Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for March, 2020

At Home Tools for Mental Health: Cognitive Behavioral Therapy, Mindfulness and Medications.

Posted by Dr. Vollmer on March 31, 2020

Today’s topic is about things you can do from home that will promote mental health.

We have all lost control over our lives. We can no longer gather in person, and we are all forced to have new routines which give us meaning and fulfillment. For many people losing control is the beginning of a downward spiral of mental health issues which include anxiety, depression, and somatization. Feeling helpless can lead to a persistent feeling of lethargy which manifests into a very constricted life with little joy.

Point number one: Even though this is a hard time for everyone, it is still mandatory to feel happiness, joy and fulfillment. If you are not feeling these feelings most of the time, then you need tools to put those feelings back into your life.

Point number two: Telehealth is here which is ideal for mental health issues, as the primary mode of communication needs to be a narrative. Patients should feel free to reach out to their provider online to discuss how they are feeling and how they are coping during this challenging time.

Point number three: Given that anxiety is the most common feeling during this uncertain time, and given that when anxiety persists, depression often follows it is imperative to attend to your anxiety until it resolves.

Point number four: Self-directed cognitive behavioral therapy is a very useful tool for anxiety. Many studies have shown that self-directed CBT can be very effective. In particular, self-directed CBT-i for insomnia has good scientific evidence. Further, two reviews that each included over 30 studies found that self-help treatment significantly reduced both anxiety and depression, especially when the treatments used CBT techniques. The average amount of benefit were in the moderate range, meaning people did not feel 100% better but were noticeably less anxious and depressed. and Psychol Med. 2007 Sep;37(9):1217-28. Epub 2007 Feb 19.

Please note that self-directed CBT is most appropriate for someone with mild to moderate symptoms who is generally able to function well. A person who is severely depressed and barely able to get out of bed is probably not a good match and will likely need online psychotherapy.

Point number five: There are many books which can be used at home. The Association for Behavioral and Cognitive Therapies maintains a list of books which they endorse. My personal favorite is “Retrain Your Brain: Cognitive Behavioral Therapy in 7 Weeks” by Seth Gillihan PhD. The workbook presents tools from CBT in a user-friendly way. The cognitive techniques include..

A. Identifying your thought patterns

B. Discovering how your thoughts affect your feelings and behaviors.

The behavioral techniques include..

A. Scheduling activities that bring you enjoyment and a sense of accomplishment

B. Recognizing how your actions influence your thoughts and emotions.

When doing in-home therapy for anxiety or depression, the key issue is to set aside time, as you would if you were to go to psychotherapy. Create a space which is quiet and solitary. Create a time which is rigidly adhered to. Creating space and time for self directed CBT will reinforce your self-esteem because you are devoting yourself to self-care. In other words, you are making yourself a priority and that is a good first step to feeling better about yourself and those around you.

In this time of high-anxiety and limited access to health care, especially mental health care, self-directed CBT has many advantages. Devoting yourself to CBT can lower your anxiety, improve your mood and provide you with life-skills which will give you resilience to both our current challenging situation as well as future challenges.

Part 2: Mindfulness

Mindfulness is also an evidence-based treatment for anxiety and depression.

Mindfulness is the process of observing what is in your mental interior without using judgment. Applications such as Headspace are tools you can use at home to help with experiencing and accepting the current moment. There is scientific evidence to support mindfulness.
Blanck P, Perleth S, Heidenreich T. Kroeger P, Ditzen B, Bents H, Mander J. (2018). “Effects of mindfulness exercises as stand-alone intervention on symptoms of anxiety and depression: Systematic review and meta-analysis”. Behaviour Research and Therapy. 102: 25–35. doi:10.1007/s12671-014-0379-y.

Studies also indicate that rumination and worry contribute to the onset of a variety of mental disorders, and that mindfulness-based interventions significantly reduce both rumination and worry. Further, the practice of mindfulness may be a preventative strategy to halt the development of mental health problems.

Mindfulness can be seen as a strategy that stands in contrast to a strategy of avoidance of emotion on the one hand and to the strategy of emotional over-engagement on the other hand. Mindfulness can also be viewed as a means to develop self-knowledge and wisdom.

This current era of uncertainty and fear is a great time to begin a mindfulness practice. Crisis presents new opportunities, and so this current crisis allows us time and space to look inwards. Mindfulness is a good tool to use for inward reflection.

People who incorporate mindfulness into their lives often report heightened levels of happiness, patience, acceptance, and compassion, as well as lower levels of stress, frustration and sadness.

Practice mindfulness meditation can be a great way to cope with today’s landscape. Using an application such as Headspace gives you education about how the mind behaves during meditation, leads you through a particular meditation technique, and suggests how to integrate this technique into your everyday life. The major goals of these techniques is to create calmness and clarity of thought.

Let’s move on to part 3 of this discussion about home tools for mental health.

If your depression or anxiety is inhibiting you from functioning, and by that I mean you are not taking care of your responsibility as a parent, a friend, an employee, or a spouse, then along with self-directed CBT, and mindfulness, I would suggest you seek an online consultation for medication.

To begin, if you are experiencing uncontrollable palpitations associated with anxiety, then consult your clinician about Propranolol. Those folks with asthma may not be candidates, but in general, this is a very useful medication to help with the peripheral symptoms of anxiety. This can be taken as needed or multiple times a day, depending on the severity of anxiety.

Second, if you are feeling listless, apathetic, with very little motivation to start or complete projects, and/or to initiate contact with friends or family, then consider asking your doctor about Prozac. Yes, this is old school at this point, but you might be thinking that your behavior is consistent with the current state of the world, but that would be a false assumption. Even in this uncertain time, you should have energy and excitement for new experiences and deepening relationships. If you do not have that enthusiasm then there is something wrong and you need to attend to your feelings so that there is a shift in your mental state. Medications are appropriate to consider in that they can jump-start you into a more energetic position and thereby enable you to connect with pleasurable activities. Prozac, in particular, can be helpful because it tends to activate folks who have become couch potatoes.

On the other hand, if you are feeling like the energizer bunny who just cannot sit still because you are internally disrupted, then consider asking your doctor about Celexa. Celexa can serve as a calming medication which allows you to settle down and reflect on the triggers to your mental state. The current situation is not only difficult by itself, it is also triggering past traumatic experiences, and as a result, it is important to try to connect the past to the present so that you can have a more coherent narrative about your internal process.

Now, let’s suppose you have tried SSRIs..such as Prozac or Celexa and they have not helped you in the past. At this point I would suggest you consider Gabapentin for anxiety. This can cause weight gain, which is undesirable for most people, but at the same time, it can take the edge off, which like I stated for Celexa, is important so that you can reflect on your internal experience.

In summary, there are a lot of tools at home that can promote mental health. The shelter at home mandate gives us an opportunity to explore our internal worlds such that we can find happiness, enthusiasm and vitality in the midst of a very uncertain and scary time.

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Healthcare Provider Mental Health and Self Care

Posted by Dr. Vollmer on March 30, 2020

Welcome to my second post/podcast brought to you to share with you different aspects of how Covid-19 is contributing to mental health challenges.

Today’s topic will be the health care provider, those on the frontlines of this scary and all too often, fatal disease.

The first point I want to make is that no heath care provider signed up to risk their life and the lives of their loved ones. For all of us, including our medical teams, this viral explosion came to us with little warning, and thereby little psychological preparation. This little time for psychological preparation is a major contributing factor in the stress to the health care provider. They are caught between doing their job, risking their life, the lives of their loved ones, vs. taking time off and feeling cowardly and not truly devoted to their field. This dilemma right there is often an enormous moral dilemma/stress for the clinician. They are faced with a lose/lose proposition. They can go to work and risk their health and the health of their loved ones, or they can take a leave of absence and be plagued with guilt. For some, there is simply no good answer and so they are left with symptoms of stress which include exhaustion, stomach aches, poor sleep, poor eating habits, and poor concentration.

The second point I want to make is not every health care provider has support from their family. Prior to Covid-19, most health care providers were the pride and joy of their support system. After Covid-19, the health care provider became an object of fear and avoidance. This rapid transformation in how others are viewing clinicians reflects the fact that the loved ones are now faced with protecting themselves from a healthcare provider who is now a potential super-spreader.

The third point I want to make is health care providers are feeling very let down by a system which does not provide enough PPE-personal protective equipment. The system, the government, the leadership, however hard they are trying are not able to provide the basics of viral protection. As such, there is stress from feeling unsupported from the higher ranks. This can feel very disappointing and contribute to stress symptoms.

Now, I want to move on to three action items that can help the stress of the health care provider.

1. Talk about what you are going through to one trusted supportive person in your life. Ask this person to be your confidant, because you need to share your experience, your perspective, and your mental and physical reactions to all of this stress.

2. Discuss and even write down the pros and cons of going to work every day. Talk about what it would feel like to take a leave of absence. Talk about what it would feel like to not take a leave of absence. Talk about how your loved ones feel about you working. Talk about how your loved ones would feel if you took a break. Begin an on-going narrative about life in the “trenches” and give yourself permission to do a thought experiment about having another life where you put your profession on pause.

3. Eat well, sleep well, exercise, and know your limits. By this I mean, the first priority is your day to day health. Create a routine of meals that work for you and nourish your body. Make sleep a priority because without sleep you will diminish your functioning capacity. Exercise daily to manage stress. Punch a bag, go for a run, walk uphill. Get your heartbeat up so that the blood flows throughout your body, waking up your brain so you can think more clearly. Finally, know your limits. You may be able to work, but perhaps not as much as what is demanded of you. Negotiate your time so that your schedule works for you.

In summary, history will write that the healthcare providers during this pandemic were heroes and they are. Still, it is a personal decision to be a hero, and there should be no shame, no feeling of weakness, if your job does not suit you during this time. Stress means it is hard to prioritize, and so during this period, stress is high because healthcare providers have to make very difficult personal decisions. Accepting this difficulty and appreciating that each person makes a decision that works for them is the first step. In this challenging time there is no room to be judgmental, and there is no room to be around judgmental others. There is only room for love, acceptance, and understanding.

Posted in Musings | 2 Comments »

Social Distancing vs. Social Isolation

Posted by Dr. Vollmer on March 27, 2020

Welcome to my first post in the Corona virus era. These posts will be the basis for my upcoming podcast series about staying mentally healthy in an unstable and scary world. These podcasts will be available through Pri-Med and I will have more details in the coming weeks.

Today’s topic is social distancing vs. social isolation or in other words, how to maintain relationships in an era that generates the fear that other people can unwittingly infect you and thereby your loved ones. Although not rational, many folks assume that social isolation will protect them, as this disease is transmitted from human to human, but with a gentle reminder, such as this post, social connection will help and is in fact essential during this vulnerable time.

So, let’s talk about social connection. We need to re-establish relationships with our loved ones, our close and long-term friendships, and we need a sense of community, of “meeting” people who have similar interests who we know as acquaintances now but who might become friends in the future. Maybe some of us have exercise buddies, people we see in yoga class or at the gym. We need to regain those relationships too.

The challenge is on. Maintaining strong and weak bonds in an era where hugging, eating together, and going to the movies is strictly out of the question. But wait, we need to re-define being together. We need to broaden our understanding of that concept. Being together means listening to one another, so perhaps during this time of quarantine we will need to sharpen our listening skills, an unintended benefit of these challenging time. We can listen on the telephone and we can listen through video conferencing. We can do most of our activities over video chat which allows us to tell our stories, share our worries and talk about common interests. We can have dinner parties, happy hour, walking groups and movie time, all by phone or video. We can change our language from “virtual happy hour” to “happy hour”. The trick is that we have to feel committed to showing up for “happy hour” in the same way we feel committed when we promise to meet a friend for a drink. In other words, we need to prioritize our virtual activities as we used to prioritize our in-person activities.

Isolation is bad for our mental health. There is no question about that. Isolation is vital for our physical health. There is also no question about that. And so, we need a new language. A language which says physical isolation is mandatory, and social connection is also mandatory.

What are the action items that I want you to take from this post?

1. Fill up your calendar with social commitments, be they dinners, happy hour, shared movie watching, or walking friends, where each friend goes on their solitary walk but that the two of you are talking on the phone while walking.

2. Restore your calendar. If you had a book group, set it up virtually, for the same time, with the same host. If you were going to church or synagogue, join a virtual group so that religion can return to your life.

3. Go outside and maintain social distance. Even seeing new and old faces from a distance will remind you that we are all in this together and we are all trying to cope with the fear and uncertainty that surrounds us.

4. Meal times should still be social. Make coffee, lunch and dinner dates with your friends and share meals over phone or video. Talk about what you are eating and how it is tasting. Talk about how these dates may be in person one day, but for now this is how you want to catch up with their lives.

5. Look at your calendar and take everything that was canceled, including cultural events, sporting events, family events, work meetings and ask yourself how you can modify those activities by using technology?

To conclude, the natural response to being told to stay safe at home, is to think of home as a place to hibernate until spring comes or the danger passes. Don’t do that. Stay safe and active at home. Use technology to replace in-person experiences. Prioritize that so that your mind, your body, and your soul stay healthy.

Posted in Musings | 2 Comments »

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