Shirah Vollmer MD

The Musings of Dr. Vollmer

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. https://doi.org/10.1186/1471-244X-12-5. 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. https://doi.org/10.1016/j.beth.2005.05.002 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. http://www.abct.org/SHBooks/. 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. https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=29080597

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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220915

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.

2 Responses to “At Home Tools for Mental Health: Cognitive Behavioral Therapy, Mindfulness and Medications.”

  1. Shelly Tannenbaum said

    Great, great blog post and a perfect one for a podcast. Just thinking that it would be really helpful to either hear your thoughts on this aloud or actually see some of the data you talk about would be better effective than simply seeing it in writing (i.e. a zoom meeting or whatever). If people are feeling isolated or alone and depressed, they might not feel together enough to even do the mindfulness exercises, or read the studies. But hearing the podcasts or watching you on a video via Youtube might be more effective and make people feel less isolated and lonely in today’s social-distancing times. Also, don’t know if you are allowed to advocate for any websites for telehealth networks, but providing a link or two might be helpful. Go Shirah!

    • Thank you Shel……It is interesting what you are saying about telehealth networks. Now, most psychiatry is done by telehealth, individually and not through a company, but as you say there are companies that provide mental health care by text and by video and by phone. Pre-Covid-19, those companies were thought of with suspicion and now of course, they make a lot of sense. How quickly our world has changed. Yes, perhaps one day I will add on to a video platform. In the past, my audience for my presentations have been primary care clinicians, and now I am expanding to a more public audience. I agree that these tools are good for mild issues and when the feelings are more severe, it is hard to get motivated to do self-help work or to seek online assistance. The goal is to catch yourself early before you spiral down into despair. Easier said than done, but that is why it is important to act now, before the potential cabin fever/depression sets in.

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