CEimpact Podcast
The CEimpact Podcast features two shows - GameChangers and Precept2Practice!
The GameChangers Clinical Conversations podcast, hosted by Josh Kinsey, features the latest game-changing pharmacotherapy advances impacting patient care. New episodes arrive every Monday. Pharmacist By Design™ subscribers can earn CE credit for each episode.
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CEimpact Podcast
Understanding the Gut-Brain Connection Part 2
Building on the science of the gut-brain axis, this episode focuses on actionable strategies pharmacists can use to counsel patients on mental health, gut-related medication effects, and evidence-based lifestyle interventions. From tailored counseling tips to supplement and nutrition guidance, pharmacists will learn how to support patients managing both GI and mental health symptoms. Tune in to discover how small conversations can lead to big health improvements in both gut and brain function.
HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact
GUEST
Lara Zakaria, PharmD, MS, CNS, CDN, IFMCP
Owner, Founder
Foodie Farmacist LLC
Pharmacist Members, REDEEM YOUR CPE HERE!
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)
CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Identify evidence-based strategies pharmacists can use to support patients with gastrointestinal issues linked to mental health conditions.
2. Explain how lifestyle, diet, and complementary supplements influence the gut-brain connection to support patient care.
0.05 CEU/0.5 Hr
UAN: 0107-0000-24-154-H01-P
Initial release date: 5/5/2025
Expiration date: 5/5/2026
Additional CPE details can be found here.
Josh Kinsey. Hey, ce Impact subscribers, welcome back to part two of our series on the gut-brain connection. I'm your host, josh Kinsey, and I'm excited to jump back into the conversation with Laura Zacharia as we continue exploring the powerful link between the gut and the brain.
Speaker 2:Laura Zacharia.
Speaker 2:Yeah, I think I'm going to put it into three categories for us, right?
Speaker 2:We're going to talk about the education and the counseling opportunities and the little gems, little pearls that we can drop for our patients to help them become a little bit more aware and start making these connections.
Speaker 2:Category number two is going to be counseling points on those common medications that we talked about and opportunities to weave in some guidance talked about and opportunities to weave in some guidance. And category three is gonna be what are the other tools in our toolkit when it comes to supplement recommendations, lifestyle recommendations or dietary recommendations that we might be able to leverage and when that patient has the education and the awareness and the willingness to make those changes, we can also intercept with those options as well. We know a lot of patients. They're more interested in a holistic approach, right? We know that most of them they want somebody that they can go to, that they can trust, that can give them recommendations when it comes to diet lifestyle, that can think outside the box, that understands how their medications are impacting them, understands how to get the most out of their medication and understands how to skirt some of the problems, the side effects, that come along with those medications.
Speaker 2:So, what we're advocating for is actually the opportunity to be that standout pharmacist or pharmacy that can be their go-to, that can be that resource for them, and I don't know. That's kind of why I became a pharmacist, right. So here we go.
Speaker 1:That's the root cause of it, yeah.
Speaker 2:Kind of yeah, it's kind of exactly. I don't know, it's up my alley. I feel like this is what pharmacy is all about, so being that problem solver, being that go-to community resource for patients to maximize their health right.
Speaker 1:Absolutely.
Speaker 2:So number one, counseling points. So we touched a little bit on this, but I think worth repeating again that we want to make sure that when we're counseling particularly if somebody comes to you because they are taking an SSRI, considering starting an SSRI, concerned about their SSRI not getting the results they want from their antidepressant right that we ask the right questions. So number one I want you to be thinking about is do they experience any GI symptoms? And this might have to be introduced a little bit to them because they may not be making that connection between their GI symptoms and their mental health.
Speaker 2:And there's a statistic somewhere about the incidence of depression and anxiety in folks who have IBS, and it's about 80% of patients who present with a diagnosis of IBS whether it be constipation dominant, mixed, or diarrhea dominant about 80% also have either depression, anxiety or both. So it's on us to make sure that they understand that there is a relationship between those two things, right, and to start paying a little bit more attention to their body. If symptoms get worse when the other symptom gets worse, so their depression gets worse, does their GI symptoms get worse, and vice versa, right. So I think that's a great counseling point and a great opportunity to introduce a little bit of awareness to your patient and help them start to see if maybe some of the side effects they're experiencing to their gut might be interfering with their progress in terms of their mental health right and that could be from the SSRI itself, or it can be from another medication they might be taking.
Speaker 2:So, going back to asking them a little bit more about what else are you taking? How do you, you know? Do you experience headaches and how do you handle them? Do you have irregular cycles or irregular periods, and how do you manage that?
Speaker 1:Right, do you have?
Speaker 2:painful PMS symptoms Right? Are you taking an oral contraceptive? What's your blood work? What has past blood work said about the health of your liver? Has that other you know? Have you ever had issues with your thyroid? Have you ever had issues with your insulin? Do you experience insulin resistance?
Speaker 1:Do you?
Speaker 2:have pain, joint pain.
Speaker 1:Sure.
Speaker 2:Right, because joint pain is a marker of inflammation or causes more inflammation. Inflammation is also a driver of depression, anxiety and GI issues and vice versa. It's also sort of playing in that same pool and changing the microbiome, changing our immune response and altering some of our hormonal signaling too. So all of these questions can start to. You're not necessarily even trying to get to a solution yet, but even just starting to explore and help them start to see the relationship and make the connections. Pain, joint pain in particular, is a very common manifestation of depression, right, and they might notice when their depression gets worse, their pain gets worse and kind of almost reinforcing. It's not in their head and that it's a little bit of the chicken or the egg. The two are driving each other, and so that might be a way for them to really check in with their body and see how their depression is showing up physically and not just psychologically.
Speaker 1:Yeah, laura, I'm going to stop right here for one second, so we're at 30 minutes, but I feel like you still have a lot to give.
Speaker 2:Yeah, I could probably do it in like 10 to kind of wrap up those three points.
Speaker 1:Well, what I'm thinking is if you do it in like 10 and then maybe we have five minutes of like a debrief and whatever yeah and I'm just going to make this two episodes. And right from you, right when you started saying I have three points to share, was that almost like the 23 or 24? Minutes, so maybe that's like one, I'll just make it like, I'll be like and come back for the next episode as long as you feel like it's good stuff so my only question was are you okay to continue?
Speaker 2:Yeah, I have time yeah.
Speaker 1:I always buffer myself. I know, okay, okay, well, let's just do that. No, this is great and it's actually super helpful to just to get another episode out of it.
Speaker 2:Great, I'm happy to you know what I was doing you a favor, Josh.
Speaker 1:Yeah, no, seriously, you are. Yes, very much. Okay. I'm just going to tell my person to um. I'm just going to tell Allie to um cut out a little bit of that in the center, okay. So let's start um. Let me just go back to something on my lips. Yeah, okay, so we were at um. What was your? What was your second bucket?
Speaker 2:So the second bucket I was going to talk about uh, I said medications and then lifestyle stuff.
Speaker 1:Um so bucket number one is counseling tips bucket number two are things that we can do when it comes to their medications. Okay, I'm just gonna say circle back to bucket. Number two is that okay?
Speaker 2:yeah, go for it.
Speaker 1:Okay, all right, laura, that was great, that's so good. So now let's kind of circle back to the bucket number two that you mentioned before. Some more of those. You know super great tips for pharmacists, so I'll let you have the stage again, because you're just giving us so much good info, so have at it.
Speaker 2:Thank you. So we talked a little bit in bucket one about kind of creating awareness, starting the conversation, starting to build that rapport with your patient.
Speaker 1:Right Asking the right questions.
Speaker 2:Asking the right questions. Now, bucket number two may happen in the same conversation as those counseling points in number one, or they might require a few contact points with your patient, depending on where they are, because, remember, when it comes to depression and anxiety, they're not always ready to jump right in with a change right. It might feel overwhelming, they might not feel motivated in that moment, they might feel like they're a little lost or they just want to do their own research or, frankly, they just want to wait on it a little bit.
Speaker 2:So it's really important to keep, or they may not be ready to talk about it or want to talk about it exactly yeah, there's still a big stigma when it comes to mental health and I'm finding that, although we've come a long way, there's still a significant stigma and I find that patients, even when they start medication, they're often reluctant or there's a shame around it.
Speaker 2:So just being able to talk about it in a way that doesn't shame them and that never makes them feel like the fact that they decided to start this, they're giving up or even framing their human or it makes them changing who they are, or anything Right, right right, exactly, exactly, and so, even when you're offering other solutions or you're offering complimentary solutions, it's really important that we're sensitive in the way that we're presenting it, not that it's a failing or it's a repercussion of the decision that they made to take or not take medication, but that rather it's just more options for them to make an informed decision about their health and to empower them, and I think that's a really, really important counseling point yeah, I love that, yeah, so as we're transitioning, then, and thinking about the medications.
Speaker 2:we're going to start with the obvious thing, and that is the SSRI itself. Let's say they're taking an SSRI and they're not feeling like it's working optimally. You're going to do all the basics in terms of making sure that the timing is correct, that they are taking it consistently, that the dosage is appropriate right, Making sure that it's at the correct dose. Sometimes there's a miscommunication they may get started on a starter dose but they've never gotten to their optimal dose, right?
Speaker 2:So, just making sure all those things are in place, that they have the most appropriate SSRI class for their condition and that they're also getting cognitive behavioral therapy or some access to some form of therapy whether it be talk therapy, somatic therapy, et cetera to complement that SSRI. I think to think that the SSRI is going to be this magic bullet that does all the work. It's really more like a crutch that's going to get them to the point where they're ready to do the additional work that they need to do, and it's really important to remember that that is part of the guideline and that is part of the counseling recommendation when it comes to using SSRIs. And this is your chance to jump in and say okay, I actually, if you've been taking this now for two months, you're not experiencing benefits. I don't see a reason why it's not working to make that recommendation to say, let's call your doctor and talk about an alternative medication or a secondary medication to address xyz symptoms. Remember, that is your job as their advocate, as their pharmacist, so keep that in mind.
Speaker 2:Okay, number two uh, if you have that conversation with them and it turns out that they've been taking a ppi for a really long time or that they experience gi issues.
Speaker 2:They happen to have either IBS or GERD or some other GI issue. I think this is the opportunity for us to start to address that, so addressing and screening whether the PPI itself or the long-term use of that PPI is appropriate in that patient. There are situations where long-term PPI use is indicated. I'm not going to get into those. But if it turns out that they're using it because they have not been either fully evaluated or they have been sort of using it as a crutch or unaware of the fact that it's not intended for long-term use and that there are repercussions on our microbiome balance, on our pH, on our ability to absorb certain nutrients, and that there are long-term ramifications and neurological ramifications associated from long term use of PPI, this is your opportunity to gently educate them on that and in my experience a lot of people with depression and anxiety tend to also have GI issues. Again, it's that gut feeling. They're feeling it in their gut and that very often they're not making that connection between those two and they're not aware that there's alternatives.
Speaker 2:So I'll cover the alternatives in the lifestyle diet piece but, having that conversation deliberately about the use of PPIs, coming up with a plan or a protocol or strategy to get them off. The PPIs might be appropriate at this point.
Speaker 1:Yeah.
Speaker 2:Number three NSAID use. This one is a big one because I find that a lot of people again they have depression they're using a lot of NSAIDs. Maybe they have hormonal issues because, again, your hormones, your sex hormones, particularly for women, if you're experiencing pms, pmdd symptoms, etc. You're very often relying on nsets in order to get through the day. Frankly, yeah, there's also a trend now I'm seeing this a lot on social media where women are resorting to using pepsid because pepsid has a a.
Speaker 2:We know it's not an antihistamine, but it has an antihistamine effect because it's a non-selective history, histamine block and there's a relationship between excess histamine production and excess estrogen production, and that causes more PMS or more pronounced PMDD symptoms. So they're finding that using a Pepsid is a way for them to manage that. Again, similar to PPIs, it's not intended for long-term use. Some women only use it during the days leading up to their period. Some women are using it all cycle long. Some women also have GERD, so they're using it for their GERD and they're finding it as like a two-for-one deal. So, again, an opportunity to talk a little bit more about things that they may not think are related to their mental health, but are very much a driver not only of their mental health, but of the decisions they're making around over-the-counter medications that might be having an impact on their gut health. That's then having an impact on their mental health.
Speaker 1:Yeah, yeah, wow. And you think about all the time. You hear someone say that situation made me sick to my stomach, and so if you think about what that connection is, it's the anxiety or the fear of whatever was happening and they literally get sick to my stomach. Or, and so if you think about what that connection is, it's the anxiety or the fear of whatever was happening, and they literally get sick to their stomach because of that connection. And you know whatever was happening, they get diarrhea or they get nauseous or whatever. Yeah, so yeah exactly or or.
Speaker 1:That gird that reflex feeling that you got when you're really stressed out about something.
Speaker 2:I have found, found in my experience. I cannot successfully get somebody off a PPI or get them successfully managing their GERD until I get their anxiety under control, and vice versa.
Speaker 1:I feel very seen right now, laura, I got you, josh, I got you. I've been on a PPI for a very long time and I just, every time I try to go off of it. I think also the anxiety of going off of it and what would happen.
Speaker 2:Yes, probably makes it worse and and also the gird is sort of a symptom of the anxiety right, that's what I mean. It's just, it's just feeding itself, and then you think about the reflux you're going to get when you stop the ppi, and that gives you anxiety. And then exactly.
Speaker 1:So then I just stay on it. Yeah, and I have for almost a decade Exactly.
Speaker 2:And so we are talking to you, josh, we are talking to you.
Speaker 1:This whole conversation is mine. Yeah, absolutely.
Speaker 2:And this is why I think it's so. It just goes to show this happens to the best of us, this happens to so many people, right? So it's very important for us to keep in mind that there's a lot of people that are getting diagnosed for depression and anxiety, but there's even more people that don't have that diagnosis, that aren't even aware. So I keep talking about the people that are coming to you and are telling you and or you know from their prescriptions that they're suffering with depression or anxiety. But what about all the people that maybe it's just a little surface level, maybe it's not significant enough to be considered diagnostically, right?
Speaker 1:Or maybe they're just dealing. They're exactly.
Speaker 2:They're embarrassed to talk about it or they think that they need to just get through it power through it. Whatever exactly hold it in, tough up. You know, toughen it up right.
Speaker 2:There's all these people. So what an opportunity to then have a conversation about the folks that are telling you that they're always in pain, that they're taking a lot of NSAIDs. They're telling you that you know they've been on a PPI for a decade and they're afraid to get off of it because their GERD comes back. What an interesting opportunity to talk to them about their mental health and what are the strategies that they're using to manage their stress and what are the tools or the resources or the community that they have in order to help manage that stress as well.
Speaker 1:Yeah, yeah, super helpful, super helpful, all right. So you talked about a third bucket and you tease this with that. So let's talk about what. What is another opportunity for us as pharmacists? So what, what places in that?
Speaker 2:bucket. So the third bucket happens to be my favorite bucket.
Speaker 2:Because, to me, this is where we really have the opportunity to shine and to really show our patients something that they either may not be aware of or might be intimidated by, and that is the lifestyle piece. This is where we also can talk about diet with them, we can talk about habits with them, and we can talk about supplements and alternative medicine with them, and to me, this is what really sets up part of great pharmacists that has all the right counseling points, that could talk about drug interactions and that can really like make sure that their patients are safe from a drug safety perspective, from an awesome pharmacist that not only can hold space for all those things and then take it to the next level and give them additional, complimentary, safe and effective advice. So this is why this is my favorite bucket, because to me this is really empowering, not to just us as pharmacists, but to our patients as well, that now can see you as this like awesome resource.
Speaker 1:On their healthcare team Right yeah.
Speaker 2:So now number one um, we're going to start with diet, because the foundational diet cannot be ignored. That said, people with depression and anxiety aren't always really super motivated to be eating healthy. We talked a little bit about folks that might be on a GLP one agonist, that might also be experiencing like I don't really care what I eat right now because I'm losing weight, I feel okay. My doctor says my numbers look good. I'm not really motivated to eat healthier. Why should I be eating healthier?
Speaker 2:So, this is where we start talking about nutrient density, we start educating about the importance of feeding the microbiome with fiber and with polyphenols, and I always talk to my patients from the framework of eat the rainbow, eating colorful variety and really, rather than sitting there and focusing on how many calories did you take in, how many grams of protein did you have? How did you do in terms of getting in enough XYZ nutrient? That's a little pedantic for most patients, right? Most of them are busy people. They're not.
Speaker 1:I'm a nerd, I like that stuff, but they may not be into it. So to me Well, and it also might be off, putting in a sense of like I don't have time for that, I don't want to measure my food, or you want me to like start, like putting it in an app.
Speaker 2:I'm not doing any of that, right? But when you start talking about qualitative things, so the two kind of go-tos that I have depending on the person I'm talking to is I have them. Either I talk about colorful food and how to build a plate that's colorful and then support it with some protein, and that usually gets us talking about eating a variety of fruits and vegetables. It gets us talking about increasing their fiber intake, and then I go pair that with a protein, and then I just educate them on what a protein looks like, on what their typical habit, what they like, you know, and to me it's very much agnostic, right, because it doesn't matter what cultural background they come from, it doesn't matter what their philosophy around, you know, their carnivore, vegan or whatever like it's.
Speaker 2:There's something that I can talk about that is relevant to their, to, to their philosophy around, and what I'm talking about essentially is the literature that talks about the more variety that we have in terms of our diet, the more color, the more phytonutrients, polyphenols, et cetera that we introduce into the diet that's signified by those variety of colors the better we feed the microbiome. Remember how I talked about the different neighborhoods and the different little bugs that live in the different neighborhoods and how much of them we need relative to each other. That variety of color is one of the best ways to predict the variety and the volume of those healthy, good, commensal, good bacteria right, so we feed everybody in the neighborhood with multiple colors.
Speaker 2:It's like a food program for those, the microbiome right so exactly, and the more diversity of color, the more diversity of microbiome. Super simple concept it's very visually appealing it.
Speaker 2:The prettier your plate, the better. I used to. Um, I used to have a tool for my kids patients, where I would have them fill in a rainbow and, like every meal they would like fill in the color of the rainbow and their goal at the end of the day was to have the whole rainbow colored. And the kids would get super excited and they'd be like I gotta find a blue food, mom, I gotta find like, a purple food, and so you get super excited about it. And then I realized the parents were really stoked on it. So I started doing the same thing with parents I just made it a little bit more adult.
Speaker 2:So rather than coloring in a rainbow, I started just telling them to start to pay attention. I gave them a tracker to pay attention to the amount of color that they're having.
Speaker 1:Hey, don't look to color too. They really do yeah exactly Exactly.
Speaker 2:So I just take, take the same and honestly, sometimes I'm like do you want the coloring version? Cause I totally can give that to you if you want to download that and color it in yourself so that a hundred percent and it serves as a um cause. Coloring is also supposed to be a great like stress reliever, so two for one deal right.
Speaker 2:And really visual, takes us away from the calorie counting and the worrying about am I getting enough? X, y, z? And yeah, sure I want to make sure you're getting enough protein, because protein is super important for the production of those neurotransmitters as well, particularly complete protein that have enough of tryptophan and tyrosine and phenylalanine and iron sources and foods that contain zinc and things like B vitamins. These are all really important because those help shape and make those neurotransmitters that we need and help balance our blood sugar at the same time, which also can impact our mental health status. But at the end of the day, again, lowest hanging fruit pun intended is to make sure that they're just aiming for colorful variety and pairing it with a protein and as they're feeling better and more motivated, we can have deeper conversations.
Speaker 1:Yeah, and you know, laura, I think that you know this is no tea, no shade, but for the majority of our listeners they're they're probably not trained dietitians like you are also a pharmacist, so you know, I think, understanding that you don't have to be it's. You know the the information you can share is is minimal, as minimal as keep it colorful, make sure it's got a protein in there too, and then when they, if they master that and they say I have colorful plates and I want to learn more, then connect them with a nutritionist, with a dietician. You know, have someone on your team that either is that, or have a person that you partner with in your store that you say, okay, I've got a patient who they're ready to to make some changes and some decisions.
Speaker 2:And it doesn't have to be that complex. You can simply up-level that to the Mediterranean diet. So if you're comfortable talking about the Mediterranean diet, that's actually also had been proven to be just as effective as medication intervention in improving mental health scores.
Speaker 1:So the.
Speaker 2:Mediterranean diet. There's actually a trial from a few years back called the SMILE study that actually had a group of participants as a RCT trial. So there was a group that had the interventions alone and the group that had it with the Mediterranean diet, and it was modified specifically for this trial, and the group that had the Mediterranean diet intervention outperformed the other group leaps and bounds. So it's really like it is a truly effective strategy, but again, that might not be where they're at today.
Speaker 1:Right, right, I mean, they may not be ready to talk about exactly what I should be eating, but to give it from a from a, you know, high level view. Just say keep it colorful, add a protein. Here's what colorful means. And you know, I feel like, after listening to what we just talked about, any pharmacist can do that, you know, like that's super easy to do. And if you don't feel comfortable going to the next step or having the next conversation, do have a partnership already formed to where you can send them to a dietitian and a nutritionist or you know whatever.
Speaker 1:I mean, offer your office space to a nutritionist to come in twice a week and meet with patients exactly, exactly there's opportunities there for you to continue to build a service for your patients and again you still look like the winner as the pharmacist, because you made that initial connection and then you passed them off to get more information.
Speaker 2:Absolutely, and I'm going to plant a seed here. I'm going to come back to it when I talk about supplements, but if they're not willing to make the dietary changes, there are supplements and ways that we can kind of like bypass that initial hesitation.
Speaker 1:And.
Speaker 2:I'm going to come back to that, so keep in mind even have the conversation, because I'm always a believer in having that foundational conversation with them, because you cannot outrun an unhealthy diet. There's been studies that also prove that diets are high in ultra processed foods, high in high carbohydrate, low fiber diets, low protein diets all contribute to depression and anxiety as well. So we don't want to ignore that research because we're leading with evidence here, but sometimes they're not ready for that.
Speaker 1:They just don't have the motivation or the capacity. I mean, maybe they're still reeling with the idea that I'm suffering from depression and anxiety or I'm going through this or whatever. I had a patient.
Speaker 2:part of her anxiety was feeling like she was never good enough and she never met her parents' expectations or her husband's expectations. So she refuses to cook, because cooking is a trigger for her, because she's always worried she's going to mess it up Like that something's going to go wrong and she's going to mess it up. That's a real trauma, right? So?
Speaker 1:I'm not going to.
Speaker 2:It's a vicious cycle, because then if she does mess it up or somebody gives her critique or she doesn't like it, that's going to just make her less likely to try again. So until that's addressed at its root, me telling her just try, let's see what happens no big deal, is dismissive and, frankly, is not trauma informed. So, yes, we do always want to meet the patients where they're at. Sometimes they're ready for it. We want to give them the lowest possible low hanging fruit option.
Speaker 1:There are.
Speaker 2:there's so much that we can frankly explore in this conversation in terms of like the nutrient density and why Mediterranean diet works and all those things, but we need to also keep in mind that not everybody is ready for that. So let's start there, and then I think of the supplements as a way to bypass that, to get the impact, get them feeling better, get them past that, and then we can start having more meaningful conversations around diet and lifestyle.
Speaker 1:Yeah, so diet is the first level, the cornerstone. So what would you say is the next step?
Speaker 2:Two is going to be lifestyle. There's again I'm trying to simplify this conversation, so keep that in mind. So anybody out there who's like she forgot to talk about, keep this in mind. I'm trying to simplify it because there's environmental factors, there's going to be stressors that that patient can't get to. Socioeconomic factors right, there's a lot of layers to this, right, trauma, like we talked about in that example.
Speaker 2:But just honing down on movement, sleep and stress management right, those are really essential. What it looks like for that individual is going to look a little bit different, but essentially, getting them into a routine that gets them on a regular rhythm throughout the day, that addresses their circadian rhythm, that we're ensuring that they are waking up at a regular time, going to bed at a regular time and that their cortisol and their melatonin are offsetting each other. Excessive blue light exposure at night not only impacts our cortisol response and impacts our melatonin production. Overnight impacts our sleep quality, is also going to impact our mood the next day, not just because you didn't sleep well and you're cranky, but you're also going to experience altered mood as a result and the shift in those chemicals. Right?
Speaker 1:And when you say blue light, I'm assuming you mean looking at your phone or your iPad before bed.
Speaker 2:Yeah, I'm not going to make a lot of friends saying this, but scrolling on your phone, scrolling through the phone right before you're trying to fall asleep, falling asleep to the TV, having too many lights on at night even all of that is stimulating blue light. Blue light sends signals to the brain that this is daytime and it's very confusing to the brain. You know what you can do. You can listen to a podcast. So there's that A little alternative. A little podcast, an audio book, those are all fine.
Speaker 1:Well, I hope we don't put them to sleep though. Laura, I hope we don't put them to sleep. That's a very excellent point.
Speaker 2:But that's really important Then countering it with blue light in the morning. So part one is limiting blue light exposure, at least one to two hours before bedtime. I would say the longer the better. And part two is getting blue light exposure in the morning. That means getting eyes on sunlight don't stare at the sun, but getting eyes on sunlight so that you are getting the blue light to the brain and you're saying hey, brain, this is what real blue light exposure looks like. Wake up, let's get things moving, because we want cortisol to gradually rise.
Speaker 2:So it starts around 5, 4, 5 am. It gradually rises. It hitsa peak at late morning and then it's supposed to dip low enough around 4 pm where melatonin is like okay, cool, let me come out I'm going to take over. Yeah, exactly, and so those, those are largely dictated by blue light and then red light exposure.
Speaker 2:And so another thing you could do is potentially that's another thing that you could do is potentially use red light exposure. So there's like red light bulbs that you can use and there's actually light machines that folks can use, where it will automatically change the light in the room and they can use a blue light in the morning and a red light at night and that could help to reset their circadian rhythm. That is going to go a long way in improving not only their sleep quality, but that is a form of stress response and stress support. Obviously, there's other things you could do. There's talk therapy, which is obviously kind of the gold standard when it comes to supporting patients who are on SSRI, but there are also other stress management techniques that you can talk to your patients about Simple box breathing techniques, for example, taking a walk outside.
Speaker 2:I like to combine the morning light exposure with an opportunity to take a walk outside and to get some exercise to get a little bit of movement and if you have the luxury to be able to get into nature, so if they live near a park or an area that's grassy or has trees. The actual exposure to nature has also been shown to reduce stress and to improve stress response as well, and is a great way to manage mood.
Speaker 1:Yeah, yeah, wow. It's also a great way to get some pollen in the spring.
Speaker 2:Absolutely Very good point.
Speaker 1:Good or bad, but very good point. No, I love that and I love. I love the idea of you know again, hopefully, as pharmacists, we're trying to give the information in those bite-sized formats again, because our patients are not always ready to be overloaded with everything. But I love the idea of hey, you can kill two birds with one stone. I would hate that saying and I think that's the best one.
Speaker 2:It's a little violent to birds.
Speaker 1:Maybe I should come up with another one, anyway, um, anyway, addressing two things with one, by getting the cortisol and by also moving, and so I love the idea of doing that. You know, brisk, walk in the morning or exercise in the morning outside, especially, you know, as we get um better weather, but um, that's a great takeaway. That's a great takeaway right there is that, if you can get them to avoid, light at night to wake up in the morning, get outside and take a walk.
Speaker 2:You've addressed sleep, you've addressed stress and you've addressed movement yeah, that's great.
Speaker 1:Yeah, easy peasy, okay, easy peasy.
Speaker 2:So that allows us to now move into complementary support. So there's so many nutritional factors that impact our mental health, so keep in mind we're going to kind of go through them. You don't need to do all of them all at once. Use your instinct and your understanding of the situation to sort of make that recommendation. But no, you have a ton of options on your proverbial shelf or on your bookcase or in your toolkit that you can pull out and use to support your patients, and sometimes that's going to be conditional and sometimes it's just going to be like you're going to come up with a protocol that you see works. And that is where, you know, the fun of clinical practice comes in. So I'm going to go back and address what happens.
Speaker 2:When you've got someone who's not willing to make the dietary changes foundational dietary changes. What do we do? And I would recommend a medical food that has a good amount of protein in it, that might even have some polyphenols in it or some anti-inflammatory ingredients in it, and there are some that also have a pretty decent amount of basic nutrients vitamins, minerals that can be really useful. So a good example of that, one that I actually use often, is a product called MitoCore from Ortho Molecular, and I use that one because it was studied specifically for people who have chronic fatigue. Chronic fatigue's hallmark is inflammation uh, you know, fatigue, difficulty concentrating.
Speaker 2:They mimic a lot of the symptoms that you'll see in folks that have depression and anxiety, and the takeaway here the ingredients are really going to be helpful, especially if you're using the protein form is you're going to get a protein in them. They can make it quickly into a shake, so it's super easy. They can either make a fancy smoothie or they can just mix it with water if they want, and then they're going to get things like magnesium, b vitamins, zinc, um, all the major you know the main nutrients that they need to power their mitochondria powder, the neurons, and it's got a few antioxidants resveratrol, egcg, etc. So I say that because there's a few different formulas that you can look at, things like ag1, which is like that greens powder formula. There's a bunch of different greens products.
Speaker 2:There's things like whey protein that you can use and you can combine them and, depending on the patient, what they're willing to do you might find your favorite combination to recommend or a one go-to option, but that's essentially what you want to look for.
Speaker 2:You want to look for protein to get their day started. You want to look for some polyphenols, antioxidants, and then you want to look for a good, balanced multi-nutrient that's going to be well absorbed, because not all multi-nutrients like most of our over-the-counter common you know, common multivitamins don't absorb very well. They're actually also don't have a high enough concentration of most of the nutrients that we're looking for.
Speaker 2:So, keep that in mind. They tell you oh, I'm already taking a centrum or one a day, Just make sure that they are eating adequately enough that they don't need a more robust multinutrient.
Speaker 2:So that's my one go-to Like. If they do nothing else and they can at least do that, I can get them on a baseline. That's usually a great starting point From there. Fish oil, or thinking about inflammation. So fish oil is one of the most studied interventions when it comes to depression in particular. But fish oil omega-3s can be really helpful for improving inflammation and therefore improving mental health. Fish oil can also change the microbiome. It can have a positive effect on the microbiome as well. This is actually more recent research. So a high-quality fish oil can be a really great intervention intervention. This is where I'm pretty staunch about a high quality, because if there's contaminants, heavy metals, if it is been processed in a way that alters the quality of the fat and denatures it, or if it is in transport it's getting overheated, et cetera that's going to have a very. Not only it's not just going to neutralize that fish oil, it's going to have a very. Not only it's, it's not just going to neutralize that fish oil, it's going to actually make it more inflammatory.
Speaker 1:So I'm very like.
Speaker 2:this is the area where I'm like, if they're going to splurge on anything, this is what I want them to splurge on. Everything else, I keep kind of usually find a low cost alternative, but this is the one that I'm pretty bull on. Like we have to have a high quality fish oil, so that's one one kind of like pearl to to kind of keep in mind. And if you're noticing somebody is taking a fish oil and they're not getting the benefits.
Speaker 1:Explore whether or not it's a high quality fish oil Exactly If they're getting fish burps from it you should never get fish burps from it.
Speaker 2:That's a low quality fish oil right there.
Speaker 1:Yeah, yeah, that's good feedback.
Speaker 2:Yeah, the third intervention, which is, I feel like, pretty baseline, is magnesium. Magnesium is a great go-to. Honestly, most of us are deficient in magnesium. Most of us can actually use a little bit more magnesium. Depending on the form of magnesium, we could see different benefits. So I usually recommend a magnesium glycinate or a magnesium threonate. When it comes to depression, anxiety, glycinate could be a little bit more relaxing. 3 and 8 has better absorption neurologically, so you have a more direct brain effect which can be relaxing, can also support sleep, can also support anxiety, et cetera. So either of those 3 and 8 tends to be a little bit more expensive, so glycinate tends to be a little bit more affordable and I can kind of play with the dosage and see what's working for them. And that, to me, is an important baseline intervention for most people, especially, though, if they're experiencing insulin resistance. They're pre-diabetic, diabetic, they're on that cardiovascular risk spectrum. Super important intervention. And I find it very useful again if they're experiencing sleep disturbances, either because of their mental health or vice versa.
Speaker 1:Yeah.
Speaker 2:The next one is vitamin D. There is a very strong connection between low vitamin D and increased risk of depression, in particular, and, to a smaller extent, to anxiety. So making sure that we're maintaining adequate vitamin D levels. It's not the main reason that we experience seasonal affective disorder, but is a contributor to seasonal affective disorder. So making sure that they have adequate levels I call adequate over 40 on their blood work. So making sure that we're checking their blood work and seeing where it's at and then dosing them appropriately to ensure they get hot.
Speaker 2:they get, uh, optimize their vitamin d levels okay magnesium helps to optimize that vitamin d level, by the way. So we go back to magnesium and I usually pair uh vitamin d3 with k2 for better absorption and utilization and conversion of that vitamin d. Okay, okay that's a lot. That's a lot. I've got one more for you.
Speaker 1:This is so good One more for you guys.
Speaker 2:The last one I'm going to mention is probiotic. Okay, there's a ton of different probiotics on the market. There is some evidence that suggests that the use of probiotics can help to improve mental health is specifically, anxiety and depression scores tend to improve. However, it is more strongly associated with certain strains of probiotics. So where you might see a general probiotic, one that has multiple strains, do okay with some people, especially if they have a pretty significant dysbiosis if you really need a targeted approach, then you need to be more strain specific in how you prescribe that probiotic.
Speaker 2:So the species that's most associated with particularly depression is Bifidobacter longum 1714. That specific strain of bacteria has been shown to be really effective or really helpful for improving depression and even sleep disturbances associated with mental health status.
Speaker 2:There's a particular product that I know has this in combination with saffron, and I want to highlight this for two reasons. Number one we have nightmares about St John's wort, because I remember being warned so much about all the drug interactions with St John's wort, because I remember being warned so much about all the drug interactions with St John's wort right.
Speaker 2:We all remember it's absolutely no-no to give St John wort with anybody who's on an SSRI, so we all know that. However, what St John's wort also does is it acts as a natural SSRI. So although in a person who is on an SSRI, or maybe on multiple medications, that may not be an option, st John's wort is a great option in those cases. One with less drug interactions and less risky is saffron. And saffron as an extract has been shown to be as effective as not necessarily new generation SSRIs but old antidepressants, so things like trazodil and ritazapine et cetera has some really good benefits in terms of mood regulation. And there's a particular product that combines the bifidobacterium longum with a saffron that has been shown to target specifically serotonin production in the gut. First warning if they are an SSRI, be mindful of that interaction. Second warning is not everybody necessarily does well with that on its own, but I have found different combinations of those probiotics to be helpful, but the most effective in my experience has been the straight, specific probiotics.
Speaker 1:Sure, sure, wow. Well, this is so good. I want to try to debrief a little bit and just make sure that I know our listeners are probably well, probably about halfway through. They decided to pull out a pen and paper and take notes because you were giving so much good stuff, but some of them may be in a position. I hope if you're driving, you're not taking a pen and paper.
Speaker 1:Please don't take notes if you're driving yeah please don't do that, just listen to the episode again. But I want to try to debrief and kind of do like a summary. If you don't, yeah, let's do it. So basically, just kind of starting over, and this being a two-part episode series, the first part, where we really kind of dug into the gut and the brain talk, they talk, they chit-chat all the time.
Speaker 1:There's multiple pathways in which they discuss things. They affect the two of them together affect our mood, our cognition, neurological health in general. There are a lot of. We also broke down microbiome in the first episode and so we talked about exactly what that is, the multiple neighborhoods that are involved in that process, and then we talked a little bit about some of the medications that commonly are kind of interacting with that and things to kind of be on the lookout for. And then you gave us these three buckets at the end of the first episode, which we teased and made you come back and listen to the second episode and so just quickly remind us of just the overview of those three buckets and just like the quick take home from each as just like a summary.
Speaker 2:Yes. So I'm going to start with yeah, let's, let's, let's try.
Speaker 1:Let's see if we put them in order, right.
Speaker 2:I remember, because this is how my, this is how I organize things. I think, about them, from what's the most kind of high level awareness building technique for our patients down to what's going to be a quick, easy consultation point regarding their medication. And then three gets into what typically is a little bit harder, longer for protracted conversation which is going to be diet and lifestyle.
Speaker 1:Yeah, and a little bit more of you're really changing something. So yeah, exactly.
Speaker 2:It takes a little bit more behavior change and a little bit more coaching around that and that might open up opportunities for referrals to other clinicians that might be doing that deeper work.
Speaker 1:And, quite frankly, it takes a little more of them feeling comfortable with you and growing a relationship and being communicative.
Speaker 2:Yeah, so building that rapport in that way. So if you kind of follow that roadmap, you're also building that rapport and strengthening that communication building trust. So box one yeah, bucket one are those counseling opportunities where they either come to you because they're having depression symptoms or considering starting an SSRI, they're on SSRI or they have questions about their SSRI. Flip side of that is that they have GI issues and they have questions about their GI health, the symptoms they're experiencing, or medication that they're taking and its impact on their gut.
Speaker 1:So either we're thinking about starting it. It's not working I don't see the effect or I'm having a terrible side effect, or I'm having an annoying side effect.
Speaker 2:Or you're filling it and you're saying do you have any questions? And you go. I'm curious are you experiencing any of these symptoms? Or I happen to see that you're picking up a medication, an over-the-counter NSAID right, or you also have this other medication. You have this oral contraceptive. Are you aware, are you interested in learning more about this interaction?
Speaker 1:Are you interested?
Speaker 1:in learning more about this connection and you know, sometimes it is important to make the connection for them. Like you said earlier, I've used the example. I'm currently going through some uh vein procedures and when I first went I didn't think it was that big of a deal and the doctor said, are you experiencing this? And I was like, well, yes, I am, and it's because of this. And so it's important sometimes to make the connection for them, because then it it is a bigger impact and you're going to be able to really impart information and it's not their job to make the connection.
Speaker 1:Right, right.
Speaker 2:It's our job to help them see those connections and when they are saying, oh my God, I feel crazy because X, y, z is happening. But when I looked online, this wasn't a side effect of this medication and you can say you're not crazy, here's the explanation. But I feel like such. I feel feel like like so cool when I can, like me, help them see that connection. They think I'm so smart and now I've got their attention and I can educate them about how to like take it to the next level yep, and you're building that rapport and it's getting stronger and stronger exactly, exactly, exactly.
Speaker 2:So that opens up the opportunity in stage two, when they're feeling a little bit more open and ready to have that conversation, they might be coming more proactively with questions. Or now that you've built that rapport and you're on that same page that they go hey, um, I read the article that you sent me, or I, you know, listen to that podcast that you recommended on this topic, or whatever it is and they go hey, um, I would love to know if there's something I could be doing or I should be thinking about because of this medication.
Speaker 2:Or they're asking you and you can start to say okay, here are some of the side effects or the impacts of this other medication that you may not realize is impacting this, or some of the symptoms from this other diagnosis that you don't realize is connected to this. Because, look, in our allopathic training we do a really, really good job of breaking things down and putting them into buckets right. We have hyper specialties, like I always have a friend, I have a colleague who is a nephrologist. Like, think about, like they are a specialist in, like one of the tiniest parts of an organ. That's already a specialty you know what?
Speaker 2:I mean, like think about the sort of depth of knowledge that they have on just one piece of the body. We're really good at that and compartmentalizing and understanding how things work at a cellular level.
Speaker 2:What we're not, as good at and I think where we're potentially there's a gap in and our patients are suffering. The consequence is in making that whole connection and helping them understand that there are relationships between. These are not silos. Your body doesn't go well, that's a heart thing. I have nothing to do with that. I'm the gut over here right. Like that's not a thing, right? It's all connected and I think it's our job to help them understand those connections.
Speaker 2:And again, that really is going to help set you apart as that expert and I think, as pharmacists, we are already kind of positioned as that whole person care clinician, because we have to know a little bit about everything I don't care if you're an ER pharmacist. I don't care if you have a special you still have to know a little bit about everything, because you can't like be filling a prescription for like a GI med and somebody's like here's your antidepressant. You're like I can't fill that. That's not on my.
Speaker 2:I only do GI right you have to know a little bit about everything. So I think that helps us make those connections and I think we can use that then to help support our patients. And that brings me to bucket number three is when they are ready to actually take steps and they're looking for something that they can do. Um number one, you know, gauge their interest in changing their diet. I think, first and foremost, I'm biased. I'm a nutritionist, so I believe that diet kind of leads in that but it might not be diet.
Speaker 2:It may not be big changes. It might be just talking about eating the rainbow or talking about you know, are you getting adequate amounts of protein? What's your appetite even look like and what are you ready to eat today? What are you willing to do? And maybe what they're willing to do is have a shake in the morning and that's all they're ready for and that's okay, and that's totally okay, that's an awesome first step because you know what they weren't getting yesterday 30 grams of protein in the morning right.
Speaker 2:So start where you can, no-transcript. If you just go get the mail and come back, that counts, totally counts.
Speaker 1:What it'll eventually do is it'll extend and then they'll walk around the neighborhood.
Speaker 2:Yeah, it's like oh, I put my sneakers on, I guess I'll go walk down the block, and then they get down the block. I'm like I guess I could go a little bit longer.
Speaker 1:It's such a nice day yeah.
Speaker 2:And so hopefully that that that builds and that grows and as they get more, as they start to feel better, they get more motivated and that drives that behavior change and really reinforces that. And then from there you can add supplements, right, like you're already talking about. You know, we're talking about vitamin D. That's a pretty kind of low hanging fruit, fish oil, multi nutrients, combining a multi nutrient with a protein shake, making it really comprehensive in one shot. Thinking about sources of antioxidants, high quality nutritional support, like a good like you know, even a greens formula. That's going to do it all in one shot. That's going to be that we're going to hopefully get better absorption out of. And then we can also support them with magnesium and a probiotic.
Speaker 2:Ideally I would suggest a strain specific probiotic, but again, probiotics in my opinion are cost prohibitive for many. A really good one often is very expensive. Same with fish oil. So if I had to choose and I can get them to eat fiber or eat polyphenols or take a antioxidant formula, then I might opt for the fish oil and then maybe just feed their microbiome. But that's a decision you're going to have to make depending on their symptoms, their budget and what they're drawn to, one versus.
Speaker 2:there there's a lot of conversations on social media about microbiome and probiotics so they might be more motivated to take that.
Speaker 1:So it really depends, or I'm willing to splurge on that because I've heard it's really effective.
Speaker 2:Exactly, exactly. So let's take advantage of the marketing and sort of just follow their lead.
Speaker 1:Exactly, exactly. So let's take advantage of the marketing and sort of just follow their lead, yeah, yeah. Well, laura, this has been so insightful and I really appreciate you giving your time for two very informative episodes. So what's the game changer for this episode? We always like to leave our learners and our listeners with a take home point, a summary. So what do you feel like is the overall game changer for today's episode?
Speaker 2:So the game changer for me is being the healthcare professional on their team that is willing to have a conversation with them that helps them connect the dots about whether it be the gut brain connection, about the connection to diet, about the options that they have in terms of how impactful a habit change or dietary change or even a supplement or nutraceutical can have on their health, and really just being their advocate, being that person that they can trust to go to and have that conversation with, where they feel safe, they don't feel judged and they know that you are going to steer them in the right direction, you're going to use evidence-based thinking to drive that and that they can trust that they can come back to you and say, hey, this worked or this didn't work or what else can we do next?
Speaker 1:Yeah, yeah, so good. Well, laura, thanks again. It's been so great to have you, and we've worked on a few projects together here and there, but we've never had a chance to see each other face to face until today on the episode. So it's been great to get to know you and talk with you. So thanks again for taking time out of your schedule. We really appreciate it.
Speaker 2:Thanks, I appreciate you, josh, appreciate this opportunity and, for those of you stuck through both episodes, thank you so much for listening.
Speaker 1:Yeah, I mean it's. Clearly you can tell that you're passionate about the topic and very well, well versed, so thank you. If you're a CE plan subscriber, be sure to claim your CE credit for this week's episode of Game Changers by logging in at CEimpactcom and, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all again next week.