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A recent study has found that repetitive Transcranial Magnetic Stimulation (rTMS) is effective in treating depression. The results showed that the majority of patients experienced a significant reduction in symptoms, with some even achieving complete remission.

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Psychiatry at Ascend: Tamara Bowling, PMHNP discusses Spravato, TMS, and Oral Medications

How does psychiatry work? What methods help psychiatrists and psychiatric nurse practitioners decide on a diagnosis? Nick Angelis, CRNA asks Ascend Health Center’s newest NP all about mental health.

[Music] hello and welcome to the Ascend Health show I’m Nick Angelis I’m your host I’m a nurse anesthetist and I’m the owner of Ascend Health Center and I’m here with Tamara bowling a psychiatric nurse practitioner who just started with us this week at Ascend Health Center

yes I’m very excited

not as excited as I am it’s great well our patients have been asking for a female nurse practitioner for quite some time which is really funny because if they ask for any other class of person it’s like no that’s inappropriate but in this particular like yeah that actually makes a lot of sense let’s there’s enough guy talk around this Clinic let’s get you a female nurse practitioner so it’s very I’m very glad to have you both at the clinic and on the show

well I am very glad to be here and I cannot wait

so yeah well why don’t we start with uh before I get off on tangents which will probably happen about 30 seconds into the show per usual uh why don’t you to tell us a little bit about yourself like how you decided to become a psychiatric nurse practitioner because before this you were also a family nurse practitioner correct so you can go back as far as like if you know you were eight years old and decided to be a nurse or just you know how you decide to get into Psychiatry whatever is more fascinating for you

uh back when I was working as an RN in the emergency room um I worked in an emergency room that was the intake for the entire city of Rochester New York wow um for all the like patients so everyone was brought there uh I got I would say interested probably at that that point I really enjoyed um working with those patients differentiating who was impaired or under the influence of substances or mental health issues or both um and then after I became a family nurse practitioner I spent some time working in Urgent Cares and and also um some primary care clinics and found that so many of the patients that were coming in had either addiction issues or or substance use disorder issues or both W right so um I found that I really enjoyed talking with those patients. there’s a lot of stigma that they feel when they come into the Health Care system and making them feel um accepted and like somebody wants to help them I found that that was really rewarding so I wanted to what I did was first is I ended up going into addiction medicine while I went back to school for psych so oh interesting you know cuz there’s such a tie in between the two um often go hand in hand so that’s how I got involved in Psych

no it makes sense I mean that’s one of the reasons that we started Ascend Health Center was we realized so many of these patients have to go to the ER there’s no other options for them and sometimes it still is you know we sometimes send patients straight to the emergency room as well but we’re like well there’s there has to be other cases where there’s some alternative or there’s some in between so I mean actually uh before Co we would have patience if they didn’t feel safe but they weren’t so bad that they needed to immediately go to the ER we’d have them hang out in our waiting room just like well just come hang out with us for a little bit till they see if you feel better and obviously that’s unique to us being in the Fairlawn area so as mostly patients who lived a few minutes away where would just tell them well just stop on by see if you feel any better but it’s so difficult when you see them all in the ER because it’s not meant for mental health and sometimes I feel it can make the mental health worse

yeah they don’t have um a lot of the providers that work in those settings don’t feel comfortable really dealing with those issues and so I don’t think that the patients um they don’t feel that somebody there is really hearing them and and knows what to do and so I think that’s some one of the challenges um that we face in those settings and

uh as we know it takes a long time to get somebody in to see a mental health provider right so yeah unless you come to a sendal center now that camera can see you within a week but you’re right anywhere else in Akron or Cleveland good luck it be two or 3 months yeah exactly out and sometimes it’s challenging too because finding the right fit so once in a while we’ll see a patient and we tell them like well you know what we’re not really sure if you are a right fit but we also know it’s months until you can get in somewhere else so if you’re fine with either a second opinion or we might not take on your care then let’s do this right um and again it’s it’s that same challenge of how can we break down the barriers and at least get people seen and get the conversation started to see what they really need absolutely so well one question I had and this will be a long question which you’re not supposed to do in TV did you know that like I’m supposed to ask really short questions so that we don’t lose the audience’s attention but instead I have some sort of Meandering thing and usually the guest is wait what was that so and this is I think like my 46 show so I’ve I’ve learned nothing just so you know I can try to make short answers but yeah or or you can try to guide me you know like a lot of times I’ll have therapists on the show and it’s basically my personal therapy so we we we’ll figure it out so uh but there’s a recent there’s an article in the New York Times about this recent Trend to self-identify with social media uh I hate to use the word but influencers so they’ll say look I’ve got borderline personality this is what I’m like and then someone watching like o o I have that too and it’s really more like horoscopes that oh that’s exact what a Scorpio would say or oh you must be a Virgo where you see one Salient fact and then you generalize it for everything but at the same time some of it is a little healthy because as you said before you know there’s a stigma with mental health a lot of times people don’t want to talk about it but what do we do when it’s gone the other way where someone comes to us and says you know what I absolutely have this issue yes and I think we’ve we’ve all seen that in practice lately um Tik Tok has been a big influence on people and um people want to feel like that they belong and that they’re part of something and I think sometimes that is behind some of their desire to think they have this diagnosis because now they’re part of this group right of people that have this uh so it can be a little bit of a challenge but I think the first thing I usually do is talk to the patient and have them tell me why they think they have this MH so that I can get an idea of where their thoughts are around what they think um they might be feeling because most of the time it’s going to be the case where it’s not something that that’s going to be a diagnosis for them sure but I do want to hear what they have to say about it and then you know we form our diagnosis based on the dsm5 criteria and that’s how we come up with a diagnosis uh people have to meet certain symptoms I guess I would say symptoms or um issues that they might have and then we follow those criteria to make that diagnosis so a lot of times what I will do is I will get out the dsm5 and we’ll go over it together you know and um is this something that you have is this something that’s a problem for you um and usually then when they go through that they’ll realize that no this isn’t me so yeah so that can be really helpful in it’s probably good training too because part of Psychiatry is that Psychotherapy uh standpoint and so if you’re teaching them how do you feel what’s going on then over time they uh and the word self diagnose has negative connotations but in a good way they can have a better sense of what’s going on with me you know do I need an appointment with a therapist do I need to see my psychiatric nurse practitioner do I just need to be by myself without my phone for a few minutes and and as they learn those skills then they’ll need us less and less which is of course the whole goal of what we’re trying to do is bring take people from a place of desperately needing medical help to in most cases being able to uh know what the right intervention is and then you know if they still need a they’ll reach out to us absolutely and I think sometimes too there might be something going on with that patient still that you haven’t uncovered yet and sometimes that can give you a sense of what that is it’s not that they have that diagnosis but maybe something else is going on with them and as you said in that case it could be just you really need some more therapy you need to work through this or um process this or something like that so it can also give you Insight on sometimes things that are the patient might be going through that you haven’t really been able to you know discuss yet so it might almost be like peeling an onion that okay you don’t fit these criteria but if we continue to work on you as things continue to go up then we might actually find out what at the core of this right exactly that makes sense that’s often how the the ketamine infusions work where it uh I tell the patients this might be a little rocky it might stir up some things that have been repressed or bring to the surface some subconscious issues um but it allows us to get a better understanding of what’s going on because it does serve as a mirror of the person sees themselves uh as they are and this is a bit more of like the Psychedelic mystical side of it as opposed to the science but u and sometimes it’s difficult for patients um for example the patients who don’t do well at all with ketamine infusions are those who have physical pain but U deny any sort of mental health issues that they say this is and sometimes this is true where it’s just a physical issue we don’t have to Deep dive into how did my childhood affect this pain just you’ve got some pain so I don’t want to uh you know make everything more profound than it is but in many cases the physical and mental health are tied together and because the patient has denied that connection uh we instead see that oh wow like there’s a lot of stuff here that we need to deal with so right very helpful to uncover things that maybe they haven’t even approached yeah absolutely we may have lost our cameras I’m not sure this may have just turned from a uh you’re good oh okay that would be kind of neat though if it went from a video to all of a sudden oh we’re a podcast now I was defining that for one of my guests if you have an oversized microphone between us then we’re officially a podcast I without that then I think we’re just a TV show yeah in in the loosest sense of the word see we don’t only diagnose patients we’re diagnosing what we’re doing actively here a little bit of metacognition there for everybody so you’re saying that uh we’re taking deeper dive you’re seeing what’s at the root of it we’re also careful not to uh overanalyze it because that can be an issue too um so and this is honestly from my own knowledge too what’s the correct balance cuz I’ve had many patients who are trying too hard for the mental health analyzing every thought am I getting better is this working what’s going on um one case is a patient who said I’m going to quit my job to focus on my mental health and it didn’t work out she just stayed all day in bed um so a lot of times it’s one of those things where it’s almost like pursuing happiness like if you’re so I must be happy you’re you’re not going to be happy you’re going to be miserable and everyone else around you is going to be miserable so what’s the correct balance to try to figure it out like what’s going on with me sorry that was one of those like long questions I warned you about yeah it’s um you know it’s so individualized on how people deal with things and there are people that um sometimes when you get into therapy or any there it could it could could be medication as well but um it can actually make someone worse before they start to improve because as we uncover some of these things um especially when it comes to trauma uh it can be very painful and it can cause symptoms that maybe they didn’t even have before initially so there are times I think when people need to kind of walk away from not treatment so much but trying to focus on analyzing everything that’s going on with them and just take a break from that because you know if you’re if you’re overthinking it all the time and you’re pushing yourself that’s a form of stress and pressure as well right and you’re not going to um be able to accomplish the things that you want if you’re adding increased stress to what’s going on with you so I think that it’s important to recognize you know when someone is Maybe overloaded or pushing too hard or um you know trying to think that you know if I do this if I just get into this more and more and more it’s going to make me happier and happier and and it’s not always the way it works so I think letting them know that is is yeah the freedom to not be 100% the freedom to take your time with healing that because there is this expectation in American culture that I got to be as good as I can be at all times and do all these things uh I was talking to a clinician the other day uh who’s a single mom and I was like well look you’re trying to juggle all these balls and by necessity one of them has to hit the ground at all times like you can’t do all these things and do them all well and that’s part of the acceptance process right so it’s sort of like you’re saying sometimes we need to get to the root cause and heal the issue and sometimes we need to just slow down and do some symptom management for a while step back a little bit which sounds terrible to me because I come from this Natural Health world even before I became an atist where you have to always get to the root cause and even a lot of the things I talk about about as sental center it’s always like let’s get to the real problem but that’s exhausting after a while it is because it’s a journey and it’s not quick usually it takes some time um which is another thing I think it’s really important to let people know patients need to understand that um we don’t have like a magic pill per se that’s going to make everything better right away and make everything go away make your life perfect right you know doesn’t work like that life’s up and down like this normally MH um so I think that setting that expectation that this is a journey and it’s going to be maybe a little while before you get where you want to be and I feel like the best treatments that we have at a sent Health Center actually revert the patient to this kind of life that instead of being like at a low normal functioning because of some anti-depressant sometimes the TMS or the ketamine will actually restore the normal uh flx situations of life and the patient’s like what’s going on and we just say like no we’re a more natural more permanent way of healing is to get back into the rhythms of having a good day and a bad day instead of multiple blah days exactly um it’s not is and sometimes it’s really uncomfortable for them because their comfort zone is being used to that maybe that BL or people that are the other direction and maybe a little hypo manic um a little bit up here all the time when they get into more of a normal pattern at first it’s a little disconcerting maybe confusing and they have to readjust right to that I mean it’s challenging for me as a person and I probably have some diagnosis that we’ll discover before the end of the show but I’m always busy besides owning the clinic I have all these little side anesthesia gigs so I can keep up with my skill set in case I need to I don’t know anesthetize some somebody middle of my clinic in fairon and I realized over time that nope this is this hero compx this hero complex of like I must save everyone do all the things be always busy all the time and so for me it’s like no I need to take some time off I need to make sure things aren’t running at full capacity because we were talking about this the other day in mental health uh practitioners come and go often there’s a lot of burnout that occurs and it’s actually a terrible idea to run at full capacity or to you know I I I almost want to say it’s terrible to give 100% that sounds so Blasphemous maybe there’s a better way to say that but you have to pace yourself maybe that’s a better as both patients and providers there’s a pacing of do we need to quickly solve a problem can we take our time um and really also normalizing patients taking a break from treatment because it’s almost another stigma yet another stigma of like what do you mean you you stop seeing your psychiatrist this is awful and some like no I need a break from this and finding ways to do that in partnership with the patient instead of them just dropping off or no showing of like no let’s take a step back and that’s fine yeah so they can they need to know that you are not judging them and they shouldn’t feel bad if they do need to take a break um I’m a big believer in shared decision making when I work with patients um I my main focus initially is creating that connection that and Trust um not jumping on something right out of the gate you know um and working with them for making decisions as far as their treatment because they know what they’re feeling they know what works for them and what doesn’t so I think that if they feel that you’re accepting and you know I’ve had patients say to me especially in trauma situations they were in therapy and and they’re starting to get to something that’s really painful and right kind of at the root right and they may start having much worse symptoms they may have more nightmares or they may have you know um a little bit much much more difficult maybe than where they had been as far as now they’re maybe reluctant to come to therapy and you know and sometimes then in that case it’s it’s the best thing to do is just to say you know let’s take a little break from this for a little while and let you have some time and um and that can be very helpful I really like what you said about Rapport I feel that earlier in my career the goal was well let me quickly fix something so the patient can see that I’m This brilliant genius and then they’ll trust me but that’s not how it works it’s more like let them see that I care let them see that I’m being careful and considerate and then everything else because sometimes we have these genius answers and sometimes times we don’t and it’s important to have that relationship so that because again we’re talking right now about mental health so the relationship is a core part of getting better yes because a lot of the patients that we have are ones that have been on a number of medications they’ve had bad side effects or they feel like they haven’t been helpful and I hear you’re not going to just put me on yet another thing right away that’s not you know there at that point frustrated and and which is one of the reasons that we’re doing the treatments that we are at the end um but yeah so building up that trust firste getting to know them sometimes is very helpful um as far as knowing what treatment decisions you know and then I discuss it with them always you know this is this is what we can look at this is what the alternatives are this is what the pluses and minuses are and side effects and let them be in that decision-making process rather than going in and having somebody just right yeah give them a prescription here you go take this yeah and a lot of them have experienced that they’re kind of

gunshy31 of uh what’s going on yeah well you need to recognize first of all that in one visit one little chunk of time you are not going to really be able to discuss everything fully to understand that patient that takes a little bit of time so when it comes to certain things especially like personality disorders for instance you need to really get to know that patient sometimes before you give them a diagnosis because new symptoms can come up that they tell you about or behavior as you get to know them that you see that they might not recognize and so there is a a fluidity to it as well and so um and good communication with therapy if you have if they’re working with a therapist in your same office it’s great because they can come and say Hey you know I’m worried about this because of this and and then maybe you can explore that further and really part of it is and maybe this is main my personality but we don’t all have to agree because you know this isn’t like a black and white issue these people are multifaceted as we’re trying to see what’s going on and over time it’ll Express itself sometimes it is because oh this medicine worked well we didn’t think you had this but maybe there is an angle of this um because again mostly at a scent we’re discussing with patients who’ve tried multiple medications and been diagnosed multiple times with all sorts of different things and it’s probably still also important for them not to find their identity in that diagnosis because of how fluid it is yeah and different points of their life I think there’s been a problem um lately of people getting diagnosed with bipolar disorder in rehab inpatient addiction treatment facilities detox right and they really are being diagnosed at an inappropriate time for you to do that I mean know if somebody is using methampetamine and they’re coming off of that right well see a wide range of behaviors and EM exactly so um we’ve been getting a lot more patients that say they were diagnosed with bipolar disorder and as you see them you get to know them you talk to them you realize this this doesn’t sound like bipolar disorder right but your point about medication response can also give you a cue to things because a patient could have a response to a certain medication and then they take that and and you say oh yeah maybe maybe we need to look at this right you know so um I think that that’s the the big key is you’re we’re not all going to always agree we’re not always going to agree at different times somebody could be diagnosed with something six years earlier you know and then then you’re seeing them and they’re everything’s completely different so recognizing that and allowing the time to really understand the patient I think is key so you’re saying there’s a practicality with it that hey this medicine is working we’re going to go with it you know cuz a lot of times we’ll see this with uh the ketamine infusions where patient say well I think I have chronic lyme disease but maybe I have this and sometimes it’s like well you know financially speaking I feel that you can afford an extremely accurate diagnosis or we can start some treatment but you can’t afford both so which way do we go and there’s always that risk of what if we use the wrong treatment but again when we’re talking about complex disorders that have inovations into physical and mental health and everything is all tied together you do have to start somewhere and see if you can make some progress before you move forward right exactly and if something is really helping we don’t want to rock the boat right you know which is another thing so and that can be a challenge with insurance companies but that’s where we’ll have peer-to-peer meetings with the insurance company and try to explain to them that no this is working let’s not make this too complicated just let them take this drug so and then my last question would be uh what you’ve mentioned the methamphetamines and how you uh come from a background where you dealt with a lot of addiction what’s been most helpful for those patients where they’re struggling with addiction and mental health issues and again it’s all kind of combined into this complex web yeah I think the the biggest thing to remember with patients with addiction issues is you really need to be non-judgmental that that is number one you need to make them feel accepted um and get that relationship going going with them um because they’ve been judged so many times that they’re very much A lot of them reluctant to work with you um so that I think is the number one important thing and and then a lot of it is you know we don’t know all the time what comes first the chicken or the egg are we having addiction issues because we’re self-medicating for a mental health issue or are we having mental health issues that have led to the addiction right there’s a lot of um taking a look at at that kind of component um I think one of the biggest challenges though is people that continue to use it’s very hard to regulate things like their mood and their um their sleep their anxiety level and that’s a discussion you know that you really need to have with them um but working with people with addiction issues it is important for them also um to understand that it is a chronic disease and you know and that there are things that we can do to help that um I think that a lot of them have had a number of um treatment failures I guess I would say and that they can understand that you know we have things that we can we can help you we can help you yeah it’s never quite the because we hear that a lot like oh this is my last chance and my last effort if ketamine doesn’t work or the transcri magnetic stimulation doesn’t work nothing will we have to assure them like no there’s there’s always something so well thanks for coming on the show and again if any of has resonated with any of you uh Tamara’s open for business here at asent Health Center so you can see her uh either as your psychiatric nurse practitioner or we also accept patients who go other places for specialized treatments uh whatever works best for your care we’re extremely collaborative so this has been the Ascend Health show and thanks for watching

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