Apr 3, 2014|
Automatically Generated Transcript (may not be 100% accurate)
News radio 930 -- dvd -- I wore us down -- the -- with great. But yeah if you go to the -- looked up moderately anxious and my brother. -- usually a good week. And they will have the decency to -- -- -- this into. We've reached and now Christmas. Time now we're laying out. News radio 930 cooler -- cool -- -- -- cool whip Cooper Gary. WB ES. Talking today about medical. Elvis and all the families of Western New York could have been touched by at about a zillion shows about mental illness going back to the 1980s. And the shooting yesterday at Fort Hood -- once again we have a situation where somebody who was. Apparently mentally ill and prescribes specific medications. Decided to be a danger not only to himself but also to others. And I wanna get an update from somebody who is an expert because this is something. We -- she deals every day. Mental illness and has a background in it. Her name is doctor Maria Cartagena she is the chief medical officer at brylin. Doctor thanks very much for being with us glad you could take the time. Doctor are you there. We're gonna have to get a better phone connection guys I don't know why we have to go to this John we got to get a better phone connection argue about speakerphone. -- would every do now is not as important as talking with -- doctor and getting a phone connection Erica. We got to get a better phone connection -- make sure she's off speaker off Bluetooth so -- can do it and it sounds good. As we move along the -- phone number is 8030930. Start like thirty and 180616. WB yet but if you're calling into the show. I would rather not take calls let's let's -- the Bluetooth in speakerphone so much. I would rather talk to myself. Then take calls from people on Bluetooth or cellphones with speakerphones because of the sound quality is being bet that. Aren't were I have to take a break we'll get back and WB. Are -- -- we've addressed the ought. Audio issue because about to have somebody the talk about something this serious I think we all need to be able to hear what you have to say doctor Maria Cartagena is with -- -- news radio 930. WB and doctor thank you very much up again for your time. Is it. My imagination. Or is serious mental illness on the rise in the United States. Well I don't know I think that this tape we have the numbers that substantiate that it on the right but we actually doing a better job of identifying it as healthcare professionals we do. We we are able to recognize that a -- your colleagues they're recognizing it more and more and obviously. You know people in the community are able to recognize. What did that to our but some of the symptoms aren't that -- I was a little boy in the late sixties early seventies when this process of has set strategy been a failure. Well I would say that it's. It's not and that's -- that's -- nineteen act that we elect injected that emergency -- Jails in addition -- And in people who really just aren't doing it why are they should be with that strategy. On but I understand that the health visit in a healthy -- why didn't continuum from high functioning individual with a peppers and anxiety insomnia. And from depression is more the chronic illnesses such as schizophrenia. It's -- affective disorder. And that sometimes those individuals you know do not it was well when that they are mean should go when they aren't much supported -- I am and they should be. Doctor tried to explain this to people in a lot of people just don't understand. Com bad one of the problems you guys in every other mental health professional is faced -- Is defective people when -- released or given a script the doctor is adamant you must take this medication every single day. Then after week two weeks maybe after year the person says the patient says boy I feel great I guess second stop taking this lithium now and then they get right back to what got them to the hospital and into the system. In the first place why is it's so difficult. Out of all the illnesses out there to make sure that mentally ill people who can't be mainstreamed who can't have productive lives. Why it is so difficult to keep -- on the -- Well actually it -- they act that complaint is actually not an issue just for the mental illness -- that the met mile if you look at patients recover from schizophrenia. They'll quote you -- on average yet that the average complaint is about it deeper and it -- -- and although -- are taking Mac and the people that are not immediately after discharge. But if you look at actually even -- and some studies that situation and hopefully there'll medication. That debt not -- and trickled but the -- I heard. And in the general population it's estimated that gap percentages -- -- that complaint did not -- the issue of -- -- -- suffer from the -- opponent. So it's it's no. It's it gets across so noncompliance. Is a a larger issue across the broader. Spectrum of health in general. The human condition. It is you know is an issue not complaint that this is -- the -- back -- -- certain individuals they do. I take their medications on -- regular -- But if you I do not take a Claritin for you know seven days you know we get a runny nose -- Ichi and red and puffy eyes. But what patients who suffer from psychotic disorders. He can be a lot more devastating to meant just two to three doses of medication. I wanna. Well I wanna get back to what I said about being a little boy in -- in the late sixties and seventies and I don't have the metrics and I don't have the statistics and I think because of the changing definitions of certain mental conditions we may never have those. But I must tell you that as a grown up. Even what they wide that circle of friends from a number of different disciplines and backgrounds. I doctor Cartagena and hard pressed to think of a family that has not been touched personally and severely. By a member with mental illness in my overstating. Million CD and it -- and definitely between I -- -- such as major depression and bipolar disorder up at the compulsive disorder. Well you know you're really getting to. A huge percentage he the American population. So at some point somebody whether and -- personally or somebody in in Italy is gently touched on. Google worker somebody you know I by. And back that electric and an apology. For accurately as treatment. And we have you know we have different types of treatment available and different treatment facilities. And -- growing in the community. Well I wanna get into the very much but the issue of vaccines I have to ask you this question because it comes up every single time I do a show on mental illness there are people who believe. That despite the benefits of common vaccines. That there's a percentage of our population. For whom. The vaccine that medium. Is gonna trigger some kind of mental illness or psychiatric side effect if not immediately down the line is there any scientific. Basis to support vaccines. As an ideology. The mind I'd have IE I -- -- -- with any data in live pictures that the Jack. That vaccination. -- -- Psychiatric illness now we do you know act. Mental illness can be -- have. And genetic and incurable. Traits. So when we look it at least it's it's being done. -- -- -- -- -- -- We do know that they are there is -- some irritability associated with it but. It certain illnesses at apple story they can't -- it can be genetic vulnerability -- inherited. But -- media play -- invited mental. Impact on the development of the full blown. Psychiatric illness and whether they exceed payroll and that we do not have the leader right now I am aware -- to support that. Well it's always controversial when you mentioned things like cancer clusters or MS Clijsters is there any evidence to suggest that there we have a mental illness cluster in some parts of the United States. Well I did there is there is a four he agnostic -- obsessive compulsive disorder. He eat -- with some. Documents did literature suggests that it out. One of the if it's heating. Actors although CD can be in some cases the vote CD can be a big picture the popcorn action packed with that if they I. -- -- I I -- an infection but it's not the only -- or weight at which people can develop that illness. No I view I think we all do it could be in the community that they can't be multiple realities. Leading to sort of a game. I actually. Political picture. But they states that I don't I don't -- it ended the day when we do -- -- without completely it's going to be just one factor the thing we don't believe that it's. It's a variety of factors that. So multi effect -- unlike anything else we can never forget the influence in the importance of by genetics is a component. We're talking with doctor Maria Cartagena -- brylin and I have to tell you folks everybody have ever met associated with brylin does an amazing. Job and I think the world of brightly and as a place for people to go. To get better can you define doctor Cartagena mental illness. Well essentially mental illness is the range of disorders like he actually wake up brain disorders. Where's your chemistry of the brain. -- back itself in a variety of different. -- changes and that the apple logic states and by that I mean that I -- state can be altered. Picket the bipolar disorder when you have to -- -- but. Policy is that euphoria. -- peak energy. Ages that last about a week or longer. And then. Substituted they -- it's -- to Cherie is very low energy depressed. Eight in ways that no ambition. Change is that your -- it's eight and sometimes even scary thought of it was cited with that it and they are American chemical. Issues that can result in hallucination or are people -- being lost touch with the reality such is in the primary that -- disorders like the spreading out. It's -- that this disorder. They are the illnesses debt because of a chemical certain economical situations in the brain. Opposite result could be people being out overly anxious or in -- compulsive and repetitive behaviors. The spectrum is very light mental illness. And again it reaches. You know the entire population regardless of the state economic -- with our look at education. There is the prevalence of mental illness. And in began. You know it's it's a matter of identification. Appropriate that patient and diagnosis. Treatment and adherence to actually and greens. We are talking with doctor Maria Cartagena was the chief medical officer act -- Lynne and I hope we're gonna be able to take some telephone calls for her I'd I'd have so many questions about this and I think people are gonna want answered. SS RIs. First of all what are today. And a walk and given the fact that they seem to be connected to so many mass casualty events. Are we still able to say that the benefits of SS RIs outweigh the risks. Absolutely they are which are afraid Sparta selective serotonin re uptake inhibitors there. Intake -- -- and that are all being used to treating I 88 as well being flake out prozac Zoloft -- both black elect the prowl. These agents actually wore. That you would sort of outweighed. -- medication. Right after the development in the tried cyclic and had a -- He. Development idea that our -- was an enormous trepidation. In the field of a tight chip particularly the -- height -- -- individual set up for a depression. In bad idea would be quite the medications or better tolerated. They wouldn't act is dangerous in overdose as the and at the previous. Class of medication and they were quite tolerable. And we'll get a weapon or try to get adjusted and monitored on by a appropriate action. Dull even in you know absolutely -- if you if you take a survey of people who have been treated exactly the -- that are right. These medications can be life altering in terms of normalizing and being able to control and them. That. You know in after you would've been completely disabling. On and possibly would have resulted in catastrophic things like -- the marriage -- that job turn toward substance. Alcoholism. The agent can be out. And now all but not 18 and it's right for everybody and also sometimes medication I felt if not we should be enough. To really. Be able to -- keen ability if there are -- Other Mal adapted behaviors that is if there's overwhelming tractors. On if they are crying about substance abuse issues. They can restore the balance. A level that they're toning certain parts of the brain. But they they can't you know -- and so often times we do. Put forth a plane for patience -- in -- involve medication management manage my degree or medication on debate. They are the like. It therapist. And sometimes even faintly. Namely there appear to be in the meetings that we look at the entire dynamic of what maybe worked. How well they they're when somebody has a severely mentally ill person and their family there circle of friends it affects everybody -- that affects every decision it affects air so many aspects of people's lives. I have a theory. And I want to bounce it off do you wanna take some phone calls -- very intelligent people to call them. And I and I hope you're able to join us more than just until 530 but I also respect your time. I believe number one bad mental illness is America's number one. Public health crisis by far. More so than aids heart disease lupus. Or anything I can think of I believe mental illness is the number one problem. I believe that mental illnesses and number one problem that result in incarceration. And homicide and violence agree or disagree. I think I would agree -- you. But I can't under where it affected heart disease is actually pleaded that the beat the number one killer in -- state but what you're afraid that. In terms of it -- disability. That is. But my. Heart attack isn't gonna kill anybody else. That's correct. Unless you have a behind a drag car something but. But you're right you that you bring up an important point 888 Aetna the health untreated. Psychiatric illness more under treated psychiatric illness getting can really -- to spiral. Other the injured behaviors -- out sequences that we don't always appreciate when we look at the epidemiology -- -- psychiatric field. We're talking with the medical director of brylin doctor Maria Cartagena a news radio 930 WBE. And once again and what I hate to bring politics and things all the time of but I can't help the new York state budget. Is reducing the number of patient beds and facilities for mentally ill people. Why don't we get this in our society in 2014. That offering fewer resources for those who worry and genuine and desperate need it is not a good idea. Well I think it's the it's really the expert institutional or they can just like we're pushing. To go from inpatient. Delivery of health care. -- inpatient settings to outpatient at. I think we're trying to Allen back yet -- And. But that paradigm does not work with mental illness. Well out anyway it doesn't work it doesn't work which shut down -- that you don't open up or I'm being outpatient facilities for patients to receive treatment and support at. I mean that's just the numbers. You know issue and it doesn't take that. We need to consolidate those number. That -- still don't have appropriate Al outpatient support of the residential treatment facility. Supported -- seen. And India outpatient services tech and service though. The patient and not just you know provide. -- once the week or a one month appointment with Ethier hit -- -- like -- check. The if they are the individuals that really do -- -- A lot more than that more support eighty daily treatment they need 78 the week of moderate rain and being needs support waived that compliance with their medication. And if we don't have that we don't build that we don't provide. And we don't develop those types of facilities. And those type of support bar. Our patience it's you know it's just except -- -- -- we wind up sending. Op patient Don we're lack of bad in the community in and then they bounced back and we have this rapidly ignition. Situation where they note that front -- that at its facilities becomes the revolving door in -- and that QB it's set up for really. Not such experience -- and why did he have to get -- rock bottom before they are actually treated. That really the criteria now for being able to -- medication. -- your break you're preaching to the choir here because these have been issues are brought up repeatedly on the shell and unfortunately nothing ever seems to change doctor I'm going to we eagle and cajole you into giving up more of your time to us because they know just working you know six to five is an along an update for your cell. I've got people with -- intelligent questions I promise you intelligent questions for my audience after the news break and we'll continue with doctor Maria Cartagena from brylin. Well let's get back to our guests doctor. And excuse me doctor Rick Cartagena is weather -- be -- chief medical officer at brylin. And before I get the phone calls out in I notice is gonna come up especially for those who work listening earlier. Doctor there is. A web site. Basically devoted to SS RI horror stories. And talking about all of the violent. Acts people have committed. While on SS RIs. Now I know that you say that lives have been positively changed by them. But when you read stories like the SS RI stories that are on line. Does that do any thing to make you reassess. No actually sent it doesn't understand is the pharmaceutical billion dollar industry and I'm sure that there is. There are people out there that are putting up experiences that they have had. But I'm not sure that we can count all of built or story that -- -- -- more than half that one. I'd be back gently I think definitely. You know it Ali that that -- Are you know that individual has into work. Adverse reactions and and he had -- sentimentality. Or had had behavior that it uncharacteristic. When they are being treated with medication to meet get it it's really. -- it doesn't really point to. A failure the medication as much as it is. You know a whole treatment. Plant where if you're having an especially if you're the only member yelled get individuals Mac acting appropriately. Particularly when medications are started and -- being need to bring that individual -- for help needed to the treatment provided that. -- -- -- -- more or twelve or America facility which has hospital. Or Americans. I have one more quick question for you again I ask this because I think this is a very common question and wanna get it out of the -- People with whom I've spoken who have been through the system. What they will tell me about psychiatrists. News. It is like what you saw on The Sopranos there's very little hawking and there's a lot more accurate your prescription here -- -- prescription here's your prescription. But that if you want to talk therapy you really need to see a social worker or preferably a doctor of psychology. When did psychiatrists. Stop. In involving guns as selves get as much in talked therapy and more in pharmaceutical author. Well I think -- you know it's okay. It it symmetric it's absolutely. That -- that maybe are on medical doctors were physicians that are trained in -- narrow. I like chicken that he actually attack halfback. Behavior of not pathology of the brain. We spoke with them in Europe chemical stack -- behavior and mood. And dole and there has been an explosion in our knowledge of the miracle chemicals and how. Medication. Back certain receptors in the brain. That I -- have been relegated to bat at that eight -- particular -- and make decisions based on what particular. Diagnoses. Warrant treatment with her medication. And it's not definitely an exact science there's it's beat them. An experience that are associated -- it. But we we actually don't try to prescribing it back to me it's important -- -- get to know our patience he rarely do we see patients. -- without trying to get a sense or are there any issues that warrant further discussion. I'm because he needs have the facts about what may be happening to stop what you're personally and wait to really back are they more depressed by the lack deprived are they making rational decision. One of the problems if you'll forgive my interruption one of the problems I know you're faced with every day at your institution and other psychiatric institutions. Psychiatric patients tend to be among the very best actors in the entire universe and they will have you believing that they are 100%. Cured in normal. They will try to get you to believe that because they want out. Well at the Little -- but they need to act -- yet he can't be and and tactic that much of an actor is really don't have. The ability to -- formulate sentence structure to get to a paragraph four. The B Hayes you know in the manner why 120 ports that -- deprivation the average individual. That try to hold together that they can't because psychotic symptoms remote said that it. Usually can do it for twenty minutes and so generally get a rough -- But if we have patient at a hospital that you know we are -- and that was. We expect may not be being a 100% truthful we try to -- that in them more closely amended. Ways in which could teach -- with a perfect thank -- certainly if you want to let you can elect but it -- today. You know the patient's point of pulling out. On the other -- to get back on to get back to. The the medication issue in just give you script. Is that we do actually partner and utilized treatment -- approach with the that I can doesn't. You know prescribing medication we -- China working on their with a therapist and then you know there is dialogue generally. Between the therapist and at that tight chipped in the ideal situation. About how he progressed thing and in -- approach with eight and our. Complaint with both the medication management with a -- should end up there it is really what the app app itself and the data -- -- do act support that. So -- -- multi disciplinary. So that each specialist pays. It is basically able to utilize his or her time to the maximum benefit to the most patients. Are -- Well let's let's get some calls on this best I could talk with you all my long about this kind of -- because this has been a major issue of mine since the 1980s I'm sure the name doctor -- Shuster. I mean something to you. She opened my eyes many years ago with the -- alliance for the mentally ill to what a huge problem. Mental illness is in western new York and around the country and I wanna go to work Tammy Williams -- first of all -- welcome to the show -- on with doctor Maria Cartagena from -- I am -- -- -- questions. When my mother has an epic iron and it was like yours or your outfit out. Well for all of my life. We didn't know -- they really -- And member. That really. Don't support. Whatever treatment there is that you know she can't get -- With these laws. Person or more before hit -- averaging around -- actually did have their own confidentiality. But it's 388 we we where we try to respect people's privacy particularly -- that it would. Are coming off into the information that we felt was extremely privileged however. -- and hit but they're allowed in cases of emergency. Or we feel like the patient. Or people around -- are imminent danger we are able to apple -- BP hit spot and confidentiality. Laws we do it act has not only a duty to warn. We feel like anybody in danger. At is involved with the patient but the beauty -- -- is well. So I you know definitely -- and institutions can take this. You know and that the they see allowed it to be a barrier to communication treatment and it shouldn't be all we know it can get all -- galactic high each wrist. If they do not have a release that information to speak -- family. And if he is not an imminent danger although they may not be able to give you information about what treatment plant involved with the patient. They can always beat the information and -- contact and you can. Beat them on one -- -- you know one sided action or you can sent a letter detailing. Which -- concerned our might -- would be it's something theory you know significant -- would put it right because that's become a part of medical record. And it more difficult with -- if it's written. It's in red and and and in need is evaluated and it's -- gently with the treatment team. To doctor forget forgive my interruption but I wanna make sure that we we understood Tammy correctly Tammy here's what I'm getting out of out of your question. You love your mom you wanna play a role in your mom's treatment and improvement but hip has stood in the way in your mom is about is as tight as a clam -- telling you what's going on in my correct. And I think. Where and whenever news in the situation where she is. You know Eden. A place such sprightly and most recently -- at all. You get -- information that. Sister were able to every in it and read it. Like the cat for her in the last time. And fortunately. It aren't you mentioned treatment for him I don't see -- -- -- Very opt. After that radical stabilization is hurt and -- -- yet. You know bet in compliance. Or. That -- addict and it puts people at all. Well underway. We didn't talk about that earlier Tammy I thank you for the call and a doctor can you just to mention again the idea of noncompliance. And with these medications which are vital for somebody's. Sure I think definitely has that athletic -- -- -- world -- -- program and the world if you can't eat. You think at ethnic he's on board repeat it it'd be very difficult. It -- -- each -- be -- like about. Thankfully did there is a new area pharmaceuticals which -- -- long acting injectable medication that can be checked it in -- hop but -- and then once a month thereafter. Leon the patient doesn't really need to play it that much if any. Medication by -- and that actually improved compliance -- patient and but you know getting back is to -- -- concerned about her mom. You know he read generally Riley will -- -- -- gaming meetings particularly in frankly ill patient. Sometimes the -- information comes across to the treatment he reports it's -- tight and an outpatient based says. On that eat that the -- -- have information. That that I can can state of the patient it's very important and I am requesting that you allow obviously to come and it really depends on how. How much does he it will dig their -- and about deputy general. When the height -- the treatment team. Will convey and the concern and a desire to speak with the played on many patients. He -- we act so it's not a perfect system and I can certainly appreciate her for -- -- -- I think the most important part of what you said the Tammy is gonna be valuable for other people as well is if you and other family members have concern about a mentally ill person in a facility put those concerns in writing put it in writing. Because that's real hard to ignore. Let me can I go -- are delighted to break -- I need to break. All right I'm gonna break we've got a call coming in about PT SD and also another call about Mets and we're gonna get him -- before sex with doctor Maria Cartagena from brylin. After a long day she's still willing to join us for an hour talking to me for an hour would be enough to drive anybody to. Wanna drink at least on WB. It is -- cowardly and -- generously doctor Maria Cartagena and brightly and she's going to be here with us until six and I've asked a lot of questions. I still have more questions but a lot of you've been on hold with intelligent. Questions and I love intelligent questions even when I don't have the let's go to rise in the pew with doctor Cartagena on WB Ian Ryan welcome to the show thank you for holding and what would you like to know from the expert. They don't expect Michael. I wanted to -- How you feel about you or prescribing a medication then at their full understanding. How these medications. Are supposed to work I'm calling it somebody who's been on any number of medications over the years. And over the years on depression has worsened. And there's been quite all of being committed. And also suicide. Ryan I don't what should hang up do not hang up but you've asked a lot right there and let's get the answer to that first and then we'll proceed from there that's okay with you doctor. I do agree that some patient hand away and got being I'm Al are too many medications that call up -- -- -- And again I have to really. Support. The importance of being treated by a qualified individual pool can and do. A combined medication in an appropriate way and it. Active way without causing a worst opening up and and that without causing -- over Medicaid state the proverbial downbeat if people don't want to be content. And dull aching when patients starts to deteriorate that they use of medications. We have to really app at certain points and reevaluate do we have the right diagnosis. If there's something organic or from being if you -- -- that -- what's happening in the sprinkling I'm. Do we have to have more medical acting and that's what what is preventing hugging me and sent it. On and what is the next that in terms of helping to improve the patients at that strategy isn't working yet have to change. And Ryan is it possible and here's what I'd like to know right you sound like a younger man am I correct. When did your symptoms first present when you were a teenager. When I was about thirteen fourteen years old. OK excellent because that's going to be great follow up question doctor isn't it true. That the younger someone presents with symptoms the more difficult it is defined the mad that will be right for them. And over time at the mad and the dose of med is quite likely to change as one's body chemistry changes with maturity. Well certainly I think we have it we have except if that debt. You know at thirteen the ideology is normal but not quite as that of an adult and medication can get her medication can be processed differently. I'm -- -- -- at -- state team you know we we we can't see actually a carton of anxiety. In in the younger. Younger patients. -- depression and it developed appropriately Iran instill a lot of -- that -- event and they say that I treat symptoms probably back and you know when I went -- you know a child. All we usually is the red flag but not always wrecked by far and I eighty and I think that definitely. There is. You know treatment important and being. It -- there's no question that when you're able to. -- stabilize the symptoms of anxiety on a young individual. Can really help to her -- up steam. He can't help to prevent. The that this constant negative thinking that later on life can result additional strapped to America chemicals. Ryan are we are -- cool. Did you feel good with that answer or did you one more question wanted to give him. Like this one -- course an arm. I won't say it over the years have been on any number of different medications. And it did lead to more or less a problem of increased depression and like that suicidal tendencies. And I feel like going through all the different doctors and psychiatric -- through over the years that there is there any problem. Not wanted to talk to me but just -- scripts. And different medication to over the years and I want it far it almost like just walking a doctor's office that. They just want to and you keep the papers say take this you'll feel. Well Ryan and I'm gonna let you go and I'm gonna follow up but what you said with a question. I've always regarded or shall I say I regard the psychologist. -- licensed psychologist as the person for the talk therapy and the psychiatrist. As the person to write the methods. After consultation. With the psychologist is that wrong doctor -- -- The medications don't warrant it to allow that thick with therapeutic process it to go along. Better and more actively. And they can refer to it that tight chip and it can be called and it's that way and convert me I keeping him out the kidnappers seen another act that congress or mr. cheaper provider. I mean back and I am off usually offer the additional. Therapist. That it became -- that collaborate team. Some patient you really just don't want to see there is -- -- being blocked you know take the prescription and it sounds like what's happening right indicated that. He's he's only being offered medication and this is a situation in which perhaps I'm -- definitely therapy. That the combination of that medication and that popped therapy. Would be batter and path leads to better results for him. Now time is becoming a factor but Randy has been holding on Randy I'd like to ask a quick and concise question for doctor Cartagena I wanted to get John the year going. Thank you Graham hurled actor. I understand that PT SD can resolve from the comments here there and can escalate the question specifically is. The ability for someone prior to the enlistment to have a preexisting demand so don't miss. And just the similar ability to be a functional alcoholics. As a result of the exposure. -- -- fear there can an escalade and can it be somewhat document -- flags. -- escalated. From a previous big addition to that level. Resulting with the additional. Such trash. All right well periodic an easy way to ask the question thank you actually questioned by the way it is her way to predict who is more susceptible to PT SD in a combat situation. No at this. Point I mean it's generally more prevalent in not it went but I'll -- it's not it's a bad. It cannot occur in men and we you're right we do see quite a few he is he he did that develop within a combat experience. And people who are perhaps only susceptibility went -- disorders. You know can actually happened that we've peaked yet -- get the -- -- and more commonly in response to traumatic event. Doctor -- -- I'm gonna have to cut you off because I've imposed upon your time I am running out of time. I do wanna get you back a -- into a text message in just a moment but I I just I want to thank you very much for. Joining me for frankly the most intelligent interview you're ever gonna have with somebody in the media and I appreciate your brilliance and your insight thank you so much. Our doctor Maria Cartagena firm -- and what a pleasure can't wait to -- here in studio.