Tagged Anxiety and Stress

Need to Dust Off Your Social Skills?

After a year of virtual gathering, getting back to real-life relationships can be intimidating. These eight simple exercises can help.

As we move through the spring of The Great Vaccination, many of us are feeling cautious optimism, and also its flip side: creeping dread.

Maybe you have a sense of ambivalence about how to interact with others again. If you used to work in an office, you might be worried about returning to work — but eager to see people again. Or you find yourself having to confront a neighbor about a longstanding problem — but you’re out of practice with conflict resolution. (I’m not sure I remember how to talk to another human anymore, let alone one I disagree with.)

Whatever the specifics, “there will be new forms of social anxiety, said Dacher Keltner, a professor of psychology and the director of the Social Interaction Lab at the University of California, Berkeley.

“People are really anxious about being out in restaurants with friends, or about dancing with a big sweaty group of people — or even about sharing a yoga mat,” he said. “It’s always good to remember individual differences — there’s a lot of variability. But there will be a lasting societal legacy around intimacy, the noise that comes with returning to school, the complexity of the playground and of work.”

Dr. Keltner has studied human behavior and the biological and evolutionary underpinnings of emotions for decades, with a focus on “pro-social” states — behavior that strengthens connections between individuals — that are especially good for society.

“We’re hyper-social mammals — it’s our most signature strength,” said Dr. Keltner, a co-founder of the Greater Good Science Center who was also a scientific consultant on emotions for the Pixar film “Inside Out.” “It’s what sets us apart from other primates: We help, we laugh, we collaborate, we assist.”

Lately, we’ve been living our lives siloed away online, missing many of the essential face-to-face experiences that are key to human interaction. It’s notable that Dr. Vivek Murthy, the newly reappointed U.S. Surgeon General, has talked not only about the physical and economic toll of the pandemic, but also of “the social recession.”

Before Covid, this kind of post-isolation anxiety was most often suffered by people who re-enter the civilian world after prison, wartime deployment, humanitarian aid work or remote expeditions. The challenge now is that so many more of us will be experiencing some aspect of this all at once, and coming back to social situations with others who likely have their own fears too. It is stalled social development, on a societal level.

Debra Kaysen, a clinical psychologist and a professor of psychiatry and behavioral sciences at Stanford University, said that coming back to so-called “civilian life” can be disorienting, surreal and difficult — and not just for combat veterans. Her clinical and research work focuses on anxiety disorders and trauma, and she has worked on developing coping strategies for health care workers dealing with mental health concerns during the pandemic.

Now, everyone is trying to navigate conflicting threat levels in a way that used to be specific to those populations, she said. Cues that used to be neutral or positive, like being around other people (I love my friends and family!) are now associated with threat (my friends and family might infect me with Covid!). And we are confronting the challenge of how to turn off that alarm. “What’s a true alarm and what’s a false alarm has gotten more confusing for all of us,” Dr. Kaysen said.

So how do we relearn how to be together?

Give yourself permission to set small, achievable goals. And accept that other people are going to have different responses than you — the friend or family member who wants to eat inside the restaurant when you don’t, for example, or who is ready to get on a plane and take a vacation.

Accept that certain activities may feel tough for awhile. Driving an hour to a meeting. Flying a red-eye to a conference. Attending a family reunion, say, or four pandemic-postponed weddings in one month.

All of this can prompt you to ask, of your family or your boss or even yourself: “Is it really worth the time?” and “Now that I know things can be different, do I want to go back to my old life?”

Recovering doesn’t mean you go back to the way you were before, Dr. Kaysen said, using kintsugi, the Japanese technique of repairing broken pottery with gold, as an analogy for coming out of hard times with awareness of the change, and stronger than before. “It’s that you create a new normal, one that’s functional and beautiful — and different.”

Dr. Keltner agreed that we may need to “re-educate ourselves” — “like, how do we hug again?” Your timing might be off for a hug, or a joke or even a compliment. “How do you look someone in the eye so that it’s not intrusive? How do you compliment someone? You might not have done it for a year.”

Rather than be overwhelmed by everything at once — for example, going to a party where you have to adjust to greeting acquaintances, eating with others and attempting to make small talk — all at the same time — why not take things step by step? This moment can be an opportunity.

8 Exercises to Strengthen Your Social Muscles

Here are eight small, science-based exercises Dr. Keltner recommends to help ease back into your community. Go at your own pace.

Share food with someone.

Eating a meal together boosts mood and is a potent antidote for loneliness — aiming for in-person interaction around the ritual of eating is a great goal, even if you don’t meet it every single day. An outdoor picnic or a distanced backyard happy hour is a great and safe option for reconnecting with friends and family.

Tell someone a joke in person.

You may be out of practice and have to work on your timing. But making eye contact and laughing together is essential to feeling connected to someone else — even if the joke falls flat, being silly together will feel really good.

Ask someone what they’re listening to or reading right now.

Music and literature can be a community-building gift. Listen to music together; exchange books and have an in-person discussion afterward. This is a social exercise, but also one that will give you a much-needed hit of novelty along with the insight.

Reach out to someone you’ve lost touch with.

Make a phone call, send a meaningful text, write an email. It’s time to start rebuilding the larger social infrastructure outside our immediate circles.

Strike up a conversation with a stranger.

Pick someone with whom you have passing contact: a fellow dog-walker, the cashier at a grocery store, a delivery person on your doorstep. Make eye contact; talk to each of them as a person rather than as a function. It’s so easy to ignore the human behind a mask. Make the effort to ask something outside the normal transaction — what’s changed since the last time you saw each other, what they’re looking forward to.

Move with someone.

Dance, walk, run, swim, bike — or even do the dishes and fold the laundry together. Physical synchronicity is one of the most important ways we have to connect with someone else.

Sit quietly with someone …

and remember how to comfortably be, without talking, in companionable silence, with someone else. Let the other person know it’s OK to not always fill the air. Nonverbal communication is important to practice — and it’s a way to deepen your relationship.

Make a date for the future.

Think of something fun to do with someone you love — it could be a summer beach weekend, or maybe a ski trip next winter. Having something to look forward to is essential for well-being. Practice optimism, in anticipation of normalcy. Plan with hope.


Bonnie Tsui’s books include “Why We Swim” and “The Uncertain Sea.”

Music Therapy: Why Doctors Use it to Help Patients Cope

Music therapy is increasingly used to help patients cope with stress and promote healing.

“Focus on the sound of the instrument,” Andrew Rossetti, a licensed music therapist and researcher said as he strummed hypnotic chords on a Spanish-style classical guitar. “Close your eyes. Think of a place where you feel safe and comfortable.”

Music therapy was the last thing that Julia Justo, a graphic artist who immigrated to New York from Argentina, expected when she went to Mount Sinai Beth Israel Union Square Clinic for treatment for cancer in 2016. But it quickly calmed her fears about the radiation therapy she needed to go through, which was causing her severe anxiety.

“I felt the difference right away, I was much more relaxed,” she said.

Ms. Justo, who has been free of cancer for over four years, continued to visit the hospital every week before the onset of the pandemic to work with Mr. Rossetti, whose gentle guitar riffs and visualization exercises helped her deal with ongoing challenges, like getting a good night’s sleep. Nowadays they keep in touch mostly by email.

The healing power of music — lauded by philosophers from Aristotle and Pythagoras to Pete Seeger — is now being validated by medical research. It is used in targeted treatments for asthma, autism, depression and more, including brain disorders such as Parkinson’s disease, Alzheimer’s disease, epilepsy and stroke.

Live music has made its way into some surprising venues, including oncology waiting rooms to calm patients as they wait for radiation and chemotherapy. It also greets newborns in some neonatal intensive care units and comforts the dying in hospice.

While musical therapies are rarely stand-alone treatments, they are increasingly used as adjuncts to other forms of medical treatment. They help people cope with their stress and mobilize their body’s own capacity to heal.

“Patients in hospitals are always having things done to them,” Mr. Rossetti explained. “With music therapy, we are giving them resources that they can use to self-regulate, to feel grounded and calmer. We are enabling them to actively participate in their own care.”

The Healing Power of Music

“A Song for Wayne,” performed by Edie Elkan and written as she played at the bedside of a student who was dying.

Even in the coronavirus pandemic, Mr. Rossetti has continued to perform live music for patients. He says that he’s seen increases in acute anxiety since the onset of the pandemic, making musical interventions, if anything, even more impactful than they were before the crisis.

Mount Sinai has also recently expanded its music therapy program to include work with the medical staff, many of whom are suffering from post-traumatic stress from months of dealing with Covid, with live performances offered during their lunch hour.

It’s not just a mood booster. A growing body of research suggests that music played in a therapeutic setting has measurable medical benefits.

“Those who undergo the therapy seem to need less anxiety medicine, and sometimes surprisingly get along without it,” said Dr. Jerry T. Liu, assistant professor of radiation oncology at the Icahn School of Medicine at Mount Sinai.

A review of 400 research papers conducted by Daniel J. Levitin at McGill University in 2013 concluded that “listening to music was more effective than prescription drugs in reducing anxiety prior to surgery.”

“Music takes patients to a familiar home base within themselves. It relaxes them without side effects,” said Dr. Manjeet Chadha, the director of radiation oncology at Mount Sinai Downtown in New York.

It can also help people deal with longstanding phobias. Mr. Rossetti remembers one patient who had been pinned under concrete rubble at Ground Zero on 9/11. The woman, who years later was being treated for breast cancer, was terrified by the thermoplastic restraining device placed over her chest during radiation and which reawakened her feelings of being entrapped.

“Daily music therapy helped her to process the trauma and her huge fear of claustrophobia and successfully complete the treatment,” Mr. Rossetti recalled.

Some hospitals have introduced prerecorded programs that patients can listen to with headphones. At Mount Sinai Beth Israel, the music is generally performed live using a wide array of instruments including drums, pianos and flutes, with the performers being careful to maintain appropriate social distance.

“We modify what we play according to the patient’s breath and heart rate,” said Joanne Loewy, the founding director of the hospital’s Louis Armstrong Center for Music & Medicine. “Our goal is to anchor the person, to keep their mind connected to the body as they go through these challenging treatments.”

Edie Elkan plays the harp as part of the music therapy program at Robert Wood Johnson Hospital in New Jersey.
Edie Elkan plays the harp as part of the music therapy program at Robert Wood Johnson Hospital in New Jersey.Edie Elkan

Dr. Loewy has pioneered techniques that use several unusual instruments like a Gato Box, which simulates the rhythms of the mother’s heartbeat, and an Ocean Disc, which mimics the whooshing sounds in the womb to help premature babies and their parents relax during their stay in noisy neonatal intensive care units.

Dr. Dave Bosanquet, a vascular surgeon at the Royal Gwent Hospital in Newport, Wales, says that music has become much more common in operating rooms in England in recent years with the spread of bluetooth speakers. Prerecorded music not only helps surgical patients relax, he says, it also helps surgeons focus on their task. He recommends classical music, which “evokes mental vigilance” and lacks distracting lyrics, but cautions that it “should only be played during low or average stress procedures” and not during complex operations, which demand a sharper focus.

Music has also been used successfully to support recovery after surgery. A study published in The Lancet in 2015 reported that music reduced postoperative pain and anxiety and lessened the need for anti-anxiety drugs. Curiously, they also found that music was effective even when patients were under general anesthesia.

None of this surprises Edie Elkan, a 75-year-old harpist who argues there are few places in the health care system that would not benefit from the addition of music. The first time she played her instrument in a hospital was for her husband when he was on life support after undergoing emergency surgery.

“The hospital said that I couldn’t go into the room with my harp, but I insisted,” she said. As she played the harp for him, his vital signs, which had been dangerously low, returned to normal. “The hospital staff swung the door open and said, ‘You need to play for everyone.’”

Ms. Elkan took these instructions to heart. After she searched for two years for a hospital that would pay for the program, the Robert Wood Johnson University Hospital in Hamilton, N.J., signed on, allowing her to set up a music school on their premises and play for patients at all stages in their hospitalization.

Ms. Elkan and her students have played for over a hundred thousand patients in 11 hospitals that have hosted them since her organization, Bedside Harp, was started in 2002.

In the months since the pandemic began, the harp players have been serenading patients at the entrance to the hospital, as well as holding special therapeutic sessions for the staff outdoors. They hope to resume playing indoors later this spring.

For some patients being greeted at the hospital door by ethereal harp music can be a shocking experience.

Recently, one woman in her mid-70s turned back questioningly to the driver when she stepped out of the van to a medley of familiar tunes like “Beauty and the Beast” and “Over the Rainbow” being played by a harpist, Susan Rosenstein. “That’s her job,” the driver responded, “to put a smile on your face.”

While Ms. Elkan says that it is hard to scientifically assess the impact — “How do you put a number on the value of someone smiling who has not smiled in six months?”— studies suggest that harp therapy helps calm stress and put both patients and hospital staff members at ease.

Ms. Elkan is quick to point out that she is not doing music therapy, whose practitioners need to complete a five-year course of study during which they are trained in psychology and aspects of medicine.

“Music therapists have specific clinical objectives,” she said. “We work intuitively — there’s no goal but to calm, soothe and give people hope.”

“When we come onto a unit, we remind people to exhale,” Ms. Elkan said. “Everyone is kind of holding their breath, especially in the E.R. and the I.C.U. When we come in, we dial down the stress level several decibels.”

Ms. Elkan’s harp can do more than just soothe emotions, says Ted Taylor, who directs pastoral care at the hospital. It can offer spiritual comfort to people who are at a uniquely vulnerable moment in their lives.

“There is something mysterious that we can’t quantify,” Mr. Taylor, a Quaker, said. “I call it soul medicine. Her harp can touch that deep place that connects all of us as human beings.”

Depression in Young Children

We tend to think of childhood as a time of innocence and joy, but as many as 2 to 3 percent of children from ages 6 to 12 can have serious depression.

When parents bring their children in for medical care these days, there is no such thing as a casual, “Hey, how’s it going?” We doctors walk into every exam room prepared to hear a story of sadness and stress, or at the very least, of coping and keeping it together in this very hard year, full of isolation, loss, tragedy and hardship, with routines disrupted and comfort hard to come by.

Parents have carried heavy burdens of stress and responsibility, worrying about themselves but also watching their children struggle, and there is worldwide concern about depression and suicidality among young people. But it isn’t only the adults and the young adults and teenagers who are suffering and sad; young children can also experience depression, but it can look very different, which makes it challenging for parents — or doctors — to recognize it and provide help.

Rachel Busman, a clinical psychologist at the Child Mind Institute in New York City, said that it can be hard to think about depression in younger children because we picture childhood as a time of innocence and joy. But as many as 2 to 3 percent of children ages 6 to 12 can have serious depression, she said. And children with anxiety disorders, which are present in more than 7 percent of children aged 3 to 17, are also at risk for depression.

Dr. Helen Egger, until recently the chair of child and adolescent psychiatry at N.Y.U. Langone Health, said that according to her epidemiologic research, between 1 and 2 percent of young children — as young as 3 — are depressed

Depression was originally conceived of as an adult problem. Maria Kovacs, professor of psychiatry at the University of Pittsburgh School of Medicine, said that in the 1950s and ’60s, there were child psychiatrists who believed that children did not have sufficient ego development to feel depression, but that research that she and other colleagues did in the ’70s showed that “school age children can suffer from diagnosable depression.”

Before adolescence, depression is equally common in girls and boys, though among adolescents, it is twice as common in girls, and that predominance then lasts across most of adult life, until old age, when it again appears to equalize.

What does depression look like in younger children?

When young children are depressed, Dr. Kovacs said, it’s not unusual for “the primary mood to be irritability, not sadness — it comes across as being very cranky.” And children are much less likely to understand that what they’re feeling is depression, or identify it that way. “It almost never happens that they say, ‘something’s wrong because I’m sad,’” Dr. Kovacs said. It’s up to adults to look for signs that something is not right, she said.

The best way for parents to recognize depression in young children is not so much by what a child says as by what the child does — or stops doing. Look for “significant changes in functioning,” Dr. Kovacs said, “if a child stops playing with favorite things, stops responding to what he used to respond to.”

This might mean a child loses interest in the toys or games or jokes or rituals that used to be reliably fun or entertaining, or doesn’t seem interested in the usual back and forth of family life.

“You’ve had a kid who was one way and then you see that they’re more irritable and sad,” said Dr. Egger, who is now the chief medical and scientific officer at Little Otter, a new online mental health care company for children. Children may seem flattened, have less energy or tire easily. And they may start complaining about physical symptoms, especially stomach aches and headaches. They may sleep more — or less — or lose their appetites.

A preschool-aged child might be depressed if she is having daily tantrums, with behaviors that risk hurting herself or other people. Depression “may look like a behavior problem but is really being driven by what the kid is feeling inside,” Dr. Egger said.

“It’s like walking through the world with dark-colored glasses,” Dr. Busman said. “It’s about myself, about the other person, and the world — I suck, this sucks, everything sucks.”

Should I ask about suicidal thoughts?

The irritability and the anger — or the flatness and the shutting down — can be signs of profound sadness. And while suicide attempts by elementary school-aged children are rare, they do happen and have increased in recent years. Suicide was the second leading cause of death in children 10 to 14 in 2018, and a 2019 JAMA study showed increasing emergency room visits by children for suicidal thoughts or actions from 2007 to 2015 — 41 percent in children under 11 years old. The presence of suicidal thoughts should be seen as a call for help.

The most problematic myth about suicide is the fear “that if you ask about suicide you’re putting the idea in their heads,” said Dr. Kovacs, who developed the Children’s Depression Inventory which is used all over the world.

“If you’re dealing with a child for whom this is not an issue, they’re just going to stare at you like you’re out of your head,” Dr. Kovacs said. “You cannot harm somebody by asking them.”

But what if children say they have thought of suicide? As with adults, this suggests the child is living with pain and perhaps thinking about a way out. Dr. Kovacs said, children may imagine death as “a release, a surcease, a relief.”

Dr. Busman said that she works with children who may say, “I don’t want to kill myself but I feel so bad I don’t know what else to do and say.”

If a child talks about wanting to die, ask what that child means, and get help from a therapist if you’re concerned. A statement like this can be a real signal that a child is in distress, so don’t dismiss it or write it off as something the child is just saying for attention, she said.

How can treatment help?

“Parents should take child symptoms very seriously,” said Jonathan Comer, professor of psychology and psychiatry at Florida International University. “In serious forms it snowballs with time, and earlier onset is associated with worse outcomes across the life span.”

In a 2016 longitudinal study, Dr. Kovacs and her colleagues traced the course of depression starting in childhood, and found recurrent episodes in later life.

So if you see changes like withdrawal from activities, irritability or sadness, fatigue, or sleep disturbances that persist for two weeks, consider having the child evaluated by someone who is familiar with mental health issues in children of that age. Start with your pediatrician, who will know about resources available in your area.

Parents should insist on a comprehensive mental health evaluation, Dr. Busman said, including gathering history from the parent, spending time with the child and talking to the school. An evaluation should include questions about symptoms of depression as well as looking for other problems, like attention deficit hyperactivity disorder or anxiety, which may be at the root of the child’s distress.

Early treatment is effective, Dr. Comer said, “There’s terrific evidence for family-focused treatment for child depression — it focuses on family interactions and their impact on mood.” With children from 3 to 7, he said, versions of parent-child interaction therapy, known as PCIT, are often used — essentially coaching parents, and helping them emphasize and praise what is positive about their children’s behavior.

As much as possible, parents should try to keep children going outside, taking walks, even playing outdoor games, even if they are less enthusiastic about their usual activities. As with adults, physical exercise has both mental and biological benefits — as do fresh air and sunshine.

Depression does not necessarily lend itself to simple cause-and-effect explanations, but Dr. Kovacs emphasized that with a first episode in a child, there is almost always a particular stressor that has set off the problem. It could be a change in the family constellation — a parental divorce, a death — or it could be something more subtle, like an anxiety that has spiraled out of control. If a child does begin therapy, part of the treatment will be to identify — and talk about — that stressor.

How can I find help for my child?

If you’re concerned that your child might be depressed, start with your pediatrician or other primary care provider. Some clinics and health centers will have in-house mental health services, and you may be able to have your child seen there. Some doctors will have links to local therapists with experience with young children. Mental health specialists can be in short supply (and there’s a lot of need right now), so be open to the possibility of care being delivered remotely, through telehealth. Dr. Kovacs also suggested that parents who are looking for treatment consider clinical psychology department clinics at a local university, where students in psychology and counseling are supervised by licensed psychologists; she said such clinics often have good availability.

[The Society of Clinical Child and Adolescent Psychology has advice on how to know if treatment is evidence-based.]

“Parents should see children’s struggles as opportunities to intervene,” Dr. Comer said. “The majority of early child mood problems will go away with time, sensitive parenting and supportive environments.”

Closing the Social Distance

After a year spent social distancing, mask wearing and sheltering in place, the prospect of readjusting to in-person social engagements can be a daunting one.

As the days grow warmer and vaccination shots reach more arms, you may be looking ahead to getting out and about. An Axios-Ipsos poll released this month found that “the number of Americans engaging in social interactions outside the home is increasing.” And the Centers for Disease Control and Prevention recently issued new recommendations that individuals who have been vaccinated against the coronavirus can start to gather in small groups, without masks, offering a measure of hope in particular to those who have missed the intimacy of double dates and dinner parties.

But after a year spent internalizing public health precautions for social distancing and mask-wearing, the prospect of readjusting to in-person social engagements may be a daunting one. For many, it provokes a sense of profound discomfort, apprehension or ambivalence.

“It’s a new version of anxiety,” said Dr. Lucy McBride, an internist in Washington who writes a newsletter about managing the coronavirus crisis. You may discover that your continuing concerns about the virus are colliding with a new set of worries about seeing others more regularly: What am I comfortable with? How do I act? What do I say?

“There’s two feelings that are continuing to exist for me,” said Allison Harris-Turk, 46, an events and communications consultant and mother of three in San Diego. Mrs. Harris-Turk created the Facebook group Learning in the Time of Corona, where many among the roughly 16,700 members are discussing the pros and cons of re-entry. “There’s the excitement and the optimism and the hope, and then there’s also the grief and the trauma and ‘oh, my goodness, how are we going to recover from this?’”

Here’s how some individuals and experts are starting to think about closing the social distance.

Start small.

Though you may be chafing at the confines of the lockdown, remember that it’s still not entirely safe to resume social activities as before. Across most of the country, the risk of coronavirus transmission remains high.

If you’re wary of re-entry, begin with a lower-stakes outing. “It’s like little baby steps getting back into it,” said Dr. David Hilden, a Minneapolis-based internist who hosts a weekly radio show during which he answers listeners’ pandemic questions. He’s observed this firsthand: Earlier this month, he met up with a friend to share a beer for the first time since the onset of the pandemic. “Now that we’ve dipped our toe in the water, a lot of Zoom meetings end with, ‘Hey, I think we can get together now,’” he said.

Understand that hanging out might take more effort.

After receiving her first shot of a coronavirus vaccine, Aditi Juneja, a New York-based lawyer, expected to feel the same flood of relief that some of her peers had described after getting theirs. While on the phone with a friend, she started to consider future late nights and travel to far-off destinations. “I was like, ‘Man, I want to dance on bars,’” Ms. Juneja, 30, said. “There was a euphoria about imagining the possibilities.”

But after 10 minutes, she found even the fantasy versions of these scenarios exhausting. The reality can be, too; she described the sensory overload and disorientation she felt while dining outdoors with a friend for the first time in months. “I think our ability to take inputs has really lowered,” Ms. Juneja said.

This is especially true for individuals suffering from social anxiety, for whom the lockdowns have offered some relief, and for whom reopening presents new stressors. But even extroverts may experience an adjustment period as our brains adapt to planning and monitoring responses to unfamiliar situations. At the beginning of the pandemic, people had to change their behaviors to comply with social distancing, mask-wearing and sheltering in place. But learning those new behaviors — and now, relearning old ones — can take a cognitive toll.

“Social settings are particularly demanding,” said David Badre, the author of the book “On Task: How Our Brain Gets Things Done” and a professor of cognitive, linguistic and psychological sciences at Brown University. “When we have to really focus and plan what we’re doing, that comes with an experience of mental effort,” he continued. “It feels like a mental fatigue.”

There is good news, however: You’ll most likely find it easier to relearn old behaviors than learn entirely new ones. “The key is to not avoid that effort,” Dr. Badre said. “By re-engaging, you will get used to it again.”

Set boundaries for yourself.

Though the past month has seen a spate of reopenings across the country, some scenarios might still set off a siren in your head. And because these facilities are open, doesn’t mean you need to go.

But what if a friend or family member does want to see a movie, or dine out? If you express disagreement over what is safe, you might feel as though you are implying your companions are less responsible or unethical.

Sunita Sah, a professor at University of Cambridge and Cornell University has researched this phenomenon, which she calls “insinuation anxiety.” In studies, Dr. Sah has found that patients frequently follow medical advice from their doctor even if they believe their doctor to have a conflict of interest, and that job candidates often answer interview questions they know are illegal to ask. These reactions come partly out of concern that to disagree would suggest the other person — the doctor or the job interviewer — is not trustworthy.

A similar situation can play out if you’re confronted with someone whose attitude toward public-health protocols differs from your own. Dr. Sah’s research has shown that when individuals have the opportunity to weigh their decisions in private, they are less likely to experience this anxiety and do something that makes them uncomfortable. She recommended writing down the boundaries that you would like to adhere to and taking time before agreeing to someone else’s plan.

“Assess your own risk level and comfort,” Dr. Sah said, “so you’re very clear about what you would and would not like to do.” This will also provide you with a clear document of how your comfort levels are changing over time as you readjust.

Brace for tough conversations.

Over the past year, public-health guidance often wildly varied on federal, state and even city levels, with some areas flinging open their doors while experts still advised caution. This has also been reflected in interpersonal relationships. It’s created friction between couples, families and friends, and prompted individuals to ask challenging, sometimes seemingly intrusive questions. Now, you may be adding “Are you vaccinated?” to that list. (On Twitter, one woman recently proposed “re-entry doulas” to help families navigate conversations about setting boundaries.)

Still, it will continue to be important to have these conversations in the coming months. “This isn’t abstract,” said Marci Gleason, an associate professor in the Department of Human Development and Family Sciences at the University of Texas at Austin whose lab has been surveying relationships in quarantine. “It comes directly to the question of whether we can socialize with others or not, in the way that they want to.” Sometimes, it can feel like a proxy battle over how much you value each other’s friendship. Be open about your own fears and vulnerabilities, and make it clear that when you disagree, you’re expressing your own preference and not rejecting the other person. Keep it simple, too, especially with friends or relatives with whom you don’t frequently have emotional, candid talks.

This empathy and candor will also be an asset if you find that your friends and peers have developed the tendency to over share, either out of anxiety or being starved for conversation. (You may be doing it yourself, too.) If a conversation subject makes you uncomfortable or anxious, say so.

“Being really open and direct is the best way,” said Dr. Danesh Alam, a psychiatrist and the medical director of behavior health services at Northwestern Medicine Central Dupage Hospital. Dr. Alam suggested studying up for conversations, preparing some questions and topics in order to chat with more intention and keep things on topic.

Take your time.

It’s OK if you don’t feel ready to see people socially again. Through the challenges of the lockdown period, you may have found that “your mental health is served best when you have time for calm and rest and introspection,” Dr. McBride said.

So pace yourself while considering the benefits of getting back out there: Even casual interactions have shown to foster a sense of belonging and community. “Social interaction is critical to our existence,” Dr. Alam said. Remember, too, that there are bound to be some weird moments as you start seeing others more regularly and your pandemic instincts (no hugging) and before-times instincts (“Do you want a bite of this?”) collide.

“If you’re comfortable going to a dinner at a small family restaurant, you can do that,” Dr. Hilden said. “If you want to wait a month or two, that’s OK, too.”

Learning to Connect With My Male Friends

For some men, long-term, meaningful relationships are harder to build and maintain into adulthood.

I was 20 when I learned that my parents were splitting up.

Two and half years later, I hold no hard feelings against them and have loving relationships with both of them. But, in the immediate aftermath of their split, I was a mess.

I cried in my car. I cried in my bed. I cried while picking up cold meat at the grocery store.

Despite my very public displays of distress, I did my best to maintain a stoic exterior when I was around people I knew. I didn’t tell my closest male friend and former college roommate, Tim, about my parents’ separation for weeks. Instead, I bantered about the latest sports news as if nothing had happened.

I’ve always regarded my sensitivity as one of my greatest weaknesses.

At my high school outside of Vancouver, British Columbia, the boys with quick jokes, often about other boys, were the most popular. I was someone who skirted on the periphery of social circles, wanting to be a part of the group, but desperate not to attract attention that would subject me to ridicule.

I started counseling for anxiety and depression in 11th grade. My therapy sessions were directly after school, so they conflicted with my routine walk home with two of my male friends.

Rather than telling them that I was seeking help, I came up with excuses — a doctor or dentist appointment — to explain why I couldn’t join them. Eventually, I got in the habit of simply saying I had an “appointment.”

Years later, when I learned about my parents’ separation, I similarly struggled to confide in my roommate.

Why was that? Why, even after counseling, was I still so scared to open up to other men my age?

Although research has shown that maintaining friendships as you age leads to a healthier life, men often struggle to have personal conversations and to keep friends.

In a 2020 study of more than 46,000 participants from 237 countries and territories led by researchers from the United Kingdom, young men living in “individualistic” societies, cultures that place a higher value on self-reliance rather than a collectivist mind-set such as the United States or United Kingdom, were more likely to report loneliness than older people or women.

In 2015, Dr. John Ogrodniczuk, the director of the psychotherapy program at the University of British Columbia, launched an online program called HeadsUpGuys that helps men manage depression. Looking to understand why men have trouble seeking mental health help, the organization developed an online survey to identify stressors that can contribute to depression.

Even before the Covid-19 pandemic, loneliness was consistently ranked at the top of its survey for stressors on men. According to Dr. Ogrodniczuk, the pandemic has only compounded feelings of isolation for men.

Why might men be lonelier than women — both in normal times and during the pandemic? After talking with experts in the psychology field, they reiterated it may have to do with a hesitancy to be vulnerable, which can come at the cost of intimacy in relationships.

Holding in my emotions contributed to the demise of my first (and only) romantic relationship. Entering university, I was self-conscious about partying, since I never attended parties in high school. I was also nervous about living on my own and I was insecure about studying creative writing, a field that seemed impractical compared to the science and math degrees that most of my friends were pursuing.

Rather than telling my ex-girlfriend about those anxieties, I consistently shut her out when she tried to help me cope, until we broke up.

Niobe Way, a professor of developmental psychology at New York University, believes that boys are conditioned to view emotional vulnerability as a weakness. As they grow up, boys are told that men should suppress and hide their emotions. “It’s a tragedy,” Dr. Way said in a phone interview.

In 2005, when Dr. Way was grappling with her crumbling marriage, she decided to pretend that all was well in front of her 5-year-old son, Raphael.

After work one day, when she greeted Raphael with an ear-to-ear grin, he asked, “Mommy, why would you smile when you are feeling sad?” His question struck Dr. Way because it demonstrated Raphael’s recognition of both her real, internal state and her performative, outward demeanor.

“Boys start off in the first decade being remarkably emotionally astute and attuned,” Dr. Way said.

Unfortunately, according to Dr. Way, when boys are socialized to become men, they learn to avoid disclosing difficult emotions, especially to other men.

In high school, I played basketball with Ben Wezeman. We both played on the varsity team, an arena where I never felt comfortable sharing my anxieties for fear of losing my starting spot in the lineup and appearing mentally weak in front of my teammates. I was a year older than Ben and we rarely talked. Years later, I found out that Ben, like me, silently battled with depression and social anxiety in high school.

Last year, I noticed he started a GoFundMe and planned to run at least three miles every day for one year to raise money for breast cancer research after his mother received the diagnosis in 2019. I met with him last summer for the first time since high school and wrote about his run streak, but we didn’t discuss our shared mental health struggles in adolescence.

In January, Mr. Wezeman posted on his Instagram about a manic episode that ended his running goal and caused him to spend nine days in a hospital. He was diagnosed with bipolar disorder.

Reading his message, I reached out to him again to finally discuss our shared anxieties.

“I was fearful about what would happen if I told a friend. Would they want to be friends with me anymore?” he said to me in a phone interview days after he published his post.

It wasn’t until after he received positive comments and direct messages from strangers on his Instagram post that he began feeling comfortable discussing his vulnerabilities with friends — and began encouraging other young men to do the same.

“There will always be people in someone’s life that will care,” he said. “They might just not know. So that’s why we have to talk about it.”

Four years after the only romantic relationship in my life ended, I’ve realized that all relationships require a certain degree of vulnerability.

I remember when I finally told my roommate about my parent’s separation. One evening, in one breath, I opened up about their split and my pain. It felt like a weight was lifted off my chest.

Having gone years believing “real men” suppressed their feelings, I felt extremely relieved and comforted when he listened and showed empathy.

It strengthened our relationship. Sharing that intimate detail played a key role in him becoming my closest friend, and why we still regularly talk.

In my conversation with Dr. Way, she emphasized how boys — like her son — at young ages have the emotional astuteness to comprehend when someone is feeling sad.

Those emotions must be nurtured, not altered by cultural stereotypes and perceptions of manhood. She says boys and men have the ability to understand emotions, their feelings are just waiting to be valued.

“This is not a depressing story,” Dr. Way said.

I agree.


Josh Kozelj is a writer based in Victoria, British Columbia. He is a senior at the University of Victoria studying Creative Writing.

Teenagers, Anxiety Can Be Your Friend

Think of it as a personal warning system that will help you notice when things are on the wrong track.

For many teenagers, anxiety is riding high these days.

A new report from the University of Michigan’s C.S. Mott Children’s Hospital National Poll on Children’s Health found that one in three teen girls and one in five teen boys have experienced new or worsening anxiety since March 2020.

And a year into the pandemic, there’s certainly plenty to worry about. Maybe you’re feeling nervous about catching or spreading Covid-19, or about returning to in-person school. You might be feeling tense about where things stand with your friends or perhaps you’re on edge about something else altogether: your family, your schoolwork, your future, the health of the planet.

While I wish there were fewer reasons to be anxious right now, I do have good news for keeping yourself steady. Psychologists actually understand a lot about anxiety — both the mechanisms that drive it and interventions that get it under control — and what we know is quite reassuring. So if you’re looking to feel more at ease, start by letting go of these common myths.

Myth: I’d be better off if I never felt anxious.

Without question, anxiety feels bad — it’s no fun to have a pounding heart, sweaty palms and tightness in your chest — and for that reason, it’s easy to assume that it must be bad. But the discomfort of anxiety has a basic evolutionary function: to get us to tune into the fact that something’s not right.

You can think of anxiety as the emotional equivalent of the physical pain response. If you accidentally touch a hot burner, the pain makes you pull your hand away. In the same way, if your friends want to take a Covid-safe outdoor event and move it into a cramped indoor space, you should feel a surge of discomfort. That odd feeling in the pit of your stomach will help you to consider the situation carefully and be cautious about your next step.

Try to view anxiety as your own personal warning system. It’s more often a friend than a foe, one that will help you notice when things are on the wrong track.

Given this, when is anxiety unhelpful? While most of the anxiety you feel is likely to be healthy and protective, psychologists agree that anxiety becomes a problem if its alarm makes no sense — either going off for no reason or blaring when a chime would do.

In other words, you should not feel anxious when all is well, and when you do feel anxious, the intensity of your nerves should match the scale of the problem before you. Feeling a little tense before a big game is appropriate and may even improve your performance. Having a panic attack on the sidelines means your anxiety has gone too far. It may be worth talking to a mental health care provider for advice on how to manage it, but first you can try the proven techniques below.

Myth: There’s not much I can do about anxiety.

You do not need to feel helpless when your anxiety alarm goes off, and even when anxious feelings cross the line from healthy to unhealthy, there’s a lot you can do to settle your nerves. Keep in mind that anxiety has both physical and mental components. At the physical level, the amygdala, a primitive structure in the brain, detects a threat and sends the heart and lungs into overdrive getting your body ready to fight or flee that threat. This is helpful if you’re dealing with a problem that calls for attacking or running — you’re about to miss the school bus and need to break into a sprint to catch it — but bothersome if your one-note-Johnny amygdala gets your heart pounding and your lungs hyperventilating while you’re trying to take a test.

A really good way to curb the physical symptoms of anxiety? Controlled breathing. Though it can sound like a daffy approach to managing tension, breathing deeply and slowly activates a powerful part of the nervous system responsible for resetting the body to its pre-anxiety state. There are many good breathing techniques. Find one that you like. Practice it when you’re feeling calm. Put it to work when your amygdala overreacts.

For the mental component of anxiety, watch out for thoughts that are extremely negative. Are you thinking, “I’ll probably get sick if I go to school,” or “I’ll never find someone to sit with at lunch”? Such intense pessimism will almost certainly set you on edge. Counter your own catastrophic thoughts by asking yourself two questions: Am I overestimating the severity of the problem I’m facing? Am I underestimating my power to manage it? Weighing these questions will help you keep your concerns at healthy levels.

Myth: If something makes me anxious, I should avoid it.

Understandably, if we’re scared of something, we’re inclined to stay far away from it. Avoidance alleviates anxiety in the short term, but here’s the rub: In the long term, avoidance entrenches it. There are two separate factors at work here. The first is that it feels great when we steer clear of the things we dread. If you’ve been doing school remotely this year and get nervous when you picture your return to in-person learning, resolving to stay home will cause your worries to instantly drain away. It’s human nature to want to repeat any behavior that leads to feelings of pleasure or comfort, but every boost of avoidance-related relief increases the likelihood that you’ll want to continue to avoid what you fear.

The second factor in the avoidance-feeds-anxiety double whammy is that you rob yourself of the chance to find out that your worries are exaggerated. For example, the realities of in-person school are sure to be more manageable than the harrowing scenarios your imagination can create. Going to school would likely bring your worries down to size.

Facing our fears can reduce anxiety. But you don’t have to dive into nerve-racking experiences when wading in is an option. If social distancing has left you feeling unsure about the status of your friendships, you might be tempted to isolate yourself. Instead, come up with a small first step, such as making a plan to hang out with just one or two buddies before returning to the broader social scene. Get your feet wet and then take it from there.

With the world beginning to open up, it makes sense that you might feel nervous about easing back into it. Knowing what’s true about anxiety — and not — will make it easier to navigate the uncertain times ahead.


Is Ringing in the Ears a Symptom of Coronavirus?

Researchers are just beginning to untangle how Covid might be linked to a ringing in the ears. Here’s what we know.

Shortly after she fell ill with Covid-19 last April, Andrea Ceresa, an office manager and singer in Branchburg, N.J., noticed an unusual sensation in her ears: a ringing and buzzing that had never been present before. Now, nearly a year later, Ms. Ceresa, 47, said that of all the debilitating post-Covid symptoms that have lingered — the heart palpitations, headaches, stomach troubles, numbness and weakness in her hands and feet — the most frustrating one is the tinnitus, a condition that can cause sufferers to hear phantom ringing, buzzing, whistling, chirping or other sounds.

“There’s never not a time when I don’t have noise running through my head,” Ms. Ceresa said. “It makes it hard to concentrate, it makes it hard to hold conversations with others, it makes it almost impossible to lie down and go to sleep. It’s maddening, and you can’t fully understand it unless you experience it yourself.”

Following the recent death of Kent Taylor, the founder and chief executive of the Texas Roadhouse restaurant chain who took his own life at age 65 after suffering from post-Covid-19 symptoms, including severe tinnitus, many are wondering how Covid and tinnitus may be linked. Also, how might tinnitus — a vexing condition that afflicts as many as 60 million people in the United States — influence mental health?

While some early research and anecdotal evidence suggest an association between tinnitus and Covid-19, experts caution that it’s still too early to make a definitive link. “Am I seeing patients who come in saying they noticed tinnitus after developing Covid-19? Yes,” said Dr. Douglas Hildrew, an ear, nose and throat specialist and surgeon at Yale Medicine. But, he noted, it may also be exacerbated by other factors, like stress.

Here’s what we know.

What causes tinnitus?

According to Dr. Maura Cosetti, an ear, nose and throat specialist at Mount Sinai Hospital in New York City, the most common cause of chronic tinnitus is age. As the hair cells inside your inner ear become damaged over time, she said, they may no longer send sound waves to your brain, so your brain tries to recreate them on their own, which is what might cause the ringing.

But experts have long known that some viruses can temporarily cause hearing loss or ringing in the ears, too. When the body fights an infection, the overall inflammation from the virus can damage the nerves or hair cells in the ear, Dr. Cosetti said.

“Sometimes, a patient has already had mild tinnitus that they never really noticed before,” said Dr. David Friedmann, an ear, nose and throat specialist at NYU Langone Medical Center. “But once it’s temporarily exacerbated by a virus, they continue be bothered by it even after the initial infection has resolved.”

Can Covid-19 cause tinnitus?

There’s not enough research to say for sure. “There haven’t been any studies yet that I’m aware of that compare rates of tinnitus among survivors of Covid-19 with those in the general population,” Dr. Hildrew said.

In one review, published Monday in the International Journal of Audiology, researchers pooled data from nearly 60 case reports and studies and found that nearly 15 percent of adults diagnosed with Covid-19 reported tinnitus. Another study, published in the same journal in July, followed 138 patients for eight weeks after they had been discharged from a hospital in the United Kingdom after suffering severe symptoms of Covid-19. Among them, 16 (13 percent) reported either a change in hearing or tinnitus.

Natalie Lambert, an associate research professor of biostatistics and health data science at the Indiana University School of Medicine, surveyed nearly 5,200 “long-hauler” Covid-19 patients and found that nearly 17 percent reported new tinnitus, with more than three-quarters of those people saying it was ongoing. She cautioned that more research is needed to confirm the results, which have not yet been peer-reviewed or published in a medical journal.

There’s also evidence that Covid-19 symptoms can exacerbate existing tinnitus. In one online survey of about 3,100 people from 48 countries who suffer from tinnitus, researchers found that among the 237 people who experienced Covid-19 symptoms, 40 percent said that their tinnitus symptoms had been significantly worsened. Nearly a third of all the respondents also reported the stress of the pandemic itself exacerbated their tinnitus, even if they hadn’t contracted Covid-19. “We know that anxiety can worsen tinnitus, and it becomes a vicious cycle: The worse your tinnitus, the more anxious you are,” Dr. Hildrew said. “It becomes a very aggressive loop that can be difficult to break.”

How does tinnitus affect mental health?

When Marlene Suarez contracted Covid-19 during the second week of January, her symptoms of fever, cough and difficulty breathing weren’t so severe that she needed to be hospitalized, but they were bad enough to warrant treatment with monoclonal antibodies to reduce her risk of serious complications. About a week after her diagnosis, while watching TV, she noticed a ringing in her left ear, and that she couldn’t hear anything in her right.

“I went to the emergency room, where the E.N.T. on call said it was probably from Covid-19,” said Ms. Suarez, 62, an attorney in Collinsville, Ill. The ringing continued for weeks. “I was so depressed and scared I’d never get better,” Ms. Suarez said. “I speak and talk for a living — how was I going to be able to have a conversation with a client or present in court if it constantly sounded like bells were exploding on my left side?”

Ms. Suarez was given oral corticosteroids for several weeks, and now, more than two months later, her tinnitus and hearing loss have mostly resolved. But for many with more chronic ringing in the ears, the result can be devastating.

Tinnitus has been linked to several mental health conditions, including anxiety and depression, and mostly in women. “It can be particularly challenging for many people initially because it’s something they have absolutely no control over,” said Richard Tyler, an audiologist at the University of Iowa Carver College of Medicine. “No one can tell them if it will get worse, or if it will eventually go away. Suddenly, they have trouble sleeping, they can’t carry on a conversation, and they can’t concentrate. It can seem an overwhelming challenge.”

The condition has also been linked to an increased risk of suicide. In a research letter published in JAMA Otolaryngology–Head & Neck Surgery in 2019, researchers found that among more than 16,000 adults in Sweden who had ever experienced tinnitus, women — and in particular, those with severe tinnitus — had a small increased risk of suicide. However, those who had been diagnosed, and possibly treated for, the condition were not at increased risk.

“For most people with tinnitus, the worst time is the first six to nine months after it begins,” Dr. Tyler said. “After that, most people adjust and learn to live with it, especially if they’re given the right treatments.”

How is tinnitus treated?

If you are diagnosed with Covid-19 and you experience tinnitus that lasts for more than two days, tell your doctor right away. “The same treatment that can help you recover from tinnitus and sudden hearing loss is a steroid, which can also help treat Covid-19,” Dr. Hildrew said. Nonsteroidal anti-inflammatories, like ibuprofen, can also temporarily cause tinnitus, Dr. Cosetti added. This usually resolves within a few days once you stop taking them.

If your tinnitus persists after you’ve recovered from the virus, make an appointment with an ear, nose and throat doctor, who can check for blockages in your ears (like from fluid or ear wax), which can cause symptoms. If no blockage exists, you might be sent to an audiologist to check your hearing.

If your tinnitus does persist and is related to hearing loss, your E.N.T. may refer you back to an audiologist to get fitted for a hearing aid, Dr. Friedmann said. Your audiologist may be able to add a device to it that produces low-level sounds to help mask tinnitus noise.

There’s also good evidence that cognitive behavioral therapy, a type of talk therapy that can help you strategize ways of ignoring your tinnitus or dealing with the stress of it, can help. One study found that incorporating C.B.T. with mindfulness techniques, like meditation, significantly reduced tinnitus-related distress.

After many months of dealing with the tinnitus that began last spring, Ms. Ceresa is now being treated for her constellation of lingering symptoms at the Center for Post-Covid care at Mount Sinai Hospital in New York City. Tinnitus is still near the top of her list of complaints. “It’s always there and with me all the time — I can never escape it,” she said, adding that she has to take sedatives now to fall asleep. “I have days when I don’t know if I can handle this anymore. But I have to go on being hopeful.”

Hallie Levine is a health journalist who lives with her three children and two Labrador retrievers in Fairfield, Conn.

The Pandemic as a Wake-Up Call for Personal Health

Personal Health

The Pandemic as a Wake-Up Call for Personal Health

Too many Americans fail to take measures to combat obesity, the second leading risk factor for death from Covid-19.

Credit…Gracia Lam
Jane E. Brody

  • March 15, 2021, 5:00 a.m. ET

The pandemic has shed a blinding light on too many Americans’ failure to follow the well-established scientific principles of personal health and well-being. There are several reasons this country, one of the world’s richest and most highly developed, has suffered much higher rates of Covid-19 infections and deaths than many poorer and less well-equipped populations.

Older Americans have been particularly hard hit by this novel coronavirus. When cases surged at the end of last year, Covid-19 became the nation’s leading cause of death, deadlier than heart disease and cancer.

But while there’s nothing anyone can do to stop the march of time, several leading risk factors for Covid-19 infections and deaths stem from how many Americans conduct their lives from childhood on and their misguided reliance on medicine to patch up their self-inflicted wounds.

After old age, obesity is the second leading risk factor for death among those who become infected and critically ill with Covid-19. Seventy percent of Americans adults are now overweight, and more than a third are obese. Two other major risks for Covid, Type 2 diabetes and high blood pressure, are most often the result of excess weight, which in turn reflects unhealthy dietary and exercise habits. These conditions may be particularly prevalent in communities of color, who are likewise disproportionately affected by the pandemic.

Several people I know packed on quite a few pounds of health-robbing body fat this past year, and not because they lacked the ability to purchase and consume a more nutritious plant-based diet or to exercise regularly within or outside their homes. One male friend in his 50s unexpectedly qualified for the Covid vaccine by having an underlying health condition when his doctor found he’d become obese since the pandemic began.

A Harris Poll, conducted for the American Psychological Association in late February, revealed that 42 percent of respondents had gained an average of 29 “pandemic pounds,” increasing their Covid risk.

So what can we learn from these trends? Tom Vilsack, the new Secretary of Agriculture, put it bluntly a week ago in Politico Pro’s Morning Agriculture newsletter: “We cannot have the level of obesity. We cannot have the level of diabetes we have. We cannot have the level of chronic disease … It will literally cripple our country.”

Of course, in recent decades many of the policies of the department Mr. Vilsack now heads have contributed mightily to Americans’ access to inexpensive foods that flesh out their bones with unwholesome calories and undermine their health. Two telling examples: The government subsidizes the production of both soybeans and corn, most of which is used to feed livestock.

Not only does livestock production make a major contribution to global warming, much of its output ends up as inexpensive, often highly processed fast foods that can prompt people to overeat and raise their risk of developing heart disease, diabetes, high blood pressure and kidney disease. But there are no subsidies for the kinds of fruits and vegetables that can counter the disorders that render people more vulnerable to the coronavirus.

As Mr. Vilsack said, “The time has come for us to transform the food system in this country in an accelerated way.”

Early in the pandemic, when most businesses and entertainment venues were forced to close, toilet paper was not the only commodity stripped from market shelves. The country was suddenly faced with a shortage of flour and yeast as millions of Americans “stuck” at home went on a baking frenzy. While I understood their need to relieve stress, feel productive and perhaps help others less able or so inclined, bread, muffins and cookies were not the most wholesome products that might have emerged from pandemic kitchens.

When calorie-rich foods and snacks are in the home, they can be hard to resist when there’s little else to prompt the release of pleasure-enhancing brain chemicals. To no one’s great surprise, smoking rates also rose during the pandemic, introducing yet another risk to Covid susceptibility.

And there’s been a run on alcoholic beverages. National sales of alcohol during one week in March 2020 were 54 percent higher than the comparable week the year before. The Harris Poll corroborated that nearly one adult in four drank more alcohol than usual to cope with pandemic-related stress. Not only is alcohol a source of nutritionally empty calories, its wanton consumption can result in reckless behavior that further raises susceptibility to Covid.

Well before the pandemic prompted a rise in calorie consumption, Americans were eating significantly more calories each day than they realized, thanks in large part to the ready availability of ultra-processed foods, especially those that tease, “you can’t eat just one.” (Example: Corn on the cob is unprocessed, canned corn is minimally processed, but Doritos are ultra-processed).

In a brief but carefully designed diet study, Kevin D. Hall and colleagues at the National Institutes of Health surreptitiously gave 20 adults diets that were rich in either ultra-processed foods or unprocessed foods matched for calorie, sugar, fat, sodium, fiber and protein content. Told to eat as much as they wanted, the unsuspecting participants consumed 500 calories a day more on the ultra-processed diet.

If you’ve been reading my column for years, you already know that I’m not a fanatic when it comes to food. I have many containers of ice cream in my freezer; cookies, crackers and even chips in my cupboard; and I enjoy a burger now and then. But my daily diet is based primarily on vegetables, with fish, beans and nonfat milk my main sources of protein. My consumption of snacks and ice cream is portion-controlled and, along with daily exercise, has enabled me to remain weight-stable despite yearlong pandemic stress and occasional despair.

As Marion Nestle, professor emerita of nutrition, food studies and public health at New York University, says, “This is not rocket science.” She does not preach deprivation, only moderation (except perhaps for a total ban on soda). “We need a national policy aimed at preventing obesity,” she told me, “a national campaign to help all Americans get healthier.”

The Pandemic Happiness Gap

Mind

The Pandemic Happiness Gap

New surveys show that in the last year, older adults tended to be more positive than younger ones, suggesting that the ability to cope improves with age.

Credit…Nicole Xu
Benedict Carey

  • March 12, 2021, 12:00 p.m. ET

For all its challenges to mental health, this year of the plague also put psychological science to the test, and in particular one of its most consoling truths: that age and emotional well-being tend to increase together, as a rule, even as mental acuity and physical health taper off.

The finding itself is solid. Compared with young adults, people aged 50 and over score consistently higher, or more positively, on a wide variety of daily emotions. They tend to experience more positive emotions in a given day and fewer negative ones, independent of income or education, in national samples (work remains to be done in impoverished, rural and immigrant communities.)

But that happiness gap always has begged for a clear explanation. Do people somehow develop better coping skills as they age?

Or is the answer more straightforward: Do people sharpen their avoidance skills, reducing the number of stressful situations and bad risks they face as they get older?

To test these two scenarios, scientists needed an environment where both older and younger populations were in equally stressful situations.

But “there’s never been a way we could somehow test the effect of extreme stress on this relationship, in any ethical way,” said Susan Charles, a professor of psychology at the University of California, Irvine.

The coronavirus changed that. If the outbreaks across the country through the spring showed one thing clearly, it was that older people have been at much higher risk — both of getting sick and dying of Covid-19 — than the young.

“This was, from the beginning, a threat to older people that they simply could not avoid — and, crucially, it was prolonged stress,” said Laura Carstensen, a psychologist at Stanford University’s Center on Longevity.

A research team led by Dr. Carstensen studied that reality. In April, after the potential scope of the pandemic was apparent, the team recruited a representative sample of some 1,000 adults, aged 18 to 76, living across the country. The participants answered surveys with detailed questions about their emotions over the previous week, including 16 positive states, like relaxed or amused, and 13 negative ones, like guilt or anger.

They also rated the intensity of those feelings. People who said they had been angry over the past week, for example, would see an item asking, “When you felt angry this past week, how angry did you typically feel — a little, somewhat, very, or extremely angry.”

If older people indeed manage their emotions by choosing to avoid stressful situations, the scientists reasoned, then their study should show the happiness gap shrinking, if not disappearing.

Yet their moods remained elevated, on average, compared with those in younger generations, the survey data showed — despite the fact that both groups reported the same stress levels.

“Younger people were doing far worse emotionally than older people were,” Dr. Carstensen said. “This was April, the most anxiety-producing month, it was novel, cases went from nothing to 60,000, there was lots of attention and fear surrounding all this — and yet we see the same pattern as in other studies, with older people reporting less distress.”

In a similar study, psychologists at the University of British Columbia exhaustively surveyed some 800 adults of all ages in the first couple of months of the pandemic — and found the same thing.

“The Covid-19 pandemic has led to an outbreak of ageism, in which public discourse has portrayed older adults as a homogeneous, vulnerable group,” the authors conclude. “Our investigation of the daily life amid the outbreak suggests the opposite: Older age was associated with less concern about the threat of Covid-19, better emotional well-being, and more daily positive events.”

These results hardly rule out avoidance as one means of managing day-to-day emotions. Older people, especially those with some resources, have more ability than younger adults to soften the edges of a day, by paying for delivery, hiring help, staying comfortably homebound and — crucially — doing so without young children underfoot.

One of the few investigations to find no age-related differences in well-being, posted last year, was focused on 226 young and older adults living in the Bronx. In this, New York’s most underserved borough, older people often live with their children and grandchildren, helping with meals, school pickup, babysitting, in effect acting as co-parents. No “age bump” in emotional well-being for them, the researchers found, in part, they concluded, because “the sample was somewhat ‘more stressed’ than average levels nationwide.”

Even with that crucial distinction noted, these studies bolster a theory of emotional development and aging formulated by Dr. Carstensen that psychologists have been debating for years. This view holds that, when people are young, their goals and motives are focused on gaining skills and taking chances, to prepare for opportunities the future may hold. You can’t know if you’ll be any good running a business, or onstage, unless you give it a real chance. Doing grunt work for little money; tolerating awful bosses, bad landlords, needy friends: the mental obstacle course of young adulthood is no less taxing for being so predictable.

After middle age, people become more aware of a narrowing time horizon and, consciously or not, begin to gravitate toward daily activities that are more inherently pleasing than self-improving.

They’re more prone to skip the neighborhood meeting for a neighborhood walk to the local bar or favorite bench with a friend. They have accepted that the business plan didn’t work out, that their paintings were more fit for the den than for a gallery. They have come to accept themselves for who they are, rather than who they’re supposed to become. Even those who have lost their jobs in this tragic year, and face the prospect of re-entering the job market — at least they know their capabilities, and what work is possible.

These differences will be important to keep in mind in the near future, if only to blunt a widening generational divide, experts say. A pandemic that began by disproportionately killing the elderly has also savagely turned on the young, robbing them of normal school days, graduations, sports, first jobs, or any real social life — and shaming them, often publicly, if they tried to have one. Now, in a shrinking economy, they’re at the back of the vaccine line.

“I think the older generation now, as much as it’s been threatened by Covid, they’re beginning to say, ‘My life is not nearly as disrupted as my children’s or grandchildren’s,’” Dr. Charles said, “and that is where our focus on mental well-being should now turn.”

How Exercise Affects Our Minds: The Runner's High

Phys Ed

Getting to the Bottom of the Runner’s High

For years we’ve been crediting endorphins, but it’s really about the endocannabinoids.

Credit…Kevin Hagen for The New York Times
Gretchen Reynolds

  • March 10, 2021, 5:00 a.m. ET

We can stop crediting endorphins, the natural opioid painkillers produced by our bodies, for the floaty euphoria we often feel during aerobic exercise, according to a nifty new study of men, women and treadmills. In the study, runners developed a gentle intoxication, known as a runner’s high, even if researchers had blocked their bodies’ ability to respond to endorphins, suggesting that those substances could not be behind the buzz. Instead, the study suggests, a different set of biochemicals resembling internally homegrown versions of cannabis, better known as marijuana, are likely to be responsible.

The findings expand our understanding of how running affects our bodies and minds, and also raise interesting questions about why we might need to be slightly stoned in order to want to keep running.

In surveys and studies of experienced distance runners, most report developing a mellow runner’s high at least sometimes. The experience typically is characterized by loose-limbed blissfulness and a shedding of anxiety and unease after half an hour or so of striding. In the 1980s, exercise scientists started attributing this buzz to endorphins, after noticing that blood levels of the natural painkillers rise in people’s bloodstreams when they run.

More recently, though, other scientists grew skeptical. Endorphins cannot cross the blood-brain barrier, because of their molecular structure. So, even if runners’ blood contains extra endorphins, they will not reach the brain and alter mental states. It also is unlikely that the brain itself produces more endorphins during exercise, according to animal studies.

Endocannabinoids are a likelier intoxicant, these scientists believed. Similar in chemical structure to cannabis, the cannabinoids made by our bodies surge in number during pleasant activities, such as orgasms, and also when we run, studies show. They can cross the blood-brain barrier, too, making them viable candidates to cause any runner’s high.

A few past experiments had strengthened that possibility. In one notable 2012 study, researchers coaxed dogs, people and ferrets to run on treadmills, while measuring their blood levels of endocannabinoids. Dogs and humans are cursorial, meaning possessed of bones and muscles well adapted to distance running. Ferrets are not; they slink and sprint but rarely cover loping miles, and they did not produce extra cannabinoids while treadmill running. The dogs and people did, though, indicating that they most likely were experiencing a runner’s high and it could be traced to their internal cannabinoids.

That study did not rule out a role for endorphins, however, as Dr. Johannes Fuss realized. The director of the Human Behavior Laboratory at the University Medical Center Hamburg-Eppendorf in Germany, he and his colleagues had long been interested in how various activities affect the inner workings of the brain, and after reading the ferret study and others, thought they might look more closely into the runner’s high.

They began with mice, which are eager runners. For a 2015 study, they chemically blocked the uptake of endorphins in the animals’ brains and let them run, then did the same with the uptake of endocannabinoids. When their endocannabinoid system was turned off, the animals ended their runs just as anxious and twitchy as they had been at the start, suggesting that they had felt no runner’s high. But when their endorphins were blocked, their behavior after running was calmer, relatively more blissed-out. They seemed to have developed that familiar, mild buzz, even though their endorphin systems had been inactivated.

Mice emphatically are not people, though. So, for the new study, which was published in February in Psychoneuroendocrinology, Dr. Fuss and his colleagues set out to replicate the experiment, to the extent possible, in humans. Recruiting 63 experienced runners, male and female, they invited them to the lab, tested their fitness and current emotional states, drew blood and randomly assigned half to receive naloxone, a drug that blocks the uptake of opioids, and the rest, a placebo. (The drug they had used to block endocannabinoids in mice is not legal in people, so they could not repeat that portion of the experiment.)

The volunteers then ran for 45 minutes and, on a separate day, walked for the same amount of time. After each session, the scientists drew blood and repeated the psychological tests. They also asked the volunteers whether they thought they had experienced a runner’s high.

Most said yes, they had felt buzzed during the run, but not the walk, with no differences between the naloxone and placebo groups. All showed increases, too, in their blood levels of endocannabinoids after running and equivalent changes in their emotional states. Their euphoria after running was greater and their anxiety less, even if their endorphin system had been inactivated.

Taken as a whole, these findings are a blow to endorphins’ image. “In combination with our research in mice,” Dr. Fuss says, “these new data rule out a major role for endorphins” in the runner’s high.

The study does not explain, though, why a runner’s high exists at all. There was no walker’s high among the volunteers. But Dr. Fuss suspects the answer lies in our evolutionary past. “When the open savannas stretched and forests retreated,” he says, “it became necessary for humans to hunt wild animals by long-distance running. Under such circumstances, it is beneficial to be euphoric during running,” a sensation that persists among many runners today, but with no thanks due, it would seem, to endorphins.

Drinking Alcohol and Cancer: Should Your Cocktail Carry a Cancer Warning?

Should Your Cocktail Carry a Cancer Warning?

As pandemic disruptions lead many of us to drink more, experts underscore the link between alcohol and disease.

Credit…Getty Images
Anahad O’Connor

  • March 4, 2021, 5:00 a.m. ET

When the pandemic struck last year, many Americans rushed to stock up on alcohol, causing retail sales of wine, beer and liquor to surge across the country.

But the uptick in sales was a worrying sign for health experts focused on cancer prevention. In recent years, a growing number of medical and public health groups have introduced public awareness campaigns warning people to drink with caution, noting that alcohol is the third leading preventable cause of cancer, behind tobacco and obesity.

In October, the American Society for Clinical Oncology (ASCO), which represents many of the nation’s top cancer doctors, along with the American Institute for Cancer Research, the American Public Health Association and five other groups called on the federal government to add a cancer warning to alcohol labels, saying there was strong scientific consensus that alcohol can cause several types of cancer, including breast and colon cancers. While medical experts have long recognized alcohol as a risk factor for various cancers, including cancers of the mouth, throat, voice box, esophagus and liver, a survey conducted by ASCO in 2017 of 4,016 American adults found that fewer than a third recognized alcohol as a risk factor for cancer.

Other countries are stepping up public health efforts to rein in alcohol consumption as well. The European Union, which has some of the highest levels of drinking in the world, announced earlier this year that it planned to slap new health warnings on alcohol and explore new taxes and restrictions on the marketing of alcoholic beverages as part of a $4.8 billion plan to reduce cancer rates. In France, famous for its wine and champagne, the government announced that it would issue new warnings and policies to discourage heavy drinking as part of a 10-year plan to tackle cancer, which is the country’s leading cause of death.

The ongoing pandemic underscores the urgency of these efforts, as stress, lockdowns and economic uncertainty continue to take a toll. In the past year, hospitals across the United States have reported an increase in admissions for hepatitis, liver failure and other alcohol-related diseases. A study in the journal Psychiatry Research found that in the first six months of lockdowns, alcohol abuse rose most sharply among people who lost their jobs or who were confined to their homes because of shelter-in-place restrictions. The pandemic has also made it easier for people working from home to drink throughout the day without fear of colleagues noticing.

“Workers who would never consider consuming alcohol at the office are now free to drink to excess during work hours while at home,” the study found. “There are grave concerns over the long-term health implications of the rising level of alcohol dependence.”

In the United States, 41 percent of men and 39 percent of women will develop cancer at some point in their lifetimes, according to the American Cancer Society. The group estimates that around 42 percent of newly diagnosed cancers are potentially preventable, by avoiding such measures as cigarette smoking (accounting for some 19 percent of cancer cases), excess weight (7.8 percent of cases), drinking alcohol (5.6 percent of cases), ultraviolet radiation (5 percent of cases) and physical inactivity (2.9 percent of cases). While heavy drinking poses the greatest hazard, moderate drinking — generally defined as two drinks a day for men and one drink a day for women — can also imperil health. According to the cancer society, even small amounts of alcohol — less than one drink a day — can raise the risk of breast cancer in women and some other forms of the disease.

The link between alcohol and cancer was the focus of a recent large study that found that alcohol causes 75,000 new cases of cancer in America every year, as well as 19,000 deaths from the disease. The study, published in January in Cancer Epidemiology, concluded that alcohol accounted for more than one in eight cases of breast cancer in women and one in 10 cases of colorectal and liver cancers nationwide.

“It’s a substantial number of cancer cases and cancer deaths that could be prevented,” said Dr. Farhad Islami, the senior author of the study and the scientific director of the cancer disparity research team at the American Cancer Society. “The cancer burden is considerable.”

Scientists have known that alcohol promotes cancer for several decades. The World Health Organization first classified alcohol consumption as cancer-causing in 1987. Experts say that all types of alcoholic beverages can increase cancer risk because they all contain ethanol, which can cause DNA damage, oxidative stress and cell proliferation. Ethanol is metabolized by the body into another carcinogen, acetaldehyde, and it can influence breast cancer risk by elevating estrogen levels.

But surveys continue to show that most people remain unaware of the risks. When the American Institute for Cancer Research surveyed Americans two years ago to gauge their awareness of different cancer risk factors, the results were striking: fewer than half were aware of the alcohol-cancer link.

Experts say one reason for the lack of awareness is the popular idea that moderate alcohol intake, especially of red wine, is good for heart health, which has drowned out public health messages about alcohol’s impact on cancer risk. But while moderate drinking has long had a health halo, recent studies suggest it may not be beneficial at all. The American Heart Association states that “no research has established a cause-and-effect link between drinking alcohol and better heart health,” and that people who drink red wine may have lower rates of heart disease for other reasons, such as healthier lifestyles, better diets or higher socioeconomic status.

Other analyses have found that moderate drinking can appear to be beneficial in large population studies because the “nondrinkers” who are used for comparison often include people who don’t drink because they have serious health issues or because they are former heavy drinkers. When studies take these factors into account, the apparent cardiovascular benefits of moderate drinking disappear.

For that reason, the federal government’s Dietary Guidelines for Americans, which once promoted moderate drinking for heart health, no longer makes that claim. A panel of scientists that helped shape the most recent edition of the guidelines called for the government to lower the recommended daily limit for alcohol consumption to just one drink a day for both men and women, citing evidence that higher levels of alcohol intake increase the risk of early death.

But the alcohol industry lobbied fiercely against that change, and the latest guidelines, published in December, did not include the lowered drink recommendation. The guidelines, however, did for the first time include strong language about alcohol and cancer, warning that even moderate drinking can “increase the overall risk of death from various causes, such as from several types of cancer and some forms of cardiovascular disease.”

“For some types of cancer,” the new guidelines state, “the risk increases even at low levels of alcohol consumption (less than one drink in a day). Caution, therefore, is recommended.”

The American Cancer Society also issued new guidelines last year that for the first time took a tough stance on drinking, warning that for cancer prevention, “there is no safe level of consumption.” Dr. Timothy Naimi, a member of the government’s dietary guidelines advisory committee, said the new recommendations make clear that moderate drinking is not protective and that drinking less is always better than drinking more.

“The new guidelines are very strong in framing alcohol as a leading preventable health hazard,” said Dr. Naimi, the director of the Canadian Institute for Substance Use Research. “I think the relationship between alcohol and a number of the most important cancers is still not widely recognized. But I feel that’s changing.”

Nigel Brockton, the vice president of research at the American Institute for Cancer Research, said he worried that people who increased their alcohol intake in the past year to cope with the pandemic might continue their new habits into the future. But he advised people who drink to avoid making it a daily habit, and to take other steps to lower their risk, such as exercising and improving their diets.

“We’re not expecting everyone to become teetotalers,” he said. “But if you’re going to drink, then one is better than two, and not every day, because those are the behaviors that across all of these cancers increase your risk.”

Diagnosing Autism in the Pandemic

The Checkup

Diagnosing Autism in the Pandemic

Autism spectrum disorder is often suspected when young children stand out as being different from their peers. That can be much harder in this isolated time.

Credit…Yifan Wu

  • March 1, 2021, 5:00 a.m. ET

We talk often in pediatrics about the importance of early identification and early treatment of autism spectrum disorder, with its hallmark issues of social communication problems and restricted repetitive behavior patterns. “Early” means paying particularly close attention to the behavior and development of children between ages 1 and 3, and checking in with their parents about any concerns.

But what does that mean for young children who have now spent half their lives — or more — in the special circumstances of the pandemic?

Dr. Heidi Feldman, a professor of developmental and behavioral pediatrics at Stanford University School of Medicine, said, “We don’t know what the impact of one year of very restricted social interaction is going to be on children.” Some of the behavior patterns that children are showing now may be the result of these strange living conditions, or they may reflect stress, trauma and the social isolation that many families have experienced, she said.

Dr. Feldman said that first-time parents who have been operating in the increased isolation of the pandemic may have very limited context for appreciating where their child’s behavior falls. They’re missing the input they might usually get from teachers and child care providers.

Dr. Eileen Costello, a clinical professor of pediatrics at Boston University School of Medicine and chief of ambulatory pediatrics at Boston Medical Center, said, “Especially for the really little ones, the only eyes that are on them are their parents’. They’re not seeing uncles and aunts and cousins, not in preschool.”

Dr. Costello and I are co-authors of the book “Quirky Kids: Understanding and Supporting Your Child With Developmental Differences.” We use the word “quirky” to encompass children whose development does not follow standard patterns, whether or not they fit the criteria for a specific diagnosis. Some of these children will accumulate several different diagnoses as they grow and change — and as different demands are made on them in terms of academic performance and social life — and others will never fit the criteria for any specific formal diagnosis.

Dr. Adiaha Spinks-Franklin, a developmental behavioral pediatrician at Texas Children’s Hospital and an associate professor at Baylor College of Medicine, said that because parents right now are at home more, sometimes they are more likely to notice unusual or concerning patterns — repetitive behaviors, or communications problems like echolalia, in which a child repeats words. This can be completely normal, and is in fact part of how children learn to talk, but it can be concerning if it’s the major part of a child’s language as the child grows. By the age of 2, children should be saying lots of their own words.

When parents — or teachers or doctors — do have concerns, getting a developmental assessment done has its own complexity in the pandemic.

Catherine Lord, a professor of psychiatry and education at the University of California, Los Angeles, said, “I’m doing diagnoses right now in my back yard, which is insane.” But with the protective gear that would have to be worn at the hospital, she said, “we look like we’re from outer space,” and could be too intimidating to small children.

Dr. Lord said. “We do remote interviews with parents, we try to see videos of the kid, then have them come — we have a big back yard.” And they continue to use the Zoom technology, even across the yard.

The standardized assessment for autism spectrum disorder can’t be done masked, because it depends on interpreting the child’s expressions and observing reactions to the examiner’s facial expressions. Dr. Lord said there is a shorter version that children can do with their parents — everyone unmasked — while the clinicians watch without being in the room. This may not be as accurate — researchers are still analyzing the data — but they are hopeful that it will be helpful in many cases.

“When we see kids in clinic, we have to be masked, and if they’re over 2, they have to be masked,” Dr. Feldman said. Earlier in the pandemic, a family that was convinced that their child had autism came to the clinic. “This kid had not seen anybody other than his parents and had not been anyplace other than his home — he was so terrified — the in-person visit was very, very hard.” They used a room with a one-way mirror, so the parents could be alone with the child, and could take their masks off, but “even with that, he had such a hard time settling down.”

Dr. Lord was the lead author on a review paper on autism spectrum disorder published in Nature Reviews in 2020. She emphasized the importance of early diagnosis so that children can get early help with communication: “Kids who are going to become fluent speakers, their language starts to change between 2 and 3, and 3 and 4, and 4 and 5,” Dr. Lord said. “We want to be sure we optimize what happens in those years and that’s very hard to do if people are stuck at home.”

She recommended that parents request the free assessments that can be done through early intervention, in many cases now being done remotely.

Developmental assessments can include remote visits. “We have gotten quite good at doing telehealth evaluations,” Dr. Feldman said. “We get the kids in their own environments and their own toys, we get to see what they do at home.”

“Sometimes making the diagnosis of autism over telehealth in a very young child is incredibly challenging,” Dr. Spinks-Franklin said. “Families that don’t have access to consistent reliable high-speed internet are also impacted — a video visit may not be possible or may be interrupted.”

Even before the pandemic, many families faced long waits to get those developmental assessments. “Those who are vulnerable already are always going to be more severely affected — families who already had more limited access to primary care providers or are underinsured or uninsured already had a harder time,” Dr. Spinks-Franklin said.

Now, she said, the pandemic is placing those families even more at risk, because of the likelihood of economic hardship from jobs loss, underemployment or lost health care benefits. The disparities are exacerbated, and the chance of getting to the right clinic and the right health care professional go down.

Right now, because families are isolated or may not have good access to medical care, neurodevelopmental problems may be being missed in these critical early years, when getting diagnosed would help children get therapy. On the other hand, some children who don’t have these underlying problems and are just reacting to the strange and often anxiety-provoking circumstances of pandemic life may mistakenly be thought to be showing signs of autism.

Parents and even doctors may worry about autism spectrum disorder in children who have attention deficit hyperactivity disorder or anxiety, and who are being seen in unusual situations — in a parking lot, for example. “I’ve been undoing diagnoses,” Dr. Lord said. “It’s not surprising that a kid is looking a bit less relaxed.”

Dr. Spinks-Franklin said that the pressures of the pandemic may act on children as other stresses do, and show up as more extreme behavior, such as more frequent tantrums or increased irritability.

“All that bounces is not A.D.H.D.; all that flaps is not autism,” Dr. Spinks-Franklin said.

What Parents Can Do

To understand whether a child’s extreme behavior represents chronic stress and increased frustration related to the hardships that families are living through, or is a sign of a neurodevelopmental disorder, it’s important to figure out whether these behaviors were present before the pandemic, Dr. Spinks-Franklin said.

If parents have concerns about a child’s development or behavior, a good place to start is to talk the question through with the child’s primary care provider, who can also review the record with the parents and talk about the child’s early developmental course.

If parents still have concerns, it’s reasonable to request a referral for a full developmental assessment. Early intervention, a federally mandated program, offers help and therapy if a child seems to be significantly delayed in any developmental domain, but does not make diagnoses.

Some developmental markers reflect a child’s early progress with speech and language, and with social interactions. The following are adapted from “Quirky Kids.

  • A baby babbles by 6 months, and the babble increases in complexity

  • By 9 months, a baby responds to his or her name

  • By 15 to 18 months, a child can say some words and follow simple directions

  • By 18 months, a child can put two words together

  • By 2 ½ to 3, a child can speak in simple sentences with some fluency and inflection — a question sounds like a question

  • By 4 months, babies make eye contact and respond with social smiles

  • By 1 year, they can point to show interest, and wave goodbye

  • From about 2, they respond to other children and can interact in games with some back-and-forth

How to Help a Teen Out of a Homework Hole

Adolescence

How to Help a Teen Out of a Homework Hole

The more students fall behind in the pandemic, the less likely they are to feel that they can catch up.

Credit…Marta Monteiro
Lisa Damour

  • Feb. 26, 2021, 2:33 p.m. ET

Pandemic school is taking its toll on students, especially teens. A recent study, conducted by NBC News and Challenge Success, a nonprofit affiliated with the Stanford Graduate School of Education, found that 50 percent more kids in high school report feeling disengaged from school this year than last. In December, Education Week reported that schools were seeing “dramatic increases in the number of failing or near-failing grades” on report cards.

A major symptom of school disengagement is not turning in homework, a problem that can easily snowball. The further students fall behind, the more overwhelmed they often become and the less likely they are to feel that they can catch up.

The good news is that finding out about missing homework is a first step to helping kids get back on track. You just need to keep a few considerations in mind.

Empathy will get you further than anger

At this point in the pandemic, finding out that your child has let schoolwork slide may trigger an angry response. Everyone is worn down by the demands of pandemic life and many parents are already operating on their last nerve. Getting mad, however, is likely to cause kids to adopt a defensive or minimizing stance. Instead, try to be compassionate. What students who have fallen behind need most are problem-solving partners who want to understand what they are going through.

If you’re having trouble summoning your empathy, bear in mind that there are many good reasons a student could fall off pace this year. For instance, Ned Johnson, a professional tutor and co-author of the book “The Self-Driven Child,” noted that most teens have very little experience managing email, which is now a main source of information for those in remote or hybrid arrangements. “We know how overwhelmed we as adults are by email. Imagine not being comfortable with it, and then suddenly getting everything — from Zoom links to assignments — that way.”

Some students learning remotely may also have unreliable broadband service; others may miss key information because their attention is split between the teacher on the screen and distractions at home.

“Many adults are having the exact same issues,” said Ellen Braaten, a psychologist and the executive director of the Learning and Emotional Assessment Program at Massachusetts General Hospital. “They are really productive when they can physically be at work, but may find themselves less attentive in the unstructured environment of working from home.”

Even teens who are attending school in person and using familiar systems for tracking assignments may be having a hard time managing their work now. The mental skills that help us stay organized — commonly called executive functioning — are being undermined by psychological stress, which is unusually high among today’s teens.

Work together to diagnose the problem

Finding out that your child is in academic trouble can tempt you to jump to solutions. It’s best, however, to properly diagnose the problem before trying to address it. Liz Katz, assistant head for school partnership at One Schoolhouse, an online supplemental school, suggested looking into the reasons students fall behind at school. Some don’t know what they’re supposed to be doing, others know and aren’t doing it, and still others “are doing their best and just can’t meet expectations.”

As you talk with a teenager about where things have gone off the rails, be kind, curious and collaborative. “This isn’t about you being in trouble or getting off the hook,” you might say. “It’s simply about figuring out what’s going wrong so we can solve the right problem.”

Students who are struggling to keep track of what’s expected of them may need to reach out to their teachers, either for clarification about specific assignments or for general guidance on where and when they should be looking for information about homework. As a parent or caregiver, you can coach them on how to approach their instructors. Start by pointing out that teachers are almost always eager to lend support to students who seek it. You can also offer to give feedback on a draft email to an instructor explaining where the student got lost and what they have already tried.

“For many students, the ability to ask for help is not fully formed,” said Ms. Katz, “or it can feel like an admission that they’ve done something wrong. Normalizing and praising self-advocacy is so important.”

For students who know what they’re supposed to do but aren’t doing it, other approaches make sense. They may be having a hard time sustaining motivation and need support on that front, or they may be swamped with commitments, such as caring for younger siblings, that make it impossible to complete their schoolwork. Here, parents and students will want to work together to make a realistic plan for addressing the biggest priorities in light of these circumstances. This might mean coming to an agreement about where the teen’s energies should be directed or exploring what additional support might be put in place.

In some cases, academic problems may be linked to issues with mental health. If there’s a question of whether a student is suffering from depression or anxiety; using drugs; or exhibiting any other significant emotional or behavioral concern, check in with the school counselor or family doctor for a proper assessment. Treatment should always take precedence over schoolwork. “If you’re depressed,” Dr. Braaten said, “no amount of executive function coaching is going to help, because that’s not the issue.”

Some students have subtle learning or attention disorders that became an issue only when school went online. Under regular conditions, said Mr. Johnson, instructors can notice when a student is tuning out and bring back his or her attention in a gentle way. Unfortunately, “Teachers really can’t do that effectively on Zoom.” If this is a concern, parents should consider checking in with teachers or their school’s learning support staff to get their read on the problem and advice for how to move forward.

Step back to see the big picture

“We all need to be easier on ourselves,” Dr. Braaten said, “and to sort through what students really need to do and what they don’t.” Well-meaning parents might hope to motivate students by emphasizing the importance of high grades, but that can make it harder for kids to recover from a substantial setback.

As students start to work their way back, give some thought to how comprehensive their turnaround needs to be. Do they really need to get equally high grades in every class? Could they instead direct their energy toward getting square with the courses they care about most? Could they work with their teachers to agree upon trimmed-down assignments for partial credit? According to Mr. Johnson, “Lowering expectations, for now, can actually help kids to get back on track.”

Dr. Braaten also noted that much of what students gain from school is not about content, but about learning how to solve problems. Engaging teens in constructive conversations to figure out how they fell behind can be an important lesson unto itself. “Having a 16-year-old who understands, ‘When I’m stressed, this is how I react,’” says Dr. Braaten, “may put us further ahead in the long run.”

In any school year, students learn a great deal beyond academic content. This year, more than most, might be one where students gain a deep understanding of how they respond when feeling overwhelmed and how to ask for help or rebound from setbacks — lessons that they will draw on long after the pandemic is gone.

Navigating My Son’s A.D.H.D. Made Me Realize I Had It, Too

Navigating My Son’s A.D.H.D. Made Me Realize I Had It, Too

Experts say some symptoms, especially in women, are mistaken for other conditions such as mood disorders or depression.

Credit…Natalia Ramos

  • Feb. 25, 2021, 2:25 p.m. ET

I heard my 7-year-old son’s cries of frustration loud and clear despite the closed door between us. Seconds earlier, I’d left him stationed at a desk in my bedroom, hoping he’d complete at least a portion of his virtual school assignments without me at his side while I left to wash the dishes.

“This is so BORING,” he groaned. Finishing each of his math problems required enduring an animated character’s long-winded ovations and cheers. The work was easy for him, but the system didn’t allow him to zip through it. Pulling up a chair, I sat with him in solidarity as he finished up.

Remote learning is daunting for most parents; it’s particularly thorny when your child has attention deficit hyperactivity disorder. As I tried to guide my son through his online lessons over the course of the pandemic, I began to see parallels between his struggles and my own. While hyperactivity was never an issue for me, we had many other traits in common: impulsivity, distractibility, lack of organization and low frustration tolerance — all key signs of A.D.H.D.

Primary school was easy for me; from third grade on, I was enrolled in gifted classes and earned straight A’s. Nonetheless, I recall many tear-laden homework sessions where exasperation over a tricky math problem threw me into emotional overload. During study sessions, I often became disinterested and zoned out, rereading sections of text until I could focus enough to absorb the information. I attributed my difficulties to character flaws: I was spacey and forgetful, a master procrastinator lacking drive and ambition.

Though I received an academic scholarship and entered college with a 4.2 grade point average and 15 credits from Advanced Placement classes, my performance at university was subpar. Lacking structure, it was tough for me to stick to any semblance of routine. In large lecture halls where I was an unknown in a sea of students, I floundered. I changed my major five times and eventually lost my scholarship. I never imagined an underlying neurological disorder was at play.

People who have A.D.H.D. but who do relatively well in school often don’t get diagnosed until later in life, said Lidia Zylowska, associate professor of psychiatry at the University of Minnesota Medical School and author of “Mindfulness for Adult A.D.H.D.” She said the expression of A.D.H.D. symptoms can change as life gets more complex, becoming more overwhelming as responsibilities increase in adulthood. For those who have advantages such as intelligence and family support, “school may be a place where you thrive. But when you don’t have that support, whether it’s in college, or you get your first job,” or if you become a parent, Dr. Zylowska said, “that’s when the impairment really starts showing up.”

No one in my family (nor my husband’s) had been given an A.D.H.D. diagnosis, yet research suggests a strong genetic component to the disorder. “We’ve known for many years that A.D.H.D. runs in families; it’s not just a childhood disorder,” said Mark Stein, director of A.D.H.D. and related disorders at Seattle Children’s Hospital. He said 20 percent to 30 percent of children with A.D.H.D. will have another family member who has it. “A big part of it is genetics, but it’s also awareness. Once you’re aware of what A.D.H.D. is, you’re more likely to recognize it in others,” he said.

Dr. Stein said it’s not unusual for parents to realize they have A.D.H.D. after their child is diagnosed, as in my case. “That’s a real common pathway,” he said. “A child has symptoms and problems and is being evaluated, and then the parent for the first time looks at their life and views it from the frame of, ‘Well, maybe I have this, and this is why I had those difficulties.’”

As a 3-year-old, my son was evaluated by a school psychologist because of hyperactive, disruptive behavior in preschool. He was formally given an A.D.H.D. diagnosis at age 5; by then I’d become his tireless advocate, collaborating with our school district to ensure he was set up for success in the classroom. In 2020, I reached out to my doctor about my concerns about my own symptoms and received a preliminary diagnosis of A.D.H.D; I’ll undergo a comprehensive neurological evaluation this spring.

When I was in elementary school in the ’80s, no one ever brought up the possibility that I had A.D.H.D. Experts say that’s not uncommon. Because men tend to exhibit more disruptive symptoms than women, they’re far more likely to be given diagnoses early on, said Russell Barkley, a psychiatry professor at Virginia Commonwealth University Medical School and author of “12 Principles for Raising a Child With A.D.H.D.

Dr. Stein noted: “For 10 or 15 years now we’ve been talking about how it’s not identified in females, and that it’s often missed, and even though we’ve improved somewhat it’s still much more likely to be missed in females, especially in moms.”

Research shows girls with A.D.H.D. tend to internalize their struggles rather than acting out. “Girls tend to be a little bit more inattentive and less hyperactive,” Dr. Barkley said. “If they’re disruptive, it’s mainly talking too much and socializing, whereas the boys, if they’re disruptive, it tends to be more reactive emotion and aggression, as well as defiance and oppositional behavior.”

Dr. Stein said the increasing stressors and external demands of motherhood can worsen A.D.H.D. symptoms. “I think of A.D.H.D. women as typically suffering in silence,” he said. They may seek care for something like being demoralized or having low self-esteem, or feeling overwhelmed, he said. “It’s often assumed this is a mood disorder or depression.” He added, “We’re treating the effects and the aftereffects” of A.D.H.D., “but not the underlying cause.”

I’ve had anxiety for most of my adult life; experts say the longer A.D.H.D. goes untreated, the more likely people are to experience comorbidities like anxiety, depression, substance abuse, and bulimia/binge eating. About 30 percent of children with A.D.H.D. have an anxiety disorder, a statistic that increases in adulthood. While many women do have depression and anxiety, Dr. Barkley said, “It’s just that it’s being picked up as the primary problem without looking behind the curtain, so to speak, to see what else might be there that could also be contributing to these difficulties.”

Dr. Zylowska said treatment tools for adult A.D.H.D. are very similar to those for children, but newly diagnosed adults often have an additional problem of struggling with feelings of self-doubt and shame. “You sort of have this long-life experience of getting in your own way, of having good intentions, but not being able to deliver, and that can be really demoralizing,” she said. Part of the treatment is to “help develop this less judgmental, less negative view of yourself, understanding A.D.H.D. as a neurobiological difference and developing self-acceptance and self-compassion, which can really be important,” Dr. Zylowska said.

Mindfulness-based therapy is a helpful self-regulation tool for working through feelings of inadequacy and shame, and developing self-compassion, she said.

Medication can play a role in managing A.D.H.D. symptoms for many people, but Dr. Stein said it’s part of an individualized treatment plan that may also include good nutrition and sleep. While A.D.H.D. can be a big problem for kids in school, adults often have more control about choosing to be in an environment that suits the way their brains work. “It’s less of a problem if you have the right fit with your occupation,” he said, because it’s easier to focus if you find a career you’re passionate about.

This diagnosis has been eye-opening for me. My treatment plan will most likely include medication, but my doctor is waiting for data from my scheduled neurological evaluation before she prescribes me anything. There are so many options when it comes to A.D.H.D. medications; testing will ensure that I receive the most effective one based on my individual needs. Experiencing the improvement medication may have on my daily functioning will allow me to make a more informed decision if and when the time comes to medicate my son. Thus far, it hasn’t been recommended for him.

Meanwhile, I’m able to more deeply empathize with my son when he is frustrated; after all, I’ve been there too.

Heidi Borst is a freelance writer and mother of one based in Wilmington, N.C.

Learning to Listen to Patients’ Stories

Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.
Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.Credit…Andy Manis for The New York Times

Learning to Listen to Patients’ Stories

Narrative medicine programs teach doctors and other caregivers “sensitive interviewing skills” and the art of “radical listening” to improve patient care.

Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.Credit…Andy Manis for The New York Times

  • Feb. 25, 2021, 5:00 a.m. ET

The pandemic has been a time of painful social isolation for many. Few places can be as isolating as hospitals, where patients are surrounded by strangers, subject to invasive tests and attached to an assortment of beeping and gurgling machines.

How can the experience of receiving medical care be made more welcoming? Some say that a sympathetic ear can go a long way in helping patients undergoing the stress of a hospital stay to heal.

“It is even more important now, when we can’t always see patients’ faces or touch them, to really hear their stories,” said Dr. Antoinette Rose, an urgent care physician in Mountain View, Calif., who is now working with many patients ill with Covid.

“This pandemic has forced many caregivers to embrace the human stories that are playing out. They have no choice. They become the ‘family’ at the bedside,” said Dr. Andre Lijoi, a medical director at York Hospital in Pennsylvania. Doctors, nurses and others assisting in the care of patients “need time to slow down, to take a breath, to listen.”

Both doctors find their inspiration in narrative medicine, a discipline that guides medical practitioners in the art of deeply listening to those who come to them for help. Narrative medicine is now taught in some form at roughly 80 percent of medical schools in the United States. Students are trained in “sensitive interviewing skills” and the art of “radical listening” as ways to enhance the interactions between doctors and their patients.

“As doctors, we need to ask those who come to us: ‘Tell me about yourself,’” explained Dr. Rita Charon, who founded Columbia University’s pioneering narrative medicine program in 2000. “We have fallen out of that habit because we think we know the questions to ask. We have a checklist of symptom questions. But there is an actual person in front of us who is not just a collection of symptoms.”

Columbia is currently offering training online for medical students like Fletcher Bell, who says the course is helping to transform the way he sees his future role as healer. As part of his narrative medicine training, Mr. Bell has kept in touch virtually with a woman who was being treated for ovarian cancer, an experience of sharing that he described as being both heartbreaking and also beautiful.

“Simply listening to people’s stories can be therapeutic,” Mr. Bell observed. “If there is fluid in the lungs, you drain it. If there is a story in the heart, it’s important to get that out too. It is also a medical intervention, just not one that can be easily quantified.”

This more personalized approach to medical care is not a new art. In the not-so-distant past, general practitioners often treated several generations of the same family, and they knew a lot about their lives. But as medicine became increasingly institutionalized, it became more rushed and impersonal, said Dr. Charon.

The typical doctor visit now lasts from 13 to 16 minutes, which is generally all that insurance companies will pay for. A 2018 study published in the Journal of General Internal Medicine found that the majority of doctors at the prestigious Mayo Clinic didn’t even ask people the purpose of their visit, and they frequently interrupted patients as they spoke about themselves.

But this fast-food approach to medicine sacrifices something essential, says Dr. Deepu Gowda, assistant dean of medical education at the Kaiser-Permanente School of Medicine in Pasadena, Calif., who was trained by Dr. Charon at Columbia.

Dr. Gowda recalls one elderly patient he saw during his residency who suffered from severe arthritis and whom he experienced as being angry and frustrated. He came to dread her office visits. Then he started asking the woman questions and listened with interest as her personal history unfolded. He became so intrigued by her life story that he asked her permission to take photographs of her outside the hospital, which she granted.

Dr. Gowda was particularly struck by one picture of his patient, cane in hand, clutching onto the banister of her walk-up apartment. “That image represented for me her daily struggles,” he said. “I gave her a copy. It was a physical representation of the fact that I cared for who she was as a person. Her pain didn’t go away, but there was a lightness and laughter in those later visits that wasn’t there before. There was a kind of healing that took place in that simple human recognition.”

While few working doctors have the leisure time to photograph their patients outside the clinic, or to probe deeply into their life history, “people pick up on it” when the doctor expresses genuine interest in them, Dr. Gowda said. They trust such a doctor more, becoming motivated to follow their instructions and to return for follow-up visits, he said.

Some hospitals have started conducting preliminary interviews with patients before the clinical work begins as a way to get to know them better.

Darrell Krenz of Madison, Wis., recounted his Army days as part of the V.A.’s “My Life, My Story” program.Credit…Andy Manis for The New York Times
Orlando Dowell, a 16-year Marine Corps veteran and “My Life, My Story” participant, at his home in Dakota, Ill.Credit…Andy Manis for The New York Times

Thor Ringler, a family therapist, started the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis., in 2013. Professional writers are hired to interview veterans — by phone and video conference since the onset of the pandemic — and to draft a short biography that is added to their medical record and read by their attending physician.

“My goal was to provide vets with a way of being heard in a large bureaucratic system where they don’t always feel listened to,” Mr. Ringler said.

The program has spread to 60 V.A. hospitals, including in Boston, where more than 800 veteran stories have been compiled over the past three years. Jay Barrett, nurse manager at the VA Boston Healthcare System, said these biographies often provide critical information that can help guide the treatment.

“Unless they have access to the patient’s story,” Ms. Barrett said, “health care providers don’t understand that this is a mother who is taking care of six children, or who doesn’t have the resources to pay for medication, or this is a veteran that has severe trauma that needs to be addressed before even talking about how to manage the pain.”

Dr. Lewis Mehl-Madrona, a family doctor who teaches at the University of New England in Biddeford, Maine, has been studying veterans who were undergoing treatment for pain. Those who were asked to tell about their lives experienced less chronic pain and rated the relationship with their physician higher than those who had not. The doctors who solicited the stories also reported more job satisfaction and were subject to less emotional burnout, which has become an especially worrisome problem during the Covid pandemic.

Demands have never been greater on health care workers’ time. But narrative medicine advocates say that it only takes a few moments to forge an authentic human connection, even when the communication takes place online, as it often does now. Dr. Mehl-Madrona argues that remote videoconferencing platforms like Zoom can actually make it even easier to keep track of vulnerable people and to solicit their stories.

Derek McCracken, a lecturer at Columbia University who helped develop training protocols for using narrative techniques in telehealth, agrees. “Telehealth technology can be a bridge,” he said, “because it’s an equalizer, forcing both parties to slow the conversation down, be vulnerable and listen attentively.”

The critical point for Dr. Mehl-Madrona is that when people are asked to talk about themselves — whether that happens in person or onscreen — they are “not just delivering themselves to the doctor to be fixed. They become actively engaged in their own healing.”

“Doctors can be replaced by computers or by nurses if they think their only role is just to prescribe drugs,” he added. “If we want to avoid the fate of the Dodo bird, then we have to engage in dynamic relationships with patients, we have to put the symptoms in the context of people’s lives.”

The Pandemic Probably Caused Your Hair Loss

Skin Deep

You’re Not Imagining It: The Pandemic Is Making Your Hair Fall Out

Many doctors report an uptick in patients suffering from stress-related hair loss. Here’s what to do about it.

Hair loss can be a side effect of Covid-19.
Hair loss can be a side effect of Covid-19.Credit…Phimchanok Srisuriyamart/EyeEm, via Getty Images

  • Feb. 18, 2021

With every month that passed in 2020, Samantha Hill’s part seemed to widen, the increasingly bald stripe of skin a representation of what she calls “a four-part terrible play” in her life. Reeling from the death of her father in January, Ms. Hill, a 29-year-old freelance photographer, had barely adjusted to her new normal when the pandemic hit and further upended her life.

After the death of a friend in June, when her hair appeared to thin even more, she created a folder on her phone titled Hairgate, featuring every selfie she’d taken in the last four years.

“I was trying to figure out where it all went wrong,” said Ms. Hill, who lives in the Williamsburg section of Brooklyn.

It’s a quandary many people, particularly women, have agonized over in recent months, as their brushes and shower drains filled with tangles of hair. Google searches for hair loss increased by 8 percent in the last 12 months, according to the data science firm Spate, with the topic being searched an average of more than 829,000 times a month in the United States.

The phenomenon is not all in our heads, according to experts, but is another frustrating byproduct of both immense stress and post-viral inflammation from Covid-19. Known as telogen effluvium in the medical world, temporary hair loss results from fever, illness and severe stress, pushing more hairs than normal into the shedding phase of the hair growth life cycle.

Although hair loss tends to be associated with men because of the prevalence of male-pattern baldness, telogen effluvium is more common among women, who often experience it after childbirth.

“Any type of severe stress can trigger it, whether it’s stress on your body from illness or emotional stress such as the death of a loved one,” said Dr. Abigail Cline, a dermatologist at New York Medical College who has conducted research on pandemic-related hair loss. “Even though not everyone has been infected with Covid-19, we’re all living with it.”

Tackling Hair Loss Holistically

For those who have had the virus, hair loss has become a common symptom of the recovery process, usually occurring three to four months after getting sick but sometimes experienced sooner. Dr. Jerry Shapiro, a dermatologist at NYU Langone Health who specializes in hair loss, said that while a healthy head of hair usually includes 90 percent anagen, or growing, hairs and 10 percent telogen, or resting, hairs, that ratio can shift up to 50-50 after experiencing a high fever or flulike illness.

For Misty Gant, a 35-year-old wellness coach living on the Lower East Side, the change happened fast. After being infected in March, Ms. Gant started losing handfuls of her long red hair in the shower and began to notice balding at her temples a few weeks after recovering.

“It was really hard because my hair is important to me — it’s part of my identity,” she said, noting that before it thinned, it was her most complimented feature.

Ms. Gant, who regularly dives into health and wellness research for clients, soon landed in forums full of people who had gone through similar post-Covid-19 hair loss. After doctors confirmed her suspicion that she was suffering from a post-viral inflammatory response, she readied an arsenal of holistic remedies to try to fix it.

Her first point of attack was an anti-inflammatory diet that cut out sugar, gluten, dairy and alcohol and incorporated colorful fruits and vegetables, oily fish and healthy fats like avocados and nuts. She kick-started a new supplement routine of Omega 3-6-9, turmeric with fenugreek, evening primrose oil and two tablespoons of aloe juice a day, a combination she believes to be anti-inflammatory and lubricating for the skin and hair.

She began giving herself daily scalp massages using Bumble and Bumble Tonic Primer, which includes rosemary oil, an ingredient that some studies have found to encourage hair growth. Two days a week she doused her hair in a mixture of coconut oil and pure rosemary oil and left it in for 24 hours. Though not a quick fix, it seemed to pay off: She now has tufts of baby hair growing in at her temples.

“I try to do everything the natural way, and as a wellness practitioner, I know that things take time,” Ms. Gant said.

A Less Intensive Approach

Although it can still take months to see a significant difference, many people have had similar results from a combination of supplements, thickening shampoos and illusion-creating haircuts.

After her husband noticed a few bald spots on the back of her head early in the pandemic, Martyna Szabadi, a 34-year-old business consultant who hasn’t had Covid-19, experimented with products said to promote hair growth, including various scalp scrubs, a hair serum from the Ordinary and a daily drink of flax seed water. Nothing helped until she began using RevitaLash Thickening Shampoo and Conditioner and taking four capsules of Nutrafol core supplement for women.

“After half a year of this combination, I finally have the hair issue under control,” Ms. Szabadi said.

Nutrafol supplements also seemed to help Ms. Hill get her hair back on track after she began taking them in July, leaving her with a slimmer part and new hair growth around the crown. It was a boom year for the company, with revenue increasing 60 percent in 2020 compared to 2019, according to Giorgos Tsetis, the chief executive and a founder of the company.

Mr. Tsetis said that 80 percent of the company’s sales increase can be attributed to its two core formulas for women: Nutrafol Women and Women’s Balance. They include ingredients like vitamin A, vitamin D, zinc and biotin, the last of which has become widely known as a hair growth supplement despite the fact that dermatologists disagree over its efficacy.

“No one’s really been able to prove it helps hair in a randomized controlled study, and they’ve had a long time to prove it,” Dr. Shapiro said.

But with wellness ruling the day, Nutrafol’s chemical-free, made-from-the-earth virtue has made it a popular option. Nutrafol bills itself as a “natural, holistic” alternative to old-school remedies like Rogaine, or minoxidil, which is a topical solution used to improve blood flow and stimulate hair growth.

Another treatment option is platelet rich plasma therapy, known as P.R.P., which involves the injection of a patient’s own blood into the scalp to stimulate hair growth. Priced between $500 and $1,800, P.R.P. doesn’t work for everyone and is best done alongside other treatments, according to Dr. Shapiro, who believes it’s a better fit for people experiencing female or male-pattern baldness, which has a genetic cause.

The Quicker Fix

If waiting three months for a shampoo or supplement to kick in doesn’t thrill you, consider a haircut that will make your hair look healthier than it is. Justine Marjan, a hairstylist whose clients include Kardashians and the model Ashley Graham, recommends a shorter, blunt cut to create an illusion of thickness.

“It’s best to avoid longer looks, as the hair can end up looking weak and frail at the ends,” Ms. Marjan said. If your hair loss is most noticeable at your hairline or part, she suggests using an eye shadow or root touch-up spray that matches your hair color to create depth and the appearance of fullness. Using headband-style extensions that you can easily pop on and off without damaging the hair is another favorite trick.

Most important, be gentle and strategic with your hair. Ms. Marjan recommends drying fragile hair with a soft microfiber towel and using a tool like the Tangle Teezer to prevent breakage. Sleeping on a silk pillowcase is also believed to minimize breakage. And, while many people resort to ponytails when their hair is limp, it’s best to avoid tight styling that could pull out more hair.

What’s definitely not great for hair growth? Constant panic.

“Stressing about it will only cause more hair loss,” Dr. Cline said, noting that a deep, six-month-long breath is a better prescription. “I reassure patients with telogen effluvium that their hair will grow back, but it’s going to take time.”

Are Some Foods Addictive

Are Addictive Foods Making Us Fat?

Food researchers debate whether highly processed foods like potato chips and ice cream are addictive, triggering our brains to overeat.

Credit…Richard A. Chance
Anahad O’Connor

  • Feb. 18, 2021, 5:00 a.m. ET

Five years ago, a group of nutrition scientists studied what Americans eat and reached a striking conclusion: More than half of all the calories that the average American consumes comes from ultra-processed foods, which they defined as “industrial formulations” that combine large amounts of sugar, salt, oils, fats and other additives.

Highly processed foods continue to dominate the American diet, despite being linked to obesity, heart disease, Type 2 diabetes and other health problems. They are cheap and convenient, and engineered to taste good. They are aggressively marketed by the food industry. But a growing number of scientists say another reason these foods are so heavily consumed is that for many people they are not just tempting but addictive, a notion that has sparked controversy among researchers.

Recently, the American Journal of Clinical Nutrition explored the science behind food addiction and whether ultra-processed foods might be contributing to overeating and obesity. It featured a debate between two of the leading experts on the subject, Ashley Gearhardt, associate professor in the psychology department at the University of Michigan, and Dr. Johannes Hebebrand, head of the department of child and adolescent psychiatry, psychosomatics and psychotherapy at the University of Duisburg-Essen in Germany.

Dr. Gearhardt, a clinical psychologist, helped develop the Yale Food Addiction Scale, a survey that is used to determine whether a person shows signs of addictive behavior toward food. In one study involving more than 500 people, she and her colleagues found that certain foods were especially likely to elicit “addictive-like” eating behaviors, such as intense cravings, a loss of control, and an inability to cut back despite experiencing harmful consequences and a strong desire to stop eating them.

At the top of the list were pizza, chocolate, potato chips, cookies, ice cream, French fries and cheeseburgers. Dr. Gearhardt has found in her research that these highly processed foods share much in common with addictive substances. Like cigarettes and cocaine, their ingredients are derived from naturally occurring plants and foods that are stripped of components that slow their absorption, such as fiber, water and protein. Then their most pleasurable ingredients are refined and processed into products that are rapidly absorbed into the bloodstream, enhancing their ability to light up regions of the brain that regulate reward, emotion and motivation.

Salt, thickeners, artificial flavors and other additives in highly processed foods strengthen their pull by enhancing properties like texture and mouth-feel, similar to the way that cigarettes contain an array of additives designed to increase their addictive potential, said Dr. Gearhardt. Menthol helps to mask the bitter flavor of nicotine, for example, while another ingredient used in some cigarettes, cocoa, dilates the airways and increases nicotine’s absorption.

A common denominator among the most irresistible ultra-processed foods is that they contain large amounts of fat and refined carbohydrates, a potent combination that is rarely seen in naturally occurring foods that humans evolved to eat, such as fruits, vegetables, meat, nuts, honey, beans and seeds, said Dr. Gearhardt. Many foods found in nature are rich in either fat or carbs, but typically they are not high in both.

“People don’t experience an addictive behavioral response to naturally occurring foods that are good for our health, like strawberries,” said Dr. Gearhardt, director of the Food and Addiction Science and Treatment lab at the University of Michigan. “It’s this subset of highly processed foods that are engineered in a way that’s so similar to how we create other addictive substances. These are the foods that can trigger a loss of control and compulsive, problematic behaviors that parallel what we see with alcohol and cigarettes.”

In one study, Dr. Gearhardt found that when people cut back on highly processed foods, they experienced symptoms that were comparable to the withdrawal seen in drug abusers, such as irritability, fatigue, feelings of sadness and cravings. Other researchers have found in brain imaging studies that people who frequently consume junk foods can develop a tolerance to them over time, leading them to require larger and larger amounts to get the same enjoyment.

In her clinical practice, Dr. Gearhardt has encountered patients — some obese and some not — who struggle in vain to control their intake of highly processed foods. Some attempt to eat them in moderation, only to find that they lose control and eat to the point of feeling ill and distraught. Many of her patients find that they cannot quit these foods despite struggling with uncontrolled diabetes, excessive weight gain and other health problems.

“The striking thing is that my clients are almost always acutely aware of the negative consequences of their highly processed food consumption, and they have typically tried dozens of strategies like crash diets and cleanses to try and get their relationship with these foods under control,” she said. “While these attempts might work for a short time, they almost always end up relapsing.”

But Dr. Hebebrand disputes the notion that any food is addictive. While potato chips and pizza can seem irresistible to some, he argues that they do not cause an altered state of mind, a hallmark of addictive substances. Smoking a cigarette, drinking a glass of wine or taking a hit of heroin, for instance, causes an immediate sensation in the brain that foods do not, he says.

“You can take any addictive drug, and it’s always the same story that almost everyone will have an altered state of mind after ingesting it,” said Dr. Hebebrand. “That indicates that the substance is having an effect on your central nervous system. But we are all ingesting highly processed foods, and none of us is experiencing this altered state of mind because there’s no direct hit of a substance in the brain.”

In substance use disorders, people become dependent on a specific chemical that acts on the brain, like the nicotine in cigarettes or the ethanol in wine and liquor. They initially seek out this chemical to get a high, and then become dependent on it to alleviate depressed and negative emotions. But in highly processed foods, there is no one compound that can be singled out as addictive, Dr. Hebebrand said. In fact, evidence suggests that obese people who overeat tend to consume a wide range of foods with different textures, flavors and compositions. Dr. Hebebrand argued that overeating is driven in part by the food industry marketing more than 20,000 new products every year, giving people access to a seemingly endless variety of foods and beverages.

“It’s the diversity of foods that is so appealing and causing the problem, not a single substance in these foods,” he added.

Those who argue against food addiction also point out that most people consume highly processed foods on a daily basis without showing any signs of addiction. But Dr. Gearhardt notes that addictive substances do not hook everyone who consumes them. According to research, about two-thirds of people who smoke cigarettes go on to become addicted, while a third do not. Only about 21 percent of people who use cocaine in their lifetimes become addicted, while just 23 percent of people who drink alcohol develop a dependence on it. Studies suggests that a wide range of factors determine whether people become addicted, including their genetics, family histories, exposure to trauma, and environmental and socioeconomic backgrounds.

“Most people try addictive substances and they don’t become addicted,” Dr. Gearhardt said. “So if these foods are addictive, we wouldn’t expect that 100 percent of society is going to be addicted to them.”

For people who struggle with limiting their intake of highly processed foods, Dr. Gearhardt recommends keeping a journal of what you eat so you can identify the foods that have the most pull — the ones that cause intense cravings and that you can’t stop eating once you start. Keep those foods out of your home, while stocking your fridge and pantry with healthier alternatives that you enjoy, she said.

Keep track of the triggers that lead to cravings and binges. They could be emotions like stress, boredom and loneliness. Or it could be the Dunkin’ Donuts that you drive by three times a week. Make a plan to manage those triggers by a taking a different route home, for example, or by using nonfood activities to alleviate stress and boredom. And avoid skipping meals, because hunger can set off cravings that lead to regrettable decisions, she said.

“Making sure you are regularly fueling your body with nutritious, minimally processed foods that you enjoy can be important for helping you navigate a very challenging food environment,” said Dr. Gearhardt.

You’re Not Imagining It: The Pandemic Is Making Your Hair Fall Out

Skin Deep

You’re Not Imagining It: The Pandemic Is Making Your Hair Fall Out

Many doctors report an uptick in patients suffering from stress-related hair loss. Here’s what to do about it.

Hair loss can be a side effect of Covid-19.
Hair loss can be a side effect of Covid-19.Credit…Phimchanok Srisuriyamart/EyeEm, via Getty Images

  • Feb. 18, 2021, 5:00 a.m. ET

With every month that passed in 2020, Samantha Hill’s part seemed to widen, the increasingly bald stripe of skin a representation of what she calls “a four-part terrible play” in her life. Reeling from the death of her father in January, Ms. Hill, a 29-year-old freelance photographer, had barely adjusted to her new normal when the pandemic hit and further upended her life.

After the death of a friend in June, when her hair appeared to thin even more, she created a folder on her phone titled Hairgate, featuring every selfie she’d taken in the last four years.

“I was trying to figure out where it all went wrong,” said Ms. Hill, who lives in the Williamsburg section of Brooklyn.

It’s a quandary many people, particularly women, have agonized over in recent months, as their brushes and shower drains filled with tangles of hair. Google searches for hair loss increased by 8 percent in the last 12 months, according to the data science firm Spate, with the topic being searched an average of more than 829,000 times a month in the United States.

The phenomenon is not all in our heads, according to experts, but is another frustrating byproduct of both immense stress and post-viral inflammation from Covid-19. Known as telogen effluvium in the medical world, temporary hair loss results from fever, illness and severe stress, pushing more hairs than normal into the shedding phase of the hair growth life cycle.

Although hair loss tends to be associated with men because of the prevalence of male-pattern baldness, telogen effluvium is more common among women, who often experience it after childbirth.

“Any type of severe stress can trigger it, whether it’s stress on your body from illness or emotional stress such as the death of a loved one,” said Dr. Abigail Cline, a dermatologist at New York Medical College who has conducted research on pandemic-related hair loss. “Even though not everyone has been infected with Covid-19, we’re all living with it.”

Tackling Hair Loss Holistically

For those who have had the virus, hair loss has become a common symptom of the recovery process, usually occurring three to four months after getting sick but sometimes experienced sooner. Dr. Jerry Shapiro, a dermatologist at NYU Langone Health who specializes in hair loss, said that while a healthy head of hair usually includes 90 percent antigen, or growing, hairs and 10 percent telogen, or resting, hairs, that ratio can shift up to 50-50 after experiencing a high fever or flulike illness.

For Misty Gant, a 35-year-old wellness coach living on the Lower East Side, the change happened fast. After being infected in March, Ms. Gant started losing handfuls of her long red hair in the shower and began to notice balding at her temples a few weeks after recovering.

“It was really hard because my hair is important to me — it’s part of my identity,” she said, noting that before it thinned, it was her most complimented feature.

Ms. Gant, who regularly dives into health and wellness research for clients, soon landed in forums full of people who had gone through similar post-Covid-19 hair loss. After doctors confirmed her suspicion that she was suffering from a post-viral inflammatory response, she readied an arsenal of holistic remedies to try to fix it.

Her first point of attack was an anti-inflammatory diet that cut out sugar, gluten, dairy and alcohol and incorporated colorful fruits and vegetables, oily fish and healthy fats like avocados and nuts. She kick-started a new supplement routine of Omega 3-6-9, turmeric with fenugreek, evening primrose oil and two tablespoons of aloe juice a day, a combination she believes to be anti-inflammatory and lubricating for the skin and hair.

She began giving herself daily scalp massages using Bumble and Bumble Tonic Primer, which includes rosemary oil, an ingredient that some studies have found to encourage hair growth. Two days a week she doused her hair in a mixture of coconut oil and pure rosemary oil and left it in for 24 hours. Though not a quick fix, it seemed to pay off: She now has tufts of baby hair growing in at her temples.

“I try to do everything the natural way, and as a wellness practitioner, I know that things take time,” Ms. Gant said.

A Less Intensive Approach

Although it can still take months to see a significant difference, many people have had similar results from a combination of supplements, thickening shampoos and illusion-creating haircuts.

After her husband noticed a few bald spots on the back of her head early in the pandemic, Martyna Szabadi, a 34-year-old business consultant who hasn’t had Covid-19, experimented with products said to promote hair growth, including various scalp scrubs, a hair serum from the Ordinary and a daily drink of flax seed water. Nothing helped until she began using RevitaLash Thickening Shampoo and Conditioner and taking four capsules of Nutrafol core supplement for women.

“After half a year of this combination, I finally have the hair issue under control,” Ms. Szabadi said.

Nutrafol supplements also seemed to help Ms. Hill get her hair back on track after she began taking them in July, leaving her with a slimmer part and new hair growth around the crown. It was a boom year for the company, with revenue increasing 60 percent in 2020 compared to 2019, according to Giorgos Tsetis, the chief executive and a founder of the company.

Mr. Tsetis said that 80 percent of the company’s sales increase can be attributed to its two core formulas for women: Nutrafol Women and Women’s Balance. They include ingredients like vitamin A, vitamin D, zinc and biotin, the last of which has become widely known as a hair growth supplement despite the fact that dermatologists disagree over its efficacy.

“No one’s really been able to prove it helps hair in a randomized controlled study, and they’ve had a long time to prove it,” Dr. Shapiro said.

But with wellness ruling the day, Nutrafol’s chemical-free, made-from-the-earth virtue has made it a popular option. Nutrafol bills itself as a “natural, holistic” alternative to old-school remedies like Rogaine, or minoxidil, which is a topical solution used to improve blood flow and stimulate hair growth.

Another treatment option is platelet rich plasma therapy, known as P.R.P., which involves the injection of a patient’s own blood into the scalp to stimulate hair growth. Priced between $500 and $1,800, P.R.P. doesn’t work for everyone and is best done alongside other treatments, according to Dr. Shapiro, who believes it’s a better fit for people experiencing female or male-pattern baldness, which has a genetic cause.

The Quicker Fix

If waiting three months for a shampoo or supplement to kick in doesn’t thrill you, consider a haircut that will make your hair look healthier than it is. Justine Marjan, a hairstylist whose clients include Kardashians and the model Ashley Graham, recommends a shorter, blunt cut to create an illusion of thickness.

“It’s best to avoid longer looks, as the hair can end up looking weak and frail at the ends,” Ms. Marjan said. If your hair loss is most noticeable at your hairline or part, she suggests using an eye shadow or root touch-up spray that matches your hair color to create depth and the appearance of fullness. Using headband-style extensions that you can easily pop on and off without damaging the hair is another favorite trick.

Most important, be gentle and strategic with your hair. Ms. Marjan recommends drying fragile hair with a soft microfiber towel and using a tool like the Tangle Teezer to prevent breakage. Sleeping on a silk pillowcase is also believed to minimize breakage. And, while many people resort to ponytails when their hair is limp, it’s best to avoid tight styling that could pull out more hair.

What’s definitely not great for hair growth? Constant panic.

“Stressing about it will only cause more hair loss,” Dr. Cline said, noting that a deep, six-month-long breath is a better prescription. “I reassure patients with telogen effluvium that their hair will grow back, but it’s going to take time.”

Mental Health Providers Struggle to Meet Pandemic Demand

‘Nobody Has Openings’: Mental Health Providers Struggle to Meet Demand

With anxiety and depression on the rise during the pandemic, it has been challenging for people to get the help they need.

Credit…Jo Zixuan Zhou
Christina Caron

  • Feb. 17, 2021, 5:26 p.m. ET

After Jessica W. was laid off from her job as an executive assistant in November, she began backsliding into the eating disorder that she thought she had overcome.

“I started to not want to eat again,” Jessica, 33, said. “Those thoughts and behaviors — they’re just debilitating and they drain you. It becomes a constant battle with yourself.”

Jessica, whose last name has been withheld to protect her privacy as she searches for a new job, was also struggling with anxiety and depression. So she went online and started searching for mental health providers in Connecticut, where she lives. One of the therapists she called wasn’t accepting new patients. Two of them told Jessica that they didn’t have the right skill sets to help her. Others simply didn’t respond.

“It’s emotionally draining to tell your story,” she said. “You have to be resilient.”

Since the first coronavirus case was confirmed in the United States more than a year ago, the number of people in need of mental health services has surged. But many say that they are languishing on waiting lists, making call after call only to be turned away, with affordable options tough to find. Providers, who have long been in short supply, are stretched thin.

“Never at any time in my practice have I had a five-person waiting list,” said Brooke Huminski, a psychotherapist and licensed independent clinical social worker in Providence, R.I., who specializes in treating people with eating disorders.

Dr. Gregory Scott Brown, the director of an outpatient psychiatry clinic in Austin, Texas, said he recently had to hire an additional nurse practitioner to help care for more patients. “I’m busier than ever and just don’t have room,” he said. “I’m full.”

A rise in demand

According to an American Psychological Association poll of nearly 1,800 psychologists published in November, 74 percent said they were seeing more patients with anxiety disorders compared with before the pandemic, and 60 percent said they were seeing more patients with depressive disorders. Nearly 30 percent said they were seeing more patients overall.

But according to Vaile Wright, the senior director of health care innovation at the A.P.A., this might not capture the full extent of the demand for mental health practitioners because the survey did not ask the therapists whether they had to turn away clients because they were already booked.

“There’s always been more demand for services than there are mental health providers to provide them,” Dr. Wright said. “I think what the pandemic has done is really laid bare that discrepancy.”

Online therapy platforms have seen a rise in demand during the pandemic as well. Mindy Heintskill, the chief growth officer of MDLive, a telehealth provider with more than 62 million members in the United States, said their online therapy and psychiatric care services increased fivefold in 2020 compared with 2019. Nearly half of these patients cited stress and anxiety as the main reasons for scheduling their visits, Ms. Heintskill added.

In August, the Centers for Disease Control and Prevention published a report which concluded that in late June, 40 percent of adults in the United States had been struggling with mental health or substance abuse issues, and rates of depression and anxiety had risen since 2019. In addition, a study of almost 190 million emergency department visits found that visit rates for mental health conditions, suicide attempts, drug overdoses and child abuse and neglect were higher in mid-March through October 2020, than the same period in 2019.

While companies that provide online counseling or psychiatric services like MDLive, Talkspace and BetterHelp have helped to improve access for some, mental health experts have said that these outlets cannot alone address the chronic inequities and provider shortages that were already plaguing the country.

A 2018 study published in the American Journal of Preventive Medicine found that there was an unequal distribution of psychiatrists, psychologists and psychiatric nurse practitioners across the United States, with more pronounced deficiencies in non-metropolitian counties.

‘Every single person I see needs therapy right now’

Ms. Huminski, the psychotherapist in Rhode Island, has tried to accommodate more patients by scheduling people at odd times, but that hasn’t been enough, she said. She can no longer take new clients, in part because her current ones are seeking more sessions than they have in the past. She would offer to make referrals, she added, but “nobody has openings right now.”

Even Ms. Huminski’s local hospital, which has an intensive therapy day program where she sometimes refers patients, is fuller than usual. In the past, she said, it would usually take up to four weeks to get in. Now, she added, it’s around four months.

Jennifer Kittler, a clinical psychologist who is also based in Providence, said that she, too, has had almost no availability for new clients over the past 10 months. As her case loads have increased, she’s taking steps to prevent burnout.

“In my case, it has led to my being less willing to extend my hours or schedule — in an effort to prioritize family time and self-care,” said Dr. Kittler, who is working from home while her 12-year-old learns remotely for at least half of the week.

Finding the right team can be even more difficult for patients who require both a psychiatrist and a therapist.

“Every single person I see needs therapy right now,” said Dr. Jessi Gold, a psychiatrist based in St. Louis, Mo., who mostly sees college students and health care workers. “They come back and say, ‘I’ve called 20 people and I don’t know what to do.’”

Bailey, 27, a medical student in New York who did not want to use her last name for privacy reasons, said that last fall she started searching for both a therapist and a psychiatrist who took Medicaid and was “striking out all over the place.”

In November, she spoke to therapists from the Telemedicine platforms BetterHelp and Happier Living, but the cost per session was too much for Bailey to afford long-term. Earlier, she had tried speaking with the therapist at her medical school, but “our personalities just didn’t click,” Bailey said.

She’s currently on several wait lists and is receiving psychiatric prescriptions from her primary care provider.

As for Jessica, who had been searching for a therapist and a psychiatrist in Connecticut, after two weeks of intensive research she finally located an in-network therapist, and recently started seeing an out-of-network psychiatrist.

In many ways, Jessica was more fortunate than most. She still had insurance through her husband’s employer. And she was already well versed in the process of finding mental health providers.

“I have my insurance card ID memorized,” she said. “Like, that’s not normal.”

How to find help if you’re struggling

If you need to see a mental health provider but can’t find one that is taking new patients, don’t just say ‘OK’ and hang up after calling them, Dr. Brown said.

“Ask if they happen to know someone who may be accepting new patients,” he said. “Usually, if I’m not able to help, I can surely point a potential patient in the right direction to a colleague who can.”

If that leads to a dead end, you might try asking a primary care provider for referrals or treatment.

“Some of them do have enough basic training in mental health to be able to help a little bit,” said Dr. Amy Alexander, a psychiatrist who sees students at Stanford University. “Some are even comfortable starting medications for mild to moderate mental health problems.”

If you still can’t find help, try calling local colleges or universities and ask to see a clinician in training. Large academic institutions with outpatient psychiatry departments might also have appointments or provide referrals. Consider also expanding your search to other types of experts. If you were hoping to see a psychologist, a licensed clinical social worker might be a comparable option. Or if you were planning to see an individual provider, think about group therapy options.

Psychology Today maintains a large list of providers that you can filter by location, type of insurance covered, specialty or other criteria. The federal government also has a website where you can search for facilities that treat substance use disorders, addiction and mental illness.

If you’re looking for support groups, check out the resources at the National Alliance on Mental Illness, the National Eating Disorders Association, Alcoholics Anonymous or the Depression and Bipolar Support Alliance.

For those with insurance, an in-network provider will typically be the most affordable option. But if you can’t find someone, check if your plan has out-of-network benefits to help broaden your choice. Online therapy services may also be worth exploring since they can help you speak with someone quickly and in some cases, may reduce out-of-pocket costs.

If you are uninsured, search for providers who offer low- or no-cost options. You may find some who charge fees based on a sliding scale, or interns or postdoctoral fellows at private group practices who may see clients at lower fees, Dr. Kittler said. And government-funded community-based health care centers provide care to patients regardless of ability to pay.

If you have a job, check whether your employer offers certain benefits, like a flexible spending or a health savings account, which allow you to use pretax money for certain medical expenses.

Finally, if you are having serious symptoms that need to be addressed quickly, go to your local emergency room. The doctors there are trained to address mental health crises, Dr. Alexander said.

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).

How Many Are Struggling to Book Appointments With Mental Health Providers Through Pandemic

‘Nobody Has Openings’: Mental Health Providers Struggle to Meet Demand

With anxiety and depression on the rise during the pandemic, it has been challenging for people to get the help they need.

Credit…Jo Zixuan Zhou
Christina Caron

  • Feb. 17, 2021, 5:26 p.m. ET

After Jessica W. was laid off from her job as an executive assistant in November, she began backsliding into the eating disorder that she thought she had overcome.

“I started to not want to eat again,” Jessica, 33, said. “Those thoughts and behaviors — they’re just debilitating and they drain you. It becomes a constant battle with yourself.”

Jessica, whose last name has been withheld to protect her privacy as she searches for a new job, was also struggling with anxiety and depression. So she went online and started searching for mental health providers in Connecticut, where she lives. One of the therapists she called wasn’t accepting new patients. Two of them told Jessica that they didn’t have the right skill sets to help her. Others simply didn’t respond.

“It’s emotionally draining to tell your story,” she said. “You have to be resilient.”

Since the first coronavirus case was confirmed in the United States more than a year ago, the number of people in need of mental health services has surged. But many say that they are languishing on waiting lists, making call after call only to be turned away, with affordable options tough to find. Providers, who have long been in short supply, are stretched thin.

“Never at any time in my practice have I had a five-person waiting list,” said Brooke Huminski, a psychotherapist and licensed independent clinical social worker in Providence, R.I., who specializes in treating people with eating disorders.

Dr. Gregory Scott Brown, the director of an outpatient psychiatry clinic in Austin, Texas, said he recently had to hire an additional nurse practitioner to help care for more patients. “I’m busier than ever and just don’t have room,” he said. “I’m full.”

A rise in demand

According to an American Psychological Association poll of nearly 1,800 psychologists published in November, 74 percent said they were seeing more patients with anxiety disorders compared with before the pandemic, and 60 percent said they were seeing more patients with depressive disorders. Nearly 30 percent said they were seeing more patients overall.

But according to Vaile Wright, the senior director of health care innovation at the A.P.A., this might not capture the full extent of the demand for mental health practitioners because the survey did not ask the therapists whether they had to turn away clients because they were already booked.

“There’s always been more demand for services than there are mental health providers to provide them,” Dr. Wright said. “I think what the pandemic has done is really laid bare that discrepancy.”

Online therapy platforms have seen a rise in demand during the pandemic as well. Mindy Heintskill, the chief growth officer of MDLive, a telehealth provider with more than 62 million members in the United States, said their online therapy and psychiatric care services increased fivefold in 2020 compared with 2019. Nearly half of these patients cited stress and anxiety as the main reasons for scheduling their visits, Ms. Heintskill added.

In August, the Centers for Disease Control and Prevention published a report which concluded that in late June, 40 percent of adults in the United States had been struggling with mental health or substance abuse issues, and rates of depression and anxiety had risen since 2019. In addition, a study of almost 190 million emergency department visits found that visit rates for mental health conditions, suicide attempts, drug overdoses and child abuse and neglect were higher in mid-March through October 2020, than the same period in 2019.

While companies that provide online counseling or psychiatric services like MDLive, Talkspace and BetterHelp have helped to improve access for some, mental health experts have said that these outlets cannot alone address the chronic inequities and provider shortages that were already plaguing the country.

A 2018 study published in the American Journal of Preventive Medicine found that there was an unequal distribution of psychiatrists, psychologists and psychiatric nurse practitioners across the United States, with more pronounced deficiencies in non-metropolitian counties.

‘Every single person I see needs therapy right now’

Ms. Huminski, the psychotherapist in Rhode Island, has tried to accommodate more patients by scheduling people at odd times, but that hasn’t been enough, she said. She can no longer take new clients, in part because her current ones are seeking more sessions than they have in the past. She would offer to make referrals, she added, but “nobody has openings right now.”

Even Ms. Huminski’s local hospital, which has an intensive therapy day program where she sometimes refers patients, is fuller than usual. In the past, she said, it would usually take up to four weeks to get in. Now, she added, it’s around four months.

Jennifer Kittler, a clinical psychologist who is also based in Providence, said that she, too, has had almost no availability for new clients over the past 10 months. As her case loads have increased, she’s taking steps to prevent burnout.

“In my case, it has led to my being less willing to extend my hours or schedule — in an effort to prioritize family time and self-care,” said Dr. Kittler, who is working from home while her 12-year-old learns remotely for at least half of the week.

Finding the right team can be even more difficult for patients who require both a psychiatrist and a therapist.

“Every single person I see needs therapy right now,” said Dr. Jessi Gold, a psychiatrist based in St. Louis, Mo., who mostly sees college students and health care workers. “They come back and say, ‘I’ve called 20 people and I don’t know what to do.’”

Bailey, 27, a medical student in New York who did not want to use her last name for privacy reasons, said that last fall she started searching for both a therapist and a psychiatrist who took Medicaid and was “striking out all over the place.”

In November, she spoke to therapists from the Telemedicine platforms BetterHelp and Happier Living, but the cost per session was too much for Bailey to afford long-term. Earlier, she had tried speaking with the therapist at her medical school, but “our personalities just didn’t click,” Bailey said.

She’s currently on several wait lists and is receiving psychiatric prescriptions from her primary care provider.

As for Jessica, who had been searching for a therapist and a psychiatrist in Connecticut, after two weeks of intensive research she finally located an in-network therapist, and recently started seeing an out-of-network psychiatrist.

In many ways, Jessica was more fortunate than most. She still had insurance through her husband’s employer. And she was already well versed in the process of finding mental health providers.

“I have my insurance card ID memorized,” she said. “Like, that’s not normal.”

How to find help if you’re struggling

If you need to see a mental health provider but can’t find one that is taking new patients, don’t just say ‘OK’ and hang up after calling them, Dr. Brown said.

“Ask if they happen to know someone who may be accepting new patients,” he said. “Usually, if I’m not able to help, I can surely point a potential patient in the right direction to a colleague who can.”

If that leads to a dead end, you might try asking a primary care provider for referrals or treatment.

“Some of them do have enough basic training in mental health to be able to help a little bit,” said Dr. Amy Alexander, a psychiatrist who sees students at Stanford University. “Some are even comfortable starting medications for mild to moderate mental health problems.”

If you still can’t find help, try calling local colleges or universities and ask to see a clinician in training. Large academic institutions with outpatient psychiatry departments might also have appointments or provide referrals. Consider also expanding your search to other types of experts. If you were hoping to see a psychologist, a licensed clinical social worker might be a comparable option. Or if you were planning to see an individual provider, think about group therapy options.

Psychology Today maintains a large list of providers that you can filter by location, type of insurance covered, specialty or other criteria. The federal government also has a website where you can search for facilities that treat substance use disorders, addiction and mental illness.

If you’re looking for support groups, check out the resources at the National Alliance on Mental Illness, the National Eating Disorders Association, Alcoholics Anonymous or the Depression and Bipolar Support Alliance.

For those with insurance, an in-network provider will typically be the most affordable option. But if you can’t find someone, check if your plan has out-of-network benefits to help broaden your choice. Online therapy services may also be worth exploring since they can help you speak with someone quickly and in some cases, may reduce out-of-pocket costs.

If you are uninsured, search for providers who offer low- or no-cost options. You may find some who charge fees based on a sliding scale, or interns or postdoctoral fellows at private group practices who may see clients at lower fees, Dr. Kittler said. And government-funded community-based health care centers provide care to patients regardless of ability to pay.

If you have a job, check whether your employer offers certain benefits, like a flexible spending or a health savings account, which allow you to use pretax money for certain medical expenses.

Finally, if you are having serious symptoms that need to be addressed quickly, go to your local emergency room. The doctors there are trained to address mental health crises, Dr. Alexander said.

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).

Grind Your Teeth? Your Night Guard May Not Be the Right Fix

Grind Your Teeth? Your Night Guard May Not Be the Right Fix

Some experts say tooth-grinding is a behavior rather than a disorder, and the dentist’s chair isn’t the best place to address it.

Credit…Jon Han

  • Feb. 16, 2021, 5:00 a.m. ET

Everyday stressors like a report due at work, the refrigerator breaking and the dog throwing up can sometimes make you want to grit your teeth. But layer on top of that a pandemic, economic uncertainty and political upheaval, and you might start to give your jaw a serious workout — gritting and grinding with as much as 250 pounds of force.

Dentists have reported an increase in patients with tooth fractures since the start of the pandemic, which they attribute to bruxism, the technical term for gritting, grinding or clenching your teeth. Thought to be precipitated or exacerbated by stress and anxiety, bruxism is largely subconscious and often occurs during sleep. Most people don’t know they grind their teeth unless a dentist tells them so, based on tooth wear. Less obvious indicators include itchy or plugged ears, neck pain and even premature aging of the face.

Expensive acrylic or rubber mouth or bite guards — often called night guards — are typically prescribed as a prophylactic.

While night guards may help to prevent some dental wear and tear, some studies suggest they can be ineffective or even make the problem worse. This has led some experts in the fields of dentistry, neuroscience, psychology and orthopedics to say there needs to be a paradigm shift in our understanding of the causes and treatment of bruxism. They say it is a behavior, like yawning, belching or sneezing, rather than a disorder.

“It’s not abnormal to brux,” said Frank Lobbezoo, a bruxism researcher and professor and chair of the Academic Center for Dentistry Amsterdam in the Netherlands. “In fact, it can be good for you.”

Sleep studies indicate that the majority of people have three or more bursts of activity in the jaw’s masseter muscle (your major chewing muscle) during the night. It also happens during non-REM sleep. So, contrary to popular belief, you’re not doing it while you are dreaming.

Moreover, the evidence suggests that this muscular activity can have the salubrious effect of opening up your airway to allow in more oxygen. Clenching and grinding also stimulates salivary glands to lubricate a dry mouth and neutralize gastric acid. As a result, experts say it can be dangerous to wear a night guard or splint if you have sleep apnea or severe gastrointestinal reflux disorder, or GERD.

“There’s tremendous overtreatment for a non-problem,” said Karen Raphael, psychologist and professor at New York University College of Dentistry, referring to the widespread use of bite guards, tranquilizers and even Botox injections to prevent bruxism. “There is no evidence that tooth wear patterns reflect current grinding.” Indeed, she said, tooth wear is more often associated with an acidic diet, which both erodes enamel and triggers bruxism to increase the pH in the mouth. Treating bruxism in this instance would be treating the effect rather than the cause.

Of course, an overproduction of stomach acid and reflux often occur during times of stress, which might in part explain why dentists and patients are reporting more cracked teeth and jaw pain since the start of the pandemic. Also, people tend to drink more alcohol when they are anxious. Even mild intoxication leads to more flaccid neck muscles, which can cause an increase in both the duration and force of bruxism to restore airflow.

Other factors that may increase bruxism are poor sleep hygiene and bad posture. If you are a light or poor sleeper, you spend more time in non-REM sleep, which is when people naturally brux. This might be caused by stress, but also consuming caffeine or sleeping with your phone.

And we tend to take our postural habits to bed with us. If you’re tight and clenched when you are awake, you’re likely also tight and clenched when you are asleep, or at least it takes you longer to unwind. This is especially true now as people spend so much time hunched over their devices with head, neck and back forming a taut and orthopedically ill-advised “C.”

So the question is not so much whether you brux, but why you might be bruxing more than is normal and possibly causing jaw or dental problems. “Bruxism is not a disease,” said Giles Lavigne, a neuroscientist, dentist and professor at the University of Montreal. “It’s just a behavior, and like any behavior, when it reaches a level that it’s bothersome you may need to consult someone.”

Perhaps a physical therapist who can teach you how to relax your jaw and do abdominal breathing. And maybe a psychologist can help you modify behaviors that lead to an increase in bruxism, like eating too much before bed and drinking more than your share of wine and whiskey.

But simple awareness of the position of your mouth, tongue and teeth throughout the day may go a long way toward preventing tooth-grinding. “Nobody knows where their tongue is when they are at rest,” said Cheryl Cocca, a physical therapist at Good Shepherd Penn Partners in Lansdale, Pa., who treats patients with bruxism. She recommends continually checking to make sure you are breathing through your nose with your mouth closed, your tongue resting on the roof of your mouth, and your teeth apart. Set a timer if you need to remind yourself or do it every time you stop at a red light or get a text alert.

Part of the problem could be our modern diet. A growing body of evidence supports the once-fringe notion that, following the agricultural and industrial revolutions, as humans began eating foods that are more processed and easier to chew, we came to have smaller jaws than our ancestors and underdeveloped orofacial muscles. A result, researchers say, is that we tend to breathe through our mouths, with our tongues resting on the bottom of our mouths.

“Watch people on subway, watch people on the bus, they’re all on their phones, their mouths are slightly open breathing in and out. Particularly kids, they all are,” said Dr. Tammy Chen, a prosthodontist in New York City who has written about the increase in tooth fractures. “As soon as the mouth is open, the tongue is down. The tongue should always be on top of the mouth pushing up and out,” which strengthens face and neck muscles, widens the jaw and opens the airway.

At night, our modern penchant for soft pillows and mattresses, rather than lying on the ground as our ancestors did, makes our mouths more likely to fall open and for us to drool, leading to a drier, more acidic mouth microbiome, not to mention sagging neck muscles, which further obstruct the airway.

A firm pillow, or a folded blanket under the head, can help, as can committing to an orofacial, neck and airway stretching and strengthening routine. Ms. Cocca recommends daily repetitions of pulling your head back into your neck as if you were trying to retreat from someone leaning in for a kiss and also nodding your head down until your chin touches the base of your throat.

Other good exercises are squeezing your shoulder blades together and holding, as well as putting your arms up like a goal post and leaning into a doorway to stretch out your chest.

Research also indicates diaphragmatic breathing and singing can strengthen and expand your airway muscles to reduce both snoring and bruxism.

While bite guards worn during the day or night won’t stop you from grinding, Dr. Chen said, they can act as a bumper to protect teeth. But only if they are carefully designed according to the size and shape of your mouth, and of materials specific to whether you are a grinder, clencher or chomper. Hard acrylic guards are thought to be better for grinders and chompers while softer rubber guards are better for clenchers. However, experts caution guards can sometimes make the problem worse, particularly if they are poorly made.

“Bruxism often comes down to a breathing or airway issue,” Dr. Chen said. “Night guards are a band aid, but if you want to stop grinding, you have to get to the root cause of the issue.”


Emptying the Dishwasher Can Enrich Kids’ Mental Health

Emptying the Dishwasher Can Enrich Kids’ Mental Health

Guiding children toward mastery of new skills can help them thrive — and get some household chores done at the same time.

Credit…Jack Taylor

  • Feb. 11, 2021, 5:00 a.m. ET

I begged my 12-year-old to help me with the pandemic task of learning to dye my hair at home. I could have done it myself, but I’ve learned that small opportunities to feel useful and successful are good for kids’ mental health, which I’m especially attuned to in our current circumstances.

Among the other ideas I’ve tried during these long months: Letting my kids practice phone skills by having them call to order takeout and asking them for help with setting up the Wi-Fi booster. In some cases, it would be faster to just do these things without their “help,” but I’m doing it deliberately, to benefit my kids.

It might seem like a strange time to ask parents to take a new approach — don’t we have enough to juggle? But focusing on helping our kids develop what psychologists call “self-efficacy,” or a person’s belief that they are capable of successfully meeting the tasks or challenges that face them, can yield immediate benefits.

But can such small tasks really instill a sense of control right now, in a pandemic? It’s possible, experts say, and allowing kids to try to meet real-life challenges is the best way for them to build that healthy self-efficacy. Albert Bandura, the Stanford University psychologist who first developed the concept of self-efficacy in the 1970s, called these important first-person accomplishments “mastery experiences.”

Lea Waters, professor of positive psychology at the University of Melbourne, Australia, said self-efficacy “is a primal part of the formula of good mental health, because without that sense of efficacy, without that belief that I can get things done, you can really easily see how a young person or even an adult would not only lose their confidence, but lose their motivation to move forward.” Humans thrive on a sense of control and capability; low self-efficacy, or learned helplessness, is associated with anxiety, depression, lack of hope and lack of motivation, she said, while higher self-efficacy is associated with life satisfaction, self-confidence, social connection and growth mind-set.

Mastery experiences don’t have to be grand accomplishments. Dr. Waters pointed to things as small as kids completing “a Lego build that was a little bit hard,” packing their own backpacks or walking the dog by themselves.

She suggests that parents become detectives who notice a child’s successes and narrate them. This purposeful shift toward noticing and acknowledging small wins helps parents take a positive approach while it also helps kids internalize a sense of their growing abilities.

“We can spot those things and acknowledge, ‘You did that really well; you did that all by yourself,’ or ‘You didn’t need as much help from me this time around,’” she said. These successes build up what she called a “bank account” of feelings of efficacy for children that they can draw on the next time they face a challenge, when parents can remind the child, “You know, last time you felt that way, and then you ended up being able to do it all by yourself.”

Of course, you don’t want to pile on more responsibilities than a child can handle. Parents should always be attentive to children’s health, ensuring that they don’t see signs of mental health issues that warrant professional support, said the child and adolescent psychotherapist Katie Hurley, author of “The Happy Kid Handbook.

“Every kid is different,” said Ms. Hurley. “Take a deep breath and say, ‘What is my kid like without a pandemic?’” Watch for concerning changes in sleep; eating significantly less or more; new anxious behaviors such constant reassurance-seeking or clinginess; a significant loss of focus; and less interest in connecting with friends, even in favorite ways like social media or video games, she said. “Trust that when you feel that in your gut that something isn’t right, then it’s probably a good idea to get help.”

Apart from monitoring health concerns, the impulse to “help” our kids by doing more for them is sometimes more about us than it is about our kids, said Ned Johnson, co-author of “The Self-Driven Child: The Science and Sense of Giving Your Kids More Control Over Their Lives.”

Research has shown that when parents jump in to help kids with a frustrating problem, that intervention can lower parent anxiety while leaving the child’s anxiety elevated, Mr. Johnson said. That’s because the anxious parent gains a sense of control from taking action rather than remaining helpless on the sidelines, but the child is still left feeling ineffectual and stressed.

It can be hard for parents to let children do more, and perhaps mess up, when a parent could do a task more quickly and effectively. But the pandemic has lowered the stakes in some common family situations. For example, when kids are doing remote learning and don’t have to catch the bus, they can take on responsibility for waking themselves up. If the child oversleeps, the parents aren’t stuck playing chauffeur; only the child will experience the natural consequences of lateness, Mr. Johnson said, making it easier for parents to let go of some control.

With everyone spending more time at home, families can share tasks more readily, too, even if they’re not done perfectly. A preschooler with a broom may not necessarily be cleaning the floor well, but the child feels that efficacy-building sense of accomplishment and helpfulness when they are encouraged to try it for themselves, Mr. Johnson said, and “the experience of coping increases.”

If this all sounds like too much work in a pandemic, remember that parents who encourage their children’s strengths and self-efficacy not only help their kids, but also themselves. “Parents are really depleted,” Dr. Waters acknowledged, but a positive, proactive approach is “kind of a win-win. It’s good for your kids,” and seeing children thrive is “good for us as parents as well,” she said. And her research has found that using a strengths-building approach — finding areas where your kids can take on more responsibility — is also correlated with an increase in parental self-efficacy, a sense that “you are doing the right thing as a parent.”

Courtney E. Ackerman, author of several positive psychology books, also counsels parents not to wait until the present crisis is over to instill more self-efficacy in children. Yes, working on developing resilience in these unpredictable times may feel like shoveling while the snow is still falling, she said, but that’s OK. “I think it’s always snowing,” she said. “It’s a specifically difficult time now with the pandemic, but life is full of ups and downs.”

Now is an excellent time, perhaps better than any other, she said, to work on building a sense of self-efficacy in kids. And if that means parents aren’t the only ones endlessly loading and unloading the dishwasher, so much the better.

Sharon Holbrook, the managing editor of Your Teen magazine, is writing a book about how to raise capable kids.

The Pandemic Brought Depression and Anxiety. Reaching Out Helped.

Voices

The Pandemic Brought Depression and Anxiety. Reaching Out Helped.

Connecting with others on social media has helped ease the fear and loneliness of pandemic living.

Credit…Evan Cohen

  • Feb. 9, 2021, 5:00 a.m. ET

Depression crept up on me over the summer and into the fall, so slowly that I wasn’t aware of the change in my well-being — until suddenly I was.

For most of that time I chose to tough it out, largely keeping quiet about my downward trajectory. I knew I wasn’t alone. A few months into the pandemic, the Centers for Disease and Control and Prevention warned that mental health diagnoses — anxiety, depression, thoughts of suicide — were on the rise. By year’s end, a government survey found that the nation’s mood had continued to darken.

Still, many people I know continue to say they are “fine” — or defiantly “fine, fine, fine,” as one friend answered when I checked in with him.

To be honest, “fine” had been my go-to response when someone asked how I was doing, even as depression and what I often call its first cousin, anxiety, set in. Years ago, a psychotherapist helped wean me off “fine” as an answer to the question, “How are you?” He explained, “Fine is neither an emotion or a feeling,” urging me toward greater self-awareness and a more honest response like “happy” or “content,” or “angry” or “sad.” Apparently, I had forgotten that lesson.

In the run-up to Election Day my outlook had dimmed sufficiently that I could see the depth of this darkness. For instance, every time my friend Amy phoned I realized I was taking a nap, preparing to take one, or just finishing one. That’s long been one of my telltale signs that all’s not well. “Maybe I can sleep through the rest of the pandemic,” I said to her one day, joking but not joking.

About that time, a fellow writer asked on Facebook how people were faring, after admitting she found herself struggling. A deluge of posts expressing worry and sadness and loneliness resulted. That outpouring of emotion told me many of us had been hiding our true feelings; it also indicated the importance of someone going first, as if to break the ice by admitting, “I’m not OK.”

Soon after, I raised my hand by posting on my Facebook feed, “Yes, this is a hard time for me.” I provided some additional detail, like the fact that a topsy-turvy stomach had whipped me into such an anxious state I’d become convinced I had pancreatic cancer instead of a simple bellyache. What turned out to be merely a pulled calf muscle started off — in my mind — as a Covid-induced blood clot about to break free.

Fear had become my constant companion.

Even though I’d gone public about my struggles with depression before, I still worried about talking openly about my state of mind, largely because of the stigma surrounding mental health issues. I reached out to David Cates, a clinical psychologist and behavioral health consultant to the University of Nebraska Medical Center’s Biocontainment Unit and National Quarantine Center. He explained what I already knew but had sidestepped. “Acknowledging that something is wrong is the first step to addressing a problem,” he said. “It allows us to begin problem-solving. When someone else acknowledges their difficulties, whether one-on-one or in a public forum, it can make it easier for us to acknowledge our own.”

That Facebook post of mine — the one where I raised my hand — helped me tremendously. And apparently many others. More than 200 friends responded with their own painful confessions. “Anxiety, depression and loneliness x 100,” wrote one, who added, “body aches which at 3 a.m., betwixt and between anxiety nightmares — become sure signs of debilitating disease eating away my insides.” Another posted, “In my mind I’ve had five major diseases yet all my labs are fine.”

Friends posted about insomnia, nausea, lack of focus, eye tics, agita, anxiety, relationship issues and being “angry, cranky and crazy.” Almost as quickly as one friend would acknowledge a condition, someone else would volunteer: “me too.”

My admission had the intended consequence: It created an opening for others. “You’ve put words to what I think is a collective sentiment,” posted a neighbor whom I see often, but who had never before discussed any of these feelings with me. “Everyone seems to feel disconnected from others, irritable and frightened,” a colleague wrote, helping to make universal our ongoing challenges.

Since then I’ve posted regularly: “It’s Friday check-in time. How are you all doing this week?” Friends and followers have continued to acknowledge their trials and tribulations as well as their successes and triumphs.

I also scheduled a virtual appointment with my primary care physician, who told me to take an antacid for my stomach upset, which has helped.

Now, in the depths of winter, more people I know are acknowledging their mental health issues in public. “I must admit I am feeling a little despairing this morning,” wrote one woman I know, adding, “I am sure I am not the only one. If you are, too, you are not alone.” Her friends quickly followed up. “The weight is heavy today. Thanks for connecting.” And another: “I see you. Sitting silently beside you.”

So many of us think we are the “only one.” That we’re by ourselves, invisible. I find it comforting that many of my friends are finding connection with each other through social media. “I feel terrible and feel terrible for everyone posting here, but there is some consolation in seeing that we’re not alone,” posted a friend.

To see each other, we need to make ourselves visible. To help each other, we need to acknowledge we need a hand, too. I’m trying.

Can Technology Help Us Eat Better?

Can Technology Help Us Eat Better?

A new crop of digital health companies is using blood glucose monitors to transform the way we eat.

Credit…Leann Johnson
Anahad O’Connor

  • Feb. 8, 2021, 5:00 a.m. ET

A new crop of digital health companies is offering consumers an unusual way to transform the way they eat, with the promise of improving metabolic health, boosting energy levels and achieving a personalized road map to better health. Their pitch: Find the foods that are best for you by seeing how they impact your blood sugar levels.

The companies, which include Levels, Nutrisense and January, provide their customers continuous glucose monitors — sleek, wearable devices that attach to your arm and measure your body’s glucose levels 24 hours a day, no skin pricks required. The devices transmit that data to your smartphone, allowing you to see in real time how your glucose levels are affected by your diet, sleep, exercise and stress levels.

The devices can show users in real time which of their favorite foods and snacks can make their blood sugar levels spike and crash, leaving them feeling tired and sluggish after meals. They can reveal how engaging in regular exercise, or simply going for a short walk after a big meal, helps to improve blood sugar control. And for some people, the devices can provide warning signs that they may be at increased risk of developing Type 2 diabetes and other forms of metabolic disease.

Continuous glucose monitors were originally developed decades ago to help people with diabetes manage their blood sugar. For people with Type 1 diabetes, the devices, which require a doctor’s prescription, are considered the standard of care, freeing them from the burden of having to prick their fingers multiple times a day to check their blood sugar. But now digital health companies are using the devices to market programs that tap into the growing demand for personalized nutrition, a multibillion-dollar industry.

“We’ve had trackers for many other things like sleep, stress and fitness,” said Dr. Casey Means, a surgeon who co-founded Levels and serves as its chief medical officer. “But a continuous glucose monitor measures an internal biomarker like a tiny lab on our arms. This is the first time it’s been used for a mainstream population for the specific purpose of making lifestyle decisions.”

While most people know that eating sugary junk foods like cookies, cake and soda can wreak havoc on their blood sugar levels, studies show that people can have a wide range of responses to many foods. In one intriguing study from 2015, researchers in Israel followed 800 adults for a week, using continuous glucose monitors to track their glucose levels. They found that even when people ate identical foods — such as bread and butter or chocolate — some people had substantial blood sugar spikes while others did not. The researchers concluded that a variety of factors unique to every person, such as your weight, genetics, gut microbiome, lifestyle and insulin sensitivity, determine how you respond to different foods.

In general, health authorities consider a healthy fasting blood sugar level — measured after an overnight fast — to be below 100 milligrams per deciliter. It is normal for blood sugar to rise after meals. But in a 2018 study, researchers at Stanford found that when they had 57 adults wear continuous glucose monitors for two weeks, many people considered “healthy” by normal standards saw their blood sugar soar to diabetic levels on frequent occasions, a signal that they might be on the road to developing Type 2 diabetes. Other research shows that such large blood sugar swings are linked to heart disease and chronic inflammation, which is increasingly thought to underlie a wide range of age-related ailments, from heart disease, diabetes and cancer to arthritis, depression and dementia.

“The nice thing about using a C.G.M. is that it’s an early way of catching what’s going on, and it gives you a chance to change your behavior before you’re diabetic,” said Michael Snyder, a senior author of the 2018 study and a professor in genetics at Stanford.

Nationwide, about 88 million adults, or more than one in three Americans, have pre-diabetes, a precursor to Type 2 diabetes that causes chronically high blood sugar levels. But according to the federal government, more than 84 percent of people with the condition do not know that they have it.

Dr. Snyder’s research led him to co-found January. The company provides its customers with continuous glucose monitors and then uses artificial intelligence to help them make decisions about what to eat, including predictions about how they might react to different foods before they even eat them.

The programs, which are not covered by insurance, are not cheap. The starting price for Levels is $395, which includes a telemedicine consultation and two Abbott FreeStyle Libre glucose monitors that are programmed to run for 14 days each. Nutrisense offers its customers a variety of packages that range in price from $175 for a two-week program to $160 a month for an 18-month commitment. And January charges $288 for its “Season of Me” introductory program that includes two glucose monitors, a heart rate monitor, and access to the company’s app for three months.

But are they worth it?

To get a better sense, I signed up to use the Levels program for one month. As a health reporter who writes about nutrition, I try to follow a fairly healthy diet and exercise regimen with plenty of fresh foods and few junk foods or sugary snacks, so I wasn’t expecting to learn much from the program. But I kept an open mind.

To get started, I filled out a brief health questionnaire online. Then Levels shipped me two FreeStyle Libre glucose monitors, which were prescribed by a doctor affiliated with the company. As instructed, I attached the device — a small patch with a tiny sensor about the size of a human hair — to the back of my arm. The sensor measures “interstitial fluid” beneath the skin, which it uses to estimate blood sugar levels.

The monitor helped me identify foods that I had no idea were spiking my blood sugar, like protein bars and chickpea pasta. But through trial and error, it also helped me find alternatives. One day I ate a salad with grilled salmon and noticed that it caused my blood sugar to soar. I soon realized why: I had drenched my salad in balsamic vinegar, which, it turns out, contains a lot of sugar. The next day I repeated the meal but with red wine vinegar, which contains no sugar. The result? My continuous glucose monitor showed there was no blood sugar spike or crash.

Dr. Means said that people are often surprised to learn just how much sugar is hiding in their foods, especially in things like sauces, condiments and dressings. But not everyone is the same, and people learn tricks, such as pairing carbs with protein or fats — for example, by adding almond butter to oatmeal or an apple — to blunt the blood sugar response to certain foods.

The monitor also reinforced the value of exercise. I noticed on days when I went for a run, or even a 15-minute walk, that the physical activity helped to keep my blood sugar in a steady range after meals.

I reached out to Dr. Aaron Neinstein, an endocrinologist at the University of California, San Francisco. Dr. Neinstein prescribes continuous glucose monitors to most of his patients with diabetes and has used them himself to monitor his blood sugar and make changes to his diet. By wearing a C.G.M. he found, for example, that a particular type of soup that he regularly ate at his hospital cafeteria was causing a “surprisingly sustained elevation” in his blood sugar levels, leading him to cut back on it.

Dr. Neinstein said there was evidence from rigorous studies that wearing a C.G.M. benefits people with Type 1 diabetes, leading to improved blood sugar control. He predicted that by 2025 every person with any form of diabetes would be using a C.G.M. But he said he hoped there would be more research looking into whether they can improve health in people without diabetes before they become more widely adopted by the general public.

“Anecdotally, I have seen it have benefit in people without diabetes,” he said. “But I think it’s really important that it be rigorously tested. It’s an expense to people and to the health care system, so we really do need to have evidence of benefit.”

Dr. Neinstein said he encourages people who try programs like Levels to treat their glucose devices as part of a personal science experiment.

“There is so much unhealthy food all around us, and we’re in an epidemic of metabolic disease,” he said. “If people can use these devices to test different foods and get a little feedback on what are the behaviors that are making them less healthy, then that seems like a valuable thing to me.”

How to Help When Adolescents Have Suicidal Thoughts

Credit…Grace J Kim

The Checkup

How to Help When Adolescents Have Suicidal Thoughts

Even when rates of suicidal ideation increase, there are ways to keep kids safe.

Credit…Grace J Kim

  • Feb. 6, 2021, 5:00 a.m. ET

With some evidence suggesting that more adolescents have been reporting suicidal thoughts during the pandemic, experts and parents are looking for ways to help.

One issue is that the Centers for Disease Control and Prevention has not yet compiled and released statistics on suicide deaths, so it’s not clear whether the problem is worse than usual. But there are questions about whether suicide risks are increasing — especially in particular communities, like the Black and brown populations that have been hit hardest by the pandemic.

Even during normal times, many mental health problems tend to emerge in adolescence, and young people in this group are particularly vulnerable to social isolation. In Las Vegas, an increase in the number of student suicides during the pandemic spurred the superintendent’s recent decision to reopen schools.

“We don’t have the data to know the relationship of suicidality in children and youth and the Covid epidemic,” said Dr. Cynthia Pfeffer, a professor of psychiatry at Weill Cornell Medical Center who has worked extensively on grieving and bereavement in children and adolescents. “The tremendous stress for families might make a child feel like they need to get out, or feel depressed.”

During the early months of the pandemic, there may have been some sense of common purpose — the kind of spirit that can increase people’s resilience after a disaster. In a research letter published on the JAMA network in late January, researchers compared internet searches related to suicide during the two months before and four months after March of 2020, when the United States declared a national pandemic emergency. Searches using the term “suicide” went down significantly in the 18 weeks after the emergency was declared, compared with what was predicted.

In a new study in the journal Pediatrics, researchers looked at the results of more than 9,000 suicide screenings that had been performed on 11- to 21-year-olds who had visited a pediatric emergency department in Texas. Everyone coming in, for any reason, was asked to complete a questionnaire which asked, among other things, about suicidal thoughts or suicide attempts in the recent past.

The researchers compared the responses from the first seven months of 2019 with those from the same months in 2020. They wanted to see if there was evidence of more suicide-related thoughts and behaviors between March and July of 2020 as the pandemic took hold. Ryan Hill, an assistant professor of pediatrics at Baylor College of Medicine who was first author on the study, said that his team expected that while in January and February, the pandemic would not have been on people’s minds, “we expected to see some differences later — and we did see some, but they were not consistent.”

Dr. Hill and his team found higher rates of suicidal thoughts in some, but not all, months of 2020. “In March and July, the rate of ideation was substantially higher than in 2019,” Dr. Hill said. “Something’s going on — we interpret it as due to the pandemic, though other things were going on in 2020.”

Dr. Christine Moutier, the chief medical officer at the American Foundation for Suicide Prevention, emphasized that even when rates of suicidal ideation increase, suicide rates do not have to rise.

“I think it is terrific that there is more universal screening going on; it represents an opportunity to employ some of the evidence-based strategies that we know can help,” she said.

In a comment published in JAMA Psychiatry last October, Dr. Moutier wrote about how important it is to prioritize suicide prevention during the pandemic. She included several strategies for health care providers, communities, government, and also friends and family to do just that, with some designed to improve social connections by taking advantage of technologies for virtual check-ins and visits. Her foundation also recently released a statement on what parents can do to protect children’s mental health during remote learning.

“Now more than any other time is a time for parents, for any adults who work with adolescents and youth, to be paying attention to the well-being of all adolescents,” Dr. Moutier said. “It’s really a time to be checking in.”

Parents should think about the different ways adolescents might respond to stress, said Dr. Rebecca Leeb, a health scientist at the Centers for Disease Control and Prevention who led a team on emotional well-being and mental health in the pandemic. Perhaps they are withdrawing and sleeping more; eating more or less; or trying drugs, alcohol or tobacco.

Parents can encourage their teenagers to get out of the house and to use the right safety measures — masks, hand-washing, distancing — so that they can spend time outside with friends. She emphasized that “social interaction” is important, whether that’s “exercise or drawing or hiking or taking the dog for a walk.” Kids take cues from their parents, she added, so adults should do those things as well.

It’s also important to make sure that your own mental health is taken care of before you “jump in and start checking in on your kid’s mental health,” Dr. Moutier said. Find moments to relax and laugh, she said, and make sure to talk about how you’re maintaining your own wellness and resilience, so that you can acknowledge and model the importance of those coping strategies for your kids.

Checking in with your kids might also give them an opportunity to open up, said Dr. Moutier, which, for many families, is something that they used to do in the car.

“Our children will feel loved and cared for if we’re practicing that kind of dialogue,” she said. “Do not shy away from asking the deeper, harder questions.” Dr. Moutier recommended being curious about your teenager’s world, asking things like, “How is that situation at school affecting you and your friends?”

Laura Anthony, a child psychologist at Children’s Hospital Colorado and an associate professor at the University of Colorado School of Medicine, said that one common mistake that even she sometimes makes is trying to solve a child’s problems. “What I need to do is just listen,” she said.

She works as the co-leader of the hospital’s youth action board, and teenagers with mental health histories compiled suggestions about how they would like their parents to help. One suggestion: Don’t assume that your kids are struggling all the time, Dr. Anthony said. Instead, consider questions like, “What’s taking up your head space?” Or, “What are you grateful for?”

[Click here for more of the Children’s Hospital Colorado teenagers’ advice on helping teens through the pandemic.]

Another suggestion: Parents should not discipline kids by taking away their phones. “Our teens say, this is not the time for a lot of punishment, you need to give us encouragement, help us have fun,” Dr. Anthony said, “and taking away the phone is really like taking away a lifeline.”

We need better data on mental health, Dr. Leeb said, and on well-being and quality of life. “We are learning a great deal,” she said. “I personally am hopeful for the future,” adding that she’s had several discussions with her children (who are 11, 15 and almost 18) about what the future looks like.

Ask teenagers, “How is this time affecting you?” Dr. Moutier said, and if they are experiencing any kind of struggle. And make it clear that no challenges are insurmountable, she said, “those are really important words for parents to say.”

Giving kids a sense of agency is also vital, said Dr. Sarah Vinson, an associate professor of psychiatry and pediatrics at Morehouse School of Medicine. “Think how kids can be part of the solution,” she said, whether that’s encouraging them to do volunteer work, or helping them understand that concrete steps, like wearing masks, can play a vital role in “reclaiming our day-to-day lives from this pandemic.”

If you’re concerned that your child is depressed or anxious, or if an adolescent talks about feeling overwhelmed, Dr. Anthony suggested asking directly, “Are you having any thoughts of suicide?” You don’t need to ask them every day, but if you’re having any concerns, you should definitely ask.

“Help is out there and it works,” Dr. Anthony said, pointing to the increased availability of virtual mental health services. “Suicidality is partly not being able to see the future,” she said. “If we can change that, we can see remarkable changes.”

Much as the hardships of the Great Depression and World War II forged what is known as “the Greatest Generation,” she said the challenges of the pandemic could strengthen today’s young people.

“I think we are going to have a generation of really remarkably resilient kids and teens who grow up to be really remarkable human beings as adults.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.