What Is Psychopharmacology And How Can It Help With Therapy?
Published on
May 9, 2023

What Is Psychopharmacology And How Can It Help With Therapy?

Tyson sits down with Matias Massaro, Psychiatric Nurse Practitioner, PMHNP. They discuss psychiatric medications, how to get them, how they help alongside psychotherapy, and reasons that people may be resistant to medications.
Hosted by 
Tyson Conner, MA

‚ÄćTyson Conner¬† 00:10

Do you want to learn about psychological growth without sorting through the jargon? You're in the right place. This is the Relational Psych podcast. I'm your host, licensed therapist, Tyson Conner. On this show, we learn about the processes and theories behind personal growth and experience a little bit of it ourselves. Join me twice a month for candid conversations about therapy and psychological concepts with real mental health professionals using understandable language and simple experiments that you can try yourself. Keep in mind this podcast does not constitute therapeutic advice, but we might help you find some. And today, we are here with Matias Massaro. Mati is a clinical psychologist who graduated from the University of Buenos Aires in Argentina, and a psychiatric nurse practitioner, completing your doctorate in nursing from Vanderbilt University. He's also the founder of Cognia Health. Mati, welcome. 

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Mati Massaro  01:14

Yeah, man, thank you for having me, Tyson. 

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Tyson Conner  01:17

And today, we are going to answer the question "How can medication help my treatment? And how do I get it?"

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Mati Massaro  01:26

Yep. I am all ready to discuss these things. It's basically what I do on a daily basis. And one of the things I find most fun to discuss is how collaboration between psychotherapy and medications can lead to very good results overall.

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Tyson Conner  01:45

So I'm really excited for this conversation. For the sake of the Listener, coming into this conversation, because I'm a psychotherapist and because of my training, I know nothing about psychopharmacology, none at all. And Mati, your training is in both psychotherapy, and now also in psychiatry. And at least in the way that we've done education, at least in the US, there's not a lot of overlap between those two schools, right? It's not common for someone to have that sort of dual experience. So I'm really excited to hear what that experience and background - kind of - how that informs your approach to what you do now. Great. So, let's dive right in! Briefly, you know, how can medication help the Listener's treatment? And how do they get it? 

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Mati Massaro  02:46

Yeah, of course! Well, you know, the first easy thing to address is that medications can be accessed through anybody that has "prescription benefits." Somebody that can write prescriptions in this case, particularly for psychotropics. So there are a variety of credentials and professionals that can be prescriber clinicians, including MDs, PAs, NPs and other providers. Now, how do they work? It comes down to the details about every single medication, right, and we can obviously have a discussion and dig deep into the pharmacology and the mechanism and action of every track, right? In fact, I love doing that. I think it's my nerdy passion and what I do in my free time, because I think it's fun. But at the same time, to go back a few steps and seeing how the medications and psychotherapy play together, we find that collaboration between those areas can be very beneficial in several examples and contexts/circumstances.  So the first one that comes to mind is when psychotherapy has maybe created, or helped contribute to a partial response. So a proper course of psychotherapy may have been implemented on a specific client or patient, regardless of diagnosis -- we can be talking about depression, anxiety, ADHD. And despite trying a proper course of therapy, doing everything that's recommended and evidence based - and despite maybe the client or patient trying their hardest - in some cases, that effectiveness may not be enough. And you know, just to make sure the psychologist in me speaks its mind, I'm not by any means, saying that psychotherapy is not effective. Both psychotherapy and medications have extensive evidence showing they're effectiveness. So what we see very commonly is that sometimes one of them in a particular context is only improving things halfway. And this happens to both of them. So sometimes psychiatry, in my world of things, we may be implementing medication for this and that, and we see moderate improvement, but still, there's a little bit of room for improvement where psychotherapy shines so much. And then the other way happens as well, where proper course of therapy has been helping but there's still maybe not a full response or a full symptomatic remission where we're hoping to achieve our therapeutic goals with a little bit more oomph. If I'm making any sense. What do you think, Tyson?

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Tyson Conner  05:54

Yeah, yeah. So a couple things I'm thinking. One is, I want to define one of the words you used early on. You said "psychotropics." Psychotropics and psychopharmacology - for anyone who's listening who might be like, "what are those things?" - psychopharmacology is the area of study around drugs that impact a mind, right? That's what the word means, psychopharmacology. Drugs that impact the mind and how we study them. Psychotropics - I can't break down the Greek and Latin roots there - but that's another word for drugs that impact the mind. So antidepressants, ADHD medications, antipsychotics, mood stabilizers, the whole gamut. Benadryl, right. All have applications, or you can use them to impact someone's psychological functioning; that's a psychotropic. And some people have 'prescription privileges,' which means that they are legally allowed to write a prescription and say, "Pharmacist, give this person this controlled drug." And the kinds of people who are allowed to do that are like medical doctors, nurse practitioners, there's a few other different degrees and licenses that you can get that give you prescribing privileges. And the majority of psychotherapists don't have them. There are a few people who do practice psychotherapy and prescribing together at the same time. But in the modern mental health system that we have in the US, those are two separate streams.

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Mati Massaro  07:35

That's right. And what we've seen is, of course, there are all kinds of situations where psychiatry could be benefited from therapy and therapy could benefit from psychotropics or psychiatry in general. And that's why, you know, I typically suggest - and I mentioned this to Tyson before - that psychiatry and psychotherapy are a little bit of a dream team. This is not just me being, you know, optimistic and friendly. But we have so much research then has shown, on one hand, the efficacy of psychotherapy, solid science. And then solid science showing the efficacy behind medications. And we've seen research that suggests how both of them can yield even better results, almost aiming to these same therapeutic goals through different angles that can be beneficial for both.  So to break it down to the daily life of a specific person, let's talk about ADHD for a minute. There are several behavioral interventions for ADHD that we have found that are extremely effective, helpful, beautiful stuff, right? Now, in some cases, behavioral interventions may not be enough to address the experience or the symptoms that someone may be experiencing. So medications could be really helpful in those cases. We have strong evidence for several kinds of medications that could help address symptoms or the experience of ADHD for several folks. Another example that comes to my mind right now is, as we may or may not remember, at times psychotherapy -- it's a little bit of a mental exercise, it requires a lot of engagement. 

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Tyson Conner  09:36

Absolutely.

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Mati Massaro  09:37

Right, and action and thought and reflection, and at the end of the day, it needs the client or the patient to be engaged, energized, to invest a part of themselves in their treatment and recovery. And this could be particularly hard if someone maybe didn't sleep for the past five days. And different presentations involves sleep dysfunctions, like anxiety, depression, trauma related conditions, and several others--

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Tyson Conner  10:16

Mania.

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Mati Massaro  10:17

Well, yes. And when people haven't been sleeping well for a long time, it can be very challenging to do what we need to do in therapy, and I can't expect it from from them. And I can't expect it from myself, I know for a fact if I haven't slept well for a few days... Man, it's gonna be challenging. So these are situations where maybe medications -- and I'm not necessarily suggesting, you know, all of these cases require medications, but sometimes somebody that hasn't slept an hour, for five days, regardless of a manic episode or not, right, could benefit from at least temporary relief for a few days. So that they could, for lack of a better word, regroup, get a little bit of rest, let's reactivate therapy, let's reengage in whatever we have going on. But now we at least got a little bit of sleep, let's see where we go from there. So these are cases where therapy and medications play very well, ADHD, sleep. I've seen many cases where anxiety or trauma things can be severe enough, where people experience such degrees of hyper arousal. They are essentially so on edge, thinking about their experience of anxiety or trauma in therapy can be so stressful, triggering, that doing the therapy becomes a little bit unmanageable. And in those cases, maybe we try with therapy and we're not getting too much done. We are a little bit in front of a brick wall, if you will, that's being very resistant - honestly, most of the times for good reason, you know. People experience all sorts of unfortunate experiences that create these walls that are very strong. And sometimes medication can help reduce a little bit of that hyper-aroused state, so that we can feel a little bit more in control.  I like to explain, in general that the stressors won't disappear. So let's say I'm very anxious about COVID. Right, a lot of people experienced that. "Hey, man, I'm very anxious about catching COVID, of what's going on with COVID, et cetera." And they can't do anything about it or think about it, do anything therapeutic wise. And maybe we start a gentle medication for anxiety, an SSRI - which stands for selective serotonin reuptake inhibitor. Some of those classic ones are your Prozac, Lexapro, Zoloft. And maybe this medication can help decrease this extreme anxiety or stress, so that we can focus on our therapy work. And what people told me is, "You know, it's not like something dramatic changed. COVID is still there. And it's still stressful. But now I feel like I can handle it. I feel like now we can talk about and will work in therapy for long term thought and cognitive work. But now I can actually do that." Am I making sense so far, Tyson?

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Tyson Conner  14:08

Yeah! It sounds like so far you've described two similar but distinct, different, situations where psychotherapy and psychiatry work really well together. The first one is one where one or the other, either the meds or the therapy is going like part of the way, but it needs a little boost from the other. Right? And then the second is this situation that we're talking about now, where like the symptoms of the distress or the overwhelm - or whatever is getting in the way of someone's daily life - is so extreme, that it makes making progress in therapy difficult to impossible, because the distress is too high. And one of the things -- I used to I work with a lot of kids, right? Still do. But I used to work with a lot of them -- one of the things that I would talk to them about and their parents was the idea of like "taking the edge off;" that a lot of times medications are really helpful for taking the edge off so that you can approach something and actually engage with it without getting cut.

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Mati Massaro  15:25

No, I agree. And essentially, like you said, in some cases the collaboration helps balance each other out towards maybe that partial response on either option could benefit from extra help. That's where I see a little bit of therapy and psychiatry is shoe or a sock for each foot. And we can, you know, work a little better if we have one on each foot. And in some cases, like you suggested, things can be pretty acute sometimes in mental health. So we have cases of extreme substance dependence, we have situations where somebody feels frequently suicidal, or has suicidal ideations or actions that are pretty significant and debilitating where we might want to collaborate between therapy and medications. And then we have situations where therapy has been extremely effective, like specific phobias, for example. And in those cases, therapy has been very effective. But at the same time, it also takes a little bit of time to get going, you know? Exposure therapy, and things that have been found to be so effective, might benefit from a medication, at least temporarily, while we address long term, this specific phobia. Am I making any sense here?

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Tyson Conner  17:00

Absolutely. Yeah. And so I'm thinking about, like, a Listener who might be listening to this and is wondering, like, "Should I look into medication?" Whether they're in therapy or not. Right? It sounds like one of the things that I'm hearing you say, is, if you've been in therapy for a while, and you've hit a plateau, maybe look into seeing if medication would help it along. Alternatively, I'm also hearing you say, if you're in therapy, and you're having a really hard time getting started because it's so distressing, medication might be helpful to get the ball rolling. 

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Mati Massaro  17:37

That's right. Yep. I agree with that. And to your point of like, maybe in these situations, it could be helpful to bring on a medication. And you're right about that. And I think the other half of that idea is that a psychiatric evaluation, in general, a consult with psychiatry, can be helpful in a few more ways than just a medication point. So for example, psychiatric providers have been trained in several biomedical related underlying things. So a lot of times, some of these things influence our mental health experience, right? So maybe we have plateaued in therapy in working around our depression and we are not sure what's going on. We made some improvements, but it's getting a little rough. During a psychiatric consult, we can discuss medications that could be helpful, but during the assessment, we might start finding hints of underlying biomedical conditions that could play a role in this. For example, thyroid dysfunctions, like hypothyroidism, are a very common factor that influences mental health in general. So hypothyroidism can often lead to the depressed mood, and/or eventually contribute to a full on diagnosis of major depressive disorder. So there are different biomedical variables and items that have an influence on our mental health experience, including our thyroid. Iron levels, maybe chronic conditions like diabetes, and it's influencing mental health. Pregnancy - a person that goes through pregnancy goes through several changes in their body and metabolism, and they may or may not have a an important influence on their mental health. Chronic pain is another. So trying to understand hormones, our thyroid, and some of those things can be extremely important and influence our overall progress in our therapeutic goals.

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Tyson Conner  17:38

I'm remembering -- I'm having a memory back to grad school when I was learning about diagnosis and how to go about diagnosing. And the professor who was teaching the class, she would tell us, "You always have to rule out the organic factor." And for Listeners, the organic factor just means something's happening in this person's body. So psychosis is like big, scary word. And it means that someone is experiencing hallucinations or delusions, disconnects from reality, different kinds of experiences, all sorts of things. And something that my professor loved to remind us is that the vast majority of people who are diagnosed with psychosis, it is because something is happening to their body. It's not because they have a major mental health issue that's surfacing. It's because they were in a motorcycle accident, got hit on the head, or it's because some hormones in their body got unbalanced. I once worked with a with a client for a couple of months - they were younger, this was in community mental health - and they just like, moved across the country. And when they landed here, they had these like, psychotic symptoms, this paranoia, delusions, and hallucinations. And they went to their medical doctor -- I was working with them and like, 'All right, I'm gonna put on my big therapist pants, and I'm gonna, like, get into the psychosis." They went to their doctor, and they got a vitamin shot, right? And then they were like, " Bye Tyson, I don't need you anymore." They were fine. It all went away. So part of what I'm hearing you say is that going to someone who has been trained in psychopharmacology means you're going to someone who is aware of all of these kinds of physiological embodied medical factors that your standard psychotherapist, like me, probably isn't. And also that maybe your primary care physician doesn't have the specific training for either.

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Mati Massaro  22:16

Right. So it may be in this particular case, we assess and maybe do some diagnostics -- and diagnostics can be lab work, they can be imaging, they can be genetic panels, we can do a sleep test, polysomnography to possibly assess for sleep apnea that's contributing to the sleep dysfunctions in anxiety or depression. And maybe we see "Oh, hey, our thyroid levels are pretty low. I think we might be onto something here and you meet certain other symptoms. And we talked about your family history, it sounds like your mom and your grandfather have a history of hypothyroidism. So you know, we might be onto something." And then, let's say we gather everything to make a diagnosis of hypothyroidism. We maybe introducing medication typically, it varies case by case, but most of the times it's a synthetic thyroid that we just add to our bodies to increase our thyroid levels overall. And by readjusting our necessary thyroid functions, we start noticing that our mood improves. And a cascade of other things, like for example, they noticed that they might have a little more energy, that they're not putting on weight for no reason. So that could be it. And then we notice significant, major improvements that has an enabling effect on therapy as well. So in some cases, we may not do a psychiatric medication or psychotropic, but we find that there's an underlying history or an underlying influential factor that's contributing to either their mental health experience, or possibly the primary culprit, if you will.

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Tyson Conner  24:17

Yeah, I just had an analogy pop into my head. Let me know if this is off or wrong, but it kind of makes me think like, if you're hungry, right, and you go to a chef, and they keep giving you good food. You say, "Chef, I'm hungry," and then they make this meal for you and they give it to you, but you just can't eat it. You just can't eat it. And it's because you have a toothache and you need a tooth extracted. That it sounds like that's kind of the relationship between like psychotherapy, psychotherapists being the chef and psychiatry sometimes. Like the dentist will be like, "Yo, this is great food you're getting but you can't take it down because you have this massive toothache!"

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Mati Massaro  25:03

That's right! And sometimes it's more than one thing, you know. Your tooth is hurting, let's see how we can decrease the pain. And then, oh, we realize that you have a little bit of a genetic, influential factor that makes it hard for you to swallow. So not only your tooth is hurting, but it sounds and looks like, from what I'm assessing, that it's very hard to swallow. And, well, we can do stuff about it.

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Tyson Conner  25:35

Right. So to stretch the analogy, bring it to its breaking point, that's when the dentist would turn to the chef and say, "Stop giving this guy hamburgers, right? And maybe make a soup." Do you ever find that? Where you discover through your assessment of a person, you realize, 'oh, here's this factor we weren't aware of.' And then you go to their psychotherapist and say  'you should change what you're doing. Because of this thing we discovered.' Is that part of how you work?

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Mati Massaro  26:03

It can happen. Typically, most therapists are working very appropriately and well, and they're doing everything that makes sense. And every now and then we'll discover something significant that could suggest an adjustment or an addition to what they're working on. But yeah, it can be informative to us. And that's why the collaboration piece can be so important. If we keep this communication open between us, we can wear all the same jerseys and be part of the same team and help the client or patient improve a little bit. This is unfortunately, common, where we see a lot of clients or patients who identify as female, and they experience chronic pelvic pain that can be very debilitating in their daily routine and/or sex lives. And it can be something so stressful, that it's a common theme in therapy, right? And maybe then they, through a medical assessment, through a consult with an OB or women's health provider -- let's say during diagnostics, there might be a little nodule, a little something that was like, "Oh, well now makes sense that you were having pain. We found something." So kind of like your tooth analogy, right? And we're like, "Okay, let's see what we can do." And little did we know that there are medications in psychiatry that can address some of these, both mood concerns and chronic pain. So based on these factors, we tried to pick our drug and see how it could help the most. Am I making sense here? 

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Tyson Conner  28:01

Totally. Yeah, it sounds like part of the benefit of talking to a prescriber is broadening the scope of what you're looking at and what you're thinking about and what you're talking about, to more of the body. 

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Mati Massaro  28:18

Yeah, bringing in the general physiology and biological factors that could be contributing at a large scale. And that also could be addressed to enable the progress in therapy, and ultimately, both play a key role. Medications can enable this progress can make things feel a little bit more in control. And at the same time, therapy will be most likely what will create and contribute to the best long term outcomes. "Now that you've slept, let's talk about what's stressing you. Let's figure out coping mechanisms, let's talk about preventive strategies for next time you go spend Christmas with your in-laws, right?" Or anything that contributes to any sort of anxiety. So they are a little bit like two shoes for each foot. That's kind of how I how I see it a little bit. And this team approach has people with similar skills and at the same time different trainings that can address multiple things. And it's like having a little bit of a football or basketball team and one of you guys plays defense, one of you guys plays offense. One of you guys is the goalie and, you know, we're all doing a role to win this game in a way.

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Tyson Conner  29:56

Yeah! It sounds like in the way that you work with medications, there are some situations where people are taking meds for a little while, and then the therapy does the work of making the underlying changes to address the issue. But it sounds like there are also situations where someone might be on meds for a long time maybe the rest of their life. Can you talk about like the difference between those two situations? 

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Mati Massaro  30:22

Yeah, of course. It's obviously a very case by case situation, right? Well, let's talk about - maybe using an example that's very relatable to most people, like depression or anxiety. And one of our probably most common consults are depression, anxiety, because unfortunately, they're very common.

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Tyson Conner  30:44

 Yeah.

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Mati Massaro  30:48

We've seen and learned through time that people experience depression or anxiety at a frequent or recurrent rate, or sometimes at an episodic rate. Sometimes people who experience a major depressive episode, they've experienced it, let's say once, and therapy was helpful. And they they keep on with their lives perfectly great, right? 

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Tyson Conner  31:15

Yep. Yep. 

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Mati Massaro  31:15

Now, other people experience major depressive episodes pretty frequently. And they've experienced them not only frequently, but for long periods. So maybe instead of someone who experienced a major depressive episode for two weeks, some folks experience it for two months. And maybe that episode could be pretty acute. So sometimes, one course of treatment can be beneficial, effective, and some folks have at least one or two episodes and, you know, good for them. And that's it. They may or may not require or be appropriate to continue the prescription for medications.  In other cases, where these episodes are recurrent, frequent, very long, very intense, it might be beneficial to keep the medication longer. So what we found through research is that once we try, let's say, a medication for depression or anxiety - typically our first line are these SSRIs, like Lexapro, Prozac, Zoloft. What we've learned is that it's protective, and effective to take them for something around 12 to 18 months. 

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Tyson Conner  32:42

Okay. 

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Mati Massaro  32:42

We've learned that if we stop them earlier than that, there's a bigger chance that we may re-experience an episode. In a way, we're hoping to set people up for success. So that once they finish this course of treatment, we don't have an episode again, right? Those who experienced those so frequently, for so long and more acutely may benefit from a longer route of treatment, for a more sustained treatment that will prevent these major depressive episodes, or decrease their duration, their intensity and their frequency. So in some cases like these, it could be appropriate and recommended to -- "We've learned together that we've experienced these episodes, or this intensity pretty frequently, and they've been very debilitating. How would you feel if we continue this treatment for a little longer so that we can decrease this?" Am I making sense here?

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Tyson Conner  33:54

Yeah, it sounds like -- it's interesting. I wasn't familiar. I think, Listener, Mati and I are gonna do an episode in the future about SSRIs. Specifically, I think, because they are such a common -- I think, I feel like most primary care physicians are probably comfortable prescribing them. If you're like most people who try medications, if it's not for ADHD, and even sometimes if it is, you'll get started on an SSRI. So stay tuned, Listener, in a future episode we'll get more into those specifically. But I'd never heard the 12 to 18 month thing before, that's interesting to me. It makes sense because antibiotics have a similar thing, right? A lot shorter, but you want to use an antibiotic all the way through to the end, so that you get the full dose, so that you get the full effect. Even if you start feeling better before the end of that course, if you stop it early, it can make the trouble comeback and sometimes worse. Sounds like there are psychotropics that work that way too. And in some situations, and it sounds like it really is case by case. 

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Mati Massaro  35:07

It is. 

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Tyson Conner  35:08

Some situations, people will be on meds for a little bit, and then they'll get what they need from it. And there'll be done. Some people, they'll be on meds for a little while. And then it sounds like it's a conversation. It sounds like you don't, like, in a first appointment with someone know, "All right, I'm gonna have you on meds for the next decade." Like it's an ongoing thing.

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Mati Massaro  35:32

Yep, that's right. And that's what I tell everybody that comes my way. Not only this is an alliance in a collaborative approach, where my role here is to give you my best clinical recommendation. And that is as far as I go. You're the driver here, I'm your copilot. And I will tell you what my science map tells me, but at the end of the day, it's your body, your treatment, I want you to have all cards on the table, pros and cons for each option. And, you know, make an informed choice. And I'll be here guiding and supporting and making sure that things are safe as well. And not set things in stone for you. And this is not only important for our initial appointment, but for the future too. So people need to be encouraged to know that things shouldn't be set in stone. So let's say we meet for the first time, and we are excited to try an antidepressant. But if we change our minds in a month, that's okay. We can discuss it too, and see where we go from there. We go back to the drawing board. And we see how we feel. So that's the important part and piece of the conversation, where like, "Hey, I'm very excited that now you're feeling better. You're thriving, you're doing amazing, these past three months, I hear that you're feeling back, like yourself, and that's awesome. And I also hear that you're ready to stop the medication. And you know, I respect that. I will bring up this information and the science behind it. I will, based on the science, recommend that we stay a little bit longer on it, because it will set you up for success and prevent a future episode in the near future. But at the end of the day, you make the call. If you want to stop it now, we'll work on it." And I'll help you stop it because typically we recommend progressive discontinuation. That is also something we found can be protective of future episodes. And it can be a safer way to discontinue medication, because some people may experience discomfort if they stop a medication cold turkey. But it's still an option for you. And if otherwise, you would like to continue it. Yeah, we'll continue it. And most people in my experience, they hear the recommendation, they see what the science is behind it. And they're like, "Yeah, you know, I came here thinking it would be a good time to stop it. But the science makes sense. And, you know, I'll continue taking it just because last time I felt this way, it sucked. And I don't want to do it again.' I mean, it's your call, you know, both options are on the table. Here's all the information, I'll help you whichever way you prefer. Am I making sense here?

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Tyson Conner  38:42

Yeah, absolutely. And part of what I'm hearing is that like, for our Listener, if you're talking to your prescriber, and you're feeling like they're just telling you how it's going to be. "Do this and then talk to me in a month or whatever" then maybe that's a therapeutic relationship that you might want to question. Sounds like the way that you practice at least, and the way that you recommend people practice, I imagine, is one that is a little bit more collaborative, and more of like a team based approach. With the idea of the patient, or the client, the Listener, in this case, as the one who makes the final decision. And your role then is to be the one with the expertise and the training and the experience, and to make your suggestions based on your best clinical judgment. But at the end of the day, the person is the one who has agency over their own body. They're the one who decides what's going to happen one way or the other. And you're gonna give them all the options that you believe are available to them. 

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Mati Massaro  39:50

Yes, and discussing, you know, pros, cons, and cards on the table. And, "Hey, I will be here supporting you whichever way you prefer. I think that's the safe way to do it. And that's my way to practice but it is your call." And in your line of thought, I always encourage patients, clients, and other providers to remember that we don't have to make a decision right there right now. I think all of us, and myself when I'm a patient to other clinicians, I think we've been modeled to think that we have to tell the clinician right there, what we want to do. And some of these are heavy things that we want to think about. So that's what I recommend in general. During the first appointment or whatnot, once we talked about everything, and it's my time to give a little bit of feedback and my clinical recommendation, I encourage people to take their time. So "Hey, you know what, we talked a little bit about everything today, some of these things were actually a little heavy. They were traumatic themes and whatnot. So you don't have to start to medication or tell me what you want to do today. (If that was the recommendation. Of course, there are times where we don't recommend the medication.) Take your time, think about it, sleep on it. Talk to your mom, talk to your partner, talk to your friend, and send me a message in a few days." I like to send little PDF files with psycho-educational material about every medication I recommend. 

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Tyson Conner  41:27

Cool. 

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Mati Massaro  41:28

That's a little bit of a starting point for people to learn a little bit about the recommendation and not just take a decision blindly, if you will. Also a little bit to give them a starting place with information because I think we all have Googled random stuff. And we end up finding out that our final diagnosis is that we are a Pokemon. So it's good to -- we can't stop people from from Dark Web Googling, you know, but we can at least give them a starting point that's a little bit more official, clinical information. And from there, they can do their research. And Tyson, to be honest, what happens most of the time is people come back a day or two later, they message me and they're like, "Hey man, you know what? I talked to my best friend. And they told me they take the same medication. And they weren't very... They didn't feel like talking about it. But now that I opened up, they opened that up about it. And they told me how much this helped them. And now I'm pumped, like, I can we start it?" I'm like, "Yeah, of course. Let's check back in a few days, weeks, whatever the case is, and see where we go. But I do think they should be the protagonist of their treatment. I think it's a matter of agency and empowerment. But I think it's also maybe one of the most important parts of recovery, where we are responsible for our healing. I think it's important that we are the ones that are choosing to heal ourselves in whatever's going on, and that we are the ones that are doing the healing. Sure, we have some cheerleaders, our therapists, our psychiatric provider, they're giving us some shoes, some socks, our therapist is constantly giving us some of those little water cups every time you take a lap, but they are the runner here they are the protagonist, and they should be the ones that hopefully feel that 'I am doing the work. I am responsible for the improvements that I'm noticing.' Am I making sense here? 

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Tyson Conner  43:48

Yeah, I like that a lot. And I think a lot of our listeners will hopefully feel encouraged - or at least less afraid - of medication management and talking to a prescriber, hearing this way of thinking about it. I think, what I hear from a lot of folks who are considering medications is a fear that they're just going to be put on something. That they're going to walk in, fill out a questionnaire and then someone's going to give them a prescription and say, "See you in six weeks," right? And there won't be this dialogue. There won't be that time to think and there won't be that relationship. And I think a lot of people are afraid of that. Because honestly, that's been their experience. And in my experience, the people who are most freaked out about that are oftentimes people who were on medications when they were younger. Because especially for kids, if the doctor is having that relationship with someone, oftentimes it's with the parents. And so kids can get over medicated that way and can feel like they have no conversation. And then that becomes what people expect in their medication management. And it sounds like what you're suggesting is like a pretty significant left turn away from that sort of authoritarian - "I'm going to tell you what to do," like, clinical in the sense of sterile and detached. Like that might be something that people have had experiences with. And it sounds like you're working to avoid falling into that particular trap.

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Mati Massaro  45:31

I sure hope so. It's definitely my intention and my hope that can have a different model. I think what you describe is what I joke around calling the 'car shop model,' where we go to the car shop, or the mechanic, we drove our car for a 15 minute appointment, and they make a few questions, that quick little screening tool, and "Okay, hears your oil change and a quick dose adjustment, go home." And I don't think that's good. 

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Tyson Conner  46:00

Yeah.

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Mati Massaro  46:01

I think we need to talk about what's going on. And to understand the experience of mental health, this person is telling us, to understand how we can make an impact, with or without medications. How we can recommend therapy, how we could talk about exercise, nutrition, sleep, sex, and everything that could be influenced, maybe doing some labs, like I suggested. Seeing how, let's say, that thyroid's working, maybe assessing a little bit of everything and trying to understand that. I think we've all fallen into this vicious cycle of a medical model where shorter appointments were maybe the default, and they're so long - We can have a whole discussion about this.

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Tyson Conner  46:51

Some of our listeners might be wondering, "Okay, this sounds pretty good. Tyson, Mati, great idea. How do I get this kind of medication management?" So, I mean, one option would be for people to Google you, of course. Links to you are in the show notes. But let's say someone's listening who's in New Hampshire, right? Or your caseload is full, because everyone's heard this episode. How would you recommend someone go about looking for a prescriber who will try to avoid some of those pitfalls we were talking about? How do you find medication management, that's this more holistic, thoughtful, less low pressure.

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Mati Massaro  47:44

It's tricky. But it's possible. And my recommendation is to, if possible, start by asking a provider you trust. That might be your therapist, that might be your primary care provider who might start engaging in that kind of treatment, or prefer to refer to therapy or a psychiatric specialist. But sometimes he's your OBGYN or your woman's health provider. Sure, sometimes it's a midwife that you used three years ago. A provider you trust may be a great starting point, because they may know and trust a colleague, or they may be like, a therapist, that you've been working with for a few months or so. And when you are exploring this conversation, maybe your therapist knows someone, or they can help you find one, because they already have both feet in the mental health field. So, of course, you can Google, you can do all sorts of things. And, of course, feel free to do so. I think starting by asking someone that you trusted before, a provider that's helped you before, could be a good starting point. If you have the unfortunate experience that you haven't found that one yet. You don't see a therapist or you don't have a primary care provider. Well, in that case, it might be good to start looking at searches online like Psychology Today and other specialized web search engines for mental health providers and read their descriptions, read their websites, see if something resonates with you and give it a try. What would you recommend to clients or patients you see when they might want to explore a psychiatric consult?

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Tyson Conner  49:50

I think if people come to me, then usually I will refer right? I'll refer to you, you'll be on the list. And honestly, there were a few years where I knew some prescribers in the area I worked. But then I moved to a different area. I didn't know the prescribers there. But I did get plugged in to certain professional communities. And then I started to learn of people's reputations. So I started referring people to folks who I'd never had an individual conversation with, but I knew from going to conferences and seeing them there and hearing other colleagues talk about how helpful they'd been with another client. So that's how I did my referrals. And I agree, I think that the way that mental health providers market themselves, online is important - it's important to try to communicate 'this is who I am, this is how I practice.' And if you're not savvy to what all of the buzz words mean and imply about how someone works, it can be really confusing to try to understand and to read profiles on psychologytoday.com. If you're not familiar with the world of psychotherapy, and you're reading through psychotherapist profiles, they all sound exactly the same.  They are exactly the same. So when I've had the unfortunate situation of working from scratch with literally no information, I've honestly told people "Go on their profiles, read it, maybe schedule a console call if they offer that. And then just trust your gut." If you're reading someone's blurb that they've written about themselves, and it's all Greek to you. But something in your gut is like, "Yeah, okay. I like the way this person uses commas." I think that's actually really valuable.

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Mati Massaro  51:11

That's right.  I think that gut feeling is fundamental too, because people might be in front of the most amazingly trained clinician, and they might not find it a good fit. And hey, that clinician might fit extremely well with a million other clients or patients, but it might not be the fit for you. So regardless of training, education and skill, gut feeling is a big factor too. And, of course, I encourage you to see someone who's educated and trained and certified. But I'm saying gut feeling will probably be one of the most important factors in saying, "Okay, you know, I feel comfortable and confident that this is the setting for me." 

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Tyson Conner  52:44

Is there a specific introductory resource that you would point people to who have this very broad general 'medications for mental health care'?

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Mati Massaro  52:56

That's a great question, because I don't have one, which is why I want to work on one. That's my upcoming project, is to work on that introductory material for clients and patients. Because one, I think it's fun. And two, because otherwise, I repeat the same information all day. I can point out to "Hey, I made a quick video or wrote this little article explaining 'this' about Lexapro or SSRIs in general, at a friendly level, introductory level that can help both patients, clients, or maybe at a level that could be helpful for therapists. They are very savvy of mental health in general, but they may want to learn more about specifically psychiatry or psychopharmacology.

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Tyson Conner  53:51

Yeah, well Listener watch this space, because as soon as Mati finishes, whatever one of these are, we will plug it. Because that sounds really useful and like something that would really serve a need, right?

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Mati Massaro  54:04

I hope so. 

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Tyson Conner  54:06

Well thank you for coming on the podcast. We we will have you back. And I'm excited to keep learning about this stuff because, genuinely this feels like an integrated way of doing mental health care that sidesteps maybe one of the, weirdly more tension-filled divisions in mental health care, in my experience. At least in the greater Seattle area. There is this kind of - psychotherapist tend to be a little bit like "Eh, medications." And a lot of medical providers tend to be like, "Eh, talk therapy." And what I love about this way that you're talking about doing it, is that it's truly integrative Which, to me, feels like the obvious thing to do.

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Mati Massaro  55:04

That's right. That's why I talk about shoes and teamwork. And the way I see it, it's salt and pepper, you know. We use both, they're both excellent. And they both have different properties that lead to a great meal. And we deal with a great outcome and with improved therapeutic goals. And it's unfortunate that we've come to this divide. Because that's also not what science has shown us, right? Both are extremely effective. And both are effective together. So collaborating on them sounds like the way to go to me.

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Tyson Conner  55:50

See, that's the bit that makes me pull my hair out. And this is true for so many things in mental health treatment, is that every camp -- you know, the EMDR people have their evidence, psychoanalytic people have their evidence, the CBT people have their evidence -- and I'm like, "Great, look at all these things that work!" But the feeling is, "Look at the proof that my thing works." And this sounds like a way of being, "Yeah, guys, look at all the stuff that works. Let's try to let it work together. For the sake of the patient."

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Mati Massaro  56:24

Yeah, it's like discussing what's better, salt and pepper. Like, they're both awesome. And we use them together for pretty much everything. So let's be a little more reasonable and open minded and mindful of the science and set people up for success. That's the bottom line, right? We want to work together, be part of the defense, be part of the offense and help clients or patients feel a little better. That's the bottom line.

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Tyson Conner  56:59

Right. To the Listener, you are living your whole life. And we can help you with the parts that we know about. And the parts that you show us and the parts that we have our own specialized training and understanding about, but you want to live your whole life. We don't want to just focus on one way of of treating to the exclusion of all others. 

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Mati Massaro  57:22

That's right. 

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Tyson Conner  57:23

Thank you for coming. We're gonna wrap this up because we've hit over an hour of recording. So this will be a long one. And I look forward to having you back and continuing this conversation. This is exciting.

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Mati Massaro  57:36

I'm excited too. This is fun.

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Tyson Conner  57:42

Special thanks to Matias Massaro. Mati can be found at his website cogniahealth.com. The link to his website is in the show notes. There is no experiment for this episode, try as we might, neither Mati or I could think of a responsible way to assign an experiment involving psychotropics. If you think you may benefit from psychopharmacological intervention, consult with your primary care provider or psychiatric prescriber. For further learning, we actually recommend Mati's website cogniahealth.com link in the show notes, where he will be publishing blogs, videos, and podcast episodes of his own all about the topics we discussed in this episode. This podcast is scheduled to release right around the time that Mati is hoping to have launched his website. So I'm as excited as you are to see what he puts up there. In two weeks, we'll be speaking with Mati again, this time specifically about SSRIs, the most commonly prescribed psychiatric medication. So if this conversation interested you but you're curious to get more into the weeds about a particular medication, consider giving that one a listen.  The Relational Psych Podcast is a production of Relational Psych, a mental health clinic providing depth oriented psychotherapy and psychological testing in person in Seattle and virtually throughout Washington state. If you are interested in psychotherapy or psychological testing for yourself or a family member, links to our contact information are in the show notes. If you're a psychotherapist and would like to be a guest on the show or a listener with a suggestion for someone you'd like us to interview, you can contact me at podcast@RelationalPsych.group. The Relational Psych podcast is hosted and produced by me, Tyson Conner. Carly Claney is our executive producer with technical support by Sam Claney and Ally Raye. Our music is by Ben Lewis. We love you buddy.

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Further Learning: 

Mati‚Äôs Website: http://cogniahealth.com/‚Äć