Psychiatry is not something mystical. Psychiatry is not something very out of the world. It is just the larger Siamese twin of the original brain medicine. [Music] [Music] The biggest takeaway is that instead of fitting people into criteria, you are now more concerned about understanding the process which is causing the distress or the dysfunction. Believe nothing. Psychiatry unfortunately is riddled with exumes. We never had this many number of young women suffering from PCOS. Every young woman you talk about is complaining of pisoria, PCOS and those related symptoms which are a direct result of an irritated or a challenged brain. People should start thinking psychiatry as the next radiology or as the next branch of medicine. Anything and everything that was said in the past is a holy truth in psychiatry. What is that one message which you would want people to know about modern medicines of psych? Though you are actually contesting the idea that these medicines are just symptomatic and you are endorsing the idea that these medicines actually are disease body because with antibiotic they are not succumbing to eventual illness. They are living longer. They are producing their offspring. Those offsprings are passing these rare variants more and more into gene. In my 40s, I started taking methile candidate for a lifelong ADHD. There is a population genetic population genetic always large number of common genetic pattern. We can trust our molecules and understand the science to feel confident to give ourselves the brain which we deserve. Now people know very well that an orthopedician is somebody who takes care of the more serious bone related injuries and defects. And as a psychiatrist I think I I feel blessed that science and the best brains in the world are working at making these molecules more and more userfriendly. What would you say about the brain based understanding of psych? One area where a certain amount of misdirection happened is when we started putting too much of emphasis on theoretical psychological processes. Hello everyone. This is the interview portion of the course. As you know, I am Dr. Basan Mukharji, a student of psychiatry brain. Nobody very senior to you. Just a senior student who has started his journey in the interesting role. Now here we have Dr. Satyan Sharma a second generation psychiatrist a very good friend of mine he is in the psychiatry for the same duration as mine as a psychiatrist but he also has experience of psychiatry as a second generation psychiatrist because his father is Dr. Sharma who has retired from head position of patiala medical college psychiatric department. So I would like to know from Satan that how he has seen the change in psychiatry throughout his 46 years experience in psychiatry. Yes and thank you for inviting me to this Dr. Baska. This is such a pleasure you know and and uh when you mention the major changes you know we many a times I like to say that you know a psychiatrist and a psychologist have the same relationship which a orthopedician has with a physiootherapist right because that sometimes is a basic area where people find it difficult to understand what does a psychiatrist do now people know very well that an orthopedician is somebody who takes care of the more serious bone related ated injuries and defects. But what does a psychiatrist do? Well, a psychiatrist is a doctor who is trained in these tools and these molecules which I have seen from the time when my father was a student joined his post-graduation in psychiatry. He had three molecules plus ECT the fourth component which was which unfortunately is demonized in popular culture. M it is not at all like they show it in movies and series. It's a very peaceful process and it still has very relevant uses in modern psychiatry. Exactly. My biggest understanding of the past 40 years of psychiatry is that our pharmacopia psychopharmarmacology has grown from those three molecules to today more than 250 which are core psychiatry molecules. Plus we have also appropriated old beta blockers, anti-hypertensives, you know, other groups of drugs which we find can be very useful in optimizing brain function, right? And what has this huge increase in options done is that it has become more and more receptor specific. We now have the liberty. I think we are spoiled for choice and we can actually choose molecule based on their side effect profile. The effect is already well established. But now you know having 30 odd molecules in each so-called group of diseases that gives us the liberty to extremely personalize the treatment. Yes. And you know many times I tell people look your mobile phone. Now if you if you were to say k I I I want to buy a mobile phone but then I'll have to go book a phone and then somebody has to you know put a line to my house and then you know I have to get an instrument and permissions for it. We are talking of 30 years back 40 years back today you just need to put a cellular tower you need a smartphone and you are online. Similarly, now you don't need to go into the psychotherapy and finding the entire structure of what is happening in the brain and how the process is started. Now it is simply a function of identifying dysfunction, identifying distress, finding out which process we need to target and the last frontier I guess is the human brain. We don't know a lot but we know enough to help almost every patient who walks into our ops. Yes. And as a psychiatrist I think I I feel blessed that science and the best brains in the world are working at making these molecules more and more user friendly you know and and they they actually increase lifespans. They definitely increase quality of life and they make the life of the entire family better. Yes. Right. So, so that that's that's that's my biggest takeaway in the last 40 years. Yes. And what would you say about the brainbased understanding of psychiatry that has started becoming mainstream of psychiatry in last 10 years? Agreed. you know when when I was a student of psychiatry for us the DSM4 text revision I think when both of us were doing our postgraduation that was the gold standard you know with which we tried to classify various disorders and we found ourselves trying to fit patients into those you know criteria and then trying to treat that particular diagnostic label. Now, ever since having come in touch with you and having you know started this journey on going deeper into the underlying process rather than just externally observable, you know, behaviors and and subjective feelings. The biggest takeaway is that instead of fitting people into criteria, you are now more concerned about understanding the process which is causing the distress or the dysfunction. And when you target the process, you know, one layer behind what is visible, you almost always are able to help the patient better. Right? That is the biggest takeaway. No, for example, saying that this is psychosis and it is a silo and you have to treat it with antiscychotics. Ever since learning about brain based approach, you now understand it as a continuum of an obsessive proh obsessive compulsive process which is now slowly from an overvalued idea to taking you to challenging reality. Yes. And when you start treating that patient based on that process, obviously your results will become better, right? And I think one of the biggest uh one of the starting points which uh which I found for brainbased uh uh you know psychiatry was the principles of neural sciences by Eric Kendall. Yes. Right. for any student of psychiatry because I think see like I I I often love to quote Elvin Tooffler on this you know that the illiterates of the 21st century will not be people who can't read or write they will be people who can't unlearn and relearn and I think it is very important that last 10 years have been revolutionary in psychiatry and we need to unlearn the very rigid structure of DSM and start learning ing the processes behind the symptoms. Yes, the symptoms are actually fairly irrelevant. The process is more important and when you target the underlying process, your chances of actually helping the patient become much much better. Yes, that's true. Very very true. Then what improvements you are seeing in your patients when you work in this So there used to be a time when you used to make peace with the fact that there will be a certain group of patients who we used to label as treatment resistant and you know who who you would not be able to help and I think the the the the fault was not in our molecules but in our understanding of both what the molecules can actually do and in which so-called off label uses they they actually make more sense because now you are targeting the underlying process, right? So, so overall my ability to take on more resistant and so-called difficult to treat cases and by changing the approach actually giving them better options towards leading a more normal, a more brain friendly life, making the brain more resilient, making the brain more efficient and overall improving quality of life. that has 100% gone up, right? I I I find that I do not slip into those ruts and into those those uh uh episodes of desperodency that oh maybe I I really cannot help this patient at all, you know, and that he he is to be labeled as treatment resistant. I think that that's one big change. I I I do not uh see any patients as as uh treatment resistant, right? and and and that's again you know thanks to uh one of these again my initial books for this was this neurobiology of mental illness and I would recommend any practitioner any student of brain to pick up uh uh shi and nestler's neurobiology of mental uh illness as a good starting point to understand that you know I think one one area where a certain amount of uh misdirection happened is when we started putting too much of emphasis on theoretical psychological processes you know and going into I mean they're very interesting of course and and to some extent you know they might be useful you know initial years but once you start sitting and working with patients you'll you'll understand that your job as an orthopedician again using the same analogy is to fix the underlying cause and then leave it to the psychologist to start using that new unlocked abilities towards more positive things. Your job is not to do the physiotherapist's work. And the more true you are and the more you increase your knowledge of actual functioning of the brain and actual effect of the molecules, the more justice you are doing to yourself, your branch as well as the patient. Yes. So you are actually contesting the idea that these medicines are just symptomatic and you are endorsing the idea that these medicines actually are disease modified 100%. Like see like any non-communicable disease. Yes. You know we have diabetes, we have hypertension, we have various types of cancers, we have certain amounts of these uh hypothyroid function for example. the die for that is cast in your genetic structure right and I think a stressor will only trigger symptoms it will not cause the symptoms the symptom causation has already happened at a genetic level and we need to accept it when we are talking about psychiatric diseases we need to see them as genetic vulnerabilities which can be unlocked at any time under stress wherever the brain's ability to maintain that equilibrium is being challenged by stressors and modern life I think is is is a fantastic way of living unnaturally and increasing stress on ourselves. The brain is still a hunter gatherer's brain. It takes millennia for the brain to actually change or evolve. But the last 200 years of human so-called development is actually very stressful for the brain. And it's no wonder that more and more humans are now succumbing to and exhibiting the so-called symptoms of mental illness. Yes. But that can also be explained in another way. Let's say there is a population genetic code. H population genetic pool would always always contain large number of common genetic vulnerabilities. Common genetic vulnerabilities are those vulnerability which would not cause any dysfunctional symptom if they are present singularly. Right? A large number of them needs to be present in a person's body to create a dysfunction. These are common genetic vulnerabilities. Now there are some rare genetic vulnerabilities which even if present in singular number can create sufficient disturbance in organ function and balance and create a disease. Right? Now what happens is nature already and always tries to cull this rare gene pool because natural selection makes these people who have this rare gene pool die earlier. Yes, they don't pass on their genes. That was the structure till 1920. Why 1920? Antibiotics antibiotics into play. Yes, we have done a major revolution. We have created a scenario where natural culling of the vulnerable population is not working because with antibiotic they are not succumbing to eventual illness. They are living longer. They are producing their offspring. Those offsprings are passing these rare variants more and more into gene poolool. Exactly. If we think about population genetics and if we think about the population genetic calculation then first this rare genetic variance would start expanding in arithmetic progression. Yes. But from two 3 to four generation onward the progression would be global. Yes. And after one or two generation after the third or fourth generation this would reach to exponential level. Yes. So we are the third or possibly fourth generation after 1920. So our offsprings are the generation who are getting the geometrical progression of these rare variant gene. So that is probably why we are getting so much young onset every non-communicable disease and young onset all the psychiatric symptoms. Agreed. That is also like like I like to say that we have actually changed survival of the fittest to survival of even the weakest. You know that is the function of what we would like to call a civilized society. But what it the the downside of it is that now there is a concentration of vulnerabilities in coming generations. And that is a simplest explanation as to why we are seeing this sudden explosion of so-called mental health pandemic or mental health symptoms especially in the young because our diseases are the root of all non-communicable diseases. Agreed. Non-communicable diseases of every organ. They start in the brain. Yes. Brain disturbance is the hidden root of this tree of non-communicable illness. We never had this many number of young women suffering from PCOS. Yes. As we have seen probably in the last one decade. I'm I'm sure my gynecologist friends will agree. Yes. That it's it's it's simply uh it it defies logic or logical progression. that it's at a level where almost every young woman you talk about is complaining of dysmenoria, PCOS and those related symptoms which are a direct result of an irritated or a challenged brain. Yes. You know and like you very rightly said a concentration of vulnerabilities. Yes. Which shows the downstream effects in every organ. More and more people now are having sleep issues. more and more people are vulnerable to gut you know imbalances and you know again because social media loves to amplify fads so gut health suddenly is everywhere yes but nobody's talking about the gut brain axis which is the root causation right so I I do follow your point and I do agree with that you know completely and and we need to start looking at making the brain more resilient Yes, in in as a response to you know I I think it it's now becoming part of brain hygiene and the earlier we are able to catch the symptoms and the earlier and thankfully that trend is now changing you know now with more and more celebrities actually endorsing medications therapy you know and a more open attitude towards humans and their natural response to stress and the of course they may not be talking about the genetic vulnerability which as professionals we are more in tune with but I think the right message is going out that the brain is just another organ. Yes. And and you need to you know take care of the master organ to to overall improve health at the cellular level in in every organ system. Agreed. That that's that's very important. So what else has changed in your practice after understanding the brain basis of psychology? So this is very patient. Yeah. So this is this is very interesting and I'm going to share this. You know when you become a psychiatrist almost everybody who you are introduced to they ask okay so read my brain read my mind right that that's a running joke and uh I used to tell them that boss look I I as a joke I used to say look I this is work for me I I don't do work when I'm not being paid for it. But the reality is that we were never trained in mind reading right we of course out of our own interest we would learn some bits about micro expressions body language things like that and uh when I would talk to my uh my teacher Dr. Bhav you know at that point in time that does does physical structure facial expressions and things like that do they really add any knowledge to us and he used to very clearly say that no Satan frenology has been proven to be a pseudocience right but now now that the approach towards psychiatry has changed and you know especially uh when when I got introduced to dysmorphology specifically you know dysmorphology as again something I think which every psychiatrist should start exploring and when I say dysmorphology I think uh Smith's recognizable patterns of human mal forations right that could be a fantastic starting point so may scale you know you often talk about the m scale of uh of mal forations you know dysmorphology facial structures which part of the face is more prominent what's the uh placement of ears, the various ratios between facial features and with a caveat that this should be applied only to OPD and and and uh psychiatric patients not to the general public you know there is a there is at present we don't have enough data to apply it to normal population that if we apply it to normal population we are actually going to dilute it we we will corrupt our data right we want to work with people who already at a at a level of distress and dysfunction like I love to say that you know distress and dysfunction to require attention from a psychiatrist. So this dysmorphology I think has been the most uh rewarding because you can now looking at the way the face and body has been created as a result of the genetic unique signature. You can actually surprise people by telling them about certain ADHD, oblique uh OC features, oblique impulse control, which is is is uh is is very gratifying for the patient. You almost feel like a like a clairvoyant, right? and and that of course that increases the patient's faith in in the doctor being able to read certain physical signs and it's it's rooted in very good science and I think this is something which which will serve every psychiatrist very well because it gives patient three things number one the idea of a non-biological mind goes out of window because the brain is there the definite Need proof is there that the traits can be analyzed from the various body structure. So that must be brain number one. Number two, we when understand that response of anything any therapeutic procedure there are actually there is actually a very fine equation. Total effect of a therapeutic application is real effect of that application plus minus expectation of patient from that application. Yes, which comes as placebo on nobo, right? Plus minus expectation of patient from that therapeutic environment which again comes into placebo or nobo plus minus understanding of the therapeutic application applier means the doctors or the medical staffs towards that procedure. Yes, that again actually contributes towards the bias cognitive bias of the therapy provider to see how well that is performing or not. So by giving the patient a rundown of their character Yes. we are increasing the placebo value of whatever we are going to offer. Agreed. Absolutely. So this is the these are the important here. Number one increased place value. Number two there is brain and it is irre is irrevocable uh the proof of brain is there and no mind is there and third is it increases patient compliance. Yes. Now if I were to ask you one message which you would want. See you have a unique position in Indian psychiatry. You are seen as a teacher as somebody who has been able to get into the core science of of brain health right for want of a better word. I I don't want to say mental. It seems stigmatized and it's a bad word. brain health. What is that one message which you would want our listeners to remember? You know which you know we still suffer from hangover of the past. When you say uh I I'll I'll be using some medication. People think of large and chloroproin induced zombie like state drooling saliva no expressions and that image unfortunately has stuck very strongly. M you know which is unfair. The telephone has changed. The car does not leak radiators. It doesn't heat up anymore. Cars are now becoming smarter and more and more reliable. What is that one message which you would want people to know about modern medicines of psychiatry? I would say there should be two different message. One message should be the directed towards listeners who are not psychiatrists just normal p people or other medical profession that they have to understand that psychiatry is not something mystical. Yes, psychiatry is not something very out of the world thing. M it is just the larger Siamese twin of the original brain medicine which got divided into two incomplete hubs which are Sami Sam. One is neurology, one is psychiatry. Psychiatry got the bigger deal. But psychiatry needed a huge technological advance to understand its role in overall schema of the thing. And now thanks to the unprecedented technological development in last two decades, we have finally reached a place where we can appreciate the nuances, the complexities and the healing potential of psychiatry. The branch of medicine that deals with function of the whole brain, function of the brain, controlling the whole body and actually maintaining homeostasis between brain, body and body with the external environment. So people should start thinking psychiatry as the next radiology or as the next branch of medicine that is going to rule the choice of medicine for next few decades. That is for general population. Now I have a special message for the psychiatrist who are now in training or who have passed their training but still trying to find their footing in their world or senior ones who have found their footing. Believe nothing. Be a lifelong skeptic. Psychiatry unfortunately is riddled with exumes, riddled with dictates. Anything and everything that was said in the past is a holy truth in psychiatry. Psychiatry is like a semitic religion. This book has diseases writing. Yeah. And that writing has to be obeyed at any cost. This is not science. This is a blind devotion. Blind faith religion. Get our subject out of this religion. Make it a science. Question everything. Taste and retest everything that was there in past. Take nobody's talk just based on belief. M if you believe me then believe me after testing what I am saying I don't demand any form of blind obedience from anyone and the same way you should not be showing blind obedience to anything be a skeptic be a lifelong learner be a lifelong student that's the only thing that you can offer to our subject. Since you have mentioned that, you know, I think I want to share this on this podcast. I I don't think I'll find a better platform. We now routinely do three generations of uh history. Yes. Right. Pedigree charts. Pedigree charts. Right. In an effort to try and identify, you know, what could be possible dysfunction which is coming into this person genetically, right? And I have started doing that very honest exercise with myself and and what I want to share currently. I am taking medicines in my 40s. I started taking mythile funidate for a lifelong ADHD. Yes. Which got missed because it was only discovered in the 80s. Started teaching in the late '9s. It became mainstream in the 2000s. By that time I was already in my MBBS and suffering from the MBBS syllabus. Yes. I would do extremely well in my vivas. Long answers were a pain for me. Right? Today I'm able to understand that that was actually untreated ADHD. Yes. Today I'm able to address it. I find that my uh deep concentration is better right and I add propanol to it in the mornings to keep the jitteriness away. At nights I'm taking my arkamine and I'm taking my vazodone at at 60 mg. And I think this is the level of honesty. This is the level of intellectual integrity at which psychiatry has to arrive. Yes. Where we can trust our molecules and understand the science to feel confident to give ourselves the brain which we deserve. Exactly. Right. And and this is this is to a large part I mean I'm I'm thankful to you for having identified the processes and having identified the combination which is actually making me you know function at the best brain health I have ever enjoyed in my life. That was just I would say a lucky guess and which ultimately helped you. Yes. Yes. Yes. And it's always a process of discovery. Yes. Right. Even even the most experienced psychiatrist with with those protocols and that understanding you can never 100% predict that this particular molecule is 100% going to suit the person. No. The human brain is a guest. Yes. Yes. Yes. So I think setting those those expectations in the very first interview with the patient that you know this is a process. Yes. Which you have entered. Thankfully we are spoiled for choice. We have like I said you know we have 30 plus molecules in each category. One doesn't suit you gives us so much of information as to what possibly will suit you next. Yes. But within those 3 months most patients I have seen we are able to find a combination which improves quality of life. And increasingly I'm I'm seeing psychiatry not as a dysfunction to be contained but as a opportunity to unlock the lesser used muscles of your brain. Yes. Right. newer pathways and to reduce those processes which are causing distress and to enhance those which can actually unlock certain abilities which you never knew existed. So when your medicine suits you like any good science, it feels like magic. Exactly. Right. And and you owe it to yourself to give yourself that chance. Right. And and you should Yeah. actually accept that. And also the thing is psychiatric drugs are are not fortunately or unfortunately only those things which are named as psychotropics. Yes. Because no drug work only in the organ. They are intended to work. Calcium channel blockers do not work only on heart or blood vessel. They also work in brain. They also work in various other body areas. Yes. All the medicines of pharmacopia have their systemic action. So all these medicines that are there in pharmacopia are in a way brain medicines too. So we don't have even 300 or 400 medication. We have the whole pharmacopia. Absolutely. At our disposal. Absolutely. And since you mention it, aging and longevity is these days a uh you know a trending uh occupation of the super rich, right? They they want to improve and increase their lifespan. And without any so-called psychiatric uh label, lithium has been identified as a molecule which actually increases tumir length which actually increases lifespan along with metformin. Right? These are the two molecules. There are not two molecule at this moment actually. But you you remember the time when lithium used to be a dreaded psychiatric molecule with a narrow therapeutic window and no other practitioner would touch lithium. Even psychiatrist would be a little you know very weary of getting those regular blood levels done and maintaining the therapeutic window and today we are finding out it is actually increasing lifespan. Exactly. Right. The thing is not only lithium there are three forms of light prolongation medication. One is cenolitic which destroys the aging cell. One is cenomorphic which changes the aging cell back to normal cell. One is cenostatic which stops aging but doesn't change the stale fate. Now our anti-depressants they are so-called anti-depressants. The so-called anti-depressants they are senomorphic they change old cell to new cell. Our so-called antiscychotics they are cenolitics. our so-called other medications. For example, let's say that drugs we use as fringe benefit for example propanol drugs like propanol right it it has you know static effect yes as well asic effect then the so-called stimulants they are again drugs which reduces the aging considerably they are probably a combination of cenostatic and cenomorphic drug. So all the drugs that we use in psychiatry are drugs which can prolong life. But the problem of this is we need to be scientific enough to prove it once and for all. Right? And then we need to present the scientific evidence to the wider audience. Agreed. Because unfortunately in India we don't have that much research data. We understand more. We see more patient than any other countries except our fellow countries in Southeast Asia. Right? But we don't compile that data. We don't come out with papers of our own, viewpoints of our own. We don't come with findings of our own. That needs to be done otherwise all these would result in idle armchair academics but it would never reach to that level where it is point well taken directed. Agreed. Agreed. We need to be producing more highquality scientific data. Yes. And I know Dr. Askar both of us could sit here and probably talk for a few more hours or until the cows come home because these are topics very close to our heart. But at this point I think I would want to stop our flow of thought. Exactly. And my viewers and people who are listening to this, I would want that they should feed us with certain topics they would want us to talk about in terms of modern psychiatry, modern brain health and we will try to do justice to it like in the most scientific evidence-based manner probably share studies and you know more more hard data on it and uh I think this would be the right time to stop today's podcast and also O invite more suggestions, ideas from our audience in terms of what would they like to pick our brains on and and you know keep us also a little sharp in terms of finding more more relable yes more challenges. Yes. Yes. So so thank you so much Dr. Basker for taking out the time inviting me to this place and uh thanks to the platform which has actually given us the opportunity to do this and I look forward to doing it again but based on uh I think audience demand we should we should let's hope audience gives us some more interesting topics and some more interesting and fascinating question which would stimulate us to come up better versions fascinating I really look forward to it. We are closing this podcast. A huge thanks to Conceptual Psychiatry for giving both of us this podcast platform and for giving me a platform where I can talk about brainbased psychiatry without holding myself back. And while hoping to reach a wider audience of thousand or more people who would get to know what is brainbased psychiatry and I am hoping some of them at least would be interested to learn brainbased psychiatry more and thus benefiting psychiatry more and more. Grateful thanks from me to conceptual psychiatry. Thank you so much. Thank you. Thank you. [Music]