean addiction too. We're not trying to get people high. So we have to kind of see who is this patient? Are they, are they prone to addiction? How are we gonna control this? But even an addictive person, a person with an addictive personality, even they can be given it. And I think almost, um, people who are self-treating with different substances, sometimes it lifts that depression in such a profound way and that like, um, and they are able to really benefit from it and not wanna use I've had patients stop using their substances like marijuana. Well
Sandra Alexander (12:52):
You think, yeah, if you're you're legally or illicitly using, you're not using in a scheduled format, you're not using in the best dosages. You're not, you're not doing that REPA, uh, treatment, but you're, you're getting those temporary benefits. So even if you do have an addiction doing it in a medical setting, we can actually do it in the right way to get the benefit that they were seeking the wrong way
Dr. Mona Gupta (13:13):
In the clinical
Sandra Alexander (13:13):
Way. I mean, in the clinical way. Yeah.
Dr. Mona Gupta (13:15):
You know, we want you to meditate. We want you to do certain things and we'll help you along with that. Um, a full treatment course for SVA is very different from, and SVAs the nasal form versus the ketamine injection or, uh, infusion. And so you wanna talk about that? SVA is a lot more complicated.
Sandra Alexander (13:31):
Yeah. So it's, it's some time intensity up front and you know, a couple of times a day for the first, a few weeks, uh, two hours, two days a week, and then you kind of scroll back to like one day a week and then roughly about a 12 week average time schedule. Um, and we're, you know, adjusting dosing as needed, we're monitoring for, you know, benefit and any risks. Um,
Dr. Mona Gupta (13:51):
And we give some, some medications if you have nausea or whatnot, but then there's the ketamine and that's six treatments for a full full course, which honestly isn't as time inve time intensive. And we can shorten that two hour window if you do. Okay. But you know, if we tailor it per patient regardless, but SVA is so monitored by the FDA that we have to do it one way. And one way only with ketamine, we can kind of be a little more.
Sandra Alexander (14:15):
Yeah. And you, you're still getting, you heard her mention neuroplasticity in those dendrites and you think about these receptors having tentacles on them and as you age or you do damage, they, they reduce or they're not as plentiful or they're not just, you just, you lose, you know, the density of them. And so these, these type of uh, treatments actually builds that density back. So the signaling and it just, and the, the recepting of the, of the happy chemistry is so much better received. You're actually repairing and making it dense again. And even in the aging patient, that's where I can see a huge benefit, huge difference, um, is because dopamine plays a part in cognition and memory, um, cuz that's the front of your brain and the midsection of the brain and this is Repar and it helps with the aging brain as well.
Dr. Mona Gupta (15:00):
What's amazing is people say it's a bath for my brain and it really is. It's like you wake up the next day, more alert, clear. Um, so I think there's gonna be many other uses for these, these alternative, uh, ways of treating depression because I don't think it's just for depression. I think it also can help for anxiety just with we've had, I don't know how many hundreds of patients at this point have gone through these treatments. The big thing they've told me is executive functioning comes back and executive functioning looks like making decisions. The clarity, the brain fog, I've heard brain fog more than ever after COVID right. Everyone's got brain fog, you know, um, I think we're just all waking up from this pandemic. We either have had COVID or know someone who's had COVID we've lost people. So the depression levels are higher than ever and brain fogs higher than ever. So I do think we have, you know, great treatments for
Sandra Alexander (15:56):
That. And, and there's just so many options here that holistic approach, vitamins, supplements, medications, non medications, a vast array of array of what those medications may or may not entail. And we don't look at a medication for forever. No, our goal is to help you heal. We don't mind losing patients because they're well <laugh>
Dr. Mona Gupta (16:14):
Oh no, we want to, right.
Sandra Alexander (16:16):
That's a goal journey. Yeah. That's our goal. And
Dr. Mona Gupta (16:18):
I, I mean, I, we are big and inter nutraceutical and vitamins, so we'll recommend those also food, you know, changing your, um, food intake and how you, what you eat, what you
Sandra Alexander (16:28):
Don't eat, inflammatory food inflammatory anti-inflammatory, um, and then, you know, adjusting your diet vegetarian and you lose some of the amino acid that you need for some of this nerve transmission to be optimal. So there's stuff that you can do that doesn't, um, take you out of your dietary choices to actually optimize your brain health.
Dr. Mona Gupta (16:46):
So I think magnesium as a whole one podcast, another one will be food. I think food is like something that a lot of people ask about. It's hard to do, but if you can do it, you can really change, not just your mind, but also your body. Exactly. Uh, a lot of people with like autoimmune diseases or whatnot. So that's something we'll talk about as well. Um, we don't have to do psychiatry only. I mean, we both can do a lot of other things as well. We'd love you to just, you know, when this gets posted, we would love you to ask us questions and, you know, ask us anything in the field of psychiatry or medicine and we'll try to answer it the best we can. Well, thank you so much for your time.
Sandra Alexander (17:20):
Thank you.
Dr. Mona Gupta (17:21):
Bye