Alex Stavros: Welcome Dr. RAMAN to our podcast Roadmap to Joy.
Thank you. I appreciate it. Alex, Dr. Brad Raman is Embark
senior clinical advisor and as a member of our Clinical Advisory
Council, he participates in clinical quality activities and
makes recommendations to Embark on care, treatment and services.
His extensive experience in mental health positions. Help
them advise us on clinical curriculum practice guidelines,
and specialty clinical programs such as obsessive compulsive
disorders, Autism Spectrum Disorder, substance use disorder
and eating disorders. Dr. Ramin really has an impressive resume.
He has been specializing in OCD and OCD related disorders for
over 35 years and is considered one of the foremost OCD experts
and clinicians across the world. In fact, Dr. Freeman is widely
regarded in the healthcare community for helping more
people recover from OCD than any other clinician in America. One
of the many areas we Embark have found alignment with Dr. Freeman
is his significant contributions to measurement based care, and
standardizations of care. He's a prolific researcher and serves
as a member of the scientific advisory board of the
International obsessive compulsive disorder Foundation,
acting as expert consultant to the organization on research
matters. And in fact, his research has been published in
nearly 100 articles and professional journals, which is
particularly impressive given.
He is someone who is in the practice setting, not the
research or academic setting. Suffice to say Embark is
fortunate to have Dr. RAMAN as a clinical leader and partner.
Welcome Dr. Raman.
Brad Riemann: Thank you very much. I appreciate that Alex,
and I'm, I'm so excited to partner with with Embark I mean,
it's such a mission driven organization. And certainly,
that's a real credit to you and your leadership team. So thank
you. Thank you. Thank you, Dr. Raman. Well, you know, there's
so much we could talk about, but what I would love to do is to
focus this conversation on teens and young adults with OCD, and
their family and parents that are looking for ways to support
them. It's really a unique disorder, and very debilitating
condition. There's also so many misunderstandings, as I'm sure
you're gonna share with us, and it's very commonly misdiagnosed.
Alex Stavros: And often parents will do things though well
intended, that can enable the disorder as well. So it's great
to be able to spend time with you to hopefully provide some
content for parents to help their children who may be
struggling with this issue. So maybe first off to lay the
groundwork. How would you define OCD? At a more high level?
Brad Riemann: Yeah. So OCD is characterized by obsessions and
compulsions Alex and and obsessions are these unwanted
thoughts, images or urges that generate high levels of anxiety.
So some common examples might be the fear of becoming dirty or
contaminated. By coming in contact with things in your
normal daily environment or doubting whether you did
something or did something correctly. Did I turn off the
stove? do that math problem, right, Did I lock the door.
compulsions, on the other hand, are some sort of repetitive act
and, and typically, it is some sort of behavioral act that we
can observe something that someone feels compelled to do to
try to neutralize that unwanted obsessional fodder to get rid of
the anxiety that it causes. So this might be something like in
response to say, the fear of dirty becoming dirty and
contaminated washing and cleaning over and over again.
But compulsions can also be another thought. I mean, it can
be something that we can't observe something that someone
does silently in their own mind, again, in an attempt to prevent
something bad from happening, or to get rid of that anxiety that
is caused by that social thought. So it's important to
think about it as really a two part problem obsessions and
compulsions.
Alex Stavros: That makes a lot of sense and providing a clarity
on OCD isn't necessarily always something that's outward, and
something that can be visible to others around you. And also,
what I found interesting is a lot of examples you gave. I've
dealt with myself and probably most people have dealt with
themselves. The question is, you know, what are some of those
common misconceptions with OCD and misdiagnosis where some
people think they may have it or may think they don't have it is
just because I have certain thoughts about something that
may be stressing me out, doesn't necessarily mean that I have
diagnoseable OCD. What have you seen in your work that are some
of the most common misconceptions and what leads to
misdiagnosis and how should people be thinking about it in
terms of when are the those behaviors? Maybe something that
more represents OCD than just typical thoughts and behaviors
that people may have?
Brad Riemann: Yeah, great questions. And, you know, there
are some that really believe that OCD is a great, great
exaggeration of the norm. You know, to your point, Alex,
everyone has probably washed their hands from time to time
when they just felt dirty. Everyone has gone back and and
checked the door lock even though they were quite certain
that they had closed that door and locked it. So some people
again feel it's it's just a tremendous, but I do emphasize
the word tremendous exaggeration of the norm. Point simply being
as we go back to our 2.2 part definition obsessions and
compulsions. The obsessional part Alec seems to be universal.
I mean, everyone gets unwanted thoughts from time to time. And
it just seems that again, this exaggeration of the norm where
someone with OCD has so many of those thoughts, and does so many
repetitive compulsions, whether it's checking, washing,
counting, cleaning, whatever it might be, that it creates
interference or disorder in their life. And then that's when
someone like me says, Well, you have obsessive compulsive
disorder. But again, to your point, everyone's you know,
this, a lot of these symptoms kind of ring bells and say, you
have done that from time to time. But you know, when your
child or young adult starts to do, you know, starts to have
these issues so much that it creates this interference in
their life, you know, that's when it really is time to be
thinking about getting an assessment and perhaps,
treatment, but it is commonly misdiagnosed as you as you said,
and the real error, I guess here is that just because someone
does or thinks something over and over and over again, does
not make it obsessive compulsive disorder. And, you know, like
the media in lay people, you know, really kind of
misunderstand that. And a perfect example, Alex is, you
know, kind of excessive video game playing. You know, I've
gotten phone calls from parents saying, oh, you know, Dr.
Freeman, you're an expert in OCD. My son has OCD. I'm so
sorry to hear that. What sort of symptoms he has, he cannot stop
playing video games. And I'll say, Well, you know, I never say
never, but chances are, that's actually not OCD. And they'll
say, Well, I don't understand. He's thinking about them all the
time. He can't stop playing them. It's the he can't go to
school, it's interfering with the social life of the
differences. Again, if we go back to the definition of an
obsession, it's an unwanted thought, right? Whereas if you
ask Johnny, do you like thinking about playing video games? He
says, yep. And do you like playing video games? Yep. It's a
problem. And it can be a serious problem. But in a way, it's
almost kind of the opposite. And so the, again, the take home
message is just because you think or do something over and
over again, does that make it OCD? Great
Alex Stavros: take home message and about on the flip side, in
terms of kind of undiagnosed, OCD. So some people may think
they have it, but it's not really there. How about those
that are struggling and kind of day to day and may not be aware
of how much it's getting in the way of their daily functioning
work and relationships? And others may not be aware of it
too, or perhaps are? How should we think about OCD? That's
undiagnosed? Yeah.
Brad Riemann: Great, great question again. You know, first
and foremost, we got to keep in mind that people with OCD for
the most part do have some level of insight into their symptoms.
And as a result, they fear embarrassment. You know, they
really are quite good at hiding their symptoms, even from their
parents or their teachers or their spouse. You know, we've
gone into the classroom and spoken to teachers, of course,
after obtaining proper consent, and teach us a passion, we had
no idea, you know, that Johnny had these problems, because,
again, Johnny, he might be washing his hands like mad at
home, but you know, he is not going to display the symptoms in
front of his friends. And so he's kind of sweating bullets
all day long at school. Because again, just this fear of
embarrassment. So you have this tendency for people with OCD to
not discuss this stuff, they tend to hide it, they tend to
keep it to themselves. Most people who come into an OCD
treatment program, for example, will say I've never met anyone
else who had this problem. I've never been able to talk with
someone else who has this problem. So there's this
tremendous relief and kind of normalization, if you will, when
patients do come in but so this is a problem that is common.
It's also commonly misdiagnosed. And then there are many, many
people who are suffering in silence because of again, this
fear of embarrassment and not wanting to discuss This with
friends, family, whatever, even to the point of not wanting to
discuss it with their mental health care providers, so they
might have engaged in mental health care. I've gotten calls,
you know, Hey, doctor even Yeah, this is Dr. Smith, I have this
patient who has OCD. I've been seeing them for three years.
They just told me last night they have OCD. Well, what were
you treating them for depression? So they were even
afraid to admit this type of issue, even to their mental
health care provider?
Alex Stavros: And what kind of advice would you give? Or what
would you suggest for those friends or family members? That,
that think that somebody may be struggling with OCD, but they're
not sure. Particularly it's, it's difficult, somewhat because
of not only a stigma, but also fairly common in our society for
somebody to say, Oh, I'm, I'm being a little OCD right now or
stop being so OCD and we throw it around flippantly is, how can
we have a more serious conversation with somebody and
get over that stigma? To figure out if we should be trying to
find more help for that family member for that child? Yeah,
Brad Riemann: yeah. And to your point, I mean, it has become a
little bit of a, you know, just a coined phrase that people kind
of do throw out there. And, and it really, you know,
unfortunately, woefully underestimates the pain and
suffering that people with OCD go through. You know, at the top
of this podcast, you had mentioned the, how disabling it
can be, and the World Health Organization, or WHO has rated
as it the 10th leading cause of disability in the world, Alex,
and they're not just talking about behavioral health
problems, they're actually talking about medical problems,
such as anemia, and falls, all these things. OCD is in 10th,
leading cause of disability so it's, it's very disabling, very
impairing causes a lot of pain and suffering. And, you know,
when, when a loved one starts to feel that maybe something's off,
maybe they start to pick up on some of these symptoms, again,
keeping in mind it's a two part problem obsessions and
compulsions. If you start picking that up, you know, I
think the best thing to do is to approach your loved one, have a
conversation with them, you know, ask them if they're having
issues. Hopefully, they would feel comfortable in confiding in
their parent, or sibling or whatever it might be. The other
thing that I would suggest, and you had mentioned the
international OCD Foundation, their website is a tremendous
wealth of psychoeducation material, I mean, that they they
go into great length of what it is what it's not what to do, you
know how to talk with a loved one? And, you know, certainly
that's another thing that someone could do just even
inform themselves a little bit, you know, hey, I don't know, is
this OCD? Isn't it? Is it normal, you know, going there
and reading up a little bit on some of the resources they have,
can be very, very helpful. And then when talking with a family
or friend, you know, perhaps even suggesting that they go on
the internet, and there are other organizations as well.
But, you know, the iocdf is really kind of that
clearinghouse for information for patients and their families.
Great.
Alex Stavros: Appreciate that. We'll put a link to that those
resources in the show notes. Can I ask you to maybe do a little
bit of role playing? Sure. And you can assume either I'm your
child or a friend. And you you observed pretty serious OCD
behaviors, and you're not sure if I am. If I have been
diagnosed, and maybe I am seeing somebody, but you feel like, I
need to hear something from us, for us to be able to start to
have a more serious conversation. Would you mind
doing that as we think about parents, and, or a loved one or
an older sibling? is they want to bring it up? They're not sure
exactly what words? How do I bring it up? And how do I start
that conversation? How would you do that? Maybe do that with me
right now? Sure.
Brad Riemann: Sure. Sure. Sure. Yeah, you know, and just to
preface it, I mean, you know, there's really no right or wrong
way of going about doing this, for the most part, I mean, you
know, and if someone goes about this in a compassionate and
empathetic way, you know, I think nothing but good things
are gonna happen. No, maybe not immediately, but at some point,
you know, that conversation is going to register with someone
and they're going to realize that, you know, hey, you're,
you're a trusted person who cares about me, but yeah, you
know, I think that my suggestions more specifically,
you know, you know, I would approach you Alex and just say,
hey, look, you know, I was noticing that you were kind of
getting stuck over there. And having trouble you know, with
that door lock or, or I notice you you know, you were avoiding
touch Everything's at the dinner table and then had to go and
wash a couple of times during the meals. And, you know, and I
don't know what's going on Alex, you know, I'm just doing this
because I care about you. And it just seems like you were really
struggling. So it's something up, you know, I mean, is there
something going on? You know, I'm a person you can trust, I'm
a person you can confide in, you know, I, assuming I'm a
layperson, you know, I don't really know, you know, but I am
aware of this condition known as obsessive compulsive disorder,
and just a little bit I know of it, it seems like, maybe some of
these things are relevant for you. But again, you know, please
feel free to talk with me, whatever you say, I'll keep to
myself, I won't share with your parents or, you know, unless you
give me permission to do so. But, you know, I'm here for you.
I can listen, I can try to help you in any way, shape, or form.
I'm not trying to exaggerate what was going on. But it did
seem like you were really struggling. And it just gave me
a sense that this is kind of a something, you know, your
parents had told me that you were kind of struggling with a
few things. And, and you know, if nothing else, you maybe you
could talk to some friends, your school counselor, but I'm always
here for you, and we'll help you in any way that I can.
Alex Stavros: Right, great, nice work, you know, I think it's
part of it is, you know, like you mentioned is we can get in
our own way, when we feel like we're trying to accomplish
something like I'm trying to get you to do something or, versus
just saying, I'm here to talk, I see you, I accept you, that
allows that person to feel more comfortable. And it may be that
they don't want to talk to you about it. But that experience of
acceptance will allow them to talk to the person they did want
to wasn't able to tell them those words, but they feel like
I really want to tell this person. And because you helped
me feel accepted in the situation. Now I feel
comfortable telling them. And so I think it's a great way to
engage with a friend or even even a child in that way as is.
It's maybe maybe it's one of many conversations, maybe it's
one and nothing comes up for a couple of weeks. And then they
say, Hey, Dad, you were you brought that up? And you saw me
during this break that I was doing this thing? Can we talk a
little bit more about that? And exactly,
Brad Riemann: yeah, and you don't need to be a trained
mental health care provider to you know, to reach out and to
show somebody compassion and empathy, right. And, you know,
to your point to it may not have that immediate impact. They
might get defensive, they might, you know, it might stress them
out. But they're going to remember that you cared about,
right. And in, like you said, a week later, two weeks later, a
month later, you know, they they may let their guard down and
have a conversation with you.
Alex Stavros: So tell me a little bit about the
environment, and maybe parenting, how much does the
environment in parenting play, first of all, into the
development of OCD in the first place? or to what extent are we
born with it? And to what extent does that environment or
parenting, make it better or make it worse?
Brad Riemann: Yeah. Yeah. I mean, so Alex, I mean, we're all
products of our past, right. And so, you know, parents have a
tremendous impact on who we are and who we're not, and so forth.
But OCD. First and foremost, we don't know what causes OCD,
we're just really learning more and more about it each year. The
evidence that comes out of research every year is pointing
more and more to a neurobiological abnormality that
appears to be at least in part genetically influenced. So when
you're talking about parents, and you're talking about
genetics, you know, obviously what that means is that at least
in part, you know, this was passed on OCD tends to run in
families, right? It does not appear, though, to be really
kind of parenting in and of itself. And so for example, when
you look at adoption studies, and so say you have someone who
is adopted, who there's positive biological family history of
OCD, and they're adopted into a family that is OCD, free, they
are more likely to have OCD because of that biological
influence. Vice versa is also true if your biological parents
were OCD free and you're adopted into a family that is positive
for OCD. You're not going to develop OCD, you can't really
make someone OCD, so it does seem to be neuro biologically
abnormality that's influenced at least in part genetically. But
again, we are all products of our our past and influenced in
the environments that we are brought up in but you know, the
the biggest thing that seems to be involved with the parents.
And you had mentioned this in some of your opening remarks is
this concept of what we call family accommodation. And it you
are absolutely right, it is always very, very well intended
to begin with. None of us like to see our children or our loved
ones in distress. OCD causes lots of distress. And so parents
try to kind of run to the rescue of their children. So they start
opening doors for their kids so that they don't have to touch a
door handle that appears to be contaminated. They start trying
to help them in other ways. And initially, it does allow Johnny
to kind of sidestep their OCD and get on with whatever it is
that they're trying to do get to their little league game on time
type of thing. But what it ultimately does, those kind of
fanned the flame of OCD, and it actually literally makes the
severity of the OCD worse, and reduces the response to
treatment, unless addressed. And so that is one way that
unfortunately, families can kind of make the situation more
difficult. But again, it's it's natural. I'm not saying I
wouldn't do it myself, right, or you. We care about our kids. We
love our kids. We don't want to see him in distress. But it has
this kind of paradoxical effect, it has this kind of opposite
negative impact on the OCD in the long run. So it has to be
addressed in treatment.
Alex Stavros: Yeah, that I think that's a great point of just,
you know, well intended. And it's even when you have a child,
for example, that struggles in in social situations, you you
almost want to go and talk to them or pull them aside because
you don't like to see them feel uncomfortable. Yeah. And so what
would you say, if, as a family member, as a parent, if, in that
case where we got to get to the baseball game, or we got to get
to school on time, we're going to be late again, instead of
accommodating, which they do instead?
Brad Riemann: Yeah, great question. And, and it's not an
easily answered one. I'll just say that right from the get go.
But, you know, in the context of treatment, right. And so we've
been talking about, you know, OCD being a two part problem
obsessions, and compulsions. And in the treatment of choice, so
the gold standard of treatment is something called exposure and
response prevention. So it's a two part problem with a two part
solution. So the exposure is geared toward the obsessions,
the response prevention, as some people refer to it as ritual
prevention, is targeting the compulsion. So again, two part
prompt two part solution, if a if a family is engaged in that
type of treatment, then their clinician, their provider, will
be instructing them in kind of a series of steps to address and
reduce accommodation. It's tricky, Alex, if you try to do
this without being in that context of treatment, and let me
tell you why, you know if that child is because is going to
become quite dependent on that accommodation. And if parents
were to just say, okay, look, you know, I listen to this
podcast, it's Reman guy said accommodations bad starting to
come out, we're just not doing it anymore, right? That's not
gonna go so well. I mean, it could cause World War Three in
the house, it could cause a tremendous rush of distress for
that young one, because, again, they've become dependent on it.
So it's something that, you know, I think families need to
note has to be addressed, I would encourage them to reach
out to a provider to try to get some assistance on kind of the
step wise approach to reducing and ultimately eliminating that,
but just pulling the rug out from under on probably is not
gonna go so well.
Alex Stavros: Yeah, great advice. How earlier you had
mentioned about that colleague of yours that had been treating
that client for three years and found out that they had OCD, how
common are co occurring disorders, like depression with
those OCD? And how should a parent think about treating
these co occurring issues? is, should one be more important
than the other should both be handled the same time? Should I
be going to find an OCD expert, or should I find it depression?
Expert? Sometimes they're the same. A lot of times, they're
not or maybe there's other anxiety issues, or there could
be substance use issues or eating disorder. Eating issues
is how often do you find co occurring disorders and how
should parents think about seeking help for their child?
Yeah,
Brad Riemann: great, great quote. And so comorbidity is the
rule when it comes to OCD. But keep in mind, you know,
behavioral health issues, do kind of cluster. So I mean, it's
it's not just an OCD issue, it's pretty common for someone who
has, you know, issues in one area of their life to
potentially have it in another but pertaining to OCD,
comorbidity is the rule meaning. Most studies find that children
with OCD have about 60% of kids with OCD will have at least one
additional diagnosis, the really common comorbidities in kids,
ADHD, tic disorders, depression, as you mentioned, other anxiety
disorders. So it is pretty common. And, you know, some of
these things like the depression, Alec seems to be
kind of secondary to OCD. In other words, as you learn more
about OCD, it's not really a question as to why is somebody
sad and feeling hopeless and helpless, it's a bad thing to
have, right. And so I think quite naturally, it starts to
pull people's mood down. So depression, for example, is
commonly secondary to the OCD. And what I mean by that is, if
you get into good treatment, if you are in treatment for OCD is
really kind of you want high quality exposure and response
prevention, but you also need the right dose of it. And I'll
get back to that in a moment. But if you're getting high
quality treatment for their OCD, and their OCD symptoms go down,
the depression tends to go along with it more often than not, I
mean, they're depressed because they're anxious, right. And so
the good news is there as you you know, you can kind of get a
little too for one, but some of these other things that you
brought up are freestanding problems. And at times, there
may be some treatment overlap, a clinician treating your OCD
could maybe just pivot the treatment plan slightly to be
able to address some of these other conditions. And then some
of them may need some expertise that your OCD provider might not
have. And so then there there may need to be, you know, a
referral elsewhere. And the the order of that treatment also
depends, I mean, again, if it's a primary OCD, that really means
that it is the number one problem causing interference in
your child's life, then that should be the priority. And
these other things can, can can wait. Now, it also depends get
back to the dose from for a moment, and we talk about dose
of treatment all the time when we think about medication, you
know, 20 milligrams of this versus 40 milligrams of this
dose rarely comes up Alex when we're talking about psychosocial
treatments, but there is truly a dosage effect for many
behavioral health and addiction problems with OCD for sure. And
what I mean by that is, you know, the, the more complex, the
more complicated the OCD, and that is within OCD, also with
comorbidity, right, I mean, you know, do they have other things
going on, which we said is already the rule. It's how much
good ERP how much high quality treatment do you need to get
better, and there is this dosage effect. And many people because
of that level of disability, remember, it's a 10th leading
cause of disability, the world may need more than high quality
one or two hours a week. So they may need intensive outpatient,
which might be two, three hours a day, three to five times a
week, they may need a day treatment program, they may need
residential care, and that 24 hour support. Now, thankfully,
you know, that is a small minority of these patients. But
it is enough that obviously there are specialty OCD
residential programs that in that case, they have they have
enough time with this youngster to not only address the severe
OCD, but these other comorbid problems as well. Yeah.
Alex Stavros: So we had a you mentioned ERP, we have a as you
know, Southern California outpatient clinic that offer OCD
programs for teenagers in an IOP using ERP, which as you
mentioned is the gold standard. And we also offer a virtual IOP
OCD program also using ERP as as the gold standard. We once had a
child who lived nearby one of our brick and mortar outpatient
clinics and had enrolled in the OCD program, but can never get
there. They just weren't able to leave the house. And so there's
part of it in terms of there was this initial step and it didn't
mean that that first step we couldn't even accomplish. So
fortunately, we were able to enroll in the virtual program as
a first step with the main goal of helping this young boy teen
boy be able to leave the home first of all, to be able to
transition to be to his near his Tom and accessible to be there
in person and continue that treatment. You know, we we know
that you recently co authored an article on the benefits of
telehealth for pediatric OCD, I would love if you could share a
little bit what you found in that study?
Brad Riemann: Yeah, yeah, no, that's, that's, it's
interesting. And you brought up a perfect example. I mean,
sometimes, you know, whether it's a child or an adult, I
mean, they're debilitated enough by this condition and their
anxiety, that they're really not able to access care outside of
their home. You know, COVID, obviously changed everything.
And all of the programs that I had been associated with over
the years, were always in person treatment. But we had to pivot
very, very quickly, right. And within seven days, we
transitioned, you know, literally over 1000, patients
that were receiving intensive treatment in IOP, AND PHP, to
telehealth because of the, you know, the pandemic, obviously.
And we began to collect data immediately, because we wanted
to make sure that this treatment was still effective. This study
that you mentioned, that we published, really supports that.
So to make a long story short. Now, again, this is primary OCD.
In kids, and they're receiving three hours a day of treatment,
a day or six hours a day of treatment in the day treatment,
or partial hospital programs, the outcomes were basically
identical. This treatment, when done in a high quality
structured kind of protocolized or manualized, fashion, produced
equal outcomes in these in these patients. The only difference is
we needed two days longer for the telehealth IOP to get the
same benefit, which was kind of an interesting little thing.
It's not insignificant. I mean, especially if you're a payer, I
mean, two extra days that there's a cost to that. But the
bottom line is, is these kids got better equally telehealth or
in person. Now, what I think will be fascinating, Alex, any
kind of follow ups to those things? Is we also however, were
aware that there were probably, you know, some young individuals
who did not do as well, telehealth I mean, at the
individual level, not at the group level with hundreds and
hundreds and hundreds of patients. And there were
probably people who didn't respond to telehealth, who would
have responded to in person. And I think the the interesting
thing would be to kind of find out what predictors, you know,
would we be able to what kind of data could we collect from an
individual who is considering treatment, and say, you know,
what, Alex, based on your responses to this, you have a
choice, you could do telehealth or in person, or based on your
responses here, you know, you really need to do in person. And
that ability to predict would be incredibly powerful. You brought
up a perfect example of someone who could get geographic access
to this clinic, but was too anxious. And the goal in
treatment was to lower that to get him to come up with some, as
you know, no matter how many clinics you have, say,
California that you brought up, it's an enormous state. And you
could still be four or five, six hours away from your nearest
specialty clinic. And as a result, being able to plug in
telehealth would be a huge advantage.
Alex Stavros: Yeah, yeah. It's really a great, great study and
great conclusion, given the issues of accessibility and
realizing that the vast majority of teens who are struggling with
OCD, vast majority do not have geographic access to high
quality. That's right. IOP for specialized in OCD, or PHP using
the gold standard of ERP, it's the vast majority don't have
that. So knowing that there are these telehealth options, that
when done right, can provide similar outcomes.
Brad Riemann: Yeah, yeah. And to your point, I mean, even though
it's such a common problem, and it's such a treatable problem,
the vast majority of sufferers do not have that geographic
access. In obviously, you were mentioning the programs that
Embark is opening up that's welcomed, right, I mean, in
other words, the the demand exceeds the ability to provide
and these new programs are going to open up access to a lot of
young people who need care.
Alex Stavros: You mentioned how treatable disorder is can you
share a little bit more that can provide some hope for if there's
a teenager young adult watching this podcast or for a parent?
What are some of those statistics or some of your
experience around when when treatment is done? Well
standardized and with protocols and, and using ERP with
experienced clinicians? How treatable is it? Yeah,
Brad Riemann: In my opinion, Aleks, honestly, it's the most
treatable psychiatric problem we have, when treated properly and
properly being again defined as the right kind of treatment
delivered in a high quality care, and then the right
quantity that we're talking about that dosage effect, right.
And so plugging somebody into the appropriate level of care,
the majority of people with OCD can benefit from high quality
ERP just one or two hours a week. But then there's a subset
of patients who just have to have more than that, I mean,
it's just the dose isn't high enough. And so then this is
where the IOP has come into play. In some cases, even those
partial hospital programs or PHPs, provide six hours and then
of course, residential for thankfully, the minority of
patients. But again, it is a fairly large number because of
how common the problem is, but it's very, very treatable. Just
some examples. You know, the the overall kind of success rates
that one will read about in the field 80 to 85% of people who
will engage in this treatment, respond to care and get
significantly clinically meaningfully better. In my
world, you know, 90% of our IOP patients responded, 81% of our
residential patients responded. And that's interesting, because
these residential patients were considered treatment refractory,
you know, they were considered patients who were were not able
to get better from treatment. And it's all about the dose
piece, right, they just didn't have enough dose of it. And once
given that proper dosage, they got better. The reality of
though is this, you get out of it, what you put in it, and this
is not a treatment, Alex that one can benefit from, passively.
This is not something that one can absorb, but it is one that
you have to be an active participant in. And as a result,
you know, when you hear things like 85%, or 90%, or whatever it
might be, you know, there are patients who do put in effort
who don't respond, nothing's perfect. But the vast majority
of patients who don't respond are unfortunately, either
unwilling or unable to really do the work that they need to do it
is against something where, you know, it is an active engagement
in this treatment. But if people do that, they get better.
Alex Stavros: You mentioned about the doses and and levels
of care. Something that's so important to be able to provide
that as simply having a continuum of care were starting
at that lower level of care. And maybe that one or two hours a
week is able to address the issue. But if it's not, we want
to move to that three hours a day, three times a week. And if
that doesn't work three hours a day, five times a week, then
five, six hours a day, and RTC being able to step up. And
that's good, just good health care, good health care system
where we intervene at the lowest level of care, possible, least
invasive, try to get that to work. But if it doesn't, we can
quickly step up so we can nip nip it in the bud and then step
them back down, it's less expensive, less invasive, that
continuum of care is really important for delivering good
outcomes.
Brad Riemann: And as you point out, both up and down. In other
words, you know, if somebody is in a residential program, you
know, as you know, Alex, the goal is not to get them symptom
free. It the goal is to get them to the point where they're, you
know, responding to care that they don't need 24 hour support
anymore. And then if they go right back into outpatient, if
they go from that to one hours a week, that's kind of a big thud,
if you will, and, and and to your point in, in medicine, in
a, you know, general medical surgical world, you know,
there's these step downs. And that's exactly what we have to
build in our world. And, and so it's, it's being able to ratchet
it up if they need more dose, but then it's that stepping down
as well. And in the key here, to your point, Alex, is that even
if someone has tried what they believe is truly high quality
ERP, you don't want to throw the ERP baby out with the bathwater,
so to speak. You don't want to sit back and say, Well, we tried
that and it didn't work. It could be again, that the dose of
the treatment you're receiving did not match the severity and
the complexity of what you needed.
Alex Stavros: Yeah, yeah. And I love that you brought up the
kind of general health care as you don't see people going to
get knee surgery and then being sent home without a brace or any
physical therapy wouldn't go very well and they have follow
ups with their doctor but often that happens in our mental
health care system for you. There's they'll end up in a
hospital or even a residential treatment center and then
afterwards discharged, and haven't seen improvements and go
straight home. It's as if you had knee surgery, and you go
straight home with no physical therapy. That doesn't mean the
knee surgery. What wasn't effective, as long as you didn't
do the proper continuing, continuing care needed,
developing more of that. If I'm a parent, and I'm looking for a
therapist, because it may be the one to two hours, or maybe you
have been doing the one or two hours, but it's not working. And
so I want a higher dose. So I'm looking for an IOP, or the PHP,
partial hospitalization program, therapeutic day treatment
program, or even RTS C. Now I'm a parent, what should I be
looking for? What should I be Googling, what type of
treatments exist? What type of programs are there out there?
And how can you guide me a little bit into making sure that
it is high quality and that I know that we likely are going to
get the right dosage, the right interventions and treatments
that are the most effective?
Brad Riemann: Yeah, those are great questions. I mean, in
again, in the OCD realm, you know, the thing that you are
looking for is exposure and Response Prevention, or again,
sometimes referred to as exposure and ritual prevention.
It's the same treatment, ERP, nonetheless, that is the key
ingredient you're looking for. You don't want to just find
someone who says they treat OCD. You don't want to find someone
who says they use evidence based treatment, evidence based
treatment, Alex's. That is this idea that research has found
this treatment to work for this condition. But when we think
about evidence based treatment, we also have to make sure Yeah,
but that clinician can apply that evidence based treatment to
patients just as well as that study did, right. So you know, I
can, I can say I do these things. But that doesn't mean I
really know what to do. And so you got to do your homework,
most people spend more time picking out the person who's
going to tile their bathroom than they do their mental health
care provider, unfortunately, you know, right, Alex, and so
you got to do your homework, you have to do your due diligence,
and you want to make sure that they do this. You want to ask
them, how many patients with OCD have you treated? How many have
you treated successfully? You know, if they're starting to use
some of the jargon, ERP, obviously, or exposure work or
exposure hierarchies, and that's just the big master list of all
of the exposures that that this young person with OCD is going
to have to do that starting to ring some bells. But you know,
ask questions, I mean, be informed. This is important.
And, sadly, there are not that many people who specialize in
this, we did mention the international OCD foundation
before they do have a tab, find a therapist, I'm assuming
parents could reach out to Embark in Embark would also
steer people in the right direction. I mean, obviously,
you might have a program that could help them in the vicinity
that they live, or you could direct them elsewhere. But it
takes a very specific kind of intervention to be effective.
And in the end the dose to your point.
Alex Stavros: Speaking of dose, can you discuss a little bit the
role of medication and treat OCD? What? What are the
considerations? And What should parents know about medication?
OCD? Yeah,
Brad Riemann: so So there are medicines that have been found
to be helpful Alex and treating OCD. These medicines all come
from a subset of antidepressants that affect a brain chemical
called serotonin. The good news we mentioned before that, you
know, like, for example, depression is a common comorbid
condition. So if you have a youngster with OCD, who is also
depressed, these medicines kind of give you a little bit of a
double whammy or a two for one, you know, you're kind of helping
nudge that depression along as well as the OCD. These medicines
provide somewhere between 25 and 30% symptom reduction in the
average patient. Some people get much more production than that
some people unfortunately, get none. But on average, you can
expect about a 25 to 30% symptom reduction, which could be the
difference between being able to go to school or not, or being
able to go to work or not, or being able to engage in social
relationships or not. The medicines are rarely enough in
and of themselves. In ERP is really again, considered the
gold standard. So there was an expert consensus study done many
years ago that I participated in and the consensus of the expert
OCD community was that everyone with OCD should get exposure and
response prevention, some should get exposure and Response
Prevention Plus medication. Great.
Alex Stavros: Thank you. As you'd mentioned earlier, it's
the 10th leading cause of disability and there are
millions of people in United States who are affected by OCD.
So a lot more common than people know. In fact, my guess is some
people may be surprised to know that Cameron DS and Leonardo Di
Caprio and Justin Timberlake are all living with The OCD. And I
share that just to open up a question around awareness and
stigma. What would you recommend? And what advice would
you give? What steps can individuals take to raise
awareness about OCD and reduce that stigma? and advocate for
better understanding and support? Yeah,
Brad Riemann: no one, as you pointed out, I mean, there's
been many famous people over, over the centuries, and
certainly even currently, that have that an and I do think,
Alex, that that does help, especially young people, I mean,
you know, if you look up to athletes, or movie stars, or
musicians and, and, you know, it just, it does normalize things.
And I think, you know, to fight stigma, that is what you have to
have is normalization. You're not crazy, you're not weird. You
have a medical condition. Right? And, and we unfortunately,
separate out mind from body. This is a medical condition, as
I said, every year we get more and more evidence that it is
truly a neurobiological issue, a medical issue. And, you know, I
think that that's the key, I mean, it just realize that there
are many people out there with this condition, some famous,
most not but many people with this condition. And then I think
just that the hope of treatment, I mean, you know, I think, you
know, knowing that there is effective care out there, and
that there is hope. And there is help, also, you know,
dramatically reduces all that fear and stigma as well.
Alex Stavros: Love the overarching message of of hope
that particularly that evidence that this is one of the most
treatable of behavioral health conditions. What else would you
leave parents and others and the family or community or friends
who have a loved one? who's struggling with OCD? Any, any
parting thoughts, or comments you'd want to share with them?
Brad Riemann: Yeah. You know, it is common. It is very
debilitating, unfortunately. And it rarely goes away on its own
Alex again, I never say never, but it really doesn't, it's
going to take intervention medication, ERP or a combination
of the two. And if anything, it tends to continue to kind of
exacerbate over time, right. So in youth, it tends to kind of
continue to escalate, then somewhere in you know, young
adulthood, late 20s, maybe around 30. For most, it tends to
plateau off, but it's plateauing off at a pretty debilitating
level, right. And so, you know, it is common, it's debilitating,
it's not going to go away on its own. And there are resources to
help. And you're just going to have to, again, kind of roll up
your sleeves and find the right provider. The good news is, as
you know, there are more and more trained providers every
year. There are more and more intensive programs every year,
still not nearly enough. And then to your point, if you don't
have geographic access, you might be able to plug into a
good telehealth program. And the good news is insurance tends to
support these programs. You know, they insurance understands
OCD, and understands how debilitating it is and and
understands it's not just a whim or a phase that Johnny's going
through. And if anything, it's going to get worse. And so they
do support treatments and including intensive treatments.
Great.
Alex Stavros: Well, thank you, Dr. Raman. So much for your
time. We're really grateful for your clinical leadership and
clinical expertise. And we love that we're partnered together
and working together now as your partner Embark team on on
developing more comprehensive and even higher quality and more
accessible treatment interventions and programs. And
thank you again for your time today. We appreciate Thank you.
Thank you all for listening to today's podcast. It was great to
have Dr. Freeman on to talk about OCD. We appreciate you
following liking and sharing this episode. You can go to
where you can find our podcasts or our YouTube channel to follow
and we look forward to seeing you on the next one.