Response to Multiple reports of the reports that emerged following the posting of Mr. E. Musk’s responses to Mr. Don Lemon about the episodes of Depression, Use of Illicit drugs and being treated for Depressive episodes with a stand- alone intervention the administration of Ketamine on an episodic basis.
I thank for this interesting and even stunning information about the use of Ketamine in a seemingly unstructured manner without concomitant psychotherapy and overall health promotion efforts that is integrated with the use of Ketamine to ameliorate symptoms of depression rapidly albeit for short intervals. I believe this is to the long-term detriment for the functional capacity of the individuals depending on theses intermittent remissions to get by instead of investing in achieving more enduring recovery from the Severe persistent Psychiatric Illness that seems to Mr. Musk to be a form of disruptive and debilitating “Depression” that enshrouds him from the Blue from time to time? There are many types of Depression that are described in DSM 5:
1. Disruptive mood dysregulation disorder,
2. Substance /Medication induced Depression [Especially from the bits of information shared by Mr. Musk’s and observations documented in news reports shared online.]
3. Major depression,
4. Persistent Depressive disorder [Dysthymia],
5. subtypes of Bipolar Depression including Bipolar II,
6. Seasonal Affective Disorder, Psychotic Depression,
7. Treatment Resistant Depression,
8. Atypical Depression, besides specific categories that apply to female patients: PMDD, Peripartum [Post Partum] Depression, Depressive disorder associated with another Medical Disorder or treatment interventions. Other specified Depressive disorder with new specifiers: a. with mixed features, b. with anxiety and distress. And finally, Unspecified depressive Disorder. There is helpful link in Section II B. 16.
I am sharing how my teams and I address such clinical challenges that impede the course of our patient's life trajectory including relationships in personal and professional/vocational domains. This is my experience in my career over the past fifty years or so.
As an essential part of the assessment and decision making strategy to draft a treatment plan that includes use of Prescription medications when I have received bits of information suggestive traumatic experiences in childhood or early adulthood of my patients I have often recommended a Battery of Psychological tests by an experienced Adolescent/ Young Adult Psychologist who specializes in TESTING and knowledgeable about impact of Cannabis and Recreational Drugs of Abuse on Cognition, learning, Executive function, Emotion Regulation, Object Relations and Psychosocial development especially if the person has experienced what appears to be significant Psychotic episodes and impairments I when they were transitioning through adolescence and early adulthood or during past experiences of serious personal crisis. I would definitely not treat a patient with Ketamine especially because of Drug -Drug interactions in the brain that can result in emergence of psychotic experiences or acting out irrational poorly thought-out decisions because of impaired capacity to assess reality in real time and assess the consequences of impaired cognitive functions and emotional dysregulation.
My patient would have to make a conscious urgent definitive choice before and during the course of Treatment with Ketamine, whether to stop using THC containing Cannabinoid Compounds for even up to a month or six weeks depending on frequency and volume of Cannabis use before discussing initiation of Ketamine treatment and be reasonably certain that DDI interaction and interaction with personality factors, severe mental illness needing Ketamine and other meds will not increase the risk of emergence of Psychotic Symptomatology. I am more likely than not depending on the results of clinical assessments and interpretations of the Battery of Psychological Test protocols to be willing to treat the patient if Cannabidiol is being used in a systematic manner for a specific reason for Neuropathic pain. I offer a link in section II B.11 below.
I would hold the same prerequisites for person who like Mr. Elon Musk has been using LSD, Cocaine, Ecstasy, [MDMA] and Psychedelic Mushrooms with reports from senior management official Ms. Linda Rice about this person alleged behavior that may be manifestation of the influence of the one or more drugs being used or when the person is off one or more of the reported drugs. In 2018, Mr. Musk landed in trouble with NASA after he was seen consuming marijuana on the Joe Rogan Show. Unless the drug tests are random, mandatory at certain frequency and cannot be switched from the scheduled date for the Drug Test the results may be an artifact of plans to avoid detection of drug use. I am offering a link to a report about the use of Psilocybin from Magic mushrooms [Polyphyletic Mushrooms] for Psycho therapeutic strategies. The research suggests 2 doses of Psilocybin with supportive psychotherapy supported amelioration of depression symptoms for up to a year. Please see Section II. B.12 below.
It will be great to have the data from the hospitalizations and treatment he received back then and since especially if Psychometric assessments were done even before the psychotic experiences for any reason when he was in Grade school or Middle school or even High school when the Psychotic experiences occurred and recorded in accessible places to help determine the best interventions can be selected and implemented collaboratively with our patients consistently with his values and if desired genomic testing.
Psychometric data from the past can be helpful right now by serving as a baseline for comparing progress and outcome of multi-pronged interventions he has received over past 5-6 years.
I am offering a list of tests that are very important to consider and get through as soon as possible while he is still in his current baseline of being under the influence of high level of THC alkaloids for a sustained stable period:
A. 1.WISC-IV is for people under 16 generally and WAIS IV [Denoting Edition] for ages above 16 to elderly persons. The experienced Psychologist can decide after interviewing the person we are referring to.
2. It will be very useful to complete this test: MMCMI-III Millon Clinical Multi-Axial Inventory -III [Interphases well with DSM diagnostic categories] or similar Personality Test,
3. Then the Projective tests that can offer major insights into what may be influencing his behavioral choices and suggest more helpful approaches than have been tried adequately: TAT, Rorschach.
4. Bender Visuo-Motor Gestalt test can reveal concrete data about the real time functioning of the complex components of the Nervous system and point out potential blocks in the learning prosses be it educational based on a curriculum or in therapy or in life experiences and suggest remediation strategies.
NOTE: The WISC-IV test [<16] or the WAIS-IV does more than merely provide IQ scores. It presents important and necessary information regarding a child’s cognitive functioning level. The test is often times used to help identify potential learning disabilities in children, as well as to determine if a child may be considered as “gifted.” {The WISC-IV cannot be used to measure extreme intelligence IQ scores below 40 and above 160 points; however, it is considered a very useful to tool to determine a child’s intelligence.}
B. Secondary Learning disabilities, impairments of Executive functions after being impacted by the Drug abuse for a decade or so can also cause relationship challenges in all sorts of situations, regardless of the specific alterations of CNS especially if he has not successfully transited important stages of Psychosocial development he goes down on himself for not being able to address real time problems at hand and establish what behavioral repertoire he observes from his age peers and even younger children in similar circumstances.
Psychological Testing [a Battery of tests] is important not just because it provides a comprehensive diagnostic assessment of the person’s mental apparatus but offers specific opportunities that can be adaptively developed to get the best outcomes under the best of circumstances sans Drug abuse and on the road to such a circumstance. I have provided a link that provides a multi factorial assessment of anomalies of Cognitive function and Emotional disequilibrium. Section II B 12 below.
I recommend the Care provider of a person experiencing significant Depression, PTSD, or the Clinical coordinator of treatment setting providing treatment for Mood disorder or our patients or their Parents or Family members make a list of Psychologists based on 1. Your personal knowledge of competent people in these areas in different parts of the state 2. Checking with the Insurance Carrier who they know to be experts in this sector of psychological expertise for both the assessment and for the therapy needs to remediate the neuro deficits and psychological issues that can engender episodes of depression, or mood disorders, and evoke suicidal or high-risk personal, professional and Executive decisions with potentially lethal or high-cost consequences for the patient and those around them.
From the list of potential referral resources of Clinical Psychologists our patient and or their family members can call and make enquiries and if they choose our patient’s PCP can make a referral with the necessary clinical information permitted when the Release of Information is signed to the specific Psychologist they wish to enlist in the careful assessment and treatment of their family member. It is best our patient and his family to select and work with the person of their choice based on their preferences and values beyond the published credentials/reputations.
This important choice must be part of Shared Decision making between Clinical Team members who are providing evidence-based observation and recommendations that can have important bearing on remediation and rehabilitation on the road to total abstinence-based recovery [I include Illicit drugs and Licit drugs used illicitly to avoid Drug interactions exacerbation of Cognitive deficits and Behavioral dysregulation while the differential diagnosis of the mood disorder and treatment plans are being worked on over the first 6-12 months because even the striking, virtual benefits from Ketamine administration can peter away in a few weeks and Medications generally used for treating Depression and mood disorders have potential for significant Drug -Drug Interaction.
I am offering how I utilize an atlas of differential diagnoses in determining the etiology, pathogenesis, enable risk assessment, formulate potential treatment strategies and collaborative Treatment plans with Team members, our patient, and significant others. I developed these plans based on what was reported about the Hon. Mr. Mitch McConnell’s videotaped behaviors in August 2023. I offer a link to this report in Section II, B. 17.
I offer two additional links: Section II, B.18: Multi- Modal treatment of Depressive Disorders and Section II. B. 19: The Bidirectional interactions between Stress and Depressive disorders and recommendations to address the symptoms and sources of stress while managing suicide risk. Often persons caught up in the recurring cycles of Stress and Depressive disorders may be suffering from treatment resistant depression [TRD] and may choose to ameliorate, anxiety, agitation, pain and suffering and end it all by going to sleep and not waking up or waking up relieves of the pain of their existence through the use of Illicit drugs. Gambling and various Addictive disorders. This potentially lethal combination between Stress-Depression- TRD can greatly exacerbate Suicide Risk and worsen duration and level of disability. These comorbid disorders must be especially looked for and concomitant treatment must be instituted, and the persons stabilized before offering Ketamine for treatment of Treatment -Resistant Depression should it emerge.
II.
I offer these reports on the relatively recent emergence of the unique use of a drug Ketamine used in Rave Parties along with MDMA, and Stimulants. Many sought the dissociation caused by Ketamine at the Rave Parties and elsewhere and sought access to K – Hole because they had a personal personality structure that sought dissociative experiences. Even during the IV infusion under therapeutic circumstances if the patients don’t keep their eyes closed during the 90-minute infusion of specific uncontaminated drug and the popular Special K which quite a draw in some populations.
A.
1.https://www.psycom.net/mental-health-medications/ketamine: Is ketamine an effective treatment for people suffering from debilitating depression? Here's what you need to know.
This is quite informative and helpful. Since Ketamine is fast acting and can really reverse the deep depressed state with high risk of suicidal behavior Ketamine therapy has been life- saving and quite restorative in terms of personal functional capacity and worthy of consideration even if it means repeating the infusions periodically. VM
2.https://www.health.harvard.edu/blog/ketamine-for-treatment-resistant-depression-when-and-where-is-it-safe-202208092797
3.https://www.cuimc.columbia.edu/news/ketamine-treatment-depression-what-you-need-know
4.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767816/
5. 7 Things to Help Manage Your Treatment-Resistant Depression (everydayhealth.com). This is comprehensive report with helpful/useful information about Ketamine and both Psycho-behavioral treatment modalities.
6. How electroconvulsive therapy heals the brain − new insights into ECT, a stigmatized yet highly effective treatment for depression (msn.com)
a. Two types of electrical activity make up brain waves. The first, oscillations, are like the highly synchronized, melodic music you might hear in a symphony. The second, aperiodic activity, is more like the asynchronous noise you hear as musicians tune their instruments. These two types of activities coexist in the brain, together creating the electrical waves on EEG records.
b. A long-standing theory of depression states that severely depressed patients have too few of a type of brain cell called inhibitory cells. These cells can turn other brain cells on and off, and maintaining the balance of these on and off states is critical for healthy brain function. This balance is particularly relevant for depression because the brain’s ability to turn cells off plays an important role in how it responds to stress, a function that, when not working properly, makes people particularly vulnerable to depression.
c. Using a mathematical model of cell type-based electrical activity, I linked increases in aperiodic activity, like those seen in the ECT patients, to a huge change in the activity of these inhibitory cells. This change in aperiodic activity may be restoring the crucial on and off balance in the brain to a healthy level.
d. …though our sample size is relatively small, our findings indicate that ECT and MST likely treat depression by resetting aperiodic activity and restoring the function of inhibitory brain cells. Further study can help destigmatize ECT and highlight new directions for the research and development of depression treatments. Listening to the nonmusical background noise of the brain could help solve other mysteries, like how the brain changes in aging and in illnesses like schizophrenia and epilepsy.
7. Depression recovery can be hard to measure − new research on deep brain stimulation shows how objective biomarkers could help make treatment more precise (theconversation.com)
Clinical depression is a debilitating condition that causes significant personal and societal suffering. It is one of the largest contributors to the overall disease burden of many countries. Despite the many approved treatments available, nearly 30% of the 8.9 million U.S. adults taking medications for clinical depression continue to have symptoms.
a. Deep brain stimulation can alleviate treatment-resistant depression for some patients.
b. Depression recovery can be hard to measure − new research on deep brain stimulation shows how objective biomarkers could help make treatment more precise.
c. Researchers have been working to find alternative options for those with treatment-resistant depression, and many decades of experiments have identified specific brain networks with abnormal electrical activity in those with depression. we monitored the brain activity of 10 patients receiving deep brain stimulation for severe treatment-resistant depression over six months.
d. At the end of six months, 90% of the patients responded to the therapy – defined by a reduction of symptoms by at least a half – and 70% were in remission, meaning they no longer met the criteria for clinical depression.
e. Finding an objective biomarker that measures recovery in depression has the potential to improve treatment decisions. For example, one patient in our study had a relapse after several months of remission. Were a biomarker available at the time, the clinical team would have had warning that the patient was relapsing weeks before standard symptom surveys showed that anything was wrong. Such a tool could help clinicians intervene before a relapse becomes an emergency.
B
I offer these posts to offer a comprehensive overview of the antecedents of the serious emotional dysregulation, deficits in Executive function and impaired Cognition.
1. Health Promotion - Educational Materials (psychiatristsites.com) This link provides access to several illustration between Psycho-Neuro [including Vagal and Autonomic NS influences] Immuno-Endocrine- Microbiome systems and inflammatory cytokines etc. I introduced my teams and my patients to the SENSS Paradigm that I developed over the years
2. TreatmentRecommendationsforRestoringWellbeing: Managing Depression in comprehensive manner including adopting the tenets of the SENSS paradigm described in previous post.
3. What Is Mindfulness? (webmd.com)
4. Mindfulness, and Self-Regulation resources (velandymanoharmd.com)
5. The God Solution: Spirituality as a Coping Mechanism and Healing Tool for Mental Illness and Addiction | Digital Collections.
6. There are more health benefits to yoga than just being bendy (msn.com)
7. Your Guide to Lowering Your Blood Pressure with DASH (nih.gov)
8. The Mediterranean diet and health: a comprehensive overview - PubMed (nih.gov)
9. https://fortune.com/well/2024/03/18/how-healthy-intermittent-fasting-heart-disease-study-91-percent-risk/
10. How do you relieve inflammation? (webmd.com)
11. Cannabidiol (CBD): What we know and what we don't - Harvard Health
12. Psilocybin Treatment for Major Depression Effective for Up to a Year for Most Patients, Study Shows | Johns Hopkins Medicine
13.Cogntive- Behavioral assessment (velandymanoharmd.com)
14. A Common Probiotic Could Boost Brain Health in Older Adults (msn.com)
15.Known to be heart smart whole grains may also lower the risk of Alzheimer’s in Blacks (endalznow.org)
16. https://www.webmd.com/depression/depression-types
17. Atlas of differential diagnoses: (velandymanoharmd.com)
18. Multi – Modal Treatment of Depressive disorders (velandymanoharmd.com) [Detailed report on website]
19. The Link Between Stress and Depression (webmd.com) Explores Bi Directional interactions between Stress and Depressive disorders and Suicidal Behaviors and recommends proactive countermeasures.
“Our stress response does pretty good in the short term, but it doesn’t do very good if you activate it in the long term,” says David Prescott, PhD, associate professor of Health Administration and Public Health at Husson University in Bangor, ME.
“If we stay under chronic stress, our physiological stress response is taxed beyond what it’s designed to do, and it starts to impair us.”
The effects of chronic, or long-term, stress can be harmful on their own, but they also can contribute to depression, a mood disorder that makes you feel sad and disinterested in things you usually enjoy. Depression can affect your appetite, your sleep habits, and your ability to concentrate.
And the effects of depression can cause stress.
“The impact of stress on depression, and vice versa, is one of the most important problems of our times,” says Carol Landau, PhD, clinical professor at Brown University.
But the reasons stress contributes to depression are less obvious.
“It’s pretty clear that chronic stress raises the incidence level of depression,” Prescott says. According to The Mental Health Survey Report from The Mental Health Institution, levels of depression among members of Gen Z went up about 4% or 5% between pre- and post-pandemic.
“We think the social isolation, the disruption in normal activities, and the general stress of having your college or work disrupted appeared to increase levels of depression. But I would say we don’t know, causally, exactly how that happened.”
Make Lifestyle Changes
Sometimes a few small changes can break the stress-depression cycle, beginning with a more positive mindset.
“If you’re stressed and feel like you’re starting to become depressed, the biggest thing is to get a little more active coping strategy in the way you’re going to deal with your stress,” Prescott says. “Don’t just think that you’re going to have to ‘suck it up and take it.’"
A more active coping strategy can include:
• Exercise. Just 30 minutes of physical activity 5 days a week is enough to make a difference. Activities like yoga and tai chi, which slow things down and help you relax, are good for reducing stress.
• Avoid binge-eating or drinking. These may make you feel better temporarily, but they’re not helpful. In addition to being physically harmful, they can make you feel guilty and worse about yourself. Overdoing alcohol can affect your sleep and make you sluggish the next day.
• Limit caffeine. Too much can wind you up and make stress even more intense. Try to cut down on coffee, soda, and other caffeinated drinks.
• Quit smoking. The idea that smoking cigarettes can help you handle stress is a popular myth. While nicotine does help relax you right away, that feeling is short-lived and can create more stress through cravings or withdrawal.
• Make time for yourself. Do things you like to do or that make you feel good. Go easy on yourself and focus on the things you do well.
• Steer clear of stressors. If you know something or someone sets you off, do what you can to avoid that situation or person.
• Sleep well. Making sure your mind and body get enough rest can go a long way toward easing stress. The National Sleep Foundation recommends 7 to 9 hours for adults every night.
“If you’re depressed and you’re trying to minimize the impact of stress on your life, it’s important to overcome that belief that ‘nothing I do is really going to matter,’” Prescott says. “It’s just not true in most cases. It may not change everything, but it’s a big thing to overcome that kind of hopeless belief.”
I welcome your esteemed responses.
Velandy Manohar, MD
Distinguished Life Fellow- Am. Psychiatric Association [APA]
Founding Member- Psychotherapy Caucus- Am Psychiatric Society, Steering Committee member until 2018.
CT. Psychiatric Society: Roger Coleman Memorial Award for Exemplary devotion to patients and commitment to Quality of Care. 2010
CT. Psychiatric Society: Cornelius Boulehouwer, MD Award for service to the CT. Psychiatric Society: 2003
CT. Federation of Alcoholism and Drug Abuse Counselors Bestows Honorary Membership in Recognition of his many contributions to field of Alcoholism Treatment to Velandy Manohar, MD.,
In-Home Addiction Treatment Institute Impact Award - In recognition of your efforts to shift the Addiction Treatment paradigm – 2019.
First President, In-home Addiction Treatment, PC and First Medical Director of Aware Recovery Care. Retired 2022
Best In Medicine- American Health Council- 2018
CT State Medical Society: Member: Quality of Care, Ethics and Disaster Preparedness Committees,
Founding Member- Community Resilience Collaborative-Mx. County-CT Focused on Identifying and amelioration of near and if possible long-term consequences including Intergenerational transmission of the impact of Early Childhood Experiences.
Member – Mx Community Coalition for Children -Mx. County, CT focusing on the significant impact of SDoH factors especially Housing, Food security, Health care access and affordability of medications for instance.
Chair, Community Engagement and Outreach Standing Committee of Community Advisory Council of Office Health Partnership.
CONNECTICUT MEDICAL EXAMINING BOARD (CMEB): 1995-2007, NON-BOARD Hearing PANEL MEMBER (CMEB) 2008 to present.
CT. Medical Examining Board: Designated to the group that formulated and drafted the Guidelines on the Use of Controlled Substance for the Treatment of Pain. Section I: Preamble The statement of the CMEB on the Use of controlled substances for the treatment of Pain June 21, 2005