Interview with our Psych NP Mark Garretson

Nick:
Hello and welcome to the Ascend Health Show. I’m Nick Angelis. I’m one of the owners of the Ascend Health Center, and I’m here with Mark Garretson, my coworker and friend. He’s a psychiatric nurse practitioner then and we’ve now done this might be the 29th or 30th show and never before have I invited anyone who works with me because it’s a terrible, terrible idea. But it’s also going to be a lot of fun. So welcome to the show.
Mark:
Thank you. Glad to be here.
Nick:
Nick and I have we were a runner up for one of our shows, so I will feature this prominently and refer to it at least 20 or 30 times. Yes.
Mark:
Well, congratulations, Nick.
Nick:
Thank you. It was all the guests who brought a smoothie. I just drank the smoothie during the show. It was great. But today, instead of smoothies, although that would be a wonderful topic of conversation, I assume we should talk about psychiatry, since that’s what you do at Ascend Health Center Where? Psychiatric mental health facility. But we both used to work at Cleveland Clinic as cardiothoracic ICU nurses. So why are we both here? Because we’re used to the Oh, someone’s dying. Quick, grab the crash cart. And now we’re more in the field of like, well, someone’s depressed and that slowly get them better. Yeah.
Mark:
Yeah. Well, I ask myself that every day. But why am I here? Well, I ended up here. Both of us have a critical care background. I did that for a number of years and then I ended up in the emergency room and had the opportunity to interact with people that were having psychiatric mental health issues a lot and got experience dealing with them there and saw how things were kind of handled in the emergency department and that there was a real need for help. And that’s kind of what inspired me to know.
Nick:
That makes sense because I had the same experience where we would put them in a room and then every hour or two we’d open up the door, Hey, do you want to hurt yourself? You won’t hurt anybody else. Okay, thanks. And then that was like the care that we’d provide in the E.R. for mental health. Yeah. So and even like, especially before COVID at our clinic, I would tell patients, Oh, well, just come and hang out in our lobby for a while until you feel better. If you’re not quite serious enough to go to the hospital because that was the experience where you go there and they’d stare at you and maybe lock you up for a little bit. So it didn’t really make you feel that much better about your mental health.
Mark:
Yeah, and that’s kind of the experience that I had. The emergency room is not designed to address people that are having severe psychiatric issues and crises and and the doctors, you know, are not trained as psychiatrists. They they do the best they can, but there’s a real need. And that’s that’s how I ended up here. And I’m glad to be here.
Nick:
Well, what about the opposite approach? So if we’re saying that the E.R. is a miserable place to go, if you have a mental health issue and obviously you still have to go there sometimes, what about people who think they can Google themselves to wellness? And I should say as a disclaimer that Mark and I very much care about patients, But when we do talk to each other, we’re very plain spoken. So you this is a little bit of an inside look of how things actually work. So so if a patient says, okay, here’s exactly what I need to get better, why do I need to see a nurse practitioner or a psychiatrist in the first place? Like how do you usually respond?
Mark:
Well, you know, online resources can can be very helpful for many things, but the information that’s available is often enact it. You don’t know what the training and background of the people that are providing the advice. Oftentimes it’s other patients on message boards, those sorts of things that are talking about mental health issues that they have. And those folks don’t necessarily have all the training and experience that a psychiatrist or a psychiatric mental health nurse practitioner has as far as understanding the appropriate treatments, the appropriate medications, that sort of thing.
Nick:
So you’re also talking about reviews of different treatments. If you look at see what patients have said.
Mark:
Yeah, absolutely. I mean, it’s you know, again, online resources, you know, trying to to help yourself is great and it can be helpful Sometimes it can get somebody pointed in the right. Direction But you know it also it’s it’s it can be it can be confusing for patients. It can create problems. Again, there’s lots of resources available online. Sometimes they aren’t the most reliable.
Nick:
And so it might not be like the first line you’re saying like maybe come to us, see what kind of medication might work or what the next step is, and then you can take it upon yourself to even go further. Since we do tell patients that often that, okay, you can come see us a lot more often or you can start exercising or eating right, or some of these other things that can at least slow down the amount of time you have to visit a professional. Because a lot of times for reviews I often tell patients, Well, think of your dishwasher like no one reviews your dishwasher unless it destroys your dishes or absolutely doesn’t do anything right. So obviously any sort of review you see on a treatment or medication that’s for like the destroy your dishwasher type of approach where it was a rare reaction that really affected someone. Yeah, And there’s still really fascinating to read. But as far as gospel truth, it might be a and I think we’ve seen that especially with with TMS or transcranial magnetic stimulation. Yeah. Where it’s a fairly innocent therapy meaning that the side effects are almost nothing, especially compared to psychiatric drugs. But then when you start reading reports, it can be challenging. I mean especially because the type of patients who will qualify from an insurance standpoint for that already have tried multiple drugs and had some issues. So we’re already talking about a subset of patients who their bodies already kind of react differently than most people.
Mark:
Yeah. And and and that’s one of the things I mean, that we have at Ascend that kind of sets us apart. We we have some treatment modalities. We’ve got TMS, which is transcranial magnetic stimulation. We’ve got Spravato and Ketamine. These are treatments that aren’t available everywhere. It’s a specialized we really do try to specialize in in helping folks that have been struggling with depression usually for many for many years. And and they’re used to taking the medications. And again, you know, online resources are great. The first thing that anybody does when we prescribe a medication now, most of these folks go and Google the medication to see what potential side effects there are and that sort of thing. And and that’s that’s okay. We understand that’s part of the process. But, you know, as I’ve told you many times, the mind you know, I tell patients all the time your mind is more powerful than any drug that I can give you. And sometimes, you know, they may go and look up medications and see all these horrible, you know, potential side effects. I mean, everybody’s seen the advertisements on TV where, you know, every medication they’re talking, they’ve got somebody smiling and, you know, playing with their dog. And in the background you hear, you know, that it may cause death or blindness or absolutely a whole multitude of issues. So, um, you know, it’s just important to remember that if we prescribe something, whether it be Dr. Molina or I, that we know the medications pretty well, we’ve studied them. And if we’re concerned about side effects, we’re going to tell you about it. Unfortunately, a lot of people take the medication, get the medications and then they have problems. Yeah, but it’s sometimes it’s the power of the mind. If you think you’re going to have problems, it certainly increases the the potential for that.
Nick:
It sounds like you’re saying, too, that it’s an individualized approach where here’s a possible side effects. But for each patient who says they might have a side effect, you have to see, okay, what were your side effects to the last medication you had? How many medications have we tried before and what were the effects? So because I know both of us have told patients before, well, you know, you’ve tried and failed seven other medications. This is a mild side effect. You just need to push through. And then another case is like, look, we’ve got five other really good ideas. That’s fine. Stop taking this one. Come in and we’ll come up with something else.
Mark:
Yeah, yeah, you’re right. I mean, it’s you know, and fortunately, medications, patients can have side effects from medications, but oftentimes, you know, they’re they’re limited. Right? They may just take some time to adjust. And one of the things that we really focus on is being conservative in our approach and our treatment and starting people out with at low doses on the medications because we know that in most cases side effects are dose dependent or dose related. And if you start somebody out at a high dose, you might have you might have problems. And the problem there is that the medication may be a perfectly good medication and may actually help the patient. But if they’re started at too high of a dose and their body doesn’t have a chance to adjust and they have side effects or problems, they’re not going to take it.
Nick:
And a lot of times when I’ve told patients that their response humorously enough was I’m sorry, aren’t you the guy that prescribed Ketamine infusions where the patient says, Oh, I might feel like I’m in outer space? What do you mean you’re conservative? But I think that’s why we are conservative because we have these tools that work rapidly and can make great changes in the brain very quickly. So there’s not this urge to take the same approach with medications or prescribe a lot of benzodiazepines or stimulants or some of these medications that traditionally in psychiatry you only look at if all these other classes have failed because as we mentioned, often there’s a lot of great short term solutions that will be terrible for people in the long term, right?
Mark:
No, you’re right.
Nick:
Not not to get you on our usual soapbox about benzodiazepines and stimulants because obviously for some patients they are appropriate. Absolutely.
Mark:
But absolutely. But we you know, again, the treatments having kind of a more holistic approach, conservative approach is, you know, I think is the way to go because it it minimizes the chance that patients are going to have problems with medications and treatments and that increases the chances that they’ll actually be compliant and take the medications and and get the benefits that we’re hoping for.
Nick:
Right. Well, I think it also depends on the approach of where someone decides to go for their mental health care because there is the idea of like a more aggressive let’s do this drug, let’s not talk to you for a few months. Let’s see how it does with us. Sometimes it does have to be a bit more fine tuned where the patients are calling and reporting back how that worked. Do we need to increase this, decrease this? So sometimes it does require more appointments or more fine tuning, but usually that’s not a complaint or the American health care system that people are paying too much attention to me, you know, it’s usually the opposite that everything’s falling through the cracks and I can’t get an appointment and that sort of thing. Right? So so, so that makes sense. A more conservative approach allows us to gradually fine tune where we’re trying to go, whether it’s avoiding mania while preventing depression or depending on the situation.
Mark:
Yeah, definitely. Okay.
Nick:
So I did have a question where how do you respond to criticism about psych medications in general or antidepressants? And honestly, some of this criticism comes from me as your coworker because I’m a nurse anesthetist. So my whole mindset is like, Oh, let’s fix someone quickly. Like sometimes I’ve even said like, Oh, you know, those psych meds don’t work as well as they should. And rather than taking this antidepressant and waiting for a month, why don’t you just do Spravato or Ketamine infusion or TMS or within days we’ll get some sort of results. But a lot of times that’s not fair and it kind of minimizes the work you do and everything that you’ve learned in your years of study. So what’s like a better response to that rather than when I try to encourage everyone that all the answers are these quick fixes, so to speak?
Mark:
Yeah, well, I’m used to being minimized, but.
Nick:
This is actually a therapy session for Mark. That’s why we’ve gathered here today. But the trauma of working with me.
Mark:
Yeah, well, you know, I’m not a big fan of a lot of psychiatric medications either. I mean, we know. That in particular with depression, the standard treatments, the SSRIs, the Snris, Wellbutrin, those medications really don’t benefit a lot of people that have depression.
Nick:
And they make you more depressed if you’re like, “Well, what’s wrong with me that this standard treatment isn’t working?”
Mark:
And they have side effects, You know, whether it be weight gain, other issues, they can have an impact on sleep. You know, there again, there aren’t very many medications that you can take that ultimately don’t have some side effects. And obviously we’d prefer, you know, in a perfect world, not not to have to medicate folks that that’s why we’re so keen on therapy and getting counseling because we know that a combination of therapy and medication if needed. We know that that’s what produces the best results, right?
Nick:
There’s very few side effects from talking to someone.
Mark:
That’s true. That is true. Absolutely. So, you know, it’s one of those things, you know, or the medications that that we use, you know. Well, for example, Spravato, it’s a powerful medication and it helps people that haven’t benefited from the traditional treatments for depression like SSRIs and Snris. But it you know, it it doesn’t work for everybody. Right? But it can be very helpful And a lot of times it can help us get people off of other traditional medications or at least lower the doses. So which is a good thing. And of course, TMS is doesn’t involve medication at all. Right. Which is another.
Nick:
If there’s a history of eating disorders or substance abuse or fixations about pills in general, something that’s a cleaner way to just treat depression.
Mark:
It is a cleaner way to do it. You know, it’s it’s a good, good alternative, particularly for people that don’t, you know, don’t want to take medications. There are some have been some recent recent developments medication wise that we’re excited about to help people with depression that work faster. And you know, we’re currently evaluating those. But it is tough when somebody comes in and they’re they’re profoundly depressed and you tell them that, you know, we’re going to start you on this medication, but you might not feel good for 6 to 8 weeks. Right, If at all. I mean, because again, they don’t work for everybody.
Nick:
Well, and sometimes if meds work right away, the it’s short lived where after a few more weeks somehow the brain finds another way, almost the way that people will start on a diet and they’ll lose some weight And then the brain is like actually my homeostasis is 10 pounds heavier than this. Sorry about it buddy. So it’s not always a bad thing if it takes a little while because many times it took several different traumatic experiences in life to make someone depressed. You know, there’s new data that maybe it’s not this serotonin deficiency that you can only treat with Prozac. Maybe sad things happen to you and now you’re sad about it and it’s that simple. Yeah, So so that makes sense. And I should say to be fair, that I have the same view of anesthesia like you’re saying, where some of these psychiatric drugs don’t help everyone. You know, I’m really like all of the anesthesia drugs. But if someone tells me, oh, I’m going to have anesthesia, usually my first approach, my first thought is, well, that’s a terrible idea. You should avoid these poisons whenever possible. Yeah. And honestly, that’s probably a healthy approach for both of us rather than thinking like, No, these are wonderful things that everybody should partake in.
Mark:
Yeah, I mean, ideally if we don’t, you know, we can get somebody in therapy and get them moving in the right direction and help them with coping skills, that sort of thing, and avoid medications altogether, that that’s the best case. Scenario. I mean, that’s something that we really you know, it makes us happy. We don’t want to prescribe medications or do treatments just for the sake of right prescribing or doing treatments because that.
Nick:
Is the thing that often people don’t think about this. But you do get locked into this system because once you prescribe a medicine, then that person needs to come back, They need to talk to you about it and then you adjust it and then you need to come back again. So whenever possible, we do try to tell patients, okay, is there a way that we can do this where you can come in for a checkup because you’re like, Oh, let’s see how I’m doing, but not because you’re locked in, which again is our issue with some of the drugs that can be more addictive or that your body responds to in such a way that it’s no longer making those chemicals itself. Sure. So and we’ve seen that a lot with substance abuse, too, where the medication assisted therapy, you can end up on Suboxone for the rest of your life or methadone and obviously there’s a time and a place, but it is a pretty chilling business model at times as well.
Mark:
Well, yeah, and sometimes it involves picking the lesser of evils. And you know, again, I think that the approach that that we take is very helpful for patients and it’s the way that I certainly and you’re probably the same way if you go in to a doctor’s office and somebody just starts prescribing a whole bunch of different medications for you and throwing a whole bunch of things at you, you know, sometimes we kind of recoil a bit just because of our experience in in medicine and in nursing.
Nick:
So yeah, you end up like what kind of box of Lucky Charms is this? There’s funny colored marshmallows everywhere. And I mean, that’s a good point too, where both of us feel that because at Ascend we have different therapies not available other places we don’t need to take over everything for patients. They can stay with their psychiatrist. We won’t touch any of their medications and just simply do the treatment because and this is a fault of mine. Once you start tinkering with multiple receptor sites and multiple medications, it’s hard to tell what worked. What was the secret formula that made you feel better? And we can’t tell if we’re altering too many things at once.
Mark:
So yeah, it’s you know, what variable, what what variable produced the the positive result or was it a combination of all. Yeah, that makes it tough. But you know, I think that you’re that’s a good point When we’re treating people with treatment resistant depression in you know most of those folks have a psychiatrist that may well have referred them to us because we’re again, kind of a have kind of a specialty focus but we can collaborate with their psychiatrist and it’s important to try to maintain a dialog. Right. But it it gives us, you know, kind of a sharpened focus and lets us really, you know, kind of drill down on whether it be Ketamine infusions or Spravato or TMS. We can really focus specifically on that and and hopefully adjust things and Right.
Nick:
Personalize it. It helps too, because in that way it’s a limited role and oftentimes it’s limited in time too, which, you know, no one wants to be dragged into a lifetime of psychiatric care if there’s other options. And I should mention too, for anyone watching or listening that the normal disclaimers about unless we send you a bill, this isn’t medical advice, you need to go to a doctor, as we said about there’s plenty of resources online, but they’re not personalized for your specific case. So you may hear some things that sound exactly like what you need, but it helps to work with someone to hone in on, okay, what therapy is going to work the best? Because especially if there’s been failures in the past, it’s important not to go down a road where it’s unlikely that it’s going to be beneficial. Right. And that’s something that we are very passionate about. Like let’s you know, most of the patients that we see, they’ve taken some wrong turns in their journey to getting better. And the last thing we want is to send them down another dead end.
Mark:
Well, and you’re right. And. And we’re not giving you no medical advice here. We’re just trying.
Nick:
Brilliant advice but not medical advice. Right.
Mark:
Well, true. But you know, the important thing is to have, you know, have a good psychiatrist work with them and follow their advice and be compliant. But we do have some things at Ascend that can help people that aren’t you know, they’re they’re a little different. They’re outside the box. And we’re always happy to talk with psychiatrists who may be interested in trying to help patients that that haven’t benefited from traditional treatments. Absolutely.
Nick:
And so if anyone has any questions, you can always go to ascend health center.com because we haven’t had enough time today to really define the difference between Spravato and TMS and Ketamine. But that’s what our website is for because if we start explaining it, then the 22 seconds left in the show will go very quickly. But yes, thanks for joining us and I’m glad that we got to hang out today.
Mark:
Yeah, that was great. It’s always good to talk with one of one of my buddies from the trenches That’s right at the clinic. So really enjoyed it and hope to have a chance to make it back here again. And we can talk more specifically about some of the treatments.
Nick:
Thanks for joining us, everyone. Thank you.
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