UNDERSTANDING THE REAL COSTS OF DELAYING MENTAL HEALTH TREATMENT

One of the many reasons I love my work is that I have the honor and pleasure of seeing most of my clients get better. Do I have special skills that other mental health clinicians do not? No, my work simply mirrors the statistics on the efficacy of mental health treatment. Research shows that therapy is effective at least 80 percent of the time.

Since therapy usually helps, and no one wants to suffer, why are we our own worst enemies when it comes to getting help? Our tough inner critic tells us "you should be able to snap yourself out of this", or "you don't have it so bad, think about what Mary next door has been through", or "you need to help the kids, you're not as important." My wish for folks suffering from mental health challenges or family struggles is that they view mental health treatment as a tool that can help them move towards their future, not as a failure and a last resort.

Recently I have noticed an increase in the length of time clients are waiting to get themselves or their kids to treatment. My colleagues have shared the same observation with me. There are good reasons: financial challenges, increasingly spartan or absent insurance coverage, busy family schedules, and the still present stigma in our culture towards mental health treatment. The problem with delayed treatment is that it increases the likelihood of the development of a second mental health challenge, a substance abuse problem, and physical illness.

Not only does the client get worse if not getting help, but family members and co-workers are also sorely tested by caring for or working with a depressed, highly anxious, bi-polar or substance-involved individual. Many times the people that end up in my office have anxiety or depression that has been triggered by living or working with someone who has not sought help for their own challenges. Delays in getting help often leads to multiple family members in crisis. Jobs are lost, marriages fail, and academic careers stall.

The decision to see a therapist does not bind you to a never-ending series of weekly appointments. One of the important roles a trained therapist plays for you or your child is "assessment".  We evaluate a client's functioning in their environment: home, school, work, relationships, and community. We work with clients to collect data by interview, observation, surveys and test (psychologists) instruments. Thanks to the assessment process, clients can decide whether to enter the "therapy or treatment" phase of mental health treatment after gaining an understanding of their diagnosis and treatment options. After the assessment, I may recommend that a client meet with a psychiatrist, nutritionist, career counselor or life coach. Sometimes I work with parents to help them sort through parenting challenges without ever seeing the child.

The bottom line is that there may be much to gain by investing in a few visits. Unfortunately, waiting until you or your child are too sad to get out of bed in the morning, or your daily glass of wine has turned into a daily bottle, will likely cost more time and more money, and more importantly, needless suffering.

Guest Blog: "SLEEPING WITH THE TURKEY" by Jon Brody

This week I am featuring a guest blog by Jon Brody, Executive Director of Keiler Healthcare.
Enjoy!

SLEEPING WITH THE TURKEY

POSTED BY EDITOR PROGNOSIS 2.0 ON NOV 20, 2013 IN UNCATEGORIZED, WEEKLY NEWS

This week most of us will be sitting down to a turkey feast.  Many of us have heard that the L-tryptophan in the turkey is what makes us drowsy after the huge meal.  Well, as it turns out, turkey contains no more of the amino acid tryptophan than other kinds of poultry. In fact, turkey actually has slightly less tryptophan than chicken, according to a report on Web MD.  It’s more likely the huge calorie intake, maybe the wine or maybe just wanting to tune out a noisy and nosey relative that gets us napping.  We at Prognosis 2.0 think anything that gets us a bit more sleep is a really good thing, because insomnia is directly linked to depression, heart disease and other illnesses.

It’s too bad that turkey doesn’t work, because curing insomnia in people with depression could double their chance of a full recovery, scientists are reporting. This week The New York Times and ABC News reported the findings, which are based on an insomnia treatment that uses talk therapy rather than drugs. These results are the first to emerge from a series of closely watched studies focused on sleep and depression that will be released in the coming year.

Depression is the most common mental disorder, affecting some 18 million Americans in any given year, according to government figures. And more than half of those who are depressed also suffer from insomnia.

The cycle is tough to break. You lie in bed depressed and worrying.  The anxiety keeps you awake; you become even more tired and then more depressed.

The depression-insomnia connection is indisputable and confirmed by a new study, which is the first of four on sleep and depression. The other three studies are nearing completion, and all are financed by the National Institute of Mental Health. In these studies researchers are evaluating a type of talk therapy for insomnia that is cheap, relatively brief and usually effective, but not currently a part of standard treatment.  This treatment might actually find a way to reduce the amount of Prozac and other medications that are currently used to reduce depression.  If we combine both, then maybe we can dramatically improve sleep and reduce depression.

As reported in The New York Times, a team at Ryerson University in Toronto found that 87 percent of patients who resolved their insomnia in four, biweekly talk therapy sessions also saw their depression symptoms dissolve after eight weeks of treatment, either with an antidepressant drug or a placebo pill — almost twice the rate of those who could not shake their insomnia. Those numbers are in line with a previous pilot study of insomnia treatment at Stanford.

Full-blown insomnia is more serious than the sleep problems most people occasionally have. To qualify for a diagnosis, people must have endured at least a month of chronic sleep loss that has caused problems at work, at home or in important relationships. Several studies now suggest that developing insomnia doubles a person’s risk of later becoming depressed — the sleep problem preceding the mood disorder, rather than the other way around.

The therapy is called cognitive behavior therapy for insomnia, or CBT-I for short. The therapist teaches people to establish a regular wake-up time and stick to it; get out of bed during waking periods; avoid eating, reading, watching TV or similar activities in bed; and eliminate daytime napping.

As reported in The New York Times, the four larger trials are to be published in 2014.  In these studies, the participants keep sleep journals to track the effect of the CBT-I therapy, logging what time they go to bed every night, what time they started trying to fall asleep, how long it took, how many awakenings they had and what time they woke up.  I have been in a similar study, as I averaged 2-3 hours of sleep a night for 13 years.  Even Thanksgiving Turkey couldn’t get me to rest for more than a few hours.

So get some rest, enjoy the holiday and come back to work refreshed.  If you are feeling a bit depressed maybe a little CBT along with the turkey is just what the doctor ordered.

Let the Sunshine In

As a clinical social worker, I have observed firsthand the effects that vitamin D levels can have on mood.  The shorter days of Winter are tough on many people. Vitamin D- which our bodies make when exposed to the sun, is crucial for making hundreds of enzymes and protein and interacting with more than 2,000 genes vital for health and fighting disease- is in limited supply.  Vitamin D deficiency has been linked to chronic modern diseases such as heart disease, diabetes, cancer, osteoporosis, and depression. 

Several studies suggests that Vitamin D deficiency and depression are linked, and that increasing Vitamin D levels can help. We do not know whether low levels of vitamin D cause depression, worsen it, or are a symptom of the underlying depression. One study included  adult women with depression, all of whom were taking antidepressants. The women were also being treated for Type 2 Diabetes or an underactive thyroid gland. All were deficient in vitamin D, with levels under 21 ng/mL. Levels below 21 ng/mL are considered vitamin D deficient.  The women received vitamin D therapy for eight to 12 weeks. After treatment, their levels increased to 32 to 38 ng/mL. The women also reported improvements in symptoms of depression following vitamin D therapy. One woman's depression score changed from indicating a major depression to mild depression.  

I believe that many doctors and mental health professionals have had similar experiences with patients. I have had three clients who presented with major depression, tested below 10ng/ml in vitamin D, and after 10 weeks of receiving vitamin D supplements and weekly therapy, experienced a remission in their depression. Of course we can't measure how much improvement was caused by the increase in Vitamin D, and how much was caused by therapy.  My stance regarding treatment is to  use every helpful, healthy tool available to combat depression.

In addition to the clients who have suffered from major depression and had their Vitamin D levels tested, I have had many clients who have described and exhibited increased symptoms of depression in the late Fall and Winter. Seasonal Affective Disorder (SAD) is real, can be debilitating, and is prevalent when vitamin D stores are low.  In one study, eight subjects with SAD received 100,000 I.U. of vitamin D daily and all experienced a significant lessening of their depression as measured by the Hamilton Depression Inventory. Vitamin D blood levels improved by 74% in all eight subjects.  Vitamin D may be an important treatment for SAD. More, larger studies will be necessary to confirm these findings.

Vitamin D is called the sunshine vitamin because our bodies produce it when exposed to sunlight. Sunlight is an excellent source of vitamin D.  A person sitting outside in a bathing suit in New York City gets more vitamin D in 20 minutes than from drinking 200 glasses of milk.  Many experts suggest getting 10 to 15 minutes of sunshine sans sunscreen three times weekly.  Talk to your doctor about the pros and cons of sun exposure for you. 

Vitamin D is also added to milk and other foods, and is available in small amounts in fatty fish like tuna, salmon, and mackerel; beef liver, cheese, and egg yolks. It can be hard to get as much as we need from our diets, which is why supplements are often needed. Many, but not all, doctors include Vitamin D levels in their standard battery of blood tests when patients come in for a physical. Make sure you check with your doc if you are depressed, and request a blood test for Vitamin D levels. Your health depends on it.

Anxiety or Imposter?

We all experience some degree of anxiety in our lifetime. It can range from mild and time-limited, such as nervousness before a test, to debilitating and pervasive, such as struggling daily to leave home. Anxiety is one of the top reasons people seek therapy. Fortunately, therapists have made great strides in the past two decades in our knowledge of how anxiety affects the brain and the body, and how to treat it effectively.

I have worked with clients who came to therapy with different experiences of anxiety: panic attacks, being scared to be alone, being afraid of bridges, and living in fear of throwing up in public. Other clients suffer horribly from frequently being in a general state of high anxiety. 

Anxiety can make us miserable

What is heartening is that with a combination of relaxation techniques, cognitive strategies, and exposure therapy, most of my clients got better within a few months. Sometimes, however, these strategies have not helped clients. Several times the client and I have identified that their anxiety was actually a decoy.

This may sound strange, but anxiety is actually easier for some of us to experience than our emotions. Most of the time, when treatments for anxiety are ineffective, it becomes apparent that clients are struggling deeply with grief, a painful decision, or depression. Once the client and I agree that there is more going on than anxiety, we can get to work on strategies to help them face the underlying issues. It requires work, but clients report a decrease in anxiety within a few weeks of beginning to recognize and experience their emotions. 

If you suffer from anxiety and have struggled to feel better,  try to identify if you have been avoiding a difficult emotion or decision. If you think this is a possibility, spend 15 minutes at a set time every day for a week allowing yourself to "feel" that emotion or discomfort. Hopefully you will begin to feel better. If not, you may benefit from a few visits with a therapist or counselor. Don't let anxiety, real or imposter, keep you from enjoying life.


Please let me know if you suffer from anxiety, and what techniques help you feel better by commenting on this blog post.

Be well-

Laura

Superwoman Syndrome

All too often women, especially mothers, use the three dirtiest words in the English language: "should, could, and would".  This type of thinking is an energy-draining, unproductive trap that is important to avoid.

You are likely carrying a very heavy load of responsibilities, which makes it impossible to do anything perfectly. In addition to taking care of yourself, chances are good that you are also caring for several others: a partner, children, an aging parent, a pet, your home, and a business. There is not enough time in the week to perform all of these roles well. It is easy to slide into a negative thought process and focus on what you “should” have done differently- beating yourself up rather than acknowledging the many things you are doing well.

This type of thinking is common in perfectionists. It contributes to exhaustion, high stress levels, and low self-esteem, which can in turn contribute to depression and anxiety.  It is really important to observe your tendency to be self-critical, and work to change your negative thought processes.

Change your thought patterns and behavior for the better:

•   Repeat until you believe: "The best thing I can do for everyone is take care of myself." in addition to getting enough sleep, eating well, and exercise, schedule doctor and dentist appointments for yourself religiously.

•   Prioritize and be realistic. Studies show we usually under-estimate how long everyday tasks will take. Block out time on your calendar for everything from grocery shopping to running errands to exercise. With practice, this technique may help you break the cycle of always feeling behind and/or running late.

•   Think about or write down what you HAVE accomplished.

•   Ask for help. It may be painful at first, but you will be doing everyone a favor if children and your  partner become more self-sufficient and you become less stressed.

•   Evaluate and adjust relationships. Which friendships are truly genuine and reciprocal? Which ones feel like obligations and are draining?

•   Are you being penny-wise and pound-foolish? Unless you really enjoy pulling weeds, your time investment in your job or business will likely eventually reap more money than the going rate for yard work will cost you.

•   Review decisions. Some decisions are wonderful in theory but do not stand the test of time. Volunteer commitments, children's activities, certain social obligations, and household rules can and should be re-evaluated and adjusted frequently.

Women are twice as likely to become depressed as men, and are particularly vulnerable after giving birth and during the years around menopause. If you notice your are engaging in an unhealthy habit such as over or under-eating, drinking to excess, abuse of prescription or street drugs, isolating yourself from others, or engaging in an inappropriate relationship, seek help.

You deserve to enjoy some peace of mind and free time long before retirement or your children are grown. It is time to put the Superwoman myth to rest.

Be well,

Laura

Surviving Snow-Fatigue, or Snow Derangement Syndrome

With the huge amounts of snow, cold and grey skies we have had this Winter, many of us are feeling desperate for warmth and sunshine. Unless you have the good fortune to be able to flee to a tropical hideaway, it's a good idea to shake up your routine. 

• Humor is healing. Seek out a funny friend or a favorite comedy.
• If you have children, remember that you are not responsible for entertaining them. Challenge them to come up with new games and to entertain themselves. A great book full of old school, inexpensive activities is "The Orange Mama Laid", by Kirsten Denny. (Available on Amazon)
• Get outside on sunny days. Even better, leave your sunscreen off for 15 minutes to maximize absorption of Vitamin D.
• If you exercise, try a new sport or class to create some novelty for your body and brain.
• Plan your real or imagined spring garden. Consider starting seedlings indoors in March. Visualizing a bountiful garden and planning for fresh food will lift your spirits.
• Do a good deed. Even small acts like offering a smile to a cranky neighbor or letting someone into traffic have been scientifically proven to reduce stress and create a feeling of well-being.
• Check your caffeine intake. We often unconsciously increase our caffeine consumption during the Winter to keep the cold at bay. If this is the case for you, gradually bring it back down to no more than two to three cups a day. More than that can cause irritability and interfere with sleep.
• More hours indoors can lead to more hot Toddys and wine by the fire. If you are prone to the blues, limit your alcohol intake as much as possible- it's a depressant, and it interferes with sleep. 
• Low folic acid levels are associated with depression. A good source of folic acid is found in leafy green veggies. If they aren't your top food choice, chop them and add them to soups and stews for the last five to ten minutes of cooking. This works well with swiss chard and spinach.



Even my snow-loving Golden Retriever, Ginger, is struggling this Winter!

• You've heard it before, but I would be remiss if I did not mention Omega 3 fatty acids, which play a crucial role in overall health. However, Omega 3's are found in greater concentrations in the brain than in other parts of the body, and have been shown to alleviate depression. Omega-3s can be found in fatty fish like wild salmon, sardines, Atlantic mackerel, and in lower quantities in ground flaxseeds, walnuts and omega-3 fortified eggs. Ground flaxseeds can be substituted for small portions of flour or pancake mix without sacrificing taste. Kirkland Signature Natural Fish Oil Concentrate with Omega-3 Fatty Acids - 400 Softgels

Making all these changes would be daunting. Try choosing a few that appeal to you, and monitor your mood, health and overall level of functioning for the next few weeks. Hopefully you will see some positive results. If your low mood persists, you may be suffering from Seasonal Affective Disorder (SAD) or depression, and should consider getting a professional opinion from a licensed therapist. 

Medicine, Therapy, or Both?

Twice yesterday clients asked good questions about medication, therapy, and how they relate to each other.

A new client, "Mr. X"*,  was prescribed an anti-depressant by his doctor for ongoing depression due to his wife's death several years ago.  He asked my opinion about anti-depressants. He was reluctant to take an anti-depressant, feeling that he should be able to "get over it" on his own.  Like many wise individuals, my client is concerned about his health, and does not want to ingest anything that could harm him. Although like all medications, anti-depressants can cause side-effects, for most people the benefits far outweigh the side effects. Furthermore, we live in an era when there are a number of effective medications for depression, and if the first medication you try leaves you with undesirable side effects, there is a good chance that the next one your doctor prescribes will not.

What I have observed is that for some clients, anti-depressants are a temporary bridge between depression and a return to being "yourself".  Many people who are depressed are bothered by cloudy thinking and/or circular, repetitive thoughts. In such a state, clients are not always able to use therapy to it's full potential. However, anti-depressants help many people return to their normal, logical thought process. When clients can think clearly, they are able to use techniques that they learn in therapy and apply them to their outside life. Once a client feels that they are functioning and feeling better, it is often possible to gradually discontinue anti-depressants. Contrary to what some believe, anti-depressants are not addictive, but discontinuation absolutely needs to be monitored by a qualified physician.

"Bridge the Gap" between medicine and therapy

At this point you may be wondering if I am in the back pocket of a pharmaceutical firm. Absolutely not. I cannot prescribe medication. In fact, I always work with a client on natural stress reducing and mood boosting techniques before making a referral for a medication evaluation.  However, in some situations, the ongoing stress of a death, job loss, or family problems can wear people down to the point where their brain chemistry needs stronger support- ie-medication.

Many well-done independent studies have been done to research what the best treatment is for depression. The results are consistent: many people get better from therapy, many people get better from anti-depressants, but the most effective, quickest way to feel better is through a COMBINATION of medication and therapy. 

Regardless of what "Mr. X" decides regarding medication, I look forward to working with him to help him find his unique path to healing.

Be well,

Laura

 *Details changed to protect client's anonymity.

A helpful model for recovering from depression from Positive Psychology News

In working with clients, I help them try many different techniques to start their recovery from depression.

One strategy that is helpful for some people is a cognitive behavioral technique called structured writing.

Another technique,  described in the excellent article I have linked you to, is to "re-write" your own life in a more helpful way. The article also has an excellent visual model of depression that you may find helpful.

http://positivepsychologynews.com/news/bridget-grenville-cleave/2010053011260

Be well,

Laura

Beating the Winter Blues

With three times the normal amount of snowfall already recorded for January, many of us are feeling desperate for warmth and sunshine. Unless you have the good fortune to be able to flee to a tropical hideaway, it's a good idea to shake up your routine. 

• Humor is healing. Seek out a funny friend or a favorite comedy.
• If you have children, remember that you are not responsible for entertaining them. Challenge them to come up with new games and to entertain themselves. A great book full of old school, inexpensive activities is "The Orange Mama Laid", by Kirsten Denny. (Available on Amazon)
• Get outside on sunny days. Even better, leave your sunscreen off for 15 minutes to maximize absorption of Vitamin D.
• If you exercise, try a new sport or class to create some novelty for your body and brain.
• Plan your real or imagined spring garden. Consider starting seedlings indoors in March. Visualizing a bountiful garden and planning for fresh food will lift your spirits.
• Do a good deed. Even small acts like offering a smile to a cranky neighbor or letting someone into traffic have been scientifically proven to reduce stress and create a feeling of well-being.
• Check your caffeine intake. We often unconsciously increase our caffeine consumption during the Winter to keep the cold at bay. If this is the case for you, gradually bring it back down to no more than two to three cups a day. More than that can cause irritability and interfere with sleep.
• More hours indoors can lead to more hot Toddys and wine by the fire. If you are prone to the blues, limit your alcohol intake as much as possible- it's a depressant, and it interferes with sleep. 
• Low folic acid levels are associated with depression. A good source of folic acid is found in leafy green veggies. If they aren't your top food choice, chop them and add them to soups and stews for the last five to ten minutes of cooking. This works well with swiss chard and spinach.
• You've heard it before, but I would be remiss if I did not mention Omega 3 fatty acids, which play a crucial role in overall health. However, Omega 3's are found in greater concentrations in the brain than in other parts of the body, and have been shown to alleviate depression. Omega-3s can be found in fatty fish like wild salmon, sardines, Atlantic mackerel, and in lower quantities in ground flaxseeds, walnuts and omega-3 fortified eggs. Ground flaxseeds can be substituted for small portions of flour or pancake mix without sacrificing taste.

Making all these changes would be daunting. Try choosing a few that appeal to you, and monitor your mood, health and overall level of functioning for the next four to six weeks. Hopefully you will see some positive results. And if you happen to have that tropical hideaway, count me in.