Ep. 161 | How to Find a Psychiatrist: Online vs. In-Person Care

Karin Ryan (00:01.336)
Hello and welcome to another episode of Everyday Therapy. My name is Brett Cushing. I'm a licensed marriage family therapist here with Sage and Behavioral Health. I am joined with my highly esteemed co-host, Dr. Karen Ryan. Hello, hello. Who just came back from vacation. Good to have you back. It is good to be here. And it also is good for us to have with us Dr. Kirsten Utter, psychiatrist here with

Sagent Behavioral Health, and we are very glad to have you here. Welcome, Dr. Utter. Thanks so much for having me. Good to be here. Yes, I I'm very happy to have you here because we are addressing a lot of the concerns and questions people have as it relates to seeing a psychiatrist. And over the years, I think it has become and evolved into something that people they don't have as much of a stigma with, and they might have questions. So we're going to try to

Address some of those questions people have and so And the questions of who does what? Like what does a psychiatrist do? What does a psychologist do? What does a therapist do? Which are all really good questions and it can be confusing. So we hope to like answer some of those today. Yes. Yeah. Great. So maybe our first question, Doctor Otter, is what can patients expect

When they come for a medication appointment, what is that like? Are you diving deep into their past and learning all about past traumas? What what's happening there? That's a great question. so psychiatrists and mental health medication providers you know, work in the medical field primarily and so we use our medical education and training to treat mental health problems. And so

We do tend to come at things from a bit of a more medical perspective than maybe a psychologist or a therapist. And so what I would say to somebody in terms of what to expect at their first visit, it'll probably be long. It will probably be over an hour, and there will be a lot of questions. The questions will range from things about the symptoms, of course what's bringing them to the visit, what they have already tried, and getting into also things like their medical history, other medications that they're on.

Karin Ryan (02:18.262)
In terms of diving deep into kind of trauma, I think it varies from provider to provider. Personally, I think those things are are often better explored down the line. Initially in the first visit, a lot of times I will you know, ask ask a patient, are there things in your past that you feel like continue to follow you around and give you a lot of distress on a day-to-day basis? but we don't need to go into the details of that. But it does help me with diagnosing.

Issues and diagnosis is obviously the foundation of our treatment. So that's that's kind of what the first visit is often like is a lot of questions. Mm-hmm. And yeah. Yeah, and you ask all those questions, right, so you don't miss anything. You get kind of a full picture of the person, right? Like what are some of the things that like are helpful for a psychiatrist to know when they're kind of meeting with a client coming in for a mental health needs.

Yes, absolutely. Well, so we always try to make evidence based decisions, make evidence based recommendations for patients, and that really comes back to making an accurate diagnosis because all of our clinical trials are based on, you know, are done in patients with the same diagnoses essentially. and so we really are asking a lot of questions to make sure we fully understand somebody's diagnosis. not just about symptoms, but also things like, you know, okay, how much

You know, how much maybe have you been also kind of like self-medicating with things like substances? And that's not coming from a place of judgment. That's coming from a place of trying to understand how much of your symptoms might be due to other things as well. and same with asking about other, you know, medical problems. We're also trying to get at, are we sure this is a hundred percent psychiatric, so to speak? Is there any chance that this could be related to other medical problems? we ask a lot about people's social history.

you know, for example if I if I'm worried about somebody who has a lot of mood instability and worried about a bipolar disorder and I find out they work nights or they work an irreg a really irregular schedule, you know, that might actually become part of the treatment recommendation is I I think you need to make a more regular work schedule for yourself, that kind of thing. Yeah. So it sounds like you'll you know, you're thinking about medications but you're also thinking about in their environmental pieces and all the things that they're experiencing and how do you work as a team to figure out what's gonna help.

Karin Ryan (04:39.234)
A hundred percent. Yeah. Yep. Yeah. Now a lot of people have questions about in person versus telehealth. Do you does it matter? Is there a preference? I is one different than the other or is it just strictly based on convenience for people?

I think it's it's largely convenience. there I think telemedicine is great because it is really expanded access to mental health care for people who maybe not aren't able to drive, for people who live in rural areas, for people who maybe have really special special needs that are only met by maybe certain clinicians that are really far away. and

I think it really comes down to the and if it's not a matter of kind of convenience or need, I think it does come down to preference. so would you rather be meeting in somebody's office more kind of your your standard visit to a medical clinic? you know, going in in person, sitting in the psychiatrist's office. I would say the differences with in person is often they're they're able to

do kind of a a brief we don't we don't really do thorough physical exams in psychiatry, but you we might get a set of vitals. if you're concerned about certain side effects, we might be able to physically, you know, look at those or observe those together. and similarly if somebody has side effects that they're worried about that are hard for me to maybe appreciate on telehealth, I might ask them to come in person for their next visit. Can you think of an example of what that might be?

so sometimes people, for example, on antipsychotic medications will develop difficulties with movements. so tr tremor, stiffness, and some of that might be hard to see on telehealth and it's really important to follow and we have an objective scale that we kind of measure those side effects on. Okay. And so it'd be important for them to come in person. Now, when they come for sessions after that first one, that's pretty long. Are they all that long or what's the standard session look like and how long?

Karin Ryan (06:40.432)
Yes, at Sagent, the follow-up visits, at least in the Minnesota setting right now, are twenty-five minutes for our follow-ups. Twenty-five minutes. And then how what's the cadence by which most people need to return for follow-up visits? That's a good question. And there's a lot I would say there's a lot of variability. often when I meet somebody for the first time I want to see them in a month.

because oftentimes the first time I meet somebody I am making medication changes. I'll probably want to see them in a month or sooner. Sometimes I'll say, I actually want to see you again next week because I didn't finish going over this thing that I think is really important for me to understand and make a decision about your care. but oftentimes people can spread it out as much as three to six every three to six months.

Okay. Yeah. And what I I'm wondering your experience with how that it can be flexible and then it can vary too. So I was thinking about your response for like virtual versus in person. And I think one of the benefits too is that there's an option where you know you might start in person and then once you kind of get to know, might switch to virtual or the other way around. You might feel a little apprehensive about starting, can start virtual, and then you're like, hey, I want to come in and see this person. I have some questions. And so I'm wondering, do you experience that where there's can be flexibility?

and sometimes you're in person, sometimes you're virtual, and then sometimes symptoms are increased, so we're gonna meet more often and then other times we're doing well with the current like plan. So we'll see you in a few months. Like has that been your experience, Dr. Utter? Yep. And I think that's actually that's actually kind of all part of the medical decision making, right? Is how often am I going to see you? Is this a an interval where gosh we should really start seeing each other more often?

Are we anticipate sometimes t certain times of year are more difficult for people and we might say, Gosh, I really want to see you every couple of weeks over the summer, over the winter or whatever it be. yeah, and in terms of the the telehealth versus in person, we switch back and forth. I can think of, you know, several patients that that kind of go back and forth between in person and telehealth, and I think it depends on kind of their availability, the the convenience of it, their schedule.

Karin Ryan (08:48.374)
it's kinda fun it's actually kinda fun when I've only met somebody on telehealth and then

And then for whatever reason we have our first in person visit. It's like it's it's like, my gosh, you're you're a real person here in my office. Yeah. It's like meeting meeting a little bit meeting again for the first time. It's fun. It's it's energizing, can it be at times? Yeah. Yes. Yeah. Yeah. What would you wanna tell somebody if they're feeling nervous or apprehensive about meeting with a psychiatrist or a medication provider who specializes in mental health?

I think you know, the first thing I think I and maybe this is a little bit simplistic, but I I think the first thing to keep in mind is like this really truly is our job and something that we like to do, so you're not going to be a burden.

y you know, you're not going to and it's all confidential. That's one of the you know, the foremost pillars of medicine. This is all confidential. Yeah. and there's really there's also a lot of think a lot of people come in and are self conscious that like, I don't know if I really need this. But I think that itself is a good enough question to bring to a psychiatrist. And I'm guessing your recommendation would be,

As somebody who cares about people, I would always rather you come in earlier than later because the sooner we can start some interventions and support, like that tends to be the most helpful for people. So don't don't feel like you have to wait till, you know, too long. Mm-hmm. So Dr. Utter, you're a you're an D as a psychiatrist. You could have gone into other fields. Why did you choose this field in particular?

Karin Ryan (10:29.334)
Yeah. I so I always really liked b like the brain the brain, mind behavior connection. That was kind of my area of study in undergrad. And then when I went to medical school and I did my clinical rotations, I was trying to keep an open mind. And there there was something about every specialty that I kinda liked. But I really felt like on every specialty, even not my psychiatry rotation, people's kind of mental health,

the emotional struggles that they were experiencing, those were always the things that I wanted to talk to them more about and understand more. And so I I think so it was like I wanted to do psychiatry even when I wasn't on my psychiatry rotation. And that made it a pretty easy yeah. Yeah. That made it a pretty easy decision. That's great. That's great. Good for you. It sounds like a dream come true. And now I gotta ask

The elephant in the room question that I think a lot of people have is there's this narrative out there and I hear about it. Everyone's just over medicated today and we just very quickly put people on medications. I hear that narrative and I cringe every time I hear it. What would you say to people who have that concern?

I think it's a valid concern. I you know, I I certainly understand why you would be worried about that. I I think what I would say would be if I had somebody kind of come to me, I might want to clarify what their sp specific concern is. you know, by over medicated do you mean

like we're numbing normal emotions? Do you mean you're on more medication than you need? Do you mean we're doing something like irreversible to your body or giving you side effects? I just wanna kinda clarify clarify exactly kind of what the concern is so that we can address it. Mm-hmm. and I would also say that, you know, there's pretty there's a couple of really important again, those fundamental pillars

Karin Ryan (12:36.692)
of care in psychiatry and one of them is using the lowest effective dose. So this is why this is why we titrate medications slowly over time, because we want to make sure that we don't skip over a dose that would actually be just as effective for you as a higher dose because the less medication, the less dose we can use the better from a side effect profile.

And then the other one is we really want to stay away from polypharmacy as much as possible. So that means having multiple medications on board. so as as much as we can, like if somebody is already on one medicine and they're still having some symptoms, optimize use of that first medicine.

before we add something else if possible. Thank you. I'm so glad you pointed that out. That we start at the lowest level and that's that's our desire is to start there and we're not just knee jerk. Let's put people on meds right away and and I think people do have concerns about that. And like you said, some of the side effects that they're gonna endure. do do side effects last forever? I know this is a really general question and it's gonna

Hard because each med is different, but what if somebody were to say, I'm I hear about all these terrible side effects and I don't want to go on meds because I I just don't want to deal with that. That sounds terrible. And what would you say to that? Yeah, I would say that most of our medications do cause some type of side effect. Most medicines in general, not just in psychiatry, but

the large majority of side effects are transient, you meaning they're there when you first start the medication but eventually go away with continued use and are mild. So not not things that interrupt people's functioning, or even make them want to stop ta taking the medication. And when you say transient or short term, like are you talking weeks, months, like typically kind of how long are those kind of like more negative side effects at first?

Karin Ryan (14:40.8)
Yeah, I would I usually I usually give people anti anticipatory guidance of a c a couple of weeks. And if things aren't getting if things aren't getting better after a couple of weeks, then maybe we should go back to the drawing board. Yeah. Yeah. And my experience, Dr. Edder, has been when one of my clients starts a new medication, oftentimes they will see their med provider sooner, right? So that med provider will be like, Hey, since we're starting this new med, we're gonna meet in six weeks to check in and see how it's going. Is that typically how you practice too?

Yeah, exactly. If I'm making a medication change, I like to check in. usually within a a month to six weeks, just to follow up on how that change environments. And how you're doing on it. Yeah. Yeah. So this is a big question. go ahead, you go. I was just gonna say and I think I think the other thing about, you know, the concern about folks being over medicated is that

You know, I I do always try to give recommendations that aren't medication too. because I I know at the end of the day, you know, my my goal isn't necessarily to give somebody medication, it's to help them, right? And I I know that medication isn't for everybody. so I always try to make my approach kind of both

recommend maybe making a re medication recommendation, but also recommending other things that they could do that would probably help in an evidence based way. So whether that's different types of psychotherapy, interventions for sleep, interventions for lifestyle, exercise, diet, et cetera. So Yeah. Yeah. And I want people to know from my perspective, as someone who does therapy, why I appreciate medication. I find

This is the way I explain it to clients. I if we get stuck and we're not going anywhere in therapy and it just seems we're we're halted, no progress, nothing's happening, then I then is when I start to think about medication and think, okay, maybe we want to do a referral for that. And what I find is that people are kind of spinning their wheels. In in Minnesota in particular, we know what that's like in winter. You know, you get caught in the snow and you're just the wheels are spinning no traction.

Karin Ryan (16:52.208)
And it's frustrating for the client, it's frustrating for the therapist because we want to move forward. But when they start medication, maybe not in those first couple weeks, but as it gets in their system, ooh, all of a sudden there's traction. Kind of like when you're pushing somebody out of the snow and there's traction and then there's hope. Like, hey, I'm gonna get out of the snow. And without that that traction, you're just gonna stay there. And the medication.

provides that type of traction in therapy where we're just kind of halted. So I really appreciate it. And when that happens I see my clients make tremendous progress. I get very excited. It's probably the medication. But I like to think it's me and that's why I'm particularly appreciative of what you all do.

Well, I appreciate that. And I I think it goes both ways because I'll I will work with with people too for a long time with with medication management. and oftentimes they then, you know, at some point in the treatment connect with a great therapist and the next visit it's like those stubborn symptoms that we were trying to target with medication changes are are better.

having started therapy. So I see it go both ways. Yeah, that's great. Yeah. Yeah. What this is a big question. so I don't expect you to answer how does every single like mental health med work. But I think one that is like common for people that they hear about is like a you know, medication for anxiety or depression is a an S S R I or an S N R I. Would you explain, you know, kind of how to us, how you explain to clients and others like how do those medications work? Like how do medications help with like depression anxiety in general? Yeah.

Yeah, so you know, it is different from medication to medication. And what I'll say is that there used to be what we call this monoamine hypothesis of of psychiatric illness, meaning it all had to do with neurotransmitters, serotonin, norepinephrine, dopamine, et cetera. because the medications we use affect those neurotransmitters.

Karin Ryan (18:59.234)
But as time goes on, we're learning that it's kind of a yes and. Like it's probably more a lot more complicated than just these medications change the levels of the neurotransmitters in our brain. It's probably kind of the cumulative effect of you know, a lot of times when you start taking SSRI, your your doctor might say, We won't know the full effect for six to eight weeks.

And that's because we actually think that the the benefit probably comes from changes that happen on kind of a histologic or a cell level in your brain from having that kind of higher level of serotonin for a while. So for example, you know, neurons, the top of neurons kind of look like little trees, right, with little branches. and over time when somebody's on, for example, an SSRI, we actually see increased what we call arborization, so more branches.

with with that medication use and that that takes the six to eight weeks and so we think that's that probably has something to do with the effect of the SSRIs. Like we're making new connections, in the brain with our medications. I think I just think it's amazing and it goes to show how

Brains really are more plastic, I think, often than we give them credit for. Yeah, and I think it's so validating too, as you describe that, the the truly like neurobiological aspect to mental health needs that we can really come together and work on it and address it in different ways, but that piece of like that medications really help with that. Mm-hmm. Mm-hmm. Yep. Yeah. So what about you mentioned the word titrate, and that might be

important part of this answer to this question and might need you to explain what it means to titrate. So given that, what what about staying on meds? Do I have to be on medication forever? Do I ever get to go off? What if I just wanna stop? Any thoughts? Yeah. Yeah. it's it's definitely an individual situation type of question. I'm

Karin Ryan (20:57.814)
Remembering some some of my mentors from residency who would tell me every time you start a medicine you need to have a plan of when you're gonna stop the medicine.

you know, and talk about that with the patient up front. Is this going to be something you think they need to be on for the rest of their lives? Is this something that you think we should get you to, you know, sometimes, for example, if somebody has a single episode of depression in their lifetime, oftentimes a recommendation is let's get you to remission from your depression. Let's keep you there for at least a year. And then if you would like and if you're kind of if you're up for it, let's try to get you off the medicine.

and see if you can kind of stay there. Recommendations change a lot based on you know, the person's history, how many mental health episodes they've had, how many different medications they've tried, what the diagnosis is. but by and large, if people want to come off of medications and, you know, I I think that there's a way to do it that won't, you know, where the the potential benefits of doing so outweigh the risks, then then we can try.

So there are risks you're saying. If I'm hey, I'm feeling better, Doctor Otter, I I stopped taking my meds two weeks ago. I what what would you say? well I I mean I think the main risk is that is having relapse of whatever the symptoms were before. so I you know, I think if somebody has stopped taking their medication and th and they're feeling really good, you know, I'm

probably just going to provide again that risk benefit analysis to them. I I might say, I you know, I think your chances of relapsing are really, really high without this medication. or, you know, depending looking back at the history, I I might say, you know,

Karin Ryan (22:40.694)
Since you're feeling okay right now, I I actually don't think it's that risky to just continue like this. It would very much depend. So you're not the medication police is what you're That's right. Okay. And my guess is that you know you've kind of alluded to this a few times, Dr. Arter. Like as we wrap up, I'm thinking about that it's like a team approach. When you are working with, you know, a patient or a client, that the two of you are figuring the things out and talking about it. It's never you just telling them what to do, it's recommendations and talking through it.

And I'm just curious about kind of like your experience doing that team approach with clients. Mm-hmm. Yeah, I mean I think I think that's the most rewarding part of the job is you know, doing providing a lot of education to the patients that I work with, especially when it comes to making recommendations and providing that kind of risk benefit analysis. and coming to the decision together because I'm

Like like Brett said, I'm not the medication police. I like I very much want this to be collaborative because I I think that, you know, it the whole the whole thing works better when it's collaborative. yeah. And when of course when people feel empowered about their own medical decisions,

You know, I'm I'm also here of course to do no harm and and make sure that nothing dangerous happens. So there are there are sometimes like lines in the sand that you draw. Yeah. but where there is room for collaboration, that's I think that's the best thing. And I think we'd be remiss if we didn't highlight with Sage and behavioral health being as large as we are, we can collaborate so much better because for instance, Doctor Otter, you work at my clinic and if I have a concern or a question, I can go down the hall, I can talk to you.

And we can collaborate very easily because it's it's all integrated. It's kind of a one-stop shop for so many of the mental health disorders that we're struggling with. So I know having you at our clinic is super helpful. Yeah. Mm-hmm. Yes. And I really like talking to the therapists in our clinic too about mutual clients that we have. Yeah. Yeah, it's super helpful. Yep. Yep. I just had the same experience this morning. Just saw our shared client and updated me on a few things. And so it's just

Karin Ryan (24:54.554)
It is so w such a great experience of knowing we can all work as a team. Right? It's just the bigger team, right? More results. Yeah, it it is it's you can't find that when with just isolated clinics. It's just it's hard because you're trying to

coordinate with the med provider's schedule and your schedule and calling them and there's a lot of hurdles. So I I just wanted to highlight that because I think it's agent it it was really a nice benefit to have for people to ensure continuity of care and quality care. Yes. Yeah. And it's so much easier to connect people to also the other resources like substance use treatment, ba the behavioral sleep medicine program that we have now. So yeah. Any final words you want to make sure our listeners hear?

no, I can't think of anything profound. Just thanks for having me. It's been such a pleasure to have you and really appreciate everything you shared with us today. Yes, Dr. Otter, thank you so much. I appreciate your genuine care and concern for the mental health of all of our patients. And we hope that this has been very helpful. I'm guessing it's gonna stir up even more questions for people. So we might even look to you to join us again sometime. That sounds great. Bye all.