Category: Health

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by: Tracy S. Cummings, MD, Psychiatrist, Lindner Center of HOPE

Children and teens react, in part, on what they see from the adults around them. When parents and caregivers deal with the COVID-19 calmly and confidently, they can provide the best support for their children. Parents can be more reassuring to others around them, especially children, if they are better prepared.

Not all children and teens respond to stress in the same way. Some common changes to watch for include

  • Excessive crying or irritation in younger children
  • Returning to behaviors they have outgrown (for example, toileting accidents or bedwetting)
  • Excessive worry or sadness
  • Unhealthy eating or sleeping habits
  • Irritability and “acting out” behaviors in teens
  • Poor school performance or avoiding school
  • Difficulty with attention and concentration
  • Avoidance of activities enjoyed in the past
  • Unexplained headaches or body pain
  • Use of alcohol, tobacco, or other drugs

There are many things you can do to support your child

  • Take time to talk with your child or teen about the COVID-19 outbreak. Answer questions and share facts about COVID-19 in a way that your child or teen can understand.
  • Reassure your child or teen that they are safe. Let them know it is ok if they feel upset. Share with them how you deal with your own stress so that they can learn how to cope from you.
  • Limit your family’s exposure to news coverage of the event, including social media. Children may misinterpret what they hear and can be frightened about something they do not understand.
  • Try to keep up with regular routines. If schools are closed, create a schedule for learning activities and relaxing or fun activities.
  • Be a role model.  Take breaks, get plenty of sleep, exercise, and eat well. Connect with your friends and family members.

The emotional impact of an emergency on a child depends on a child’s characteristics and experiences, the social and economic circumstances of the family and community, and the availability of local resources. Not all children respond in the same ways. Some might have more severe, longer-lasting reactions. The following specific factors may affect a child’s emotional response:

  • Direct involvement with the emergency
  • Previous traumatic or stressful event
  • Belief that the child or a loved one may die
  • Loss of a family member, close friend, or pet
  • Separation from caregivers
  • Physical injury
  • How parents and caregivers respond
  • Family resources
  • Relationships and communication among family members
  • Repeated exposure to mass media coverage of the emergency and aftermath
  • Ongoing stress due to the change in familiar routines and living conditions
  • Cultural differences
  • Community resilience
For 7 to 10 year olds

Older children may feel sad, mad, or afraid that the event will happen again. Peers may share false information; however, parents or caregivers can correct the misinformation. Older children may focus on details of the event and want to talk about it all the time or not want to talk about it at all. They may have trouble concentrating.

For preteens and teenagers

Some preteens and teenagers respond to trauma by acting out. This could include reckless driving, and alcohol or drug use. Others may become afraid to leave the home. They may cut back on how much time they spend with their friends. They can feel overwhelmed by their intense emotions and feel unable to talk about them. Their emotions may lead to increased arguing and even fighting with siblings, parents/caregivers or other adults.

More on taking care of your family

Disasters and other crisis events have the potential to cause short- and long-term effects on the psychological functioning, emotional adjustment, health, and developmental trajectory of children. It’s important that pediatricians, and all adults in a position to support children, are prepared to help children understand what has happened and to promote effective coping strategies. This will help to reduce the impact of the disaster as well as any associated bereavement and secondary stressors.

Stress is intrinsic to many major life events that children and families face, including the experience of significant illness and its treatment. The information provided about how to help children cope after disaster and crisis is therefore relevant for many encounters that pediatricians will have with children, even outside the context of a disaster.

Talk about the event with your child. To not talk about it makes the event even more threatening in your child’s mind. Silence suggests that what has occurred is too horrible to even speak of. Silence may also imply to your child that you don’t think their reactions are important or appropriate.

  • Start by asking what your child has already heard about the events and what understanding he or she has reached. As your child explains, listen for misinformation, misconceptions, and underlying fears or concerns, and then address these.
  • Explain – as simply and directly as possible – the events that occurred. The amount of information that will be helpful to a child depends on his or her age. For example, older children generally want and will benefit from more detailed information than younger children. Because every child is different, take cues from your own child as to how much information to provide.
  • Encourage your child to ask questions, and answer those questions directly. Like adults, children are better able to cope with a crisis if they feel they understand it. Question-and-answer exchanges help to ensure ongoing support as your child begins to understand the crisis and the response to it.
  • Limit television viewing of disasters and other crisis events, especially for younger children. Consider coverage on all media, including the internet and social media. When older children watch television, try to watch with them and use the opportunity to discuss what is being seen and how it makes you and your child feel.

Healthy Children. Org provides additional insights

  • Recognize that your child may appear disinterested. In the aftermath of a crisis, younger children may not know or understand what has happened or its implications. Older children and adolescents, who are used to turning to their peers for advice, may initially resist invitations from parents and other caregivers to discuss events and their personal reactions. Or, they may simply not feel ready to discuss their concerns.
  • Reassure children of the steps that are being taken to keep them safe. Terrorist attacks and other disasters remind us that we are never completely safe from harm. Now more than ever it is important to reassure children that, in reality, they should feel safe in their schools, homes, and communities.
  • Consider sharing your feelings about the event or crisis with your child. This is an opportunity for you to role model how to cope and how to plan for the future. Before you reach out, however, be sure that you are able to express a positive or hopeful plan.
  • Help your child to identify concrete actions he or she can take to help those affected by recent events. Rather than focus on what could have been done to prevent a terrorist attack or other disaster, concentrate on what can be done now to help those affected by the event.

AACAP Recommendations for talking to children about COVID-19 :

Talking to Children About Coronavirus (COVID19)

  • Remember that children tend to personalize situations. For example, they may worryabout their own safety and the safety of immediate family members. They may alsoworry about friends or relatives who travel or who live far away.
  • Be reassuring, but don’t make unrealistic promises. It’s fine to let children know that they are safe in their house or in their school. But you can’t promise that there will be no cases of coronavirus in your state or community.
  • Let children know that there are lots of people helping the people affected by the coronavirus outbreak. It’s a good opportunity to show children that when something scary or bad happens, there are people to help.
  • Children learn from watching their parents and teachers. They will be very interested in how you respond to news about the coronavirus outbreak. They also learn from listening to your conversations with other adults.
  • Don’t let children watch too much television with frightening images. The repetition of such scenes can be disturbing and confusing.
  • Children who have experienced serious illness or losses in th
  • Although parents and teachers may follow the news and the daily updates with interest and attention, most children just want to be children. They may not want to think about what’s happening across the country or elsewhere in the world. They’d rather play ball, go sledding, climb trees or ride bikes.

 

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by: Tracy S. Cummings, MD, Psychiatrist, Lindner Center of HOPE

The best way to prevent illness is to avoid being exposed to this virus.

The virus is thought to spread mainly from person-to-person.

  • Between people who are in close contact with one another (within about 6 feet).
  • Through respiratory droplets produced when an infected person coughs or sneezes.

Clean your hands often

  • Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
  • If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.

Avoid close contact

 Take steps to protect others

Stay home if you’re sick

  • Stay home if you are sick, except to get medical care

Older adults and people who have severe underlying chronic medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness.

Based upon available information to date, those most at risk include:

  • People 65 years and older
  • People who live in a nursing home or long-term care facility
  • People of any age with the following underlying medical conditions, particularly those that are not well controlled
    • Chronic lung disease or asthma
    • Congestive heart failure or coronary artery disease
    • Diabetes
    • Neurologic conditions that weaken ability to cough
    • Weakened immune system
    • Chemotherapy or radiation for cancer (currently or in recent past)
    • Sickle cell anemia
    • Chronic kidney disease requiring dialysis
    • Cirrhosis of the liver
    • Lack of spleen or a spleen that doesn’t function correctly
    • Extreme obesity (body mass index [BMI] >40)
  • People who are pregnant
  • Pregnant women experience immunologic and physiologic changes which might make them more susceptible to viral respiratory infections, including COVID-19.
  • There is no evidence that children are more susceptible to COVID-19. In fact, most confirmed cases of COVID-19 reported from China have occurred in adults. Infections in children have been reported, including in very young children. There is an ongoing investigation to determine more about this outbreak. This is a rapidly evolving situation and information will be updated as it becomes available.

The symptoms of COVID-19 are similar in children and adults. However, children with confirmed COVID-19 have generally presented with mild symptoms. Reported symptoms in children include cold-like symptoms, such as fever, runny nose, and cough. Vomiting and diarrhea have also been reported. It’s not known yet whether some children may be at higher risk for severe illness, for example, children with underlying medical conditions and special healthcare needs. There is much more to be learned about how the disease impacts children.

 

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Margot Brandi, MD
Staff Psychiatrist
Sibcy House, Medical Director
Lindner Center of HOPE

-“ Y hasta cuándo cree usted que podemos seguir en este ir y venir del carajo? – pregunto.

Florentino Ariza tenia la respuesta preparada desde hacia cincuenta y tres anos, siete meses y once días con sus noches.

 -Toda la vida – dijo.”
Gabriel Garcia Marquez en El amor en los tiempos del cólera.

En este mes de febrero, en el que querámoslo o no el asunto del amor se convierte en protagonista ,pienso en esta frase del final de El amor en los tiempos del cólera, que tal vez no sólo habla de una relación (Fermina y Florentino), sino también del arraigo  a un pueblo, de las rutinas pesadas del proceso de inmigración.Siempre la he pensando como una propuesta irreverente ante la eternidad del amor, la idea de un vinculo que perdura para siempre como el vinculo con el lugar de nuestro origen.  Pero, de qué amor estamos hablando…?

En el más reciente  juego de super bowl, justo entre el primer y segundo cuartos, me quede hipnotizada frente al comercial de una compañía de seguros que en 60 segundos paseaba al espectador a través de los 4 tipos de amor según el lenguaje de los antiguos griegos. EL comercial comenzaba explicando cómo los griegos tenían cuatro palabras para referirse al amor. La primera es PHILIA, que se refiere al afecto que crece desde la amistad. La segunda es STORGE que tiene que ver con el tipo de amor que se desarrolla hacia los padres o hacia los hermanos. El tercero es EROS que alude a la incontrolable urgencia de decir “te amo”. EL cuarto se llama AGAPE y es el más admirable, el amor como una acción, implica coraje, sacrificio y fuerza. Es aquello que nos inspira a poner las necesidades del otro primero que las nuestras. Es la búsqueda por convertirnos en la mejor version de nosotros mismos. El intento por construir un mejor futuro para aquellos que amamos.  El comercial es un reconocimiento a las acciones que tomamos todos los días para proteger a nuestros seres queridos. La emigración puede tomar esa forma. Lo que me pareció genial no fue tanto el comercial sino el “timing” del mismo. Me refiero a presentar estas ideas cuando nuestra mente esta básicamente atrapada por un sentimiento de rivalidad entre dos equipos, y el foco principal apuntando a  un consumismo descarado. Lograr una pausa para capturar nuestra atención y recordarnos nuestras prioridades. ( claro, y también vender muchos seguros) como si alguien hubiese cambiado el canal del televisor sin darnos cuenta.

Mi reflexion de este mes es la de tomarnos el mes de febrero como una pausa que nos permita recordarnos el poder del amor como acción, bien sea a través del mas pequeño de los gestos o la mas difícil de las decisiones como lo puede ser emigrar. Recordar de qué se alimenta la tan llamada fuerza de voluntad de un emigrante que empaca sus sueños en una maleta en busca de construir un mejor futuro para si mismo y sobretodo para nuestros seres queridos. Se trata de levantarnos todos los días y “seguir en este ir y venir “de nuestro diario vivir como inmigrantes, así como lo hizo Florentino, el protagonista de El amor en los tiempos del cólera. Poder mirar atrás con un amor melancólico, en mi caso por un país perdido irremisiblemente, o hacia adelante con la esperanza de que “en este ir y venir” nos construyamos un porvenir que trascienda nuestra geografía y nuestra generación.

 

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Anna I. Guerdjikova, PhD, LISW, CCRC

Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program

Currently over 50% of the world’s population is living in urban areas with limited opportunity to engage with nature. In North America most adults spend ∼90% of their time indoors. Ecotherapy, also known as nature therapy or green therapy, is the applied practice of the rapidly evolving field of ecopsychology, a term coined by Theodore Roszak in 1992. Ecotherapy builds on the biophilia hypothesis proposed by E. O. Wilson which suggests that human beings are genetically hardwired to “affiliate with other forms of life”. He proposed that the connection humans seek and have with other life forms and nature is deeply rooted in our biology. If prevented from sufficient contact with nature, we are at risk for developing a “nature-deficit disorder” which can lead to negative consequences for our mental and physical health.

It is established through research from all over the world that people with good access to natural environments are more likely to experience wellness. For example, green space has been associated with improvements in cognitive functioning and self-esteem and reductions of depression, stress and anxiety. Blue spaces, defined as environments predominately consisting of water, lower levels of anxiety and mood lability, and are positively associated with self-reported mental and general health. Physical activities in natural settings are associated with less anger, fatigue, and sadness and might reduce the blood flow to the part of the brain responsible for despondency. Mere exposure to nature can be healing, it has been consistently shown that simply looking at environments dominated by greenery or water is significantly more effective in promoting recovery and restoration as compared to milieus lacking nature.

Nature based interventions (NBIs ) include programs and activities engaging people in nature-based experiences to enhance general health through promotion of wellness and prevention of illness. NBIs include interventions that alter the environments where people live and interventions designed to change individual’s behavior (such as promoting walks outside or gardening).

Prescription: A Dose of Nature

Some examples of NBIs as listed below. Of note, nature based interventions can be a helpful adjunct in the treatment of mental illness along with pharmacotherapy and psychotherapy.

  • Physical exercise outdoors: walking, jogging, biking, doing yoga or other exercises in a park fosters increased awareness of the natural world and can be recommended for reducing stress, anxiety, depression, and anger. Walk-and-talk therapy is a gaining popularity treatment model, encouraging patients to be more physically active for mental and physical reasons and helping them move forward, literally and metaphorically speaking, when facing challenging problems
  • Nature meditation: using nature as focus point and incorporating it in meditation and mindfulness experiences. Forest bathing, for example, is a well stablished practice in Japan since the 1980s. It requires that one just sits in the presence of trees, without engaging in any physical activity. It has been shown that in the week after the forest visit, the activity of human natural killer cells (implicated in cancer prevention and immunity) increases and those positive effects can last up to a month following each weekend in the woods. Furthermore, forest environments might help decrease contisol, pulse rate, and blood pressure as compared to city environments.1
  • Horticultural therapy: Various forms of gardening and landscaping are known to improve community connectedness, create a sense of purpose and can promote better eating habits.
  • Animal-assisted therapy: Extensive data supports the use of this complementary type of therapy, with canine and equine-assisted therapy being the most well researched, to improve the social, emotional, or cognitive functioning in various settings  (mental health centers, nursing homes, schools and prisons) and across diagnoses (dementia, ADHD, PTSD and autism to name a few).2
  • Indoor nature exposure- enriching indoor work and living spaces with nature elements (plotted plants, pictures and photos with view of nature, window view of grass or woods etc.) are known to improve attention, moods and productivity and  to reduce stress and heart rate. In one study, for example, sunlight and/or a nature view increased job satisfaction, reduced intention to quit and lowered feelings of being  worn out uptight.3

A study published in the summer of 2019 examined a representative sample of over 20000 people in England and concluded that a “two-hour “dose” of nature a week significantly boosts health, and life satisfaction”, including among those with long-term illness and disabilities.4  If spending only twenty minutes per day in natural environments can make a difference, it is certainly worth giving it  a try.

References :

  1. Environ Health Prev Med. 2010 Jan;15(1):18-26. The physiological effects of Shinrin-yoku (taking in the forest atmosphere or forest bathing): evidence from field experiments in 24 forests across Japan. Park BJ, Tsunetsugu Y, Kasetani T, Kagawa T, Miyazaki Y.
  2. Complement Ther Med. 2018 Dec;41:203-207.”We need them as much as they need us”: A systematic review of the qualitative evidence for possible mechanisms of effectiveness of animal-assisted intervention (AAI).Shen RZZ, Xiong P, Chou UI, Hall BJ.
  3. Health Promot Int. 2015 Mar;30(1):126-39  Indoor nature exposure (INE): a health-promotion framework. Mcsweeney J, Rainham D2, Johnson SA, Sherry SB, Singleton J.
  4. Sci Rep. 2019 Jun 13;9(1):7730.Spending at least 120 minutes a week in nature is associated with good health and wellbeing. White MP, Alcock I, Grellier J, Wheeler BW, Hartig T, Warber SL, Bone A, Depledge MH, Fleming LE.

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William Hartmann, MD; Lindner Center of HOPE Psychiatrist, Medical Director, Willliams House

Navigating the realm of psychiatric medications can be challenging, often hindered by common misperceptions. Managing and understanding expectations can go a long way in ensuring treatment success. Seeking out help is often complicated by preconceived ideas. Preconceived notions about psychiatric medication often get in the way of successful treatment. Building a trusted relationship paves the way for educational opportunities, treatment adherence, and recovery.

5 Common Misperceptions of Psychiatric Medications

1 – “It’s just a chemical imbalance.” 

The advent of serotonin reuptake inhibitors (SSRIs), with their efficacy for depression and anxiety and reduced side effect risk compared to their predecessors, remains a major milestone in psychiatric care. It became increasingly commonplace to hear of the “chemical imbalance” of these illnesses. For as much as “chemical imbalance” helped spread the word that this is a brain disorder, not a moral failing, this wording unfortunately has promoted an overreliance on the power of the medication. The medications do alter brain chemistry and lead to a chain of biochemical events influencing symptom reduction and recovery. What the medication will not do is eliminate stressors, change one’s lifestyle, or cause satisfaction with an otherwise unhealthy situation. I find that those with the greatest success are those who recognize that medication helps facilitate deeper work in psychotherapy and making constructive changes to promote wellness. The medication may help substantially, but it will not do all of the work.

2 – “I don’t want to be a zombie.”

Many will fear that medication will change their personality substantially, or cause them to feel or appear sedated. The goal of treatment is to help a person function as their best self, not change who they are, or make them void of emotional response. While any effective medication has side effect potential, most patients can work with their prescriber to find the right fit for them to manage the illness with success.

3 – “I don’t want to take happy pills.”

Addressing the stigma associated with psychiatric medications, particularly antidepressants, is crucial. Depression is more than the usual sadness one inevitably encounters from time to time. Treatments for mood disorders are not instant “uppers” nor are they performance-enhancers. 

The effects of antidepressants are gradual and usually occur over about 4-6 weeks. Moreover, they will not make you “happy” so much as reduce and resolve symptoms of clinical depression. They aim to restore the capacity for contentment and joy. Treatment allows reduction of the “thought constriction” which limits one’s perspective to seeing few options. One may then see the broader opportunities to connect with core values in a rewarding way. It is about getting back to being your best self. Psychotherapy helps bring this together.

4 – “I don’t want to be dependent on a medication.”

The fear of dependency on medication is a valid concern for many. Taking medication may be a constant reminder of the illness, but the illness exists whether taking the medication or not. The majority of psychiatric medications, except benzodiazepines, do not produce true physical dependence. Turning the focus to the goals of recovery, and how the medication is part of the process, can help.

5 – “Don’t you put everyone on medication?”

There is not a one-size-fits-all approach. A common misconception is that every psychiatric patient is put on medication. Correct diagnosis is essential and, for some conditions, medication may not be the appropriate first line of treatment. A large portion of a psychiatrist’s work involves evaluating and managing the use of psychiatric medications. Most people will not come my way unless they have reached a point where medication appears necessary. A person may be experiencing sadness, grief, anxiety, milder depression, or an adjustment problem that is better suited for psychotherapy. A person might make gains in exposure response prevention for anxiety without the aid of medication. There may not be adequate or applicable evidence for medication helping a particular problem. Evidence is weaker for antidepressants in milder major depressive disorders, for example, but antidepressant treatment is recommended for moderate to severe depression. In some conditions, such as bipolar I disorder or schizophrenia, medication is crucial for the treatment and prevention of recurring episodes of illness. In opiate use disorders, prescription medications such as naltrexone and buprenorphine have emerged as a best practice, something that was not the case decades ago.

Ultimately, the decision regarding the role of medication for a given individual is between patient and prescribing clinician. Addressing attitudes and expectations early in the process can make a better experience for everyone. Empower yourself with knowledge to make the best choices for your mental health journey.

For more information and resources on psychiatric medications, contact us at Lindner Center of HOPE.

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Margot Brandi, MD
Staff Psychiatrist
Sibcy House, Medical Director
Lindner Center of HOPE

 

Si alguna vez han visitado al oftalmólogo sabrán que la vision 20/20 se refiere a la agudeza visual que te permite ver con claridad los objetos a 20 pies de distancia, lo que equivale aproximadamente a 6 metros. Es la vision “normal”. Las estadísticas reflejan que solo un 35% de todos los adultos tiene una vision 20/20. Esto explica porque a la mayoría nos toca usar algún método correctivo, por lo general lentes o cirugía. Y es que al final lo importante es que logremos ver con claridad encontrando al lente y la luz que nos acomode mejor.

Este primero de enero mientras compartía a la distancia las distintas formas de celebrar el nuevo ano a través de instagram me encontré con el hashtag (etiqueta digital) #vision 20/20 al pie de muchas de las fotos que contemple.

Se me ocurrió que el año 2020 puede ser una invitación a lograr la vision normal y a tener agudeza visual en lo que tengo a mi alrededor, al espacio en el que puedo influir y como explicaba antes la mayoría de las veces no es mucho mas que los 6 metros que tengo de radio de acción. El ano 2020 es una invitación a preguntarse, que es lo que quiero y puedo ver? Veo desenfocado? Necesito lentes? Que tipo de lentes necesito? Cuanto estoy dispuesto a invertir para corregir mi vision? Necesito mas luz? Me gusta lo que veo? No me gusta? Como lo puedo cambiar? Que puedo hacer para mejorarlo?

Nuestra vision como inmigrantes tiende a estar marcada por la dificultad para enfocarnos en nuestro presente. En la mayoría de los casos nuestro foco sigue aferrado a nuestra tierra de origen, a todo lo que perdimos en la transición a otro país, a todo lo que no pudimos traernos en la maleta (afectos, olores, sabores, colores) y que va tiñendo nuestra mirada de un halo melancólico que limita nuestra agudeza visual. Otros, en cambio intentan borrar la vision de su pasado y de su historia y no quieren saber nada de lo vivido hasta entonces pretendiendo comenzar una vida “totalmente distinta o nueva” y renegando de sus raíces pensando que así la adaptación sera mas fácil y podrán saltarse el duelo de todo aquello que dejaron atrás. En este caso también el resultado es una vision borrosa porque no se puede construir vida presente sin historia y sin pasado. La vision normal la obtienen aquellos inmigrantes que se interesan por conocer la cultura y tradiciones locales tratando al mismo tiempo de mantener sus costumbres y rituales propios de su region. Es un esfuerzo que requiere de gran esfuerzo y de mucho trabajo.

Lo primero es detenerte a reflexionar cuanto de tu tiempo y de tu vision estas dedicando a tu vida en este país en comparación con la vida en tu país de origen. Sabes mas de las noticias de tu país que de lo que pasa en tu vecindario? O por el contrario hace ya demasiado tiempo que te desconectaste por completo de tu país de origen? En ambos casos, la metáfora de los lentes correctivos nos puede servir para ilustrar la necesidad de ajustar nuestro foco y nuestra vision hasta lograr un balance que nos permita ver y estar en el presente y al mismo tiempo integrar nuestra experiencia pasada a esta nueva mirada para enriquecerla con los colores únicos de nuestra tierra.

En este mes de Enero, donde todos hablan de resoluciones o intenciones de ano nuevo, atrévete a invertir en tu vision personal y pregúntate que necesitas para que esa imagen de lo que quieres hacer o lograr sea lo mas nítida posible. Abrete a buscar ayuda, trabaja en equipo, porque como dicen por allí “cuatro ojos ven mejor que dos”. Enfócate en los 6 metros que tienes a tu alrededor y pon toda tu energía en ese espacio de trabajo o personal en el que puedes influir y dejarte influir. Abrete a nuevas imágenes.

Vengo de un pais con una montaña mágica que nos obsesiona a todos los que nos sentimos venezolanos. No conozco venezolano, especialmente caraqueño que no busque dentro o fuera de si esa vision del Avila en un intento por recordarse a si mismo que sigue habiendo belleza y prodigio en la capital de la peor economía del mundo. A veces me siento que me estoy volviendo adicta a ver imágenes del Avila y de Caracas en la redes sociales para no perder de vista de donde vengo y por tanto quien soy. Hay muchas cosas que debería estar haciendo en vez de eso y también debo mirar más a mi alrededor a la ciudad donde vivo y no a la que deje atrás. Es enero, y la nostalgia me quiere desenfocar entonces me aferro a los 6 metros a mi alrededor y encuentro que son muchas last fotos de esta ciudad que también puedo tomar y que he tomado a lo largo de estos años. Q ue la vision de un inmigrante no es la de una imagen sino la de multiples imágenes que pueden convivir y enriquecer el panorama si estamos dispuestos a enfocar y desenfocar según lo amerita el caso.

¡Deseándoles un Clara y nítido año 2020!

 

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Jennifer Farley, PsyD

Lindner Center of HOPE, Staff Psychologist

The holiday season can be an enjoyable and peaceful time for many of us. We adults know that this can also be a busy, tense, overstimulating, overindulgent, and overwhelming time. Any of these experiences can be triggered, for example, by holiday memories of the past, our current experiences, or worries about the future. We also may have expectations for how our holidays “should” be, which can bring about even more stress in planning them or sadness or anger if our experiences fall short of what we wanted.

Using mindfulness, or focused attention on the “here and now,” can be helpful in making the holiday season more tolerable and, hopefully, more enjoyable. Mindfulness involves being self-aware of one’s thoughts or feelings or behaviors in the current moment and without judgment. Why the current moment? Because thinking about the past can bring about sadness (and depression) and thinking about the future can bring about worry (and anxiety). Being mindful without judgment is also important – it helps prevent an emotion from being experienced more intensely. For example, telling oneself, “I’m a horrible friend for not giving them a gift,” is far different than, “I have the thought that I am a horrible friend for not giving them a gift.” Similarly, reflecting, “I’m sad that my family member isn’t here,” is experienced differently than “I have the feeling of sadness about my family member not being here.” The without judgment part also comes from not judging oneself or anyone else for having a particular thought, feeling, or behavior. Telling oneself, for example, that they’re “bad” for thinking or feeling a certain way is a judgment – having a thought or feeling simply makes one human. What we do with a thought or feeling is what matters more.

Thoughts about how the holidays “should be” can intensify people’s emotional experiences further. Many people, for instance, experience “shoulds” surrounding holiday traditions. While these can bring comfort to our holidays, “shoulds” can also weigh people down with guilt, burden, or anxiety. Family traditions are important, but so is the consideration of how a specific tradition might be unreasonable to expect – for oneself or others. Letting go of the word “should” allows more flexibility and adaptability to an experience, and as such, can bring about more joy and a lot less tension. Do you really “need” to host Christmas dinner? Or is it that you prefer it but can adapt to having someone else host?

Mindfulness can be practiced by observing and describing one’s current thought(s) or feeling(s). Mindfulness can also involve doing something with intention. Consider how you might – with focused intention – wrap a present, look at Christmas lights, drink your cup of coffee or hot chocolate, hug a loved one, sing a Christmas carol, hang ornaments on your tree, watch a favorite holiday movie, or study the fire in the fireplace. Doing something with intention helps you remain in the present moment. Be aware of how your phone or other distractions prevent you from being fully present with others. If you find yourself diving deeper into a holiday memory, try to catch yourself first, and mindfully reflect if it’s a happy or heartwarming memory or one that could bring about sadness or hurt or anger.

One classic holiday movie (A Christmas Story) features Ralphie and his myriad of Christmas-related incidents. There are two scenes that highlight mindfulness practice: 1) when Ralphie looks with amazement at the snow-covered scene outside his bedroom window on Christmas morning, and 2) when Ralphie’s parents sit together in the dark and gaze at their Christmas tree. Another movie (Elf) depicts a father making a choice to fully participate in singing a carol with his family. These pop culture references may help highlight ways you might practice mindfulness in your own ways this holiday season. As a result, may your next month or so be experienced with mindful moments that bring self-awareness, peace, and joy.

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La gratitud de un inmigrante.

Cuando pregunté por la fecha limite para entregar esta mi segunda columna me informaron tambien que saldría publicada justo antes del dia de acción de gracias (Thanksgiving) Entonces, me parecio casi obligatorio dedicar este espacio a la gratitud, y su impacto en la salud mental.

A kilómetros de distancia de nuestro lugar de origen, los inmigrantes somos también un poco huérfanos. Migrar es también una tipo de orfandad.  Y es solo atravesando ese miedo que acompaña la falta de referentes familiares al llegar a un país distinto que podemos entonces reconstruirnos y reinventarnos como ese huerfano con desesperación que busca un nuevo hogar. Hay quienes mueren (literamente) en el intento, otros que toman la decisión de ni siquiera intentarlo, y aquellos que deciden apostarlo todo en esa nueva tierra dejando atrás su historia. Es un viaje titánico imposible de transitar en solitario. Todos podemos nombrar a un familiar, un amigo, un trabajo, un colega, un vecino que nos tendio la mano o nos facilito el hilo a la hora de tejer nuestro nuevo nido. Por eso digo que no conozco a nadie mas agradecido en la vida que a un inmigrante. Y cuando escribo pienso en mi abuelo italiano que hasta el nombre se cambio para parecer mas venezolano.

No pretendo ni espero que todos nos comportemos con ese animo “rosadamente” positivo a diario, sobretodo considerando los dolores y las cicatrices que acompañan a la orfandad. Independientemente de cual haya sido la manera o la circunstancia en la que se emigró, cada uno de nosotros lleva consigo un duelo y una melancolia que nos es única e incomparable y que tiende a hacernos mas sensibles y conscientes de lo que nos falta o de lo que hemos perdido, haciendo difícil el poder conectarnos con todo aquello que vamos reinventado en nosotros mismos y a nuestro alrededor. Mi reflexión va por el lado de compartir lo que me va pareciendo son los dos elementos claves para vivir en gratitud. Primero, la posibilidad de conservar “pequeñas expectativas”, sin que eso signifique renunciar a nuestras ambiciones  y segundo, la habilidad para vivir en el presente.  Se refiere a vivir sin dar nada por sentado. Como un aprendiz o principiante que se asombra ante cualquier vestigio de progreso en la tarea que ejecuta y que no se atormenta por aquello que debe para el dia siguiente o la semana próxima. Es poder disfrutar de un dia cálido y soleado sin atormentarse porque mañana será frio y lluvioso. Es disfrutar de la visita de un familiar o de un amigo sin contar los días para la despedida.

Muchos estudios científicos afirman que vivir en gratitud es una estrategia robusta para combatir la depresion y la ansiedad. Se trata de prestar atención a cosas que podrían pasar por insignificantes o inútiles. No hace falta hacer una lista de mercado (a menos que para usted si tenga sentido). Basta con detenerse aunque sea una vez al dia a saborear un olor, un sabor, un gesto o una sonrisa inesperada como inesperado ha sido mi propio camino para llegar a ustedes.

 

Margot Brandi, MD

Medical Director, Sibcy House

Staff Psychiatrist

Lindner Center of HOPE

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Angela Couch, RN, MSN, PMHNP-BC
Lindner Center of HOPE, Pyschiatric Nurse Practitioner

Making decisions about which medication to prescribe is a complicated process.  Janicak, et al (2006, p. 1) described the complexity of the issue fairly well,

“…while improved therapies to ease a patient’s suffering are constantly emerging, the practitioner is required to continually assimilate new information about recent advances, including novel agents targeted to affect specific components of various neurotransmitter systems, combination strategies, alternative uses of existing agents, and the specialized requirements of a growing number of identified diagnostic subgroups.”

The clinician must first have identified a valid diagnosis, and determine whether treatment with medication is indicated.  In some cases, psychotherapy alone may be an adequate treatment; whereas pharmacotherapy is less frequently an adequate treatment all by itself and is often paired with psychotherapy.  Diagnosis will somewhat narrow the field of choices, and comorbid mental health conditions must be considered as well. If the patient has more than one mental illness, it is wonderful when there is a class of medication which may be able to treat all the symptoms in one drug, but often that is not the case.  Treatment of mood disorders is often prioritized, particularly if a bipolar spectrum illness is present. For instance, though antidepressants are generally a first line treatment for anxiety related disorders, giving an antidepressant to a patient with a bipolar spectrum illness can be quite destabilizing. In that case, the mood disorder should be addressed with mood stabilizing medication prior to consideration of antidepressant use.

There are potential risks and benefits to any medication, and the clinician much consider these and discuss them with the patient. Special populations require special considerations. Treating pregnant patients, children or adolescents, the elderly, or those with certain medical conditions, may pose additional risks; this may make many medications, which might otherwise be appropriate, be contraindicated due their side effects profile.  Sometimes, the potential side effects of a given medication may be beneficial to certain patients and their mental health or other comorbid symptoms, and this may help narrow the field of choices.  During treatment, the patient is continually reassessed to determine if they continue to benefit from the medication, and whether they are experiencing any side effects that should be closely monitored or may require a treatment modification.

Patients may have had prior positive or negative experiences on medications, and this can also help drive the decision making process. For instance, this may help a clinician to decide whether to try the same or very similar medication again, or to consider changing class of medication.  Sometimes, a close family member’s prior response to medication may be considered.

Pharmacogenetic testing is a recent advancement in pharmacotherapy.  There is a lack of consensus about the value of this genetic testing.  It would be misleading to state that the genetic testing results can indicate the medication to which a patient will respond favorably.  However, it can identify whether patients may metabolize various drugs that pass through the CYP P450 system in different ways, which may impact outcomes or suggest dose modification. Also, there a limited number of medications for which the FDA has specific labelling regarding recommendations for certain types of metabolizers. So it is possible that pharmacogenetic testing would be a consideration in the decision making process, but not a required one. It is not often covered well, if at all, by insurance, and the out of pocket portion can be cost prohibitive for some patients.

Practice guidelines can be very beneficial. For instance, the APA has been developing practice guidelines since 1991, and these cover a wide range of topics, which undergo periodic updates. The guidelines are formed by work groups of actively practicing psychiatrists who are selected based on their experience in various topic areas.  Recommendations are based on evidence that includes research studies and clinical consensus.

Last but not least, cost is a factor that unfortunately must be considered for many patients.  For those that have high deductible insurances, or no insurance, many drugs may be out of reach including those that may add an extra layer of medical monitoring such as frequent laboratory testing.

In summary, decision making regarding medication choice is complex process.

References:

APA Practice Guideline Development Process (n.d.) Retrieved from:  https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/APA_Guideline_Development_Process.pdf

Janicak, P.G., Davis, J. M, Preskorn, S.H., Ayd, F.J., Marder, S.R. & Pavuluri, M.N.  (2006). Principles and practice of psychopharmacotherapy (4th ed.).  Philadelphia, PA: Lippincott Williams & Wilkins.

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By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief
of Adult Psychiatry

 

Innovations in Mental Health Treatment

By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief
of Adult Psychiatry
The past year has brought exciting innovations in treatment options for people with attention deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), and obsessive-compulsive disorder (OCD.) The U.S. Food and Drug Administration (FDA) approved the marketing of two devices which offer non-medication alternatives for the treatment of OCD and ADHD.  In August 2018, the Brainsway Deep TMS (Transcranial Magnetic Stimulation) system was approved for the treatment of OCD.  Deep TMS uses specially designed magnets to stimulate specific larger volume areas of the brain beneath the surface of the skull.  It is a non-invasive treatment that involves five 20-minute sessions per week for six weeks while sitting in a chair wearing a helmet with a sensation of tapping during the treatment.  Patients can continue medication and psychotherapy while receiving deep TMS.  According to the National Institute of Mental Health (NIMH), the lifetime prevalence of OCD among U.S. adults is 2.3% and 50% of these have had serious impairment.  Having another treatment option will bring hope to many people with severe OCD.

In April 2019, the Monarch eTNS (external trigeminal nerve stimulation) system was approved for the treatment of pediatric ADHD as monotherapy in children ages 7 through 12 years old who are not currently taking prescription ADHD medications. The Monarch eTNS System is intended to be used at home under the supervision of a caregiver when the child is sleep. The cell-phone sized device generates a low-level electrical pulse that feels like a tingling sensation and connects via a wire to a small patch that adheres to a patient’s forehead, just above the eyebrows. The system delivers electrical stimulation to the branches of the trigeminal nerve, which sends therapeutic signals to the parts of the brain thought to be involved in ADHD. The NIMH reports that the prevalence of ADHD is increasing, and severe ADHD is being diagnosed at an earlier age. This can be a treatment alternative for parents who prefer to avoid medications at an early age. Clinical response is expected in four weeks.

The mechanism of action of most antidepressants involve the neurotransmitters serotonin, norepinephrine, and dopamine. In March 2019, two antidepressants with novel mechanisms
of action were approved. Zulresso (brexanolone) was the first drug specifically approved for postpartum depression. Postpartum depression affects about 15% of women. Zulresso modulates the neurotransmitter GABA. It is administered as a 60-hour intravenous infusion in a registered healthcare facility. Symptom improvement was seen at the end of the infusion and at the end of 30-day follow-up. There has never been a medication that treats the symptoms of postpartum depression so rapidly, so this can significantly improve the quality
of life for the mother, infant, and her support system.

Spravato (esketamine) nasal spray was approved for treatment-resistant depression in conjunction with an oral antidepressant. Patients must have tried at least two antidepressant treatments at adequate doses for an adequate duration in the current depressive episode before trying Spravato. The spray must be administered in a certified medical office where the patient can be monitored. Spravato is taken twice a week for four weeks then once a week for a month, then once a week or once every two weeks. It is an antagonist of the NMDA receptor, a type of glutamate receptor. Approximately 30% of people with MDD are considered to have treatment-resistant symptoms and have the potential to benefit from esketamine.

For more information about these treatment options: https://www.brainsway.com/treatments/obsessive-compulsive-disorder 

http://www.monarch-etns.com/ 

https://www.zulresso.com/ 

https://www.spravato.com/