Psychiatrist Breaks Down How Mental Health Really Works-Dr. Ronen Hizami S2-Ep14

I prefer to work with individuals and parents that are hesitant to give medicine than those that think that the solution to every problem lies in a pill m. Medicine is not supposed to be given out like candy. You know, when we marry our kids off, they are at the highest risk time for in theory statistically for, you know, having bipolar disorder come out, for having schizophrenia come out. We don't know where they're going to end up. People will typically come in and they'll tell me, you know, the FBI is after me and uh they're Mashiach. >> Yeah. >> Everyone's into eating organic. Yeah. >> Um and then, you know, they buy, you know, drugs from the drug dealer. there's the problem that they're not so transparent about it. So, it's well, you know, I'm selling the car as is, >> you know, and your headache if there's a problem. We don't do that with our kids. >> What message do you have for parents who are afraid to give medication to their kids? >> [music] >> Okay, today we have our guest has dedicated his life to understanding healing and human mind. His name is Dr. Ronan Hizami, boardcertified child and adolescent psychiatrist >> and a good psychiatrist >> and um you have 30 years of experience in the business. Wow. He works a lot in the community. Welcome to the struggle. >> Thank you. >> What we want to do is we are going before we even start talking, we want to get to know you a little bit and find out what drew you so many years ago into this field. So first let's start with the riddle. First of all, thank you for for having me. Let's start with the riddle. >> What happens when you get when you take one quarter sad? >> Yes. >> One quarter vision and half te. >> Wow. >> You get a stubborn te psychiatrist that likes to make jokes about kafel. >> That's me. >> Excellent. So you have you're a little you have kasides in you. >> Oh yeah. >> And you also have tani, right? >> This is a beautiful combination. >> It's interesting. It's an interesting >> The other joke is, you know, that I used to make when I was younger is what happens when you mix this, you get a psychiatrist, right? It's uh um so it's interesting. I never thought I was going to be a psychiatrist. I knew from when I was little that I wanted to go into medicine. And it's funny because I had two friends that were going through school with me and we each accurately predicted the other's fields. >> One of them is a thoracic surgeon today. The other one is a plastic surgeon. And when they told me I was going to be a psychiatrist, I was offended. Um, but when I was in medical school and I did my first psychiatric rotation, I absolutely fell in love with it. >> It was the one field that I felt where the personal relationship between the psychiatrist and the patient really had a tremendous effect on the healing process for the person. You know the pediatricians are very important, the primary care doctors are very important but anybody can write for the blood pressure pills for the antibiotics the place where the kesher is so important. >> The connection was like >> mental health and um yeah >> and also the making a difference you know the when you see the result and you see a finished product uh the fulfillment is beyond words. >> Yeah. And I'm at the stage in my career where I have, you know, where I'm treating three generations within the same families. So, it's um it's quite the privilege. It's uh >> it's it's tremendous work. It's it's it's different than the surgery and it's it's it's when a person is in a very dark place, they don't see light by the end of the tunnel and you come in like an atsula guy. >> Um okay. Um [laughter] >> I think that the biggest part um the most important part in the beginning is trying to understand what's happening and to give it a name. >> Because when we don't feel well, if we're not opening up and we feel very dark inside, we feel like we're the only one suffering. >> Okay? And when you go to someone and they can say, you know, it has a name. It's called this. And I I can't express the feeling that I get when someone comes into my office and they start to say, well, you know, I'm really not feeling well. And they speak for a few minutes and then I say to them, do you have this and this and this and this? And they say to me, how did you know? >> I said, well, because this is actually very common. It has a name. And when it has a name, we then can apply the statistics. We can apply the research. We can apply guidelines. >> They feel like it's not the end of the world. What do you mean? I'm not the only one. And you actually have a name for it and you have the solution for it. >> Yeah. So, I mean, it's interesting because people say, why do you have to label everybody? But the label is actually very important. >> Yeah. >> Wow. Very interesting. So, let's start um let's start from the beginning. And this is I have to bring in the shalom into this. A child is born into this world. Um and later in life or sometimes I'm going to ask you this is one of the question I want to ask. What age when a child is born into this world and grows up when do you start seeing signs? But before that this is something that I think and I want to hear your opinion is that there's no answer for it. person comes into this world and they are the bunch of gave him this gift of uh struggle with mental health and there's no ifs spots where when we don't understand it and sometimes people say it's in the genes and it's family history and stuff like that but sometimes it skips gender we this is an answer that we don't have an answer for this is like one of those things that the gave you and your journey in your life So when does when does a parent or a school or a person start seeing mental health problems um from when a young child is born? >> So really it depends [clears throat] on the disorder that we're talking about. You know there's this false dichotomy between nature versus nurture >> right >> which is false because we know that it's really nature through nurture. So I'll give you an example that I use all the time. Um, you can imagine that we're building two skyscrapers. We have the same construction crew. We have the same architecture, the same material, and we're building one of these buildings in Miami in the middle of the summer. The other building we're building in Toronto in the dead of the winter, right? >> Even though we're using the same architectural plans and the same construction crews and the same material, the buildings are not going to be exactly the same. The DNA is where we have the the architectural plans to build the body and DNA strands are very very very very long. It's interesting because you get different things depending on where you start to read the DNA >> and the environment and stress levels can affect where you start to read. So the the nature is something that we're born with. Now there are certain things that can happen that can affect our genetics. But the stress that we live with can also affect how the architectural plans are read. >> You wake up something over there. >> The Yeah. And um so then so then well how do we know what we're dealing with? So >> so that is nature. >> Nature is our genetic programming, >> right? But to wait to for a person to have stress to be in a stressful environment or whatever >> even even growing up in a home that's very very stressful. So there are there are reports they call them studies of twins that are separated at birth identical twins that grow up in different environments and they come out differently >> because their environments are different. >> So again it's you know Miami versus Toronto. The buildings are not going to be exactly the same. You know, people say, "Well, why did it come out when I was 20 or 25?" >> And I say to them, you know, >> baldness runs in my family, but when I was younger, I had a full head of hair. Things tend to come out at certain ages. >> Um, so, you know, there are some conditions that we see early on. >> Um, so for example, autism is something that uh we see early on, especially a very very clear case of severe autism. >> Where do you see it? by the learning part, by the behavior? >> No. People with autism tend to have developmental delays early on. You can tell pretty early on that they're either not developing at the usual rate and at the well visits with the pediatrician >> or when, you know, they start to go to preschool, you see that there's there's a problem with their interactions, there's a change with how they play, >> right? Um so you know the very very clear obvious cases are are there very early on but something like um anxiety that can come out during childhood it can come out >> later >> later something like bipolar disorder um sometimes we see simonum earlier on very severe cases that happen before puberty are disastrous and very obvious but typical case person is absolutely fine and then all of a sudden bam >> their symptoms come out. Um >> usually in the teens or closer to 20, right? >> So there are different times when it comes out, different peaks or spikes. Um in boys the first episode is usually in the late teens or 20s and in girls it's usually in the 20s or even later. You have to be careful with the usually word. Statistics are not >> kakua. Right now the the the few famous ones that that everyone knows the ones who are not educated in this field but they know it is bipolar uh schizophrenia and and um borderline. So can you give us a short uh uh explanation what is bipolar? What is schizophrenia? What is borderline? >> Sure. So um schizophrenia let's start with that. um is a disorder that happens seems to be because there's a problem in the migration of the neurons during the pregnancy. So what happens early on in pregnancy even uh is that you have the sperm and the coming together making one cell and that sp that cell replicates becomes two cells becomes four cells. Eventually, you get a ball of cells and then eventually that ball of cells hollows out and then folds up over itself like a bubble C. It's at that point until that point all of the cells are identical. If you would take one of those cells off or multiple of those cells off, you would get identical embryos, twins, triplets, etc. At that point is when the cells start to differentiate which is right when a woman notices oops or oh wow I'm pregnant >> right >> um is when the brain starts to develop the central nervous system I should say and the cells start to develop and there's a migration that happens when it seems to be that a problem with the migration of those cells leads to some of the psychiatric disorders. So, schizophrenia is from the more severe of the disorders. People with schizophrenia typically were never quite right. Um they're kind of off socially when they're growing up, maybe seeming anxious, not in all cases, but in most cases, and then um all of a sudden they explode out with very serious symptoms. The symptoms are broken up into two categories. Positive symptoms and negative symptoms. There's nothing positive about the positive symptoms. >> The positive symptoms mean that something is there that shouldn't be there. >> And negative symptoms is they're missing something that should be there. >> It's like co positive and negative. >> No. No. >> Yeah. >> So positive symptoms are hallucinations which are experiencing something that isn't there. So they can hear things and it seems like it's coming from outside their head like my voice now but no one else hears anything as opposed to being something in their head like a thought. >> They see things. Um those are the two common what we call auditory and visual hallucinations. >> And this is very scary stuff. >> Yeah, very scary stuff because >> most of the time these thoughts this the auditory and the >> they're not positive. They're talking to you stupid stuff. >> They scare you and and and people suffer from this in silence on a tremendous level. >> It's uh it's really really quite impactful on their lives. It's it's debilitating. Um they also have delusions. Delusions are fixed false beliefs. So here you get the usual paranoia >> um that comes in. Yeah. So it's but it's a fixed false belief. So it's it's not something that changes. So, if I tell you, you know, if a patient says on one day I'm 7 feet tall, and they're really not. They're my size. >> And the next day they say that 7 and 1/2 ft tall, that's not a delusion. But, um, people will typically come in and they'll tell me, you know, the FBI is after me. And, uh, I've had patients tell me that, uh, you know, the government is following them and spraying them all day with poison gas. >> Uh, and they really believe it's not a joke. They in their life, they believe it. So you want to tell me there are people who are walking down the street. You're going to sh with those people if someone doesn't take care of it. But this guy is just sitting over there being tortured by his mind. >> That's right. That's right. >> That is one uh one illness that is uh >> it's it's it's usually pretty obvious when someone is symptomatic. >> Um at least in the beginning, it's usually pretty obvious. And then medications can we'll talk about that in a sec. Um, there's also something called a thought disorder, which is where their thoughts aren't structured the way that they're supposed to be. And there are different types of thought disorder. So, sometimes their thoughts don't make sense. One thought doesn't connect to the other thought, at least to us outside. To them, it makes sense, but when you talk to them, they just they're not able to communicate effectively because they're speaking about things that have nothing to do with each other, at least to us on the outside. >> So, those are the from the positive symptoms. The negative symptoms are things like, you know, not feeling emotion, not having any motivation or drive, those those types of things. So, Barack Hashem, one-third of people with schizophrenia do very very well with medication and can live completely normal lives. Onethird are severely impacted and medications don't really help them much. And one third are kind of in the middle. >> So, what do we do with those people who are severely affected and the medication does not do the job? So we do the best that we can. There are in addition to medication there are other treatments and they get a lot of support within the community >> and they suffer they suffer sufferably. Yeah. And there are other treatments like shock therapy that can sometimes be helpful >> but it's uh it it's a frightening thing when it happens. Even more frightening is when people get misdiagnosed with schizophrenia >> and they're really suffering from a medical condition. >> And uh those cases come up every once in a while. There have been, you know, I've had cases in my office that have come in where um someone legitimately had Lyme disease and the diagnosis was missed. There are cases where people have seizure disorders. doesn't happen commonly but there are cases also people have rheumatological diseases that are completely missed not diagnosed and people end up really not functional losing decades end up in uh living in community residences it's really it's really frightening what happens sometimes >> now what you're saying is that this um is in the genes >> so this tends to run most things the vast majority of things run in families it's not 100% so if someone has a parent that has schizophrenia, it does it's not a guarantee that their child is going to have and we don't have all of the genetics quite figured out because there isn't one specific genetic process that explains most psychiatric disorders. So when you look at population studies which are not perfect, you get a sense um but there are families where there are multiple members that have this disorder or that disorder. Um and um so and some families where it just seems to pop up and there's one person. Now of course with the Holocaust our family histories were chopped off at the knees. Um and >> why because of that because because we lost people we lost so many people >> records we lost the communication >> forget first that that you know people don't talk about these things and you know the field of psychiatry was really not was not a subject >> was it really so uh back then >> right? So with the the work, it's hard work now to start from fresh >> and start making statistics and holding records and and so there's double the work. Well, it's an interesting thing because there are uh happens in my office quite frequently that people will tell me that they have no family history of anything and I know more about their family history than they do and I know that I'm treating multiple >> also because families don't share parents will not share with the share with the kids which is a crime for itself >> and then this not a subject this is something that is so taboo this is there's such stigma even in your own family >> yeah and how do I know that that they're the same because the same grandparents are paying for the kids, >> you know. So, um but um yeah, so that's that's schizophrenia. >> Schizophrenia and bipolar. >> So, bipolar disorder is is interesting. Um the way Hashem created us, it's normal for us to have a range of emotions, right? If someone doesn't feel anything emotionally, that's a different type of problem, >> right? >> But there's a limit. Um, so even if something bad happens, there's a limit to how down you get. So even if something good happens, there's a limit to how how good you feel. >> Um, so some people have leaky borders like the United States now, right? >> So um, there are some people that can get stuck at extremes of mood. >> When there are some people that just get stuck too low, we call that depression. >> There are some people that can get stuck too high or too low, we call that bipolar disorder. M now bipolar disorder um like everything else runs in families. Um and people will typic people can typically have completely functional lives if they take care of it. Um we have great medications that help to keep mood steady for most people. Um the challenge is that many times they go off medicine, they're feeling good for a long time. Of course, they forget one time and they say, "Gee, I was fine." And then they >> they don't understand that this is the medication that did it >> that that's helping to keep them steady. >> So the the high of bipolar disorder comes in two forms. There's something called hypomomania, which is not as bad, and then there's mania, which is extremely debilitating and can be life-threatening. Um, a person has to have an extreme mood elevation which can be uh be being euphoric or too happy or uh extremely angry or irritable. When they get like that, one of the things that happens is that they will typically be involved in pleasurable things with poor judgments. >> So, um I've had patients that uh signed up to join the military when they've been like that >> and we had to fight to get them out. I've uh you can imagine that someone um can become hypersexual um and without a hben. So there are interesting shilas that come up um you know if there's a married lady and she's manic and then um she ends up going out and maybe it's not so obvious at home what's going on uh in the beginning and before you know it she slept around and what do we do? How do we look at that? Um so it opens up all sorts of shilas and problems that um but people in if they if they lose their judgment and they do things that are pleasurable. So people can use extreme amounts of substances that are very dangerous. I've had patients walk miles and miles and miles through bad neighborhoods without even thinking twice um when they're manic. So obviously they're opening themselves up to danger. So other symptoms that that can be part of mania are um speaking much faster than usual. Uh sometimes you can't even get a word in because they just speak so fast. >> Mind is racing. >> Yeah. Their their thoughts can race. Um they don't need to sleep so much. They can be working on two three hours of sleep. >> Um so mania is considered an emergency. And of course people with bipolar disorder have a higher rate of suicide. Um so you know they bipolar disorder needs to be taken very very seriously >> because you can hear always couples you know between couples who are fighting or whatever is oh she had bipolar he has bipolar and can you live with bipolar without being treated or no? >> No >> very difficult. No, it's um it's you know bipolar disorder is a recurring illness >> and uh people that don't take care of it. If a person is manic and they don't take care of it after a few months they tend to burn out exactly the way it sounds. >> Um and I mean they they they can't avoid taking care of it unless they're living by themselves on a desert island because they become so symptomatic um and unable to care for themselves and sometimes they can become psychotic. they can have symptoms of schizophrenia as well, >> right? >> Um, you know, one of the interesting symptoms um is that um they can become grandiose and I have had many times when people have come into my office telling me they're Msiah. >> Yeah. >> Telling me that they're Eliovi, telling me they know exactly where the 10 shatim are. >> And [snorts] um so yeah, so it's uh >> it's serious. It's serious stuff and sometimes they can be fun to be with. They can they can be the, you know, the comedian that brings the room down, make everybody laugh, but it's it's a frightening frightening disorder >> and needs to be taken very seriously. So, >> most of the time you can't tell that someone has bipolar disorder until it explodes out. >> Um, there are some cases where you can kind of see it when they're younger. Um, but those tend to be the more serious cases. And then you asked me about borderline personality disorder. >> So let's talk about personality disorders in general because everybody knows about borderline but there are other personality disorders. >> Correct. >> So uh in the most simple of terms a personality disorder is when there is an impairment in the way a person does business with the world and themselves. That's the simple. And then there are different flavors like there different flavors of ice cream. Borderline personality disorder is uh the most wellknown. It used to be a nice insult to say this person is borderline, that person is borderline. Um it it really can be quite debilitating. Um people with borderline personality struggle with their identity. Um they will frequently be involved with self-injurious behavior >> as opposed to suicide >> like cutting and >> cutting and burning >> and and what about anorexia and all these >> they can have those symptoms as well. Um they can have brief times where they become paranoid. They can become extremely moody and they they tend to go from loving people to hating people. Um quite debilitating. There are more symptoms too but it's quite debilitating and um medications don't help as much for it. We can smooth the edges out with medication but um there is a very very effective modality of therapy called dialectical behavior therapy uh which if people really take it seriously can be quite effective. >> What kind of therapy is that? >> So dialectical behavior therapy was designed by Dr. Marshall Lahan, who's a psychologist in Seattle. Um, she was working uh in a psychiatric hospital on an inpatient unit working with women with borderline. [snorts] And at the time she was into Buddhism. I've heard since then she was into Cabala and I'm not sure where she's holding now. >> Um, and what she did was she took some of the principles of Buddhism which are not unique to Buddhism. They exist in every organized religion. um and basically formulated a plan. So what it involves is two separate components. There's a dactic component which according to the program is done in a group setting where people learn certain skills. So you can think about it as um I remember when I was growing up there were posters that said everything I ever needed to learn in life I learned in kindergarten. And then it says like how to say please, how to say thank you, how to share. >> Right? So the skills you can think of as being they teach people how to have relationships. They teach people how to live in the moment. They teach people >> teach the border lines. >> Yeah. Well, we use it for a lot more than just borderline today. >> Um they teach people something called distress tolerance, which is exactly what it sounds like. They teach people mindfulness. >> So that has nothing to do with medication. >> Nothing to do with medication. physical uh and and does medication help them to sit on the chair at least or you don't need that. >> So so medication can help with some of the moodiness um and it and it it comes to the point of medication in general which I guess we'll talk about in a minute. Um but so basically they they go through this didactic part. So they have once a week typically where they're going through the didactics and the dactics are taught in modules and then they also have a typical one- on-one therapy session uh as well where they're in addition to the usual stuff that happens in talk therapy where they're taking from the cl of the dactics and bring it into their props. Um, so it's quite effective and it's kind of like ketchup today. You know, you can imagine that ketchup was designed for French fries, but it's used for just about everything today except ice cream, right? So DBT today is used for addictions. It's used for uh eating disorders. You know, we use it for lots of different things. Now, it's interesting. Marshall Lahan's kesh wasn't in the skills. The the kdesh that she did was just basically in how she structured >> things. Um so it's quite effective. Um and you know also sometimes while we're on the topic of borderline personality disorder you know you say tomato I say tomato that this suga of called chronic PTSD where sometimes people have been through a tremendous amount of trauma um and they look like they have borderline personality disorder. potentially they're treated uh similarly in some aspects and not always. Um if you want now I can answer your question about medication. >> Yes. So because my the the question is um all these three that you were saying bipolar schizophrenia are treated with different type of medications which means the medication does something to the in for the brain that everything has a different type. So not exactly. Um we'll use um similar medications for for for different for different types of problems. Sometimes same doses, sometimes different doses. One other key component of a personality disorder is that it doesn't just pop up suddenly in adulthood. It has to have been there from adolescence. And um and it's one of the mistakes that I see a lot of clinicians making is that they'll very quickly make a personality disorder diagnosis without let's say someone comes in and they're 40 years old and they'll have a pattern that's consistent with one of the personality disorders, but they forget that the symptoms have to have been there from adolescence. And if these types of symptoms present all of a sudden later on in life and they weren't there before, >> it's something else. >> Yeah. >> Um, you know, there's almost no symptom in the field of medicine, not just psychiatry, that's pathonmonic. Pathonmonic means that the symptom equals a diagnosis. So, if someone comes in with symptoms of ADHD, sometimes it's ADHD, sometimes it's something else. >> Um, someone comes in with symptoms of psychosis, sometimes it's schizophrenia, sometimes it's something else. Someone come in with symptoms of a personality disorder, sometimes it's a personality disorder, sometimes it's something else. And this is really where some of the arts um in psychiatry comes in is really trying to figure out exactly the problem that's driving what's the engine that's driving this. >> But it's also uh throwing darts sometimes. You know, we are at the mercy of a doctor sitting over there and trying to help you and figure it out and he tries one, it doesn't work, you go off, he goes on another one. Is that is that the process? >> So we don't know. which medicine is going to work and even before that we have to have a realistic and reasonable expectation of what medication is going to do. We don't always use medicine. Um it depends on the condition. So there there's a whole that goes into first understanding what's going on, establishing whether whether there's even a diagnosis or not. Mhm. >> Um if there's a diagnosis then okay well what is what are the treatment guidelines now? Treatment guidelines are guidelines. Um we're allowed to deviate from them when we feel that it's appropriate. >> Um we're not robots. Um but anyone who guarantees that a patient is going to improve with this specific medicine is lying >> or is a fool. Um, you know, I'll I'll give them a better price for the George Washington Bridge Virgin Throw in the Verzano for free. >> Um, we don't know. There's a lot of trial and error, but it's an educated and informed trial and error. Um, medication response tends to run in families. So, here's another part of another CO with when families aren't open with each other, um, it can really affect treatment. >> Of course. Of course. Now, let me ask you something. There is a couple who got married and they're marrying young couples today are marrying very young. Um in their 20s or their mid20s it pops up one of them just woke up something woke up the monster. Something came out. What does this other spouse supposed to do? How is that other spouse supposed to deal with this situation? And is there hope from your point of view? What would you say to the spouse? Just we're in good hands. We'll try to help him and we'll put him on we'll put him on this on this medication and they will be a productive member in society. So, I never tell people what to do in those situations. I can't make a decision for someone. Um, I've actually had several instances where people became manic for the first time right before their or during shvaas. >> Wow. >> And um, and it's frightening because you marry someone, they have no history before. There's nothing in the family. um in these cases happens to be there's nothing in the family and all of a sudden um the person becomes extremely symptomatic in a very very obvious way. Um it depends on the diagnosis. um you know all we can do um from the psychiatric perspective is try to stabilize the patient, try to educate everyone about the statistics. Um there are some people that stay, there are some people that go. Um it's a very very individual decision and it's always very very sad. um we know people don't choose to be sick, >> right? >> And um people don't choose necessarily to marry someone who's sick unless they were told in advance, right? >> Um so it's it's always heartbreaking. The good news is that with most conditions today, we're able um to stabilize a person in many cases and depending on the diagnosis, most people go on to live a very happy productive life. You know, the more severe disorders that really impair functioning, they tend to show simon before there's something unusual there in many cases. So, but it's always very very sad. >> It's heavy stuff. Heavy heavy stuff. >> I would want to talk about suicide. Lately in the community, you see young and you see women, you see middleage. Lately, it's been more talk about it. We've seen cases that is frightening suicide. What is the suicide? What is going on in these people's heads? Is it similar to what we spoke before that they get messages in their head or is it just uh life, you know, [snorts] they don't see light by the end of the tunnel? Um they don't they they're not positive or is it something that's out of their control? And to actually go and do it, you this is not easy. People just think you throw yourself off of off a roof, off a bridge. What is going on with the suicide? >> So, it's interesting. I'm going to tell you something that may shock you is that until recently I hadn't heard that there was such a spike in suicides. >> Um until I heard a lot of people starting to talk about it and then I had one not very long ago in my practice as well. >> Um >> one of your clients committed suicide. >> Yeah. Um, you know, when when there are some psychiatrists that before you make an appointment, they talk to you on the phone. And if it sounds a little bit too complicated, they don't want to be bothered. I I wasn't trained that way. I'm here to help. And when you treat people that are unwell, you are not always much. You know, if you cherrypick, you know, the heart surgeons that just take care of the gentle, mild cases, >> you know, they have 100% success rate. You know, it's the ones that that take on the challenging cases that are not going to be 100%. So I I've had my share of suicides um throughout the years and there are some that still to this day I scratch my head and I say after 120 keshu explain it to me please. >> Um there was one that I still remember where I was when I got the call. Um, and I had to meet with his wife afterwards. And it was one of the most difficult meetings that I've ever had, not in my career, in my life because [snorts] I had no answers for her. Um, was very, very sad. >> There is no answer. I had a friend who also committed suicide. And um, I don't know, I knew he was struggling, but he never spoke about it. And one Sunday morning, [cough and clears throat] we all heard the news. And I was always wondering what is really um is it is it at the ledge? What is the drive? What's behind this that it's that they actually take action like that? >> One of my supervisors in residency taught me something that isn't entirely true, but I think it's true to a degree. He said that people that are connected to other people don't kill themselves. Now, it's not entirely true uh because there are people that act impulsively even if they're connected to other people. There are people that are psychotic. There are people that are intoxicated. There are people that could be having a flashback to some trauma. Um you know, we just don't know. It's hard to do a study to ask people after they've committed suicide to to to send them a questionnaire and say, "Hey, you know, what made you do it?" Mhm. >> We know there are certain conditions that are more likely to end in suicide. There's an increased risk. Um what's what's really frightening with depression is that the highest risk time with depression is not when people are in the pits. It's when they start to get better. when they are severely depressed and they're in bed and they can't move and they can't do anything and they haven't bathed and we don't know how long and they're barely eating, they don't have the kayak to do anything, but when they start to get better >> after the highest risk time and um I think that's what happened with that patient that I mentioned before that I'd like the answer to. >> But um it's it's it's frightening. I don't know that anyone can quite answer. And you know, as a field, we're not very good at predicting who's going to take their lives. You know, there are risk factors, >> right? >> Family history is a risk factor. Certain diagnoses are a risk factor, >> but the biggest risk factor is a prior attempt. >> And um you know, I tell people that being a psychiatrist is not a nineto-five job. No. >> Um, you know, my cell phone is always on. >> I tell people except when I'm on a plane and actually I flew to Isurel back in December for a few days for AASA and um so I'm on LL's the only airline that's flying and I paid for the internet cuz I had to get some work done >> and so I had my cell phone connected and my laptop connected and I did what I had to do. I shut it off. I forgot to disconnect my phone and wouldn't you know it, I was just falling asleep. Everybody was sleeping. All of a sudden, my cell phone goes off and someone was calling me with an emergency. >> Um, you know, it's not a 9 to-ive job and we have to make ourselves available to people that are truly in crisis. >> Unbelievable. So, what you're saying is that, and it's very important, loneliness is something that will drive someone to suicide. It's not just loneliness, it's the lack of connection. I mean, you know, with co we learned about not just the mental health costs, but the regular physical health costs of of isolation. And isolation is different than loneliness, right? Whether not not having a connection, right? So, you can have someone that has relationships, but during COVID when we were all locked down, >> if there were people that were by themselves and they weren't going out of the house, >> even if they have a kher, >> Yeah. It's not it's not the same. They're all by themselves and it led to horrible things and all these to you know for people to call hotlines and and and stuff if they were feeling um like they were struggling a chabas on uh yeah it wasn't >> what do you think that they feel they're alone? >> Sorry. What do you think about um to conquer loneliness even though I know we're just you know we're not raonium and we're not in this business but for someone to connect a little bit more to we know in addictions they talk about higher power and they talk about but as yen we connect to the and if we put a bigger emphasis on the on these things would that help for a person to feel connected, you know, because to rely on friends and to rely on other people, you know, where that ends up. But if you if you put yourself if you take a few minutes and you and you try to go down that avenue of connecting spiritually to the and and live a meaningful life a little bit, would that help for people who suffer? I mean for regular people for sure it's going to help but even for people who suffer from loneliness >> the question is very dangerous because someone so first of all of course it can be helpful for anyone to connect to Hashem but the flip side of your question someone could read between the lines and say the reason that I'm suffering is because I have >> and I don't believe in kadesh enough and if I only did this or that would we say that with someone with heart disease? Would we do that with someone that has high blood pressure? We're talking about illness that's no less physical than anything else. And actually I I was invited to the Kiruni Shabbaton, >> right? And um one of the things that I sp I gave four talks there and one of the ones that I gave was how do we distinguish between a problem with midot and a psychiatric diagnosis. Um and it's a it's a whole suga but illness is illness. >> Wow. >> And so we have to be careful because a lot of times people will come in and say you know may maybe I don't need treatment. May maybe I just need to learn more. Now certainly >> working on your >> is helpful but you know you have an illness and and you still need treatment too. >> I don't make believe that I understand why does what he does. I know what he does is always for a reason and I know that it's always for our benefit. And I tell everybody it's our job to make ourases who decides what works and what doesn't work. And sometimes he makes us look like fools as clinicians, >> right? >> And sometimes um he makes us look like we're really smart, but at the end of the day, he's in charge, >> right? >> You know, it's interesting. I learned in a I think it was in mid [snorts] um I don't remember in which para that it says 40 days before conception um Hashem sends a specific angel to the repository of namas and it summons the nishama and it's announced 40 days before conception if they're going to be rich or poor what they're going to do for a living where they're going to live are they going to be smart or not smart are they going to be healthy or not healthy. M >> um so you know I assume that mental illness is part of that >> and um everything as a I'm not going to make believe that I know why certainly you know buckling down and talking to the boss is always helpful and you know working on our connection with Kesh is always helpful >> but um with both feet solidly planted on the ground we have a to take care of illness and that involves I was getting treatments. >> So, let me tell you what I what what I'm hearing from you. What you're saying is that and Mrs. This is all gorgeous and important >> for everybody. >> But what you're saying is that this illness that you're talking about that you're treating and this is nothing different than any physical illness. So that means if a person um is suicidal is because there is a is something in the brain that gives him wrong messages. >> There's something going on. Yeah. There's something going on not just for suicide for everything. >> For everything. So bipolar and schizophrenia and all these things because it's clear that if someone has schizophrenia you're not going to tell him to go sit down and u you know take a miss cipher. He just sees a Leon movie. I mean he's like he's not here. That's how the field looks at. >> That's how the field looks at it as a saying that these people are have a problem. It's a hard problem. Nothing different than any >> difference. When you do studies um using very fancy imaging techniques um and look at the electrical activity in the brain, we see that there are differences uh in people that have certain psychiatric disorders versus people that don't. So there are physical changes in the brain that are associated with these things. It's not, you know, that's overtaking the person and um or something that they're making up. There's a legitimate physical problem that's presenting in this way. >> Right. So you were saying before do you think that trauma something if let's say if a person uh was a totally healthy person and they're going through a very horrible time whatever the case is uh sexual abuse or any other could attribute to uh wake up uh one of these uh mental illnesses that we discussed before >> it's can certainly contribute and we also know that there are genetic differences between us there are some people that have a greater likelihood to respond with greater difficulty to trauma than others. >> Um so again, you know, people say, "Is it genetic?" And I say to them, I challenge you to find something that isn't genetic to a certain degree. >> Now, as far as addictions, I want to talk about addictions. Now, they call it a disease. They has all kinds of names. The question is addictions is an illness or addictions is something that has to be treated and um and I'm talking about alcohol, sex addictions, all these type of addictions falls into which category? >> Yeah, they're they're diseases. We know that that there are certain people that have a genetic predisposition. Addictions run in families as well, >> right? Sometimes um there are conditions that have a greater likelihood of having addictions associated with them if they're not treated. Um and politics aside, we know that addictions are diseases as well and require treatment. >> And is there medications? Because I know there are some medications that the doctors treat alcohol. I mean it brings a little bit down the urge for alcohol and for for addicts and for sex addicts. Is there something that >> So there's no medication for sex addiction officially. There are medications that we use that can be helpful. >> Um there are medications that are approved to help treat certain chemical addictions. Um but medicine is never the answer. It's part of the answer. Um yeah >> because what you're saying is that uh to treat addictions and all these uh other stuff that needs a lot of talking therapy as well and that needs a lot of selfhelp that is not just clearcut the way the other mental illnesses. This is a combination of the two. >> Yeah. I mean it's not the only disorder that also needs therapy but um >> just medication is typically not going to work. >> Now talking I want to talk about weed. I want to talk about the drugs the young people today it supposedly is becoming normal because there's it's legal now you know it's like alcohol but how dangerous is weed because what I read is that weed can flip you over sometimes if a person has something in their head sleeping weed will do that for you and people think it's a joke >> so if people walk away with nothing else from watching this podcast just what I'm saying about marijuana now I'll be happy marijuana is incredibly bad for you [snorts] >> now let's talk about it for a second you know my parents' generation people smoking for decades they seem to be okay maybe they're a little bit more stupid but no they're okay what people don't realize guys, is number one, the cannabis that we use today that's available today is much much more potent than the cannabis from prior. So when someone takes a certain amount of marijuana today, it is much much more powerful gram to gram than what was used 10, 20, 30 years ago. >> So it's much more dangerous. We also know that in some individuals that have a predisposition for certain disorders like schizophrenia for example, marijuana can bring it out earlier. We also know that there's a process that happens in the developing brain. So before when we started we spoke about when the brain starts to develop the very beginning of pregnancy >> that process continues typically you know to the mid20s the one of the later stages of brain development is something called apoptosis. Apoptosis is a pruning out of pathways in the brain that aren't needed. they're not used and it starts way before but there's this kind of um finishing up of the process. Marijuana use in kids and teenagers and very young adults can affect that process permanently. One the once the brain is done it's done. You can't fix it. At least we don't know how to fix it. So if if I were and I'm happy to say that I have never in my life used any illegal drug, >> right? >> Um but if I were at my age to use cannabis, it wouldn't have the same effect on my brain because my brain is completely developed. If you give it to a teenager, it can cause permanent harm. Wow. >> We also know that in people my age and adults in general, it increases the risk of all sorts of heart conditions. Um, increases the risk of stroke. I mean, it's what I like to call bad news for the Jews. >> Wow. >> Now, just like many other plants and substances, there are positives. So, there is there are certain medicinal uses for cannabis. Um but that cannabis is tightly regulated and it's all in the dose, right? Um there are certain substances that can be quite effective. If you take too much, it'll kill you and if you don't take enough, it's not going to do anything, >> right? >> So there are conditions for which it's it's quite helpful, >> but um it is >> you're talking about the ones who are they're selling on the streets for young kids who don't even know where it's coming from, where they're buying it from. So that's a bigger problem because but I'm talking about even the stuff that's grown and and purchased in the dispensaries is still dangerous. >> Um the the real risk of the stuff that's sold on the streets is that um many times it there are very dangerous things that are mixed in that are much more dangerous. >> Yeah. like forldahhide, like PCP, which can cause permanent severe damage. Um, and um it's it's just staggering. I mean, you know, everyone's into eating organic. Yeah. >> Um and then, you know, they buy, you know, drugs from the drug dealer and they don't care about all the pesticides and all the things that are mixed in >> that are even more dangerous than the marijuana itself. And they say, "Oh, I don't want to take medication. I'm against medication, but it's okay. I I'll use I'll use illegal drugs. That's fine. >> It's unbelievable. >> Um or or even legal drugs, but but not in the right way, not for the right indication, and certainly getting it in a way that's dangerous. So I I think this fallacy that um marijuana is safe because it's legal >> is uh you might as well say that you know the internet is completely safe too and um you know pornography is safe and everything is safe when you know okay thank you. [laughter] >> Now what's your take on psychedelics? So, um, I'm not an expert in the field and I I have a problem with the way that it's being used today. Mhm. >> Um I appreciate that there may be a role for certain psychedelics, but um I'm I'm not a big government guy, but when it comes to making sure that the things that we take are safe and consistent, like with medications, I'm a huge fan. And when something isn't regulated as a medication, um you don't know if what you think you're getting is what you're really getting. A B um the psychedelics, just like we spoke about with marijuana, are just like any other medication, are certainly helpful. The data demonstrates that some of them are helpful, but we have yet to establish clearly at what dosage for who who should be doing it, what training do they need? And it's the wild wild west. >> Yeah. >> Today. And um so in theory, I don't have a problem with it if it's done properly. But you know, there are patients of mine that you know, they want to try ketamine because they heard it's a nice thing to do >> and they end up in a horrific place, let alone some of the other psychedelics that are out there. Again, I'm not questioning that there that there are benefits to them, >> right? >> But it needs to be studied. It needs to be done properly by people that are trained. And I'm not talking about the drug companies having control over it, >> right? >> Um that's a whole other sugia. Um but we want to make sure that we're not hurting people more. And you know, there's this sugia of taking advantage of people that are struggling or people that have kids that are struggling. You know, I'm afraid that a lot of these centers that open up that are doing illegal things, I mean, psychedelics are illegal in most states. >> You know, there's a bit of taking advantage of of patients. And I've seen that with some of my patients that have, you know, kind of gone to some of these IV ketamine centers and they walk in and they BS their way through the questionnaire and they have a BS screening um and and some of them have very bad outcomes. >> Yeah. And why do you think people are running to these places? Are they running away from themselves? Are we coming back to the same idea of uh people not being fulfilled and not being content? And I'm not talking about mental illness. I'm just talking people who experiment these things for recreation or for other reasons. >> I I would be careful to give kind of one explanation. Um I think there are some people that are curious. >> Mhm. [clears throat] >> Um I think there are some people that are escaping from life. >> People escape from life in lots of ways. Sometimes it's drugs, sometimes it's the internet. I mean, you know, it's uh there are lots of escapes and there are some that are more dangerous than other >> escapes. Let me ask you a question about um psychiatric hospitals, mental health institutions. Um when does a person know that it's time to admit somebody to a mental health institution? And is it bad? Is it a scary place? Can you walk us through what is really happening in a mental institution and is the patient benefiting the of it immensely? >> So the general rule is that we like to treat someone in the least restrictive environment. When I went into the field um 30 years ago, my supervisors were telling me about, you know, the heyday, the golden days of psychiatry when people would go into the hospital for a few months and have intense therapy every day and um they would come out different when >> you're talking about talking therapy. You're talking about because all the you what supposedly what they're doing is they're just giving medication. So, it's different today, but but back then, >> um, people would go in, you know, medication back then wasn't what it is today. >> And people would go in and have a lot of therapy and, um, and they had time, >> but they used to be locked in, though. >> So, not always. >> It was a volunteer type of thing. >> Yeah. Yeah. And, um, there were some units that were open, kind of like a country club type of setting. >> Um, and um, and they had time to really get better. When I went into the field, the beginning of managed care and you know my supervisors were were complaining that people were in the hospital just for you know a couple of weeks until we stabilize them with medication and we're doing some therapy. Today um hospitalization is primarily when someone is a danger to themselves or others for rapid medication stabilization >> and then they get discharged to uh if relevant to um a more intensive outpatient program >> and they kind of step down eventually back to regular treatments in the in the community. So, um, you know, there's not necessarily a lot of therapy happening today. I mean, I haven't worked on an inpatient psychiatric unit in decades. So, but I hear from the rare patients that I have to send into the hospital, uh, it's usually not a very pleasant experience. It's usually locked in today. Um, the insurance companies will only approve [snorts] if a person really, really needs to be there. What is the average length of a patient usually? >> I I don't know since I don't work in that setting anymore. Um I can tell you from my rare patient that goes into the hospital, it's usually just a few days unless someone is really very very sick. >> Um then sometimes it can be a few weeks. I mean the um by definition um regular hospitalization is until 30 days. if someone needs to be in the hospital beyond that then um the way it used to be and I presume it's still the same in New York is that uh they get transferred to a state hospital for what's called longerterm care >> right >> um >> so when do you find that you need to send the patient then is when a person refuses to take medication or a person thinks that I don't need it when is when is the appropriate time >> if a person is a danger to themselves or others now you know a danger to themselves ves can be not being able to take care of themselves, >> right? If they can't meet their basic needs, >> um that could potentially be a reason to send them to the hospital, but it has to be very very clear. If someone is very aggressive to themselves or to others, someone is threatening suicide, that's another reason, >> right? >> Right. >> Um but uh it's quite limited today. It's not it's not easy to hospitalize someone and there a person can go into the hospital voluntarily even today. Mhm. >> Um or they can be forced in involuntarily. There are different uh legal mechanisms with which to do that. >> Um but it's not done uh lightly. It's it really takes a lot of [snorts] careful deliberation before sending someone to the hospital. >> Right. And let me talk about um people with not such severe mental illnesses just anxiety and stuff like that. And there's these also these famous drugs that everybody knows about Xanax and Zoloft and this is for depression. These are fully functional people who are have families and their their lives are not, you know, that they run decent lives. But sometimes doctors, you know, the word on the street is that doctors push a lot of these medications. They push it on teenagers, they push it on kids, and they push it on adults also. You don't feel good here. Take a Xanax, Zoloft and and and stuff like that. What is your uh uh opinion about is it a temporary is it a long-term is it the sleep medicine >> ambient >> thrown around like uh you know so what's your opinion about those >> so let's talk about medication and the sio of medication in general yeah to help understand the answer >> so I'm going to tell you a tiny little secret as long as you promise not to keep it a secret >> okay >> and that's that with very rare exception not just in psychiatry but But in the entire field of medicine, medicines don't fix problem. >> They alleviate. Meaning everything is a glorified Tylenol. When you take it, it helps. >> When you stop taking it, unless you changed something, the problem's going to come right back. So, if we have someone that has uh someone who's overweight and they have diabetes and they have high blood pressure and they have, you know, all the typical problems, they have high cholesterol, the problems that typically go along with being very overweight. Um, so let's say we put them on blood pressure pills. >> Well, okay. So, let's hope the medication works. >> Yeah. >> And if what happens if they go off the medicine? Well, unless they, you know, lost weight and change the way that they eat and follow the instructions that they were given and that they worked, if you stop the medication, the blood pressure is just going to shoot right back up again. Uh, it's the same thing with psychiatric >> uh disorders. Um so we have to be reasonable and realistic in our expectations of the role of medications. So um if you take a look for example at anxiety disorders the research is pretty clear. There's a modality of therapy called cognitive behavior therapy. Cognitive behavior therapy whether it's OCD or whether it's uh you know some of the other some of the forms of anxiety um is quite effective. Cognitive behavior therapy teaches the person how to manage the symptoms on their own and it can be equally effective to medication depending on the disorder. So takes a little bit longer to work than medication. But the standard of care is not necessarily to give someone a medicine for anxiety. So then okay. So then when do we give medicine for anxiety? So the research shows that even though medication and therapy in that circumstance are equally effective, you get a much more robust response when you do both. >> Okay? So doesn't mean I have to give medicine, >> right? So if someone is able to function and they're able to participate in the therapy, go for therapy first, >> right? >> But that means you have to see a proper licensed trained therapist. Um, and you actually have to do you have to do what the therapist is telling you. It's like taking a course CBT. Um so if a person isn't able to function or the therapy isn't working because their symptoms are so severe for example or they just may not be a cliche laabell for for the therapy to work for them. Those are circumstances in which we'll give the medicine >> but we're always looking. >> It's not it's like an elevator. It doesn't just go up. >> Yeah. >> It's also supposed to come down in many people >> and uh and a lot of practitioners forget that. Mhm. >> Um so medicine is not supposed to be given out like candy. I think there is a lot of irresponsible prescribing um by lots of doctors unfortunately. Um you know there are diagnoses where you know schizophrenia requires medicine >> right? >> ADHD requires medicine especially in kids. Um are there modalities of therapy that can be helpful for certain disorders? Sure. Someone with bipolar disorder needs medication, >> right? >> But um it's usually not just medication. There are other things that go in and there are times when we can go down with medicine. Um sleeping medications in particular can be addicting. >> Um I can tell you that I can count on one hand the number of patients that I've prescribed ambient or similar medications for. I do not prescribe them. Also things like Xanax, I very rarely have to prescribe them. >> Well, this is torture not to be able to sleep to to twist. >> People I help people to sleep it with things that aren't addicted. >> Mhm. >> I had a supervisor in residency, God bless his soul, um who would tell me, you know, when you start your practice, make sure you give patients Xanax because they're going to have to come back. And I said to him, my patients are going to come back without me putting them on Xanax. Um, you know, the the name of the game is to help patients, not to get them hooked, >> right? >> And um, to this day, I'm not sure if he was serious or joking. He was a big joker. I hope he was joking. >> Yeah. Yeah. But >> it's harsh. >> Yeah. It's it's more than harsh. It's actually unethical. >> It's destructive. Yeah. >> Yeah. >> Now, let me let's talk about stigma. Stigma in the community probably coming down. It's coming down a little bit, but I wonder if you can eradicate this thing completely. I was just talking to another person who has a therapy center in Brooklyn and he was saying that uh even when you come into these offices, you have these little cubicles with these curtains and you hide the people. You're actually uh showing them that there's something to to be hidden here. It's a secret in it. And he's trying to do an open floor plan. Everybody comes in. We're all here. What's going on? This is nothing. So it would be beautiful in a perfect world to get rid of the stigma, the shame and there is so many people suffering in silence and and and nobody wants to talk about it. It's like the elephant in the room. But when it comes to shadik, especially in our community, it's very very tough. And why it's tough is also was what you described in the beginning you were saying about that this is in the genes family history. And what do you expect from people? They're petrified and they're trying to make all the research in the world although nobody knows anyway and nobody's stronger than the bunch of them. And if you end up in one place and then you end up you end up there because this is how it's meant to be and this was your journey in life. But to remove the stigma and to and when you're dating, you don't even know if a person goes out and they're dating, you have no idea what their family history is. What is your opinion? How would you improve? What is your two cents when it comes to stigma and and how should one go about it? So there's been a clear movement in the right direction when it comes to stigma. um there's a much greater acceptance sometimes even too much there areim that you know if if you ask the hala you know 98% of the kids have ADHD because they send so many kids for evaluations and treatment >> and they forget that kids aren't necessarily meant to be sitting they aren't meant to be sitting like robots all day >> right >> um but there's been a clear improvement. It's not something that's going to happen overnight. We have to continue to very very slowly chip away um and help people understand that even though psychiatric disorders present differently than most medical conditions, they're just as physical. Um the shik business is a whole other suga and it's a pet peeve of mine. Um, let's leave aside the hik right >> part because I'm not a rabbi, >> but there's a lot of game playing when it comes to shidim. And you know, I have a patient that just sold his car. I actually just sold my car >> as well. I got into a different car. And the my patient told me that you know he had this car and he had a Shila he was selling it to Carvana whether he could tell them that you know it has transmission problems or not and he asked RV and Isra showed him the gum and he said no you have to be open you know just because you're selling to a you still have to be straight okay is not selling a used car And it is on many levels problematic to not be open. Um, and I think the message we're giving our kids is so horrible. our kids that suffer with mental illness. You know, I I have multiple times a week when I am on the phone for call, whether it's about one of my patients that's in shim or whether it's speaking to a shad or a RV who wants to clarify the implications of a certain diagnosis potentially on a person's ability to live life. as it pertains to. And what we're forgetting here is that we're taking our child and we're trying to help facilitate, if not arrange, the single most important relationship that they're ever going to have in their life. God willing, just once gonna happen to get married and should be it should be wonderful and last until 120, but we're doing it in a disingenuous way. So, we're we're we're taking this very important relationship and we're building it on a foundation of sheer when we're not open. That's a even worse than that is what's the message we're giving the kid >> here we have someone who if they're going into vast majority of the time they're stable or it's as good as it's going to get. We'll put it like that. >> Right. And so if they're seeing me about it, then they're on medication and they've very likely been in therapy and they've fought through and they've built a life and they're recovered to a certain degree. And when the parents aren't open, what are we telling them? Are we reinforcing the the sticker that says you're defective? >> Okay. what are we what are we doing? You know, I when I have these conversations about shidim so when I speak to the other person many times they don't know what to ask. Um and I treat it like a deposition. You know, I have to say the truth and I answer what they ask and I don't help them. Mhm. >> Um, and they'll say to me, well, if it was your kid, and I'll say to them, you know, first of all, I can't answer that because my frame of reference is very, very different than yours. >> It takes a lot to get me excited. And um but you know when we marry our kids off they are at the highest risk time for in theory statistically for you know having bipolar disorder come out for having schizophrenia come out. We're we don't know where they're going to end up. we don't know all of the you know not everything has come out yet >> right >> and we're we're you know going to go ahead start life I said we don't know what the genetics are we can't control for them you think you know the family history many times you don't and even if there's nothing in the family it can still come out >> I also do >> but what do we know I say and I I tell people you know you can divide the world up into two categories there are those that take care of their problems and those that don't. And if if I'm on the phone here, you see that this is a kid who comes from a family that doesn't ignore their problems. Something comes up, they go for help, and they take care of it, and they're being open and transparent about it. I said, "Most of the time, 20, 18, 19, 22, 23, whichever community you're looking at, you don't know much about them yet. They're not tested by life. >> These kids are tested and the vast majority are coming through bumps and bruises, but they're showing that they take care of business. They can handle adversity." And there's something to be said about that. But we have to be careful about the message that we give >> to the to the children to the children. Let me ask you a question. Should the parents of course I understand what you're saying that um the support and the validation and understanding that this is nothing more like you call it a physical problem because physical is accepted by us. >> Well, it depends. Some things yes some things no. >> There are physical problems that people hide. >> Sure. Also >> sure >> yeah but normally if someone wears a cast nothing is you're good but I understand the support part but what do you feel about sharing it before a if someone knows that there's something something going on with the child this is a child's history should they share so that's a shila um and I encourage people if they come from a background in which it's relevant to speak to their love Um I can tell you what the usual answer is. The usual answer um that I hear back is you know at date number three at date number four to say something >> to say something. >> Now there are those that you know someone that has a severe mental illness >> someone with schizophrenia. So that's already a different right. So there there are that deal with more challenging >> um and there it's wise to be open because if not you know the person goes out and they say you know they go out and maybe it goes well and then they keep getting rejected because it's not oh I have anxiety which is one thing if the world is on Zoloft today >> um it's I have schizophrenia people are like oh my god is and they should react >> um >> um in a in a measured reasonable way um so the more serious ious illnesses, I think it's probably wise to be more uh more open about it. But um again, it's it's usually if it's appropriate from where the person's coming from, it's usually a good conversation to have with one's r. And then there's um you know, even when people say there's the problem that they're not so transparent about it. though it's well you know I'm selling the car as is >> you know and your headache if there's a problem we don't do that with our kids >> um >> now as far as a as a from a doctor's point of view would you uh recommend that two people a boy and a girl that is one is suffering from schizophrenia and one is suffering from borderline should you have a special shot that is going to put just like you put two physical problems together a lot of times you see that should they do this in mental health as well so it's interesting this comes up frequently um and I think a lot of times what people try to do is to take someone with a certain medical condition and someone that has a psychiatric condition and put them together but we have to be very mindful about something there's always a concern bad. Well, if I take two people that have the same diagnosis, the same psychiatric diagnosis, well, that means that their kids are going to be I mean, oh my god, right? >> So, statistics are not >> statistics mean that if I take a thousand people, the numbers are going to play out a certain way. You need huge numbers, right? Um you know I have five biological kids and two stepkids. Okay the six boys and one girl. I according to statistics it should be three and a half and three and a half or three and four. >> Okay. So if I had a thousand kids then it would be 500 and 500 you know >> right? Um so you got to be careful um because we you know most of the time even you know the largest of families that I've seen you know 14 kids 16 kids I've heard about 20 21 kids >> but we all need to cool it when it comes to the statistics you know um you know it requires an individual conversation about looking at this family and that family and how much of the problem seems to be there. Um, and you know, there needs to be an educated uh conversation that's had, but it's not an automatic no. >> And people have to stop making that the most important thing. There's still the midot of the boy and the girl and the families and whether they mix or not. >> Um, there are so many factors, but you know, people just get fixated on this and sometimes it's worthy of being fixated on, but many times it isn't. Just like some medical conditions are worthy of being fixated on and some are less of an issue. >> Wow. What message do you have for parents who are afraid to give medication to their kids? They're afraid of the side effects. They're afraid of the growth of the child. They just so against it with such a passion that is beyond yours. I prefer to work with individuals and parents that are hesitant to give medicine than those that think that the solution to every problem lies in a pill model. >> I think that uh every time a prescription is written, it needs to be done thoughtfully. I think there are lots of instances where medications are overprescribed >> and people should be extremely cautious just like they're cautious with everything else in medicine you need to you need to question you know do I need to give this medicine or that medicine also in the field of psychiatry but if it makes sense then sometimes you got to do what you got to do you know our job I I tell parents all the time. You know, our job as parents across every culture across every religion just about is you're given this beautiful little presence and it's your job to turn that beautiful presence into a productive member of society. The definition of productive member of society varies from culture to culture, but that's our job. And there are different impediments that come up across the way along the way. And it's our job to deal with them. And there are some kids that will need extra tutoring and some kids that will need uh you know leg braces and some kids that need physical therapy and there are some kids that need psychotherapy and some kids that need medication. And failing to do so if it's warranted has staggering implications. you know, we we don't prescribe so easily, at least not in the psychiatric world. We're not supposed to. And people always have to ask themselves. What are the risks versus the benefits versus the cost of doing nothing? >> Right? >> So, if we talk about ADHD very quickly in a kid, so we know that very young kids between the ages of three and five, that in some of those kids, very intense behavior therapy can be very, very effective for ADHD. But after that, if you're not giving them medication, you're really doing them a disservice if they really have ADHD. Not every kid that struggles with their learning or that has a hard time sitting or that has behavior issues has ADHD. That's we come back to the importance of a diagnosis, right, >> and the right label. But if the diagnosis is done by someone who's qualified to make the diagnosis and it's done properly, then not giving the kid medicine for ADHD is absolutely positively doing them a tremendous disservice. Uh, you know, they have higher rates of addiction. Doctors like me see, you know, kids having much higher rates of going off the derek. It's heartbreaking. It's heartbreaking. >> You know, kids that with ADHD um in very from or frim settings, especially the boys, you know, they if they're not able to learn well, eventually it really, you know, playing sports goes so goes so far. So if you're not able to learn well and you're having bad experiences with your rebum and your manal, well, why would you want to be interested in Judaism? Why would you want I mean it's like pushing them off with both hands like you know here you go >> are checking out. >> So it it's really really horrific when that happens and parents will bring me their kids you know they're teenagers and they're not interested and you know they're on the streets and you know I can try but it's so hard at that point because they're so turned off. Um you know it's our job as parents. It's not about us and you know that involves getting you know if a kid's struggling figuring it out figuring out what it is and addressing it and if you think that this doctor is nuts because he wants to write a prescription go for another opinion. Talk to your pediatrician about it. That's the job of the pediatrician. Your pediatrician is your partner in raising your kid. And they're >> they're they they're a jack of all trades, a master of some things. Psychiatric medication is not one of them. >> But at least take their advice. >> They know what's reasonable and what isn't. And if you have legitimate questions, go for another opinion. >> Wow. >> But don't just ignore stuff. >> Dr. Isami, you are a guide. You are a lifeline to teens, to children, and to families and individuals. You're getting through people in their darkest times, which is an amazing amazing thing. May the continue to give you clarity to give you and to be a messenger that's your in this world and you give hope to thank you and I wanted to give you a braha that eventually the podcast is going to turn from being called the struggle to being called the solution. >> Excellent. >> May you have tremendous ongoing sata desaya. Thank you. >> You're doing >> Thank you. Thank you. I really appreciate your time and thank you for coming.