Giving Thanks After Thanksgiving…How an Attitude of Gratitude Will Change Your Life

The last of the mashed potatoes have been scraped from the Tupperware, the can shaped cranberry sauce somehow looks even more like a science experiment as the gelatinous blob splatters in the trash can. Every remnant of Thanksgiving is gone.

Are we still thankful?

For many, the spirit of giving, kindness, and joy lasts through December. Suddenly when the last string of tangled lights has been placed back in it’s designated box to collect dust into until next year, we seem to pack that sense of joy, gratefulness, and compassion along with it.

Why?

I thought about this as the stuffing, pumpkin pie, and green bean casserole rumble in my stomach. It’s easy to be grateful when we’re reminded to be. Now, I don’t think this is because humans are innately selfish or ungrateful. I reflect on the countless sessions I’ve had with patients and many stressors, obstacles, traumas, and heartbreak fill our daily lives. Something I find myself echoing to many patients when they express shame, or even guilt about seeking treatment is that: we live hard lives. It can be argued that many of those stressors are ‘first world problems’ and they might be, but it doesn’t make them any less real when we experience them.

We live in a world where we’re expected to work harder, work longer hours and to be constantly connected to our jobs. We’re inundated with carefully curated photos that convince us that everyone but us lives the perfect, magical, happy-at-all-times lives. Heavily edited and filtered photos cover our screens, and tell us no one else has wrinkles, or cellulite, or blemishes. We see nothing but smiling picture perfect families that tell us we must be awful parents because our kids would never wear those disgusting saccharinely sweet matching pajama sets, let alone smile together in the same picture.

All of these stressors don’t disappear during the holidays, however at this time went tend to be more generous and patient, often we donate more of our time and money. Most people at some point during the holiday season will sit around the table with loved ones and share something we’re thankful for. The calendar turning to November doesn’t magically change the stressors and challenges we have, however one thing is different. We are essentially forced to reflect on what we have to be thankful for, whereas the rest of the year we don’t often have similar prompting.

Our perception and thoughts are powerful things. Our thoughts and beliefs are much like the old saying “birds of a feather flock together,” or “like attracts like.” The more negative or irrational thoughts we have, the more they seem to multiply, the same being true for positive thoughts.

One trick that I like to teach patients is how the change of a very simple word in our thinking can alter our entire perception. Changing “have” to “get” can completely change the context and our thinking of a situation.

Flipping, “I have to go to work today,” to “I get to go to work today” elicits a very different feeling. It makes me think of something my dad said years ago while he was working a job that came with some pretty severe stressors, “I might not like my work, but if I didn’t have a job, I’d sure want this one.”

During the holiday season we’re literally told to ‘give thanks’ or ‘be thankful’ hundreds of times. I find the happiest people are the ones who think of something to be grateful for the instant their feet hit the floor in the morning.

So give thanks this holiday season, and enjoy the festivities, but especially if you’re struggling with any kind of mental or emotional pain, I invite you to accept the challenge of starting every day, this holiday season and beyond, with something, no matter how small, that you can be grateful for.

You might find it’s not as hard to face the work day, your kids aren’t as exhausting, you may just feel better about yourself and life overall.

And with that… I’m thankful for you reading this 😉

Ketamine, a Break-through Treatment for Depression?

Over the last couple days the news has been exploding with a new ‘miracle medication’ for depression. There has been a lot of attention given to this new medication, more-so than probably any other treatment for depression in recent times. So, what it is? How is it different? And what do I need to know?

What is it?

Ketamine is a medication that has been largely used as a potent anesthetic, it has also been abused as a street drug due to potential dissociative properties. Ketamine has been used off-label for some time to acutely treat depression, particularly suicidal thoughts.

Spravato is a medication closely related to Ketamine that has been approved for treatment resistant depression in the form of a nasal spray.

Why is it different?

Traditional treatment for depression has been based on the theory that depressive symptoms are a result of an imbalance of neurotransmitters serotonin, norepinephrine, dopamine, or a combination of the three. Many people don’t respond or have limited response to traditional medications for depression. Even if a person does respond to these medications it typically takes several weeks for any effect to be noticed. Our neurotransmission (the way neurons communicate with each other) is basically like one giant game of mouse trap, this lever makes that marble drop, which lowers that ramp, which makes that basket drop and catches the mouse (p.s. if anyone has successfully set up this game please let me know, three degrees and this is still an impossible task for me). It’s similar to how the neuronal transmission in our bodies work, a medication might lead to an increase in serotonin, and a higher level of serotonin leads to further downstream effects. The theory of why ketamine and ketamine-like medications work for depression and why they work so rapidly is that they immediately target what traditional medications only effect indirectly (hence the immediate vs. delayed onset of effect). In short, theoretically this new treatment basically cuts out the “middle-man.”

What do I need to know?

  • Ketamine and Spavato certainly have demonstrable and rapid effect on depression and suicidal thoughts, however there is still more we need to learn about long-term effects. A concern with Ketamine is abuse potential because it does have dissociative properties, hence why it is used as the street drug “Special K.” It has also been theorized that there is additional effect on receptors similar to those targeted by opioids.
  • You have to be under the direct supervision of a healthcare provider to receive the medication. The nasal spray is not something you can bring home. You can physically administer the medication yourself, but it must be directly supervised by the healthcare provider.
  • Not every provider can prescribe/administer this medication. The clinic/healthcare site must get certified to use and administer this medication, each patient also has to enroll in this specified program.
  • There must be a history of not responding to traditional treatments. Because this treatment is indicated for ‘Treatment resistant depression’ this cannot be the first go-to. A person must have tried and not responded to a minimum of two previous anti-depressants.
  • It’s not used as a sole treatment. The nasal spray is intended to be used in conjunction with an oral anti-depressant.
  • The risks of this treatment include sedation, ‘feeling intoxicated,’ disassociation, abuse/dependence, sedation, vertigo, suicidal ideation, among others.

Psychiatry, like all areas of medicine is continuously evolving and treatment is becoming more sophisticated, it’s a continual learning process for patients and providers alike. This is certainly a treatment with promise, and has the potential for great benefit for individuals with severe depression, but as with any other novel treatment long-term effects/benefit still have room for assessment.

You Can’t Sit With Us. What the Mean Girl Effect has on Mass Shootings

“You Can’t Sit With Us!”

The recent tragedy in Thousand Oaks has invoked a heated and polarizing debate about gun control, even within my own family. I have people that I love and value dearly on both sides of the political spectrum, they are all good people, they’re all intelligent, they all essentially want the same thing: protection and safety for their families and themselves. The difference is in ideologies of how to get there.

I was having a conversation with my dad about the matter, and a trait he has (that I like to think I inherited to some degree) is really being able to see a disagreement from multiple vantage points. We got into the same impassioned conversation that I’m sure millions of people were having across the country: what role gun control and what role mental health treatment plays in stopping these senseless massacres. Our conclusion came to an agreement mirroring the nature vs. nurture question, and the answer being that “it’s both.”

He asked me a poignant question after we agreed on this, asking about what the root of the problem was. I came to a very simple conclusion:

We need to stop being horrible to each other.

I’ll stop a subset of people right here who will say “People need to stop being such damn snowflakes” or something of the sort. This is not one dimensional in that the “mean girls” have sole responsibility for every violent action that happens. A huge part is also being able to accept that others have differing opinions, views, and beliefs from us, and that’s okay. We also need to be able to accept criticism and accept that we are not the entity the world revolves around, and that we are all capable of fault.

I’ve talked about “internet autism” in previous posts, but it is applicable here too. On whatever platform, may it be Twitter, Instagram, SnapChat, Facebook, whatever, you will likely find a plethora of comments: You’re ugly. You’re a bitch. Go kill yourself. Slut. Drink bleach. You’re a waste of space. Everyone hates you. Your mom should have gotten an abortion. …. etc…etc…etc….

My point is not to say that people saying mean things to a person in some way excuses or justifies a person committing a horrible crime. My point is rather that we, as a culture, have fostered and fertilized an environment (in many areas/ in many people) of anger, hate, exclusion, and intolerance. My point is that yes, we need to figure out some common sense gun laws that at the same time protect the second amendment, but also ensure people who purchase/own firearms are competent to do so. Another piece is mental health treatment and eliminating the obstacles people face in seeking treatment (I’ve had patients come in for initial evaluations [especially kids/adolescents] that have been waiting weeks/months to be seen). This really is only the tip of the iceberg, in that by the time most people are sitting on the couch in my office they have been struggling with whatever issue it is for a long time…it has now just gotten to the point where it is unmanageable and they are at such a point of distress they are willing to get help.

Psychiatric treatment is no different from any other medical specialty whether it be family medicine, oncology, neurology, etc. in that preventative care, or early treatment are going to have the best outcomes.

But why is there such an influx in the need for this treatment? There is no easy answer for this, but it goes back to a few key factors: from an early age we need to be teaching and learning emotional intelligence and distress tolerance, learning how to deal with failures, adversities, and unmet expectations (the snowflake argument), while also not subjecting each other to mental torture. It’s easy to say that millennials are being overly sensitive on the surface, but this really is the first generation that has been exposed to 24/7 notifications from their classmates and peers, often receiving sentiments similar to those mentioned earlier.

There have been numerous studies showing the effect negative experiences such as insulting/negative talk have in comparison to positive talk. This has been shown on many things from plants to pitchers of water and the outcomes are pretty astounding. It makes sense if a person is told something enough, odds are they are going to believe it.

Sometimes all it takes to change someone’s life is a smile or a kind word. If you’re not able to do that, at a minimum don’t be a jerk. More often than not if someone has a need to put others down it’s likely because of some insecurities/perceived inadequacies, or unresolved emotional issues the perpetrator is experiencing.

The truth is we can have great gun control laws, we can even have great mental health care, and these things will likely make a difference, but the reality is we’re not going to get very far without kindness and compassion for each other.

Recently when the Dali Lama was speaking at UCSD he was asked how he dealt with difficult people or was abe to continue expressing compassion for them. His answer was simple but remarkable, “I think of them as my fellow human being.” He went on to describe what an amazing thing it is that out of all times we could be living, out of all the matter we could be, as humans we’re sharing this planet as the same beings, and that as humans, largely, we all have the same objective and are just trying to get through our day, rarely are we meaning intentional harm to another person. As different as our life circumstances may be, we have this in common: we’re all human beings just trying to live our lives. So he said in unpleasant situations he reminds himself to think of the other person as “my fellow human being.”

It’s something that seems so rudimentary, but it really can be profound. I found myself in a day of the grumpies driving home from work in gridlock and saw a car going around and cutting in front of dozens of other cars all patiently waiting to move down the freeway. My mom was sitting next to me in the passenger seat and watching this happen, and I let her know what a jerk i thought the guy was for purposefully using an exit lane to cut in front of dozens of people in traffic.

Later that night talking with her I reflected on how bad I felt about getting so frustrated. I thought about it and realized how I had no idea what was going on in that person’s day. Maybe his wife was giving birth to their first child unexpectedly and he was trying to get to the hospital, maybe he just got laid off from a job he loved and his family was depending on him to provide with, maybe his best friend just got served divorce papers and he needs to go talk him off the so to speak, ledge, we just don’t know.

In psychology there is something called Maslow’s Hierarchy of Needs. This model tells us that love and belonging are some of the most basic needs a person has aside from food, clothing, and shelter. Whenever a violent act occurs it comes into question if the person was mentally ill. When most people think of this it’s in terms of whether the person was psychotic or not. However that’s not the case. No one who can go into a school, bar, movie theater, etc. and murder innocent people can be mentally healthy. They may have the capacity to understand what they are doing, or be in touch with reality but there is clearly something wrong with the individual’s thought process, impulse control, and/or other executive functioning. This goes back to the importance of early intervention in mental health, to identify, assess, and treat this.

This is clearly a complicated, emotional, and political issue with no easy answers. I think the solution is a combination of common sense gun regulations, better access to mental health treatment, but also starting to just be nice to each other.

I have many patients who participated in the school walk-outs following the Thousand Oaks shooting, and I think this made a powerful statement. However, my challenge to any kiddo who participated in these walkouts, to any adult who has participated in the debate on gun control or mental health treatment to just actively engage in the simple act of being kind to each other. Think about what you say or type, insulting or berating another person accomplishes absolutely nothing, being kind on the other hand can change the whole dynamic of our culture.

Let’s Talk About Sex(ual) Assault

With the recent Supreme Court appointment, and the #metoo movement sexual assault has had a light shown on it in a way that we have never seen before. This have been very polarizing issue with people both cheering that women are finally speaking out against their attackers, and others saying “It’s a scary time for boys.”

Sexual assault is probably the most common cause of trauma I see patients seeking treatment for in my practice. There are countless others who are seeking treatment for various other reasons that report some form of sexual assault at some point in their lives. One criticism of victims who have come forward is “Oh if it really happened they would have said something earlier.” “They would have reported it.” I can tell you from working with countless victims of sexual assault, (men, women, and children) this is just without a doubt absolutely, positively, 100% not true.

I cannot tell you the countless number of patients who tearfully tell me their story and conclude with a cathartic cry saying that was the first time they had told anyone about the incident. I always ask if the assault was reported and (excluding cases regarding children) I could probably count on both hands the number of people who had ever reported it to police. Out of all of these people I can think of maybe two or three who’s attacker was ever prosecuted.

When I ask these victims if there was something that stopped them from reporting this, there is almost always some variant of “I was afraid what people would think,” or “I was afraid no one would believe me.” Another common thing that happens is that victims blame themselves. “Well I shouldn’t have been at that party,” “I shouldn’t have let myself be alone with him.” As a result victims often don’t seek any kind of mental health treatment, which often leads to significant mental health issues down the road.

So what happens when a person experiences a trauma? Each person may respond differently, but frequently what happens is over-activation of a part of our brain called the amygdala. The amygdala is often referred to as “the fear bean” (if you were to look at the structure that’s kind of what it resembles) and one of it’s functions is that it kind of serves as an alarm system. When we experience a trauma the amygdala sounds the alarm, when it does this it basically sends out very intense excitatory signals, warning us to be on high alert. Now trauma does not effect everyone in the same way for a variety of reasons (biologic, environmental, genetic, etc.) but frequently it results in some kind of anxiety disorder and for victims of sexual assault this commonly manifests as Post-Traumatic Stress Disorder (PTSD).

We hear a lot about PTSD related to service members and deployments, but it is important to remember that this can affect anyone who has experienced a trauma. This may present in a person as frequent distressing memories, or dreams of the trauma, re-experiencing the trauma (feeling that you are back in that traumatic situation), amnesia about an important aspect of the trauma, heightened startle response, irritability, sleep disturbances, among many other symptoms (American Psychiatric Association, 2013). This affects a person’s daily life in many ways. Imagine re-experiencing the assault every time your significant other touches you, being afraid to go to sleep due to fear of having another nightmare, or going into a panic when you hear footsteps behind you.

We spend so much time teaching and warning girls and women about precautions to take to keep themselves safe. I think it would be pretty rare to find a woman who at some point hasn’t been advised to or warned:

“Don’t ever let your drink out of your sight.”

“Don’t wear headphones or at least take them out of one ear when you’re jogging.”

“Make sure you park in a well lit area.”

“Don’t drink something you haven’t seen made in front of you.”

“Stay in groups if you have to walk somewhere at night.”

“Carry your keys in your hand so you can use them to protect yourself.”

“Don’t talk on your phone or be unaware of your surroundings when you’re walking somewhere alone.”

These are just a handful of warnings that, like I said, I’m sure every woman has heard. And the truth is we spend so much time teaching and instilling these warnings for one reason. We believe and know that it is completely possible for someone to be assaulted. Think about it, is there any other kind of event we give so much warning to? I can’t think of any. We give these warnings because we know this is not out of the realm of possibility. So why do we act like it is when someone speaks up?

We need to start fostering a culture of not condemning victims when they do report an assault so that when it does happen people are comfortable speaking up immediately, not living in fear or blaming themselves for years, and then being questioned or mocked when the courage to speak up does arise.

Something that I always try to leave my patients with who have been victims of sexual assault is acceptance that what happened is not their fault. It doesn’t matter what you were wearing, it doesn’t matter if you were drunk, it doesn’t matter if you’ve had some kind of sexual relationship with the person before. It. Is. Not. Your. Fault.

If you or someone you know has been the victim of sexual assault and needs help contact the National Sexual Assault Hotline (800)-656-4673

The Opioid Epidemic and Substance use, What’s it All About?

Recently, I was at a concert with some friends, I noticed the floor was slick, and warned my best friend, “Be careful, the floor is really slippery, don’t fall.” Within five minutes I reinforced the sentiment that my parents should have named me “Grace,” a joke they have made since I was a small child. I slipped, fell, and ended up fracturing my fibula and required surgical repair. This resulted in having to reschedule my planned trip to Thailand. So, being relatively immobile, in a fair amount of pain, and having pain medication and addiction being frequent topics of recent conversation, I figured this would be a good opportunity to explore opioid use and the controversial topic of naloxone/Narcan.

Over the last few years there has been a pretty heated debate on whether Narcan should be more readily available for people suffering from opioid addiction and/or their friends/family members. So what’s the problem, and what is naloxone?

Naloxone is an opioid antagonist, meaning it is something that counteracts the action of opioids. Opioids are substances like heroin, oxycodone, hydrocodone, etc. that bind to specific receptors in our brains. A benefit of opioids is the binding of opioids to these sites results in pain relief, however danger comes because this can result in a sense of euphoria which can trigger a very intense reward system in our brains thus potentially leading to addiction/abuse/misuse.

Basically naloxone acts as opioid “police” or “bouncers.” Imagine opioids as underage kids at a wild party, the job of naloxone is to round them all up and boot them out. Naloxone is often used for rapid opioid reversal in an emergency situation (kind of like an antidote). Since an opioid overdose can cause respiratory depression and coma it can be deadly, naloxone can reverse the action of opioids and prevent these lethal outcomes.

So what’s the controversy? There has been a push to make this medication readily available for people with substance use disorders and/or friends/family members to have on hand so that it may be administered in case of an overdose. Some argue that making this medication readily available will only encourage people to start or continue using opioids because the risk of overdose would be significantly reduced. Now, everyone is certainly entitled to his/her own opinions and beliefs, however to me this seems very similar to arguments that we shouldn’t have sex education, make contraception available, or administer the HPV vaccination to children because “it will only encourage them to engage in these behaviors.” In my belief, the more education someone has on a matter the better informed they are and thus make more educated/informed decisions and multiple studies support this.

This gets a little tricky in regards to substance use because the decision making/reward system parts of our brain are exactly what gets affected by substance use. Most frequently overdoses occur in a few situations: 1. a person has been using a substance, tolerance has developed, as a result of continued use, higher doses of the substance are required to get the desired “high” a person is seeking, or 2. a person has been using a substance, he/she sustained some period of sobriety and relapse, using the same amount of substance in question, however since there has been time without use of the substance some of that tolerance has gone away (meaning it won’t take as much to get the same high), the body gets overwhelmed and overdose results. Now this doesn’t mean it’s impossible to overdose on the first use of a substance, or that there aren’t some people who may try a substance because there is some kind of perceived safety net, however in my professional experience this is not the majority of cases.

So what should you know about Naloxone?

It is an opioid antagonist a.k.a. it is the opioid police. Imagine the chaos of people fleeing a party and getting put into a police car when the cops show up.
It is unpleasant, uncomfortable chaos. When naloxone comes on board, it basically displaces all the opioids from where they have bound which is UNCOMFORTABLE. One reason opioid use is so hard to kick is the withdrawal. Naloxone essentially makes a person go into instant withdrawal, which is NOT FUN.
There is no “high” with naloxone. There is no intrinsic reward that comes from naloxone use. If anything, say someone hypothetically was experimenting with opioids knowing he/she had this perceived safety net, the sheer discomfort of this instant withdrawal would in itself likely be a deterrent from future use.

One of the most important things I hope to leave people with is a better understanding of substance use. Generally speaking, people do not start using/abusing/misusing substances when things in his/her life are going fantastically. The majority of times substance use is a maladaptive coping mechanism used to numb some kind of intolerable emotional pain. What I frequently remind family/friends of is THIS IS NOT AN EXCUSE, rather an explanation of behaviors.

So why do some people become addicted and others don’t? This is a complicated question with no easy answer. However there are physiological changes that happen in our brain when we use substances. It may start as “Hey this feels good, and helps me get away from the **** going on in my life right now” which we can call ‘impulsive behavior’ a specific part of the brain is activated in this process. However when it shifts to compulsive behavior ‘I need this to get me through the day and you are going to be in massive suffering/you are going to die if you don’t get [substance, A,B,C,D, etc.] an entirely different system in our brain is activated.

Ok, so what flips the switch from impulsive to compulsive? A bunch of different things. However one of the most important seems to be social supports. There have been animal studies that have animals both exposed to addictive substances. One with a very uncomfortable environment with limited supports, the other with a significantly more supportive environment. While the subject in the supportive environment may try the addictive substance, the same kind of dependence doesn’t occur. This is not to say this is the only factor, but it is a key one.

There was a stand-up bit I saw YEARS ago where the comic poked fun saying “Alcoholism is the only disease you can get yelled at for having.” Every once in a while I need to let this sentiment sink in and resonant with me, and something I will tell you is that it makes me angry. It makes me angry at what a poor job we do of educating others on substance use, and treating it as what it is, a psychiatric/physiological condition that should be treated with the same understanding, compassion, and concern that any other kind of medical condition is instead of as a ‘character defect.’

It may be easy for people to scoff at this and continue to lack compassion, but what I would say is if you are able to exert enough energy to have contempt or distain for people suffering from these conditions and say “Well why don’t you just go get help?” Why don’t you just get a job?” I challenge you to earnestly speak to someone or the family member of someone who has been struggling with a substance use disorder.

Does the woman now addicted to heroin who was eight years old when she was shot up with heroin for the first time and forced into prostitution by her dad deserve public ridicule or disdain? What about the (wo)man who spent years of his/her life sending and receiving gunfire in war zones who comes home and ends up finding his/her only escape pain medication prescribed to treat injuries he/she sustained? What about the doctor or the lawyer who comes home after days on end of shouldering the emotional burden of each and every one of his/her patients/clients and can find no solace outside of a whiskey bottle? Likely we don’t see these people the same way we do the indigent person downtown carrying all of his/her worldly belongings in a shopping cart. However it’s relatively rare for someone passing these judgements (out of distain, discomfort, fear, or whatever) to actually speak to these people like the actual living, breathing human beings they are. If we look at the actual science and neurochemistry that is involved in addiction there is absolutely no question this is an actual disease, not a character defect, and we need to start treating it as such.

My opinion is that I have seen more than enough people struggle with addiction in both my professional and personal life. Narcan saves lives. It is something that is INCREDIBLY uncomfortable to be administered during an overdose, people do not get a high off of it, people don’t feel good after using it. Withdrawal is something so uncomfortable and so powerful that it is a perpetuating factor in addiction… going into instant withdrawal is not desirable. Remember, people go to EXTREME lengths to avoid symptoms of withdrawal.

My final question or thought would be, if a medication is available to save the life of a person with a potentially life threatening condition why would we not make it available? If it was your child/sibling/significant other/friend/etc. who was struggling with an addictive disorder and had the possibility of dying of an overdose, would you not want something available to save his/her life?

Please, comment, share, subscribe, ask any addiction/mental health questions! I

 

f you or someone you know is experiencing a mental health/substance use condition contact the national mental health and substance abuse hotline
SAMHSA’s National Helpline – 1-800-662-HELP (4357)

Body Positivity: What it is, What it isn’t, and How to Get There

Over the last few years body positivity is something that has been getting a lot of attention. Supporters of this movement have the stance that this helps improve a person’s self esteem and overall wellbeing, and reducing judgment. However there is also the thought that this puts people in danger of ignoring larger health problems. So who’s right? Both, well, kind of.

When I explain body positivity to patients I describe it as loving and accepting yourself for where you are currently at. This doesn’t mean you get to put blinders on and ignore any health issues you are experiencing. It is rather that accepting of you where you are at. Feeling guilt, shame, or anger towards yourself certainly will not resolve these issues. Let’s take a step back and look at our body in a different way. Imagine your body as a car. Let’s say for whatever reason, you hate this car. If you have negative feelings towards it it probably won’t be a priority to take it to the car wash, you may not care that there’s trash strewn about, it might be easy to ignore that maintenance light. What happens? The car further deteriorates. Now imagine your dream car. Do you treat it the same way? Probably not. You probably will ensure maintenance is kept up, take it through a car wash, maybe even put premium fuel in it.

We cannot take care of something we don’t value, and our bodies are no exception to this.

Valuing ourselves means valuing our bodies and this is something we need to start prioritizing in childhood. I got started thinking about this earlier this month when I was getting a massage. Ok, so the best way I can describe this message was an hour of being pinched, tickled, and poked. It was awful. I hate to admit this, but it took me a lot longer than it should have to speak up. While laying on the table I remembered having the thought “Why am I not saying something? This is in no way enjoyable. You are paying for this come on.” I realized how ridiculous it was for me to be valuing the feelings of a person (who I was paying to perform a specific service) over being uncomfortable with something that was happening to my body. We need to start instilling this from a very young age; if your child does not want to hug a friend/relative/whoever he/she does not have to! When we force or pressure our kids into things like this it starts a thought process that your body is not as valuable as someone else’s feelings/wants/needs.

Traveling is one of my big passions, and I like to think it is something that helps me think on a more global level and fuels the fires of curiosity. So when thinking about all of this I began to wonder about different things that affect the perception of our body’s value. Thailand is one of the most (if not the most) infamous areas for sex tourism/sex trafficking/sex work, etc. I began to question how having this be such a prominent part of a culture affected people’s sense of self worth. How do people involved in these industries perceive and feel about themselves, how do others view the individuals working in this industry? I’m so excited to say this is something I will be fortunate enough to explore at the end of September, so check back to see what the experience is all about!

Tips for Adopting a Body Positive Mindset

1. Place a sign, post-it note, whatever on your mirror with a positive message for yourself. I love having people put something like “Hello, gorgeous” up. This is helpful for a few reasons. One being that it starts your day with a positive thought about yourself. It begins to make you feel comfortable with thinking/feeling/accepting nice things about yourself. The more that we practice this, and replace negative self talk with these thoughts the more second nature it becomes.
2. Focus on health and wellness not numbers. We can get so tied up in wanting to hit that magic number on the scale that sometimes we neglect what is more important, overall health. If you start treating your body like that brand new car I talked about earlier, guess what happens? We start putting higher quality fuel in, we’re more attentive to regular maintenance (exercise, time to de-stress, etc.) and we overall perform at a higher level.
3. Adopt an attitude of gratitude. An exercise I commonly have patients struggling with this do is body mapping. So either draw or list it out, head to toe write something that you like about each body part. If you cannot think of something you like about a particular body part write something that you can appreciate about it (eg. you may not like your stomach but you can appreciate that it houses organs that digest food to nourish you).

Just remember, you deserve the same love, kindness, and compassion you give to others, so be kind to yourself!

Mental Health in Mexico

It seems that the topics of deportation and the matter of separating parents from their children has been everywhere lately. This made me want to explore (setting aside any arguments about the legal/political issues associated with this on either side) what is this really doing to these kids, these families, and what kind of mental health treatment is available in Mexico for these people? How is mental health treatment approached in Mexico?

So what really happens when a child experiences a trauma like being separated from a parent? Childhood is when a lot our core beliefs, patterns of thought, and coping skills develop. This is a time that really sets the stage for how we relate to others and the world around us. A trauma like this certainly could lead to depressive, anxiety or trauma related disorders as well as problems with attachment. When a trauma like this happens it may lead the child to view the world as an unsafe place, have difficulty trusting others, develop feelings of inferiority, or have difficulty establishing their own self-identity. It would not be unusual for the parents in these situations to  develop extreme feelings of guilt, hopelessness and subsequent depressive, anxiety, or trauma related disorders. Personality disorders, especially Borderline Personality Disorder are also very strongly related to unhealthy attachment and fear of abandonment. The cultural importance of family puts these individuals at even higher risk.

I wondered if providers had been seeing an increase in people seeking mental health treatment specifically related to these issues. So I went down to Tijuana’s only psychiatric hospital, Hospital de Salud Mental de Tijuana and met with some of the providers to learn about the treatment and perspective of mental health in Mexico. While the providers I spoke with said they may have seen a very modest increase in hospitalizations/treatment specifically related to these issues it didn’t seem to have the major impact I suspected it would.

There is still a fair stigma about mental health issues in the U.S. and the providers I spoke with felt there was a similar if not harsher stigma about mental health treatment in Mexico. This stigma often discourages people from getting mental health treatment, frequently a person may be afraid to tell his or her family there is a need to seek treatment, or may be actively discouraged to do so if it is discussed. Mental health conditions are frequently seen as something that should can be managed by religious or family support. This puts individuals experiencing a mental health condition in a very difficult spot and seemed to be the primary barrier to seeking treatment.

I toured the facility for about two hours while the doctors I met with patiently answered my 1,001 questions. About five minutes into the tour it hit me like a Mac truck, these people have it right. There were some stark differences in how treatment is approached and I started to take note of what we need to bring to the states.

1. Length of stay. The average length of stay for inpatients is about 2 weeks. That is the average, frequently stays are 3-4 weeks. I compared this to the inpatient units I’ve worked on where the average length of stay is probably 2-3 days. If someone’s length of stay is approaching a week administration usually starts to sweat. Why is this? The most basic answer is insurance coverage. Generally speaking an insurance company will only provide coverage for a psychiatric hospitalization if a person meets one of three criteria: they are an imminent danger to themselves, others, or are gravely disabled (cannot provide for basic needs like clothing, shelter, food, or water, due to a psychiatric illness). This means that people are generally not hospitalized until their symptoms are so severe it becomes a liability if not treated. What’s more, the minute a patient no longer meets this criteria insurance coverage stops (some really good plans may authorize a few additional days, but this is pretty rare). This basically means we are using inpatient treatment as basically a means to stabilize someone to the bare minimum level, or until they are no longer assessed to be a liability.

2.  Holistic treatment. This kind of goes along with the idea of what really is the purpose of treatment, to simply stabilize someone, or actually provide treatment of the symptoms. Most inpatient units in the states will offer things like group therapy, AA meetings, and maybe art therapy, these activities are fairly minimal and not the largest part of treatment. I was amazed to see at Hospital de Salud Mental de Tijuana they had displays of expansive works of art therapy done by patients, there were volley ball courts, a gym, yoga classes, even a garden that patients tend to and what is grown is used in the meals served that are specially planned by a nutritionist. We know that good nutrition, exercise, a sense of community and purpose are vital for our mental health and yet we put such a minimal focus on it.

3. Community outreach. As mentioned above the stigma about mental health treatment is prevalent across borders, these providers are rolling up their sleeves to fight it. They host meetings, and also visit schools and other community facilities to provide education about mental health to the community. Starting in elementary school these providers are actively working to change how the next generation perceives mental health.

I left the facility dumbstruck and with one thought. As providers, as a community and society we need to be better. I believe that the vast majority of providers do want to give the best care possible and heal their patients but become limited by administrative and financial barriers. like any other kind of medical issue, doing primary prevention is without a doubt the best thing we can do, we first need to start educating our kids about mental health treatment and  and we need to be better about community outreach. We also need to fight for the ability to actually be able to treat our patients instead of giving them the bare minimum level of stabilization. It’s up to us to talk to our legislators, and to push for expanded coverage of treatment. Let’s be better.

13 Reasons Why our Kids are Depressed, Anxious, and Suicidal (Side B)

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Depression and anxiety in kids and adolescents certainly isn’t something that’s new, but is it getting worse? We’re definitely seeing a rise in mental health conditions across the board, but it’s difficult to determine if this is because we’re simply getting better at recognizing it and more willing to treat it. Even though we are making great strides in identifying these issues in kids, we’re still learning, and new factors and issues effecting our mental health continue to emerge. So this is a continuation of my last post exploring a few more of the issues contributing to mood disorders.

7. Pressure: You know the way you might feel that your boss keeps wanting you to do more and more with fewer resources? Our kids frequently feel the same way about school. I regularly have kids who are not even in high school come into my office in tears because they didn’t do well on an assignment/test and are now convinced they will never get into a good college, will never get a good job, and will be a miserable loser for the rest of their lives feeding feelings of self-doubt and hopelessness. This kind of distorted thinking is common even for adults with anxiety, it’s called catastrophizing (going to the absolute worst case scenario) which is particularly problematic with kids because the parts of our brain that allow us to think more abstractly, control impulsivity, and realistically weigh consequences of events or actions are still under development. The pressure is not only academic, in many senses our kids are truly becoming mini-adults at younger and younger ages. I look at so many of the young girls that come into my office with perfectly coordinated outfits, contoured makeup, acrylic nails, and listen to them sadly talk about how they think they’re not pretty enough, thin enough, good enough. They need to hear they are good enough, and they need to hear it until they believe it.

8. Our brains are getting wired to be depressed and anxious. Dopamine is a neurotransmitter that plays a huge role in our mood, it’s also a key player in things like addiction and reward processing. There’s a reason we get so sucked in to wanting to get more and more ‘likes’ or followers. Dopamine. Every time we get a ‘like’ we get a little boost of dopamine. This basically makes our brain tell us “Hey this is awesome, we gotta get some more of that!” We subconsciously train ourselves to self-medicate with these dopamine boosts. This means that when we’re not getting that insta-dopamine we notice we don’t feel as happy, we get more depressed and may even get cravings for that dopamine boost.

9. Substance use: This really can be a chicken or the egg situation. Many people start self-medicating with substances as a way to try to escape from negative emotions. Momentarily it may work, however when the effects wear off we’re more likely in a worse place than we were before we used. This is physiologically for a number of reasons, a big part is activation of that reward cycle in Reason 8. This basically turns into a horrible self-perpetuating loop where we continue using to mask and escape from negative emotions, our brains continue to tell us “Yes this is helping, sweet!” then we crash, and repeat.

10. Everyone is stressed and we feed off each other. I think it’s a pretty fair assertion that right now pretty much everyone has some major stress right now, whether it’s worrying about making rent, the health of a loved one, the political climate, meeting a work deadline, etc. we live in a stressful time. We also tend to be pretty awful at self care, meaning we frequently don’t really manage our stresses effectively. We pick up on each other’s stress and oftentimes internalize it. I don’t think I’ll ever forget a kiddo of mine coming into my office absolutely distraught because the family was going through a lot of financial and marital stressors. She thought if she gave her dog away it would solve the family’s problems. Or the kid who thought she was causing the stress and problems leading to a parent’s substance abuse. Parents are often so wrapped up in the well-being of their children, work, school, or whatever it is they often ignore or de-prioritize their own mental health. One thing that I find myself frequently reminding parents is that it is not selfish to take care of yourself, the happier and healthier you are, the happier and healthier your kids will be.

11. We’re more and more reliant on external validation to determine our self worth. The feelings of love and belonging are some of the most basic human needs. Humans by nature are social creatures, and even from an evolutionary standpoint we have a need to be accepted by others and be part of a group. This becomes problematic when our self esteem becomes reliant on the approval of others. How many people liked our post? How many parties did we get invited to? How many texts do we have? When we let these external sources of validation dictate our self worth we aren’t really able to see ourselves through a clear lens. Another distorted way of thinking we can get into the habit of is polarized or black and white thinking, or minimizing the positives while magnifying negatives “I didn’t get invited to that party so that means no one likes me, and I’m a loser who doesn’t have any friends.” This can make it difficult to accurately evaluate ourselves or the situations we’re in and crush our self esteem. Relying on this form of validation can also lead us to behave in ways that we might not feel comfortable with in order to fit in, or avoid conflict, however when this happens we often develop huge feelings of guilt afterwards, feeding into the cycle all over again.

12. We’re disconnected. While technology is an amazing tool that gives us access to people and information, this can lead us to have less quality face to face time with each other. Think about it, look at almost any group of people, at anytime how many people are on their cell phones, or at least have them out? When our attention is split like this we limit the quality of the experience we’re having in real time. When we feel disconnected, we likely end up feeling lonely which goes back to Reason 11. The primary reason that group therapy is effective is the sense we are not the only one experiencing what we are, or that other people understand, and maybe the most important factor in psychiatric treatment is the therapeutic relationship, these things all give us that sense of love and belonging and lets us know that we are not alone.

13. It’s everywhere. Every time one of my kiddos come to me and describe these things or tell me they’ve attempted or have considered suicide it breaks my heart, and I try to think back to how old I would have been when I would have even been aware of what the concept of suicide was. It really does seem that it’s been everywhere TV, movies, news, music, you name it. Now coverage and discussion of these issues is something that is necessary and important. Risk comes when it is sensationalized or glamorized. Parents ask me all the time if they should let their child watch a show like “Thirteen Reasons Why” and my answer is usually that it depends on the purpose. I believe it can be a helpful tool in facilitating a conversation, but this should be done with guidance. Like I mentioned earlier there is still so much fine tuning and brain development that is going on during this time that kids are not able to process and analyze information like this in the same way as adults do. Kids just do not have the executive functioning to fully understand what suicide really means. Many times it may be viewed as a way to show someone how much pain they are experiencing or to prove a point. The finality of these actions is not something that they are able to process which is where the danger comes in. A good example of this is in the most recent season of Thirteen Reasons Why the protagonist who committed suicide in the first season is featured throughout the entirety of the program, seeming to still interact and communicate with at least one of the characters, continuing to tell her story and help guide others through the season. This is where the major disconnect comes in (for the purposes of this discussion let’s put aside religious beliefs about the afterlife, which would add a whole other layer to this). The finality of suicide is what is a difficult concept for kids/adolescents to understand, and the protagonist’s continued presence even though she is dead is often how kids conceptualize it.

So what do we do with all of this? The number one thing I can say is talk. Have the uncomfortable conversations. It may be the immediate reaction (and reasonably so) to hit the roof when you find an empty bottle of vodka in your kid’s room, or find inappropriate pictures on her phone, but I would ask for you to look at what else is going on. Is there something she is trying to escape? Is there some kind of validation or need that isn’t being met? I’m not saying this is an excuse, but rather may be an explanation of certain behaviors (which still need to be addressed and corrected). Encourage them not solely to succeed in school, athletics, or extracurriculars, but teach them how to handle disappointments and shortcomings and not let failures negate successes. One of the most beneficial things to do to improve overall mood is to foster an environment of gratitude. At some point in the day share things that you are grateful for and encourage your kids to do the same. When we’re able to express gratitude it helps counteract that negative all or nothing/black and white thinking and helps us bring the positive into focus. The last thing I advise would be to take care of yourself. Don’t feel selfish for taking time to go to a yoga class, have a date night with your significant other or go to a therapy session (whatever your self care is) we can’t help others effectively if we don’t help ourselves. Just remember, if you have any doubt or concern bring your kiddo in for an evaluation! Worst case scenario is you spend an hour of your time with your child discussing your concerns. Remember it is not our job as providers to make judgements on you, your child, your parenting, etc. while sometimes people may be hesitant because of past negative experiences or beliefs about psychiatry/therapy I truly believe that 99% of providers sincerely want to help and only want what is best for you and your child.

If you or someone you know is struggling with suicidal thoughts there is always someone there to help.

Call the National Suicide Prevention Lifeline available 24 hours every day 1-800-273-8255

“No matter how many reasons why, there are always more reasons why not.” –13 Reasons Why

 

13 Reasons Why Our Kids are Depressed,Anxious, and Suicidal (Side A)

With the recent release of season two of the Netflix original “13 Reasons Why,” along with the recent tragic shootings I have had more and more parents and patients asking about depression and suicide, especially among children and adolescents. One of the most common questions parents ask me is how or why his/her child (relative, kid’s friend, etc.) is depressed and/or anxious, feeling the child is “too young” to be experiencing this and it is “just a phase they must be going through.” It’s a confusing and difficult experience for both the child suffering and for all other family members to go through. I want to start with the reassurance that depression, anxiety, bipolar disorder, psychosis, or most other mental health disorders are completely possible for children to experience.

So, why? Why are our kids depressed, anxious, and committing suicide, and what can we do to address these issues, prevent, or treat them?

  1. It is very rarely (if ever) that one single issue is the root cause. Many parents feel extreme guilt if their child experiences any of these conditions feeling that they “passed it down” or there is something they could have “done better.” It is more likely a combination of genetic, “chemical” (biologic/physiologic), and environmental factors. Frequently I describe this to my patients or their parents as a bridge relying on supports. One support being disrupted (i.e. genetic factors) will likely not cause the entire bridge to collapse, however the more supports you start taking out (environmental, biological, etc.) the less stable that bridge becomes, and the risk of collapse arises.
  2. Social Media. There is an amazing phenomenon that happens when we get engrossed in social media: We get depressed. More and more research is demonstrating that there is a correlation between the use of social media and depression. When we use social media we see a carefully edited, curated, photoshopped version of a life people want to show us. It is not reality, but it’s difficult for us, especially kids, to register this. We start to compare our lives to what we are seeing on Instagram, Snapchat, or Facebook, which makes our lives seem pretty lame. We wonder why we can’t look like that, or have those awesome clothes/gadgets, why we aren’t on vacation in some amazing location. When we start to compare ourselves to others it is very easy for a mood disorder to creep in or worsen. However what we see is not real life. I don’t know many people who post photos of themselves washing the dishes, or taking the garbage out. I always recommend limiting screen time. Yes, your kid will be mad and probably yell and cry and scream what an awful parent you are for doing this, let me assure you, you are not. It is ok for your kid to be mad at you! Let me reiterate that: IT IS OK FOR YOUR KID TO BE MAD AT YOU. The initial battle may not be pretty, but I see it countless times that both parents and the child/adolescent report almost an instant improvement in depression or anxiety if his/her cell phone or social media use is restricted.
  3. Bullying: This goes right along with the social media factor. When we are online/via text we do and say things that we never in a hundred years would say to someone’s face…so why do we feel comfortable doing it online? There’s another interesting issue we develop with more screen time, I’ve heard it called “Internet Autism.” Meaning when we cannot hear or see a person we are unable to pick up on the social/human cues, and we stop thinking of the person we are speaking to as a genuine, living, breathing human being and more as an object.
  4. Diet: This is a hard one particularly for teens who may be stubborn, but it is crucial. Think about it, when any of us live off a diet of Chili Cheese Fritos,  Snickers Ice Cream Bars, and Dr. Pepper (which I will admit was my standard throughout junior high and high school) and stay up all night binge watching the latest Netflix show we do not feel like we are at our prime. We deplete ourselves of crucial vitamins and minerals that directly effect mood (Vitamin D, B Vitamins, Omega-3’s are huge).
  5. Exercise: Exercise really does help stimulate all of those “feel good neurotransmitters” that regulate our mood, so even if it’s for 20 or 30 minutes getting some exercise WILL help. Again, another thing that we see related to increase use of social media/screen time, increased sedentary lifestyles.
  6. Sleep Deprivation: Most of our kids are on some kind of device until they go to sleep, if not falling asleep next to them or with them on. The light these devices omit suppresses our body’s ability to produce/release melatonin, which is crucial to regulate our circadian rhythm. Also, when we’re tired our body wants us to have energy and looks for the easiest source of this. This is why when we’re dead tired we tend to find ourselves eating more, and eating foods high in carbohydrates or processed foods that are easily broken down for our bodies to use as energy. Then we get into a horrible on-going cycle with reason four.

Obviously this is a very difficult and complex subject and there are many more factors in kids developing mental health disorders, which we’ll leave for Side B.

So what are some warning signs of depression or risk of suicide?

  1. Anger: Depression/anxiety often presents as anger in children and adolescents, so if it seems that your kid hates everything from their teacher to the spaghetti that’s on the table, or seems to argue about any and everything this may be something to explore.
  2. Withdrawal: One symptom of depression is something called anhedonia, which is the inability to enjoy things that we typically would. A kid who refuses to come out of there room or is uninterested in seeing his friends may be struggling.
  3. Dark thoughts: Recurrent thoughts about death or harming themselves is a fairly obvious red flag, but pay attention to the music he’s listening to, what they’re writing about, jokes he’s telling, what kind of movies he is watching.
  4. A sudden drastic change in friends or appearance. A drastic change in appearance may be a way for someone to express he is not happy with who he is or is trying to send a silent cry for help in an attempt to get more attention. A sudden change in friends may also signal anger (frustration/arguments with current friends or disinterest in them).
  5. Suddenly developing a really good mood or become overly generous. This may seem counter-intuitive but if a person is contemplating suicide and make the decision to follow through with this, in some ways it may be a source of relief. Giving away possessions may be seen as generosity, but may be part of a person’s preparation for suicide.

What do we do? There are clearly no easy answers, limiting screen time, good nutrition and sleep are fairly intuitive (albeit not always easy interventions to implement) but perhaps the most important piece of advice I can give is: talk to your kids, if something seems wrong, ask. There has been a kind of myth or fear that asking someone about suicidal thoughts will give them the idea or motivation to do so, which has been proven many times to just not be true. One of the biggest concerns my kids/adolescents report when they come to see me is that they feel misunderstood, invalidated, or unheard, whether it be by peers, their previous mental health provider, or their family.

“I wouldn’t say a single word to them. I would have listened to what they had to say, because that’s what no one did.” –Marilyn Manson