Dr. Brian Evans: Welcome to Mountain Health Today, the show where we explore the people, the stories, and the innovations that are shaping healthcare here in the Sierras. I’m Dr. Brian Evans, Chief Medical Officer of Tahoe Forest Health System. From everyday wellness to the latest advances in medicine, our goal is very simple: to give you clear, trusted information that helps you and your family live well.
Today we’re going to be discussing a crucial topic. It touches really every single one of us, and that is mental health. We’re going to discuss some treatment options for anxiety and depression and the many resources that we have in our own community.
And I brought in an expert today who can help demystify all this for us, Jonathan Lowe, who is a mental health expert here at Tahoe Forest Health System. Jonathan is a licensed psychiatric nurse practitioner. He practices full-time here with us.
He has a ton of experience treating anxiety, depression, PTSD, substance use issues, many other conditions, and he has helped countless people in our community that now live their lives with more joy and more peace. So, Jonathan, welcome to Mental Health Today.
Jonathan Lowe: Thank you so much for having me. I’m excited.
Dr. Brian Evans: Yeah, really great to have you here. And before we get going, I just want to say thank you for impacting so many people. I mean, the community is full of people that are better because of your care. So thank you for that.
Jonathan Lowe: Well, I appreciate that. It’s awesome to be a part of the community in this way.
Dr. Brian Evans: Yeah, yeah. And there’s a lot of need out there. There’s a lot of issues out there. And I guess I’d like to start with asking you: what does a psychiatric nurse do, or nurse practitioner do? And how does that interface with all these different other types of providers that are out there? So what is your sort of niche for this?
Jonathan Lowe: So psychiatric nurse practitioners have advanced training specifically in psychiatry. So we diagnose, we treat — usually with medication. Oftentimes you’ll see us in clinics and hospital systems, primarily diagnosing and prescribing medicine. However, many of us, myself included, are trained in psychotherapy as well. And, throughout the life spectrum, you can find psychiatric practitioners, just like psychiatrists, who specialize in niche areas — kids, adults, geriatrics, addictions, eating disorders. It kind of runs the gamut.
Dr. Brian Evans: What drew you into this area of health care initially, because there’re so many different things that you could have been drawn into with your background? And why this particular specialty?
Jonathan Lowe: So a few different things. At the time, I think I was working at Planned Parenthood, working as a medical technician for Planned Parenthood. And then I was asked to run a program for at-risk youth. It was basically like an after-school sexual education program. And so that drew me in a bit to just health care in general. And at the time, my now wife had just started a midwifery program out on the East Coast, where we were living. And so I got more and more interested in her education, looking into mental health. And my roommate was a pre-med student, and he seemed miserable.
Dr. Brian Evans: Is that true for all pre-med students?
Jonathan Lowe: Hopefully not all. Hopefully not all. But yeah, there is some misery there, I would say.
Dr. Brian Evans: As I got more and more interested in psychiatric care —
Jonathan Lowe: I was looking at different ways of educating myself, or different ways to be involved. And nursing and the holistic approach really spoke to me. And that’s the path I chose.
Dr. Brian Evans: Well, we’re glad you did, because we do know that there’s a lot of need out there. There’s a lot of mental health issues and disorders, and people are struggling in a lot of different ways. And we certainly have seen some of those numbers increase because of societal forces — you know, like COVID, when everybody was on lockdown, and social media, and everybody staring at their phones all the time. So what have you seen in your career in terms of just trends? I mean, are you feeling like, okay, we’re getting our arms around this mental health problem across the country? Or is it really just like we’re just barely scratching the surface, or somewhere in between?
Jonathan Lowe: Maybe somewhere in between. I will say, in the past couple of decades, just the awareness — even programs like this that talk about it, raising awareness of mental health issues, de-stigmatizing mental health issues, allowing more patients to feel comfortable accessing care — it’s been a real win for us, in terms of the things that I’ve seen coming here to Truckee. So I grew up in South Lake Tahoe. That’s where I went to high school. And growing up there, I see a lot of the same issues existing in Truckee today that existed when I was growing up in a very similar community. And we see higher rates per capita of things like ADHD in towns like Truckee, higher rates per capita of things like eating disorders and addiction disorders. So yeah, that’s a real increase from other practices I’ve been at, like on the East Coast in Connecticut. Not that I didn’t see those issues — I certainly did. But it’s just, for such a small town, we just see higher rates of these things. The other thing is the stressors — the unique stressors, I think, that we have in a town like Truckee: cost of living, stress, right? The loneliness that some people experience, kind of feeling secluded, right? Not socializing as much in a rural area. And then a very interesting kind of existential threat that many of my patients face as they age, or if they get injured, because so much of their life is built around the Truckee lifestyle and being active. And when that is taken away, either naturally or because of an accident, it causes a lot of distress.
Dr. Brian Evans: Yeah, those are all interesting and concerning sort of influences on mental health. And, you know, you think about Truckee and North Lake Tahoe generally being just this beautiful area, and a lot of people are drawn to it for sort of the restorative properties of Lake Tahoe and being here and being healthier, being active. But there are some real issues. And so when those issues are starting to happen, I like to talk about stigma, because, you know, it didn’t used to be okay to talk about mental health, right? It used to be something to keep yourself — keep within the family, don’t let anyone know that you’re struggling, and just kind of deal with it. And now we’ve seen a lot of high-profile people speak about it. And I think most people now know that it’s absolutely okay and warranted and good to seek help for yourself, for family members, for friends, and ask people how they’re doing. And so you and your team are absolutely doing that on a regular basis. But yeah, there’s definitely some interesting pressures — and not just the season passes have gone up in price for the ski resorts, which that’s an anxiety inducer for me — but lots of other things too, you know, and trying to stay independent and mobile in a mountainous community like this is not always easy.
Jonathan Lowe: No, it’s not. Yeah, major stressors are coming at us from all angles — not just financially. Many of my patients are having political stressors, and just access, right? Just making sure that they have access to care, and that can be hard too.
Dr. Brian Evans: Yeah, yeah. People are stressed about politics. They’re stressed about the environment. They’re stressed about AI. And it’s hard to say, “Oh yeah, don’t worry about it.” I mean, these are very serious things. So what should people do — if someone’s out there listening right now and they are thinking, “Gosh, I’ve been dealing with anxiety, or I’ve been dealing with depression, or I’m just not finding joy in life” — what would you recommend those people do at this point to seek help?
Jonathan Lowe: Well, first off, I think it’s important to understand that the brain is just an organ in our body, right? And just like every organ in our body, it’s capable of illness and dysfunction. And so recognizing that the brain is not unique — it’s not somehow controllable through thought alone. We can’t, quote-unquote, pull ourselves up by our bootstraps and just get over these things. And just like we would attend to any other area of our health — if our stomach was in pain, if our knee was in pain, we would hopefully seek the advice and guidance of a medical professional — no different from the brain. I think where it gets tricky, I think, for my patients, is that the brain is the organ that also helps us to understand who we are, what reality is. So when we’re suffering symptoms of the brain, we often inadvertently absorb them as who we are. So I might not come to you, Dr. Evans, and say, “Nice to meet you, Dr. Evans, I have left-knee pain,” or “I have chronic stomach pain,” right? But what do we say to our providers? We say, “I am anxious, I am depressed.” And for me, that language is incorrect. This is just an organ that is acting in a way that it might not normally act. And just like every other organ, it’s stress on that organ that is most likely to produce symptoms of illness. And so when we’re under this stress and we start to recognize that these symptoms are happening, understand: this is not who you are, this is a symptom, and it can be addressed effectively.
Dr. Brian Evans: I love that. I love that. Yeah, it’s sort of like getting a little separation away from it so that you can be more objective and say, “Hey, there’s an issue going on that I’d like some help with” — just like you might do if you sprained your thumb, or — I went to my doctor recently and said, “Hey, I got this weird rash,” and I don’t have it anymore, by the way. It’s gone. So you don’t have to worry about that. You took care of it. But there was no angst about, “Oh, I’m going to mention this to my doc.” And it should be the same way with a mental health symptom.
Jonathan Lowe: Yes, correct.
Dr. Brian Evans: I love that. You know, one of the areas of your practice which is really interesting to me is esketamine. And I know it’s not your entire practice — you do many things, and you work with all kinds of members of the community — but esketamine is getting some really impressive results here in Truckee, in your practice, but also in other places as well. So for the folks listening, can you tell us: what is esketamine? What is that drug, and how do you give it, and what’s it for?
Jonathan Lowe: So a simple explanation would be esketamine is a version of a drug that many people are familiar with, and that’s ketamine. It’s the first FDA-approved — what might be considered a psychedelic treatment — first FDA-approved for mental health purposes. And this is important because it allows my patients to access these treatments through insurance, including our state partnership or Medicaid, at a very low cost or no cost for some patients. Esketamine is approved for two different diagnoses currently in psychiatry. I expect to see more in the coming years. Right now it’s for treatment-resistant depression and major depression with acute suicidal ideation. And treatment-resistant depression is important because there’s no one definition for treatment-resistant depression, but it is a trial and a failure of at least two traditional antidepressants — pills that a patient might take every day — and they’re just not seeing the results that they would hope, right? Which is a huge portion of patients, at least over a third.
Dr. Brian Evans: Yeah, I mean, the antidepressant medicines have been around for a while and they’ve been used a lot, and they don’t always work that good, right?
Jonathan Lowe: No. And then when we look back at a very famous study, say like the STAR-D trials, when we analyze that information, what we see is that our hope is to go into remission, right? Anxiety, depression — many of these are chronic illnesses, meaning there is no cure. They’re just treatments for them. And when we look at data from the STAR-D, what we see is that the first trial of a traditional antidepressant might produce somewhere around 25% success rates in terms of remission, if that’s our goal. And then a second trial, about the same, right? Third trial, you start to see a little less, right? Maybe a third medication, maybe an adjunct medication. And then a fourth trial, you’re down into the teens in terms of percentage rates of success and remission. And that’s where treatments like esketamine come in really handy, because what we see is over a 70% rate of success, meaning that patients will respond to this medicine, seeing a reduction of 50% or more of their symptoms quite quickly.
Dr. Brian Evans: And these are not pills they’re taking every day, right? This is a completely different treatment modality, right? So how are they getting the medication, and what’s going on there?
Jonathan Lowe: Yeah, so esketamine is administered intranasally. So it is not a nose spray — it’s kind of like an encapsulated, very particular dose of esketamine that patients inhale through their nose. And they will have — again, not a traditional psychedelic, right — it’s more of a psycholytic, meaning that the effect, or the change in the state of consciousness, still allows one a lot of agency and influence over their thoughts, control their movement. So they’re very much aware of their surroundings.
Dr. Brian Evans: Yeah, so this is not like somebody going on sort of what they would consider a typical psychedelic trip.
Jonathan Lowe: No, not at all.
Dr. Brian Evans: So it’s not like going to a party where they’re doing something like that.
Jonathan Lowe: No, no, nothing like that. But it does change the way the brain is functioning in that moment and allows for some longer-term, longer-lasting benefits to take place.
Yeah, the real benefit of the treatment is not the medication being in the system itself, although that can be a very profound and healing experience for so many of my patients. It’s this burst of a neurotransmitter called glutamate. And if we can think about glutamate as the number-one restorative, reparative, excitatory neurotransmitter in our brain — if we force this neurotransmitter to burst in our brain, and we do so with esketamine because it’s what’s called an NMDA receptor site antagonist (fancy way of saying it blocks NMDA receptor sites) — and NMDA receptor sites are where glutamate likes to hang out and sit. So if we block those receptor sites, glutamate will burst. And what we see is the strengthening of dendrites and axons, the quickening of new neuronal connections, the repair and restoration of damaged neuronal tissue that we often see in mental health issues like depression.
Dr. Brian Evans: And so the effect of these treatments that you’ve been providing, and many others have been providing, for depressed patients have been pretty dramatic. I mean, you talked about some of the numbers, but you’re seeing better results for a much higher percentage of patients than you might see with other types of treatments. And it’s sort of a one-and-done kind of thing, right?
Jonathan Lowe: So we’re not seeing one-and-done yet with any of these new kinds of novel treatments that are soon to be available for prescription. Again, depression is a chronic illness. And so if someone is to stop treatment — any form of antidepressant — if they have treatment-resistant depression or recurrent depression, there could be an 80% chance that they will go out of remission of symptoms. The nice thing about esketamine is that it is dosed very infrequently for many patients. So patients who I treat might come in once a quarter, once a month, once every two weeks, once a week. And even though that is — engaging with treatment takes up a portion of their time — they get all of these other hours back in their day without having to take something daily. Because again, glutamate works almost like a miracle growing on the brain. And that’s the real magic of these types of medicines.
Dr. Brian Evans: So while we’re on the topic — I mean, there’s a lot in the news about psychedelic treatments. And in fact, the most recent thing was that there was an executive order signed at the White House on essentially fast-tracking some of these other types of psychedelics that aren’t currently allowed, aren’t FDA-approved, for other psychiatric illnesses like PTSD and anxiety and depression and those types of things. So what was your reaction to that? And are people interested in psychedelics as potential treatments for these kinds of illnesses? And what do you see happening in the future?
Jonathan Lowe: Well, there’s a lot of education, I think, that needs to be provided to the public about psychedelics and where they might play a role in psychiatry. Really, there’s not a lot of research and development dollars being put into the next daily antidepressant, Prozac-like medication. Most of the focus is on electricity and psychedelics in order to help the brain and help with these conditions in really profound ways. With the new executive orders, what we’re seeing is, yes, there may be a fast track, but it is not going to do away with the need for, and the requirement of, really good and well-designed studies in order to approve these medicines. One of the difficulties with psychedelic medicines in particular is that studies are really hard to do.
Dr. Brian Evans: Yeah.
Jonathan Lowe: Right? To do a placebo trial — I think most patients would know whether or not they took the placebo or if they took a psychedelic.
Dr. Brian Evans: Yeah. And I think it’s really important to — yeah, what you just said about this is not like, “Oh, everybody can start using these psychedelic medications to treat everything under the sun.” It still needs the science to be done. It was more of an administrative thing, to improve the efficiency of the administrative part.
Jonathan Lowe: Yeah, just to improve the efficiency. So, right now, off the top of my head, there are at least seven psychedelics — varying from psilocybin to forms of LSD, or DMT, or MDMA — that are in what’s called a phase-three trial. So they’re close to FDA approval. And I think that they’re just looking to maybe not remove, but make some of the barriers that prevent these medicines from going forward — just make it a little bit easier.
Dr. Brian Evans: Yeah, to study them. So, my sense of this is that there’s a lot of people out there who are hoping that these types of psychedelics will be sort of magic bullets for treating all kinds of different things very easily. And there’s a lot of people seeking those treatments outside of traditional medicine. And some of that is not legal — they’re leaving the country to have things done. There’s a lot of people talking about it on social media. And so it makes me nervous. And I don’t know — I’m curious if you feel the same way about this — because when people are just kind of going everywhere for information and treatments outside of traditional health care, and a lot of it’s dubious, then what could happen? What are the risks of that?
Jonathan Lowe: So there might be cardiovascular risks, and that’s being closely monitored with treatments like Ibogaine. And it’s good that we’re monitoring, or being aware of, these risks. There are risks to certain mental health conditions, like certain types or subtypes of bipolar illness or schizophrenia, with these medications that will be a contraindication to use them, and can be dangerous. And even things — conditions for medications that are very safe, like ketamine and esketamine — there are some contraindications to be aware of. So it’s important to talk with a health care provider that’s knowledgeable about these things, and not just go to social media, or one or two news stories. And I can see how the public would be excited, as I would, if there was a potential treatment that could radically improve my life very quickly.
Dr. Brian Evans: Sure, right? Yeah.
Jonathan Lowe: I would like that too. But yes, I think it’s just making sure that you’re talking with somebody who’s knowledgeable — providers that have advanced training, myself included, with certifications in psychedelic treatments — to help guide safe practice.
Dr. Brian Evans: And I really appreciate the perspective, because I think what the community wants from our health system, and wants from you, wants from me, wants from all of us, is to make sure that we are not closed-minded about these things — that we are curious about these things, but we’re also scientists about these things. And so we’re going to make sure that we’re going to use the latest information in a way that’s safe.
Jonathan Lowe: Correct. Safe for our patients.
Dr. Brian Evans: So, we’re about wrapped for time here, but I just want to ask: what other message would you want to leave our listeners with? If someone’s struggling, or if they need to do something with their own mental health, or someone else in their family, what message would you leave them with today?
Jonathan Lowe: Well, I want everybody to imagine that there is an invisible boardroom table in your head. And the way the brain is supposed to work is that we’re supposed to sit at the head of this table, kind of run this company, so to speak, with a gavel in our hand to make executive decisions. And around this table, we all have a lot of parts that we can never get rid of. We can’t fire these board members. We all have our trauma, anxiety, depression, ADHD, any varying things that might affect us. The real problem is that when we’re not holding the gavel, when we’re not the executor of our own lives — and so to recognize and think about it, you know, when to seek help, right? When to seek help is when you feel like you’re not holding that gavel — when your depression is making the decision for you, when your addiction is making the decision for you, right? When those boardroom members are holding the gavel and you’re just kind of along for the ride — what psychiatry can do at best is just help you feel you’re holding that gavel again, and can make better decisions for yourself, healthier decisions for yourself, and manage that invisible boardroom that we all have and will always have.
Dr. Brian Evans: I really love that image, and I love that description. And I really appreciate your time today. Anyway, that does wrap up our conversation today on Mountain Health Today. I want to thank our guest, Jonathan Lowe — really appreciate your insight and all you do for this community. So on behalf of the community, thank you for what you do. And thank all of you listeners for spending part of your day with us. I’m Dr. Brian Evans, Chief Medical Officer at Tahoe Forest Health System. And you can learn more about today’s topic and find resources at tfhd.com — that’s our main website. Until next time, take care of yourselves, take care of each other, and stay healthy here in the mountains. Thank you.
