Podcast transcript

INTRO
Welcome to Docs in a Pod, presented by WellMed. Over the next half hour, Docs in a Pod will educate you about the health and wellness of adults everywhere. Co-host Dr. Rajay Seudath that's an award winning veteran broadcaster. Ron Aaron will share information to improve your health and well-being. And now here are Ron Aaron and Dr. Rajay Seudath.


RON AARON
Hello there and welcome to the award winning Docs in a Pod. I'm Ron Aaron and delighted to have you with us. We're going to be talking today about a really, really interesting subject. It'll be looking at depression and anxiety later in life, and it turns out it is unfortunately pretty common. Our special guest today is Johnathan Rhoads. He's a board certified physician's assistant. He currently practices family medicine at Well at Oak Cliff in Dallas. He graduated from the UT Southwestern Physicians Assistance Program and is deeply committed to building meaningful connections with his patients. Johnathan, when he's not at the clinic, loves to play tennis and pickleball. He told me he comes from a very small town in Texas. Murchison, Texas. Total population is 600. Now down to 599 because he left. Hey, Johnathan. Thanks for joining us on Docs in a Pod.


JOHNATHAN RHOADS, PA
Thank you for having me. An honor to be here with you.


RON AARON
You've had a lot of experience working with an older population. You mentioned to me that before coming to WellMed, you worked at an assisted living facility for some three years. What attracted you to older people?


JOHNATHAN RHOADS, PA
Actually, I just had an opportunity for the job. I didn't really know the attachment that I had to the geriatric population until I really just went for that opportunity. I started there in the maintenance department actually. I always knew that I wanted to go into health care, so I was pursuing that aspect of my life. I further got acquainted and started doing caregiving at the assisted living facility and started interacting with that population and really just fell in love.


RON AARON
It's interesting working in maintenance. You get into everybody's rooms fixing air conditioners, right? You saw everybody.


JOHNATHAN RHOADS, PA
You would think I was fixing air conditioners, but sometimes we had those long talks.


RON AARON
That's a really good point. Talk to me about challenges for depression and anxiety in the older population. I know, for example, according to the Center for Disease Control that ages 65 and over, white males are very likely to be depressed and commit suicide.


JOHNATHAN RHOADS, PA
Yes. Exactly. That's definitely the case. Over 14% of adults age 60 and older are actually affected by depression. Oftentimes depression is linked closely with anxiety, so this is definitely a population that it affects a lot. Many people think that it's a common part of aging, but it's really not, so it's important to seek that help. Although that's one of the main problems surrounding the mental health disorders is ultimately that people see the stigma surrounding them and sometimes don't feel so secure reaching out for that help that they actually need.


RON AARON
When you look at the statistics and see patients as a physician's assistant, is it apparent to you when someone comes in that they may be depressed?


JOHNATHAN RHOADS, PA
Oftentimes whenever you walk into a room, you can tell first hand if someone looks sad or depressed. But for the most part, some people can hide it very well. So, without them being honest on our screening tools that we use at visit and without them coming to us with these problems that are concerning them, we may never know if we don't ask. So, that's why it's so important to ask these patients these simple questions to see if they're being affected by this condition.


RON AARON
What do you ask?


JOHNATHAN RHOADS, PA
Generally speaking, for the population that's 65 and older, we have some screening tools that we ask at their Medicare annual wellness that’s like being screened for anxiety and depression. For depression in general, there are different screening tools, including the PHQ2 and the PHQ9. These are questionnaires that are very highly sensitive and specific for finding out if there's depression. In addition, there's another screening tool for anxiety. For depression in general, we want to know in the last two weeks if you've felt depressed as far as your mood goes, or if you've felt like you haven't wanted to participate in activities that you once enjoyed. These are two things that are required for the diagnosis of depression, and they kind of lead us into a further investigation.


RON AARON
Are people honest with you?


JOHNATHAN RHOADS, PA
Sometimes they're not, and that's where stigma plays a role. I think it's important if there's a message out there to the patients to be honest with your providers because honestly, we want the best for you and there's no judgment whenever you walk into that clinical room. We ultimately are just there to help you. So, without you being honest and telling us the symptoms that you're having, we can't do that.


RON AARON
Stay with me for just a minute. For those of you who may have just joined us, you're listening to the award winning Docs in a Pod. Our podcast is available wherever you're listening to your podcasts. We're also on the radio in a number of cities in Dallas, Fort Worth, San Antonio and elsewhere across Texas and in Florida as well. I'm Ron Aaron. Our special guest today is Johnathan Rhoads. He's a physician's assistant, and we're talking about anxiety and depression among older Americans. Johnathan's at the WellMed at Oak Cliff clinic in Dallas. Johnathan, when you discover that somebody may be depressed, what can you do about it?


JOHNATHAN RHOADS, PA
It's important to assess the severity of the depression, and to also rule out any underlying medical conditions that may be factoring into the depressive symptoms. We want to ensure that this is an accurate diagnosis. Sometimes there can be other medical conditions that may mimic signs of depression, such as hypothyroidism.


RON AARON
What is hypothyroidism?


JOHNATHAN RHOADS, PA
It's the under activity of your thyroid gland, which overall decreases the amount of metabolism in your body. It can lead to other symptoms like weight gain or it can lead to constipation, but some other symptoms can be mood changes like depressed mood. So, we want to rule out these things as well in the workup of someone that may present with these symptoms to ensure that's not what's going on.


RON AARON
I know there are a lot of medications over the years that have been used to treat depression. Do they work in older people as well?


JOHNATHAN RHOADS, PA
They do. They've been shown to be pretty effective; however, our approach is a little bit different sometimes in the older population because the good rule of thumb is for clinicians to start low and go slow in our older population. Sometimes these patients in this demographic can be a little bit more susceptible to certain side effects, so we just want to monitor them a little bit more closely. But they do have good outcomes.


RON AARON
One of the things I was thinking about when you're interviewing a patient, I would think it'd be helpful if they have a caregiver or a spouse or a significant other to have them come in with them.


JOHNATHAN RHOADS, PA
Oftentimes that’s a really great thing and that's part of that prevention in general is just to have someone there that’s going to support you throughout the process. One being your clinician throughout your visits but another one being a family member or a close friend that's going to encourage you to kind of carry through with the recommendations that were given to you and be there as a mental support.


RON AARON
Like, hey, come on, Ron, tell Johnathan Rhoads you really are depressed. You're hiding it from him. Do you get that sometimes?


JOHNATHAN RHOADS, PA
Yes. Especially with spouses. You can kind of see whenever you're interviewing a patient and you ask them a question, and then their wife is behind them saying, no, that's not right. They're not telling you the truth. So, that's definitely helpful. Oftentimes, they allow you to have that heart to heart conversation and allow them to know, again, to reassure them that there's no stigma associated here in the clinic. We have no judgment towards you, and we truly won’t judge.


RON AARON
Now, what would be the kind of symptoms that a spouse or a son or daughter or a loved one might see in an older person that signifies depression?


JOHNATHAN RHOADS, PA
They can just see a change in mood. Loss and interest, like we said before. But other things can just be like a loss of energy in general. They can see that they may have, like, low movement, restlessness, poor sleep, or maybe increased sleep. Some other symptoms include weight gain or loss or maybe they're not eating as much anymore because they have a decrease in their appetite. Or maybe they're eating too much because they have so much increase in appetite. So, these are some of the symptoms that we can watch out for. But some of the main symptoms, the serious ones are talks about death, suicide or planning anything.


RON AARON
That's a good point because as I noted earlier, according to the Center for Disease Control, white males who are 65 and over are susceptible to suicide. But it's not just them.


JOHNATHAN RHOADS, PA
You're exactly right. It's not just them. About 37% of the depressed older adults may present with suicidal thoughts or ideations. So, it's important that we are asking all of our patients these questions. With that topic, and just so everyone's aware that the National Suicide Prevention Hotline is a simple number. I know everyone remembers 911, and the suicide prevention hotline is 988. So, if someone is out there and they're too scared to bring it up to their PCP or their provider, it's important to talk to someone at least.


RON AARON
One of the challenges, of course, is the old wives tale. If I ask you if if you're thinking of killing yourself, you'll go ahead and kill yourself.


JOHNATHAN RHOADS, PA
That's not necessarily true. I think it's important to identify the problem at hand, and then allow us to give you the resources to overcome those challenges. Sometimes people don't know where to go. So, oftentimes that's why we see most of the cases of depression and anxiety present in the primary care world. So, we have those resources available and we can lead you in the right direction.


RON AARON
As you think about older people and the challenges that they face, financial pressures are one of them. And that, of course, can lead to depression.


JOHNATHAN RHOADS, PA
Exactly. That is definitely one of those factors that can lead to depression. You're exactly right.


RON AARON
Loss of job. Death of a loved one.


JOHNATHAN RHOADS, PA
Definitely. One of the big ones is social isolation. If you're having trouble with sleep or loss of physical activity, these are just the simple things that may lead to depression or depression.


RON AARON
When you talk about social isolation, I'm thinking of you growing up in a town, Murchison, Texas, with about 600 people, everybody knew everybody, right?


JOHNATHAN RHOADS, PA
Exactly. You've got to be careful there.


RON AARON
The good thing is there was support for friends and neighbors that you might not find in a bigger city.


JOHNATHAN RHOADS, PA
Exactly. That's definitely true. That's kind of what we hope for in the older population. As you get older, it is natural to not have as many people around. Children grow up, grandkids may be far away, but you have to find that sense of closeness to something or someone. Whether that be church or planning to visit your grandkids on the weekend, getting involved in some type of community service or maybe a community center. It's definitely a great idea. And somewhere to start.


RON AARON
Stay with me for a minute. I want to find out the difference between depression and anxiety and how they relate. I'm Ron Aaron. We're talking with Johnathan Rhoads. Johnathan is a physician's assistant. We're talking about managing depression and anxiety in later life. You're listening to the award winning Docs in a Pod.


AD
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RON AARON
We are so pleased you are staying with us right here on the award winning Docs in a Pod. Our program is available on podcasts wherever you get your podcasts. We are also on the radio in several cities in Texas and Florida. I'm Ron Aaron, and we're talking with physician's assistant Johnathan Rhoads. We're talking about managing depression and anxiety in later life. It turns out to be very, very common. Johnathan, depression, anxiety, what's the difference?


JOHNATHAN RHOADS, PA
Anxiety is more of an excessive amount of worry. This is something that can be associated with other symptoms in addition to worry. A lot of times a diagnosis is required to have the symptoms for six or more months but we'd want to know if you're experiencing any of them. Some other symptoms to be aware of are restlessness, feeling very keyed up or on edge. Also fatigue, which kind of leads hand-in-hand with depression. You can kind of see where they overlap. Difficulty concentrating, which is also seen in depression. Muscle tension and then also disturbances in sleep. As we discussed earlier, some of the symptoms of depression, you can kind of see there is overlap in both areas. But this one's more of a sense of worry as opposed to a depressed mood.


RON AARON
I know some folks self-medicate. They may not tell you they've got a problem, but they're taking all kinds of over-the-counter sleep medications. Maybe they're drinking too much. Are those things that you try to probe and find out about?


JOHNATHAN RHOADS, PA
Yeah, it's very important because in order to have an accurate diagnosis, you have to rule out those things. Anxiety and depression can be caused by other disorders, including alcohol use disorders, different substance uses. So, we have to kind of roll those things out whenever we're interviewing a patient just to make sure that that's not the cause. Because if that's the cause, then it may not be a major depressive disorder, it may just be an alcohol use disorder or another type of substance use. So, it is important to differentiate between the two.


RON AARON
How do you get to the facts? Because we know a lot of folks who may be drinking too much don't always tell you that. You ask them how much are you drinking? They have a drink a day and they'll lie to you. How do you penetrate the deception?


JOHNATHAN RHOADS, PA
I think you just have to have a face to face conversation with someone, and just let them know that their honesty is going to lead to a better outcome for them. So, that's kind of something I always lead with, and allow them to know that ultimately, again, I'm not judging them. I truly am here to help. So, whenever I ask them how much they drink, I say, okay, how often do you not drink? I have some questions like that to get into the mix. Maybe they're more susceptible to answering those types of questions. Okay, you drink liquor. Do you drink five mixed drinks or do you drink shots? Do you like crown and coke or what do you like? Whenever you start talking to them person to person, it gets a little bit more comfortable and allows them to be more open and honest.


RON AARON
When they say, well, I only have four martinis at night, you don't go, oh my God.


JOHNATHAN RHOADS, PA
No. It can be surprising sometimes and what patients will tell you, but it's important to remain in your composure. Because if you tell someone that you're not going to judge them, it's important to stick by that, and I think it's important for the trust that is built between you and your patient. So, definitely try not to react that way but offer understanding. Maybe there's a reason why they are drinking that much and find out that instead of having so much judgment.


RON AARON
It's interesting, you said when you were working on maintenance at that assisted living facility, a lot of the time you spent in rooms was talking with people. A lot of lonely people, and when you get that conversation going and if you listen, I imagine you can learn a lot.


JOHNATHAN RHOADS, PA
You can definitely learn so much. The population has so much wisdom to offer. They also often are just ready to talk to someone. Oftentimes this is the population where they want to come in the room and they just want to have a therapy session with you. They are eager to talk to you and share their experiences about visiting their grandkids over the weekend or a trip that they just went on. So, definitely you can learn a lot just by having an open ear and listening.


RON AARON
How do you get them talking?


JOHNATHAN RHOADS, PA
Generally speaking, you can ask about the grandkids if they have grandchildren or their pets, and that kind of opens the door from there.


RON AARON
Pets are big door openers, right?


JOHNATHAN RHOADS, PA
Exactly.


RON AARON
As you think about the challenges you face as a provider with an older population worried about depression and anxiety, what are your biggest challenges?


JOHNATHAN RHOADS, PA
I think my biggest challenges are expectations. Patients often have this expectation that this is going to get better after I start this medication or this is going to get better after I start therapy. I think talking about these expectations upfront is important because that is not always the case. Sometimes these medications can take 4 to 8 weeks to start taking effect, so that's really important to know upfront that way you eliminate that to begin with.


RON AARON
As you think about those expectations, they also have expectations for you as their provider.


JOHNATHAN RHOADS, PA
That is 100% correct.


RON AARON
As you think about the number of people that you're dealing with, spending time with them gives you knowledge and expertise that you might not have otherwise. If you were working in a clinic where you were paid by the patient and you had to get them in and get them out, that would be quite a challenge.


JOHNATHAN RHOADS, PA
That's definitely correct. I agree with that statement. I do think it's important to spend the time with the patient as well as to have close follow-up with them. Genuinely speaking, after starting a medication, we want to see you back or at least make contact with you in two weeks and again at one month. So, we kind of see how you're doing over the period of time. Just like we talked about in the beginning, we screen you for depression and we ask these questions, and we'll ask the same ones later on if we start a medication or something just to see how you're doing over time. So, don't think that we're just going to start you on a medication and throw you out into the world, but also know that it takes time for these things to change.


RON AARON
What are some of your go to medications?


JOHNATHAN RHOADS, PA
In this population, the first line medications are Selective Serotonin Reuptake Inhibitors, also known as SSRI. These medications have a better tolerable side effect profile and they're more tolerated by the older population. These are some of the first line medications that we use.


RON AARON
What are some of the brand names?


JOHNATHAN RHOADS, PA
Some of the brand names include Celexa, Lexapro, Paxil and Zoloft.


RON AARON
When a patient says to you, I go to a senior center and I was talking to Mr. Jones, a good friend, we are pool players, and he's taking this medication that helps him, and he's been sharing it with me.


JOHNATHAN RHOADS, PA
That's definitely a hard one. We do get that from time to time or we'll say, oh, my aunt let me take one of her medications. We do recommend against that for sure. But if you're having these symptoms, we need to address that, but we need to give you a thorough evaluation and make sure that this is the correct medication for you. So, I wouldn't recommend taking someone else's medication, but if you feel like you have one of these problems, definitely discuss it with your provider.


RON AARON
So, you have people who are doing that, sharing medication?


JOHNATHAN RHOADS, PA
From time to time. Yes, sir.


RON AARON
Again, you have to be non-judgmental. How do you wean them off of that?


JOHNATHAN RHOADS, PA
Oftentimes, in my experience, they've taken medication intermittently or from time to time, and it's not something that they're taking for a prolonged period of time. Different medications take different amounts of time to wean someone off. Sometimes, these medications, like the SSRI, can take a month or maybe two months. But other medications can take longer.


RON AARON
To wean them off?


JOHNATHAN RHOADS, PA
Exactly.


RON AARON
Wow. So, slowly but surely, you withdraw.


JOHNATHAN RHOADS, PA
Exactly.


RON AARON
For you, what is the psychic income you get from helping your patients? What makes you feel good?


JOHNATHAN RHOADS, PA
It's really saddening and disheartening whenever you see a patient come in with these challenges, but whenever they come in for their follow up visit and you see that their screening results are starting to look better, and you just have that conversation with them and they're like, yeah, I got my life back. That's really rewarding. That makes it all worthwhile.


RON AARON
As you think about all the people who are facing financial challenges, there's not a lot that you can do to help them with the money side.


JOHNATHAN RHOADS, PA
Not so much. We can offer different things. For one, Medicare and Medicaid often pay for these medications, and they often pay for the coverage of the treatment of anxiety and depression. So, if that's something that you're concerned about, oftentimes it's covered. If not, there are social workers that we can get engaged in your care, and sometimes they can offer financial assistance for medications or certain treatment. So, those are always available, we just have to know what your barriers are. So again, that honesty is very important.


RON AARON
So, you have resources that can help people.


JOHNATHAN RHOADS, PA
Exactly.


RON AARON
Taking a look at the large numbers of people with depression and anxiety, it's not a cookie cutter solution, but I guess some of the problems are very similar.


JOHNATHAN RHOADS, PA
Yeah. Everyone presents a little bit differently, so our treatment plans are tailored to their individual needs. One SSRI or one medication in general may not be effective. We may need to add an additional medication or we may need to increase the dose or maybe we're going to try psychotherapy in addition to medication. Talking to someone is often shown to be beneficial, especially in moderate to severe depression. So, there are different treatment plans.


RON AARON
For talk therapy, do you have people you can refer folks to?


JOHNATHAN RHOADS, PA
Yes, sir. We have psychiatrists as well as psychotherapists that we can refer to. They have different treatment therapies available.


RON AARON
I know that in an older population, sometimes there's resistance to talk therapy. How do you get over that?


JOHNATHAN RHOADS, PA
I think just allowing your patient to be open. Sometimes I have resistance to other types of things, but I always say it's worth a try, right? Whenever your children say they don't like the green beans on the table, just try it at least once, and then we'll see after that if we are going to continue with it or not.


RON AARON
I got to stop you right there. We're flat out of time. Thank you, Johnathan Rhoads from WellMed at Oak Cliff in Dallas. I'm Ron Aaron, and this is Docs in a Pod. Thank you for joining us.


OUTRO
Executive producer for Docs in a Pod is Dan Calderon. The producer is Cherese Pendleton. Thank you for listening to Docs in a Pod presented by WellMed. Be sure and listen next week to Docs in a Pod presented by WellMed.


DISCLAIMER
This transcript is generated using a podcast editing tool; there may be small differences between this transcript and the recorded audio content.

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