|Plus and Minus|
Sunday, December 29, 2019
This week's focus is on mental health.
A new decade! The 2010’s are in the books, and it’s time to start the 20’s (a new roaring 20’s? Let's hope flapper dresses make a comeback.) The next decade can be all that you’ve dreamed of, but it will take intentional focus, hard work, and yes, CHANGE.
While every new year is a great time to reflect and make positive changes in your life, it’s even more important at the start of a new decade. What better time to take stock of your life, to look at those things that are bringing you closer to living a full, balanced and abundant life, and those things that may be standing in the way.
As New Year’s approaches, look a little closer at your life. I’d suggest evaluating it on at least three levels: physical, mental/emotional, and spiritual. I was recently a guest on the Carlette Christmas On Point Talk Television show and we talked about these three core areas of life, and she expands them to six adding social, financial and family as well. (To learn more about Carlette and her show click here: On Point Radio Talk .) Your own list of core areas may be longer or shorter, but regardless, look at your life through the lens of those things that are important to you in the long term. Fast forward to when you are 90+ years old, in a cardigan sweater rocking on the porch, what are the things that you consistently valued over your life? Where are you doing today that is in line with those values? Congratulate yourself. What else could you be doing? What are you doing that is in opposition to those values? What needs to be cut back on or cut out? Time to make a change.
It seems like resolutions always involve stopping something. And that’s a good thing. Who doesn’t have at least one thing in their life that they should stop doing, or at least do less of? But for many people, despite their best intentions on Jan 1, they break thier resolution with in days. In fact, research conducted by Strava on 31.5 million people showed that most people failed their resolution by Jan 12.
So what can you do? In my outpatient practice, a lot of my work with patients involves helping them to stop doing something. And it is always a three steps forward, two steps back process so remember to be patient with yourself. But those that are successful seem to have something in common. Those people who find success take the time to look at the benefit that they are getting from that bad habit. What purpose is overeating at night serving? What is gained by overindulging in alcohol or using other substances? What is the plus side of staying in an unhealthy relationship? Once a person looks at the gain, they can then identify a healthier activity/action that could also provide a similar gain, and then replace what they are giving up with that new healthier alternative. To try and just quit something ignores the fact that even bad habits fill an emotional hole in people's lives. You have to find something else to fill that emotional spot if you are going to be successful in editing out those things you know you’re better off without.
So the simple rule to help you keep your resolution is this: do not just quit/cut back, but quit/cut back AND simultaneously add something in. Plus minus. It’s the best recipe for success.
What’s your resolution?
Sunday, December 22, 2019
|Leonardo Da Vinci's Benois Madonna|
This week's focus is on spiritual health.
Last week I drove south of Reno before sunrise. I found a peaceful spot in a valley by a half-frozen stream with snow covered mountains to both the east and west. I settled in to watch the sunrise. I’ve always loved sunsets, but this was a new experience.
As I waited, I noticed how cold and dark it was. The dried out, dormant grass around me seemed far removed from the verdant green of only a few months before. The once fertile ground was now frozen, and the stream that would have been an inviting place to swim was now cold, bleak, and even dangerous.
And then the sun began to rise. From the darkness there first appeared a deep reddish hue above the snow-capped mountains. Slowly the light began to pierce the darkness, and more of the mountains became visible. And then the sun appeared, first as a barely perceptible glow and then just a small sliver before it became fully visible over the eastern mountains. As the sun rose and the temperature warmed, a beautiful low fog developed over the boggy banks of the stream—the breath of dawn as a friend once called it.
This sunrise reminded me of what the birth of Jesus represents. It is the power of God’s love to come into this world and pierce even the darkest and coldest places in our lives, in our memories, and in our world. Where there is ice, fallow land, and darkness, God’s love penetrates and transforms.
And to me that is what Christmas is. It is the celebration of the birth of Jesus, the celebration of eternal light piercing and overcoming darkness in all its forms.
Merry Christmas friends.
Sunday, December 15, 2019
This week’s focus is on mental health.
This year I’m working as an outpatient psychiatrist. It seems like a lot of my work with patients involves their decisions—past, present, and even future. The consequences of past decisions that in retrospect were not in thier long-term best interest cause a great deal of mental angst. Examples include forming unhealthy relationships, using/relapsing, going off psych meds without consultation, making impulsive choices, taking the easiest path, sticking to a decision that in retrospect was wrong, etc. Making today's decisions can also be very difficult or seemingly impossible for some people (but to quote a line from the band Rush—"you can choose not to decide—you still have made a choice.”) And others seem to get caught in a spagetti bowel of future decisions and hypothetical “what ifs” which is a sure recipe for anxiety. And the problem isn’t just with bad decisions, sometimes choosing between two good options can be absolutely debilitating.
Making good, well thought out decisions is critical to our overall happiness and mental health. Towards that end, this week I’m sharing a decision-making tool that a trusted mentor taught me years ago when I was trying to decide if I should accept a permanent church position in New Zealand or return back to the United States. It’s a method that helps to clarify our core values and keep them in mind when we make decisions. Here’s how to do it:
- Make an empty chart (you can fill in rows and columns as you go).
- On the left side of a chart, write out each of the factors in your life that are important to you that are related to this decision. Take time doing this part. Really think about your core values and what is important to you long-term. You might need to go back and add to this list over time.
- Across the top of the chart write the different options you are considering. Try and be creative. Even if it doesn’t seem realistic try and include as many options as possible. Someone once told me it takes an average of 13 different options to reach the final best option. I wonder how often we falsely limit our possibilities.
- On a scale of 1-10, with 10 being highest, assign a numerical score in each box for how well that option fulfills the value/important factor that you’ve listed on the left.
- Once completed, on the bottom of the chart add up the numerical value for each of the options in the columns.
- The option with the highest overall numerical total signifies the choice that best fulfills your values.
Remain in New Zealand
Return to US
Meaningful vocation—serving God, answering God’s call
Proximity to my parents
Opportunities for my children
Ability to support family financially
At the time this process was very helpful for me. I really hadn’t realized how important my own culture was to me, and how much I was missing my parents and that I wanted to be near them in the years to come. What felt like a very hard decision because the options seemed evenly matched prior to this exercise became clear when I saw the numerical difference. I realized that I could fulfill my vocational call in either place but that family and cultural considerations were best served by returning to the US. As hard as it was, I declined the offer to serve permanently in New Zealand and returned home.
This is just one tool to assist in making good decisions. I hope it’s helpful…
Sunday, December 8, 2019
This week the focus is on spiritual health.
Today marks the second Sunday in Advent. As I sat in church this morning, I thought about all the things I have yet to do before Dec 25--buy gifts for family, colleagues and friends (should residents buy attendings a small gift during outpatient year?), get a Christmas tree, and haul out the outdoor decorations so I don't feel like Ebenezer Scrooge every time I drive into my cul de sac where my neighbors' homes were already completely decorated by the day after Thanksgiving.
However, this morning as I sat in the quiet, holy space of a small Reno congregation, I was struck by how easy it is, even for a priest, to get caught up in a secularly catalyzed "to do" list. It is so easy for December to be a month of buying, parties, activity and even competition, and forget that as followers of Christ we are called to be preparing in a different, or at least in an additional way.
The Christian calendar marks the four Sundays before Christmas as the four Sundays of Advent. The word advent is from the Latin word that means "coming". It is a time when people who seek to follow Christ are to prepare. We are to prepare ourselves for the upcoming joyous celebration of Christ's birth on Christmas day, as well as for the final coming of Christ in "power and glory." Each of the Sundays of Advent focus on a different theme.
This morning in church we prayed the following prayer (from the Book of Common Prayer):
Merciful God, who sent your messengers the prophets to preach repentance and prepare the way for our salvation: Give us grace to heed their warnings and forsake our sins, that we may greet with joy the coming of Jesus Christ our Redeemer; who lives and reigns with you and the Holy Spirit, one God, now and for ever. Amen.
In a season when we are bombarded with secular messages to prepare for the winter holidays, this prayer is a reminder to prepare in a different way. It asks us to prepare for the coming of Christ by looking at ourselves and the ways we have fallen short. And who among us doesn't have something in their life that they feel ashamed about, something they wish that they were doing differently, and/or an "I'm sorry" that needs to be said?
Making amends for the ways we fall short (sin) is quite contrary to all that we see around us in the weeks that lead up to Christmas. But think about it. How much more authentically joyful will the celebration of Christ's birth be if you prepare yourself in addition to all of the external preparations over the next few weeks?
Sunday, December 1, 2019
This week the focus is on mental health.
Currently I'm taking part in a training to learn how to use transcranial magnetic stimulation (TMS) for patients with major depressive disorder. My training and source of information is provided by Neurostar (the company whose machine we use in the outpatient practice I'm working in this year), and I've also supplemented Neurostar's information with information from Up to Date. This week, I will briefly share what TMS is, who might be a good candidate, and some of the research findings about the effectiveness of the treatment.
TMS is non-invasive (i.e. outside of the body) and non-systemic (localized effect). Simply stated, it involves placing a metal coil (seen in the picture above) against the scalp. This metal coil generates rapidly alternating magnetic fields, which penetrate approx 2-3 centimeters into the head. There are several steps the physician must take to find the effective target area which is located in the dorsolateral prefrontal cortex. Once identified, the magnetic fields generated leads the neurons in this area to depolarize. While the exact mechanism of action is unknown, it is likely that this discrete cortical area is connected to a network of other areas in the brain that are involved in mood regulation. The magnetic fields change pathological activity within the network.
Who might be a good candidate for TMS? First, a person should have the diagnosis of major depressive disorder. They also should have failed to receive satisfactory improvement from prior antidepressant medication in the current episode of depression. Of note, the American Psychiatric Association Practice Guidelines recommend considering the use of TMS after evidence of failure of an adequate initial antidepressant medication attempt. In practice, this means that TMS can be considered before SSRI augmentation with other antidepressants or antipsychotic medications after just one antidepressant has been tried.
And who is not a good candidate? People who have conductive, ferromagnetic, or other magnetic-sensitive metals implanted in their head or which are non-removable and are located within 30 cm of the treatment coil cannot receive TMS. Other medical conditions also need to be assessed, including a person's risk of seizures (risk of seizure is the most serious possible adverse effect of TMS).
Multiple studies have found that patients with treatment resistant depression do benefit from TMS. Compared to placebo, TMS alone showed a 14% remission rate in depression, compared to 5% in the placebo group, and TMS combined with antidepressant medication saw a reduction of symptoms in 47% of patients, compared to 22% in the placebo group. However, TMS is less effective that electroconvulsive therapy (ECT).
This post just scratches the surface of information about TMS. If you're interested in learning more, here is a link to assist you in finding a NeuroStar doctor: click here.
Monday, November 25, 2019
This week the focus is on spiritual health.
Several years ago I accepted a call to serve in a parish in New Zealand. I love the prayer book used in that part of the world, and some of my fondest memories are from our family's time in that country.
As we approach Thanksgiving week, I share with you a beautiful prayer that offers thanksgiving for creation (for churchy types it is a form of the Prayers of the People) that is part of the Eucharistic (Communion) service in New Zealand:
Sunday, November 17, 2019
This week the focus is on physical and mental health.
A 78 year old woman with end stage renal disease is seen in the emergency department after calling 911 due to abdominal pain. She is confused (thinks the year is 1974 and that she is in a medical center in another state) and admits she has missed several dialysis appointments. She refuses a nephrology consult and proposed dialysis, and states she is going to leave against medical advice with plans to take the bus to go home and die because she’s sick of living with kidney disease. Temperatures are below 25 degrees F outside. No family are listed as emergency contacts. A psychiatry consult is placed to determine capacity.
Having a loved one whose ability to make decisions is in question can be very difficult. It may happen suddenly due to a temporary medical condition, such as having low blood levels of sodium or a urinary tract infection. Or maybe that person doesn’t want to start life-prolonging medical treatments, and loved ones disagree with this decision. Or maybe the person is suffering from an acute episode of a mental health disorder and is refusing treatment for another medical issue due to psychotic beliefs.
Part of working in consult and liaison psychiatry involves responding to consult requests to determine capacity in the hospital setting, such as the one described in the opening vignette. I find that people (patients, families, and even other physicians) are often confused about capacity.
So first some definitions. First, it’s common for people to not understand the difference between capacity and competence. Capacity is a person’s ability to understand the nature and effect of their actions (more on that later in this post). Physicians can determine capacity. Conversely, competency is a legal finding. Competency is determined by the courts and involves determinations about a person’s ability to make decisions about their personal safety, provide for their necessities, and/or to make decisions about their financial affairs. If a person is found incompetent, a conservator or guardian is appointed by the courts. (States differ in the terms they use as well as the specific meanings and consequences and subdivisions of these terms).
So what does a capacity assessment involve? There are four general areas. First is a patient’s ability to understand the treatment and the proposed options for care. Questions in this area would include ones about the person’s understanding about their condition and what the treatment options are. It’s important to assess if the person knows what the risks and benefits are, and what will happen if nothing is done.
The second area of a capacity evaluation involves questions about how the information applies to the person’s own situation. Questions might include what the person really believes about their medical condition, why the doctor recommended that particular treatment, and which treatment the person thinks is best for them and why.
The third area to assess is the person’s reasoning ability with the information given and how they support it with the facts and statements about their own values. The physician may ask about what factors are most important in making the treatment decision, how the person is balancing the pluses and minuses of particular treatments, and if they trust their doctor.
Lastly, the patient must be able to communicate and express their choice.
(There are formal assessment tools available—one is the Aid To Capacity Evaluation or ACE).
So returning to the opening vignette, what would you do if you were the consulting psychiatrist?
While it is certainly a person’s right to decide to make the decision to stop life prologning treatment such as dialysis, I would argue that this patient did not have capacity to make that decision at that time. She was confused due to electrolyte imbalances brought on by missing dialysis. While she could understand her treatment options and communicate her choice, her altered mental status likely affected her ability to fully understand her particular situation as well as her ability to apply her values and the given facts in making her decision. Furthermore, to allow the patient to leave against medical advice with severely altered mental status in freezing conditions would have likely led to her death due to hypothermia as it was doubtful she could make her way home safely given her condition at the time. Keeping the patient in the hospital against her will until her mental status cleared would allow her to then make the choice about continued dialysis with a clear head (and full capacity).
What would you have done?
(The AAFP article “Can the Patient Decide? Evaluating Patient Capacity in Practice" was used as a resource in preparing this post).
Sunday, November 10, 2019
This week the focus is on mental health.
Happy Veteran’s Day and thank you to all who are now serving or have ever served our country. I’m remembering my father who was Commander in the US Navy and worked in Intelligence. He’s in the above photo at the top left (the bald guy).
In my current work I have the honor of working with veterans. In Cincinnati I worked at the VA in psychiatry as an outpatient psychiatry resident, and in Reno I cover inpatient service for vets hospitalized for mental health reasons.
The suicide statistics for veterans are deeply troubling. While studies over the past years have differed somewhat in what was reported, since 2008 there have been at least 6000 veterans every year who have taken their own life. That means that on average over 16 veterans, people who loyally served our country, take their life every day. (See https://www.mentalhealth.va.gov/docs/data-sheets/OMHSP_National_Suicide_Data_Report_2005-2016_508.pdf for the full report).
In my own work I’ve seen PTSD as a contributor to the suicidal thoughts and other mental health difficulties that vets and many other people who have been through traumatic events experience. So on this Veteran’s day, in addition to giving thanks for service and sacrifice, here is a checklist of 20 problems that people can have in response to stressful experiences (from Cognitive Processing Therapy for PTSD by Resick et al). As you look over the list think about how often you have been experienced the following in the past month:
- Repeated, disturbing and unwanted memories of the stressful experience
- Repeated, disturbing dreams of the stressful experience.
- Suddenly feeling or acting as if the stressful experience were actually happening again.
- Feeling very upset when something reminded you of the stressful experience.
- Having strong physical reactions when something remined you of the stressful experience.
- Avoiding memories, thoughts, or feelings related to the stressful experience.
- Avoiding external reminders of the stressful experience.
- Trouble remembering important parts of the stressful experience.
- Having strong negative beliefs about yourself, other people, or the world.
- Blaming yourself or someone else for the stressful experience or what happened after it.
- Having strong negative feelings such as fear, horror, anger, guilt or shame.
- Loss of interest in activities that you used to enjoy.
- Feeling distant or cut off from other people.
- Trouble experiencing positive feelings.
- Irritable behavior, angry outbursts, or acting aggressively.
- Taking too many risks or doing things that could cause you harm.
- Being “superalert” or watchful or on guard.
- Feeling jumpy or easily startled.
- Having difficulty concentrating.
- Trouble falling or staying asleep.
If you have lived through a stressful experience and found yourself answering yes to the above questions, you may be living with PTSD. There are good options available for treatment, and I’d encourage you to reach out to a mental health professional or ask your primary care doctor for a referral to someone who can help. That trauma doesn't need to overshadow your life or continue to have a negative impact.
If you are experiencing suicidal thoughts or urges, call 911 or the National Suicide Prevention Lifeline at (8255). There is also a Crisis Text Line: Text HOME to . For crisis support in Spanish, call
Sunday, November 3, 2019
This week's focus is on physical (and mental) health.
I’m writing this post while working an overnight shift on inpatient psychiatry. Sleep (or lack there of) is on my mind.
One of the most frequent complaints I hear in my outpatient practice is that people have a hard time sleeping. It’s also a common late-night call from nurses concerned about their patient’s inability to sleep. Good sleep is important for everyone, and it’s especially important for optimizing both our physical AND mental health. So what can we do to sleep better?
Good sleep hygiene is the first step. What is sleep hygiene? It’s those practices that can help us to sleep well. The National Sleep Foundation lists eight practices that can help us achieve good quality sleep—I’ve added some additional information from my rotations with a sleep specialist. There is much more information on all of these 8 areas, but here is a brief summary:
1. Be in your bed and sleep the right amount—not too little and not too much (reminds me of Goldilocks and the Three Bears). Beds should only be used for sleep and sex—nothing else. Setting regular bedtimes and regular times to get up can also help.
2. Limit day time naps to no more than 30 minutes.
3. Avoid caffeine and nicotine close to bedtime, and use alcohol only in moderation. While alcohol can make you fall asleep faster, it interferes with your sleep later in the night.
4. Exercise every day—even as little as 10 minutes of aerobic exercise helps. However, some people have a hard time sleeping if they have a strenuous work out close to bed time so if you fall into that category it is best to exercise earlier in the day.
5. Avoid foods that give you heartburn/indigestion before sleep. For me drinking a sparkling water right before bed results in waking up with painful heartburn a few hours later. Other people are bothered by spicy foods. You probably know your own offenders so it’s best to avoid them.
6. Make sure you get some sunlight every day, and keep your room dark at night. This can strengthen your sleep wake cycle which can improve the overall quality.
7. Establish a calming bedtime routine. A bath, lavender or other calming scents in an infuser, reading or whatever works for you. Make your own rutine and que your body into knowing it is time to turn off the day and restore itself.
8. Set up a sleep environment that’s pleasant for you. Comfortable bedding, cool temperatures, limited lighting (including screens—you can even set your iPhone to dim to a “Night Shift” setting which changes the screen to warmer color to help you sleep better), noise machines, anything that works for you. I have black out curtains in my new home and my sleep has improved dramatically.
But what happens if you try all of the above and still have difficulty? I recently attended a lecture on CBT-I. I’d never even heard of it. It’s a type of cognitive behavioral therapy specifically for people with insomnia and it reportedly works extremely well and fairly quickly. I’d love to hear from anyone who’s had success with it because the data presented with the lecture was encouraging.
Another option is to try melatonin which is sold over the counter. Melatonin is the hormone that our pineal glands produce that regulates our sleep wake cycle. It can help reset the body’s clock (such as when you are working night shifts or traveling across time zones). For some people it can also improve sleep. For a natural remedy that has few side effects trying approx. 3mg-6mg can be very helpful for some people. There is even a new time-release form available by prescription called Rozerem. (Stay tuned for a future post on melatonin as it is one of my most commonly prescribed medications).
And, if sleep is still elusive it is time to see your doctor. There could be an underlying medical problem interfering with your sleep, or other issues such as an undiagnosed depressive or anxiety disorder. Prescription medications could also be indicated, although in my practice they are never the starting point.
Now time for some ZZZZZZs.
Sunday, October 27, 2019
This week's focus is on spiritual health.
The Today Show interviewer asked me to name my favorite biblical verse. In the end I answered John 10:10, The thief comes only to steal and kill and destroy. I came that they may have life, and have it abundantly (NRSV).
This was in some ways a more difficult question than it might seem on the surface. When I approach holy scripture, I look at it on four levels. I look at the particular verse (which was what her question was focusing on). But I also look at that verse within the larger passage in which it occurs. And then I look at that passage with in the social context of the time and what meaning it would have conveyed. And finally, because scripture is alive and continues to re-reveal itself generation after generation, I look at how this timeless message might speak God’s word to us today. It is through looking at a verse with in this larger context that scripture is best interpreted. To just look at a single verse runs the risk of misinterpretation.
Let’s look at what the verse about abundant life might mean using this method. I used William Barclay’s The Gospel of John (vol 2) to help with the interpretation.
First, on the verse level what I hear is that there is a distinction between mediocre and abundant life. A lot of people live a life that is run-of-the-mill—not terrible, not plentiful, just average. And I think fear has a lot to do with it. Average is okay, but to risk pursuing something greater makes people afraid because there can be a lot to lose. For example, I hear people say that they’d love to do something, but then come up with endless excuses why they can’t. And most of those excuses seem to be based on fear. To me this seems like a terrible waste—when I hear this I think of an old dried out plastic kitchen funnel, with one’s life slowly swirling toward the small constraining end with fear being the dried out plastic that keeps them limited and confined. Abundance isn’t for tomorrow; it is for today. In this verse the Greek phrase used for have it abundantly means “superabundance of a thing.” To follow Christ is to have a superabundance of life now AND in the future.
This verse falls within a larger section of the Gospel of John that addresses the doorway to (abundant) life:
So again Jesus said to them, “Very truly, I tell you, I am the gate for the sheep. All who came before me are thieves and bandits; but the sheep did not listen to them. I am the gate. Whoever enters by me will be saved, and will come in and go out and find pasture. The thief comes only to steal and kill and destroy. I came that they may have life, and have it abundantly. (John 10:10 NRSV)
Just prior to this Jesus had painted the comforting and familiar picture of himself as the Good Shepherd, but his listeners were still not fully grasping the meaning so he switched to explaining that he himself was the gate.
His listeners would have known that villages had two types of enclosures for sheep to keep them safe at night. In the villages there was a literal gate that kept the sheep safely in the enclosure. But when the sheep were out grazing in the hills, they could come and go through a gateless enclosure, but at night once all the sheep were in the shepherd himself would lie down and sleep across the entry making himself the gate to protect the sheep. The listeners at that time would have recognized the well-known Hebrew phrase to “come in and go out” as a description of a life that is secure and safe and without fear. Knowing God through Jesus’ “gate” opens the door for a life where worries and fears are no more.
And isn’t that what abundant life is? It is when we seek to know God and trust that life is indeed in God’s hands that we can walk without fear and find the superabundance that is promised us all…