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In the News, Medicine and Society, Mental Health, Pediatrics

Advice and guidance on teen suicide

Advice and guidance on teen suicide

12389778613_ed6496a72f_zNot again, I thought as I read the opening line of a recent Palo Alto Weekly op-ed: “As a community we are grieving.” Reading further, my fears were confirmed: Now, additional teens have died by suicide in this California city.

A handful of years ago, I was a reporter for the Weekly. I was so grateful to cover city government, rather than schools — what a pressure cauldron, I thought at the time. As a teen, I too struggled with perfectionism, the drive to earn straight As and attend a top college, while excelling at extracurriculars. How awful to be surrounded by others like me, I thought.

Of course this is a one-dimensional glimpse at the problem. Suicides aren’t explained by perfectionism or academic stress and they certainly aren’t a Palo Alto-only problem. Shashank Joshi, MD, a child psychiatrist with Lucile Packard Children’s Hospital; Palo Alto Medical Foundation physician Meg Durbin, MD; and Sami Harley, a mental-health specialist, discuss this and other issues in a piece written to offer guidance to the saddened community. “Suicide does not have a single ’cause.’ Many factors and life circumstances must be taken into account,” they write.

They go on to clarify misperceptions about depression, an underlying condition that can make suicide or suicidal thoughts more likely:

Depression isn’t something you can or must just ‘deal’ with on your own… Though positive thinking can be an important part of having a healthy and resilient life, positive thinking by itself does not treat clinical depression. Talk therapy with antidepressant medications, if needed, are the only proven treatments for teen depression.

These local experts have held depression education and suicide-prevention training sessions with several thousand students at the two Palo Alto public high-schools since 2010. “Solutions must come from all those who interact with youth, including schools, parents and family, friends, medical and mental health providers, community and faith leaders and mentors,” they conclude.

Previously: “Every life is touched by suicide:” Stanford psychiatrist on the importance of prevention, Lucile Packard Children’s Hospital partners with high schools on student mental health programs  and Volunteers watch train crossings to prevent suicides
Photo by jimmy brown

In the News, Mental Health, Patient Care

Imagining voices: A new movement is using drug-free ways to treat auditory hallucinations

Imagining voices: A new movement is using drug-free ways to treat auditory hallucinations

Artistic_view_of_how_the_world_feels_like_with_schizophrenia_-_journal.pmed.0020146.g001The idea of hearing voices, or auditory hallucinations, is an experience that frightens many of us. It can be seen as a sign that you are no longer in control of your mind. Auditory hallucinations are also a symptom of schizophrenia, and those with the disease often hear voices which are hostile, mean and disturbing. But in Europe, a small band of clinicians, led by the Dutch psychiatrist and president of Intervoice, Marius Romme, MD, PhD, is exploring new ways to treat the problem of hearing distressing voices. A recent interview with one of Romme’s colleagues, Dirk Corstens, MD, and two of his patients, was featured in The Atlantic.

Stanford anthropologist Tanya Luhrmann, PhD, has worked extensively with people who hear voices, and a recent study she conducted compared the experiences of psychotic patients with auditory hallucinations living in three very different locales – San Mateo, California; Chennai India; and Accra, Ghana. Her team found that the voices of Indian and Ghanaian patients were more likely to be playful and benign, whereas those of U.S. patients were on average more threatening.

When Luhrmann took time to talk with me to discuss the implications of her research and the new approach, which calls itself the Hearing Voices movement, she noted early on that although the treatments espoused by the new movement won’t work for everyone, “The Hearing Voices approach is very important and has an important kernel to it.”

Some of what the group advocates is controversial. “They often reject the idea of schizophrenia, are hesitant about medication, and have a model of hearing voices that identifies sexual trauma as the most important cause of hearing voices,” she says. But a growing body of scientific evidence shows that it may be useful to teach people to interact with their voices.

The Hearing Voices movement, says Luhrmann, advocates seeing the voices as meaningful, treats them as people, respects the voices and encourages patients to interact with them with the help of a trained clinician. One of the patients featured in The Atlantic piece described how he learned to work with the voices he heard:

[Dr. Corstens and I] started to work with each other five years ago, or more. I was around 20 years old. It took about two years of work to actually figure out what the relationships were, what the triggers for the voices were, and what feelings are coupled to these voices. Once you start to learn to express yourself and work out these problems on your own, the voices don’t have to act out their part. Now, when I hear voices, I know what triggered them. I ask, “What is happening with me? What am I neglecting in my own emotions?” Does that make sense?

Luhrmann says that while more research needs to be done, it seems that some patients appear to benefit and the voices they hear diminish, or at least become less aggressive and intrusive. But she cautions that the method may not be appropriate for all patients. “I think it’s important to remember that schizophrenia is a difficult heterogeneous experience,” she says. “It’s pretty clear, even at this early point, that these new techniques don’t work for everyone.” At the same time, she points out, research on related practices like cognitive behavioral therapy has been shown to ease the severity of the voice-hearing experience.

The new movement is mostly centered in European countries at the moment, but Luhrmann notes that it’s growing fast in a grassroots kind of way, somewhat in the way Alcoholics Anonymous grew in the last century. She predicts that some of the approaches used by the group will probably be used among patients with schizophrenia here in the U.S. in the next decade.

Previously: The link between mental-health conditions and cardiovascular diseaseNew thinking on schizophrenia, it’s the mind, body and social experience and Study shows meditation may alter areas of the brain associated with psychiatric disorders
Image by Craig Finn

Mental Health, Public Health, Research

Survey shows nearly a quarter of U.S. workers have been diagnosed with depression in their lifetime

Survey shows nearly a quarter of U.S. workers have been diagnosed with depression in their lifetime

4369627924_ccd7f6f7ff_zDepression is a major contributor to absenteeism, reduced productivity and disability among adults in the United States. Now results from a survey examining the societal and economic burden of depression in the workplace show that almost a quarter of employees have been diagnosed with depression in their lifetime and that two in five patients have missed work, for an average of 10 day per year, because of it.

The findings underscore the importance of decreasing the stigma associated with mental-health conditions in the workplace and providing workers with support services and resources. According to a release, additional results also showed:

…64 percent of survey participants reported cognitive-related challenges, as defined by difficulty concentrating, indecisiveness and/or forgetfulness, have the most impact on their ability to perform tasks at work as normal. Presenteeism (being at work, but not engaged/productive) has been found to be exacerbated by these challenges related to thinking on the job.

Despite how depression is affecting our workforce, 58 percent of employees surveyed who have been diagnosed with depression indicate they had not told their employer of their disease. In addition, 49 percent felt telling their employer would put their job a risk and, given the economic climate, 24 percent felt it was too risky to share their diagnosis with their employer.

These figures directly contribute to the estimated $100 billion annually spent on depression costs by U.S. employers including $44 billion a year in lost productivity alone.

The survey was commissioned by Ohio-based Employers Health and conducted by market research company Ipsos MORI. Questions were asked via an online panel of 1,000 adults, aged 16-64, who have been workers or managers within the last year. Responses were weighted to ensure the sample was representative of this profile. Funding was provided by international pharmaceutical company H. Lundbeck A/S.

Previously: Anxiety shown to be important risk factor for workplace absence, Research shows working out may benefit work life and How work stress affects wellness, health-care costs
Photo by Ryan Hyde

Addiction, Behavioral Science, In the News, Mental Health, Research, Stanford News

Veterans helping veterans: The buddy system

Veterans helping veterans: The buddy system

image.img.320.highI interviewed Army specialist Jayson Early by phone over the summer, shortly after he completed an in-patient program for PTSD at the Veterans Affairs hospital in Menlo Park. This was for a Stanford Medicine magazine story I was researching about a pilot project to help get much needed mental-health services to the recently returned waves of Afghanistan and Iraqi vets. What struck me most after talking with Early was just how clueless he had been, first as a teenaged-recruit, then as a young veteran, about the fact that going to war could cause mental wounds.

As the mother of a 17-year-old boy, though, I completely understood: Early just wanted to serve his country. He requested to be sent to war. In 2008, he got his wish and was deployed to Iraq just a year after exchanging his high-school baseball uniform for military fatigues. His first field assignment, an innocuous-sounding public affairs errand to photograph a burned out truck at an Iraqi police station, would be the first of many that left him with permanent scars:

“There were body parts, coagulated blood, hair all over,” [Early] says, pausing. “I just wasn’t expecting it.” An Iraqi family had been executed in the vehicle, presumably by insurgents. Early had gone through intense military training to prepare for moments like these. He blocked any emotions. He followed orders, clicked the camera and moved on. It wasn’t until years later that he realized just how permanently those images, and many more like them, had burned into his brain.

Stanford psychiatrist Shaili Jain, MD, interviewed in a podcast about her work with PTSD and veterans, had told me about a new pilot project that connects veterans with other veterans as a unique way to bridge what she called a “treatment gap” – the difficulty of getting mental-health services to the veterans that need them. My article – which is a timely read, given that today is Veterans Day – tells the story of Early’s connection with one of the veteran’s hired through this project, Erik Ontiveros, who went through treatment for addictions and PTSD himself, and just why it’s so hard to get treatment to veterans. As one well-known expert on PTSD explains in the story:

“It’s wicked difficult to treat anyone with moral injuries from combat in the traditional medical model,” says psychiatrist Jonathan Shay, MD, an expert on PTSD known for his books on the difficulties soldiers face returning home from war. “It destroys the capacity for trust. What it leaves is despair, an expectation of harm, humiliation or exploitation, and that is a horrible state of being. The traditional medical model – in an office with the door closed – is the last thing they want. I’m convinced that’s where peers come in. Peers are indispensable.”

Early told me many of his horror stories from war – stories that he rarely talks about. The time he was called to another execution area where there were enough body parts for 12 people who had all been gagged, bound, shot and burned. But, he said, they could only put together eight people. “We were trying to find a way to identify them,” he said. “Whenever I grabbed a hand, it would just crumble to dust.”

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Aging, In the News, Mental Health, Women's Health

Love your body, love yourself

Love your body, love yourself

10227014165_7e464321d2_zAs someone with not much regard for my body, I can hear my nutritionist cackling with glee at the thought of this post. She’s spent months trying to brainwash me into liking it anyway. I fight back, chafing at the idea.

Now along comes Martha C. Nussbaum, PhD, a leading ethical thinker based at the University of Chicago, saying we should not just like our bodies or merely tolerate our young bodies in their prime. No, she writes in a recent New Republic essay, we should consider our bodies as “dynamic, marvelous, and, more important, just (as) us ourselves.” We should celebrate our bodies with the spirit captured by the 1970s movement Our Bodies, Ourselves, sparked by the book-turned-organization. The alternative is ugly:  Prejudice, bigotry and other social ills will surge when fueled by self-dislike.

Nussbaum mourns the loss of body-embracing spirit: “I fear that my generation is letting disgust and shame sweep over us again, as a new set of bodily challenges beckons.”

Flaccid muscles, graying hair, foreheads creasing with wrinkles. Not yuck, not gross, do not withdraw, do not hide in shame, she writes:

[The poet Walt] Whitman knew that we will not be able to love one another unless we first stop hiding from ourselves—meaning our bodies…

As we age, we are yielding to all the forces we tried, back then, to combat: not only the forces of external medical control, but the more insidious force of self-loathing. Whitman knew that disgust was a social poison. Psychologists studying the emotion today confirm his intuitions about its link with prejudice and exclusion.

If you don’t like yourself, your body, then what must you think of others, Nussbaum questions. Worth pondering, I’ll concede.

Previously: Ask Stanford Med: Director of Female Sexual Medicine Program responds to questions on sexual health, Blogging may boost teens’ self-esteem and Tai chi linked to mental-health boost, but more study is needed
Photo by Jennifer Morrow

Aging, Mental Health, Parenting, Research

Girls at high risk for developing depression show signs of stress and premature aging

Girls at high risk for developing depression show signs of stress and premature aging

14465-telomeres_newsAs we age and our cells divide, caps at the ends of our chromosomes called telomeres shorten. When a telomere grows too short, it will die or lose its ability to divide, which causes our skin to wrinkle or sag, as well as damage to our organs. Previous research has shown that depression, chronic stress and inflammation can accelerate this process, causing premature aging and making our bodies more susceptible to infections and disease.

In an effort to better understand the connection between stress, depression and changes in the body, Stanford psychologist Ian Gotlib, PhD, and colleagues studied healthy girls with a family history of depression and compared them to a group of their peers without that medical background. During the experiment, researchers measured participants’ stress response through a series of tests and analyzed their DNA samples for telomere length. According to a Stanford Report story:

Before this study, “No one had examined telomere length in young children who are at risk for developing depression,” Gotlib said.

Healthy but high-risk 12-year-old girls had significantly shorter telomeres, a sign of premature aging.

“It’s the equivalent in adults of six years of biological aging,” Gotlib said, but “it’s not at all clear that that makes them 18, because no one has done this measurement in children.”

The researchers are continuing to monitor the girls from the original study. “It’s looking like telomere length is predicting who’s going to become depressed and who’s not,” Gotlib said.

Based on these findings, researchers recommended that girls at high-risk for depression learn stress reduction techniques.

Previously: How meditation can influence gene activity, Shrinking chromosome caps spell aging cells, sniffles, sneezes… and cognitive decline?, Study finds phobias may speed biological aging and Study suggests anticipation of stress may accelerate cellular aging
Photo by Paulius Brazauskas/Shutterstock

Cardiovascular Medicine, Mental Health, Research

The link between mental-health conditions and cardiovascular disease

The link between mental-health conditions and cardiovascular disease

14496537236_932d9a9acd_zA growing body of research has shown the connection between our emotional well-being and physical health. Among the latest findings: Schizophrenia, bipolar disorders and major depressive and anxiety disorders can greatly increase a person’s risk of heart disease and stroke.

In a study presented at this year’s Canadian Cardiovascular Congress in Vancouver, Canada, researchers examined connections between mental-health conditions, use of psychiatric medication, and heart health using data from the Canadian Community Health Survey. Medical News Today reports:

They found that patients who had a mental illness at any point in their life were twice as likely to have had a stroke or experienced heart disease than the general population, while patients who had not experienced heart disease or stroke had a higher long-term risk of cardiovascular disease.

Furthermore, patients who used psychiatric medications for their mental illness were twice as likely to have heart disease and three times as likely to have had a stroke than those who did not use such medications.

“This population is at high risk,” says [Katie Goldie, PhD, lead author of the study and a postdoctoral fellow at the Centre for Addiction and Mental Health in Toronto], “and it’s even greater for people with multiple mental health issues.”

Goldie and colleague said that there are three main factors that contribute to mental-health patients’ increase cardiovascular risk. They are: lifestyle behaviors, such as tobacco and alcohol use, poor diet and physical inactivity; psychiatric medications, which can induce weight gain and inhibit the body from breaking down fats; and inadequate access to health care.

The findings are significant in light of statistics (.pdf) from the National Alliance of Mental Health showing that 1 in 4 adults in the United States experience a mental health disorder in annually and that serious mental illness costs the nation $193.2 billion in lost earnings per year.

Previously: Examining how mental stress on the heart affects men and women differently, Study shows link between traffic noise, heart attack and Study offers insights into how depression may harm the heart
Photo by Holly Lay

Mental Health, Podcasts

My descent into madness – a conversation with author Susannah Cahalan

My descent into madness - a conversation with author Susannah Cahalan

Cahalan illustrationWhen you talk to Susannah Cahalan on the phone, you’d never imagine that this is a woman who has been to hell and back. Without warning 5 years ago, she descended into a nightmare of paranoia, hallucinations, catatonia and near death. One moment she’s a journalist living the high wire life in the New York media world and the next, her brain is swimming in a world of severe mental illness without any diagnosis.

With the precision of an investigative journalist, Cahalan recreates what happened to her in the New York Times-bestselling memoir, Brain on Fire, My Month of Madness. There she describes the terror of what it’s like to be a patient without a medical diagnosis. A human being lost in a sea of clinical maybes. Violent, psychotic and considered a flight risk, she was all but a shadow of her former self.

Luckily, she did eventually find clinical clarity. The diagnosis: anti-NMDA receptor autoimmune encephalitis - a disease only discovered in 2007.

Cahalan’s back at work now at the New York Post. She’s writing book reviews, science and health articles, all with a new perspective. In this 1:2:1 podcast and Stanford Medicine magazine piece, I asked her if she was a different person now, and she told me you can’t go through something like this and not be. “It has changed everything.”

Previously: Stanford Medicine magazine traverses the immune system
Illustration by Joe Ciardiello

Behavioral Science, Mental Health, Public Health, Stanford News

“Every life is touched by suicide:” Stanford psychiatrist on the importance of prevention

in-a-lonely-place-fa873a88-0c57-4b11-8f84-58c09aab94acMost people shy away from talking about suicide. Me too – I have some personal ties to the topic that still stab every time the s-word comes up. Yet after the initial reluctance wears off, that pain from grief and anger and fear turns into a motivational jab. Let’s talk about suicide nonstop. Let’s talk to make it stop.

Laura Roberts, MD, who leads Stanford’s psychiatry department, had the opportunity as editor-in-chief of the journal Academic Psychiatry to focus attention on suicide prevention. And she took it – partnering with the Wisconsin-based Charles E. Kubly Foundation to produce a special package of articles to inform clinicians about the latest efforts to prevent suicide.

Roberts and I spoke recently about the special issue and about suicide prevention:

Why did you want to publish this issue?

Suicide is such an under-recognized phenomenon, and it is an urgent threat to public health. Mental illness affects one in five people. Each year, more than 36,000 people commit suicide in the U.S. That is one person every fifteen minutes. In rough numbers, that’s twice the number of people who die from a violent injury in this country. Really, every life is touched by suicide.

Despite their serious public-health impact and life-threatening nature, illnesses and conditions associated with suicide have received little attention in society. These conditions are poorly understood and so greatly stigmatized. Learning to understand and evaluate people at risk for self-harm is an important element of medical student and resident education — we really wanted to emphasize these topics in this special collection.

New evidence-based models for prevention of suicide are emerging and inspire optimism. Integrating these new models is an exciting challenge for medical educators. Papers in this collection also document the impact of suicide and suicidal behavior among medical students and graduate students. About 350 physicians commit suicide each year in the U.S., and recently two interns in New York City ended their lives shortly after entering residency training. This is devastating.

In our special issue, a systematic review highlights the observation that psychiatry residents commonly experience the death of a patient by suicide, and three articles address coping with suicide professionally. Several articles focus on the development of educational programs that help strengthen suicide prevention, including screening skills and suicide awareness and management. Two articles address the resources and experience of from the Department of Veterans Affairs.

The journal special issue underscores there is much we can do in medical education to foster understanding and strengthen our responses to the phenomenon of suicide. Taken together, the papers also show how important it is that academic leaders better educate other about the prevention and impact of suicide.

What have we learned about preventing suicide?

We have learned a great deal about the prevention of suicide. Population data have shown that certain subgroups are especially vulnerable to suicide, including, for example, older white men who are ill and live alone, Native American youth as they make the transition to adulthood, and people living with serious illnesses that cause great physical and emotional pain. Understanding these larger population patterns has done a lot to help raise awareness of suicide and has allowed for creative interventions to address this problem.

Recently, researchers have been pursuing neurobiological markers that may signal when an individual is most at-risk for attempting suicide. Other studies are connecting other aspects of health — such as healthy sleep and exercise — to protective factors that may help diminish the likelihood of suicide. Such innovative work is very much needed because it will help us understand when a person with latent risk factors for suicide may act on this impulse, or, alternatively, how we can better support and intervene.

Other recent work has focused on psychological and situational factors that may contribute to suicidality among young veterans, and again, this line of inquiry may give us greater understanding on how best to reduce suicide deaths. As you may know, the number of veteran deaths due to suicide have been devastating. The VA has shown immense concern for members of the military and young veterans returning from conflicts around the world. In the course of studying suicide in this population, we have begun to have greater insight into when and whether an individual will act on an impulse to end his life. Three factors appear to be in play: first, a predisposition or vulnerability, for example, the presence of depression or anxiety that increases the general risk of suicide; second, access to a way to end one’s life, such as a gun; and, third an experience or set of experiences that make the individual feel like he is out of place, isn’t part of things, and doesn’t belong — what’s referred to as “thwarted belongingness.”

We are getting parts of the problem figured out, but so much more scientific investigation is needed. Ironically, suicide has been understudied because of concerns that the population is too vulnerable to be included in human research studies and because of the stigma associated with suicide. There have been so many barriers to these studies, and it strikes me as doubly tragic that suicide takes so many lives and yet has been relatively neglected by society and by science. In the Department of Psychiatry and Behavioral Sciences at Stanford, we are working to turn this around.

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Immunology, Mental Health, Stanford News

Stanford Medicine magazine traverses the immune system

Stanford Medicine magazine traverses the immune system

cover_fall2014_2If you want to understand the human immune system, try studying humans – not mice. That’s what Mark Davis, PhD, urges in a special report on the immune system in the new issue of Stanford Medicine magazine.

For decades, most research on the immune system has used mice. Davis, director of Stanford’s Institute for Immunology, Transplantation and Infection, launched Stanford’s Human Immune Monitoring Center a few years ago to change the immunology research paradigm.

“Inbred mice have not, in most cases, been a reliable guide for developing treatments for human immunological diseases,” Davis says in the special report, titled “Balancing act: The immune system.”

As the editor of the magazine, I wanted to feature a story that showed how human-focused immunology research plays out. So I was glad to learn that the center is in the midst of its largest study so far – one to figure out the cause of chronic fatigue syndrome. A team led by Stanford professor of infectious diseases José Montoya, MD, is looking for meaningful patterns in the components of blood samples gathered from 200 patients with chronic fatigue syndrome and 400 healthy subjects.

“It’s like dumping a hundred different puzzles on the floor and trying to find two pieces that fit,” Davis says in our story. We also have a video about a patient’s seven-year battle with chronic fatigue, from despair to recovery.

Also covered in this issue:

  • “I can eat it”: on a revolutionary treatment for food allergies
  • “Brain attack”: on the struggle to help children with psychiatric illness caused by a malfunctioning immune system – a condition known as PANS or PANDAS
  • “When bones collide”: on a new view on the cause of osteoarthritis: autoinflammation
  • “My rendezvous with insanity”: a Q&A with Susannah Cahalan, author of Brain on Fire: My Month of Madness, her memoir of surviving an autoimmune attack on her brain
  • “The swashbuckler”: on look back to the early days of molecular biology when Mark Davis cracked one of the greatest mysteries of the immune system

The issue also includes an article on efforts at the VA Palo Alto Health Care System to use peer-support services to help veterans with post-traumatic stress disorder, and a story on the growing concern that biomedical research results are often erroneous and efforts being made to solve the problem.

The issue was funded in part by the Institute for Immunology, Transplantation and Infection.

Previously: Stanford Medicine magazine opens up the world of surgery, Mysteries of the heart: Stanford Medicine magazine answers cardiovascular questions and From womb to world: Stanford Medicine Magazine explores new work on having a baby.
Illustration by Jeffrey Decoster

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