Thinking About Prescribing

Dr. Laura Roberts (00:09):

Hi, I'm Dr. Laura Roberts, editor in chief for the books portfolio of the American Psychiatric Association and welcome to the APA Books podcast. Hi everybody, it's Laura Roberts. Welcome back to Psychiatry Unbound. I'm really pleased to welcome you to listening to this show today with two of my absolute favorite child psychiatrists and I would say they're two of the most influential child psychiatrists of this era and have done an amazing book that I think people will really like. It's The Psychology of Psychopharmacology with Diverse Youth and Families and Families. I want to welcome Shashank who I have the privilege of working with at Stanford. Shashank is a professor of psychiatry, pediatrics, and education. He's at Stanford University School of Medicine and the Graduate School of Education at Stanford. He's also the Director of School Mental Health at Lucille Packard Children's Hospital, a faculty advisor for the Center for Comparative Studies and Race and Ethnicity. And you also were just made what an associate provost? What's your additional job?

Shashank Joshi (01:22):

I have a role now in the Vice Provost office as Assistant Vice Provost for Academic Wellbeing at the university.

Dr. Laura Roberts (01:30):

That's great. Okay. So Shashank like the rest of has like 10, maybe 20 jobs and Andrés himself has many jobs. Andrés Martin is the Riva Ariella Ritvo Professor at the Child Studies Center at Yale School of Medicine in New Haven, Connecticut. He's the Medical Director of the children's psychiatric inpatient service at Yale New Haven Health in New Haven, Connecticut. Incredible career as a leading academic child psychiatrist. So I wanted to thank you both for being here. Do you have other jobs that I failed to mention that you want to mention Andrés?

Andres Martin (02:06):

Someday I'll have as many as Shashank.

Dr. Laura Roberts (02:11):

Right. Someday we'll all have as many jobs as Shashank. So this book is really neat. So I say it again, The Psychology of Psychopharmacology with Diverse Youth and Families. And so you all took on an ambitious but incredibly needed scope work with this particular book project. And I don't know if you want to take turns, I could maybe turn to Andrés first. Why this book? Why this moment, and why were you willing to give so much of your time and life effort to this wonderful project?

Andres Martin (02:50):

So maybe I can start here because really the one reason is Shashank Joshi, I have long been thinking about this, thinking about prescribing the psychology of psychopharmacology had written a little bit on it, some of it with Shashank, but then he was the ambitious one who said, there's a book in there, we need to do something, the time is calling for it. And I said, "No, no, no." But of course he was right. And here we are Shashank.

Shashank Joshi (03:20):

Well, Andrés is being very modest, but this book would not have happened without him because he had so much experience as an editor. And I had worked with him prior to his taking over as the JCAP editor. And there were lots of things that happened during that tenure. It became the most widely read pediatric journal in the world, the most highly cited in the world over his tenure. So I knew that I needed him for not only the brand recognition, but he had so many ideas for how to convene something like this and how to really make it into something that people would want to buy. And so this tagline as our remedies are only as good as the way in which we dispense them, this book is more than about dispensing. It's about the way we are with our patients and that the first and foremost reason we all go into child psychiatry is to learn from be with and treat children and families. And because medication is one way, one important way that we do that in child psychiatry, it's important that it's emphasized as one way, not the only way. And so we spend a lot of time with our almost 50 authors getting their perspectives, having them share their clinical and research background in this area. And it just seemed like the time during COVID when we were doing even more of this and we were able to pivot obviously as a field pretty quickly into the virtual space. But the relationship became even more important as our time seemed to shrink in how much we actually had. Because we had that many more patients we needed to see over the last two and a half years.

Dr. Laura Roberts (05:02):

Yeah, no, I mean the tragedy, but also in some ways a bit of a blessing is the recognition of the extraordinary mental health needs that we've seen in the last few years. I mean, I'm interested in your impressions, but it seems like the degree, severity, the intensity of distress that nearly everyone experiences and then really the worsening of a lot of the mental health conditions that young people are experiencing over the last few years. But as they say the other side of it is that people are just starting to recognize it more. I feel like our field is struggling because we cannot possibly meet the need. But part of what I love about your book is that talks about the therapeutic meaning of being with someone separate from, I don't know, writing a prescription or doing something that would be experienced as just transactional. It's really neat.

Shashank Joshi (06:01):

Well, it seemed even more important as we had the blessing with Tim and others at APA Press that there was a lot of patients around, there were a lot of authors, so the deadlines were flexible. And so by getting a 2022 publication date, and it came out in the soft cover, but the actual copyright for the APA annual meetings. So we were able to get some coverage on in the APA news at the time of the meeting. And that resulted in a lot of books being sold. And one of our authors, two of our authors actually Max Rosen and Anne Glowinski, their chapter was featured in this concept of the brief pharmacotherapy visit the BPV, which is our effort to banish the term med check or even MedEval because we do so much more than that. Of course medicines are an important part of our treatments, but it starts and it ends with the relationship. And their chapter in particular was featured on the cover because we gave a little bit of a map for how you might use those 30 minutes and what kinds of questions you could ask, how you can use the time so that you can do what you need to do. It seems that the less time we're given as psychiatrists, the more important is the relationship and these aspects. So I think that's something that we tried to do in the book.

Dr. Laura Roberts (07:32):

That's wonderful. I understand it sold out in a day or something. It just amazing.

Shashank Joshi: (07:38)

It sold out in a day at the ACAP author's corner. Wow. The APA folks said, you're here. "Oh, Shashank and Andrés, we have bad news and we have good news. Which would you like first?" And we're like, "Okay, give us the bad news." "Well the bad news is our thing was on a Thursday and the exhibit hall open on a Monday. We sold that on Monday and we have no more books left. The good news is we sold out on Monday and there's no more books left."

Dr. Laura Roberts (08:05):

Yeah, yeah. It's beautifully written. And with so many authors, I know you all did a great deal of work and in fact had almost motivational videos to keep your authors writing and engaged. It was just a best practice and very creative way to keep the project moving forward. Andrés?

Andres Martin (08:30):

I also want to say that we seem to have hit a nerve and I know we hit a nerve within ourselves, but whenever I've gone and talked about this by myself or with Shashank, there seems to be a great hunger for this. We all want to think about this but don't quite know how to think about it. We kind of think that we're important in some way, but we capitulate in front of the all powerful neurotransmitter blocker. That's how we think about these medications. And when we allow ourselves and when we give permission, if you will, to others to think about this, there's not only a great hunger but a great expertise in being the agents really of the treatment and not selling ourselves short. We need to remember ourselves as part of what we do.

Shashank Joshi (09:23):

That's a big part of the reason Andrés, the name of the introduction is Prescriber, Prescribe Thyself. And that's really the beginning of, the invitation, the entry for really diving into whatever sections of the book will appeal to you. But that part, what he just said really is captured in the introduction and it's also captured in, Simone Hasselmo's brilliant illustrations on the cover, which is also described in another part of the introduction. So I do think that we acknowledge the biological, we embrace that and it's so much more than simply the biological, but the biological is the invitation to so much more in regarding what we do.

Dr. Laura Roberts (10:13):

And then the focus on diverse families, diverse young people. I mean, I think also speaks to what you're saying and about the therapeutic context and the alliance that you build and meaning of the relationship and honoring who the child is, who the family is, what the setting is, and then the person who's in the therapeutic role.

Shashank Joshi (10:38):

Andrés?

Andres Martin (10:40):

Yeah, I just had a thought, this is not in the book, but a thought just came up. I have been thinking of late a lot about neocolonialism in medicine and medical education and how we take to others practices that may not be relevant to them. And in some ways we could think that we do a lot of that with psychopharmacology. Think about it, a medication colonizes, I don't know, your gut, your brain. And if you come from a population that has been previously colonized, even if you're not thinking about it in those terms, that's yet another way of having some resistance of having some hesitance to it. So how can we move from that to a more collaborative collegial prescriber/prescribee and to be partners in that?

Shashank Joshi (11:37):

I think it's a big part of what we need to be working with our colleagues in and our peers around this concept, colonization. And I do appreciate really that example. But also the final chapter in the book, which was penned by Dorothy Stubbe and Isheeta Zalpuri and Mandeep Kapur. There may be another author in there that I'm forgetting, but this is about how do we think about this with the next generation? And I do think that we have a couple of chapters that are really devoted to the idea of the work in diverse youth and families. The one that really is highlighted is the one that Takesha Cooper did who is now, she's the program director at UC Riverside. And she was a Fellow of ours many years back. But she's really become really a force within child psychiatry and DEI work. And really we were able to do, she was presented this last year at ACAP, and one nice example that she gave was around how the idea of taking medication may not only be something that families may not want to do. It may be very new to them, but they may have some reluctance to rely on that because they may see that, well, this is really the only thing that's being offered. We don't have access to things like good psychotherapy or someone who looks like my child who can provide the other aspects of treatment. So if this is this all you got doc? And sometimes it is all we have. And that's the other reason why we want to embed this kind of treatment in the larger context of culture and understanding and interplay and the idea of transformation, it's the idea of the cultural humility, cultural sensibility model is we may be transformed by the interaction that we have with our patients and families as much as they are. And medicine is one part of it.

Dr. Laura Roberts (13:47):

The DSM cultural formulation is I think, a little bit abstract for people sometimes. Although I love that it is an important part of the DSM and that we're continuing to struggle with how to bring this fully into clinical practice. I think that's one of the strengths of your book is it doesn't seem remote or abstract, it's just natural. It's just a natural part of the work of. I hope you share that concern, that I trained in such a diverse multicultural environment that I can't even think differently than that. Do you know what I mean? But that's not everybody's experience. So making it real I felt like was a tremendous strength of the book.

Shashank Joshi (14:35):

Andrés were you going to add something to that?

Andres Martin (14:38):

To add also the cultural diversity as someone who comes from another country, I'm originally from Mexico and certainly we talk a lot about the diversity within this country, but there's a global diversity and talk about colonization there when we go with our fancy pants medications to other countries and how do we think about medication in those other countries? So we also have a small focus in the book on these international considerations, the medication by virtue both of their efficacy and also by virtue of the hegemony of the pharmaceutical juggernaut. And we could go on and on, but it has become a hegemony, sorry to repeat the word in the practice of psychiatry worldwide and how do we reel that back in? How do we refocus that there are these other aspects. So I think that this also touches on that if we think of ourselves as a prescriber, as half or more of the prescription, that's the beginning of moving in that right direction.

Shashank Joshi (15:48):

I mean, I think that's beautifully said, thinking of ourselves as maybe half or more. The chapter was Arthur Caye, Brandon Kohrt and Christian Kieling. They wrote a chapter called the Psycho Pharmacotherapeutic Alliance When Resources are Limited Cause it is very much about you as part of that prescription. And I wanted say my previous comment, I said there was one more author, of course it was the inevitable and unforgettable Don Hilty who is a mentor to so many of us. And one cool thing that happened out of this collaboration, one of the things that led to that as a training collaboration is Don and I shared a cab many years ago after APA and he said, "We should get a writer's group together. There are all these people on the west coast thinking about child psychiatry and on the east coast with people." So we started a monthly mentoring session and we, that's one of the most productive memories I have because there's so many products that came out of it, A number of papers, chapters here, presentations nationally. And it was around the concept of the culture of APA we were in. And we found our people even at a big meeting like that. And so Don was the senior on that. But it was a nice example of, like in this book we called on people we had never met before because we had read their work. But a lot of the folks are people we worked with who mentored us or who we've worked with or mentored. So we especially want to thank you, Laura, for the invitation to be able work on-

Dr. Laura Roberts (17:25):

Well I'm about to give you another invitation based on a couple things Andrés has said already. I can think of a couple of book projects we ought to take on. Yes, no, it's wonderful that you brought this work to us and so exciting. And maybe we could dive into the structure of the book because the book is different in that it's very, very large number, but very inclusive in the author group. And you just mentioned about how some of the people you only knew through their writing, which I want to really commend because what sometimes happens is you work with the people you know most closely and it's like it's a good reliable way to get the job done. And yet the richness that comes with bringing more perspectives in, more breadth of experience in I think is very meritorious in itself, but also is really reflected in this wonderful book. But the structure, so you had a large author group, you built it in this really elegant structure. And I know this is probably a preoccupation that editors have, but I just really loved this principles, partners, settings, populations, research, and of course the last section "Becoming". Wow, beautiful. How did you arrive at that and did you have a grand scheme? Did it change as you went along? How did you get to the structure?

Shashank Joshi (18:59):

Well, I mean I can start and I'm going to ask Andrés to add to this, because I really only had three sections in the beginning. And this is another reason I needed Andrés' experience and to help him, me with his vision and the knowledge that he had about how we can really make it, he wanted me to think big about this because like I said, I started with probably three sections initially. I really just had I think principles, partners and populations. And I think in that I wanted to include the research, I wanted to include kind of everything within one. But the chapters grew a little bit after Andrés came and certainly the sections grew. And I think having this idea of becoming was something I have to give him credit for because rather than making it a part of every chapter, it needed its own section of the book. Because a big part of this audience for us is early career folks, undergrads through Fellows and people in between. Because the people that we asked to review the book and then they asked other reviewers, many of them are early career folks and they gave us a lot of input on this book and what would be important to cover.

Andres Martin (20:38):

I'll just have two things. I'm a big fan, both of alliteration, so you had it there, Shashank with the three Ps, but I'm also a huge fan of gerunds. So becoming, there's something very active. You don't look back, it's not something done. It's something that is happening. And with a little luck, we're all becoming something better, stronger. And Laura, I do want to point out one thing that in the table of contents, it doesn't have a number but it's very intentional is both the preface, as we've talked about it, the introduction, Prescriber, Prescribed Thyself, but also Uncovered, which is very brief. And the idea of Uncovered is to uncover the mystery of the cover. We deliberately made it mysterious, wanting people to scratch their head. And we saw some head scratching and they're playful images and they drew people in and they helped us tell the story. When we talk about the book, when I talk about the book, the only slides I use are the cartoons. They're good enough to be bumper stickers or shirts. Two that I love, "Milligrams dispensed are easy. Time well spent is hard." It's pretty good. And then the last one we have here, which is "Prescribing medications is as much the Colfax of molecules as it is a warm way in which we envelope them for delivery." So these are really summaries of the book.

Dr. Laura Roberts (22:08):

Yeah, the meta communication is pretty direct.

Shashank Joshi (22:18):

I want to also call out two people who, well, I think Tim Marney was a big part of this, but there are probably other people, Laura in the APA, the publishing folks, the year that we were doing this, there were three books that took this idea of the psychodynamics of psycho-pharmacology and the relational aspect of pharmacotherapy into the publishing world. So the first group was, well, David Group psychodynamic psycho-pharmacology, caring for the treatment resistant patient, and then Warren Kinghorn and Abraham Nussbaum from Denver who published Prescribing Together, a Relational Guide to Psycho-Pharmacology. So I loved their stuff so much and David Mintz actually contributed in our book. But I had just met Warren and Abraham because of this process and Tim said, "Oh, have you seen their book?" And then we got to have a corner together at APA and I was so moved by the way that they talk, for example, about inside out prescribing versus outside in prescribing that I included a section of their book in my gratitude section because it was so powerful the way we conceptualize treatments as well as how our patients experience symptoms and how we learn about them. And it's also very useful in our teaching. So much of what happens in these books and so much of why we hope people actually want to buy something that is tangible is we go back and we read them again and we hold them in our hand and now we can take them to class because we're returning in person and we can open a book and read from a passage to something we enjoy.

Dr. Laura Roberts (24:04):

Yeah, it's actually really beautifully written. I mean the editing that you all did before it came to our team of editors at APA Publishing was really fantastic. It created, again for such a large author group, it created a sense of a continuous narrative and clear values that were woven throughout the text and it's very readable. I hope people pick it up. But that leads me to my next question. Who do you hope is going to read this book?

Shashank Joshi (24:34):

Well, as exemplified in the reviewers and in the authors we hope this book is for all people who work with children and youth where medication is something that they are either responsible for or are overseeing. Or if they're in primary care, for example, they may begin treatment or they may be seeing patients who are taking medications. There may be psychologists or social workers or other people who do conduct psychotherapy where we want them to really be aware of some of the things that are related to this work. In fact, one of the most frequently shared chapters and things that we're asked to share on is actually someone I first met through, because it's another person who trained at Yale, Andrea Tabuenca, she was working on her inpatient unit. She was a postdoc at Yale. Then she came as the psychology faculty and she wrote along with Marie Gibson, who was a psychiatrist at the time. We have trainees on that unit and it's called When Time is Tight and Stakes are high, and it's all about the Pharmacotherapeutic Alliance on the inpatient unit. And they came up with a very novel safety plan that is based on CBT and it's based on relational principles as well. And it works with families. So I think everyone from the aspiring medical student for child psychiatry to trainees in between, residents, Fellows as well as early career. And we've gotten feedback from senior folks. They've been waiting for a book like this. So for anyone [inaudible].

Dr. Laura Roberts (26:20):

Yeah, interest of course, you're a pediatrician as well as a child psychiatrist. So I think mean, my reading of the book is that it really would be good for folks in primary care and pediatrics. I don't know.

Shashank Joshi (26:34):

That was the hope in having a chapter specifically devoted, chapter eight is the Pharmacotherapeutic Role of the Pediatrician, Advanced Practice Clinician, Other Primary Care Providers. In fact, Katie Ort, who was one of our Fellows, and Amy Hennigan, who was one of my mentors at Einstein co-wrote that. And when I gave grand rounds at Yale earlier in the year, it was right before Omicron hit so I was able to go in person. We were in the Milton Sent Library. Milton Sent famously wrote a paper for pediatricians about their psychotherapeutic role being able to hold space for mothers in particular, which was the focus of his work in the thirties and forties. So I think that is evidence right there that this book really ought to be on the shelves of our primary care colleagues because I hope they will take some of the wisdom written by two pediatricians from that chapter.

Andres Martin (27:29):

By the way, little secret, I don't think that this book is irrelevant to adult people at all. I mean, there are some chapters that do have a little bit of a very specific child focused, but I would say that the majority of the book is quite relevant to patients regardless of the age. And so I would hope that some of our colleagues, even in adult psychiatry might take a peek.

Dr. Laura Roberts (27:55):

Yeah, no, I think that's right. And I think an explicit part of that relates to diversity of patients and families and the other books that you mentioned, Shashank, you can see there's a little bit of an intentional design here by trying to bring forward these books that don't view biological psychiatry as separate and distinct from therapeutic. That we do therapeutic work that we do all the time in our interactions with patients and families. But I would say that we need to work harder and to use your book as a model to be more inclusive of diversity, the unique considerations, and taking care of someone with a different background and experience from your own. And again, I mentioned earlier my own training. I often would have a supervisor of one background and experience, my own life experience and patients were vastly different experience. So now you've got a few different elements that you're working with and it's great if you can be aware of it, aware and work with it a very thoughtful way. So anyways, another strength of your book. Yeah.

Shashank Joshi (29:06):

Well thank you for sharing that. I mean, I would say now as I think more about the being able to just, we've used the term holding space, but I'm supervising a Fellow right now just before we did this podcast, who's working with someone of Native American background. He's actually, he's a college age student at another university. And now with the blessing of virtual, we can support young people all over California. But the kinds of questions that our patients have are very unique and original. What does it mean to take a medication? Does it change me? Does it make me the best version of me or does it change who I am ultimately? And in this young man's case, he's got people in his community who really are encouraging him to take the medicine and he had others who are not so sure. He has an elder who really feels that there are ways to combine spiritual practices within his own family and as it relates to their larger native community. And that aligns well with medication. He's trying to find his way. And I think so many of our patients, especially teenagers and young adults, those who've just left the home who are going to take this medicine or not, but they do rely on us to just not be in a hurry to, unless it's urgent, to start a medicine. We really need to get the story. We need to find a way that this is going to be the best fit for the patient that is before us. And it requires us to be patient, get the story, listen more, do all the things we went into psychiatry for.

Dr. Laura Roberts (30:43):

So let me come back to your gerund, Andrés becoming, which I love. So when you think about what maybe an enduring quality of this particular book, 5, 10, 20 years from now, we'll have more additions by then, but still, what, as we are really thinking about the future and the trainees of the future, I mean, what do you hope will endure about what you've shared in this particular book? I do see it as an enduring book, so just work with me. What do you recognize as an enduring dimension of this particular book?

Andres Martin (31:23):

Well, I agree and I'm delighted that you agree because medications will come and go and even psychotherapeutic interventions will come and go, and teledelivery systems will come and go. Everything will change. But at the end of the day, the relationship that we have with our patients and with our families, that will not go anywhere and we will succeed or fail through it in what we do. So that I think is the enduring message, the enduring message, the summary statement of this book is you are the medicine, the rest is commentary. And if people can really embrace that and believe that they're going to do, they're going to do well, they're going to do well. One additional, this is a small footnote, but one that I've been giving a lot of thought of and I've spoken with Shashank with is what is our role telling about ourselves? We know that a quarter of the population suffers a psychiatric illness, give or take. So that means that a quarter of psychiatrists give or take, have a psychiatric illness. How do we use the knowledge that we have based on our own experience? How much do we share? Do we never share? Do we share little? Do we share a lot? I don't know that that answers your enduring question, but that probably will be an enduring question 25 years from now for me because it can be a very powerful potion.

Dr. Laura Roberts (33:03):

Okay. Back to you Shashank. You had more time. What is going to be the enduring dimension of this book that you hope you'll see in the fifth edition in a few years?

Shashank Joshi (33:14):

Yeah. Well, in addition to what Andrés shared and maybe building off of that in the introductory chapter called Prescriber, Prescribed Thyself, there's a beautiful drawing by Simone, which appears to be Andrés actually, and he's holding an umbrella and he's handing an umbrella to the patient. And I just came from ACAP. So the first slide says, "We have nothing to disclose. I have nothing to disclose." And in this he's saying, "We have nothing to disclose, but we have much to share."

Dr. Laura Roberts (33:52):

Nice.

Shashank Joshi (33:53):

And I think based on our own lived experience, whether we ourselves have been afflicted with a mental health condition or people in our family very close to us, whether we have lost people to suicide, whether we are survivors by virtue of being clinicians and we've lost our patients, I do think that that really makes us who we are. And we do have to understand who we are in order to really be with patients. In the days when we trained, it was an unsaid requirement to be in your own psychotherapy or your own support, not only to do this work and place the proverbial oxygen mask on ourselves first, but also to know what it's like to be in the supportive holding environment and to be able to then from that place, be there for others. And so I think we're learning a lot more about how as we live this life and be the doctors of the psyche, that all of those experiences help us to be with our patients so that we can really help them in the best ways that we can. So I do think that is going to be something enduring from this work and hopefully future additions to come.

Dr. Laura Roberts (35:15):

Thank you so much for doing this wonderful, wonderful work and for all that you've done and for educating me on some best practices on motivating authors and taking on a big, big scope of work and doing it so elegantly. We really appreciate it. Nice to see you both.

Andres Martin (35:32):

Thank you so much Laura.

Shashank Joshi (35:35):

Thank you Laura.

Iain "no relation" Martin (35:46):

Psychiatry Unbound is hosted by Dr. Laura Roberts and produced by Iain Martin. Our original music is by Willow Roberts, and our executive producer is Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing. Be sure to visit psychiatryonline.org/podcast to join the conversation access show notes and a transcript, and discover new content or subscribe to us on your favorite podcast platform. Thank you for listening.