Improving Our Mental Health and Wellness with Psychiatrist Dave Paulson M.D.

In this episode of Compliance Conversations, I talked with psychiatrist Dave Paulson M.D. on improving our mental health and mental health outcomes. And why it’s so crucial to implement daily self-care routines and stay connected with friends and family for mental wellness.

The things that work the very best for long-term mental wellness can sometimes be the hardest things to do: Staying connected to friends and family, a positive mental attitude, a healthy diet, and exercise take time. They take time to learn, to do, and to work, but they’re also the best way to stay healthy and the most effective way to battle anxiety and depression, among other things. Unfortunately, when we find ourselves suffering from depression, one of the first things to go is motivating when the negative self-talk is chronic ourselves to do even basic things. Sometimes even getting out of bed can be a struggle, so forcing ourselves to go for a run can feel, when the negative self-talk is chronic, medication can give us the little boose we need to do the hard things.

“Folks want to change their lives quickly, and the medicines that we provide are helpful but it’s neck and neck as far as what the medicines can do versus exercise, maybe eating better. If someone is completely neglecting themselves, not getting regular sleep or decent nutrition, no physical activity, not connected socially, among other things, or maybe their inner dialogue is just really non-supportive or highly critical. I recommend we identify all these areas where someone is struggling or ways someone could be more supportive with themselves, and then let’s add in medicine to help if it makes sense, and then we’ve just got some hard work to do.” Said Dr. Paulson.

Dr. Paulson also explained why mental health issues might arise due to our loss of human connection. And one of the things that prevent our long-term healing is the cultural expectation of a quick fix, a pill to make us all better. And our addiction to screens, toxic foods, and negative news cycles can play a role in making us unwell.

Challenges that mental health experts face are convincing folks that the best way to help themselves is to play the long game of therapy, mindfulness, eating right, getting outside to work out, and remembering to take their meds if needed. Compliance issues they face, especially small practices, are protecting and securing data.

Listen to the latest episode of Compliance Conversations with CJ Wolf: How to Optimize Mental Health Outcomes with Psychiatrist Dave Paulson M.D., to learn how to optimize your mental health and wellness and improve mental health outcomes if you’re struggling. In this episode, we talk about the importance of:

• Social Connectedness
• Self-care Routines
• Securing Data

Episode Transcript

CJ: Welcome everybody to another episode of Compliance Conversations. This is CJ Wolf with Healthicity and today I have a guest Dave Paulson who is a psychiatrist. I’m really excited to talk to Dave about mental health. Welcome, Dave.

Dave: Thank you, glad to be here.

CJ: Yeah, I appreciate your time. At Healthicity we’ve been focusing a little bit on some mental health issues, both in podcasts and in webinars that we’ve been doing, so always make sure to check the Healthicity resources page where we have recorded webinars, blog posts, e-briefs, those sorts of things if mental health is an area that you or your organization practices in. We’d love to have you participate in those conversations. And Dave before we get started I always like to have my guests share a little bit about themselves, as much or as little as you want, if you’d like to introduce yourself, tell us a little bit about what you do and then we’ll jump into some of our questions for today.

Dave: Okay thank you CJ. I’m a psychiatrist. I was trained in medical school at the University of Utah and then went into residency there at the University of Utah. I proceeded after residency to work at a few different places. A residential treatment center at a University-based counseling center and then I started a private practice at the same time as well as working at one of the local hospitals. And so I was doing four different things at one time and then I eventually narrowed that down to doing my private practice and also working at the hospital doing on-call work.

CJ: Great, so you’re dealing both with chronic issues as well as some acute issues. Is that right?

Dave: Yes, exactly.

CJ: Great, well Dave I wanted to start by asking, I wanted to get your thoughts on this too, as things have progressed in healthcare I think mental health is becoming more acknowledged as a need and making sure that people are getting mental healthcare as well as this physical care that’s traditionally what people think about. I think some of the stigmas with some mental health issues are starting to go by the wayside a little bit if you look back twenty or thirty years compared to today. So I think, correct me if I’m wrong, but I would think that people are probably seeking out mental health experts like yourself more and more. And with that in mind, my first question is:

Question: What can patients do for themselves to improve treatment and outcomes?

• There’s a lot that you do as a professional but just like any disease or condition like if I’m a diabetic I have to be watching my diet and exercise and medications and those sorts of things.
• What can we as individuals and as patients do to improve our mental health and outcomes from your perspective?

Dave: Yeah, there’s definitely a lot more demand it seems like for mental health services. There’s just a lot of need and sometimes I wonder if it’s just the stigma has gone a little bit or if what’s going on in our society is just making our mental health worse. I’m not sure what’s going on exactly. But there seems to be an increasing need. And as I think about it there definitely are issues that have come up over time and I think that I mean I recall in residency there was some talk about how the incidence of depression was going up and anxiety issues and other issues were increasing. And there was some talk at the time, at least some ongoing research that there was just a lack of social connectedness that was going on. And essentially, especially in Western society, you know there’s just a little bit more of a desire to leave your family and become independent and then you’re considered to be more successful if you’re able to be independent and not be as connected to your family and things like that. And then I think we’ve just seen more and more of a pull in direction. As people are getting more involved in things online, their social connections are getting diluted out a bit with people in their own household just because there are so many other people they’re connecting with and then there’s that desire to leave home. And I think, I’ve met with more and more people who are just less connected with family. So there are just some forces in that way and I think also a disconnection from our community. So I think some of those things may be at play. I don’t know. There’s just so much to talk about here. Like when you’re talking about diabetes and the importance of good exercise and a good diet and things like that. I think it’s just as important for mental health. I think oftentimes people don’t recognize that. There’s a gut mind connection so if you’ve got issues with your nutrition maybe you have more inflammation in your intestinal tract that causes more problems with depression and anxiety. So I think people don’t recognize that and then we live in a time where there are so many addictive food choices out there. For these corporations to do well they’ve got to promote products that people just can’t resist and that kind of thing. They have some and that’s great but they want more and that kind of thing so that they can do just as good as the other companies they’re competing against. Their products don’t die away or something like that.

CJ: Yeah, it sounds like from what I’m hearing you say is connectedness and connection to community might be diminishing a little bit in today’s society and that could have some impact on our mental health but then also taking care of ourselves. I remember reading studies that exercise improves mental health just as well as some medications. Now I don’t know if those studies are still valid or what your thoughts are on that. I just remember in my early training many years ago that exercise was always recommended even if it was depression and you’re treating it with a pharmacological agent but then you’re also recommending exercise and activity because that also seems to boost mental health and those sorts of things. Is that still the case today?

Dave: Oh yeah definitely. For sure the case, the problem I see is that oftentimes we’ll recommend things like that. Let’s get some fruits and vegetables, some protein, balance your diet out, let’s get some regular exercise, some regular sleep,  like those self-care kinds of things, and then it’s just really hard for people to implement. You know that’s the challenge that I face on a daily basis. Somehow helping people to see that there’s hope, that in whatever they’re stuck on, you know whatever’s keeping them from doing some of those things that would be helpful. Kind of like helping them to get over those roadblocks so that they can actually move forward with it.

CJ: Yeah it seems like it’s hard enough for patients who don’t have mental health struggles to do those things right?

Dave: Yeah.

CJ: To exercise and eat well and when you tack on, maybe someone has anxiety or depression, they’re like you said kind of stuck and it’s hard to get that initial “umph” or that initial push right? To get them out of that hole and I can just imagine how difficult it can be for some people when they’re struggling mentally just to kind of get up for the day and get out and try to do these things.

Question: Cognitively they might understand those instructions.

Motivationally they can’t do it right?

Dave: Yeah, and I think they’re looking for something to just change their life and change it quick and the medicines that we provide often times give people and they’re helpful but kind of like you were saying. It’s neck and neck as far as what the medicines can do versus exercise, maybe eating better, things like that. The medicines that we have take a little while to kick in and the effect while strong and powerful it’s not quite enough to contend with these other things. If someone is completely neglecting themselves, not getting regular sleep or decent nutrition, no physical activity, not connected socially, among other things. Or maybe their inner dialogue is just really non-supportive, highly critical, things like that. It’s just like what chance do we have you know? So what I recommend is more like a full court press where it’s like let’s identify all these areas where you’re struggling and could be more supportive with yourself and then let’s add in a medicine that makes sense or a few medicines that make sense to help you and then we’ve just got some hard work to do.

CJ: Yeah absolutely. You know I imagine the last year and a half, two years with COVID that may be feeding into anxiety for people, job loss, and those sorts of things. But I think there’s probably two sides to that coin, when COVID hit I started working more from home and so I cut out an hour and a half, two hours, of a commute and I’ve used that time to go for walks and I was doing more regular activity. So personally, I know that’s anecdotal, but personally I took the opportunity to be a little more active  and I feel better but I can imagine people who are just stressed about, you know they things what “normal” is right? What have you seen with COVID affecting your patients and maybe just mental health in general?

Question: What have you seen with COVID affecting your patients and maybe just with mental health in general?

Dave: Yeah, I think when it first started I definitely saw that some people were getting out more and exercising, being in nature. It seemed like everyone was just overcome by the whole thing and overwhelmed by it and in shock and so they were just like yeah maybe I could do some of these other things to be helpful. And then as it went on longer it seemed to me like there was just a little bit more of a devotion to what was going on in social media and the news and things like that and it seemed like we were getting pushed to extremes, as far as extreme viewpoints. And then I started to see a little bit more conflict just as people were going to extremes and I guess there’s maybe reasons for that, like algorithms and artificial intelligence that’s pushing people toward what their interests are but so far down that road that when they get together with someone that’s been pushed down a different kind of road it’s like “oh” that’s a lot of conflict. There’s some stress from that but then just the whole uncertainty with the virus, how to deal with that. I’ve got some clients that had germ phobias before it even started but then it just really compounded some of their fears afterwards. Instead of getting more rational about how they deal with germs I think some gotten more irrational about it. And then all the social isolation which has been part of the pandemic like that’s how you have to deal with the pandemic. I think its lead to people just not being able to be as connected socially which is definitely a risk factor for mental health issues.

CJ: Yeah I think before the immunization or vaccine came out I was being very careful not to visit elderly parents because they’re at greater risk so I could totally see that right? That we were separated, I think the vaccine has helped a little bit because both they and I have become a little bit more comfortable in those connections but I can see how that separation from family and isolation can compound things that are already underlying in somebody’s condition.

Dave: Yeah and it’s like this whole kind of feeling that people are more like vectors of disease where they can spread disease to you or you could spread it to someone else. You could be responsible for the death of someone, that kind of thing, somehow inadvertently spread the virus to someone. It just really increases the level of stress.

CJ: That makes me think about, do you have patients who had COVID? Has it exacerbated their mental health? Like the actual virus, like the disease itself.

Question: Are there mental issues with COVID itself that you’ve seen, or is that not an area you deal a lot with?

Dave: Well I definitely have had a few patients, the sample size is very small in terms of the ones who’ve had COVID and have done worse. But I’ve definitely had some where they said that the energy levels had worsened depression and anxiety. I’ve seen that with several patients and then I’ve had a few that had the long hauler where they tend to just tend to be really tired and struggle and have other kinds of issues.

CJ: Is there anything unique that you recommend for those types of patients or is it kind of more of the same of what you normally recommend for patients with depression and low energy and those sorts of things or is there something unique with COVID patients that you’ve found?

Dave: Well nothing super unique just because it’s so new and we don’t know quite how to approach it but I definitely feel like good nutrition is important. Even though it may be hard to exercise or breathe good so you can exercise but definitely I think it’s important to increase activity as they’re able to. And then for sure better nutrition. I’m like a broken record on the nutrition side and exercise side and the sleep side of things with people just because I feel it’s so important. Especially when you’re dealing with a virus like this that’s causing damage to cells throughout your body, you definitely need good self-care to be able to recover.

CJ: And you’ve mentioned nutrition a few times not. Are there specific things that you recommend or is it basically what we all already know? Not overdoing sugars, I think in America we have a lot of sugar out there. What types of things do you recommend when you talk about good nutrition?

Question: What types of things do you recommend when you talk about good nutrition?

Dave: Yeah essentially it’s just being careful in the center section of the grocery store. That’s where processed foods are and the food that are pretty addictive. I actually just like the USDA food plate. There are all kinds of diets out there but USDA food plate is really simple. It’s essentially just keeping your carbohydrates reasonable, a fourth of your plate carbohydrate, a fourth of your plate protein, half your plate fruits and vegetables. And it seems like its super simple but very hard for people to implement.

CJ: Exactly, we don’t do it. I don’t know if it’s because we live a rushed life, we like fast food and we like convenience. I don’t know what it is.

Dave: Well I think it’s also; we’re just up against the addictive properties. When you’ve got food scientists who are creating things and you’ve got panels and they’ve got testing and refine things over the years. It gets to the point where some of these foods really stimulate the reward center in your brain and it gets to the point where anything that’s a little more healthy isn’t stimulated to that same extent. So you probably get less pressure from the foods that are better for you.

CJ: Gotcha. And do you think those things that are in those kinds of addictive foods? Is it sugar?

Question: Do you have a sense of what’s in those foods that increase that pleasure feeling of those certain addictive foods?

Dave: Yeah, it’s got to be. Sugar is for sure. The human body, we sort of crave that. Especially if you eat a lot of sugar and then your insulin goes up, and you drop low in your blood sugar, and you kind of want more of that. There must be something about some sugars plus fats that appeals to people, tastes, and textures—all of that just kind of combines, even the bubbly stuff in pop. I think there are certain rewarding properties to it that these companies are capitalizing on so they can make big profits.

CJ: Yeah, that’s a great point. And I like the way you put it. It’s that simple food pyramid that we all learned in middle school to moderate and have healthy choices. You’ve also mentioned sleep a couple of times. Again anecdotally, that makes a huge difference in my mental attitude and energy level when I get an appropriate amount of sleep and have good sleep hygiene where I have a regular pattern.

Question: Do you have specific recommendations for people whose sleep hygiene is not that great?

Dave: Well yeah. It seems to me like if you look traditionally at the TV shows available at night. We got the news; you got all kinds of crime shows, that kind of thing. Let alone the entertainment industry, it just seems like if you want people to watch, they’ve got to generate a lot of emotion, fear, sometimes get people’s heart rate up, give them adrenaline rushes, and that kind of thing, but a lot of that’s skewed to late night. And then video games, those are pretty high adrenaline activities as well, and as people are doing that, plus maybe some social media that can generate all kinds of emotion. And there’s recent, with Facebook, it’s clear that they do best when they generate more negative emotion, you get people unsettled. So I think a lot of times people are doing those kinds of activities like TV, news, video games, maybe some social media, things like that. That gets them unsettled, and then they wonder why they can’t sleep. They’re just doing those activities, and their heart rates are really high, and they’re like, “oh no, I’ve been doing this way too long, must be addicted to it. I better hurry and go to bed.” So they hurry and brush their teeth, and they run and get in bed and low and behold are like, their hearts racing, and they’re not sleeping very good.

CJ: That’s so insightful. Even as you’re talking, I’m thinking, what did I do last night right before bed? I watched a show that was kind of like that, and you’re spot on. With our kids, we try to decrease screen time a couple of hours before bed. We were told the constant looking at electronic screens right before bed can affect your ability to fall asleep quicker. I guess I need to practice that as well.

Dave: Yeah. Often, I’ll tell the adults that I work with we need to treat ourselves more like the way we treat our kids. Kind of like reading them a story, getting them all ready for bed, turning the lights down, have them feel safe and secure. Have time for that wind-down. A little stretching is good. Let go of the concerns of the day and make that an active process. A little meditation, whatever helps you to feel safe and secure, is important before you sleep. It sets to tone for your sleep, so you’re able to get a little bit more restorative sleep.

CJ: That’s excellent advice. Let me switch gears a little bit. We focus a bit on compliance in these podcasts.

Question: I’m curious what you see as issues in mental health, maybe reimbursement or management. What are some roadblocks that you see? What are some risks that might be out there for people who are practicing in mental health areas?

Dave: Well, I think if you are trying to do a smaller practice, as a private practice, it’s extremely challenging because you’re up against all kinds of hackers who want to get into your system and then all these new regulations that come through. When it comes to Medicare incentive programs, they apply a little more to primary care, it seems like, than to mental health, and so it’s a little hard to translate. During COVID, we found we were doing a lot of telemedicine, and because of that, we were like, “ Oh, we need to do something, but I was also concerned because I was the IT guy in the office. Hosting the server, we had a local network, and I heard about these bigger healthcare organizations that were getting hacked into and fishing scams and things like that and the ransomware where their data is held, hostage. They go months without being able to get any of their records. For me, that was getting in the way of my sleep. So anyway, I was like, we decided to transfer to a different program, more of a cloud-based HR program, which has helped a bit. I’ve got someone who’s hopefully watching over our data; they’ve got systems in place, so I think that’s helped a little in that regard, but it’s still tricky.

When it comes to the incentive care for Medicare, we’ve, like I tried initially. We were using the electronic medical record and everything, it seemed like we were doing everything we should, but then it was just so complicated. Trying to get through that process of getting the reimbursement, so it’s like, well, I’ll just take the hit because it’s either you pay a lot of money to try and get through that process or take the hit. For us, with the percentage of Medicare we had, it was like “oh.”

CJ: Yeah, if you don’t have that critical mass where it makes sense to go full “bore” on those incentives, I can see what you’re saying for sure.

Dave: Yeah, but we’re trying to still do what we’re supposed to do. Be good with HIPAA privacy and try and secure our data as well as we can. It is like you’re a little person in this big world, and it’s just getting increasingly sophisticated all time, and it’s tough to keep up. Your threats are getting more sophisticated, and it seems like some of these regulations coming from Medicare are getting more complicated as time goes by so it is a bit of a challenge.

CJ: Yeah, I think, as you mentioned, for smaller practices that can have a real impact. If you’re a really huge pr,actice you can employ somebody full time but smaller practices you’re doing things yourself. Trying to balance how much time and money do I spend on this, I want to do the right thing, but you can’t bankrupt your practice to make everything 100% foolproof, and that can be hard.

Dave: Yeah, for sure. That’s why I think it’s good for people like you who are out there trying to educate people and help out because it’s just so complicated.

CJ: Yeah, exactly. Well, that’s really interesting. One other thing I wanted it ask is: What are your thoughts on mental health parody laws. I ask because I recently saw a settlement in the state of New York where the attorney general of New York ended up suing United Healthcare. I think United Healthcare ended up paying fourteen or seventeen million dollars because they denied mental health services inappropriately. And this is a private insurer, or they weren’t meeting those parody laws. Years ago, these parody laws came out. I don’t know if it had any effect on people. This was one of the first lawsuits I’ve seen where the state went against an insurance company because beneficiaries were denied mental health services. And that’s kind of a win, I think.

Question: Have you seen these mental health parody laws work?

• Are you still running into insurance companies that just aren’t going to pay, or they cut visits short like you can only have four visits instead of ten. What are you seeing?

Dave: I think, for the most part, it’s been good. I remember when I first went into practice. I guess I started seventeen years ago, something like that. We had to do all kinds of treatment plans and get authorization from insurance companies for a certain number of visits, and they’d give us three visits at the most, and then we’d have to apply for more. It was just an administrative nightmare just trying to get visits approved, but it turned into a better situation after the parody laws were passed. And so, especially as we do an “E/M” code and then add on a therapy code, it looks like it’s been covered pretty well. Once in and a while there are some issues. Like I’ll have patients where if they’re seeing a therapist separately and then they’re seeing me, then they have to be very judicious about how they’re doing their visits for the year. And so they’ll be like, well, I probably do need to see you more often. Still, because I’m doing the therapy too, I can only do a certain there, and then I have to be a little more careful so we’ll just squeeze as much as we can into each visit and be as efficient as possible and do some phone calls in between to get them through. So there’s a little bit of that, but in general, it’s much better.

CJ: That’s good; I’m glad to hear that. I know that was the goal in many of those laws, and I wasn’t sure on the front lines if you saw that, so that’s good news. Well, these podcasts go so quickly. Our time is coming close to an end and but I want to save a few minutes and see if you have any last-minute thoughts or comments on what we talked about or maybe something that we didn’t raise. I’d like to give you the last say here if you have anything.

Dave: Oh yeah, I guess one other thing I was thinking about this society we live in, it seems like people are going for a quick fix. As you can imagine, everything is about they want things delivered to their door. You had one patient that was kind of struggling with their diet and a more healthy but in some weak moments ordered candy from Door Dash, you know, so it’s just like a bunch of candy comes from the store just comes to their door, that kind of thing.

CJ: It’s easy to get.

Dave: Yeah, so easy to get, and I think when they’re approaching the mental health, they want to be, you know, I’ll do this, and then I’ll get better quick. They want, almost like snake oil. Something to fix them quickly, and I tend to be a little more oriented toward the traditional we need to work on it. All those things we mentioned like the self-care things, your thoughts, spending time doing some therapy, working on your connections, and making sure you’re doing better, and with the medicine, we can use medicine but then the ones that seem to work the best take a little while to kick in. They rely on you doing the other things too, so I kind of feel like a change in people. It takes time, and it’s slow, and it’s that kind of a process. But I think even in psychiatry, we see more of that. Do this, and you’ll get immediate results and that kind of thing. I think we just have to wait a little bit and watch out for some of that. We’ll see because there’s ketamine, and people are using cannabis increasingly for mental health and psychedelic mushrooms and other psychedelics. Then there are all kinds of different things that people are trying. I think we’ll just have to wait and see if there are such things as quick fixes or if we still have to do the hard work. My inclination is we do still have to do the hard work.

CJ: Yeah, it seems like, just from a common-sense standpoint, hard work will be more lasting, but that is interesting what you mentioned about those other things.

Question: Cannabis, ketamine, psychedelics, I’ve heard that a lot as well. Is the jury still out on those?

Is there any evidence yet, clinical trials, or studies that have shown promising results in any of those things?

Dave: Well, yeah, the FDA approved “Spravato,” an inhaled form of ketamine. And that’s based on some research; it can have some pretty quick, positive effects in terms of depression. The only issue is that it doesn’t seem to be sustained. For some people, it works for a few weeks or maybe a month, but it seems like over time, it lasts for a shorter and shorter period of time where it’s helpful. And then I think we’re just back to like ECT electric convulsive therapy, was the most effective thing and it probably still is the most effective thing that we have. But even with that, if you don’t have medicines that will help you and you aren’t doing some therapy and things like that, it doesn’t seem to sustain you. I think the same thing will be true for some of these substances that were prohibited for these kinds of uses in the past.  I think that just because they’re controlled, but now they’re finding well, they’re finding there is some kind of a benefit, maybe a reset from it, so there could be some efficacy that way. Some people are doing some of these substances to aid in psychotherapy, so we’ll see where that goes. There’s kind of like a lot of movement on it, but then the research is still lagging, so that’s kind of where I’m at. Maybe I’m so old-fashioned I don’t know. I struggle with some of the things on media and now social media, and now I’m struggling with the use of some of these substances that before were prohibited, and now it’s just we’re going to do some research and see if it works.

CJ: Yeah.

Question: It sounds like the long-term jury is still out, right?

• Whether there are long-term benefits or if you need to combine those, if they’re helpful at all, with the standard which is good mental hygiene like you’re talking about with therapy and learning because some of us think wrong, right? Like that contributes to certain mental health issues if you aren’t thinking the right way right.

Dave: Yeah, exactly.

CJ: And you have to solve those things long term to have success is kind of what I hear you say.

Dave: Yeah, and I think you just have to be patient and persistent and keep the hope alive while you’re trying to work through things.

CJ: Yeah. Well, Dave, this has been really interesting. Appreciate your expertise and your taking some time to talk to us a bit about mental health and the importance of mental health and wellness in our lives and how to take care of ourselves. Appreciate your time.

Dave: Oh yeah, it’s been great to join you, and thanks for inviting me.

CJ: Yeah. Well, everybody, thanks for listening to another episode, and we’ll see you in our next episode. Take care, everyone.