JustCare

Author: Dr. Marc Manseau

  • A psychiatrist’s reflections on grief

    A psychiatrist’s reflections on grief

    In the spring of 2014, I lost my “memere” (the French Canadian term for grandmother). While I had lost grandparents before and have since, my memere’s passing was particularly painful for me. From my earliest memories, she was a constant source of love, support, and joy. She was like a second mother, from taking care of me when I was home from school for a couple weeks with the Chicken Pox, to helping me navigate the choppy social waters of adolescence, to the countless times her quick wit made me laugh. As painful as her death was, it also somehow felt “normal.” She lived to her late seventies, and while I would have wanted her to live longer, I had the sense that she lived a long, rich life. Because she had found out she was dying of pancreatic cancer while still feeling relatively well, I had the opportunity to say goodbye. And I spent the days following her passing with family, celebrating her life and cherishing her memory.

    Five months later, my father died suddenly of a heart attack at sixty-one years old. Only catastrophic metaphors seem to work here: it was like being hit by a Mack truck of grief. For all we knew before he died, he was perfectly healthy, with a stellar visit with his primary care physician only weeks prior and very few risk factors for heart disease (e.g., he wasn’t a smoker, obese, or diabetic). His relatively young age and seemingly good health made his sudden death stunning and tragic. I immediately thought about everything he would never get the chance to experience (retirement with my mother, his grandson’s birth, a new home on the coast of Maine). To make matters even worse, he died on his thirty-fifth wedding anniversary. My mother found an un-signed card. (I could go on, but I won’t . . . )

    I still wince remembering the details of that day (a psychiatrist would call this a traumatic memory), and the following days and weeks were a blur of blinding shock and grief, during which I sometimes felt like I was underwater emotionally, desperate to catch a breath but unable to surface. It was nothing less than a physical experience, and a deeply alienating one that no one could understand or ease. I hurt for my father, thinking about all the life he was so abruptly deprived. I hurt for myself, in a desperate state of disbelief about the reality that I would never see him again. Most of all, I hurt for my dear mother, who had lost her mother and her life companion in the span of five months. Seeing her in her own place of anguish and wrenching grief, where I could neither reach nor comfort her, was the worst part.

    How does one get through this? While grief is a universal human experience, every individual’s suffering is unique and in certain ways incomparable. However, I feel that my own experience five years ago, combined with my training as a psychiatrist, might benefit others. Take it one day at a time; recovering from grief is not a race. Realize that life will never go back to “the way it was before” your loss, so your goal should be to – slowly and carefully – find a “new normal.” You will never stop missing your loved one or hurting over their loss, but trust (even when you can’t imagine it) that your day-to-day experience will get easier. I still think of my father every day, but memories of him are no longer always accompanied by pangs of sadness that take my breath away. And while I don’t believe that trauma makes anyone stronger, healing is possible, and you may even find that you grow in ways that you never would have otherwise.

    Take care of yourself, by doing all the things that you don’t want to do. Eat even though you have no appetite. Go to bed early or sleep in. Exercise even if you have no energy. Avoid turning to alcohol or drugs to temporarily numb the pain (they will likely make you feel worse). Do things that you enjoy and find meaningful, even if nothing brings you pleasure and everything seems meaningless. Even though you can’t concentrate, read books about other people’s grief, or books that have nothing to do with loss whatsoever. Interact with friends and family even though you feel like isolating. Let people know how they can help you (otherwise, you will drown in floral arrangements and baked ziti). For instance, you may need help with funeral arrangements, more time off or a lighter load at work for a while, or a few shoulders to cry on. Ask for what you need.

    Finally, reach out for more formal help if you’re struggling to feel better and move forward after a month or two. Grief counseling could help, either in a group or one-on-one. And if your grief prevents you from functioning for what feels like a long time or is accompanied by serious symptoms like thoughts of suicide or crippling anxiety, be sure to let your health care provider know. These are signs that you might need mental health treatment to cope with your loss, and the sooner you start it, the better.

    Grief is part of the human experience. Everyone who experiences the joy of loving will experience the pain of losing. But even when you’re suffering so much that you can’t imagine going on, it is important to remember that healing is possible, and that you can and will move forward without your loved one, but with their memory and legacy. After all, wouldn’t they want it that way, and isn’t this one of the reasons you loved them so much?

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  • Is alcohol naughty or nice?

    Is alcohol naughty or nice?

    With the Holiday Season upon us, there are many opportunities to drink alcohol. Some are undoubtedly tempted to over-indulge, and people who struggle with alcohol may find this time of year particularly challenging and stressful. But what are the benefits and risks of alcohol? Many people can enjoy alcohol without any immediate problems, and may find that it helps them to relax and socialize. In some cultures, it is important for observing traditions or celebrating religious feasts. But does an apparent lack of alcohol-related problems make it safe?

    The science on the possible benefits and safety of alcohol use resembles a mudslide more than a crystal-clear glass of chardonnay. Certainly, heavy alcohol use is associated with myriad health problems, from mental illness and dementia, to heart disease and stroke, to cancer and liver disease, to earlier death. But what about light-to-moderate alcohol consumption? Some studies have actually linked moderate alcohol use with health benefits, including decreased risk of ischemic heart disease, ischemic stroke, diabetes, dementia, and mortality.

    However, since we can’t randomly assign people to take alcohol or placebo, these studies have numerous limitations. For one, there is the “sick abstainer effect,” whereby a subset of people reporting no alcohol may actually have quit drinking due to a history of problems from past heavy alcohol use, which would put them at elevated long-term risk of certain health problems. Another problem is confounding. For instance, people who moderately consume alcohol have been shown to have higher average socioeconomic status, which is associated with better health and a longer life. Researchers have tried to control for potential confounders, but it isn’t possible to account for all of them; only randomization can do that. Finally, almost all studies are based on self-reports of drinking behavior, which is fraught with potential error and bias. We know that people tend to under-report “undesirable” behaviors like heavy drinking, and studies have attempted to correct for this, but no adjustment strategy is perfect.

    Recently, an extremely large, international study tried to get a definitive answer to the question about the safety of alcohol use. Using data from 195 locations across the globe, including 694 data sources about alcohol consumption, 592 studies on the health effects of alcohol use, and a combined study population of 28 million people, the researchers sought to determine the total burden of disease and disability caused by alcohol use between 1990 and 2016. Importantly, they did not solely rely on self-reported drinking, but adjusted alcohol consumption estimates using alcohol sales data, which were further corrected for tourism-related and unrecorded consumption.

    The findings were sobering. In 2016, alcohol was the seventh overall cause of death and disability globally, accounting for 2.2% of deaths among females and 6.8% among males. Among people aged 15 to 49 years old, alcohol was the leading risk factor for death and disability, with 3.8% of female deaths and 12.2% of male deaths attributable to alcohol use. And the study was unable to identify any safe level of alcohol consumption (or in other words, the safest amount of drinking was zero).

    But don’t pour your eggnog and brandy down the drain just yet. Even though this was a massive study with key methodological innovations, there were still limits. Like all previous studies, it wasn’t randomized, so confounding remains a possible explanation for some of the links between alcohol and health problems. Further, the findings have more obvious implications for public health than for individual risk. That means that while the study revealed important harms of alcohol use within the population at large, the danger to any individual person remains quite small. For instance, the top three causes of alcohol-related death for younger people were tuberculosis, road injuries, and self-harm. If you don’t live in the developing world, the first basically doesn’t apply to you. And if you never mix your moderate drinking with driving and have never had a problem with suicidal thinking, the next two aren’t relevant either (though someone else’s drinking and driving could still hurt you).

    For the older group, cancers were the main causes of alcohol-related deaths. This risk technically applies to everyone who drinks any amount, but the actual increase in cancer risk that an individual would experience from moderate drinking is small. For example, if a man in the United States drinks 3-4 drinks per day (moderate-to-heavy drinking), his risk of developing colorectal cancer would increase from about 4.6% to around 5.7%. Assuming this 1.1% absolute risk increase is entirely due to alcohol (and not confounders), this would mean that alcohol is causing a lot of cancer cases in the overall population, but that it arguably does not present a very significant danger for an individual person.

    Finally, especially in wealthier countries, light-to-moderate alcohol consumption was associated with a protective effect against ischemic heart disease for men and against ischemic heart disease and diabetes among women. So you might kick yourself for drinking if you develop a possible alcohol-related cancer at 70 years old, but you’d have no way of knowing whether or not this same alcohol use prevented you from dying of a heart attack at 68.

    So, by now you’re likely asking whether you should drink. Unfortunately, I can’t make a strong recommendation. Yes, there are real risks associated with alcohol, but many also find benefits in light-to-moderate drinking, and every decision we make requires some amount of weighing the risks and benefits (e.g., driving a car is fairly risky but also confers many social and economic benefits). Each person’s calculation will be personal and different. But what we do clearly know is that heavy and/or problematic drinking is very unhealthy. Heavy drinking is defined as more than 3 standard drinks a day or more than eight a week for a woman, and more than 4 a day or 14 a week for a man; and a standard drink is much less than you might think (that martini is likely 2-3 standard drinks). If associated with social, occupational, or health problems, any amount of alcohol can be considered problematic. If your drinking habit matches these definitions, you should consider cutting back and speak with your doctor if you need help. But if you enjoy light-to-moderate drinking without any problems, you may decide that enjoying a little Holiday cheer is worth the risks.

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  • The best way to prevent suicide? Reduce gun availability

    The best way to prevent suicide? Reduce gun availability

    September is Suicide Prevention Awareness Month. During this month, you’ll undoubtedly hear messages about the need to talk about suicide, reduce stigma around mental illness, and seek help through suicide hotlines (1-800-273-8255) and professional services. You may also hear about innovative programs to prevent suicide with better screening in healthcare settings and referral to mental health services, such as the Zero Suicide model. All of this is important and necessary work, which we should have started doing long ago, and to which we are fortunately paying ever greater attention and devoting growing resources. But in all of these discussions about suicide, how often will the politically radioactive topic of guns in the United States come up? My bet is that it will come up only occasionally, usually as only a side bar, and not nearly often enough. The reality is that gun safety should be central to suicide prevention, and politics is the main factor that keeps us away from the subject.

    Our avoidance of talking about and coming up with solutions for gun violence is deadly. Despite the increasing attention on suicide prevention, it stubbornly remains a leading cause of death in the United States; it is the second leading cause of death for adolescents and suicide rates are highest in people ages 45 to 55. In fact, the Centers for Disease Control and Prevention (CDC) recently reported that suicides increased substantially between 1999 and 2016. During this period, suicide rates increased in every state but Nevada, and suicide rates went up by more than 30% in half of states. In 2016, nearly 45,000 people died by suicide in the United States, substantially more than died in motor vehicle accidents.

    Why are suicide deaths growing even as we devote more resources to preventing them? Part of it is that suicide remains a rare event, with widely varying causes and precipitating factors, which makes it extremely difficult to predict and prevent. For instance, even though mental illness is a well-established risk factor for suicide, more than half of people who die by suicide in the United States don’t have a known mental illness, so it’s no wonder interventions within the mental health system have only limited effects. Part of the difficulty is also that we don’t yet have many proven interventions to effectively reduce suicidal thinking, even when we do find out about it. But one of the biggest challenges is that we are allergic as a society to talking about – never mind addressing – our gun crisis.

    In 2016, more than half of the 44,965 suicides in the United States were by firearms, and almost 60% of the 38,658 gun-related deaths were suicides . There is a strong and consistent association between access to firearms and suicide rates. Demographic groups with higher gun ownership rates (e.g., white men) have higher suicide rates; states (e.g., in the South and West) and regions (i.e., rural) with higher gun ownership rates have higher suicide rates; and people living in households with guns have a higher risk of suicide.

    Why is there such a strong correlation between gun availability and suicide? Contrary to some popular belief, suicide is not often a carefully considered, well-planned decision. Rather, it is often a highly impulsive act, carried out amidst crisis, fueled by a toxic mix of anger and alcohol or drugs. Therefore, the lethality of the means used in the suicide attempt is key to whether the person will die or survive to get the help they need. Having a gun within easy reach can very quickly turn a manageable crisis into an irreversible tragedy. This is because guns have by far the highest fatality rate, resulting in death in 80-90% of suicide attempts, while hanging results in death in roughly 60% of attempts, and overdose is lethal in less than 2% of cases. People who survive a suicide attempt are not likely to substitute more lethal means in another attempt; in fact, only about 7% of these individuals eventually go on to die by suicide. This phenomenon is the reason that while men attempt suicide at lower rates than women in the United States, they die by suicide at higher rates; it’s because they are more likely to use lethal means, particularly guns.

    So, what can we do to solve our suicide-by-gun crisis in the United States? The single most effective public health solution for firearm-related suicide – and likely even suicide overall – would be to reduce the availability of guns within the population. We know that “lethal means restriction” works for suicide prevention. For instance, studies on barriers to prevent people from jumping off bridges show sustained, community-wide reductions in suicide rates – once impulsive acts are thwarted, most would-be suicide victims do not simply find other places from which to jump. It stands to reason that removing guns from potential crises could work in much the same way. In fact, there is striking evidence that this is true. For example, citing suicide as a major cause of death in soldiers, the Israeli Defense Force changed its policy in 2006 to require that soldiers leave their guns on the base when they went home on weekends. This policy change correlated with a 40% drop in annual suicides among soldiers, with the entire decrease attributable to a reduction in suicides on the weekends.

    While population-wide reductions in firearm availability are likely to have the largest public health impact, restricting gun access for only the highest risk individuals can also save lives. The best example of policies that can achieve this are Extreme Risk Protection Orders (ERPOs), also called Gun Violence Prevention Restraining Orders. ERPOs allow family members, household members, police officers, or district attorneys (and some allow school officials) to petition a court to temporarily remove firearms from an individual’s possession when they exhibit signs that they might be a danger to themselves or others. Preliminary evidence suggests that ERPOs are effective in reducing firearm-related and overall suicide rates.

    Unfortunately, for the time-being, politics has largely won out over good sense in the United States, and we are unable to talk about or even study ways of reducing access to guns on a population level, let alone actually start doing it. So, we continue to talk about suicide and ways to prevent it every September without getting at the heart of the matter, and suicide rates continue to increase, leaving an alarming toll of death and grief in its wake. However, there are still things that individual clinicians, family members, and community members can do to reduce the burden of gun-related suicide. First, we should ask about gun ownership, because you can’t reduce a risk that you don’t know about. Healthcare professionals should ask their patients, parents should ask other parents before allowing their children to go on a play date, and everyone should ask their loved ones about gun access. Second, when you find out someone owns a firearm, you should advise them about safe storage. There are resources to help you know what to tell them. Finally, for those who may be in crisis and have access to a gun, we must do everything we can to try to temporarily restrict their access to those weapons. ERPOs can help, but many local police departments also have voluntary safe storage programs. Or maybe you can convince the person to move the guns to a safe location in a trusted loved one’s home.

    Many people are working hard to develop effective public health and clinical interventions to prevent suicide. We must continue to support them in their efforts, and hope that they see increasing success. However, in the United States today, the single most effective public health approach to begin reversing the trend of rising suicides would be to vigorously address our gun crisis. But to do this, we first need to be able to talk about it openly and rationally. For the sake of our families, friends, and communities, let’s hope we can start doing that soon.

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  • This is your brain on exercise

    This is your brain on exercise

    To support brain health, we know many things that people should not do, such as smoke, drink alcohol heavily, use most recreational drugs, and engage in activities associated with frequent head trauma. But other than getting adequate sleep, there isn’t much that we know people should do to promote brain health, sharp cognition, and good mental health. Of course, we recommend eating a healthy, well-balanced diet, but very few individual foods or nutritional supplements have been proven to be good for the brain. The same goes for “brain teaser” activities and “cognitive skills training” programs. Contrary to logic, they haven’t been shown to produce sustained benefits. However, time and again, one activity has been connected to robust improvements in brain health and prevention of brain diseases and mental health problems: exercise. And the encouraging results keep rolling in.

    Regular aerobic exercise has been linked to reduced risk of developing dementia, such as Alzheimer’s disease. This type of exercise has also been repeatedly shown to prevent depression, and has even been proven to be an effective treatment for depressive and anxiety disorders, with effect sizes roughly equivalent to medications. These benefits have been consistently demonstrated in both human studies and in studies examining animal models of mental illness. More recently, non-aerobic weight training has also been definitively associated with positive effects on brain and mental health outcomes.

    As if this news wasn’t good enough, the amount or “dose” of exercise that people need to promote brain health is not as high as you may think. Minimal amounts of exercise such as 20-30 minutes of walking or gardening a day – not even enough to lose weight – may be enough to boost cognitive functioning and lower the risk of mental health problems. So, it should be possible to fit into all but the very busiest schedules.

    Exactly how exercise helps the brain is unclear, and there are many theories, multiple of which may be simultaneously true. Exercise may increase blood flow and oxygen supply to the brain. It may also increase the production and activity of “neurotrophic” (literally “brain feeding”) factors, such as brain-derived neurotrophic factor (BDNF) []. BDNF in critical brain areas such as a memory center called the hippocampus promotes brain health and mental resilience through stimulating the growth of new neurons and connections between them. Exercise causes chemicals to be released from muscles and bones that may be essential to sustaining proper brain functioning. In addition, physical activity causes the release of several “feel good” substances, such as endorphins and endocannabinoids, which have been implicated in the feeling of general well-being and relaxation after a workout often referred to as a “runner’s high.” Finally, exercise may benefit your brain for the same reasons that it is good for the rest of your body – it lowers blood pressure and inflammation levels and enhances proper blood flow and heart functioning.

    Regardless of the exact reasons why it’s so healthy, we know that exercise is a relatively easy-to-do, inexpensive, and fun way to improve brain health and reduce the risk of mental illness and cognitive decline. So, do your brain a favor and grab those running shoes or that bicycle and head outside!

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  • Concerns about your antidepressant? Talk to your doctor!

    Concerns about your antidepressant? Talk to your doctor!

    On April 8, 2018, the New York Times published a front-page article titled, “The Murky Perils of Quitting Antidepressants After Years of Use.” The day before, the online version, “Many People Taking Antidepressants Discover They Cannot Quit,” was the most-shared article.

    In this analysis, Benedict Carey and Robert Gebeloff describe a growing trend over the past few decades in which millions of people have been taking prescription antidepressant medications long-term. For instance, they cite data showing that over fifteen million Americans have taken antidepressants for five years or more. They go on to attribute this phenomenon mostly to antidepressants causing “dependence and withdrawal,” rather than people needing long-term antidepressants to manage psychiatric illness or choosing to remain on them because of their benefits.

    While Carey and Gebeloff do cite a few studies looking at rates of withdrawal after stopping long-term antidepressant use, they only mention one survey from New Zealand that shows that withdrawal is even a common complaint among individuals taking antidepressants. Most of their argument is based on individual stories (i.e., anecdotal evidence) combined with critiques of how antidepressants have been studied. While the individual stories are compelling and the critiques of research may be valid, this approach makes their case linking long-term antidepressant use to supposed widespread withdrawal circumstantial at best.

    Fortunately, several psychiatric care providers and even patients quickly responded to counter this somewhat misleading article. To be fair, the authors do point out that antidepressants have greatly helped millions of people, and they quote psychiatrists who are expert in treating depression, such as Dr. Peter Kramer. However, overall, the piece uses logically and scientifically shaky arguments to trigger suspicion and fear of antidepressants among the general public and mental health patients alike. Given that depression and other mental illnesses that antidepressants treat (e.g., anxiety disorders) are very common, highly impairing, sometimes dangerous, and exceedingly under-treated, this type of journalism is risky.

    The fact is, antidepressant medications are effective, especially for moderate-to-severe depression, and while all medications have side effects, newer antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are far more tolerable than older versions. In addition, the past few decades have seen a growing consensus that depression (and many other mental illnesses) is a chronic condition requiring long-term treatment, like diabetes and hypertension. (No one would say that millions of people are on long-term blood pressure medications for hypertension because of fear of withdrawal.)

    Therefore, many psychiatrists recommend (and many patients readily choose) long-term antidepressant treatment to avoid relapse once a person has had more than one depressive episode. “Withdrawal” from antidepressants (actually called discontinuation syndrome) is in fact a well-known and not-rare phenomenon. However, it is usually very mild and can be managed with a slow taper in the medication’s dose. For the relatively rare, more severe cases, a good psychiatrist can almost always reduce or eliminate it with various interventions such as adding low-dose fluoxetine (Prozac) for a while (due to its long half-life) and/or using other prescription drugs in a time-limited manner to treat discontinuation symptoms.

    Just like in any medical specialty, not all psychiatric care providers are attentive, responsive, or skilled enough to avoid or successfully manage discontinuation syndrome, but that’s a different problem that can’t be solved by avoiding antidepressant treatment to begin with. So, rather than an inability to stop them due to “withdrawal,” doesn’t it seem much more likely that growing numbers of people are on antidepressant treatment long-term either because they need the medication to prevent symptoms from returning and/or choose to remain on the medication because of low side effect burden and protection against relapse?

    The article does make some valid and important points. The research on antidepressants mostly involves relatively short-term studies, so there is a great need to examine the longer-term efficacy and adverse effects of these prescription drugs. And the discontinuation syndrome has received far too little research attention.

    These deficits in the science are indeed likely due to pharmaceutical companies having little incentive to investigate prescription drugs that have gone generic or to emphasize problems with the products they produce and market. However, it is unfortunate that these valid critiques were packaged into a misleading and highly public message, which has the potential to discourage people from seeking treatment for mental illness and encourage patients to stop their medications.

    Advice from this psychiatrist: Discuss your goals for treatment and any problems with medications with your healthcare provider before changing or stopping them on your own. No one – not even your doctor! – can force you to stay on a medication that you no longer want to take, but only an experienced professional can help you to change medications in a safe and healthy way.

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  • Caregiving for someone with serious mental Illness: Secure your own oxygen mask first

    Caregiving for someone with serious mental Illness: Secure your own oxygen mask first

    As a psychiatrist, I know how challenging it can be to ensure that individuals with serious mental illness get the right mental health and medical care, not to mention have access to basics like housing, food, and income. And as a family member of someone with mental illness, I know firsthand the toll it can take on loved ones and caregivers.

    The healthcare system can be bewildering. Navigating health insurance, coordinating between multiple specialists, understanding complex and sometimes conflicting medical advice, and getting timely answers to questions can be dizzying for anyone. Add symptoms of mental illness to this and it is often downright impossible.

    Financially affording mental health care adds another layer of stress. Federal law notwithstanding, many private insurance plans have some ways to go before they can say they provide true parity in mental health coverage. Many people with mental illness are unable to work, which puts employment-based private insurance out of their reach. They therefore must depend on public insurance such as Medicaid and/or Medicare.

    Some types of intensive mental health services (e.g., Assertive Community Treatment teams) are only paid for by Medicaid. However, paradoxically, the people who need public insurance (and other public benefits, like Social Security Disability Insurance) are often the least capable of successfully completing the onerous application process. So, many individuals with serious mental illness who are lucky enough to have supportive family members and close friends often must turn to them for help.

    But helping a loved one with serious mental illness is invariably stressful. First, navigating the healthcare and public benefits systems is complicated, frustrating, and often demoralizing. It can sometimes feel like the entire system is designed to avoid helping the people who need it most. Even as a physician and mental health professional with multiple nurses in my family, I struggled with this when trying to support my own loved one with mental illness.

    Second, the symptoms of the mental illness itself can make caregivers anxious, fearful, angry, or depressed. Family members may spend a lot of the time worrying that their loved one may self-harm or be unable to care for themselves. Caregivers may occasionally worry for their own safety during times of crisis. Loved ones may need to take people with serious mental illness into their homes and feel deprived of privacy or quiet space. They may be juggling many other responsibilities alongside caring for an individual with serious mental illness and have no time for self-care or relaxation.

    Repeatedly witnessing the suffering that mental illness can cause may drag their mood down over time, leading to emotional distress and hopelessness. The list goes on, and for these reasons, family caregivers tend to have worse mental and physical health, and may be at increased risk for suicide. Especially for those with a high level of strain or stress, caregivers are even more likely to die early.

    So, what are caregivers to do? How do we provide the help that our loved ones may so urgently need while maintaining our own mental and physical health? There are no simple answers or easy fixes to this dilemma, but several “best practices” might help. First, do not go it alone. Frequently ask other family members or friends for help or even to take over the primary caregiving responsibility for a while. Consider joining a support group for family members of people with mental illness. The National Alliance on Mental Illness (NAMI) is a wonderful organization; find your local chapter.

    Second, hold treatment providers accountable. Their jobs are stressful, and they are operating under serious resource constraints. You can empathize with this, but remember that it is still their job to do whatever they can to help people with mental illness achieve full recovery, and sometimes family members must remind them of this and focus their attention on important problems.

    Third, look for expert advice outside of the healthcare system. For instance, consulting an attorney to help sort out issues related to benefits, housing, or guardianship could save enormous time, energy, and frustration. Do not assume you cannot afford it; many communities have non-profit agencies that provide this type of assistance on a sliding scale fee or pro bono basis and it is likely worth a little research.

    Fourth, set limits. Realize that recovery from serious mental illness is more like a marathon than a sprint, that setbacks are part of the process, and that you need to reserve your energy if you are to make it to the finish line of the caregiving race. You cannot do it all, you can’t recover for your loved one, and you can’t live their life for them. If you try to do everything for someone and/or be instantly available for them one hundred percent of the time, you will burn out and be less able to help them when truly necessary. Possibly worse, you risk sapping their ability and confidence to care for themselves and (re-)attain independence.

    So, take time away from caregiving to rest, meet your own emotional and physical needs, socialize with friends who are not connected to your caregiving role, and enjoy your own life. Your loved one will likely be just fine, and even if they aren’t, it’s not your fault for taking a little time away.

    Finally, if you are suffering from symptoms of anxiety or depression, be sure to let your healthcare provider know and seek out your own mental health treatment if necessary. Remember that asking for help is a sign of strength and resilience; a good model for your loved one with mental illness and a lifeline for yourself.

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  • Losing sleep over insomnia medications? How to get healthier shut-eye

    Losing sleep over insomnia medications? How to get healthier shut-eye

    Insomnia is common, and becomes more so with age. Sleepless nights can come with a host of problems and much distress: grogginess and poor daytime functioning, anxiety, irritability, depressed mood, increased chance of accidents and injury, weight gain, multiple chronic health problems, and even elevated risk of death. So, it’s perfectly understandable that many people turn to medications to get to sleep, and that many physicians (including myself) are quick to prescribe them.

    Medications for insomnia include sedative-hypnotic medications that are approved by the Food and Drug Administration (FDA) for treatment of insomnia (e.g., zolpidem, eszopiclone, temazepam, lorazepam, suvorexant), sedative-hypnotic agents that are not officially FDA-approved for insomnia (e.g., clonazepam, alprazolam, diazepam), other classes of medications that have an FDA indication for insomnia (e.g., ramelteon, doxepin), and other classes that are used off-label for sleep (e.g., trazodone, amitriptyline, hydroxyzine, quetiapine). Many people find medications for insomnia helpful, but the science doesn’t necessarily reflect this anecdotal experience.

    First, when rigorously compared to placebo, medications for insomnia seem to only marginally improve the amount of time that it takes people to fall asleep and the total duration of sleep they get per night. In addition, insomnia medications are associated with many side effects and poor outcomes. Most reduce sleep quality by suppressing important phases of the sleep cycle, such as deep sleep and rapid eye movement sleep (REMS). So, even if you’re technically sedated, you might not be getting restful, restorative sleep.

    Studies of sedative-hypnotic medications have found that they may increase the risk of dementia and death. Many of these drugs are also potentially addictive and can interact with other medications (e.g., opioids) to increase the risk of accidental overdose. Even if you don’t get addicted per se, they tend to cause a physiological dependence, such that if you try to stop them, you will experience “rebound” insomnia and anxiety.

    Non-sedative-hypnotic sleep medications may not share these concerning side effects, but have other drawbacks. Drugs that have anticholinergic properties can cause constipation and dry mouth, may make people mentally foggy throughout the day, and could increase the risk of cognitive problems. Medications with antihistamine effects can also cause daytime grogginess and may cause weight gain.

    The risks of insomnia medications may be particularly concerning in older adults, in whom they have been associated with multiple problems including cognitive decline and increased fall/fracture risk. But all of these dangers have not deterred prescribing, and in fact rates of insomnia medication use have been steadily increasing, especially in older adults.

    So, what should you do if you’re struggling to get a good night’s sleep but don’t want the risks and problems associated with insomnia medications? First, you should speak with your healthcare provider to make sure you don’t have an underlying, treatable cause of insomnia, such as anxiety, depression, an endocrine problem, or sleep apnea. Consider requesting an official sleep study. Second, if you are already on sleep drugs, discuss with your provider how to slowly and safely taper off them. It isn’t a race, and you don’t want serious withdrawal! Third, be sure to learn about and practice good sleep hygiene.

    Avoid bright lights (especially screens!) within a few hours of bedtime; by mimicking sunlight, they send a strong “awake” signal to your brain. Instead, do something relaxing, like listening to music, meditating, or reading from a (physical) book or magazine under a relatively dim, warm light. Make sure your bedroom is as dark, quiet, and cool as possible. Try to maintain a consistent sleep routine by avoiding naps and going to bed and waking up at the same time each day. Don’t consume caffeine after lunchtime. Steer clear of alcohol or other drugs like marijuana before bed, as they will suppress restful sleep even if they sedate you. Restrict bedroom activities to sleep and sex; don’t work, eat, or socialize in bed. Set an alarm and then turn the time display away from you; repeatedly checking the clock all night does nothing other than cause anxiety, which contributes to insomnia.

    Finally, consider asking for a referral to cognitive behavioral therapy for insomnia (CBTi). CBTi is an evidence-based psychotherapy that has been shown to be at least as effective as insomnia medications, without any of the side effects. It involves correcting false beliefs that cause anxiety around insomnia and disrupt sleep (i.e., “cognitive”), and changing behaviors that harm the natural sleep cycle (i.e., “behavioral”). During CBTi, your therapist will help you over time to reduce self-perpetuating worries about sleep, and to slowly adjust your sleep schedule until it is natural and healthy.

    Insomnia is very common and highly distressing, so reaching for the pill bottle is an understandable reaction. But there are proven ways to improve sleep without drugs. Trust that with a little effort, you can get the natural good night’s sleep that you need to be healthy and function at your best.

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  • Congress must protect our community health centers

    Congress must protect our community health centers

    Every Thursday morning, I wake up excited for the 14-hour day I’m about to begin. My Thursdays are so long because that’s the day I work a second evening job at a Federally Qualified Health Center (FQHC) that serves New York City’s lesbian, gay, bisexual, transgender, and queer (LGBT+) population. Why am I so happy to work a longer day? Not because I am a glutton for punishment, but because the work is truly satisfying in the way that only feeling completely confident in the care I’m providing can make me feel.

    The FQHC I work at provides essential medical and mental health care to an often-vulnerable population. Beyond the stress of being LGBTQ+ in our society, the patients I see are mostly uninsured or on Medicaid. Many have HIV/AIDS, substance use problems, and/or significant mental illness. I see individuals from diverse backgrounds and all age groups, from trans youth struggling with histories of abuse or homelessness, to older gay men who survived the AIDS crisis and lost many loved ones. Each person comes with a painful yet inspiring story, filled with strength, resilience, and love.

    And the care provided at this clinic, like most FQHCs – also referred to as Community Health Centers (CHCs) – is not just “good for the safety net.” It is the highest quality; often better than many private practice settings on multiple quality measures. Why is this?

    First, the care is truly integrated. I share a single medical record and can easily communicate with my patients’ medical providers. This reduces the chances of errors and conflicting treatments, such as drug-drug interactions. Quality improvement initiatives from the medical clinic apply to the mental health clinic and vice versa.

    Second, as federally funded clinics that participate vigorously in the Medicaid program, CHCs are often the first to know about and participate in health systems improvements and innovations. Despite what some private providers might tell you, government does a lot more than add bureaucratic hurdles; it attempts to ensure that health care is delivered in a safe and equitable way, is informed by evidence and guidelines rather than idiosyncratic clinician ideas and habits, and is responsive to public health needs. For instance, CHCs were on the frontline during the AIDS crisis, and are now playing a similar role in responding to the opioid epidemic.

    Third, CHCs are often full of passionate, mission-driven clinicians who deeply believe in what they are doing and care about the populations they serve. At the CHC where I work, clinicians are constantly sharing recent evidence, clinical advice, and local resources relevant to the LGBTQ+ population. Wouldn’t you want to be cared for by a group of individuals who are passionate about serving you and continuously communicating about better ways to do so?

    Finally, CHCs specialize in providing high quality primary care, which has been shown to produce the best outcomes. They are beacons of well-coordinated, efficient medical care in our specialist-driven and siloed health care system. This translates to better care at a lower cost!

    There are more than 10,000 CHCs in the United States, providing care for about one in thirteen Americans (and an even higher proportion in some states). In addition to primary care and behavioral health (i.e., mental health and substance use) services, like those provided where I work, many CHCs also provide dental and vision care. For the reasons above, 86 percent of primary care providers at CHCs are satisfied with their work, and 73 percent of patients who use CHCs as their primary source of medical care feel that it is high quality.

    It is therefore not surprising that CHCs have long enjoyed strong bipartisan support. Regardless of your political leanings, CHCs are clearly a rare example of a great deal in American healthcare. However, during recent fights over funding the federal government that resulted in two brief shutdowns, the Community Health Center Fund expired on September 30, 2017, and was not reauthorized until February 9, 2018. The Continuing Resolution that reopened the government in January included funding for the Child Health Insurance Program (CHIP) but not CHCs.

    If Congress had not restored funding in the nick of time, the Department of Health and Human Services estimated that about a quarter of CHCs would have had to close, resulting in nine million people losing access to healthcare and 51,000 job losses. Many CHCs had already begun deferring important investments and delaying staff hiring.

    This barely averted tragedy has received far too little attention. Let’s not take our CHCs for granted ever again; let’s avoid this kind of near miss in the future.

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  • Clearing the air on marijuana use

    Clearing the air on marijuana use

    United States Attorney General Jeff Sessions just announced that he would reverse the Obama-era decision to not prosecute federal marijuana-related crimes in states where the drug has been legalized. And so again, marijuana is in the headlines. But amidst all the buzz, what do we actually know about the health effects of marijuana? This controversial topic could use an injection of calm, rational, fact-based discussion. As a psychiatrist specializing in the treatment of serious mental illness and co-occurring substance use disorders, I can provide a little clarity.

    First, although nowhere near as damaging to public health as other drugs including tobacco, alcohol, and opioids, we can’t let cannabis completely off the hook. Many people can use pot safely in moderation, but there are several highly vulnerable groups who should avoid it. Despite numerous claims and even some state medical marijuana laws, there is little-to-no scientific evidence that weed helps any mental illness, and it can be addictive. In fact, there are studies showing that cannabis can make depression, anxiety, and post-traumatic stress disorder worse. So, people with psychiatric problems should probably steer clear of that joint. When the brain is forming in the womb, even the slightest external disruption can cause major problems for the child later on, so pregnant women should not use cannabis. Adolescence is another period of rapid and critical brain development, so it’s little surprise that cannabis use – especially frequent or heavy use – can disrupt academic achievement and lower IQ. Parents and teachers need to help young people make healthy choices about marijuana.

    Second, speaking of adolescents, cannabis use raises the risk of developing a psychotic disorder, like schizophrenia, and lowers the age at which psychosis begins. This risk is higher with heavier use as well as use that begins at a younger age. There are also risk factors that make people much more likely to become psychotic after smoking weed, including a family history of schizophrenia, experiencing abuse or trauma in childhood, and growing up in an urban environment. Since psychotic disorders like schizophrenia cause massive disability worldwide, this is an important public health concern.

    For older adults without a history of psychiatric problems, moderate marijuana use may be relatively safe for their mental health. However, cannabis smoke has many toxins including carbon monoxide and particulate matter that could cause and exacerbate medical problems. For instance, marijuana has recently been linked to increased risks of stroke and heart failure. Vaporizing or eating pot may be safer options, though we aren’t completely sure.

    But aren’t there benefits to cannabis use? Maybe. There is some evidence that marijuana can provide relief for certain, specific medical conditions, such as severe pain from neurological problems, anorexia from HIV/AIDS, or maybe even seizures. And certain compounds in the marijuana plant – like cannabidiol – may help with some psychiatric symptoms.

    So what to do? Avoid marijuana entirely? Support Jeff Sessions in his quest to start locking people up again for marijuana possession? On an individual level, the decision whether to use cannabis for medical or recreational purposes is highly personal, but people should at least be informed by scientific evidence rather than media hype, anecdotes, and strong opinions. On a societal level, my opinion is that the War on Drugs has been a complete failure for all drugs, but especially marijuana, causing many more problems than it has purported to solve. Rather than prosecute marijuana users, we should take a public health approach to help people who have a pot problem and work to prevent cannabis use in vulnerable populations like adolescents. And we should pursue rigorous scientific research to find effective ways to prevent harm from marijuana, and search for new medical treatments that could be hiding in this multi-faceted and fascinating plant.

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