Hello and welcome to another episode of Vet Chat. I'm Doctor Ian Rountree, a veterinary technical advisor with Forte Healthcare, and I will be your host for today's episode. Behaviour medications remain one of the most misunderstood aspects of veterinary behavioural medicine. Pet owners often have concerns about medicating their animals, while many veterinarians may feel uncertain about prescribing these drugs. Today we're going to explore how psychopharmacology fits into modern behavioural medicine and how clinicians can use these tools effectively and responsibly. We're extremely fortunate to be joined today by Doctor Catherine Yan, a double board certified specialist in veterinary behavioural medicine. Currently practising out of the UAE. She is also the proud owner of Trinity Veterinary behaviour, an online platform dedicated to facilitating pet owner and vet to vet clinical behaviour consultations, as well as providing amazing educational resources, memberships, and coaching for pet care professionals on all things veterinary behaviour medicine. Catherine, thank you so much for giving up your time today. Can I firstly start by asking what prompted you to set up or establish Trinity Veterinary behaviour? Yeah, thank you so much for having me, first of all, and thanks for the lovely intro. So Trinity Veterinary behaviour is a pure online business that was actually founded during my residency, because one of the things I realised is that we're, as we as vets are quite lacking. I think in education around all things veterinary behaviour medicine, so certainly myself, you know, at university, we didn't get a whole load of education in behaviour medicine, let alone psychopharmacology, and all the vets, or many vets that I speak to, seem to have either a lack of confidence. Or just some gaps in knowledge that, I think prevent them from going down the route of prescribing behaviour meds and tackling some of those sort of behaviour cases that might come into their practise. So yeah, that's what, that's what prompted me to establish Trinity Veterinary behaviour and, and yeah, I think it's starting to fill a bit of an educational gap in in the veterinary space and the veterinary market. No, absolutely. No, it's great, absolutely brilliant, great resource to have, and particularly look with, with someone of your experience, absolutely brilliant. What do you think, I suppose in terms of when it comes to psychopharmacology being used in practise, do you think or what do you think is some of the concerns surrounding owners in the first part? What do you think in with, with regards to caregiver concerns about veterinary behavioural medicines? Yeah, and that's a great one because obviously, you know, a lot of time the patient care is led by the caregiver, and if the caregiver already has concerns themselves, then that might cause the professional to kind of shy away from using those medications as well. And there are kind of, I don't know, 3 classic questions that I get asked by by caregivers when we start talking about psychopharmacology. The first one is always, will it change my, my pet's personality? So I think caregivers are really worried that medications are going to overly sedate their pets, and you know, we always talk about the medications turning their pets into zombies, which we absolutely don't want to do, and that's never the intention of, of a, a psychopharmaceutical agent, unless we're using it specifically for sedation. During perhaps, you know, specific events. But if we're talking about a long term or baseline medication, it shouldn't ever, you know, be overly sedating or cause that kind of zombified picture which caregivers are so worried about in, in their pets. And then they're worried that it's going to change their personality, which I guess is, is a little bit sort of the same thing, but they're worried that, you know, fluffy won't be fluffy anymore. So. I always kind of talk about actually what we want psychopharmacology to do is bring out, you know, that goofy, joyful, wonderful side of them that, that, you know, the caregivers love and take away those behaviours that are perhaps caused by anxiety or fears or an inability to cope with the environment. And oftentimes that's when caregivers might start crying. A little bit because that's what they want too, right? They want Fluffy to be that fluffy that they know and love. So that's, that's one concern. And I think the other big concern is whether a psychopharmacology will have any long lasting effects on their pet's health. So I think caregivers are always worried about, you know, kidney damage, liver damage, if we do end up using a long term baseline medication. And there are currently absolutely no studies or no indications to report that psychopharmacology has any long lasting negative effects on overall health. In fact, there's actually a study that shows that reducing anxiety in animals increases longevity, so that's oftentimes something that that I'll say. And then I think caregivers also always want to know, as soon as we start medication, how long is it going to be before they're able to come off medications again. So, yeah, that's a conversation to have, and sometimes, you know, depending on the external factors, the, the environment, the social environment, the physical environment, that pet might not come off medication, or, you know, we might need to wait until sufficient learning has occurred before we can then think about weaning the pet off. So all of those things, and then obviously we talk about side effects and so on and so forth, but those would be the most common caregiver concerns and. I just think it'd be, you know, really great if, if a lot of vets had the confidence to be able to answer some of these concerns, confidently, to be able to, to sort of put the caregivers at ease and make them more open to perhaps thinking about medications for their pets. And in terms of, you just mentioned their long-term treatments, I mean, I suppose people looking at and wanting to obviously get them off medication as soon as possible. Is that something you're having an initial conversation about or is it more when they come back maybe after an initial treatment has started? I would say probably initially, quite often, because we do sort of try and lay out what, you know, what are the expectations in terms of managing behaviour cases overall, you know, it's always a long term approach, it's always a bit of a journey. We can get quick wins initially, but it is always a management, it's really difficult to cure behaviour conditions unless we've got. Something really obvious underlying like acute pain or chronic pain, but even then it's more management than cure, right? So I think it's always really important to set those expectations, you know, we're gonna be in it for the long haul, and then with that comes the conversation about that these medications are intended for long term use, and in fact, many of them get better or become more effective as time goes on because they make more changes in the brain. OK, very good. And then in terms of, I suppose then if you were considering a veterinarian in general practise, why do you think there is a lack of confidence with prescribing? Like what do you think is the barrier to prescribing, psychopharmacology? Yeah, I think that's a great question, and I do think it comes a lot back to lack of education on these medications during vet school. I think that's changing now for the newer generations, for the younger generations of vets coming through, but certainly, you know, my age group and, you know, around that time, we didn't really get much education on psychopharmacology. That's the one thing. And then I think always, right, we never want to do harm. I think as vets, that's our number one thing is, is we, we don't want to make a mistake, we don't want to do anything wrong, and we don't want to do any harm, so. There's, there's that, I think, I think that can be a little bit tricky. And also psychopharmacology, it's such a vast area and it's an ever evolving area. So even like since I started my residency, which was back in 2019, there are new medications on the market. Tessi, for example, you know, reconcile has, you know, has become licenced in Europe even since I started my residency. Venlafaxine we're using more of, so it's such an ever evolving field that even we as specialists sometimes kind of struggle to, to keep up with all the latest developments, so I think that's something that perhaps GP vets might also find a little bit tricky or challenging. No, of course, and I mean like if your baseline education isn't present, it's obviously very, very difficult. I mean, I know, as you've rightly said, we definitely, when I was in college, yeah, I certainly feel like there's a knowledge gap or an education gap there for want of a word and Certainly I would have always shied away from doing or seeing behaviour cases if they were presented in practise. Do you think that is something that a lot of GPs are still doing? Are they afraid of seeing those consults that are coming through the door? Is it just a time constraint thing? Is it just that they feel like, oh, I'm not equipped to deal with these at a base level before even thinking about psychopharmacology? Yeah, and I think you're absolutely right, I think the timepiece is a massive factor because we know that behaviour consults invariably take longer, the history that you have to get is so much more complex. I mean, my, my behaviour consults certainly during my residency were, you know, initial consults were 2 hours long. They're not quite that long anymore, they're about 1 hour long now, depending on the case, but so there's that massive time constraint, and then, and then yes, there's that again, that sort of lack of the feeling of having sort of a comprehensive approach or being able to, to grasp the case fully if you like. However, having said that, I think there's so much that GP vets can do. From a almost like a behavioural first aid point of view, you know, triaging, giving initial sort of recommendations whilst perhaps waiting for referral. Even some of the psychopharmacology can be a first aid tool, making sure that everyone in the home stays safe, you know, that the patients stay stays safe, some risk management pieces maybe. So there, there is actually quite a lot that can be done, and it's not just the vets, also our vet nurses are brilliant resources here, right, if they, if we have a vet nurse in the practise. That has an inclination towards behaviour, they can oftentimes give some really good initial advice, and then we mustn't forget that physical health can be such a massive contributor to behaviour. So if there is pain present, or if there's GI disease present, or if we've got neurological conditions, and those are all sort of under the remit of vets in, you know, to kind of think about in the first instance. So there's quite a lot that can be done without that two hour initial consult time period around it. And it's just again, getting vets more confident to, to provide that sort of first aid advice and, and some of those initial recommendations whilst then seeking out maybe a referral option. And is there anything in terms of confidence in that area, is there anything you might suggest to anyone who might be listening or tuning in, how they might start to become more confident per se, or what could they do to actually start to build up a confidence level in that? I think if we're talking about psychopharmacology specifically, start using one or two medications regularly. So, you know, maybe choose fluoxetine, choose reconcile as one of the long acting medications. I think fluoxetine is such a useful medication for so many things, and then maybe, you know, choose one event medication, whatever that might be, if it's a gabapentinoid, for example, or trazodone, or whatever, whatever it is, and just start becoming familiar and a little bit more confident with those medications. Don't feel you need to know. All the medications all at once, so that's something, and then obviously, you know, the more education that, that a vet can do, the better, and I actually have a really nice, course in Trinity called Psychoactive, which is designed for GP vets, and it is really a, you know, a how to use psychopharmacology in practise safely and effectively. But yeah. I'd say get familiar with a few initial things and then become a little bit familiar with some of those first aid pieces, you know, have a few really good safety management advice pieces. That's oftentimes will be around aggressive behaviours, I would say, you know, so how can we keep everyone in the family safe. Another really common one is, you know, new baby enters home, how can we keep everyone safe there? And just having some handouts or, you know, some, and again Trinity has some amazing resources there. We've got a a client handout ebook for example, so that you can just start providing things piece by piece, you know, and you don't have to know all about all the complex behavioural presentations in the first instance. No, and I think that's really, really beneficial. I think that's really, really interesting that you talk about how maybe getting familiar and familiarising yourself with a specific medication. We do it in other fields of veterinary, so why not do it with behaviour? Absolutely. Do you, do you think then, I suppose, and leading on from that, is there a tendency then to become a one size fits all approach? Could you potentially fall into that caveat? And, and I mean what would that potentially look like in practise or how can we avoid those potential pitfalls? Yeah, that is a great question, because yes, that is a true risk, right? So while we say yes, choose one medication and become familiar with it, also then, you know, at the same time we need to understand what the limitations of that might be. And a really common example of that would be the gabapentin, trazodone combination for everyone that comes into the practise, right? That's, that's something that I've seen happen over the years, and I think because there is now a little bit more that confidence and familiarity, which is great with gabapentin and trazodone. But now there's the danger of looking further afield and outside of that box if you like, to see what else is available. And of course behaviour medicine, just like any other medicine is all about treating the individual and not treating, you know, a group of animals as a blanket, kind of with a blanket approach. So I think that's, that's. That's a really important thing to think about. And that's then where, you know, if you, if you are interested in learning a bit more, that's then where things like the psychoactive course and understanding a bit more about the different types of behaviour meds where that starts to become important. But yeah, and an individualised approach, it's a little bit like, so my other big love is anaesthesia and analgesia. You know, again, providing that individualised patient specific anaesthetic plan, rather than just giving, you know, a triple combination to everyone, that's, it would be comparable to that a little bit, that we want to start thinking outside the box, and also understanding the limitations of some of those medications. I mean, gabapentin, trazodone can be a really useful combination, but some dogs respond really adversely to trazodone, for example, they can become, become quite the opposite, they can become quite activated and quite irritable. Which is the opposite maybe of what we're trying to achieve, and the same with gabapentin, we have to understand what the limitations are, especially in dogs. It's maybe a much more useful medication in cats, so, yeah, that's then where I, you know, I guess the further knowledge starts to come in and become really useful. And is there anything, I suppose, when you're looking at an individual patient that's walked through the door, are there any specific factors you're looking at that maybe influence your medication choices or if you were speaking to me as as a GP, what should I be looking out for or using to assess before deciding on a particular medicine choice? Yeah, so I think the first really big piece of the puzzle is understanding the difference between long acting and short acting medications and. This is almost the thing that I, I see most vets struggle with. So our baseline medications would be those medications that we use on an everyday basis for a long period of time. So that's where fluoxetine reconcile comes in, so our SSRI's are in that group, tricyclic antidepressants, SNRI's, maybe Pexion, monoamine. Oxidase inhibitors, so quite a few in that, that sort of long term group, and that would be those patients that are displaying behavioural challenges, on a daily basis, for large parts of the day. So I'll often ask the question, you know, how many hours of a day do you think Fluffy is feeling worried or anxious for? And so if it's not specific to a certain event or a certain thing that's happening, if it's this kind of all pervasive daily occurrence, that's when I might start to think about a baseline medication. Whereas event medications or short acting medications are exactly what they say, they have a faster onset, so most of the, the baseline meds, the long-term meds, take about 4 to 6 weeks to start working, whereas our event medications take anywhere between 30 and 30 minutes and 2 hours to start working, depending on the medication. And they are for events, so they'd be for vet visits, so, you know. Most of us are familiar with the concept of PVPs, pre-visit pharmaceuticals, so vet visits, but also noise events, maybe separation events, so departure events when the owner leaves the home in the case of separation, anxiety, you know, some dogs even need those medications on walks, so it, they're, and they won't last for very long, you know, they'll be, effective for about anywhere between 6 and 12 hours, again, depending on the medication. So that's the first thing to think about is, am I trying to change behaviour on a daily, long-term basis, or am I giving a medication for a specific event like fireworks or a vet visit or something like that. So that's where I'd start off, and then once I have sort of grasped that concept, then you can start looking into the different medications that sit within each of those groups and what the individual differences between those medications might be. And I suppose in and around that topic in that area, is your medication choice, particularly then we talked earlier about the potential to look at the overall health of the animal as well and pain and things like that. Is sometimes your medication decision guarded by what you're finding on a physical exam? How important I suppose is, is the overall physical assessment because I suppose it's not just a case of focusing solely on behaviour. There's obviously other things that can. Affect a pet's behaviour in the home or on walks as you say and stuff like that. So look, how important is our physical health evaluation? Yeah, so I'd say our physical health exam is invaluable. I mean it's, you know, absolutely a huge piece of the puzzle, and having said that, psychopharmacology is only one relatively small piece in a much wider treatment plan. And that treatment plan comprises, in my case anyway, so I, I work with a model called the 7 Ms. So there are 7 different areas that I look at when I'm thinking about a treatment plan. So that will be management, behaviour modification, obviously the medications are part of that, but there will also be the physical health piece, client education, monitoring, and, you know, the list goes on, making sure needs are met, enrichment, all those things. So that the physical health piece is a massive piece within that. And yes, our medication choices might be affected by what we find, it would depend on, you know, if the patient is on any concurrent medications for other diseases, but pain would be a big one here, we've got some psychopharmaceuticals that can act as analgesics and anxiolytics at the same time, so again, think about our gabapentinoids, but also venlafaxine, which is an SNRI falls into that sort of group. So that, that might absolutely sway our decision, but I think for me the most important thing when I'm making a medication choice outside of, do I need a baseline or an event medication, would be looking at the behavioural signs that the patient is displaying and understanding what neurotransmitters are involved in those signs. And this is again where it gets a little bit geeky, but this is my favourite part of psychopharmacology. Where we think about the neurotransmitters that we're trying to affect with the medication, so rather than choosing a medication for a diagnosis or a, a sign or a symptom, we actually want to be thinking, you know, do we have decreased serotonin levels, do we have decreased dopamine. Levels, do we have elevated noradrenaline or glutamate levels or decreased GABA levels? And if so, what medications are we going to choose in order to change that neurotransmitter level in the brain, because that essentially is, is what's going to hopefully help our patients. So it's, yeah, it is quite a, quite a, a complex picture, but it's really important to know that psychopharmacology is never the golden ticket, right, on its own. I'll often have clients come and say they just want the meds, and then we'll say, no, well, no, it doesn't work like that, you know. We need all the other pieces around, around that treatment plan as well. Yeah, I mean, I, I mean I think what you're alluding to really is it's, it's fair to say that behavioural medication isn't really replacing a diagnosis. It's kind of like, not, not necessarily a follow on, but it's a part of a, a larger, bigger plan in general, so it is. I is there, and, and do you perceive that there are potential risks of treating, I suppose, behaviour symptoms and signs rather than trying to look for a potential underlying cause? Is there some caveats with that, do you think? Definitely, I think, you know, if we take aggression or aggressive behaviours as a classic example, there are so many things that can cause an animal to become aggressive or show aggressive behaviours. You know, and pain is a big one again here, conflicted behaviours, so the social environment being challenging, perhaps in the home. Punishment-based training, previously, there can be so, so, so many factors, and so if we don't investigate into that, you know, what is the motivator, what's the driver, what is it that's causing the animal to behave like that. And we just choose a medication based on the sign that is aggression, which isn't actually a even a diagnosis per se, it, it's a sign, but the diagnosis is what, what is it that's causing the aggressive behaviours. So yeah, absolutely, there's a real danger in, in kind of, again, applying blanket statements or blanket. Terminology, I guess, or, or blanket in inverted commas diagnosis because they're not really a diagnosis, but applying those blanket words for patient to patients, you know, and things like he's he's an aggressive dog, you know, we come sort of to a little bit the the labelling sometimes of animals or the stories that clients that caregivers might tell themselves, you know, he's doing it because, out of spite or jealousy or all of those terms that, We're not sure whether our, our veterinary patients can experience, so trying to move away from that and, and actually evaluating the patient's behaviour and and understanding what it is that's motivating or driving the behaviour. And not to focus, I suppose, on, on aggression as a, as a presentation, but do you think that's quite a common presentation that I suppose often has an underlying physical health issue contributing, I suppose, to, to the aggression behaviour? Do you think that is something that is I don't mean a relatively common presentation, but is it something that we're maybe seeing more of that we're just a bit reluctant to dig into Pandora's box a bit on because we're afraid of what we might find or. I mean, certainly I know I suppose if a GP I'd be a bit reluctant to maybe I'd be, I'd be certainly trying to go refer, refer, refer, but is it, is it just one of those things where we're afraid to kind of start to root down into those underlying causes if aggression is more of a presentation as opposed to the actual issue itself. Yeah, that's actually a great question, and I mean, you know, aggression, it's such, like you say, a Pandora's box, and it's very emotive as well, because we as vets, we never want to put anyone in danger, or we always want to make sure that everyone stays as safe as possible. So, you know, if the recommendation is made by the vet, you know, to keep the patient in the home, and we can, you know, treat this, and then somebody gets bitten or seriously hurt. Then obviously that's a terrible situation for a vet to be in, and I think we always shy away from that, or we, we always want to make sure that we, we err on the side of caution or we give advice that is, that is very safety conscious. So I think there's that piece. I think aggression. Or aggressive behaviours can be emotive within the family itself. Oftentimes you'll have, you know, different caregivers have different opinions on things. It's really common that, you know, 11 person in the family might say, I'm done, I'm, you know, it's too risky, there are kids at home, you know, if there's a bite to, to a child, we'll never forgive ourselves. And there might be another caregiver who says they want to, you know, they really want to try everything to help their pet. And that can cause conflict within the family, which can be difficult to deal with, and that obviously is difficult for us to be caught in the middle of. And they're actually some of the conversations that I have a lot of are these kind of real sort of really quite complex conversations and, and sometimes difficult conversations, and that's some, you know, where again, that timepiece, having a behaviour consultation that is an hour or an hour and a half. Or 2 hours in length where you can really dig into these things can be really useful. Plus, you know, during the residency, we received quite a lot of training on communication and having conversations with the caregivers as well. And I know that vets in practise just simply don't have the time to do that. So having some of these difficult conversations can, can be exactly what the caregiver needs, but they can be difficult for us as vets to facilitate, especially when we're working in a busy GP setting and there's just not enough time to. To go into some of these things in depth. Right, absolutely. No, I mean, I think you, you're, you've hit the nail on the head and it's certainly very, very enlightening in that respect. So it is. I mean, I suppose we're coming close to, close to our end of our time here, but just to kind of finish up on, is there anything, anything you wish that more veterinarians maybe understood about the role of psychopharmacology when they're using it or selecting to use it in behavioural medicine? Is there one nugget of information you'd like to, to leave people as we, as we finish up? I mean, for me, the amount of animals, or the amount of pets that, that psychopharmacology has been an absolute game changer for has been absolutely enlightening, and it's been a real revelation. And it's not, it's not necessarily an easy medication group to use, but when it works, it can work so well, and it, it can transform lives beyond recognition, so. I guess for me, whilst I think it's massively important that we use psychopharmacology really diligently and with care, with knowledge, with always with safety in mind, with our patients' best interests in mind, I do still feel that these medications can save lives, they can be game changing, they can keep pets in the home, they can prevent relinquishment, they can prevent euthanasia in some cases, and yeah, I just. And I guess one thing I wish is perhaps that vets would just take a little bit of time, maybe to learn a little bit more about sort of some of the common questions they might be asked, or some of the things that are important when we do start using these medications, because I think that will, A, it'll improve the outcome, it'll improve their own confidence, and it'll make medi these medications a little bit more. Accessible, I think, and a little bit more widely used than maybe they currently are. But yeah, for me, I mean, they've been game changing. And while I absolutely am an advocate for the fact that they're only one small piece of the, the treatment plan puzzle, they're an important piece to me, and, and that's kind of, I think, you know, where, where I can really come in and, and help and make a difference. Excellent. Listen, thank you so much for not just giving up your time today, but for just the amount of knowledge you have and you can give to us and absolutely I think everyone should log on to your programme. It is absolutely brilliant. Thank you again so much, Catherine. Really, really appreciate this today. Thank you to Forte, thank you to the webinar vet for hosting, and listen, tune in again to the vet chat podcast. Thank you.