Taking Healthcare by Storm: Industry Insights with Dr. Jon Glass

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Dr. Jon Glass, a Clinical Psychologist with Northshore Psychological Associates.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website: https://www.qualityinsights.org/qin/taking-healthcare-by-storm

This material was prepared by Quality Insights, a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication number 12SOW-QI-PCH-110123-GK

Transcript

Welcome to Taking Healthcare by Storm, Industry Insights, the podcast that delves into the captivating intersection of innovation, science, compassion, and care.
 
 In each episode, Quality Insights Medical Director, Dr.
 
 Jean Storm, will have the privilege of engaging with leading experts across diverse fields including dieticians, pharmacists, and brave patients navigating their own healthcare journeys.
 
 Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania, and the nation.
 
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 Hi everyone, and welcome to another episode of Taking Healthcare by Storm.
 
 I am Dr.
 
 Jean Storm, the Medical Director here at Quality Insights.
 
 And today, we're going to be talking to Dr.
 
 Jon Glass about multiple subjects around mental health.
 
 And as you all are aware, mental health is really a big issue facing Medicare beneficiaries and all patients across the United States right now.
 
 So I thought Dr.
 
 Glass would be a great guest, as he has a tremendous amount of experience taking care of individuals in the hospital, in the outpatient setting, and in the nursing home, and really dealing with those mental health issues.
 
 So we're just going to jump right in.
 
 Dr.
 
 Glass, thank you for joining us.
 
 Well, thank you, and thank you for the kind words.
 
 Yes.
 
 So tell us about your background.
 
 Well, I'll start with my doctoral training.
 
 I have a Ph.D.
 
 in Counseling Psychology, although during my training, I focus my studies on neuropsychology, which is slightly different, and I think we'll probably get into that a little bit later.
 
 Right now, I am a partner in a private group practice that works closely with hospitals and nursing homes in the local area, providing a variety of services based on what's needed.
 
 I also have a postdoctoral master's degree in psychopharmacology.
 
 So even though psychologists are not given prescription privileges in Pennsylvania, I still provide a lot of input to physicians about medications, medication interactions, and also when to avoid medications.
 
 Yeah, that's a big need right now, I think, especially since the pandemic.
 
 So why did you decide to become a neuropsychologist?
 
 Primarily because it's much more medically oriented.
 
 As I said originally, I went into counseling psychology, but I really got interested in neuropsychology because it focuses on understanding, first of all, neurobiology and neurochemistry and how that affects behavior, keeping in mind that from that perspective, mental health, as we call it, is a behavior.
 
 Mood and cognition are behaviors that we measure and then try and treat when we find dysfunction.
 
 So tell us the difference, and I'm sure you get this a lot, the difference between a psychiatrist, a psychologist, and a neuropsychologist.
 
 Yeah, I do get that a lot.
 
 And the biggest difference is that a psychiatrist is a physician that either has a MD or a DO, and they go to medical school, and then they specialize in psychiatry.
 
 And they primarily, even though we were born of the same foundation, they primarily use medications to affect behavior change, whereas psychologists over the years have focused more on helping people understand the roots of their behavior, I'll call it dysfunction, and making changes without medications.
 
 However, as I said, neuropsychology entered the fray, and we see medications as sometimes useful and helpful and really sometimes the best solution, although as a neuropsychologist, I like to point out that we have more options than just medication.
 
 Absolutely, and I think a lot of providers maybe don't see that.
 
 You have both.
 
 You can see both sides.
 
 So what types of patients do you see?
 
 In general, I specialize in mild traumatic brain injuries, actually mild and more severe brain injuries.
 
 I also work with a lot of folks with dementia and any medical condition that can affect the brain, like multiple sclerosis or Parkinson's disease.
 
 Certainly some cancers and tumors can affect cognition and mood.
 
 Stroke is certainly a big part of our practice.
 
 So can people just make an appointment?
 
 Can they call your office and make an appointment or do they have to be referred by their physician?
 
 They can just call and set up an appointment, although I prefer to always have at least the primary care physician involved because I want a thorough medical history that sometimes patients just aren't able to provide.
 
 I forgot to add earlier when you asked about what types of patients I see, I do still do some individual therapy just focused on people with general anxiety and adjustment issues, depression, that sort of thing.
 
 I tend to see a lot of men in my practice as well.
 
 You talked a little bit about patients with dementia.
 
 What is involved in that diagnosis?
 
 I can imagine that it's an extensive process.
 
 It is a very extensive process.
 
 One of the big differences, I think, between psychologists or neuropsychologists and other physicians is we really take a lot of time to arrive at a diagnosis, and that's partly because we weren't mostly raised in the medical model.
 
 I conduct an initial interview.
 
 I review the records that come from primary care or the hospitals.
 
 We interview family, if they're available, or caregivers, if they're available.
 
 Then we also use some type of neuropsychological assessment battery, which can be fairly brief depending on if the person is severely impaired, but it tends to take several hours just to complete the cognitive assessment and then the integration of it into all the other things, including physical health that can affect cognition, and arrive at a diagnosis.
 
 And this is almost always done in conjunction with other primary care docs and specialists.
 
 For example, if neurology is involved or if psychiatry is involved, certainly endocrinology is involved sometimes as well.
 
 Yeah, a whole team approach.
 
 Sure.
 
 So you talked briefly about depression.
 
 Have you seen an increase in patients with depression in the recent years in your practice?
 
 Absolutely.
 
 You know, one thing that was pretty clear early on with the COVID-19 pandemic is that people were increasingly isolated, and that had, I think, kind of a delayed effect.
 
 Obviously, I was still practicing and seeing patients during the early stages of the pandemic, but it wasn't until things started to loosen up and people felt more comfortable coming to the outpatient practice that they really talked about how that affected them and definitely saw a major impact on some of my older patients who were living independently and staying in contact with family, but it wasn't until family was able to go visit them and see them a little bit more up close that they noticed some of the mood symptoms and even some of the cognitive symptoms from isolation.
 
 Can't imagine.
 
 Well, I was just going to say that in the nursing homes, I think it was even more profound because those patients are already so limited in how much social contact they get, and when they were essentially, I hate to use the word forced, but really they were forced to stay in their rooms a lot.
 
 They didn't have activities.
 
 They didn't have the chance to socialize with their peers or even the staff as much as they used to.
 
 I definitely saw more immediate effect on those folks.
 
 I bet.
 
 So you talked a little bit about the nursing home.
 
 So just to give all the individuals listening, what role do you play in the nursing home?
 
 Because I think when most people think about nursing home, they just think about the primary care doctor that just goes in and sees patients.
 
 And maybe they're not aware that you have a role.
 
 You go into the nursing home.
 
 So what do you do in the nursing home?
 
 Another great question, Dr.
 
 Storm.
 
 You know, it's really I wear all of my hats in the nursing home.
 
 And when I meet a patient for the first time, again, I do a thorough review of the medical record and usually try to dialogue with the nursing staff and the primary doc there.
 
 And even after doing that, I never really know what I'm going to be doing until I walk into the room and assess that patient.
 
 And that's always an interesting process and calls for a pretty thorough diagnostic interview that really sometimes might take several interviews before I really have my hands around what they need, whether they need some traditional psychotherapy and support or they need some medication intervention or whether cognition is really impacting their ability to participate in their either rehabilitation or their quality of life in the nursing home.
 
 I don't think many people think about psychotherapy and its place in the nursing home.
 
 And I will say just as an individual physician that's practiced in the nursing home, I think it is underutilized in the facilities, especially with the COVID pandemic.
 
 I think we're really quick as primary care physicians to jump on medication.
 
 But I've seen psychotherapy play a huge role in the nursing home.
 
 I agree with that.
 
 I think in part that's probably also a little bit of the responsibility falls on psychology for that because for many of our patients, we do have to adjust our view on what traditional psychotherapy is in the nursing home, that it's not come and sit in my office and talk for an hour and the person is going to be able to tolerate real insight-oriented therapy or maybe not even cognitive behavioral therapy.
 
 It takes a lot of flexibility and a broad view of what quote unquote psychotherapy means for that patient.
 
 So it is something that once we work with the nursing home, the nursing staff, and the physicians, that they start to understand what we offer.
 
 Hopefully, that's based on the response from the patients.
 
 Have you seen just an increase in depression in the nursing home since the pandemic or have there been other mental health issues that you've seen emerge as well?
 
 Yes, to all of that.
 
 Definitely an increase in depression because, again, what I talked about earlier with all the patients who are even more isolated than they would normally be in a nursing home.
 
 Nursing home placement for most patients is a pretty major disruption.
 
 They don't see their family as much.
 
 So many of them feel abandoned by family.
 
 Even though often nursing home placement is the best for them, they still feel abandoned and cut off.
 
 Unfortunately, with some of our patients with more chronic mental health illnesses, whether it's schizophrenia or bipolar disorder, I saw a lot of exacerbation of that as well for the same reasons, but it affected those people differently.
 
 Then with the dementia patients, we saw a lot more disruption and not understanding maybe why family wasn't coming or why they were being asked to stay in their rooms or wear masks or having increased restrictions placed on them.
 
 Yes, to all of the mood and mental health disorders that we see, I haven't studied this or seen any numbers, but in my experience, they were definitely amplified.
 
 Do you feel that there's a larger number of individuals suffering from depression and other mental health issues in the nursing home compared to, say, the outpatient setting?
 
 Because you're seeing patients in both settings.
 
 That's an easy yes.
 
 I think that the prevalence of depression in nursing homes is like 20 to 25 percent, and that's a lot higher than it is in the general population.
 
 I think another thing that happened is after deinstitutionalization back in the 80s, many people with chronic mental health problems are out in the community, and as they age, they are more likely to end up in the nursing home.
 
 So it's definitely a higher base rate of some of those problems than we might see in the outpatient population.
 
 Basically, your role in the nursing home, I imagine, is when you see a patient with mental health issue like depression or bipolar, you are not only doing therapy, but you are also recommending medications.
 
 So an entire approach for this individual.
 
 Absolutely.
 
 Absolutely.
 
 That's one of the things that I think neuropsychology does pretty well.
 
 I'd like to think we do pretty well.
 
 And I know a lot of people talk about holistic care, but because my training is heavily rooted in traditional psychology, but also with a healthy dose of medical training, that really we want to look at the person from a global perspective and really try to tease out what is it that's causing this person's problems.
 
 Whether it's, again, traditional mental health problems or medications or some of the other social factors that can contribute to exacerbation of mental health problems.
 
 So I wanted to shift a little bit.
 
 We were talking a little bit about medication.
 
 So there's a big push right now by CMS for facilities to really look at their use of antipsychotics.
 
 And I've taken a look at some of the data.
 
 And antipsychotic use did increase during the pandemic, unfortunately.
 
 And I don't know, maybe appropriately or inappropriately in some cases.
 
 Have you personally seen an increase in the number of antipsychotics used in nursing homes during and after the pandemic?
 
 You know, that's tough for me to answer because the only nursing homes where I would see that are at my nursing homes.
 
 And, you know, part of what I do and the physicians I work with are also very cautious and aware, you know, we really use those as a last resort due to the potential risks for this population.
 
 So, you know, again, without being able to go back and look at everything, I would say I can't say that I saw an increase.
 
 So, you know, but again, that's in part because of my role on the treatment team and the nursing homes.
 
 I mean, that makes sense.
 
 So what about adverse drug events?
 
 I'm sure you've come, you've seen individuals that have been in the hospital placed on antipsychotics.
 
 Have you seen a lot of adverse drug events associated with antipsychotics?
 
 Oh, yeah.
 
 Oh, sure.
 
 Sure.
 
 You know, I think the most common one that I see is probably movement symptoms related to, you know, some of the antipsychotics.
 
 You know, they're a risk, though.
 
 You know, they have a black box warning due to increased risk of death in patients with dementia.
 
 And, you know, I haven't seen that, you know, and I should knock on wood because we never want to see that.
 
 But also, you know, it can lead to some increased sedation.
 
 And that's something I see quite a bit as well.
 
 And, you know, anytime we see that, we want to assess not only the antipsychotic, but what's going on with the person medically and what other medications are they on.
 
 And the antipsychotics can also, unfortunately, increase confusion for some folks.
 
 And that's always tough to gauge, whether it's dementia, if that's what they're being treated for, or whether it's the medication.
 
 Sure, because I, you know, most, a lot of primary care physicians lean on antipsychotics for treating patients with dementia or having behaviors, say they're combative or aggressive in the facility.
 
 And I think there's a new antipsychotic that was recently released for, specifically for dementia-associated behaviors.
 
 You know, so it is an antipsychotic.
 
 So I think that probably the clinicians really appreciate your input in the facilities where you are, because it's very challenging.
 
 It is really challenging, and it's easy to go to antipsychotics, you know, because, you know, at least superficially, they work.
 
 You know, I think the medication you're probably referencing is Brexpiprazole or Rexalti, and it was it got FDA approval for agitation and Alzheimer's disease.
 
 And I think Pima van Sarin is also either about to get approval or already got approvals.
 
 So it is nice.
 
 But, you know, that doesn't mean they don't carry the risks.
 
 And that's something that we still need to be aware of just because it's FDA approved doesn't mean that we can use it carte blanche, you know, anytime we see a behavior.
 
 Yeah, absolutely.
 
 That's a really good point.
 
 So I am going to ask you the most what you feel is the most challenging mental health issue in each of the health care settings where you see patients, because I find it fascinating the similarities and the differences in the health care, different health care settings.
 
 So in your opinion, what is the most challenging mental health issue in the outpatient setting?
 
 Um, well, but that's a great question that, you know, and again, I think there's a little bit of selection bias here because, you know, I tend to see a lot of folks with anxiety and depression.
 
 I just because the way our practice is set up, I don't see people with some of the more severe bipolar disorders, and I don't really see many people with schizophrenia or any of the psychotic disorders that they typically go to community mental health centers.
 
 So I think probably, you know, treatment refractory depression is really challenging and it's brutal on the individual and their families that are involved.
 
 And as a clinician, it can be really challenging because often when those folks are so depressed or even depressed for such a long period of time, you know, they've seen therapists, they've done this before and they just really don't have much hope.
 
 And in part, that's because of the depression, but also in part, it's because of a history of treatment failure.
 
 And, you know, as new treatments come out for treatment-resistant depression, you know, and I don't know that we'll even have time to get into some of the, you know, psychedelics that are currently being trialed.
 
 But, you know, I'm kind of hopeful that those will provide some relief to these folks.
 
 Yeah, I think, you know, psychedelics are definitely on the horizon, you know, but they really aren't anything that, you know, the average patient today can kind of rely on, you know, just because of the, you know, legal aspects and things.
 
 But there's a lot of great research that is being conducted, you know, so that's fantastic.
 
 Yeah, I would agree with that.
 
 And also, you know, I'm cautiously accepting of the research on psychedelics because, you know, anytime a new treatment comes out and it's, you know, the silver bullet or it treats everything, you know, that should really make us aware that we might be missing something.
 
 So, you know, I'm cautiously optimistic and I'm just kind of waiting to see how things pan out with the psychedelics.
 
 Yeah, I agree.
 
 So what about that same question, the most challenging mental health issue in the nursing home setting?
 
 Yeah, you know, that's a really, really good question.
 
 I think it's when we have a patient who is has a moderate degree of dementia with behaviors because one of the keys to individual therapy is, you know, the patient being able to implement behavior change, which means they were they're required to learn new behaviors.
 
 And by definition, when someone's got that level of dementia, they're not learning new behaviors.
 
 And, you know, there's only so much we can do within the setting that they're in to change the environment and set it up to help them be successful.
 
 And often with those patients, that then leads to medications.
 
 And anytime I'm starting to provide consultation on medications, I want to make sure I treat it as a challenge because I want to make sure that I'm, you know, encouraging the right decision for that patient based on their history, the conditions.
 
 And I think of, you know, kind of using a ladder.
 
 You know, we start with maybe an SSRI or an SNRI because so often the patients respond pretty well to those, even if they don't have the classic signs of depression.
 
 And then slowly walking up the ladder and sometimes even using some older strategies like valproic acid, you know, to try and treat behaviors, even though it doesn't have great research support, there's some anecdotal support out there.
 
 And I like to try or recommend stuff like that prior to moving to the more risky drugs.
 
 I think that is a great conservative strategy for anyone to think about who's prescribing medications in the nursing home to just go start low and go slow and move up that ladder.
 
 Absolutely.
 
 Low and slow.
 
 That's it.
 
 Especially with the older population, that should always be our strategy.
 
 Even if it's a pretty straightforward depression, even in the outpatient setting, I'll often recommend the patient start on a half dose of something.
 
 And sometimes I'll get a call from a physician and they'll say, like, really, do we want to do this?
 
 And I say, just stick with me and let's see how this works.
 
 And often they respond to those half doses pretty well because of reduced clearance and physical changes in the older folks.
 
 And even though the medication is present, it's not quite as much of a load on them as a heavier dose would be.
 
 Absolutely.
 
 So we didn't talk a lot about the hospital setting, but what is the most challenging mental health issue in the hospital setting in your opinion?
 
 Yeah.
 
 You know, I think probably, you know, I see a lot of delirium in the hospital.
 
 And again, that can be really tough to manage if it's a hyperactive delirium because often, you know, patients are, they're at risk to themselves, they're at risk to nursing staff, they're very distressing for family to see.
 
 And, you know, the best treatment for delirium is treat the underlying cause and not introduce any new medications.
 
 So, again, adjusting the hospital environment to the degree that we can just kind of let them ride it out, so to speak.
 
 But then also knowing that, you know, medications might be necessary to maintain their safety.
 
 And that's for hyperactive delirium.
 
 Hypoactive delirium is extremely challenging, you know.
 
 And typically, if it gets into that type of thing, I'll want psychiatry to take a look at it rather than giving any input myself.
 
 Yeah, I think that's such a really significant patient safety issue because I feel like so many patients in the hospital when they develop delirium, everyone kind of, you know, gets really upset and they want to start an antipsychotic or benzodiazepine.
 
 And they put the patient at risk for, you know, adverse effects associated with those medications when really like a conservative approach of, you know, let's make sure we, you know, turn the lights on in the morning and turn the lights off at night and let the patient get sleep and, you know, make sure the nutrition is good and all those very basic things that can help.
 
 Absolutely.
 
 Absolutely.
 
 Yeah.
 
 Yeah.
 
 And it, you know, delirium, oftentimes I'll see people in the hospital and then I'll see them in my outpatient office for a follow up.
 
 And a lot of them are very distressed because they know they had that episode delirium.
 
 They remember some of the hallucinations or delusions and they're really distressed.
 
 And, you know, for a lot of them, there can be a PTSD element to it, depending on how bad it is and how much they remember.
 
 You know, some just don't remember it at all.
 
 But, you know, that challenge doesn't go away once the delirium is gone.
 
 For many of them, it kind of sticks with them.
 
 Yeah, that makes sense.
 
 So, we talked a little bit about, you know, navigating mental health appointments during the pandemic.
 
 Do you offer telemedicine appointments now?
 
 I do.
 
 I do.
 
 Reluctantly, you can tell by the way I answer that question.
 
 I think really, you know, mental health is about connecting with people and finding out how to treat that person.
 
 Again, we can have all kinds of treatment algorithms, but we don't just plug people into them.
 
 You know, we need to get to know the person a little bit and develop some experience and even have a little bit of a shared experience with them, you know, as much as we can.
 
 And, you know, that I was kind of forced, you know, ethically, I think I forced myself to do teletherapy during the pandemic, but I really try and avoid it.
 
 I do offer it, but I don't like it.
 
 I'll be honest.
 
 Yeah, in person is always better, but I think, you know, it's always good to offer it to those individuals that maybe are homebound for whatever reason or don't have transportation.
 
 Exactly, right.
 
 I don't want to withhold treatment from people just because they can't access it.
 
 You know, that's definitely the huge plus with teletherapy is it really opens up access.
 
 Absolutely.
 
 So final question, how do patients get in touch with you?
 
 The best way is to just call my office.
 
 We do, well, my number is 814-877-8013.
 
 We also have a website, northshorepsychologicalpractices.com or you could even do nspractices.com.
 
 We do show up as an affiliate of UPMC Hammett, although we're really not in that organization.
 
 We're completely independent.
 
 Awesome.
 
 Thank you so much, Dr.
 
 Glass, for your wealth of information and I'm sure all of our listeners appreciated the information.
 
 Well, thank you, Dr.
 
 Storm.
 
 I appreciate the chance to get to talk about this.
 
 Thank you for tuning in to Taking Healthcare by Storm, Industry Insights, with Quality Insights Medical Director, Dr.
 
 Jean Storm.
 
 We hope that you enjoyed this episode.
 
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 If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website.
 
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 So until next time, stay curious, stay compassionate, and keep taking healthcare by storm.