Dr. Ethan Levine

I’m Dr. Ethan Levine. Welcome to the latest edition of the Mental Wealth Podcast. And we’re delighted today to have as a guest, Dr. John Mazzullo. And Dr. Mazzullo, if you can give people just a brief background, because you have an interesting way in which you got to psychiatry.

Dr. John Mezzullo

Sure. I might just say that my dad probably put the seed in my head. When I was growing up, we had what was considered a glut of engineers in the country, and most of my friends’ parents were engineers, and they had been out of work almost half a decade to a decade. My dad used to sit with me. He’s really helpful and kind of got me thinking from a really young age. He recognized that I was the kind of kid that probably would want to work forever and I wasn’t the kind of person who would want to retire early. So he said, you need to pick something that would have longevity. It seemed that when we walked through town and saw the physicians’ offices and these folks were in their 60s, 70s, some working part-time in their 80s, it seemed like a good idea. That got shelved for. period of time. I went through typical kid things and went through bohemian phase and all that kind of stuff. And when it came back to professions, it seemed like medicine was a likely choice. Now, since I was a young kid, I volunteered at summer camps for handicapped individuals and mentally ill individuals. A really fine family, Jean Kennedy Smith and her family had a summer estate in our town. So all the kids in the community went there and they volunteered. So I was exposed to mental health very early on and really loved it. When I made the decision to apply in medical school, my primary thought was to go into mental health. And then I did surgery and medicines and the attendings were trying to talk me into becoming an orthopod or a cardiologist and all those things. And I found out that there was a discipline called the med psych that you can do extra years and train as an internal medicine physician and also as a psychiatrist. So that just seemed like the perfect opportunity for me or the perfect field. And when I came out, I was lucky enough to join a young group that was just starting. They wanted to become a multi-specialty group. So they let me do psychiatry, neurology, and I was one of the leads on the intensive care team. Did that scenario for a good 11 years. then was recruited out of there to help a hospitalist program in a major system that was struggling a little bit. And from there I decided I just wanted to do straight psych. So that’s where I met Ethan and we worked together and it was wonderful. One of the greatest experiences in mental health I ever had.

Dr. Ethan Levine

Well, Dr. Mishlo, one of the things I’m curious about is you’ve been, as I have, in the professional a long time. What do you think’s changed in psychiatry or mental health overall?

Dr. John Mezzullo

Very good question. I think, like most disciplines in medicine, I think the biggest change is the time pressure. When we started out, we had unlimited time. do an intake with a patient for two hours if we chose, and that would get covered. Now it’s really strict. If you can get 45 minutes, I mean, that’s also, there wasn’t a profound shortage of mental health workers then. So we’re put now in the position, folks like us with a lot of experience to be more mentors. and to be administrators and instructors in our time allowed with patients is significantly brief by comparison. Now, you and I love to spend time with patients, so we were able to cut out niches in our world that allows for that, but that’s very atypical of most programs. So we were very fortunate.

Dr. Ethan Levine

So for listeners wondering, do I go to a psychiatrist, go to a psychologist, how does that work and what made our working relationship different and better?

Dr. John Mezzullo

It really depends on the program, in all fairness, and I think that’s the biggest definer. I mean, some programs are highly social worker based. Some programs are highly primary care based. Some programs use psychiatrists and psychologists more as advisors and consultants, and then some programs use them as primary care. I think you and I had the fortunate scenario. It was an organization that was building and they were trying to figure a lot of things out. So you and I had the ability to design and decide what we were going to be in folks, what roles they would have. So I think you and I became really a hybrid of the field. became a whole from very different disciplines and very different experiences. When new patients came in, the first thing I would do is grab you and say, hey, let’s go interview this person together. I want to hear what you think from your point of view, your experience, and then I’ll share with you what I think and let’s come up with a real dynamic decision on how to approach this individual. And often we were out-of-the-box. I mean, we weren’t out of what would be considered standard approved care, but we modified things based on what we saw with the patients. I mean, sometimes we leaned into the patients, sometimes it was just emotional that they needed a friend or a family member or someone they could trust, especially the psychotic people. We were able to provide and lean in, be that friend, be that family member, let that patient feel human connection. And that was the most important thing. I thought with some of our psychotic patients, more than jumping on medicines, because those guys, if they trust the individual and they feel bonded to that individual, they’re going to respond.

Dr. Ethan Levine

What that speaks to me is a couple things. I’m curious about the average consumer out there. Let’s say the kind of practice we established was gold standard. I mean, it’s something different, something better. Could the average consumer find that in the marketplace?

Dr. John Mezzullo

That’s a good question. I think there are nooks and crannies in different practices across the board that may have that. But I don’t think to the level that you and I provided that, it’s consistent. In the organization I’m in now, there are amazingly talented psychiatrists, amazingly talented social workers, amazingly talented psychologists, and they tend to kind of find themselves or each other for treatment. But across the board, certainly the treatment is adequate, but I don’t think across the board it excels to the level that some of the providers teamed up give to the patients.

Dr. Ethan Levine

The role that primary care is playing in the behavioral health and the mental health continuum, is it really okay to have my primary care doctor writing psychiatry prescriptions, psychiatric meds?

Dr. John Mezzullo

I think Americans are specialization people, even though they may not recognize it. They really want a heart doctor treating them for their heart, and a lung doctor treating them for their pulmonary care. And folks who grew up in the internal medicine world, that’s how they are trained. So that’s how they’ll consult. Internists grew up with specialists. So they’re going to reach out to their specialist colleagues, either for a curbside or consultation. The family practice folks, in contrast, provided a really important service. They were more raised independently by family practitioners because initially the thought was that they’re going to go out to communities, not to the suburban communities with multiple medical centers or the city communities with all these disciplines. And they’re going to go out into rural environments and they’re going to have to depend on themselves. So depending on where you are will sort of dictate what you need to reach for. And in all fairness, some of probably the best providers I’ve ever practiced with are family practice providers. I mean, some of these guys are amazing. You and I both know in our previous organization, some of those folks had a really good sense of mental health. So yeah, I think certainly citing the shortage of mental health workers around, I think primary care folks who get it and understand should and can and do well-being the first stop in mental health. I think if there’s any message to the consumer, and I’m talking about the mental health patient, He or she needs to recognize that if he or she’s not getting better in a few weeks and they continue medicine trials after trial and nothing improves, probably time for a specialist consult or touchdown. But there are many, many primary care providers out there who treat these patients, get them on medicines, maybe refer them to social work or maybe not. get fine results and that folks turn around for acute depression episode or acute anxiety episode or a stressful stressor in the environment and do wonderfully there and certainly don’t need the input of a mental health specialist.

Dr. Ethan Levine

From the perspective of the physician, the provider, things are changing. in the marketplace, specifically about what’s the impact of increased substance use or legalization of marijuana? How does that change or how has it changed the practice of psychiatry?

Dr. John Mezzullo

That’s a great question. The environment I now work in is pretty much a college environment. So it’s a college town. And so the majority of my patients now, you know, are 18 years old to maybe early early 30s. The two most common disorders for mood abnormalities, unstable mood and also psychosis, is trauma and the second is substance use. With the substance abuse, the question, you know, chicken versus the egg, have many young college students having their first psychotic break. Well, the majority of these folks are on substances. There’s a meth epidemic, so they’re on meth, methamphetamine, or they’re taking THC in various forms. The kids call the smoking it flour today, and then the THC that’s not flour is constructed, it’s produced chemically. And then a significant number of these guys are doing LSD. And I’m in a skewed environment, so the numbers are going to be greater just because I’m in a referral center. But it just seems like there’s a tremendous amount of psychosis taking place in our country and these young kids that wasn’t there years ago. And so the question has to be, is it these chemicals or did they have a predisposition for it or was there no predisposition? and these chemicals are doing entirely, are we seeing more psychotic type illnesses just because of all the additional stresses? And then the other thing is trauma. Again, I’m in an environment that’s sort of skewed. It’s a referral center, but the amount of abuse that I see causing, you know, mental illness, mood instability and psychosis is just unreal. It’s probably on any given week, at least 30% of my census in the hospital.

Dr. Ethan Levine

Do these factors change how you approach treatment?

Dr. John Mezzullo

Yes and no. It’s kind of like a heart attack when you have coronary disease, right? I mean, you got to open up those blood vessels. You got to return flow. And whether that was because the patient doesn’t exercise or eats too much fatty foods or he has norepinephrine levels because his life is so stressed, on and on and on, you got to treat the end stage problem that’s manifest. So the end stage problem that’s manifest, let’s say psychosis and mood instability, you’re going to have to use antipsychotic medications initially and then mood stabilizers or antidepressants, things of that nature. Once that acute stabilization is in place, then you kind of have to backtrack and you have to cast a wide net because you have to talk to friends, family, folks who have known the individuals in the past, behaviors, thought processes, and all, and arrive at what may have initiated that. And then once you know, is it potentially a genetic underlying process versus was it stress, was it family or environmental, then you can kind of back off and treat. Because for the most part, other than things that are clearly schizophrenia and clearly schizoaffective disorder or bipolar disorder, the other flavors are really best treated with therapy. The data that’s out there, a lot of the research that’s out there earlier has suggested that therapy and medicines do better than either one alone. The later research now for some of these trauma-based conditions or familial social-based conditions. are showing that therapy might be actually more effective and may not require the medication. Once you have acute stabilization, you may be able to do therapy and back off and get these folks well. So I hasten to add, after I say that, I don’t want the listener to go, well, that Dr. Missoula knucklehead said medicines aren’t indicated. That’s not remotely what I’m saying, right? But I just think more and more we’re appreciating how therapy hits all receptors throughout the brain. And medicines are very, very targeted. Medicines will hit lots of downline receptors, but not, at least in my novice understanding, not to the extent. that therapy does. And if you think about it, I mean, someone’s talking to you, someone has a voice that’s soothing, they have comforting look on their face, maybe you can even feel their presence, or maybe they’ll reach out and touch your hand. Well, the auditory. processing takes place, the visual processing, and you have scent also, and you have touch. So there’s a lot of stimulation there that’s taking place that in addition to the lesser stimulations that are taking place with medicine.

Mukund

Is therapy more a holistic healing? Is that a good comparison?

Dr. John Mezzullo

When I hear holistic, it kind of makes me shudder sometimes because I know how the public will respond to hearing that and they’ll think of naturopaths and all those sorts of things that are kind of out of mainstream. Therapy is mainstream. I mean, there is so much data out there worldwide that is studying the impact, using imaging studies to see how many areas of the brain are lit up in comparison to what would happen if you take a medicine. it’s really not outside of standard practice. And depending on what country you go to, it’s going to be more standard. I mean, we’re more of a medicine society. We’re coming around to the benefits of therapy and therapeutic support.

Dr. Ethan Levine

Is there an impact on the different populations? You and I worked in geriatric, but you’re working with a whole different population. Do you approach it differently?

Dr. John Mezzullo

Yeah, well, I’m more of a lumper than a splitter. I look for the common thread. I want to tell you guys about Dr. Levine’s story. It’s an example of how skilled he is, really. This was in the geriatric population. We were in an assisted living facility that really almost functioned to the level of a nursing home. I mean, some of these guys were really, really sick. And then it had a locked unit, so there were lots of schizophrenics in the building. And then because it was assisted living, there were a lot of geriatric patients and they were all different stages of illness. They allow the folks out of the locked unit to go outside and then come to the front and maybe interact with the other residents and go outside for walks and things like that. And one of the patients, she was probably in her late eighties and maybe underlying psychosis in addition to dementia and end stage psychosis, and she was just tearing up the place. And all these young providers were walking up to her saying, come on, Come on, trying to hold her, put her hand around her. And Dr. Levine just saw it. He just walked in the front door. He was just walking to work and he put his arm around her and he goes, Hey, Ethel, how are you? Hey, let’s go over here and get some cookies. And that was it. It was done. I use that example to illustrate that psychosis is not so different depending on the age group or the underlying illness of the patient. When folks are psychotic and there’s not a lot of frontal lobe processing and they’re just kind of more going from the gut, make it primitive brain stem, that’s responding to the environment. And you have to go in there and just be the calming environment and interface with those folks and get them to do what’s in their best interest, what’s safe for them, taking their medicines, eating, exercising, all those things, all those times that staff need to get those patients to do healthy things, things that are going to help their illness, require that, for lack of a better term, that brain stem connection.

Dr. Ethan Levine

Speak to that for a second. A lot of times I think, whether it’s psychiatry or psychology, that the things we’re doing, and I think about psychiatric medication in particular, essentially softens the neural pathways so that we can make that connection so that they’re open to making those kinds of changes, behavioral changes. Would you agree with that?

Dr. John Mezzullo

Yeah, I would absolutely agree with that. Yeah.

Dr. Ethan Levine

So how do you know when you’re successful?

Dr. John Mezzullo

I don’t think that’s anything profound, and I think it varies from patient to patient what, you know, what success is. I mean, for Mary Jones, it might be just getting her to stop being so paranoid and eat her food. For another, it might be to stop picking up the arts and crafts supplies and throwing them at the other people across the table. Some, it may be just to be able to calm down to the point of listening to music on the radio and enjoy it. Other people, more, I guess, medicine-based, are they no longer manic? Is their frontal lobe now more engaged than it was? Because as you know, manics just lose that ability to monitor their thoughts and behavior and actions. It’s across the board. I mean, it’s definitely not the same. It’s just, it’s different for everyone. I pick on cards and most of my best friends are cardiologists, so I feel like I can pick on them. Hypertension is hypertension, right? Whatever it is this year, whether it’s 140 over 70 or it used to be higher. You’re going to get that. And you’re going to be told based on disease process, is it a forward flow process? Is it a backward flow, diastolic, systolic? Is there decreased EF? I mean, on and on and on. Are there also pulmonary disease? Based on all that, you’re basically going to go into an algorithm and know what medicine to pick and then what medicine to supplement it with. I mean, it’s very well developed. Our field is really very primitive. And if anyone tells you otherwise, you need to run because it’s primitive. I mean, it’s about where cardiology was before they developed echocardiography, when folks just had to listen to the chest and kind of try to figure out what was going on inside. So we’re kind of forefathers in this field, even today, even though it’s been going on a while. So there’s certainly a ways to go.

Dr. Ethan Levine

Yeah, I would totally agree with you. I think about some things like transcranial stimulation, which is non-pharmacological, but they do some measurement and that’s pretty rare in our profession. So flipping around to the other perspective, I’m a consumer and I’m listening to you speak and think, gee, I really want to do the right thing. So how do I become an educated consumer? We all know that there’s lots of advertisements and you get exposure to that, but how do I really become an educated consumer?

Dr. John Mezzullo

Yeah, that’s a great question, at least to my mind. Not the wealth of data you would hope would be available to the public, not the wealth of guidelines you would hope that would be out there. So I think in all fairness, if you’re having difficulty at all and you have a great deal of trust in your primary provider, I think you have to ask questions. You have to ask a lot of questions and your questions need to be answered. If it sounds too much like a recording, I think you need to move on. One of my good friends who I have infinite respect for, he’s a psychiatrist and he has had his practice that he recently just closed and he joined our group. He told me that when he did an intake, he would spend sometimes 3 hours or more on that intake. Now that was his practice, so he could afford to do it. I mean, he decided how much time he was going to spend. But these are really complex issues. And they’re deep issues, they’re intimate issues for these patients. I mean, there’s nothing much more intimate than their own mental health. And it takes as long as it takes to give them the satisfaction and the time. to understand what’s going on and what would be the next steps. So I think everyone deserves that and they don’t deserve 15 minutes. I think if these folks need more time, you need to give them more time. Wherever it starts with either a social worker that they’ve been referred to indirectly or a psychiatrist or to their primary care person, I think that person hopefully has enough understanding to guide them in the right direction and or to initiate treatment. And if they at all for a second feel like there’s fumbling, that there’s not that level of connection and they’re just going through the motions, then they need to get their information to the next step. They need to move on.

Dr. Ethan Levine

I know people ask this. I get referred to, you know, Dr. Smith. I don’t feel I’m getting the information. I don’t feel connected. You suggesting it’s okay or in fact preferable move on to someone else?

Dr. John Mezzullo

Yeah, you and I grew up on Consumer Reports, right? We were reading Consumer Reports from age 8, religiously, right? So we knew all the brands that were out there, the pros and cons of them, and then we looked and went to individual consumer evaluations, and then we went to the stores and talked to people. This is you. This is your mental health. These are not like car tires, and you deserve infinite periods of time spent with you and infinite amounts of information shared and there’s not too much information, you should demand that. should be the baseline place to start, not just good enough and let’s accept what we have. That just should never fly. And even going through five individuals to get to what feels right is certainly well within the realm of what you should expect. and what you should be delivered if necessary.

Rob

You talked a little bit about how you’re seeing younger patients now come in with certain conditions that perhaps you didn’t see before. Was there any sort of timeline that is associated with that? I’m wondering about the impact of COVID and isolation and whether you think that could be a factor behind these younger people that you’re seeing now as patients?

Dr. John Mezzullo

Yeah, when I was speaking, I was talking about severe mood instability and psychosis. So those things we would normally have said, oh, this is clearly genetic schizophrenia or schizoaffective disorder, bipolar disorder. The level of stress that these kids are experiencing, independent of any substances, would certainly rise to the level of PTSD in many, many cases, and much of it COVID-related and that isolation. not having the support initially that was available because we as a country, we didn’t know what we were in for. And I think we did pretty good at getting our online services up across the nation. But as much as we tried, we missed huge, huge swaths of the population. Yeah.

Rob

What are the sort of second order effects you expect to see from a younger person as they get older with this kind of condition? What kind of resources are available to families when they see maybe a teenager, 20 year old going into college experiencing this kind of condition?

Dr. John Mezzullo

Colleges today in general, and I can’t speak to the really small school, I’m more familiar with the universities, but they have huge health clinics, mental health clinics for their students to get evaluated. My daughter’s in Colorado. I was talking to one of the individuals who heads the clinic out there, and they have amazing services. And if there’s anything that can’t be treated, you know, at that university, they have referral resources and connections. So that’s the university center. Most mental health centers are set up so that they could certainly at least initiate that contact and help provide support and guide the families in the right direction.

Rob

That’ll be such a big help. People listening right now look up your local university and local resources to get help for that. I was also wondering, you mentioned talk therapy and the value of that. Just for myself as someone as a neophyte in this kind of language, I don’t really understand the difference, but do you see the same effect for virtual therapy as you would in person? Perhaps both doctors can speak to that.

Dr. John Mezzullo

I’ll let Dr. Levine take that one.

Dr. Ethan Levine

Answer in a couple of different ways. One is that you have to have a connection. Sometimes certain people, you can make the connection. I think about a prior experience outside of this context where I got to develop a program for virtual teams. So large global businesses can’t get together in the same room. So the effectiveness of a team, and we concluded after some research there that the first meeting needed to be in person. So if there’s a way in which you can have that first connection, it’s way easier to do teletherapy. That’s not a problem. But there’s little asterisks. There is a population of people who are highly, highly anxious. And those folks, in fact, the distance actually makes therapy a little bit more effective because they don’t have that same stimulation and anxiety about being in the same room. John, would you add?

Dr. John Mezzullo

Yeah, I would agree. I don’t think I have anything that would add to those comments. I 100% agree with that.

Dr. Ethan Levine

I’ve done both, even on the provider side. The other piece of the equation is what’s personally satisfying. If I’m not comfortable in this kind of environment, teletherapy, telemeeting environment, I don’t think I can be as good a provider. If it feels natural, I feel connected, yeah, it’s fine. Really doesn’t matter.

Mukund

What are some common issues college students are facing that you have seen?

Dr. John Mezzullo

That’s actually a good question. A lot of these Folks are certainly driven much harder than I was when I was a student and they’re all trying to beat everybody in their APP courses or trying to take more courses than anyone else. A lot of these kids are up around the clock from like their freshman year and so they’re sleep deprived. My generation of students, we got to college and no longer did we have wonderfully nutritional meals. And so we started eating lots of junk food. So nutritionally, there’s an issue. There are other activities that they used to engage in that gave them some diversity and fulfillment outside of academics often fall away. Like a lot of these kids were musicians and played in little local bands or played in their high school orchestras, jazz bands, whatever performed their plays. But one, they feel like they don’t have time to do those things. And the other is now they’re competing with those kids who are in the music programs and the thespian programs, and they’re auditioning, but they’re not getting those spots. So that goes away. And then physical activity. because they’re ending up studying more and they’re not out exercising. So that’s going away. So their life overall is just not as healthy. And then listeners are going to be not happy with me, but we do a lot more for our children than our parents did for us. We were a lot more independent. I’m guilty of this too. I openly admit it. So if anyone’s going to get skewered, I can get skewered too. But my dad, like I remember I wanted to have a basketball backstop to play basketball in my yard. And we were a pretty poor family growing up, so he couldn’t afford to buy me a basketball backstop. So he drove me to the dump and he said, okay, find yourself a pole, find yourself a backstop, get something that looks like a rim. I’ll buy you a net. So I did that and then I was like, well, what do I, I don’t have tools. So he goes, all right, I’ll buy you a hacksaw, get you a couple wrenches and things. So that’s what I learned to do and was certainly a little more self-reliant. So a lot of these kids are going away. Now they have to rely on themselves if they’re having a really difficult time with that also.

Mukund

Is it because of a privileged background, you think, or is it something else?

Dr. John Mezzullo

I’ve asked myself this a lot. It’s not like a privileged economic group. It’s just that they’re now Americans of this particular time and just across the board, they’re a little more coddled.

Dr. Ethan Levine

I would add that what happens, the difference economically, somebody who’s, you know, multimillionaire said just, you know, go out and let’s just buy it. But the aspirationally, a person who’s struggling economically still has that desire. more frequently than our generation to do it for their kids. I’ve seen parents go without eating so that their child could have a baby doll they really wanted. The mentality is what you’re speaking to, and I would agree with that. John, if there was one thing you wanted the listeners to take away, one piece of advice, about taking care of their mental health, their loved one’s mental health. What would your advice be?

Dr. John Mezzullo

I would say this. One, you deserve it. Two, you’re worth it. And three, you’re not alone. This is just a really tough time in our country, probably across the world. The stressors that folks are having to deal with now are just out of control, just off the board compared to what they were. And sometimes it’s just unreasonable to try to go that alone, do that alone. Sometimes you just need to reach out for a hand, and there are hands out there that want to reach back. So do this for yourself if you need it and for your children.

Dr. Ethan Levine

There’s a phrase, I don’t know if you’ve heard this, that encapsulates the last part of this. I often talk about the delusion of uniqueness. People think they’re the only one that’s ever felt like that. Dr. Mazzulla, really appreciate you taking your time with us. It’s been very valuable, a lot of insight, and I know our listeners will gain a lot from listening to you. So thank you.

Dr. John Mezzullo

Thank you all for the invite. I really appreciate it.