Ep. 23 – Reality Check – Dr Ramin Mojtabai (Tulane University)

Welcome to Reality Check. We're excited to be back. Hi, Ashley. Good to see you. And today we have Dr. Ramin Mojtabai with us, our colleague and friend. Dr. Mojtabai is a psychiatrist and a public health researcher. And he's going to tell us a little bit more about

Yes, very

who he is, what he does, and then we'll talk about how we're all connected.

you

Yeah.

So thank you for inviting me to talk to you guys. I've listened to some of these podcasts and they're very interesting, especially since people from different walks of life are talking here with you guys and I'm telling you about their experiences. So a little bit about my background. I grew up in Iran. I did my residency as well as medical school in Iran.

During medical school, I became very interested in psychiatry. So very early on, I was sold on psychiatry. And so there was no question of where I would go to my residency after medical

Sure.

I have a question. I have a question.

You

What sold you? That's a very profound statement. So what sold you before you move on?

Mm-hmm.

So, so.

I wasn't really interested in the biological aspects of medicine. I was always interested in the humanities, literature, philosophy, et cetera. And so the area of medicine that seemed to me to be closest to humanities seemed to me to be psychiatry. of course, there were some of the attending I was working during my medical

training in psychiatry who were very much involved in humanities. They were writers or some of them poets. so the fact that there was this affinity between psychiatry and humanities was attractive to me. yeah, so that is...

That's cool. ⁓

naturally ended up going, doing a residency in psychiatry. And during my psychiatry training, I got really interested in psychosis and psychotic thinking of patients. And it was more of a curiosity. I was just curious why people would have these forms of thinking, think so differently than other people.

and what makes it happen, what makes people ⁓ have these ideas. So especially I was interested in misidentification phenomena for those of your audience who don't know about these psychotic phenomena. These are psychotic symptoms in which the patient perceives people around them as other people, people with other...

It might be they would say, for example, that their family members have been changed or they would identify a stranger as somebody from their past life. And it seemed to me a phenomenon that really was ⁓ hard to explain why would somebody have these ideas. so early on, my interest in psychosis was focused

mainly on delusional thinking and also specifically misidentification phenomena. later on, I left Iran, I came to the States and during my residence in Iran, I had also become very interested in psychotherapy, pursuing more training in psychotherapy as well as research. And so I saw

this combination, the best way to approach this combination was to do a clinical psychology training in the States. And I did that. And during that period, I became also interested in mental health services for especially patients with psychotic disorders and schizophrenia. And that was mainly because through the influence of some of the mentors that I had during my

my training. And I chose for my dissertation an ambitious project that took me many months to complete, a meta-analysis of ⁓ psychosocial treatments for schizophrenia. So that large project actually was very interesting. I learned a lot about services and specifically about services for

schizophrenia and psychotic disorders. One of the interesting findings in that meta-analysis. First, should tell your readers who may not be familiar with what meta-analysis is. It's a way of combining many studies that are looking at the same phenomenon or same outcome or same group of patients. by combining

studies that are done different places by different researchers, ⁓ get a more accurate and more reliable estimate of the effect of, for example, an intervention. Or you can compare different interventions. So one of the interesting findings was that almost all psychotherapies for patients with schizophrenia seem to be

adding something to medication. So the combination seemed to be more effective. The other interesting finding in that study was that psychotherapy seems to be effective for negative symptoms of schizophrenia, whereas medications were more effective for positive symptoms. Again, for audience who might not know about these different types of symptoms, positive symptoms are symptoms like delusions, hallucinations.

disordered thinking, but negative symptoms are more social withdrawal and lack of motivation, those types of symptoms. And naturally, it seemed to me, and when you think about it, it logically makes sense that psychotherapy would be more effective for negative symptoms. Another interesting finding of this meta-analysis of

over 100 studies included was that psychotherapy was even effective for patients in the more chronic stages of illness. And we often think about, when we think about schizophrenia, especially in the chronic stages, as incurable or chronic illness that has persisted for very long and there's not much that can be done. The fact that psychotherapy was effective for

for these groups of patients also brings hope. so based on that study, I ⁓ later on decided to do a further research training in especially focused on schizophrenia. And I did a post-doc training at Columbia for ⁓ research in schizophrenia.

And during that period, I also got involved with a project that was going on in Suffolk County. project is now more than 20 years old, but at the time it was a very innovative ⁓ approach to do an epidemiological study of a whole county, the Suffolk County in New York ⁓ State. And they...

were able to actually capture all first admission patients with psychotic disorders in the county and follow them ⁓ over time to see what factors are related to their outcomes and whether the course of illness is really what we see in cross-sectional studies.

again for your audience, epidemiological studies that are following a group of patients from the inception of illness provide a more complete picture than cross-sectional studies because cross-sectional studies capture patients who might be in service or experiencing symptoms. But some patients who are early in the course actually recover and are no longer in the...

cohort of the patients with ongoing illness. So there is a value still to this day, think there is a value to capturing and following people who experience a health ⁓ condition early on and looking at the course and outcome of their illness. And that's what my colleagues at Suffolk County had been doing. And, and

some of the early findings of that study were really interesting. Although I should say that naturalistic studies do not necessarily capture the effect of interventions or treatments because they're not necessarily receiving the forms of treatment that, for example, in an early psychosis clinic would be provided. They were receiving just the services that were available in that setting.

But after that, after this experience with my training, I have continued researching mental health services. I expanded my focus on, I do different types of research. I'm interested in substance use disorder, as well as more common forms of mental illness, like depression, anxiety disorders. And so, but the...

major focus of my work is really service systems and how services provided in the community impact the outcomes of illness and what are the factors that make services more effective or less effective, more available or not. And I've continued doing this type of research.

That was a great overview. And I wondering what you thought when you first got to Tulane and you came full circle to us trying to look at long-term outcomes of our patients in our early psychosis service.

Yeah.

So first of all, I think your program is, when I first heard about this combination of calm with epignol, I thought, well, that's so natural. Why aren't we doing more of this? Because what I have learned over the years of my research in the services is this. We have good technologies. Our medications are much better than they used to be.

Mm-hmm.

30 years ago when I started training in psychiatry. At that time, for example, the only atypical antipsychotic we had was clozapine. SSRIs were just recently introduced. So we now have many medications. We have also very good and focused evidence-based therapies for patients. Yet the problem that we haven't solved

is the problem of access, of making these technologies available to people who would benefit from them. We have also had great success in expanding insurance, for example, through Affordable Care Act or parity ⁓ laws across the country. They make services more affordable to patients, but giving it

Mm-hmm.

insurance card to a patient or to a person is not sufficient if we don't have more services available. so issues of access availability and reducing stigma, which is one of the major barriers to accessing services among patients and the community in general. I think those are the major barriers that we have.

are focused on just improving technologies, improving medications, improving types of psychotherapy. By itself, it's not sufficient to solve the mental health problem in these states, I think, and in other parts of the world as well. So what your program does is really the CALM program is working on first, increasing knowledge, and second, reducing stigma.

Mm-hmm.

and

⁓ also making availability recognized and people would know knowledge is a form of access. And so when people know that there are resources, that the problem they're experiencing is not a odd problem. A lot of people share this problem, have had this problem, have experienced this. ⁓

Mm-hmm.

these psychotic episodes or psychotic symptoms and have recovered. Making people aware of that also helps people to want to access this service and their families. So de-stigmatizing, improving knowledge, improving access, and then having Epic NOLA is the place where they can go.

naturally leads people to contact the services. So reaching the community and ⁓ helping the community members who are in need to access services. It seems to me this package is really the way to go. And I also like that you guys are focusing on continuity of care because many of these

early onset psychosis programs just provide services for two years, three years, and then let people fend for themselves in the community. The fact that the services are willing and able to provide a continuous service, I think, is also a major component of your program. this sort of like from farm

to table service model is from community to the clinic and continuing in the clinic is the model that I think if you want to make progress in providing services for patients, this is the way to go.

Never thought about it that way.

Ha

No, me either.

Mm-hmm.

Yeah, I mean, we think so. that's, but, and, and, and how we've come together is taking this model, right? And bringing it to you to help us study it and see, understand what's working, what's not working, what continued to be the barriers, how stigma is showing up. And so we are super grateful to have found you and for your patience with us as we sit through 10 years of

you

Understand

data that we have on young people from onset of illness to and through recovery.

Yeah, think research has both, as you say, purpose of showing, first of all, identifying what are the factors, what is really working in these services, but also presenting to a larger audience. So one of the problems we as researchers have is that we produce papers and those papers are read by other colleagues of ours.

Thank

And they do not necessarily translate into services or they do not translate into improved access necessarily. And the fact that there is this collaboration between you guys who are advocates, not only providers, I think you are strong advocates for this model of service and research. This combination, I think, is helpful. Research can find a purpose here. ⁓

Ahem.

helping others understand, others see the problem and the solutions, potential solutions, and improving access to other people, improving the spread of this program, spreading the word in effect to others who might benefit from having similar programs in their communities.

Yeah, I always wondered like when I was in public health school, kind of what the translation was, like we were learning all of these, learning about epidemiology, learning, I was maternal child health epidemiology focused. So learning about all of these barriers and sort of the mass effect of different illnesses and then the community engagement part.

But we, except for like some areas of infectious disease, we never really made, there was not like a connection to what someone would do in an office. You know, and how, there was sort of a massive generalization of, know, suicide rates have decreased, we have a hotline, but that whole pathway was never fully described.

of how you make that come to that conclusion.

And so it's been...

think all of us in the clinic really love the clinical part, but then have these questions about the bigger picture and needing a different vantage point to be able to understand that or try to understand that we're just at the beginnings, I think, looking into this massive amount of data that we have to make some sense of it. But it's like a, it takes so much time too and effort.

and collaboration.

Yeah, I agree. takes time and there is a gap between even research that is well established and implementation in every field. ⁓ There very few examples where I can think that the research product came out and it was implemented very fast across the board in schizophrenia. Probably the...

Mm-hmm. Right.

Mm-hmm.

still to this day this problem, this gap, ⁓ remains between science and practice. So it's not unique to psychiatry, but I think it might be longer even in psychiatry than other fields. I agree with you. But another thing that research shows and does, a purpose that research might have is to

Mm-hmm.

Sometimes in clinic, I have been a clinician and a researcher, sometimes in clinic there are things that we believe, we come to believe and we come to practice. And you talk to clinicians, you would hear some of them advocate for this medication or another therapy. So one of the purposes of research is also to help clarify or to help...

dispel some of the myths. And one example I give you is that as clinicians, we do tend to see patients with chronic illness more than people who recover. And the simple reason for that is that people who recover don't need us anymore. They're doing so much better. And that was one of the findings we had in Suffolk County. Some of the people who dropped out of services was not dropping out because they were

Bye.

doing poorly but because they recovered. so I think research can help also for us to know that there are, even in psychosis, a sizable group of people receive treatment early on and may not need further care or may just need monitoring in later years. One of the groups of patients I was ⁓ doing research on early on was the

acute psychosis or acute transient psychosis. The different terms are used for these patients for this disorder, but these are people who experience an episode of psychosis and may not experience another one or may experience another one, but during the period they are able to function. So research helps us to know that there are these good outcomes and so we may not as clinicians see those.

Mm.

There are other phenomena I can think of, other experiences as clinicians that I have had that later on with research I saw that I was seeing only part of the picture.

Yeah, I remember very vividly when we had our first young person who would technically be called clinical high risk at this moment in time. At that moment in time, were referring, maybe they had a prodrome. And him doing so well and us

you

Not discharging him. remember, you know, one of our clinicians, Doug, and I talking about it and we're like, well, guess, I guess he could go, but are we out of the woods? Like, I'm not really sure because you can't predict the future, but felt really, you know, in, in training, there is this sort of doomsday, like teaching about the schizophrenia spectrum disorders. And it's really sad, but it, even as a trainee, kind of leaves you like,

almost hopeless and it was really cool to see our people just kind of doing well. none of us wanted to, none of us wanted to like reduce our contact with our fun patients. And we get to watch them. And I'm a child psychiatrist. like, we were watching the young people graduate high school. This is like the love of being a doctor in that field. You know, it's, you have enough.

bad days that having the good experiences are really awesome. And so we were monitoring him. I was treating his anxiety and depression and it just like, we just watched it unravel into what is schizoaffective disorder. I never, you don't learn that. You learn, once you see it, you're like, like that's...

you

That's why those criteria, I guess, were sort of clumped together to represent this that I'm seeing, but that takes time to really like, you know, learn it. And once you see it, then I think you're number one, my buy-in to like, not buy-in, but seeing diagnostic criteria, I sort of saw them as a framework instead of like, you know, this list I had to memorize for.

play out in real life. ⁓

either for a board exam or for, you know, talking to an attending doctor about, but like you see that it's just a framework, was I think just part of our experience collectively that, you know, we were learning, like in the only way we were going to learn really about what we were doing is if we were like witness to it and like there and watching, you know, and not,

He's doing great now. That's great. But you know, it didn't always work out that way. and then there's, you know, people that we lose to follow up for whatever reason. but it was definitely different, different experience as a clinician to watch people, recover from this thing that really we had only learned about from an inpatient unit. you know, from that snapshot moment in time.

you

Let me ask you this question, since you started asking me about research. Let me ask you guys, where do you see the role of, or what do you see the role of research to be in the type of services you provide? How can research help you, you think, or guide you, or enlighten you in your practices in some ways?

NNNN

No.

Well, I think it plays many roles, right? There's the best practices that we gather from research and that helps to guide the work we do at the clinic. The way we're collecting data on this cohort of people we've seen over 10 years and we're getting to the data is there to support and demonstrate the successes and challenges of treatment.

Thank

and what recovery can look like. But what I was going to come to you with, and maybe this is just a conversation for us all, is, right, so we're collecting this data. We're doing, you're doing analyses. We're witnessing the analyses and right. ⁓ And we're writing about them. But you're right, we're submitting to academic journals. We're presenting at conferences, all of which is important. But we, where do we

We're bearing witness to the analyses that... ⁓

place this data in the world, with whom do we share it to make system changes? Because really that is what's going to impact a broader range of people and it's going to reduce stigma and reduce barriers to care.

And I have, want to answer your question too, just because I feel like am I being a good student? ⁓ I think early intervention is, it feels like, of course, like, of course you would want to intervene early, even if it's just to help someone manage distress, you know, like.

Yeah.

I mean, now we know about heart disease and the role of stress. like early intervention of stress could theoretically change multiple areas of health. Like we can extrapolate that, but you have to identify stress. You have to have insight about stress to ever even think it's a problem. And so

You know, we, think anecdotally and we try to keep it anecdotal, but we look at like our clinical experience and seeing when someone's coming in and they've had this going on for like several years, we're just doing, trying to be the best clinicians possible. And like things, it's just barrier after barrier. And the more barriers somebody's face, the harder to,

You know, it's just a recovery journey or whatever you want to call it is so difficult. So how do we understand like someone's pathway, right? I mean, and this is what one of our other mentors, you know, Vinod talks about all the time is like the pathway to care. Of course, through care is important too, but like what are, how do you actually change the way people seek help?

How do you influence? so research to me is helping, is understanding how people are seeking help, especially for psychosis in particular, because it's such a highly stigmatized and misunderstood disorder across healthcare period. And so, but then how to, how to help,

other clinicians sort of buy into the fact that they have to like get out of their office. you know, or that not everybody is being a little bit dramatic, but, that it's really, really important to be in your community. And it's really important to, to also.

Thank you.

Thank

you know, have a pulse on what's happening in that pathway through this system that is very complicated. mean, you mentioning the insurance card is like prime example. We have some people that getting the insurance card into our system is like an act of Congress for whatever reason, you know, it's,

I mean, happens half the time when I go to a doctor. I never had my insurance card. I barely even had my driver's license. Like, you know, these are, these are everyday problems that have incredible impact to the way people access. And then you're asking someone with horrific experiences happening in their life, let's just say paranoia, and somehow they need to come to you and be a perfect patient. Like, it's just a ridiculous assumption. And so like, I think research could prove that.

Mm-hmm. Yeah.

you

you

you know, or like help tell that story in a way that would resonate. so yeah, that's my first.

Thank

Thank

you

True,

true. And I think like one of the ⁓ purposes this podcast you have is serving is just reaching out ⁓ and talking to different people who have had different experiences tackling these pathways. But I agree with you that one of the purposes of research is to show the problem. Problem in access, the difficulty in tackling this system. And then another purpose is to show

Mm-hmm.

Mm-hmm, right.

what has worked for some people and not worked for others and identifying the service systems that work and not work. That's another purpose. But I completely agree with you. think we need both researchers or all three researchers, clinicians and advocates. And it's a collaboration of these groups that can actually...

Right.

Yeah

Yeah.

produce improved care for patients.

And from the humanities, like you described earlier, I mean, that's like so, that's so true. You know, we've been working with like the artists that like, you know, with that fireside and these places that have a way of storytelling and like connecting with humans is, it's critical. Otherwise you just sound like an quote unquote academic.

Yes.

Mm.

I guess I didn't have to do quotes because there's video, but you don't understand. ⁓

Right.

Right.

So as I move us to a close, I wanted to zoom out a little and ask you about this moment we're in, a bit of a public health crisis and in terms of funding. And I'm curious what your thoughts are about the downstream effects of the defunding of public health in the United States at the moment.

It's just a sad story, really. But I tend to believe that this is a passing period. And I have a mentor, Howard Goldman, who talks about incrementalism. He says that if you look at long term, we have come along quite a bit.

I think if we look historically or overall, I'm less hopeless, let's put it this way. And I'm hoping that this period will pass as previous setbacks passed. And because we would recognize as a community, as a country, as a world, that we need to, we can't get any...

You can't get things without paying for them. If we want improved public health, we have to pay for it. If you want improved care for patients with severe mental disorders, we have to invest in that. And we would recognize that. And that investment pays back in many different ways in general. So that's my message of hope.

that he was wrecking myself.

Yeah, I love that you're leaving us with hope.

I

Thank you.

wanted to ask one more question, one more. Because you talked about stigma and you talked about, being from, you've experienced many different environments and cultures where stigma is a common, kind of a common thread amongst people. And if you were to advise us on,

How, what is the deal with stigma and schizophrenia and like what, what, what will we need to do? What would we need to do to better understand? I mean, we understand it because it's all over the place, but to address it, what would be your advice?

So for many years we pushed this campaign that mental illness is an illness like any other. We focused on the biological aspects. But that didn't really dispel the stigma about mental illness, especially the stigma of perceiving mentally ill as dangerous. We know that mentally ill people are more likely to be victims of violence than perpetrators of violence.

Bye.

Right.

That didn't solve the problem as we wanted it. So one thing that has been shown to really help with reducing stigma is familiarity with people who suffer from that illness or problem that is stigmatized. And I think also another thing that I like about your campaign is that people with lived experience of mental illness are involved in

in these events that you have in your podcasts, you're familiarizing the public with people who have had this experience and you make it a human experience. It's not something odd or strange to suffer from mental illness. It is part of the human experience and we encounter them without knowing something. A lot of people with mental health problems.

during our daily activities. it's when people come forward and talk about their experience and their journey and their pathways, it is helpful. It helps to reduce the stigma of mental illness. I think that's the solution really to make mental illness a familiar experience, part of the normal experience of being human.

Okay, another message of hope.

That's

Well, thank you so much for joining us on Reality Check. It was great having you.

⁓ Thank you for having

I

me.

We appreciate you working with us and helping us learn. And this ultimately helps Epic, helps Calm. So thank you.

and the greater world.