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Dr. Cheeley:
Welcome to NeuroFrontiers on ReachMD. I'm your host Dr. Mary Katherine Cheeley, and joining me today to talk about the upcoming 2023 Psych Congress is Dr. Craig Chepke. Dr. Chepke is the Medical Director at Excel Psychiatric Associates in Huntersville, North Carolina, and a steering committee member and scientific advisor for the Psych Congress. Dr. Chepke, welcome to the program.

Dr. Chepke:
Thanks so much for having me here. Excited to be here.

Dr. Cheeley:
So let's get started. You've been involved with Psych Congress for a long time now. What are the important disease states or education sessions that the steering committee wanted to focus on this year?

Dr. Chepke:
Well, even before the conference gets started, we're going to have a women's mental health pre-conference. So this is an optional addition to the Psych Congress agenda that attendees can opt into. This is just so incredibly important, and I'm honored to be co-chairing that pre-conference. And I'm not a reproductive psychiatrist myself, I didn't train that way. It's not my primary practice, but every single healthcare clinician sees women, and we're going to see women of reproductive potential. So we need to know information because we never get guidance on what meds are safe in pregnancy. What about breastfeeding? What about even outside of just the pregnancy and peripartum period? What about just general women's mental health?

There are important differences between the genders, and so there's going to be a fantastic pre-conference agenda. And then also there'll be sessions throughout Psych Congress about women's mental health. And then beyond that we're looking into new mechanisms of action coming into psychiatry for the first time in decades, half a century, there's a medication for schizophrenia, KarXT, that will likely be approved sometime next year that does not interact with dopamine receptors. So breaking with 70 years of every antipsychotic approved for schizophrenia being a direct binding medication, whether as an antagonist or partial agonist to the dopamine D two receptor, this one doesn't touch dopamine receptors directly at all. And in MDD, glutamate, GABA, and then other exciting new mechanisms of action focusing on the orexin system, the endogenous opioid system, there are so many new things that are coming out that are really exciting because we see the limitations in treatments every day that while the treatments do help many patients, there are so many who get left behind by their current treatments, and we desperately need new medications. And I'm hopeful that we're about to see a revolution in many different disease states.

Dr. Cheeley:
I'm getting excited for this already. That sounds really awesome, the new mechanisms. I love the focus on women's mental health. I think that it's desperately, desperately needed like you were talking about. So you're giving a couple of these presentations yourself. Can you give us a little preview about your presentation on major depressive disorder?

Dr. Chepke:
Absolutely. So I'm going to be co-presenting this one with my good friend Rakesh Jain, and it focuses on those new non-monoaminergic therapies. So anything other than serotonin, dopamine, and norepinephrine. So glutamate is a big one. We've got several glutamate-based antidepressant medications on the market now, there's one for treatment-resistant depression and major depression with suicidal ideation as the population, and then general major depressive disorder. But also, there's going to be some talk about the new zuranolone medication, which works on the GABA system as well. And I'm going to really hit the gas pedal with the orexin system and the endogenous opioid system and some exciting medications that are in the late stage pipeline that aren't quite ready for prime time, but over the next several years could become very important, and especially because it's going to usher in an era of precision psychiatry.

Right now, we just throw medications at everybody because we don't know what the neurobiology of that individual's MDD is. You can have 227 different combinations of symptoms and have the same diagnosis. Obviously, that heterogeneity leads to some suboptimal outcomes, whereas if we could match the right medications to the right patients based off of the neurobiology more than just matching side effects, and like we say, use the side effect to your advantage, that's a very crude type of precision. But we're looking at medications that are more targeted towards specific networks in the brain, specific pathways. And that's where we're really going to see some, I think, big improvements because if we can match our treatments to the underlying symptomatology, then we're going to see obviously a lot better efficacy for those populations. And so Rakesh and I are going to talk about that as well.

Dr. Cheeley:
For those just tuning in, you're listening to NeuroFrontiers on ReachMD. I'm Dr. Mary Catherine Cheeley, and I'm speaking with Dr. Craig Chepke about the upcoming 2023 Psych Congress.

Let's jump right back in. So let's turn our attention to your other session that you have with treating obesity in the psychiatric setting. Can you share with us some key highlights of that?

Dr. Chepke:
Absolutely. So this is one of my passion projects. So I've been prescribing the GLP one receptor agonists to patients for about seven years now and for the treatment of obesity. Now I'm not a boarded obesity medicine specialist, and I'm going to tell this story at the session, but really the way that I got started was a lot of psychiatrists and other psychiatric providers. I've prescribed metformin for some patients to try and prevent or treat weight gain due to psychotropic medications. And it really left me wanting more, and I felt like there had to be something better out there. And I came across the GLP one receptor agonist and began using them in my patients, and I saw incredible success even though they are injectable. At first they were daily. Now there is weekly, so this phobia that we have of injectable medications, which obviously we see a lot in the long-acting injectable space, which is one reason why they're so woefully underutilized.

And so I'm co-presenting with Dr. Jonathan Meyer. He's going to start off with the first half of the session being the more traditional antipsychotic induced weight gain and how to prevent and treat that. And then where I'm going to pick up is just obesity, period, because it doesn't have to be due to psychotropic medications. We know that people with psychiatric illnesses, especially SMI, major depressive disorder, bipolar disorder, and schizophrenia, have tremendously increased rates of obesity, type two diabetes, hypertension, obstructive sleep apnea, dyslipidemia, the list goes on and on even in the absence of medications that induce it. The medications, don't get me wrong, pour fuel on the fire, but it can happen with or without psychotropic medications.

What's the use of trying to improve someone's life psychiatrically if we're going to let them die 10 to 20 years earlier from cardiovascular disease? Because a cardiovascular disease is the number one killer of Americans. That includes Americans who are living with mental illness. And personally, I feel a responsibility to step up and treat these patients to try to save their life physically in addition to psychiatrically. And I'm going to review the currently approved medications that are on the market for the treatment of obesity and go into the pipeline because there is some unbelievably exciting things coming out in the near future, probably before the end of the year. Tirzepatide, which is not just a GLP one receptor agonist, but also a GIP receptor agonist. And then there are a couple others, survodutide, which is a GLP one receptor agonist and a glucagon agonist, and then one called retatrutide, which is a triple agonist. It hits all three GLP one, GIP, and glucagon. And the results of this on a phase two study are just literally jaw dropping. You have to see it to believe it, and if you come to the session, you'll get to see Excel present the data.

Dr. Cheeley:
Let's talk a little bit more about this multidisciplinary approach that you guys have. So tell me more. What about that kind of inner play between psychiatrists and other specialties who are treating patients with obesity?

Dr. Chepke:
Yeah, that's a great point. I'm lucky. I am married to a social worker who is also trained as an integrative health and wellness coach, and my wife Tiffany, she is fantastic with helping her clients with their health-related goals, and also with her social work background, a fantastic collaborative interdisciplinary approach. And so she has tremendous resources. She's like a Rolodex of dieticians and other resources that are available and can help connect patients with them because this is not just about, I'm taking a medication. It's about lifestyle. And that's not just important for the obesity. We've always utilized that approach in our practice for mental health and wellness that we talk about the bio-psychosocial model. And I tell patients, I think we should widen that out to four. There's biological factors, psychological factors, social factors, and then your physical health and wellness. Are you tending to your chronic illnesses if you have any, like diabetes, asthma, whatever it might be. But then also, are you eating well? Are you exercising? Are you doing the things that are going to promote your mental health, as well as your physical health?

We've got to have the physical health and wellness as part of the approach. And so that's another reason why having some ability to work with pharmacologically with obesity was a natural fit to add to my practice because I was already talking about all the non-pharmacological interventions already, and this just rounded out the puzzle for me.

Dr. Cheeley:
Before we conclude, are there any other thoughts that you'd like to give us about this upcoming year's site conference? It sounds awesome.

Dr. Chepke:
I think you keyed in on it early on is that sense of hope that you felt when I was describing what we're going to be talking about in the themes of this year's conference. And that's what I think the field really needs is hope because there are so many providers out there who are stressed out, burned out, and to me that's just a lack of hopefulness because they feel like they can't get any better outcomes for their patients. And I like to think that we're going to be able to help to maybe rekindle that spark of hope in clinicians who might've seen it dwindle or sustain it in those who still have it because we can't lose it because if we don't have hopefulness, how are we going to impart that to our patients? Because the most important thing that a healthcare provider can give to a patient is not a prescription. It is hope. And that's what we need to keep alive in ourselves as well.

Dr. Cheeley:
I am really, really excited about this. It sounds like the 2023 Psych conference is going to be so much great information, but also has a really amazing slate of presenters, so we are all looking forward to it. I want to thank my guest, Dr. Craig Chepke, for joining me today to share some key highlights about this year's meeting.

Dr. Chepke, It was so wonderful speaking with you today.

Dr. Chepke:
Likewise, I really enjoyed our conversation. Hope to come back soon.

Dr. Cheeley:
For ReachMD, I'm Dr. Mary Catherine Cheeley. To access this and other episodes in our series, visit Reachmd.com/NeuroFrontiers where you can Be Part of the Knowledge. Thanks for listening.