 
Welcome to our first session here.
Healthy living is our focus and our speaker today,
Dr. Leo Pozuelo will be speaking to us
about Mental Health and Well-being.
Before I ask Dr. Pozuelo to start,
let me just share some of his highlights from his beautiful,
illustrious career here at Cleveland Clinic.
Dr. Leo Pozuelo is a staff psychiatrist
at Cleveland Clinic since 1997 and was the section head
of Consultation Psychiatry from 2005 to 2019.
He is dual trained in internal medicine and psychiatry.
In 2005, the Cardiovascular Behavioral health clinic
was initiated here at Cleveland Clinic
in preventative cardiology and in 2008,
the arrhythmia behavioral health clinic was also formed,
addressing the psychiatric and psychological needs
of cardiac patients at Cleveland Clinic.
Dr. Pozuelo leads this clinic in collaboration
with our Heart and Vascular and Thoracic Institute.
He has served as psychiatry residency director for 10 years
and as medical school psychiatry clerkship director as well.
He is a fellow of the American College of Physicians
and a fellow of the Academy of Psychosomatic Medicine.
In 2011, he was appointed Vice Chair Clinical
of the Department of Psychiatry and Psychology
here at Cleveland Clinic.
Current duties include expanding consultation
psychiatry services through six regional hospitals,
collaborating with nursing and social work
in behavioral medicine education,
leading the enterprise on the Delirium Task Force,
supporting behavioral health integration
as a part of popular management as well.
His current multidisciplinary projects
have included depression and anxiety disorders,
as well as delirium management.
Dr. Pozuelo.
Thanks Bishoy.
I really appreciate the opportunity to be here.
Welcome, all of you, I understand it's almost 1,200 folks
that we have during this virtual encounter.
I think the best opening line I can tell you
is what a challenging time it's been and at the same time
of raising the awareness for mental health
and mental health well-being.
Certainly this pandemic has really heightened the awareness
of how important it is for our patients, for our caregivers
and it's testing without a doubt our limits
as to how we can weather this for the long run.
I'm encouraged by some of the measures
that have been done here
and that we can share with you in our conversation today.
I think the second point to really bring out is something
that's in really the culture and the DNA
of the Cleveland Clinic which is to work as a team
and it's been frankly fascinating to watch this,
to participate this into how mental health
has been integrated into the care delivery
and the physical health of the patients
that we take care of.
We do that routinely but I think it's actually
been heightened during this COVID pandemic
and I'm very proud of the work
that's been done in those areas
and we can certainly talk about that too as well.
And the third part to be frank is that
this is really unprecedented times.
By itself, it also has a fantastic opportunity for us
to learn about what we're doing, gather research about that
and really further the knowledge of what we're doing
as far as screening for mental health,
detecting it at the appropriate time and realize what are
the types of therapies interventions that really work.
And that's something that we're really excited about.
Again, piggybacking on the extreme talent
that exists here at the clinic
but I look forward to the conversation with you Bishoy
and I know we have the opportunity to also entertain
some questions from the audience.
So let's go at it.
Thank you, Dr. Pozuelo.
Let me start with one question that's important
and I assume the answer is yes.
How important is early detection
or early intervention critical and how critical is it
to assisting patients suffering from mental health diseases?
It's important.
Obviously, like any disease and mental health is a disease
like any other physical disease,
the earlier that we're able to intervene and detect it,
the better and sooner we are to offer treatments.
And that can definitely affect the outcome
of that individual, he or she.
One of the biggest issues is just training our colleagues
to screen and to ask the right questions
'cause as you are well aware of, Bishoy,
many people come to their primary care physician,
their OB-GYN with their primary mental health issues.
They don't necessarily go to the mental health specialist.
So it's very important that we train up those folks
to go ahead and ask those questions and facilitate
the conversation about how they're doing
from a mental wellness perspective.
Thank you, we see just from commercial news,
more talk about mental health.
Have you seen a shift in public awareness or in society
to help patients and their families seek early help?
Absolutely, I think that's one
of the most gratifying things that's happened.
It really predated obviously COVID.
Having that type of awareness, having those conversations.
One of the aspects that we noticed here in Cleveland
is the advocates that we've had from leaders
and local folks like Kevin Love as an advocacy for talking
about anxiety and how it affected him and normalizing it
as an event that is common in people to seek treatment.
That type of message repeated again and again is very,
very effective in destigmatizing what mental health is
and also facilitating people to get the right help.
Just a few weeks ago, reading in the news,
we heard about a study here at Cleveland Clinic
about broken heart syndrome and it wasn't
about relationships, it seemed to be something serious
in cardiovascular, especially during the COVID-19 pandemic.
Could you tell us a little bit about that study?
And how this nexus between your work in cardiology
or heart and vascular comes together?
No, thanks for asking.
So, it's really a clear example
of the physical manifestation of stress.
If you wanna think about how your body reacts to stress,
it does it by various ways.
You can have bodily sensations, you can have anxiety.
This one aspect is called takotsubo,
which is a type of stress cardiomyopathy
and these are folks that present to the emergency room.
It looks like they're having an acute cardiac event.
But then what happens when they do the catheterization,
the coronaries are fine and they actually recover.
But the level of stress typically, it's usually emotions
are harping outside, they're very high,
could be something like going through the COVID pandemic.
These types of stress externally
cause a direct impact on the heart and it looks like
it's somebody who's going through an acute heart failure
or going through acute cardiac event.
And the Cleveland Clinic has a lot of experience with that
and what they did is they looked during the months of March
and April, what was the number of cardiac patients coming in
that had this type of stress cardiomyopathy
called takotsubo and they compared it to months before
in the years before of 2019 and 2018.
And not surprising, that prevalence normally
in those other years was around maybe one or 2%.
During the critical months here of the COVID epidemic,
it was up to 8% of the patients being admitted
that were presenting with this.
So that's a very clear sign of how stress
can be affecting the body and I compliment colleagues
for putting that data together 'cause again,
it's more information or raising the awareness
that we have to take care of ourselves
from both the physical and an emotional front.
Let me shift now to our audience.
If you have any questions and you would like to text them
to us, we will share them to Dr. Pozuelo
If you can, our number is 216-345-7239.
Text those and I'll share them to Dr. Pozuelo.
Let me start with one, there's an app for everything.
Are there apps for mental health that followers
can subscribe to and how do we screen which ones are good
and which ones are tricky?
Yeah, that's a good one.
So we are definitely learning more and more on how to use
these types of devices, the wearable devices
and help regulate our sleep patterns.
You can pick up on how people are snoring.
You can see how much exercise they're doing.
And one of the things that we're learning
in the Department of Psychiatry and Psychology
is which ones really complement the work that needs
to be done with your mental health provider.
There are certainly some of them in the market that provide
mindfulness techniques on the apps on your phone.
There are other ones that interact with wearable devices,
such as these that you have and I think the message here,
instead of getting into the details
about which one is better,
as long as you use this information to complement
and to keep you motivated for your wellness techniques,
that's the name of the game.
It probably doesn't make a difference so much
as to which ones they are.
The reason we say that too, is there's a lot of developers
and there's a lot of information out there.
Part of that still has to be validated in clinical trials.
So as long as you use this to complement and to further
your goals about staying fit, having exercise time
and practicing techniques of wellness, go for it.
And you'll see I think more of that as we go further
in the care of our patients because this COVID epidemic,
frankly, has pushed us to think about delivering care
outside of our traditional methods.
Speaking of the pandemic, one of the impacts
we all have felt is social distancing and that isolation
or separation from society, I think we all feel it.
How are you seeing it from the clinical side
in your practice?
Yeah, the pandemics have been tough as far as the aspect
of social isolation and I think one of the key things
that we wanna say is that social distancing should not
equate emotional distancing or isolation.
Very important to drive that point.
If you're socially distant
and you're practicing that as hand washing
and you're using your mask and you're doing it for yourself,
and you're doing for society,
it should not equate for emotional distancing.
So it's been a challenge.
I think people that were already at the margins
and that were being more lonely
and that had less connections,
it's been very, very challenging for them.
I think there's also the unknown as to how that's going
to be developing as well on the younger generation
and the younger patients as far as the need
for social stimulation.
So it's a big lift for families, big lift for patients
to keep that connectedness but I think that's one
of the things that we learned here at the Cleveland Clinic
as far as our messaging is that we wanted people
to have social distancing but we didn't want them to have
emotional distancing and isolation
because we know the downward effects of that down the road.
Could you give us one tip or one piece of advice
on how to combat that or how to help people
who may be isolated to do one or two things
that might help them feel connected.
I don't have a with me
because I've been told not to have the phone, right?
But even picking up the phone as far as the old technology,
flip phones, by the way, are absolutely valuable.
Calling and having that connection via the voice.
I think that's one of the things that we owe it to ourselves
to reach out to the ones that may be more vulnerable.
But at the same time, if you can encourage
that connectedness, that's gonna be important.
The other part to be very frank, Bishoy
is we learned this in the hospital, as you know
and many of the loved ones that are listening today,
COVID required to limit the visiting
in the hospitals, right?
And talk about being socially isolated in that environment
and it was really key that our nurses,
our frontline caregivers really communicate
and make that outreach via the phone with the family
and having that lifeline.
So there's a very clear example of how that was maintained
in the midst of one of the most trying times for patients
when they're sitting there, not sure what's gonna happen
with their health by themselves in the hospital.
And that, if you wanna call it,
it's almost that human touch.
I mean, even though we had the gowns
and even though we have the face shields,
and even though you're isolative, you still needed
to be connected and I think that's the key thing to share
with your viewers today and your listeners
is that we gotta maintain that with our loved ones,
for ourselves and for the people that we care about.
Almost linked to that, tell us about your work
with the post ICU unit that you've really dedicated
to the mental health of our COVID patients.
Yeah, so this is again, a credit to the multidisciplinary
and this is the DNA of the Cleveland Clinic.
So our colleagues in the respiratory institute
approximately a year ago built this clinic for patients
that were coming out of the ICU,
that had a prolonged stay in the intensive care unit.
What they're finding is that patients that have been
in the ICU have been sick with sepsis, infections
requiring mechanical ventilation,
a machine to breathe for them.
Yet, they come out of a hospital experience
with physical, with cognitive and they also come out
with psychiatric sequela or impacts.
And so what they decided is that instead of having
that individual, two to four weeks of coming out
of the hospital, just follow up
with their primary care physician, they devised this clinic
where they would get expertise from the respiratory folks,
the pulmonary folks, they would get physical therapy
and they would also be seen by the psychiatry services
to screen for any type of emotional
or cognitive disturbance.
And not surprisingly, now with the COVID patients coming in,
the patients, unfortunately, are spending a long time
on the mechanical ventilation,
having the machine breathe for them.
And they're at a higher risk of what we call delirium,
which is an acute brain dysfunction
where you're disoriented, you can't process things.
And so what we're seeing is that there is a component,
even weeks down the road of people who've experienced
that type of delirium in these types of medical settings,
really a lot of anxiety, a lot of angst,
some memory slippage and that we're screening
to be very frank for PTSD.
People think that PTSD is typically something that happens
with horrible things, such as wars or famines
but it can also happen for medical events.
And it's very important to screen for that
because if you don't screen for it or treat it,
that patient, he or she may not wanna come back
to the hospital because the hospital reminds them
of what had occurred.
And so, I really applaud our colleagues to invite psychiatry
and mental health services to be there with these patients
so that we can heal them in a very comprehensive fashion.
Thank you, we talked about how society has shifted
and stigmas might be changing and there's more awareness
and comfort with speaking about mental health.
What do you recommend to someone who is a bit anxious
about taking that first step?
How do you get them to take that first step
and how can families help?
Yeah, one of the key things for me personally,
as you mentioned, I trained as an internal medicine doctor
and then I did psychiatry is have that initial conversation
with your primary care physician or with your family doc.
I think times have changed.
I think our primary care colleagues are actually much better
at picking up the signs and symptoms of mental stress
and to have that conversation.
So I would say to the individual and even the family member,
don't think you have to go see a mental health professional
right away, you can talk to your primary care physician,
you can talk to your doctor that you trust, he or she
and have that conversation, I think that's the first thing.
The second thing is, I hope by the examples
that we shared today about what happened
with takotsubo stress.
What we know from living with cardiac disease,
what we know about living with diabetes is that if you don't
look at the mental aspect of living with those diseases,
you don't get the best results, right?
So depression and anxiety, besides causing a lot
of discomfort to you as an individual and to your loved ones
around 'cause it robs you of experiences,
we know that it's also toxic.
It's bad for your heart, it's bad for your diabetes.
And so if you really want to look at the big picture
and to be tackling it from all fronts, it's very important
that we ask, we screen and we validate how people are doing
emotionally as they live with their medical issues.
Thank you, I think that's important
and helpful to all of us.
Looking at your CV and when I was introducing you,
you are a multidisciplinary professional
and your program is multidisciplinary.
What about the Cleveland Clinic's approach
to integrating psychiatry or mental health
is unique in a healthcare institution?
I've been here 25 years.
The gray hairs are a testament to it a little bit
but it's been a fantastic opportunity.
And I'll share with you when I started here early.
I had an interest in cardiac patients
and I asked my chairman at the time, what could I do
to see cardiac patients 'cause I was in psychiatry?
And he literally picked up the phone,
called the chairman of Cardiology at the time.
I walked over and I was a young punk back then
and I sat in front of the chair of cardiology.
I explained what I was interested in
and the next day he said, "Good, go over there.
"You're having a clinic every Tuesday afternoon."
I was welcomed by the people over there
and what we did is we actually had a co-located clinic.
I would see patients in the cardiac rehab area.
And that's what we do very well,
I think in the clinic across multiple disciplines
is that we integrate them.
You don't have to go to another building
to see the specialist or you don't have to go
to another center.
That specialist will be there for you and try to incorporate
it and do it in a very interdisciplinary fashion.
And to be frank, I think when our patients see that,
I think it really starts to validate like we have a presence
in psychiatry and epilepsy and multiple sclerosis,
and obviously in oncology and cardiology, in transplant.
They start to see that mental health is part
of the normal equation of how we treat patients
and how we make sure that they stay well.
And so I think that sends a very possible message
and to be very frank with a lot of support
from the viewers today, it's been extremely
professionally satisfying and hopefully we continue
to do good work for our patients in that regard.
So, our audience are grateful patients
who have been supportive
of the institution philanthropically.
I work in the philanthropy institute.
Professionally, it's rewarding to know
from our physicians and leaders,
how philanthropy makes an impact in their work.
Could you tell us a little bit about some of your work
that you're doing that you couldn't do
but for philanthropic supportive of our viewers?
Yeah.
No, thank you for the opportunity.
I can give you a couple examples at the macro level.
Obviously, there's been, in our department led by Dr. Malone
and the vice chair of research, Dr. Amit Anand,
there has has been fantastic seed money that's been given
and bestowed to the department which has allowed
the department to then apply for NIH trials
that are looking at cutting-edge treatment
for depression and resistant depression.
They include things such as ketamine and ECT,
electroconvulsive therapy and looking at
what are their best protocols
and that doesn't happen by itself.
That happens by starting off and by generating data,
which then allows talented researchers and clinicians
to apply for grants and they've done a fantastic job
and a great, great debt of gratitude to all of you
in supporting those missions.
We're also involved now in another one,
which is looking at how we detect this delirium
that we made reference to, Bishoy,
which is this acute brain failure.
I think all of us have had a loved one
that's been in the hospital that's been confused,
quite not there yet and why does that happen?
Or why does that happen to that individual?
And boy, if we could detect that earlier,
could we make an impact on them?
And so one of the things that we're looking at
is to get systems with trying to get a calculator
to predict who's going to get delirium?
What's the likelihood of that person
coming into the hospital based on a lot of variables,
previous experience, age, complexity?
And can we predict who's going to get delirium
with good likelihood and then intervene?
And that's very important because we know that
the longer that patients have delirium,
there's a higher likelihood of them
to having cognitive effects down the road.
And that's the story as when we do education,
from our nursing staff.
I remember I was at Fairview Hospital
and we gave a talk on delirium and the nurse came up
and spoke and said, "Thank you very much, Dr. Leo
"for talking about that 'cause that's exactly
"what happened to my dad.
"My dad had surgery over here.
"He did okay but it took him a long time
"to be not quite right and he was not quite right
"and it took a long time for him to recover."
And that was the effects of that delirium.
And so I think that just brings it into a personal focus
and challenges us to do more and to really look out
for the whole picture of our patients.
Thank you, as a member of our staff here
in the philanthropy institute, we're always looking to find
projects that have been approved but need funding.
Do you have something in your institute, in your work
that you feel you would love to have supported
in order to achieve some impact?
I think there's various areas
that are going on in our department.
Part of that is looking at the app development,
for engaging patients through their care.
This COVID has taught us that we're using virtual medicine
to do our encounters with patients
and it's important to keep them engaged.
And part of that is to be frank, some of those apps
and some of those wearable devices that can tell us
how active they are and can they enter data
that can keep us posted as how they're doing.
There's a need for frankly,
to look at how we better integrate some of our services
for the people at risk and we're talking
about the presence of mental health in the schools.
That we have a pilot program in our department
that's led with Molly Wimbiscus,
one of our child psychiatrists and looking at how
they can screen and how they can evaluate better
the difficulties that children have in the critical years.
And having these clinics on site, which frankly right now
are gonna be virtual, gathering the data,
what are the best interventions to complement
what's going on in the schools
and that's really looking at a preventive strategy.
And the other aspect is that this COVID pandemic
has raised the light, the plague of homelessness
and so there was some philanthropy support already
for looking at the prevalence of homelessness
in our electronic medical record.
How to set up a system to track that?
It's quite daunting when you have a person coming in
and you assume that they have a place to go but they don't
and unfortunately, this pandemic is going to really stretch
the socio, economic fabric of our country.
And so we have to be prepared to identify
and to put resources to help that factor of their lives
to make sure that they can go ahead and succeed
in getting their medical treatment.
And so having those types of systems in place in our record
and being proactive with outreach programs
and developing and partnering with our communities
is also an important part of really emotional wellness,
here in Cleveland to be frank and across the nation.
Thank you, we have a question from our audience.
In our introduction, we talked about some of your work
in population health, can you tell us a little bit about
that focus and how it's making an impact in our community?
Yeah, the Cleveland Clinic is a specialty hospital
and the Cleveland Clinic is also a primary care
and we have a big department
called the Cleveland Clinic Community Care.
And one of the things that we did was we looked at,
with partnership with our medicine
and family practice colleagues, literally putting
in behavioral health social workers in the practices
of medicine over there.
And the reason was a little bit what we talked about today
Bishoy, just normalizing what is behavioral health.
And so having these behavioral health social workers
in these 10 practices, which was a pilot
all through Northeast Ohio has been a godsend
because it's allowed the primary care physician
to have somebody there with a warm handoff
that could be able to talk to the patient
when they're in crisis.
And I'll never forget
one of my internal medicine colleagues when this started,
he really had this new patient, this new evaluation came in.
And about 80% of what this patient was going through
was social strife, all the stressors
that were happening in their life.
They came in with some aches and pains
but that was the crux of it.
And having these types of resources right there
in an interdisciplinary fashion has been really
cutting edge for us and we're really looking to expand that
as we go forward with the care of our patients
across the community and in other states too as well.
Thank you, let me end with maybe one final question
that donors might like to know about
is the downstream impact of their philanthropy,
especially on how researchers and leads on projects
can apply for and in many cases,
when they know what they're doing and this happens a lot
here at Cleveland Clinic receive additional grants,
for example from the NIH.
Yeah, exactly.
Now and this is something that I really am very grateful
and I speak for my Chairman, Dr. Malone
and the vice chair of research, Dr. Anand
and other of my gifted colleagues, that type of seed money
for pilots, for proof of concept, for example,
developing a delirium calculator, looking at an app
that can tell how people are cognitively doing,
that gives you the data and gives you the starting point
to then apply for other grants that would help you,
it will work with other hospitals and then to get grants
of such caliber as the National Institutes of Health.
This is clearly very important for any department
because it allows the talented people that you bring
on board to thrive and ask the next generation of questions.
And the more we learn from data and research,
the better we can take care of our patients.
And what's nice is that that type of information
then goes back to the care that we give here
at the Cleveland Clinic.
So, a debt of gratitude for all the interest and support
that many of your viewers have been
and continue to give for these endeavors.
Thank you, Dr. Pozuelo.
I personally found this very enlightening and informative.
I trust our audience did as well.
It's such an important topic in a difficult time.
I appreciate your expertise and your time with us.
I don't know if you had any closing remarks
or just a nice message to send our viewers off
to the next sessions.
Yeah, listen, thank you very much for what you do.
Stay well, stay safe and smile
and use that sense of humor wherever you can.
This is gonna be a marathon, not a sprint.
So, we need everybody on board for the journey.
Take care, everybody. Thank you, Dr. Pozuelo.
And now on with the rest
of your Cleveland Clinic Experience.
We have two more healthy living and working sessions
coming up at a few minutes, starting at noon Eastern Time.
Each is structured similar to this question
and answer session that we've participated in.
You'll be with other hosts though.
To choose to participate in one of those sessions,
please go back to the event landing page
at clevelandclinic.org/ccexperience
and click on the link for health living and working
to select the session of your interest.
And because it's hard to choose from these great topics,
and especially our great guests,
remember that all these sessions are being recorded.
So that in the coming days you'll be able to watch them
for the first time if you missed one
or watch them again if you missed us so much.
Thank you again for your time and your patience
and attendance and enjoy the rest
of your Cleveland Clinic Experience, thank you.
