Finding light in the darkness

I’m going to write about two things that personally motivated me to deal with my own demons in a very public way. The short-term inspiration for this is me rereading the acknowledgements section of Redemption. The longer-term inspiration for this is a public tragedy and a low period in my life.

Okay, first, here’s a small section of the acknowledgements in Redemption:

To Robin Williams. Yours was a life well lived, and I hope to be part of a positive story of those influenced by how it ended.

Let me go backwards. Robin Williams completed suicide on August 11, 2014. He had long suffered from a slew of mental health challenges, including depression and substance abuse. However, Williams was suffering from “diffuse Lewy body dementia,” which ultimately contributed heavily to his suicide.

William’s suicide ultimately inspired me to go public with my story. That started when some idiot on Facebook decided to spout off shortly after Williams’ death by saying something along the lines of, “So sad Robin Williams committed suicide. He just needed to pray to Jesus more!”

No, you schmuck, that’s not how it works, and that ignorant comment got me so damn fired up that I wrote an op-ed in my local paper, detailing my own struggles with depression, anxiety and suicidal ideation. That, in turn, set my career in motion in a very different way, making me become much louder about mental health issues. I’ve spoken at events detailing my own struggles, cofounded a mental health caucus, appeared in PSAs and introduced legislation designed to help those who are suffering from mental health challenges. I know that the work I’ve done in this realm has helped people – and I know I have a lot more to do to help more.

It also inspired this speech, the most difficult one I have ever made:

Fast forward about seven or eight months, and I’m struggling, in the midst of one of the most depressed periods of my life. I’m struggling at work, my wife is struggling at work, and life just generally sucks at the moment. I go back to see my therapist. I increase my medication. And then I realize something else: I desperately need an outlet. Something to help get me through everything I am suffering from. I decide to start writing again – I wrote fiction as a kid and had published the non-fiction book I wrote, Tweets and Consequences.

And I remember this goofy plot idea I had as a kid, twenty years ago, about kids getting trapped on a spaceship. And I realize something: That’s not a bad plot. But what if I could make it more? What if I could fold in a mental health message as well?

And thus, Redemption is born.

For what it’s worth: I have a character named Robin in Redemption. In all fairness though, that’s also my daughter’s middle name, so let’s call that character’s naming a 50% tribute to Williams and 50% tribute to my daughter.

The death of Robin Williams helped me and countless others find their voice and seek help. I know that this may be cold comfort to those he loved and those who loved him. But I sincerely hope that they can take some solace in knowing that Williams’ life and death helped so many, including me. His was a life well lived – and, as I said above, I hope to be a small part of that story.

You can always find light in the darkness. Pain makes us great, and with time and therapy, you can turn the most agonizing periods of your own life into something incredible.

As long as you breathe, there is hope. The trick is just finding it sometimes.

Transcranial Magnetic Stimulation?

You know, you first hear about something like this, and you think it sounds like some sort of witchcraft nonsense. Magnets? To help depression?

Apparently. And it’s scientific based.

I write about this now because I had an appointment last week to explore this as a treatment possibility, and it is likely something I’m going to pursue. Here are the basics, per the Mayo Clinic:

During a TMS session, an electromagnetic coil is placed against your scalp near your forehead. The electromagnet painlessly delivers a magnetic pulse that stimulates nerve cells in the region of your brain involved in mood control and depression. And it may activate regions of the brain that have decreased activity in people with depression.

 Though the biology of why rTMS works isn’t completely understood, the stimulation appears to affect how this part of the brain is working, which in turn seems to ease depression symptoms and improve mood.

The most important question, of course, is this: Does it work? According to the evidence I have seen, yes, and that’s in tests involving a placebo. More research is needed, but this appears to work.

Thankfully, the side effects are very mild, per the Mayo clinic.

Side effects are generally mild to moderate and improve shortly after an individual session and decrease over time with additional sessions. They may include:

  • Headache

  • Scalp discomfort at the site of stimulation

  • Tingling, spasms or twitching of facial muscles

  • Light headedness

The biggest drawback, as best I can tell? The Doctor I spoke with told me its most effective to do it every single day, for 4-6 weeks. Session, I think, are 30-45 minutes. That’s a heck of a time commitment. That being said, sucks for me. It’s not the Doctor’s fault that this is the way the brain works, but it’s certainly a challenge with my schedule – going to Harrisburg and vacation means I won’t have that kind of time until August.

So, let me conclude by asking you for your experiences. Have any of you out there had TMS? Any experiences to share? I’d love to hear them!

Coping Strategy: Do Something

I was down a few weeks ago when this particular memory bounced into my head.  I was sitting in my therapists office, discussing something – what, I don’t remember.  I think I mentioned to him how I had gone to the gym (unrelated, but hey, exercise can really help depression), despite the fact that I had been really depressed at that moment and didn’t feel like it at all.  And I remember he said that was good, because that moment when you are most down is exactly when you should get up and do something.

It wasn’t meant to be particularly profound.  But it’s one of those things that REALLY stuck with me.  My wife calls it faking it till you make it.  I referred to it as “pushing through,” but that struck me as simplistic, as if you can just willpower your way through depression (sometimes you can; often you can’t).

Imagine yourself as depressed as you have been.  What do you want to do?  The answer there is obvious: Absolutely, positively nothing, aside from this:

depressed on couch

That, as far as I am concerned, is the worst thing you can do.

Please keep in mind I’m only speaking from my personal experience and this isn’t medical advise, but I’ve always found that lying down and swimming in depression leads to one thing and one thing only: More depression.  And guilt.  “I SHOULD be doing my chores.  I SHOULD be hanging out with my kids.”

Is that guilt warranted?  Of course not.  Everyone deserves time to lounge around and do nothing – yes, you too, depressed person. But – and again, this is just my personal experience talking here – sitting around when depressed just leads to feelings of self-loathing and guilt.

This would be my advice to you, dear reader: Just…try doing something.  Anything that’s actually active and engages your mind, body or both.  It may be reading a book.  It may be going for a walk or heading to the gym.  Write.  Play a game.  Do jumping jacks.  Hell, I really don’t care.

What I do know is that, based on my own experience, is that sitting there, doing nothing, in the long-term, can equal a surrender. As best you are capable, get up, get moving. Will it make you feel better? Hopefully.  Maybe.  But doing nothing will certainly continue to sap your hope away, and anything is better than that.

Any specific strategies you want to share? Leave them below!

What anti-stigma really means

Call this one a brilliant thought that I had in the shower the other day.

There are plenty of anti-stigma campaigns related to mental health.  In many cases, the goal of these campaigns is simple, noble and necessary: to defeat “mental health challenges in the workplace and at home.”  This is vitally important work.

There’s good news related to that though.  In many areas, anti-stigma campaigns have already done their job.  For example, a poll taken in my home state of Pennsylvania (March 2017) shows high levels of comfort in terms of working with someone with a mental illness, a vast improvement over previous levels.  While there is still a long way to go, this poll shows significant movement in the area of mental illness.

I was thinking about this poll the other day, and it had me thinking: What does anti-stigma really mean?  Obviously we need to continue to work on critical areas like discrimination and access to healthcare, but I’d argue there’s more than that.

My argument is this: The most powerful sense of stigma is self-stigma.

Consider this 2012 article, which describes self-stigma as when “patients agree with and internalize social stereotypes,” resulting in:

•Patients often think that their illness is a sign of character weakness or incompetence.
•Patients develop feelings of low self-esteem and become less willing to seek or adhere to treatment.
• Patients anticipate that they will be discriminated against, and to protect themselves they limit their social interactions and fail to pursue work and housing opportunities.

As a result, patients find themselves less willing to seek treatment and social support, leading to lower rates of recovery.

This realization has had me rethinking how I approach the notion of anti-stigma campaigns.  Of course they should be focused on ensuring that all of society views people with mental illness not as sick freaks who are weak, but as real people suffering from real disorders that can be treated like any physical illness.  I want to push society to a place where all of us – those with mental illness and those without – view people who are suffering from a mental illness the same way that someone views a cancer patient.  No one who suffers from a mental illness should do so in fear, shame or silence.  They should talk about their therapy appointments the same way a cancer patient discusses chemo or someone with a broken leg discusses physical therapy.

I suppose, then, that what I am saying is this: Anti-stigma campaigns shouldn’t just address societal stigma.  They should address self-stigma as well.

As always, I welcome your thoughts – am I onto something here?  More importantly, have you found any anti-stigma campaigns that fulfill what I am describing?  Let me know what in the comments!

National Depression Screening Day

I’m a bit late on this, but October 5 was National Depression Screening Day.  The day itself, first created in 1990, is an effort to encourage people to determine if they are depressed and seek treatment for their illness.

Common depression screening tools

There are multiple depression screening tools available.  These tools, often available in online questionnaires, allow users to determine if may be suffering from depression.  Ideally, an appropriate screener will then link to resources which will enable a person to get help.

From what I have seen, the Patient Health Questionnaire (PHQ-9) is the most common tool to determine depression.  It’s brief – just nine questions – and allows for the user to easily determine if they are potentially suffering from depression.

There are, of course, many more depression screening tools, including:

  • Hamilton Depression Rating Scale (HDRS)
  • Beck Depression Inventory (BDI)
  • Patient Health Questionnaire (PHQ)
  • Major Depression Inventory (MDI)
  • Center for Epidemiologic Studies Depression Scale (CES-D)
  • Zung Self-Rating Depression Scale (SDS)
  • Geriatric Depression Scale (GDS)
  • Cornell Scale for Depression in Dementia (CSDD)

Does depression screening work?

There is evidence which shows that depression screening can make untreated individuals aware of their problems and encourage them to seek treatment.  Depression screening also appears to be relatively accurate, and its systemic use can make doctors more aware of depression with their patients.

The biggest benefit of depression screening

Depression screening is a useful, if flawed tool, which allows for an individual to determine if they are depressed.  That being said, depression screening increases awareness of depression.  It allows someone to determine if they may be suffering from depression, and seek help.  It also treats depression just like any other physical aliment – this, in turn, has the power of reducing stigma.

Study: Depression can be treated with…anti-inflammation drugs…??

A friend was kind enough to send me this article, and this one is too strange sounding not to share: According to a new study, depression is “a physical illness caused by a faulty immune system” that can be treated with anti-inflammatory drugs.

From an article on the study:

Current treatment is largely centred around restoring mood-boosting chemicals in the brain, such as serotonin, but experts now think an overactive immune system triggers inflammation throughout the entire body, sparking feelings of hopelessness, unhappiness and fatigue.

It may be a symptom of the immune system failing to switch off after a trauma or illness, and is a similar to the low mood people often experience when they are fighting a virus, like flu.

“In relation to mood, beyond reasonable doubt, there is a very robust association between inflammation and depressive symptoms.  We give people a vaccination and they will become depressed. Vaccine clinics could always predict it, but they could never explain it.

According to the article, more tests will begin next year to see if anti-inflammatory drugs can help alleviate depression.

Obviously, this piqued my curiosity, so I did a little bit more digging.  First, this area of study isn’t new – there are studies dating back at least six years that would support the notion that inflammation and depression are linked.  From that article:

Previous studies have linked depression with higher level of inflammatory markers compared to people who are not depressed. When people are given proinflammatory cytokines, people experience more symptoms of depression and anxiety. Chronically higher levels of inflammation due to medical illnesses are also associated with higherrates of depression. Even brain imaging of people with depression show that their brain scans have increased neuroinflammation.

The article went on to recommend that everyone take anti-inflammatory steps (which are good for you regardless), including better diet, stress reduction, exercise, mind-body exercises and breathing exercises.

This is new to me, and fascinating.  That being said, it makes me nervous.  I’ve always operated under the assumption that depression – and mental illness in general – are not caused by – or treatable with – a single bullet.  They are a combination of things: Genetics, stress levels, thinking patterns, etc., that make someone mentally ill.  As such, the notion that one thing – inflammation – could be the cause of depression – well, it gives me pause.

It would be so, so wonderful to be wrong!

Two points about this research, and understand, please, that they are coming from a layman, not a doctor!:

First, more tests are required, so don’t run out and buy an anti-inflammatory today.  More information, specifics and treatment options are still needed.  For now, keep going to therapy and taking your medication, darn it!

Second, let’s say, for a moment, that future studies confirm a connection between inflammation and depression.  That does not (necessarily) mean that you should stop taking your medication or going to therapy.  Remember, all body-mind reactions are a two way street.  Yes, your body can affect your mind, of course, but the way you think can affect your body.  When you are scared, your heart rate accelerates, your breathing speeds up and you get sweaty.  Don’t think that being depressed, having negative emotions or damaging thought processes can’t potentially cause the inflammation that causes depression.  I’ve always believed – at least for me – that a combination of medication and therapy are the best way to deal with depression.  If you believe that too, don’t think that therapy will no longer be necessary just because you take some pills that can make the swelling go down.

This is fascinating.  And potentially hugely promising.  I can’t wait to track more information about this, and I really hope that this can provide people with real relief in the future.

Physician shortages: The biggest challenge facing mental health in America

I often write about stigma and the devastating role it can play in terms of keeping people out of treatment.  I think a big part of the reason I discuss it so frequently is that it’s the one area that people can actually get involved in and feel like they are making a difference.

That being said, I need to be clear about this one: Stigma reduction, though important, is not the most critical issue facing mental health.  That, I would argue, is a lack of capacity, largely in terms of mental health practitioners.

The facts on our ongoing physician shortage crisis are staggering:

  • According to a report by the Association of American Medical Colleges, over the next eight years, the United States will experience a doctor shortage of between 61,700 – 94,700.
  • That problem is much more acute in the area of mental health.  According to one report, in order to meet demand, the United States needs to add 70,000 providers over the next eight years if we are going to meet a growing demand.  The problem is even worse for people who live in rural areas; 60% of all people in rural areas live in a mental health professional shortage area.  In general, according to NAMI, only 41% of all people with mental illness are treated, while that number increases to 63% of all people with a serious mental illness.
  • The shortage doesn’t just affect personnel, but facilities.  It can be extremely difficult for the mentally ill who need inpatient care to have access to it, with some surveys estimating that the United States needs a whopping 123,000 psychiatric beds.

How did we get here?
As you can imagine, there are a variety of culprits, including:

  • Incredibly high standards to get into medical school and a long length of time for training.
  • Crushing medical student loan debt (averaging $207,000).
  • A shortage of residency slots for hospitals.  These slots are almost entirely funded by Medicaid, and that funding has not increased since 1997.
  • High cost of malpractice insurance.
  • Varying reimbursement rates for different specialties (more on this later).

Why is this problem so much worse in mental health?
This problem is even more acute in the mental health universe, where amount of psychiatrists declined 10% from 2003-2013.  The shortage gets even more severe as you go into mental health specialties, such as pediatric and geriatric care.

Again, there are many reasons that this issue is so problematic for mental health.  For one thing, hospitals and insurance companies pay doctors more if they are involved in specialties that turn a profit, like orthopedic surgery and urology…not psychology or psychiatry.  Additional public cuts to human services and mental health further exacerbate the problem. As a result, there is less staff in this area, regardless of it’s importance.

Physician burnout is also a problem, with one study noting that “86 percent reporting high exhaustion and 90 percent reporting high cynicism.”

Another problematic area is physician training, where there are concerns that training models have not evolved enough to introduce more medical students to mental health areas.

There’s more – much more than a simple blog entry can handle.  For a more in-depth look, I highly recommend that you review this report by the National Council for Behavioral Health.

What can we do about it?

  • Increasingly utilize technology and telehealth, which some studies have shown to be promising in the area of mental health.  With additional capacity, telehealth can help overcome geographic shortfalls that occur.  Other systems, such as bed and doctor registries, can help patients in need of treatment find appropriate resources.
  • Expanded number of residency slots.
  • Adjustment to reimbursement rates to ensure that mental health services achieve parity with other areas.
  • Adjustment to licensure laws in order to allow for other certified professionals – with appropriate training – to treat patients.

It is important to not lose sight of this simple truth: The mental health practitioner shortage can devastate the quality of life of the mentally ill.  It can kill people, frankly.  In my government job, my office regularly fields calls from constituents who need help but can’t find it.  Mental health is an issue that society is only truly starting to understand and deal with.  We must ensure that the mentally ill have the access to the resources that they need.