Kerry Reller 0:28

All right. Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have Dr. Angela Camacho-Durán. Welcome to the podcast.

Angela Camacho Duran 0:40

Hello, Dr. Reller. Thank you

Kerry Reller 0:43

right,

Introduction to Dr. Angela Camacho Duran

Kerry Reller 0:43

so Dr. Camacho-Durán is a double board certified adult psychiatrist specializing in general psychiatry, but also consultation liaison psychiatry. She's also bilingual in English and Spanish, and specializes in the intersection between emotional symptoms and complex medical conditions, including chronic illness, metabolic conditions, overweight, transplant medicine, and medication side effects. She also has additional training in psychodynamic-focused psychotherapy, and your training is out of Columbia, right? And then you also did your additional training at Harvard Medical School. correct me if I said anything wrong, but welcome to the podcast, and why don't you tell us a little bit about who you are and what you do?

Angela Camacho Duran 1:27

Okay. Thank you so much, Dr. Reller, for this invitation. I feel very honored to be in your podcast, and yes, I'm very excited to discuss with you some of the work and experience that can hopefully be of use and offer some practical advice to everybody listening in your podcast. So Dr. Reller said, I am an adult psychiatrist. I have

Understanding Consultation-Liaison Psychiatry

Angela Camacho Duran 1:57

worked for many years in the subspecialty of consult-liaison, which is basically helping the other medical and surgical professions to care for their ill patients at the general hospital and taking care of their psychiatric and psychological needs. A lot of this work is done in the general hospital, inpatient, but also we do a lot of work out in the outpatient setting, so in the office to collaborate and help out. So more recently I opened my private practice where I can focus more on doing integrative approaches lifestyle modifications to help people with their mental health, and also offer some more in-depth psychotherapy. So yeah

Kerry Reller 2:51

Nice. Yes, I left out that you are, member and board certified of what is it? ACLM, so the... What is that? Lifestyle, help me out

Angela Camacho Duran 2:59

yeah, the APA, so the American Psychiatric Association, I'm a member and a fellow, and then the Academy of Hospital Liaison Psychiatry, and me- and a member of the American College of Lifestyle Medicine. Yeah

Kerry Reller 3:12

That's the one. Okay. Yeah, so perfect. Like blending all the, different things really helps create your own niche and everything like that. And I, like I mentioned before, I have never heard of like consult-liaison psychiatry, so I didn't know what that was. But your explanation was pretty good in that, that's more hospital-based work and networking or working with the other I guess specialists that are taking care of the patient. Now, would that be more on the inpatient psychiatry side or would that be on the inpatient medical side?

Angela Camacho Duran 3:41

So definitely not the psychiatric unit that we know m-more typical for patients who go to the emergency room or to the hospital with that main psychiatric symptom or concern. So the consultation specialty is more for people who are in the general hospital, so the medical and surgical units, with medical concern. And then

Mental Health After a Heart Attack

Angela Camacho Duran 4:08

throughout the course of their hospitalization, they have a psychiatric symptom that their doctors are concerned. So one good example is somebody with a heart attack who has a... of course, has been admitted to the hospital for chest pain for, they've been diagnosed with a heart attack. They're receiving treatment with all the medications that are protocol, and then they probably have a predating history of depression. Maybe they were already taking antidepressant medication, or after the heart attack, they have developed depressive symptoms for whatever reason, for being in the hospital, for having a new medical issue, for fear or concern of what their life may look like after this medical event. And then their medical doctors call the psychiatrist to evaluate in that point of time how to help. Definitely it doesn't entail every time to start a new medication, but particularly for the cardiac population, it is very important to identify if there is depression because that kind of pictures or has a big impact on the outcome of the overall Heart attack treatment after the hospital

Kerry Reller 5:42

Yeah, it's actually pretty common, I think, to have depression after a heart attack or maybe even anxiety as well. And I think that you mentioned it definitely can impact their motivation to do cardiac rehab, right? Which is pretty extensive if you want to, improve back to your baseline after a heart attack. So this is great to know that, people like you exist so that they can get that support because it's really common to have that depression after a significant event or even a medical condition or diagnosis, for sure. So

How Chronic Illness Affects Emotional Health

Kerry Reller 6:14

y- you mentioned other, and there may be other physical illnesses that can affect someone's mental health and, where do you typically go with that? Is that something that you see in your own practice or is that more of the consult liaison role?

Angela Camacho Duran 6:28

Both. A couple of other good examples of what we do in the hospital is, for exa- for example an elderly person a, an older adult who is admitted, let's say, for pneumonia. Then throughout the course of the hospitalization, they may get diagnosed with a UTI or some medication related side effects, and then they become confused. This is pretty common. Become confused, may even get aggressive or very disoriented. Their sleep pattern gets all disorganized. That is a very typical finding, and we can assist the, the medicine team and often, that's diagnosed with something called delirium, and we can assist, in identifying that and managing that in the hospital. In the outpatient setting or in the clinic, we may see more patients, for example, with dementia or patients who are going through difficult life transitions or grief patients who-- or people who have been exposed to traumatic events earlier in life or more recently. And sometimes they start to experience like physical symptoms, but they're not, Maybe aware whether these symptoms may have a connection with their emotional state. For example patients who have chronic conditions or autoimmune conditions typically have pain, generalized pain, but also a lot of brain fog, difficulties with concentration or attention poor sleep difficulty to find interest or zest in life or enjoy things. So in those situations, we can in the office, identify and assist those patients to be more in tune with what's happening in their body, connect their mind and body symptoms and help them manage. A lot of the times people think that coming to the psychiatrist or the psychologist is diminishing to their medical symptoms or their physical symptoms, and it's very important often for me to tell them they go together. The, those services and treatments go hand in hand. One doesn't diminish the importance of the other

Kerry Reller 9:18

Yeah, you're basically answering one of my big questions for you is, we often talk about mental health and physical health as though they're completely separate, but are they really, right? They're not truly separate, are they?

Angela Camacho Duran 9:30

Exactly, yes.

Why Mental and Physical Health Are Connected

Angela Camacho Duran 9:31

One of the big themes is there is no health without mental health, right? So yes, I'm a big advocate of that. I think that we, we force ourselves to function well to perform, to succeed, and sometimes that is at the cost of our mental health or emotional health. So we wanna make sure that as well or as good as we take care of our physical health and we go to the primary care and the cardiologist and, different doctors, the gynecologist, to take care of all our physical needs, that we also keep in check how we're feeling, our emotions, how we're handling our emotions because those are the ones that allow us to connect with ourselves and with others in a healthy way. So definitely paying attention to that is part of a healthy life.

Kerry Reller 10:36

You mentioned that the physical health can affect the mental health, and it obviously can, it can go in the other direction, right? The mental health can affect the physical health and the course of the medical condition as well. Like you were alluding with the cardiac patient. He may have had underlying depression that is, now being resurfaced or, being pro- becoming more of an issue with the heart attack,

Angela Camacho Duran 11:01

Exactly. Yeah, that's very interesting. So

How Mental Health Impacts Physical Health

Angela Camacho Duran 11:04

one of the things that we know in psychiatry is that patients with serious mental illness, like for example, patients with schizophrenia, they have a shortened lifespan because they receive less attention in terms of their medical needs. They also have heart attacks and diabetes and all these things. They get exposed to medications that have some metabolic side effects that sometimes don't get recognized or managed as, as they need to. So that is a big example. But also when we have issues like depression or trauma, those can cause in the long term more problems with chronic inflammation at a low grade and put us at a certain risk to develop physical illness. It has to do with sometimes with how we manage, for example, stress. So we accumulate all this load in our body that in turn decreases the immune response and definitely, it makes us... it's part of or is a risk factor to develop other physical medical conditions

Kerry Reller 12:23

are there actually like inflammatory markers or anything that changes or is there things measured with that?

Angela Camacho Duran 12:30

Yes. So one of the

Chronic Stress, Inflammation, and Immune Function

Angela Camacho Duran 12:32

things that are measured more and more frequently is inflammatory markers like interleukin 6 and C-reactive protein. So those have shown to be higher in people who are exposed to chronic stress. Some examples are caregivers of family members, for example, with dementia or with developmental disabilities. Also it's been shown in some studies that people under chronic stress and certain conditions are less responsive to vaccinations, like the varicella zoster vaccine or the pneumonia and the flu vaccines. So if you have people with depression those in some studies have shown to be less responsive to those vaccinations, to those immunizations

Kerry Reller 13:28

So we actually do a lot of immunization, like testing in our office because we deal with a lot of immunodeficiencies. So we are like testing the vaccine response. I was wondering if, there is like no response or is there a somewhat like a partial response? Because that's something definitely I look at and then we're trying to determine if these patients, are-- Because usually we're doing it because they're getting frequent infections, right? I've never, correlated or cross-correlated to see if these patients also have, significant trauma or significant depression or something like what you're saying. Is that something that could also be within that patient's experience? Sometimes they, we know the exposure, but usually it's just, we're just thinking like recurrent infections.

Angela Camacho Duran 14:10

Yeah, very interesting. So

Depression, Healing, and Recovery

Angela Camacho Duran 14:12

I don't know to what degree they are... L- I think it's less responsive in the studies, not necessarily unresponsive. But I know the populations that have been studied are for example, cardiac patients in... with depression, so they are less responsive. Patients who are caregivers of family members, like I said, with dementia or developmental disabilities have also been less responsive. Sometimes people who are in very stressful marital relationships. And again, we're not talking about like a day-to-day interaction, but more chronic. Also, people, adults who have been exposed to childhood trauma. In their adulthood, they have been measured for interleukin 6 and shown to have it elevated. And also one of the other studies show patients who are admitted with ulcers or chronic wounds tend to heal more poorly or slowly, or to get readmitted to the hospital more quickly when they have depression. And like you said, it has... I don't remember at this point the com- if there is other confounders in the studies, but definitely part of depression is decreased interest in taking care of yourself, right? If they get discharged to... for wound care or to take medications at home and they don't follow that routine care, then, they will get readmitted to the hospital. But a lot of the times, when I have those patients, the doctors... i-- we would maybe argue they are sick. They are in pain. They have an infection." But the doctors would always come back to me and said, "Yes, but they are depressed, and that's why they're not taking care of all these other things." So it is bidirectional, and it's a vicious cycle.

Kerry Reller 16:18

Yeah, it definitely, makes it harder to distinguish if something is due to the chicken or the egg, right? What's coming first? Is it the trauma and the depression and the stress, or is it that the lack of, self-care that could be contributing to some of those things, if that's someone who if they have that when they're depressed. Do you know what I mean? We can't really tell, which comes first, but So you've mentioned a lot of things of what chronic stress can do to the body and what symptoms someone might notice. What about is stress, like, all that bad?

When Stress Becomes Unhealthy

Angela Camacho Duran 16:49

Stress is a normal not a normal, but a human experience for all of us, right? We all go through that as an evolutionary mechanism, and it challenges us to overcome obstacles. So in itself, it's not the enemy. It's not a bad thing. It is defined as a situation in which the organism needs to overcome a demand that exceeds the coping mechanism that, that it has. But a lot of times, it is what allows us to perform better or to overcome an obstacle when it's kind of a short-term situation. So for example when we go to exercise, it stresses our body most of the time in a healthy way. It is a healthy stress. So when we are preparing to speak in public or to take a test, it is something that has an end, so it's short-lived, and it he- helps us to prepare better and meet our goal. So in those examples, it is adaptive, and it's healthy, and it's helpful. It is sometimes when we get exposed to a situation that it really exceeds our capacity to cope, but then it prolongs in time. It stays on for too long, and it doesn't allow the body to recover, to rest. So that is when it starts to become unhealthy when it is... when it persists over time in a way that we cannot recover or recuperate.

Kerry Reller 18:50

Is that when you use that kind of term like allostatic load? Is that what that is coming from?

Angela Camacho Duran 18:56

Yeah.

Allostatic Load and the Body's Stress Response

Angela Camacho Duran 18:56

Our body has a regular way to... Our organism has a regular way to maintain a balance for all the functions. That is called homeostasis, and it's around a set point, so the organ- the body tries to stay around that set point. And then there is another term con- called allostasis, in which the body actually moves to meet that new demand to in order to recuperate or to adapt. Not to recuperate, to adapt to the new demand. It has a certain wiggle room to recover. And it uses some major systems that we have, which are the nervous system, the endocrine system, so a lot of hormones involved, and the immune system. They all work in synchrony with regulatory systems in the brain to allow that coping mechanism to meet the challenge. But sometimes when we can't reset, then there is what we call allostatic load. So we become like always all these systems are ready to fire, and that's when they can't be restored to balance, and it becomes a disequilibrium because they start firing either too much or too low especially the immune system, like the hormones in the nervous system, for example, your fight or flight system the sympathetic system is gonna be firing or on guard all the time. So people are, like, persistently on a fight or flight kind of a stance when really it's not necessary. So that puts the immune system regulatory pathways in a way that is they don't know if they have to secrete too much too many markers, or they have to restore. So basically, the organism is all out of sync, and that's when you start to, to live under a low inflammatory response in a chronic way, and that's when the disease or the illness may present

Kerry Reller 21:31

It was interesting, like thinking about set point, I think about it, I guess there's many different set points of our body, right? You're speaking to this one, I think of the temperature set point, a weight, we talk about a set point. So it's interesting that the way that you're putting that into perspective as well. And yeah. I think, we're talking a lot about, more like chronic stress and some of that acute stress too.