WMH Season 2, Ep 5: Mental Health Treatment for Lifelong Psychiatric Conditions

This is a transcript of Watching Mental Health Season 2, Episode 5 with Dr. Sid Khurana which you can watch and listen to here:

Katie Waechter: Hi everyone. Welcome to another episode of Watching Mental Health, and I am really excited because today's guest is somebody who has been doing amazing work here in the space in Nevada, and I'm just so excited to have somebody of his expertise coming on board and to have a good conversation with us. And so I'm going to give you a little bit of a background. This is Dr. Sid Khurana, and he's a double board certified in adult and child adolescent psychiatry, excuse me, with the American Board of Psychiatry and Neurology and the managing partner for Nevada Mental Health.

So we'll talk a little bit about that as well. He specializes in the diagnosis and treatment of lifelong psychiatric conditions that typically have an onset in childhood, things like autism, ADHD, pediatric bipolar disorder, as well as other anxiety and mood disorders. He has extensive experience in treating neurodevelopmental conditions like FAS as well as trauma and stressor related disorders. And he prefers to optimize treatment using psychotherapy, pharmacology, complimentary integrative medicine, as well as holistic and lifestyle modifications, which I really like. He really wants to do a comprehensive treatment, I think of emotional and psychiatric conditions and I think that that's important. And so without further ado, let's bring on Dr. Sid Khurana and have him tell us a little bit more about himself. Hi, Dr. Ana, thank you so much for being here with us today.

Dr. Sid Khurana: Hi Katie. Thank you for having me. Happy to be here!

Katie: Well gave your basic background, but I want you to tell me in your own words who you are and what brought you here.

Dr. Sid: Well, I first want to say I am a human being and I am a husband and a father, and I think all those characteristics humanizes us. So I'm just a human being who fulfills the role of being a psychiatrist in my professional life. I'm originally from India and I have did my med school there and my residency and fellowship both were at University of Virginia UVA. Prior to that I did master's in behavioral science and been in Las Vegas now going on about more than 11 years.

Katie: Wow, that's great. So what brought you to Las Vegas?

Dr. Sid: I could not believe when it was said that it is really a desert and it's a desert of professionals that Nevada consistently ranked in the last three in mental health rackings in the country. So Nevada was 51st, 49th, 50th in the country and it was really, really vastly underserved and I really wanted to be in a community where I can make a difference.

Katie: Wow. Well, I think you picked a community where you can make a difference because you're right, we consistently struggle and we need professionals. We need people like yourself who are willing to come into the space and we don't see a lot of that unless people are practicing the residency here. So I think that that's really interesting and commendable that you chose a community that has so much need because it's important to go where that is. So I think that's wonderful.

Dr. Sid: Well, I appreciate that. Thank you. And really, we have not looked back at our decision. My wife and I, we are very happy that we chose Vegas, Las Vegas to be home. This is a wonderful community to live in and have children, and yet another reason why we want to do the best we can to raise the level of the bar of mental health because this is home.

Katie: Yeah, absolutely. Yeah, Las Vegas is so much to offer, and so we do need to raise the bar of mental health and healthcare in general and education so that way we can keep, I think people wanting to have their families here. So I just love to hear you say that I'm a local born and raised, so I'm always going to be a proponent for Las Vegas, so that's awesome. But tell me more about why you started to practice mental health, what brought you down that journey? Because you do have a lot of education in the space, and so you really did commit to this path. So tell me why you chose to go on this path.

Dr. Sid: So like most psychiatrists, it's a long journey. You finish very difficult medical school and then you choose your career path. And I was torn whether I want to be in surgery or in mental health. And I started out in surgery and realized that making relationships and making a meaningful connection with people was missing in that. That is something I really, really wanted in my professional life and which is where I pivoted and I switched into psychiatry training and then that explained why I wanted to do general psychiatry and then working with children and families was a passion. So I wanted to do child and adolescent psychiatry and having done child and adolescent psychiatry, I would say that has made me not only a child and adolescent psychiatrist, but also a better adult psychiatrist because I can things from a developmental framework, from a cultural framework, and that is what helps child psychiatrists as a community, we see people from the family systems and not just view things from a medication non-medication standpoint. We want to look at the whole picture and then treat the whole picture rather than just one to one piece of the puzzle.

Katie: Yeah, that's so interesting that you really do look at it from the childhood going into adulthood. So you treat both is really what it seems. And do you treat people all the way through? If they come to you as a child, you really stick with them through all the way until they're adults?

Dr. Sid: Yeah. Some of my patients now were teenagers and have now grown up and have kids of their own and they're still under my care. So the idea is to be able to maintain that continuity of that psychiatrist patient relationship.

Katie: Yeah, so that's interesting. So I'm interested in your answer to this question. So do you think that a mental health challenge or a diagnosis is something that someone can overcome and just be done with? Or is it something that is lifelong that they really do need to have consistent treatment? And does it vary based off the diagnosis?

Dr. Sid: No, you're correct. There is no one answer that fits all. It depends upon what the condition or what the diagnosis is. Some conditions can be a single episode kind of thing so people can be depressed and they can have a single episode of depression and whether they were genetically predisposed or stressed came on and they got depressed, it got treated, they're better and hopefully it never comes back again. So it was like an infection that you had that you never get back again versus for some conditions they become lifelong conditions. But that doesn't mean that every single day you are struggling with it. They're episodic but lifelong. So you will have an episode and then you are better and you could live a very functional productive life for many months or years until another episode comes. And then you do what it takes to get the train back on track and then you keep going.

So there is a difference between a lifelong but episodic condition, a onetime one episode condition or a lifelong but everyday condition. An example would be bipolar disorder. That's a lifelong condition. People don't grow out of their bipolar disorder. You have a bipolar disorder for life. You might not have another relapse or a episode of manic episode or a depressive episode for a while, but you have that condition and in between when you are, we call it in between episodes or inter episode, you just look, feel and talk like anybody else out there. So you're okay. Whereas you might have a lifelong condition like a DHD every day you have A-D-H-D-A-D-H-D is a lifelong non episodic condition. So every day you wake up and you have a DHD treated or untreated is a whole different issue, whereas bipolar is a lifelong but episodic condition. I hope that makes sense.

Katie: Yeah, that does. Thank you. That's a really good explanation, and correct me if I'm wrong, but it seems like people who have lifelong episodic conditions such as bipolar disorder, maybe they struggle a little more with maintaining treatment because there's times where they feel like they're healthy and then they're like, I don't need to do these things anymore, whatever this treatment is, and it kind of cycles them back in. Have you seen that or is that just myth?

Dr. Sid: No, that's a very common observation when especially the farther away you go from that trigger event trigger episode. So let's say you had a manic or a depressive episode, six months, one year, fast forward, you're doing really well. It's just very human and very natural to think, I think I overcome this. I think I'm okay, doc. I don't want to be in my therapy. I don't want to be on medications. I think I have overcome the struggle I had, so it makes complete sense. I've sit down with my patient and say, I get it where you're coming from that you have not had any struggles in the last two years. But the nature of the condition is that if you truly have a bipolar disorder, it's not a question of if it's a question of when that next episode will come. And again, that will change upon person to person and the severity of their pathology, how bad the next one could be. But the idea is just like having a seizure disorder, once your brain knows how to seize it finds it easier next time to seize.

Same thing as being manic or psychotic, once your brain knows how to be manic or how to be psychotic next time will be easier to get there and the time after that will be even easier. We call it the kindling mechanism in the brain. So we really, our goal with our patients with bipolar disorder or psychotic patients is not to let the next episode happen because the episode after that would even be more easier to happen. So yes, I completely come get where the patients come from and that's where we sit down with our patients and work, put our heads together eventually. It's not my decision, it's my patient's decision, it's their life, how they want to approach ongoing treatment.

Katie: Yeah, absolutely. And like you said at the beginning, I think a lot of it does have to do with diagnosis. And I'm sorry, don't mind my cat, I should have moved her. She's moving, but

Dr. Sid: She was interested in listening, so she wanted to be here.

Katie: Exactly. Yeah, she's involved. So hopefully she settles down. But the more common conditions like depression and anxiety, it seems like there are some people who have major depressive disorder, they have MDD and that's episodic. I've seen that. And they'll be okay for a while and then it hits them. Whereas other people, it seems like really maybe somebody just died in their life, they just went through a divorce, something really bad just happened and they're having a really natural response to a life event and that is depression. So can you just talk more about that and about what treatment really should be for either one of those? Do you need long-term medication for either? So just talk more about that episodic versus one time.

Dr. Sid: Yeah, yeah. Well, even the one time there are, like you said, there are real life things that happen. People get divorced, people lose loved ones, and grief or bereavement is a physiological state. It's not a pathological state. It is okay to miss the loved one that you lost. It's okay to even have a sad mood associated with that, right? That necessarily doesn't make one have a episode of depression. But some people from there on, so think about them going through grief or them going through bereavement, but there is a fine line where then that bereavement gets either prolonged or complicated and then that stress of that loss or the stress of divorce or it's a loss that can trigger on beyond the grief and bereavement can trigger on an episode of depression. So the key there lies in first distinguishing is this normal grief and bereavement.

This is what we would expect most people of that age, that gender, that culture to be going through in the context of adversity they're facing. And if it's, it is completely healthy and physiological and the medical model should stay out of it, that has got nothing to do with a therapist or a psychiatrist. The family, the individual, the family, the community comes together and takes care of those things. And that's where in the context of divorce, you have the support of the loved ones in the case of a loss of a loved one. You have people visit, people talk about it, people say what happened. That's their way of processing that loss, coming to terms with that loss, accepting that loss. And then you move on and you go to work after that and you take care of your children and you sleep and hopefully you still exercise and you don't self-medicate by drinking, smoking. And that is called a normal grief reaction. Whereas fast forward 2, 4, 5 weeks from that event and you are still not sleeping, you're still not eating and you're not taking care of yourself, you're not taking care of the little ones and you are questioning your own existence. Now you start to think has the grief entering into a depressed world and we need to then depending upon whether it's full depression or not, intervene appropriately.

Katie: Okay. That's really insightful. I think that's important for people to know that sometimes we can experience depression and extreme sadness and grief like you're saying, and that is normal because life can be hard, but it's when it becomes long-term extensive where it's really inhibiting and getting into our daily lives and really affecting our quality of life. So that's so valuable.

Dr. Sid: Being sad and having depression are not the same things. Being sad is an emotion that we all are sad at times. We all are angry, we are all are happy. Those are all the normal different emotions we experience in regards to the context of what's going on in life. And I think just like sometimes people will take a questionnaire online, have you ever been angry? Have you ever slept less than usual? If the answer is yes, you have bipolar disorder, not true, just because you've been angry and you've slept less does not mean you're bipolar disorder. Just because you've been sad does not mean you have depression.

Katie: Right, right. And that's important to know. So let's talk about treatments a little bit and let's talk about treatments for long-term psychiatric conditions versus maybe somebody who maybe more of a short-term experience. And your experience is I think, or your expertise is really in long-term psychiatric conditions. And I love that your bio really mentioned that you take a holistic approach to treatment. It's not just about medication it and it's not just about talk therapy. There's so much more that can be involved. So tell me more about what does treatment look like? And I know it looks different for everyone, but just maybe give some common modalities.

Dr. Sid: Yeah, the idea here is that meds for sure are not the only way to go about mental health treatment. And actually it's not just mental health. Even when you look at diabetes management, your insulin is not the answer to managing diabetes. We know it's the psychology of everything is very, very important. So when you go back to mental health, it is taking the individual, the family, the culture, the community, they come in, all those factors are very important and making a thorough conceptualization of what we think is going on, what's important to that individual that you're treating. And then meds are a piece of the pie. They're not the pie. And many times as psychiatrists, I would recommend my patients, I don't think a medication is needed in this context. I'm not trying to say you don't have a struggle or don't have a problem here, but meds are not the problem, a solution to every problem.

And for sure, we do not have a medication for every symptom somebody experiences. So now we have to put in the work and the work comes from social support, from psychotherapy, and then doing the other holistic things like the grandma would have said, I want you to go for a walk. I want you to exercise, want you to eat healthy. Your nutrition is very important. Exercise is very important. There's a recent meta analysis that shows that really the effect size of exercise as an antidepressant is just as much if not more than any antidepressant. So really if you are depressed, rather than trying to choose which antidepressant you should be on before you get that start to exercise and you will start to feel better. Now, it's easier said than done. It's very, very hard for people who are depressed to go get to exercise.

And that's where engaging in therapy, having their family support, maybe being on meds puts you in that position that now you can start to make those healthier lifestyle choices start to eat healthy. And that can make a big difference. Another thing I want to say is a controversial or a topic that comes in, what about complimentary medicine? What about supplements? Where do I fit those in, into mentalized treatment? And I think they have a place, it's not that they do not have a seat at the table and they are not the entire table. They have a time and place in everybody's treatment. We just need to figure out what agents for which condition for which patient. So I think we should be, as mental health practitioners, we should be open to the research that sometimes is unconventional, that doesn't fit the rigor of what we are known to think of in the pharmacological model, but to be receptive that if our patients do find a value in that modality of treatment, that we keep ourselves critically appraised of what's going on and involve that, incorporate that into the treatment as much as possible.

Katie: Absolutely. That's so important. And I love your analogy of the table. They all should have a place at the table. Anything new that comes up, I feel like if there's valid research and people are saying that it's helpful, let's bring a chair over and see if it does have a place, if it can fit at the table. Because people are really struggling so much, and it's hard. And people ask me, I'm an advocate in this space, and people have asked me, well, we talk about it more now. Well, why doesn't that help? More people are getting help now. Well, why are our rates still so high? Why are people still struggling so much? And it's hard to answer that. So what is your thought on that?

Dr. Sid: Well, absolutely, like you said, I think we need to the medical community, our job is to keep ourselves informed of what are the most recent changes in evidence, what's the new studies telling us? And we need to bring that information to our communities, to our patients at least giving them the information and using our experience to help conceptualize that information, put it into a context so that our patients can make some informed decisions. For example, thinking for treatment of psychiatric conditions, thinking beyond the pills and therapy, thinking of what research has shown us in the last 10 to 20 years. So interventional psychiatry is the new buzzword. So TMS, transcranial magnetic stimulation, absolutely a very strong evidence-based treatment for people who have treatment resistant depression, they've taken two or three different type of meds and they're still depressed. They've done talk therapy and they're still depressed.

Rather than trying the same approach in a different way, again and again, we now need to switch direction and say, you've exercised, you've taken the medications, you've done therapy, and you're not getting better. Instead of making your depression more treatment resistant by doing the same things that have not worked again and again, I need to change direction and I think I'm going to refer you to TMS transcranial magnetic stimulation that is now evidence-based F fda, a approved treatment modality. Same thing for OCD. If OCD is not getting better, you can use tms. People can't quit smoking. You can use TMS for that. So TMS is another non-invasive. You're not going to get injections, you're not need to go under anesthesia. You just sit in a chair, have a helmet over your head, and it changes the magnetic field, which changes the electricity in the brain.

Our brain is an electric organ, electricity is the language of the brain. So once through the change in the magnetic field, you can change how the neurons connect. That gets people better. So that's again, no side effects. You don't have to be taking medications all the time. And that's one way. There are other interventional, newer treatments that are out there that we need to be open-minded about critically appraised their evidence, are they truly effective if they are for what kind of patients? And as psychiatrists, our job is then to incorporate those discussions in our visits, in our sessions, so our community, our patients have that information available that it can be one of the things they could consider to choose.

Katie: Yeah, definitely. I mean, I think knowledge is power, and so the more that we know, the more we understand another treatment that's become more popular. I think just in the last maybe five years or so is psychedelic treatment. I know research has been going on on that, but I think people are now going out in the world and declaring themselves shamans and saying that they can guide people through. And so do you have any thoughts on psychedelic research and on where that's going?

Dr. Sid: Yeah, so my thoughts are only on research, not on practice because none of them have been cleared for mainstream clinical use. But from a research standpoint, we are excited about that. We are excited about the possibility. We understand that this is a complicated topic. It can have some very strong opinions from people who are for or against it, both from the general community as well as the physician scientific community as well. But what I would say is as a student of science, I am open to knowing, I'm open to what the research is going to tell us. And so far what we do know is ketamine, which is in a way a type of a psychedelic medication. Is FDA approved now for treatment resistant depression? It is FDA approved for acutely suicidal conditions. So if somebody's having acute suicidal ideation, they can get a course of ketamine that can help pull them out of it.

And psychedelics have been shown to be effective treatments in the research studies for depression and PTSD. But now the idea here is it's not just the psychedelic, it's the implementation of the whole treatment program that is effective. Those treatments are administered in a clinical therapeutic setting. While you are under the influence of that medication, you are getting trauma therapy or other modalities of effective psychotherapies that are helping broaden your perspectives. That is how psychedelics, that's how we think the psychedelics are work. So they increase neuroplasticity of the brain, ability of the brain to widen the perspectives. And it's very, very important that we use those windows when the treatment is in physiologically in our system that with the help of an expert psychotherapist help widen that perspective. And that's where we believe the research is showing us. And my caution to the psychiatric community is that we do due diligence in the practice of once they are cleared for use, that we stay true to what the research showed us, and we practice in that in a way of integrity.

Katie: Absolutely. Absolutely. That's so interesting. Yeah, we'll see where it goes. But I've heard really promising results from the research. You said that at the beginning that you were from India originally. So can you talk a little bit about maybe cultural differences in the treatment of these conditions that you're treating regularly?

Dr. Sid: Yeah, absolutely. You are looking at big cultural and societal differences. United States the most advanced nation in the world, but at the same time, culturally, there is a difference between a collectivistic society versus an individualistic society. Whereas in some other parts of the world or where I come from, if something is not going right, you have the entire neighborhood right there willing and able to help. It's a very socialistic, collectivistic social model. Whereas here, life is much more fast paced. My life is much more industrialized, much more busy, more individualistic. And still there are many people who have a lot of good social support either through neighborhoods, through their churches or other platforms, but many don't. And I think we have to account for that. On the flip side, in that culture, in the Indian culture still, there is a lot of stigma about mental health. And I think United States here, the western world has done a better job in accepting, there is stigma still. And like you said, that's your mission here. You're bringing more research, you're breaking down barriers, you're breaking the stigmas, but there is stigma. It's less. So I think there are some offsetting contingencies in the treatments in the two different meta cultures of the world.

Katie: Yeah, yeah. That's so interesting to me because I think you're right. In the states, we're more culturally I think, accepting of conditions like A DHD or autism, but we really struggle. I think because we're so fast paced and we're so individualized, we're so focused on ourselves, we struggle with things like stress and with daily depression and anxiety. Whereas I think there's maybe more of a culture of support around those things, and people don't struggle as much in those ways. But the people who maybe do have more intense conditions, they maybe get less help. Is that kind of the case?

Dr. Sid: Yeah, that is the case. You will go and talk to psychiatrists there who will say their outpatient clinics are full. But then when you go and ask general people out there, how many people do you know who have depression, they'll say, I don't know anybody who has depression. So people don't talk about it. They probably will say they know more people who have ended their life than they know people who struggle with depression, which tells us that they are not yet open to talking about it.

Katie: That's so interesting.

Dr. Sid: There's a barrier in openly saying it's very, very easy to say, I have diabetes, I have high blood pressure, but it's not very easy to say I have depression or anxiety or OCD. Whereas in this culture, I think we've made huge strides in that. I think we are seeing more and more acceptance. I don't think the job is done yet, but I think it's giving ourselves a pat on the back for things that have been positive, that we have done a good job in getting more awareness and more acceptance of mental health conditions. Just that if we can also incorporate more social supports into here, that can be a big relief, a big help for our patients who are struggling with the psychiatric conditions.

Katie: Yeah, absolutely. Just thank you so much. That was really insightful. So we have just a minute or so left, and I just want you to tell us a little bit more about Nevada Mental Health and with the services that Nevada Mental Health offers and how we can, if somebody's out there who's listening, who lives in Las Vegas and who maybe needs some help, how they can get in contact.

Dr. Sid: Yeah, we started Nevada Mental Health as our answer, our commitment to the community of where does my average fellow Nevadan, who has insurance, who does not have, who is neither indigent, not as very well off to be able to pay out of pocket, where do you get good mental health care? And our answer was, Nevada Mental Health is your place where you can use your insurance and you're going to get the care as if you were paying out of pocket for your insurance. So the key things are we don't double book appointments, everybody. The idea is it's not a place where you go get medications. Idea is it's a place where you go get good psychiatric care and medications and good psychiatric care are not synonymous. They're not the same thing. We spend time with our patients, we figure out what's going on and then decide our meds are part of the solution, or meds are not part of the solution, rather than trying to fix everything with a Prozac hammer. That is not what we do. So really the idea is come in and we will either refer you to therapy or if pharmacotherapy or medications are the answer, we'll do that. If TMS is the answer because we've tried already different meds, then we can do in-House TMS, but that would be your place for the entire family. We have psychiatrists who are board certified to see child and adolescents. We have psychiatrists who are board certified to see adults or geriatric population. So it's a OneStop shop for the whole family.

Katie: Yeah, that's amazing. And so needed, and you said insurance, is it all types of insurance? So anyone can give a call and

Dr. Sid: Anybody can just go to our website, Nevada mental health.com. They can just sign the registration form. And I would say 99% of the insurances that are here in this part of the country are accepted. So the vast chance that you have an insurance, we take that insurance and we will, I look at the audience and say, if you need to be seen within a few weeks, we'll make sure you get seen within a few weeks. So the answer is not that you have to wait with no depressed person, should have to wait three to four months to get sick.

Katie: Exactly. No, that's amazing. I know I've said it already, but it really is, and it's so needed. We're so needed. I know that a lot of people out there say that they struggle with finding somebody with access. There's wait lists. Organizations don't call them back. And so I think just to know that Nevada Mental Health is out there and is available and we'll answer the phone or call you back, I think is just so valuable. So thank you so much. Just

Dr. Sid: Fill out the form online and say, it doesn't matter how old you are, all ages, all insurances. And it is a promise to the community that we are not going to let the wait lists be the barrier of effective treatment.

Katie: Definitely. Definitely. Well, thank you so much for your time, Dr. Khurana. I just really appreciate you being here. This was such an insightful conversation and I am just really grateful that you took the time out today,

Dr. Sid: Katie, I appreciate you having me, and I really appreciate your passion for mental health. Please keep going strong.

Katie: Thank you. Thank you. And thank you to everyone. We are here every live, every first and third Wednesday of the month. But then catch all of our episodes at katierosewaechter.com afterwards. Thanks so much. Have a great day. Have a great 4th of July. We will see you all next time!