Tagged Depression (Mental)

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.

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.

How to Recognize and Address Seasonal Depression

How to Recognize and Address Seasonal Depression

Despair in the winter months can point to a serious condition. Experts recommend light boxes, earlier wake-up times and therapy.

Credit…Pablo Amargo

  • Feb. 5, 2021, 2:38 p.m. ET

Seeing friends was normally the highlight of Kendra Sands’ week. One night in January 2018, she had plans to meet two for dinner, but instead, Ms. Sands, who lives in Charlotte, N.C., crawled into bed. She wanted to go out, but she was stuck in a dark room, sobbing.

“I forced myself to put on different clothes, touch up my makeup and get in the car,” she said. “But driving to the restaurant, I realized hibernating in bed had been a pattern for weeks.”

Sands initially blamed PMS for the crying episodes, but after a month she still had no relief. After asking about her mental health pattern in previous years, Ms. Sands’ therapist eventually diagnosed her with seasonal affective disorder. “I knew I didn’t like the cold or dreariness of winter, but I never thought I had a form of depression,” Ms. Sands said.

According to Vaile Wright, senior director of health care innovation and practice directorate at the American Psychological Association, seasonal affective disorder (S.A.D.) is a type of major depression. What makes S.A.D. unique is its timing: “It has a distinct seasonal onset, typically in winter, and a spontaneous remission of symptoms,” she said.

S.A.D. patients experience classic depression symptoms: sadness, irritability, trouble concentrating, lack of interest in activities and increased sleep and appetite. It doesn’t have to be cold or snowy, people can experience S.A.D. in sunny climates like Florida or Southern California.

“The important consideration for all forms of S.A.D. is the effect of your surroundings,” said Dr. Amit Etkin, a professor of psychiatry and behavioral sciences at Stanford University. “The light you experience, how you interact with the world when you get up, and when you go to bed all have a disproportionate effect on your mood.”

Recognize S.A.D. in yourself.

Michael Terman, professor of clinical psychology at Columbia University and founder of the Center for Environmental Therapeutics, said it’s common to gain weight and feel lethargic in winter, but only around three percent of the population has S.A.D.

To be diagnosed, you need to experience at least five of nine clinical symptoms for at least two weeks, said Paul Desan, assistant professor of psychiatry at Yale School of Medicine. If you don’t, you could have subsyndromal S.A.D., a milder version Dr. Desan said people often call “winter blues.”

A distinct, seasonal pattern is key to recognizing S.A.D., feeling normal during spring and summer, then dwindling in energy and mood as days get shorter — almost like you want to hibernate. If you have a family member with S.A.D., you might be more likely to develop it, and Dr. Desan said the disorder is three times more common in women.

According to Dr. Terman, S.A.D. prevalence increases as you move north, until you hit 38 degrees (around Washington D.C.). Anywhere farther north is essentially equally affected at maximum severity. The likelihood also rises near the western edges of time zones, where dawn occurs later.

Experts agree it’s important to treat S.A.D. if you think you may have it. Here are some of the most common treatment methods they recommend.

Start with simple changes.

Many forms of depression, Dr. Wright said, benefit from changes to sleep schedule, a nutritious diet, exercise and social interaction. If you have S.A.D., put a winter spin on these behaviors.

For example, even if you want to sleep later, set an alarm each day so you can experience early-morning sunshine, which helps with S.A.D. symptoms. “Engaging actively in the world, as if you already had those rhythms, is a good way to help reset your circadian rhythm,” Dr. Etkin said.

What you do at night matters, too. Dr. Etkin suggests basic sleep hygiene like avoiding screens (and any artificial light). Try to keep your bedtime consistent — not too late — and avoid too much caffeine or alcohol, which can interfere with your quality of rest and ability to get up.

Try a light box.

Light activates a bodily signal that informs your cells what time of day it is. Morning light causes cortisol to spike, giving you energy. The time of that initial spike determines when your brain releases melatonin, a hormone that makes you sleepy before bedtime.

During winter, people often get less light in the morning and too much artificial light at night, which throws off these signals, affecting sleep and mood.

Light boxes — devices that produce artificial light similar to sunlight — may be an effective way to correct that. In a meta-analysis of 19 studies, bright light therapy was superior to placebo; another small study found 61 percent of light-therapy patients saw their depression symptoms ebb in four weeks.

There is some evidence that sitting in front of a 10,000-lux (the measure of light intensity) light box for 30-45 minutes every day around sunrise during fall and winter decreases S.A.D. symptoms. If you’re currently experiencing S.A.D. symptoms, it’s not too late to start. You can also begin treating next season’s symptoms in the fall.

As tempting as it is to hit the snooze button on weekends, Dr. Desan said your mood will start to sag again if you don’t do your treatment every day around sunrise, so build light therapy into your life. Most research-grade light boxes allow you to sit at arm’s length and move your head, so you should be able to eat breakfast, drink coffee or read.

An effective light box is usually at least $100, but not every option is equally effective. Of the 24 devices Dr. Desan tested in 2019, only seven met clinical criteria. The rest weren’t as effective as research-grade boxes.

Get outside.

According to Anna Wirz-Justice, professor emeritus in the Centre for Chronobiology at the University of Basel, in Switzerland, natural light isn’t only cheaper than a light box, it’s also brighter. Sunrise light is equivalent to 1,000 lux. A rainy morning provides around 10,000 lux, and snow on the ground is even brighter, at 50,000 lux.

Aim to go outside within 30 minutes after sunrise. “You don’t need to see the sun cross the horizon,” said Dr. Huberman. “What you’re looking for is the quality of light that happens when the sun is low in the sky.”

Duration depends on where you live and the weather. Dr. Huberman suggested around five minutes outside if it’s bright or 10-15 minutes if it’s cloudy. It’s OK to wear glasses or contacts, but skip sunglasses and never look at the sun directly.

See a psychotherapist.

Since 2000, Kelly Rohan, a psychology professor at the University of Vermont, has been conducting clinical trials comparing cognitive behavioral therapy (or C.B.T.) to light therapy. Her work suggests both treatments are effective for people with S.A.D. — especially after a new diagnosis. But when she followed people with S.A.D. for two winters, C.B.T. worked better than bright light therapy to prevent recurrences.

Dr. Rohan said C.B.T. may reduce symptoms more effectively because it provides long-term coping skills for changing negative thought and behavior patterns — whereas light therapy only works when you do it.

For Ms. Sands, the combination of lifestyle changes and psychotherapy made a significant difference in reducing her symptoms. But nothing helped more than naming the debilitating dip in her mood every winter. “Because I have a diagnosis, I can be proactive,” Ms. Sands said. “I don’t have to wait until spring to feel better.”


Ashley Abramson is a freelance writer based in Milwaukee, Wis.

Helping a Teen Who Is Angry About House Rules on Covid

Helping a Teen Who Is Angry About House Rules on Covid

Our grandson’s friends don’t socialize safely, so we don’t want him to see them. How do we keep his anger about it from causing chaos in our home?

Credit…Chloe Cushman
Lisa Damour

  • Jan. 29, 2021, 5:00 a.m. ET

Our Adolescence columnist, the psychologist Lisa Damour, responds to a reader’s question. The question has been edited.

[To submit a question, email AskDrDamour@nytimes.com.]

Q. We are having an extremely difficult time with our 15-year-old grandson, who lives with us. He has finally found friends after struggling socially and wants to spend time with them, but they do not social distance or wear masks. Some of their families are not true believers in this pandemic. It is absolute chaos at our house because of him fighting to be able to do things. He says he is tired of Covid, because while he stays in, most of his friends do not and go about their lives like nothing has changed. He is angry and depressed and we are at a loss as to what to do.

A. You and your grandson are in a heartbreaking predicament for which there are no complete or satisfying solutions. I cannot tell you how much I wish this weren’t true. Above all, I want to acknowledge the painful reality of the circumstances you describe.

Even though there are no perfect remedies, it may still be possible to improve the situation at least a little bit. First, let’s note that you are contending with two distinct, albeit related, challenges. One is that the pandemic has uprooted your grandson’s budding social life. The other is that his perfectly warranted distress about falling out of touch with his new friends has ruptured his relationships at home. On the first front, you may be hard-pressed to offer your grandson more social opportunities than you already have. On the second front, however, there may be ways to repair your connection with your isolated teenager, who needs loving support now more than ever.

Empathy, empathy, empathy is the place to start. The situation in which he finds himself is miserable and not of his creation. It may be true that he is acting out and upsetting everyone around him, and that many other young people find themselves in similar straits, and that we are starting to catch glimpses of the light at the end of the tunnel. Try not to let these factors sap your sympathy for your grandson. The adjustments that we have been asking adolescents to make, both in how they conduct their social lives and how they learn, take almost all of the fun out of being a teenager and have been in place for nearly a year. No amount of compassion for this is too much.

Without any other agenda, deliver to your grandson the message that you are deeply sorry that the pandemic has wreaked havoc on his social life. Tenderly communicate that you grasp how painful it must be to know that his friends are getting together without him. Let him know that you cannot believe that the pandemic has gone on for so long (roughly one-tenth of the lifetime that he likely remembers) and that you understand that for teenagers in particular, the support of family cannot make up for losing touch with friends.

Compassion won’t alter the lousy circumstances, but it can still help to relieve his emotional suffering. Feeling alone with psychological pain is a lot worse than believing that your distress is seen and validated. So, do all you can to help your grandson know that you are entirely on his team.

There’s another way to look at this that may help you to move toward a better relationship with your grandson: Recognize that he may be turning an intractable, internal battle — between his desire to see his friends and his knowledge that their way of socializing isn’t safe — into an external battle between him and you.

It’s not at all uncommon for teenagers to turn vexing personal dilemmas into fractious family fights. Imagine a (post-pandemic) teenager who both wants to go to a concert and also feels unnerved by its sketchy venue. She might seek relief from being at odds with herself by recruiting her parents to take up one side of the battle. Picking this fight would be as simple as wholeheartedly lobbying to go to the concert while rolling her eyes when her folks pose reasonable safety questions.

Try to ease your grandson away from this instinctive approach by warmly and sympathetically articulating his dilemma. “It’s really frustrating,” you might say, “that your friends are doing things in a way that makes it impossible for you to safely see them. I get why you’re so upset.” This might open the door for him to welcome you as a strategic ally. “We’ll do whatever we can to help you see your friends in a safe way. Can you take bike rides together or go throw a ball around outside? We’re happy to take the blame if you want to pin the need to be outdoors and wear masks on us. Just let us know if there’s anything you can think of that we might do to make this work.”

It’s possible, of course, that your grandson won’t like your suggestion or want to test the strength of his friendships. If so, there is something else you can try. New research in the journal Child Development has found that teenagers are better able to bear pandemic conditions when their families support their autonomy. Are there choices you can offer your grandson that have not been left to him before? Perhaps you can give him more say over how or where he studies, what he does with his leisure time, who controls the remote or anything else you can bring to the negotiating table. Own the limits of what you are offering. Acknowledge that getting to pick the dinner menu won’t fix things with his friends. But having some new freedoms at home might just help him feel better enough.

Hopefully, your efforts will lighten your grandson’s mood. If he remains unhappy no matter what you try, make an appointment with his health provider to have him evaluated for depression which, in teenagers, often comes across more as irritability than sadness.

You and your grandson are not alone in feeling painted into a terrible corner by the pandemic. Even with so much beyond our control, let’s not overlook the ways, however incremental, that we can comfort and support our teenagers.

This column does not constitute medical advice and is not a substitute for professional mental health advice, diagnosis or treatment. If you have concerns about your child’s well-being, consult a physician or mental health professional.


Depression in Childhood Tied to Physical Illnesses in Young Adulthood

Depression in Childhood Tied to Physical Illnesses in Young Adulthood

Youths with depression had elevated risks of liver disease, thyroid illness and other problems in their 20s.

Nicholas Bakalar

  • Dec. 14, 2020, 5:15 p.m. ET

Children and adolescents diagnosed with depression may be at increased risk for physical diseases and premature death as young adults, researchers report.

For a study published in JAMA Psychiatry, researchers used Swedish health registries to track a group of 1,487,964 children, of whom 37,185 were diagnosed with depression between ages 5 and 19. The investigators followed the group until they ranged in age from 17 to 31.

Of 69 physical diseases they were able to track, people with depression had a higher risk for 66 of them, even after controlling for other psychiatric illnesses.

For example, compared to their peers who were not depressed, they had eight times the risk of sleep disorders, more than three times the risk of liver disease, and nearly five times the risk of thyroid illness.

Boys had higher risks than girls for most diseases, but both boys and girls with depression had a rate of all-cause mortality six times as high as those without depression. Their rate of suicide was 14 times as high, and deaths from natural causes more than twice as high, as their peers who were not depressed.

“Our observational study can’t address whether this is causal,” said the lead author, Marica Leone, a Ph.D. student at the Karolinska Institute in Stockholm. “We need further research to determine that. But physicians need to look for other diseases, and not just psychiatric disorders, that flow from youth depression.”

A Rare Pandemic Silver Lining: Mental Health Start-Ups

A Rare Pandemic Silver Lining: Mental Health Start-Ups

Using teletherapy, metrics and matching algorithms, entrepreneurs are focusing on addressing aspects of the mental health care system that they view as broken.

Credit…Romy Blümel

By

  • Dec. 7, 2020, 5:00 a.m. ET

Ariela Safira was on a mission. Shaken by the attempted suicide of a friend during her freshman year at Stanford University in 2013, Ms. Safira sought to understand the opaque mental health care system. She soon learned of the shortage of qualified therapists and, even where they are more plentiful, of the hurdles to obtaining care. Although a computer science and math major, she eventually enrolled in a clinical psychology graduate program at Columbia University.

But she kept coming back to a fundamental view: that there is often a mismatch between need and services, an essential supply-and-demand question. “It’s very difficult to start and keep up a therapy business,” Ms. Safira said. “It’s a 10-person job, not a one-person job, from marketing yourself, doing your own financing and managing your own rent. But even before you get to a place where you manage all those things, what’s so challenging is making a name for yourself so that people want to go to you.”

And so, in 2019, she founded Real Therapy, a small business designed to tackle mental health and overall wellness by easing access and offering a range of services to answer clients’ needs.

Driven by personal experience — and further motivated by the pandemic, which has caused an increase in anxiety and depression among the general population, including among young adults — entrepreneurs like Ms. Safira are focusing on addressing aspects of the mental health care system that they view as broken. They seem undeterred by the complicated nature of that system: a byzantine insurance process, a wide range of provider types, and elusive fits between patient and therapist.

“It’s a crowded space,” Alex Katz, the founder of Two Chairs, which opened its doors with a single clinic in San Francisco in 2017, said of the mental health start-up scene. Nonetheless, he said, “because the problems are massive, we need a lot of great companies working in innovative ways to address the different populations, diagnoses and delivery of care.”

Mr. Katz, another Stanford graduate, began working at Palantir, the data analytics and software company, but sought to understand mental health services when his partner “was going through a tough time in her life.” He eventually quit his job and began to tap into his network of friends and family to understand the mental health care system.

He soon learned that one of the system’s biggest challenges was matching a therapist with a patient, something he thought technology could solve. Yet, after interviewing clinicians, he chose to start a physical clinic, rather than a virtual one. In trying to raise funds for his fledgling business, “I joke that I had three strikes against me: I was a first-time, solo founder of a bricks-and-mortar company in health care.” But from its inception, Two Chairs has relied on technology, using a frequently updated proprietary algorithm to match client and therapist after a prospective client’s first intake meeting.

Although both Ms. Safira and Mr. Katz initially focused on in-person care, with virtual therapy as a long-term goal, they had no choice but to change direction once the pandemic hit. Ms. Safira and her small team quickly had to shift from the Manhattan space they carefully designed and renovated, but never opened, to go completely remote. Within eight long days, she produced a remote platform to provide five types of services, largely group-oriented (one-on-one sessions will wait until the in-person location opens). Mr. Katz — whose company had grown to seven locations in the Bay Area, with a new one set to open in Los Angeles next year — also made the decision in March to continue his business by going fully virtual.

Because both had planned, eventually, to offer remote services, they already knew that the efficacy of remote sessions was already proven. David Mohr, the director of the Center for Behavioral Intervention Technologies at Northwestern University’s Feinberg School of Medicine, who has studied the issue, said that researchers had long found that teletherapy could be as effective as in-person therapy.

“There are no substantial differences in outcomes between remote and face-to-face” therapy, he said, adding that a remote option can solve issues of distance and time constraints that often discourage people from seeking therapy. (Dr. Mohr, through his work at Northwestern, is the principal investigator for IntelliCare, a university program that provides pre-therapy tools for anxiety and depression.) Practitioners have been resistant to this change, but the pandemic has forced their hands.

“We are at an inflection point,” he said. “There is a greater acceptance of the use of technology in mental health care, while at the same time there is a tremendous decrease in the stigma” that had been associated with emotional problems.

Like Ms. Safira, it was personal experience that propelled Kyle Robertson to explore a platform for virtual therapy. The son of a psychiatrist and therapist, Mr. Robertson had difficulty finding help in dealing with his own depression and anxiety while a student at Wharton School of the University of Pennsylvania. He said his parents were hands-off but “definitely pushed early on for making sure that there was integration across medication and therapy,” which they all viewed as sometimes lacking in current practice, whether remote or in-person (only psychiatrists can prescribe medication).

After running a beta test of roughly 100 users at the end of 2019, he co-founded Cerebral in 2019. His timing, of course, proved prescient, and he has secured significant venture funding as well an uptick in clients throughout the year.

As with Two Chairs, Cerebral clients can schedule individual therapy, though group sessions are not yet available. The platform asks clients to keep track of their symptoms and report them monthly. Those responses can trigger a notification to the clinician to alert them if there is any worsening of conditions. If someone doesn’t respond, then someone on the team will reach out to check in, Mr. Robertson said.

All three companies seek to provide access quickly — the first interviews can be the same day after a client has signed up, in an effort to pre-empt mental health emergencies. The goal, Mr. Robertson said, is for new clients to speak to someone “within 10 minutes, something we’re able to do with a network of clinicians across geographies.” (Some of the regulations regarding licensing have been relaxed during the pandemic to enable telemedicine across all specialties, not just mental health care.)

And though these providers must comply with the stringent privacy laws that govern medical care, they are able to use data that they gather to analyze outcomes. “It’s been hard to aggregate data and use it in an effective way in the past,” Mr. Robertson said. “Many therapists are in the equivalent of mom-and-pop shops who don’t have the resources, or the time, to analyze the data.”

The three entrepreneurs are all working with insurance companies to have their services covered. Ms. Safira said that clients could use funds in their health savings or flexible spending accounts, and Mr. Robertson is negotiating with insurers. Mr. Katz said that while his company’s services have been out of network, “we will begin working with insurance companies more broadly in 2021.”

Their platforms welcome all ages. Mr. Robertson says that though some older clients seem less comfortable with the remote format, there are many who adapt.

Ultimately, all three companies hope to connect clients with the right type of therapy and to possibly contribute to the understanding of how to make a match.

“There’s not much research on how to make a match, but there’s a lot that speaks about the importance of the alliance” between therapist and patient, Mr. Katz said. “At the end of the day, if you form a great bond, the quality of care is so much higher.”

Reading Novels at Medical School

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Credit Getty Images

Sitting in a classroom at Georgetown Medical School usually reserved for committee meetings, we begin by reading an Emily Dickinson poem about the isolating power of sadness:

I measure every Grief I meet
With narrow, probing, eyes –
I wonder if It weighs like Mine –
Or has an Easier size.

It’s a strange sight: me, a surgical resident, reading poetry to 30 medical students late on a Tuesday night. Some of us are in scrubs, others in jeans; there are no white coats. Over the past four years, as the leader of the group, this has become my routine.

The students are here after long days in class and on the wards because they have discovered that medical education is changing them in ways that are unsettling. I remember that uneasiness well. My own medical education began with anatomy lab. The first day with the cadaver was unnerving, but after the first week the radio was blaring as we methodically dissected the anonymous body before us.

Two years later, on my first clinical rotation, I discovered that it does not take long to acclimate to the cries of patients as I hurried past their rooms, eager not to fall behind in a setting where work must be done quickly and efficiently. This practiced detachment feels necessary, a form of emotional and physical self-preservation. But with little time to slow down, ignoring our own thoughts and feelings quickly hardens into a habit.

During my first year in medical school, I found myself gravitating toward my old comfort zone — literature. As an English major, I had grown accustomed to the company of books and was feeling their absence now that “Don Quixote” had been displaced by Netter’s “Atlas of Human Anatomy.” I could look to Netter for concrete answers, but I needed Cervantes to help me formulate questions I had trouble pinning down, like why it was so easy to ignore the dead (and later, living) bodies around me? Illustrated cross-sections of the brain did little to illuminate the workings of my own mind. I needed time and space for introspection. The solution came in the form of a book club that later became an official course.

At Georgetown, the goal of our new literature and medicine track is to foster habits of reflection over four years of medical school. On the surface, the assigned books have nothing to do with medicine. We read no patient narratives, doctors’ memoirs or stories about disease.

Today’s topic is Haruki Murakami’s novel “Colorless Tsukuru Tazaki and His Years of Pilgrimage,” which tells the story of a depressed middle-aged Tokyoite’s attempt to retrace his past in order to understand how his life became so empty. We talk about the main character’s colorless perception of the world, and why his mind feels so inaccessible to us.

I receive an email from a student later that evening. He, an aspiring psychiatrist, tells me the story of a much-admired college mentor. “I heard last week that he committed suicide. I am still crushed,” he writes. “He was diagnosed with depression but seemed to be doing great.” If he so misjudged his teacher’s state of mind, he worries, how will he make it as a psychiatrist?

Earlier this year, we placed the ethics of animal testing under the magnifying glass of Karen Joy Fowler’s “We Are All Completely Beside Ourselves.” The novel is narrated by a woman whose “sibling,” we later discover, is a chimpanzee who was raised with her as part of a human-chimp experiment. We used the book to think through real-life examples like the Silver Spring Monkeys — a series of gruesome primate experiments that both galvanized American animal-rights groups and led to breakthrough scientific discoveries.

A third-year student talked about the three years he spent working with rhesus macaques. Research from his lab led to breakthrough discoveries about memory and behavior and contributed to therapies such as deep brain stimulation. “Doesn’t that answer the ethical questions?” he asked.

Another student talked about studies that she worked on for several years before starting medical school. “Have you heard of professional testers?” she asked the room. “People whose only source of income is volunteering for different studies, mostly college kids and immigrants? Shouldn’t we be talking about human research also?” For me, the discussion proved transformative. I walked into that class firmly supporting animal research and walked away still supporting research but no longer eating meat.

Our busy jobs on the hospital wards require precision and efficiency, but in literature class we can slow down and explore human lives and thoughts in a different, more complex way. The class is an anatomy lab of the mind. We examine cultural conventions and conflicting perspectives, and reflect on our own preconceived notions about life and work. Reading attentively and well, we hope, will become a sustaining part of our daily lives and practice.

As I’m walking out of the classroom at the end of the evening, a third-year student approaches me to tell me he’s been thinking more deeply about his experience of being an unrelated organ donor to his step-uncle, a man he barely knew. “It’s been on my mind since we read Ishiguro’s ‘Never Let Me Go’ last month,” he says. “I want to write about it. I don’t even know how I feel about it, and I need to figure it out.”

Daniel Marchalik, M.D., is a urologist in Washington and heads the literature and medicine track at the Georgetown University School of Medicine.

How to Tiptoe Around a Depressed Mother

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Credit Giselle Potter

A depressed mother hates noise. She hates a lot of things — sometimes it seems as if she hates everything. But noise is her particular enemy. This is because she needs her sleep. She doesn’t always seem tired. But sleep is sacred to her, and you must never interfere with it. Particularly in the mornings. This makes life complicated if your bedroom — the nursery — is directly above hers and the floors are covered in linoleum, as they are in London in the 1960s. When you wake up and need to go to the bathroom you must avoid certain creaky spots. So you navigate like a cat burglar, tiptoeing on the more solid sections until you get to the stairs down to the bathroom. You hold your breath as you pee as if not breathing will somehow mitigate the sound. Do you flush? Not at this ungodly hour.

Silence is what your mother craves, but it is also her weapon. When she is in one of her moods, she settles into a powerful silence. She actively ignores you. She doesn’t respond to your attempts at conversation, your questions, your pathetic efforts to amuse her, to cheer her up. It’s as if you don’t exist, even when you’re in the same room. Over the years you learn what can trigger these silences and you do everything you can to avoid them. But when they inevitably settle in, it’s as if the world as you know it comes to an end.

Your mother’s depression, previously intermittent yet intense, has settled in with a permanence since your father left the house and your parents announced they would be getting divorced. You’ve always known she suffered from the blackest of moods. Your father has told you the story of your younger brother’s birth, and how he wanted the new baby christened Sebastian. But because your mother “wasn’t speaking” to your father throughout the period between birth and baptism, your brother is now called Paul.

Paul is the person you go to after you’ve been to the bathroom. He’s a little boy, just 4, and at three and a half years his senior it’s your responsibility to put him in his uniform, tie his tie and get him down to the kitchen where you make his breakfast. Your mother can’t tie a tie. And she doesn’t get up for breakfast. She doesn’t get up to see you off to school. The two of you eat quietly, grab your anoraks and having quietly shut the front door behind you, walk together. Recently, Paul has begun to stutter. Eventually he will be taken to a specialist who will try to find out the cause. Your father says he used to stutter a bit as a boy, too, and often imitates Paul. This drives you mad.

It’s hard to remember when you decided that you don’t love your mother. But there is a definite line in the sand when you become her fiercest critic. You hate her arbitrary moods. You hate her selfishness. You hate her neglect. Being depressed and being maternal don’t exactly go hand in hand. A depressed mother rarely puts her children first. For example, if on a Saturday morning you’ve been told to stay upstairs until your mother says you can come down, don’t (dying of boredom) find a rubber ball and start to play catch with it by yourself. Because every so often you’ll drop it. Eventually there will be a roar of rage from below. “GIVE ME THAT BALL,” she’ll yell. As you silently hand it to her, she will shout in your face, “GET DRESSED! AND GET DOWNSTAIRS!”

You’ll put on your clothes and creep down to the hallway with Paul. The two of you will half run, struggling to keep up with her as she marches rapidly and in silence out of the house and into Hyde Park about 10 minutes away. As you cross the street into the park she’ll hurl the ball into the trees.

“Go find your ball,” she will say. “And get lost.”

Having a depressed mother is an excellent way to turn a child into a liar. It’s completely against your nature, but some instinct in you makes you aware that there are some things your mother just can’t handle. So you lie by omission — you don’t tell her a lot of the fun things you do with your father. You’re hardly aware that you do this, until a few years later when Paul tells you he finds it easier to lie than to tell the truth. He’s more used to it.

Is it the lying that causes you anxiety? Or is it the general atmosphere in the house? Anxiety is the air you breathe, and it constantly affects how your body works. You’re supposed to put your light out at 7:30 at night, but sleep doesn’t come easily now, so you put your lamp under the covers and read for another two hours or so. Sometimes when you have to go to the bathroom you are too scared to, so you have accidents. You throw up from nerves. You watch yourself as if from a distance, interested in the experience, making a mental note of it.

You make mental notes of everything. (Having a depressed mother is great training for a journalist.) You note when the fridge is empty to get your mother to call the grocers. Your first experience of actual note-taking is when you decide to make shopping lists for her. You see when the laundry hamper is three-quarters full so you can start encouraging her to get the washing done. When she ignores you and you run out of clean underwear, you turn your dirty underwear inside out.

Routine is extremely important to children of depressed mothers. The clock becomes the nanny. Any deviation from a schedule is not to be allowed. The moment tea is over you take Paul upstairs for bathtime. You lay out your grubby clothes for tomorrow, and you brush your teeth. You go downstairs to say goodnight to your mother, now in her best mood of the day. There is a drink in her hand. She laughs as she allows the two of you to jump on her bed.

Then she says goodnight, and up you go to bed where you read about jolly red-cheeked children with fathers who smoke pipes and mothers who bake pies, wearing aprons over their tweed skirts, until you fall asleep.

Emma Gilbey Keller is a journalist and author who is working on a memoir about her experience of motherhood, from which this essay is adapted.

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Early Puberty in Girls Raises the Risk of Depression

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When girls come in for their physical exams, one of the questions I routinely ask is “Do you get your period?” I try to ask before I expect the answer to be yes, so that if a girl doesn’t seem to know about the changes of puberty that lie ahead, I can encourage her to talk about them with her mother, and offer to help answer questions. And I often point out that even those who have not yet embarked on puberty themselves are likely to have classmates who are going through these changes, so, again, it’s important to let kids know that their questions are welcome, and will be answered accurately.

But like everybody else who deals with girls, I’m aware that this means bringing up the topic when girls are pretty young. Puberty is now coming earlier for many girls, with bodies changing in the third and fourth grade, and there is a complicated discussion about the reasons, from obesity and family stress to chemicals in the environment that may disrupt the normal effects of hormones. I’m not going to try to delineate that discussion here — though it’s an important one — because I want to concentrate on the effect, rather than the cause, of reaching puberty early.

A large study published in May in the journal Pediatrics looked at a group of 8,327 children born in Hong Kong in April and May of 1997, for whom a great deal of health data has been collected. The researchers had access to the children’s health records, showing how their doctors had documented their physical maturity, according to what are known as the Tanner stages, for the standardized pediatric index of sexual maturation.

Before children enter puberty, we call it Tanner I; for girls, Tanner II is the beginning of breast development, while for boys, it’s the enlargement of the scrotum and testes and the reddening and changing of the scrotum skin. Boys and girls then progress through the intermediate changes to stage V, full physical maturity.

In this study, the researchers looked at the relationship between the age at which children moved from Tanner I to Tanner II — that is, the age at which the physical beginnings of puberty were noticed — and the likelihood of depression in those children when they were 12 to 15 years old, as detected on a screening questionnaire.

“What we found was the girls who had earlier breast development had a higher risk of depressive symptoms, or more depressive symptoms,” said Dr. C. Mary Schooling, an epidemiologist who is a professor at the City University of New York School of Public Health, and was the senior author on the study. “We didn’t see the same thing for boys.” Earlier onset of breast development in girls was associated with a higher risk of depression in early adolescence even after controlling for many other factors, including socioeconomic status, weight or parents’ marital status.

Other studies, including in the United States, have shown this same pattern, with girls who begin developing earlier than their peers vulnerable to depression in adolescence. Some studies have found this in boys, though it’s not as clear. But there is concern that girls whose development starts earlier than their peers are at risk in a number of ways, and across different cultural backgrounds.

“Early puberty is a challenge and a stress, and it’s associated with more than depression,” said Dr. Jane Mendle, a clinical psychologist in the department of human development at Cornell University. She named anxiety, disordered eating and self-injury as some of the risks for girls. In her studies of puberty, she has found associations between early development and depression in both genders in New York children. In boys, the tempo of puberty was significant, as well as the timing; boys who moved more rapidly from one Tanner stage to the next were at higher risk and the increased depression risk seemed to be related to changes in their peer relationships.

Before puberty, Dr. Mendle said, depression occurs at roughly the same rate in both sexes, but by the midpoint of puberty, girls are two and a half times more likely to be depressed than boys.

Some of these children may already be at risk; Dr. Mendle said that early puberty is more common in children who have grown up in circumstances of adversity, in poverty, in the foster care system. But some of it is heredity and some of it is body type and some of it, probably, is chance.

Researchers have wondered about hormonal associations with depression; Dr. Schooling pointed out that their study found that depression was associated with early breast development, controlled by estrogens, but not with early pubic hair development, controlled by androgens. “There is no physical factor that we know about that would explain this; estrogen has been eliminated as a driver of depression in earlier research,” she said in an email. “We probably need to explore social factors to seek an explanation.” They also plan to follow up with their study population at age 17.

The biological transition of puberty, of course, occurs in a social and cultural context. One very important effect of developing early, Dr. Mendle said, is that it changes the way that people treat you, from your peers to the adults in your life to strangers. “When kids navigate puberty they start to look different,” she said. “It can be hard for them to maintain friendships with kids who haven’t developed, and we also know that early maturing girls are more likely to be harassed and victimized by other kids in their grade.”

Parents should be aware of the difficulties that children may experience if they start puberty earlier than their peers, but lots of children handle early development with resiliency, and even pride.

Children who start puberty early – say, 8 instead of 12 — are faced with handling those physical changes while they are more childlike in their knowledge and their cognitive development, and in their emotional understanding of what goes on around them.

Parents should keep in mind that the same protective factors that help children navigate other challenges of growing up are helpful here: All children do better when they have good relationships with their parents, and when they feel connected at school. And we should be talking about the changes to their bodies before they happen, and make it clear that all of these topics are open for discussion.

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Overcoming the Shame of a Suicide Attempt

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Credit Jordin Isip

I don’t remember much about the first time I tried to kill myself, 21 years ago, because any time the memory popped up I deleted it from my mind like an unflattering photo on Facebook. Despite being open and public about my second attempt, in 2006, which I revealed in a memoir about my alcoholism, I’ve never told anyone else about that first one – not my partner of 25 years, my therapist of 10 years, family, nor friends – until now.

Here’s what I remember about that first time, in 1995. I felt hopeless, that my 27 years of life were done (27!). I’d come home drunk from a glamorous Manhattan book event, which I had organized as the publicist. The wattage of successful artists in literature, fashion and theater was blinding. I felt like a failure, that I would never be more than the hired help, that my own dreams were just thin air. When I came home and poured another drink and remembered the leftover painkillers in my medicine cabinet – prescribed for a sprained ankle earned by a drunken fall — I thought, “Why not?”

My attempt was impulsive, not premeditated. Had it been successful, I’d classify it as suicidal manslaughter. I climbed into the antique wrought iron bed I shared with my partner and passed out. The next morning, I woke up next to him and he was none the wiser. I got up in a daze and went to work feeling like I was moving under water, so heavy was my triple hangover from booze, pills and shame. I kept moving, kept drinking (I was blind then to the cause and effect of booze and depression) and kept silent.

My silence nearly killed me. Eleven years later, I tried again. I had been fantasizing about suicide every day for months. I was more hopeless. I was drunker. That time I did it with sleeping pills I’d been taking to prevent me from drinking as much at night. Booze, pills, suicide attempts: it was all one big happy “Valley of the Dolls” family. That time I took the pills in the morning after my partner left for work, and I didn’t wake up on my own. My partner found me in that antique bed when he came home from work. The jig was up, and my winding path to recovery began.

Why bother talking about the first one? Now that I’ve been sober for almost eight years and my artistic dreams are coming true, the secret made me feel like a house rebuilt on a foundation still riddled with termites. I knew I would have to own the attempt eventually, so when the Centers for Disease Control and Prevention recently released a report that suicides had surged to the highest levels in 30 years, I knew it was time for me to come clean. With two attempts on my score card, I forever remain in a suicide high risk group. According to the Harvard T.H. Chan School of Public Health, a history of suicide attempt is one of the strongest risk factors for suicide, and the American Foundation for Suicide Prevention reports that approximately 40 percent of those who have died by suicide have made a previous suicide attempt at some point in their lives. I don’t want the third time to be the charm.

The further away from that first attempt, the deeper the secret grew and the less real it became. I didn’t really do that. I didn’t think a few painkillers would kill me. I didn’t mean it. But I did do it and I did mean it. I’m mortified by that. It was reckless, rash, stupid, selfish, pathetic.

As a recovering alcoholic I know that admitting to my behavior and owning my story is the only way it can no longer own me. I’m not ashamed of being an alcoholic, but I’m still ashamed of trying to kill myself, even though I know I did it under the temporary insanity of alcohol. According to the A.F.S.P., approximately 30 percent of those who die by suicide have blood alcohol levels in the range of intoxication at the time of their deaths.

After my second attempt, I went to rehab and then to sober meetings. The focus quickly shifted from my suicide attempt to my alcoholism, and rightfully so. Once my alcoholism was treated, the depression lifted. It was alcohol that brought on my depression and thoughts of suicide, and ultimately twice gave me the courage to try it. Since I’ve been sober, I no longer suffer from depression, do not take antidepressants and no longer think about killing myself.

I’m fortunate to live in New York City, where there are almost as many sober meetings as there are bars. These are peer-led meetings of alcoholics helping other alcoholics, free of judgment and condescension. These meetings keep me sober, hence nonsuicidal.

But what about the nonalcoholics and nonaddicts who’ve attempted suicide? Where are their meetings? I could find only a few peer-led suicide attempt survivor support groups via Google, and none in New York City. When I called the National Suicide Hotline requesting local suicide attempt survivor support groups, the operator suggested just one option: a Safe Place Meeting hosted by the Samaritans, a suicide prevention network. But those meetings are for those who have lost loved ones to suicide, and they have no meetings for attempt survivors.

I admitted my second suicide attempt because I was found out, and had to. But shame kept me quiet about my first attempt. I admit it now, and I throw out a call for other closeted suicide attempt survivors to do the same: Own it, and find – or create — a safe group where you can talk about it.

Today I own my story, so that my story doesn’t kill me.

Jamie Brickhouse is the author of “Dangerous When Wet: A Memoir of Booze, Sex, and My Mother.

The Breakup Marathon

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Brian Eastwood during the Boston Marathon in 2016.

Brian Eastwood during the Boston Marathon in 2016.Credit Zeth Weissman

Brian Eastwood was a pretty good runner, but he’d always come up a bit short in trying to reach his goal of qualifying for the Boston Marathon.

When he set out to train for the 2015 Vermont City Marathon, though, his 12th try at qualifying, he had something new in his life: a divorce.

“The day my wife and I went to court was the first day of 16 weeks of training,” said Mr. Eastwood, 35, of Somerville, Mass. His life was, to put it mildly, in flux. Not only was he on the verge of divorce, but he was in the middle of trying to make a career shift, too.

But his training paid off: Mr. Eastwood ran the race of his life in Vermont, finishing in 3 hours, 1 minute, 17 seconds, more than seven minutes under his best time, and more than eight minutes under the Boston Marathon qualifying standard for men his age.

His divorce, he says, most likely made the difference. During that difficult time, “running was my only real constant,” he said.

For some people, a life trauma like a breakup or divorce might mean curling up in bed and shutting down. But others find more active ways to cope.

Those people “are better at compartmentalizing or utilizing some of the energy that surrounds the emotions they’re experiencing — maybe it’s anger, maybe it’s sadness — and channeling that into another venue or arena,” said Trent Petrie, director of the University of North Texas Center for Sport Psychology. For runners, that could mean challenging themselves to run better and faster, or to shoot for a longer distance.

“Chronic or traumatic stress leads to structural and functional alterations in the traumatized brain,” said Ken Yeager, director of the stress, trauma and resilience program at the Ohio State University Wexner Medical Center. And while a breakup or divorce may feel like a single traumatic event, it is often the culmination of months or even years of “mini-traumas” and ongoing stress.

“You had those tensions building up in your body,” Dr. Yeager said. “Most people don’t realize the way you release those tensions is movement.” He compares the situation to the nervous tension that builds up at the start of a race. “Before any major race, you have this release of tension, and that movement is what releases the trauma and tension,” he said.

Maya Harmon, 32, ran seven half-marathons in 2015 — the year that she and her husband of seven years divorced. She’d picked up running in 2009 when she moved to Phoenix, but started doing it more when the marriage started to unravel in 2011.

“When things really started to go bad, I started to focus on trying to do something to stay active because I knew that as long as I stayed active, it would keep me slightly happy,” she said. Even though her time was limited between work, graduate school and becoming a single mother, she still got out there, trained and ran races.

Her mother asked if she was trying to run away from her problems. Maybe, she said, though the escape that running provided was at least a healthy one, and kept her from feeling overwhelmed.

“If I had time to sit and think about it, I probably wouldn’t have made it through that time,” Ms. Harmon said. “Running gave me something to focus on that was positive.”

Dr. Petrie says that while there’s a risk that running might be used as an escape that prevents people from confronting the issues that are causing their stress, it can also be a useful tool for processing painful events. “Sometimes in the moment, these escapes into running or exercising or finding a slightly different focus is a way for us to garner the psychological resources we need to circle back and face the other stuff in a more productive way,” he said.

For Ms. Harmon, who had been casually involved with the Black Girls RUN! group via Facebook before her divorce, running gave her a chance to expand her social horizons. She dove in to the local activities of that national group’s Phoenix chapter and is now their running ambassador, a journey that may have helped to strengthen her psychological resilience.

When people are “depressed or stressed out, they tend to isolate themselves, and that facilitates negative moods,” said Jasper Smits, a professor of psychology at the University of Texas at Austin and a co-author of “Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-Being.” Studies he and his colleagues have conducted suggest that exercise may help to lessen anxiety and panic attacks and provide other benefits for mental health.

This past April, Mr. Eastwood ran that Boston Marathon for which he had worked so hard to qualify. Now his life is very different: He has a new girlfriend, a new job. He was recovering from a calf injury when he started training this time, so he set a more moderate goal. He finished in 3 hours, 24 minutes, 37 seconds, more than 20 minutes slower than his post-divorce performance, but he has no complaints.

“Everyone who saw me along the course said I looked happy and strong, which is exactly what I wanted,” he said.

Jen A. Miller is the author of “Running: A Love Story.”

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Treating Pregnant Women for Depression May Benefit Baby, Too

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Treating pregnant women for depression may benefit not just themselves but their babies as well.

A study, in the May issue of Obstetrics & Gynecology, included 7,267 pregnant women, of whom 831 had symptoms of depression. After controlling for maternal age, race, income, body mass index and other health and behavioral characteristics, the researchers found that depressive symptoms were associated with a 27 percent increased relative risk of preterm birth (less than 37 weeks of gestation), an 82 percent increased risk of very preterm birth (less than 32 weeks of gestation), and a 28 percent increased risk of having a baby small for gestational age.

They also found that among those who were treated with antidepressants for depression — about a fifth of those with the diagnosis — there was no association with increased risk for any of these problems. But they acknowledge that this group was quite small, which limits the power to draw conclusions.

Still, the lead author, Dr. Kartik K. Venkatesh, a clinical fellow in obstetrics and gynecology at Harvard, said that it was important to screen mothers for depression, not only for their health but for that of their babies.

“By screening early in pregnancy, you could identify those at higher risk and counsel them about the importance of treatment,” he said. “Treating these women for depression may have real benefits.”

Six Months Pregnant and Asking, ‘Am I Depressed?’

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Credit Stuart Bradford

On a walk with my husband through Joshua Tree National Park in late January, I felt sad for no reason in particular. Or maybe for lots of really good reasons. I wasn’t sure which it was.

At the time, I was six months pregnant. My husband, Raj, asked me what was wrong. “Nothing,” I said, and kept walking, kept stewing, kept wiping away a few tears from under my sunglasses when he wasn’t looking.

“Are you depressed?”

The Times had recently published a story about updated guidelines calling for pregnant women to be screened for depression – both during the pregnancy and after giving birth. Raj must have read the article, too.

During my first pregnancy, when I was quite happy, Raj read all about postpartum depression. Soon after our baby arrived, the questioning began. Raj would get all serious, look me straight in the eye and say: “Do you have postpartum depression?”

Umm. No, hon, I am feeling pretty good.

But this time around, this pregnancy, things have felt different.

Did I have “pregnancy depression?” Would I pass the screening? What’s the difference between being pregnant – with a crazy amount of hormones flowing through your body – and being pregnant and depressed?

It can be so hard to tell. Like when there is a blizzard back home but you escaped just in time, and you are sitting by the pool at a beautiful hotel in Palm Springs, and the air feels just right, and your toddler has finally gone down for a nap, and yet, you are crying.

Or when you wanted to go pumpkin picking so your husband tried to cheer you up by returning from Home Depot with a large pumpkin and orange mums. You know he was just trying to help, but pumpkin picking at Home Depot? Pregnancy depression might be when you can’t see the pumpkin and mums on the front steps without bursting into tears.

Is that pregnancy depression, or just pregnancy?

Pregnancy depression could be when your toddler is playing on the balcony outside your hotel room and for a split second you think: If he falls, he falls; it would be an accident. And it doesn’t immediately occur to you just how disturbing that thought is.

That’s shocking, but is it depression?

I see doctors and nurses every four weeks for my pregnancy. But they haven’t once asked me how I’m doing emotionally. One time I arrived for an appointment visibly distraught. I hoped someone would ask, but nothing.

I don’t know why I haven’t raised the issue myself. Maybe it feels like they aren’t the right people to discuss this with. The nurses take my blood pressure. I trust my doctor to perform a C-section, if need be. What do they know about moodiness?

On the other hand, in recent years there has been a real increase in awareness about mood disorders during pregnancy. If the medical professionals seeing pregnant women and new mothers aren’t looking for these things, asking the right questions and identifying patients who need help, then who is?

When we returned from Palm Springs, I looked deeper into pregnancy depression and what it means. The episode with our toddler on the hotel balcony had scared me. My thought was fleeting, but I was horrified that I could even think such a thing.

The more I read about pregnancy depression, also called perinatal mood and anxiety disorder, the more I realized it might not just go away. I began to worry that I would struggle even more once I gave birth and was home with our baby – sleepless and overwhelmed with a newborn and toddler, especially when my husband was out of town on business.

I also wondered if our toddler could sense my mood. And what if when the baby came, my sadness affected my ability to bond with him?

Moodiness on its own I can manage. But depression that could affect my children and my relationship with them? That was something I wasn’t willing to tolerate.

It was time, I decided, to talk to my husband.

When I called Raj, who was traveling, he could hear something off in my voice. This time he asked, “Are you sad?”

Yes, I was sad.

I told him I was concerned that my sadness over the past few months was a real problem. That it wasn’t going away. That it might get worse.

It helped being so honest with him, and with myself. He didn’t judge me, which now I realize was my fear. He told me it wasn’t my fault. He said he’d watch our son, and I could see a therapist or support group available on the weekends. He said he was glad I had told him – and I was, too.

The next day I contacted Postpartum Support International, an organization that supports women facing mental health issues related to childbearing, and talked to a coordinator in New York City. She gave me a handful of therapists to call.

Something changed after I acknowledged that I was struggling, that I needed help: I started to feel better.

I found a therapist who was warm and understanding and let me go on and on about my concerns about taking care of two children while my husband was away, and my fears that I wouldn’t be able to manage.

The therapist didn’t have specific answers. (And unfortunately she didn’t offer to lend a hand with late-night feedings.) If anything, she told me what I already knew – that it can be really hard to tell the difference between a wave of pregnancy hormones and clinical depression. She said it seemed that I was suffering from the former.

But we also agreed that what I was experiencing was real. That hormone fluctuations can manifest in many different ways, and that it’s often not enough to just ignore them. In fact, sometimes, it’s the very act of addressing them head-on that makes all the difference.

Hanna Ingber is an assistant editor on the International desk at The New York Times.

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Meditation Plus Running as a Treatment for Depression

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Credit iStock

Meditating before running could change the brain in ways that are more beneficial for mental health than practicing either of those activities alone, according to an interesting study of a new treatment program for people with depression.

As many people know from experience, depression is characterized in part by an inability to stop dwelling on gloomy thoughts and unhappy memories from the past. Researchers suspect that this thinking pattern, known as rumination, may involve two areas of the brain in particular: the prefrontal cortex, a part of the brain that helps to control attention and focus, and the hippocampus, which is critical for learning and memory. In some studies, people with severe depression have been found to have a smaller hippocampus than people who are not depressed.

Interestingly, meditation and exercise affect those same portions of the brain, although in varying ways. In brain-scan studies, people who are long-term meditators, for instance, generally display different patterns of brain-cell communication in their prefrontal cortex during cognitive tests than people who don’t meditate. Those differences are believed to indicate that the meditators possess a more honed ability to focus and concentrate.

Meanwhile, according to animal studies, aerobic exercise substantially increases the production of new brain cells in the hippocampus.

Both meditation and exercise also have proven beneficial in the treatment of anxiety, depression and other mood disorders.

These various findings about exercise and meditation intrigued researchers at Rutgers University in New Brunswick, N.J., who began to wonder whether, since meditation and exercise on their own improve moods, combining the two might intensify the impacts of each.

So, for the new study, which was published last month in Translational Psychiatry, the scientists recruited 52 men and women, 22 of whom had been given diagnoses of depression. The researchers confirmed that diagnosis with their own tests and then asked all of the volunteers to complete a computerized test of their ability to focus while sensors measured electrical signals in their brains.

The researchers found that the depressed volunteers showed signaling patterns in their prefrontal cortex that are associated with poor concentration and focus.

Then the researchers had all of the volunteers begin a fairly rigorous, supervised program of sitting, followed by sweating.

To start, the volunteers were taught a form of meditation known as focused attention. Essentially entry-level mindfulness meditation, it requires people to sit quietly and think about their respiration by counting their breaths up to 10 and then backward. This practice is not easy, especially at first.

“If people found their thoughts wandering” during the meditation, and especially if they began to ruminate on unpleasant memories, they were told not to worry or judge themselves, “but just to start counting again from one,” said Brandon Alderman, a professor of exercise science at Rutgers who led the study.

The volunteers meditated in this way for 20 minutes, then stood and undertook 10 minutes of walking meditation, in which they paid close attention to each footfall.

Then they clambered onto treadmills or stationary bicycles at the lab and jogged or pedaled at a moderate pace for 30 minutes (with five minutes of warming up and five minutes of cooling down).

The volunteers completed these sessions twice a week for eight weeks. Then the researchers retested their moods and their ability to focus and concentrate.

There were significant changes. The 22 volunteers with depression now had a 40 percent reduction in symptoms of the condition. They reported, in particular, much less inclination to ruminate over bad memories.

Meanwhile, the members of the healthy control group also reported feeling happier than they had at the start of the study.

Objectively, the volunteers’ results on the computerized tests of their ability to focus and their brain activity also were different. The group with depression now showed brain cell activity in their prefrontal cortex that was almost identical to that of the people without depression. They could concentrate much better and hone their attention, attributes that are believed to help reduce stubborn rumination.

“I was quite surprised that we saw such a robust effect after only eight weeks,” Dr. Alderman said.

He and his colleagues theorize that the meditation and exercise may have produced synergistic effects on the brains of their volunteers.

“We know from animal studies that effortful learning, such as is involved in learning how to meditate, encourages new neurons to mature” in the hippocampus, he said.

So while the exercise most likely increased the number of new brain cells in each volunteer’s hippocampus, Dr. Alderman said, the meditation may have helped to keep more of those neurons alive and functioning than if people had not meditated.

Meditation also may have made the exercise more tolerable, he said, since some studies indicate that being mindful of your breathing and your body during workouts increases people’s enjoyment of the exertion.

“I’ve started meditating,” said Dr. Alderman, a long-time athlete.

Of course, this was a small study and the scientists did not follow their volunteers long term, so they do not know if any mood improvements linger. They also have no idea whether similar or even greater benefits might occur if someone were to run and then meditate or to practice both activities but on alternating days. They plan to study those questions in future experiments.

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Opening Up About Depression

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Credit Arianna Vairo

I have slogged through a number of difficult situations in recent months, among them the ongoing crises of my elderly parents’ illnesses and the suicide of a friend. I never lost my appetite nor burst into tears, and I didn’t suffer from any of the other typical symptoms of depression. Maybe I was more irritable than usual, a bit more prone to snap. And yes, I buried myself in my work. But I didn’t think I’d tripped down into the rabbit hole of depression.

You would think I would have been more self-aware, both personally and professionally. As a health journalist, I have often used my own stories to write about difficult-to-discuss medical conditions, includinglearning I had testicular cancer at age 26 and my misdiagnosis with H.I.V./AIDS — back when it was a death sentence. But I had never written about suffering from depression, even though it’s plagued me since I first put pen to paper, at age 11, when I started keeping a diary.

Still, I’m far from alone. At least six million men in the United States suffer from depression, according to the National Institute of Mental Health. The true number is likely to be even higher, said Dr. Matthew Rudorfer, the institute’s associate director for treatment research, since men are less likely than women to report classic symptoms like low mood, sadness or crying, so they often go undiagnosed. Men, he told me, more often demonstrate “externalizing” symptoms like irritability, anger and aggressiveness, substance and alcohol abuse, risk-taking behaviors and “workaholism.”

Oh, that macho thing: Men don’t get depressed; they just work, drink and compete harder. Andrew Solomon, author of the pathbreaking memoir about depression, “Noonday Demon,” told me that ridiculous attitude is part of the mind-set that guys should “cover up our moods with militarism or athleticism.”

So why speak up now? If there was a specific catalyst, it would be the death of my friend (his family asked me not to disclose his real name), a personal trainer who, one August morning, worked out his regular clients — and then went home and killed himself with a single gunshot to the head.

Even with 20/20 hindsight I never would have guessed he was at risk for serious depression, let alone suicide. Just three days before his death, alive with excitement, he’d talked with me about buying his first house and applying for a management role at the health club. Still, as one of his closer friends told me later, “You never know where depression lives.”

Most people, even those who know me well, don’t see my depression. I’m a “high-functioning” depressive, for sure, and perhaps an artful one, too, obscuring its symptoms with a mix of medication, talk therapy, exercise and knowing when to close the door on the world. And unlike my surgical scars (thank you, cancer), those left by depression are invisible.

I wonder, had I talked with my friend about my own struggle, if he might have said, “Me, too.” Indulging in some magical thinking, I imagine he would be alive today if we had shared our stories.

It’s encouraging that new studies are refuting previous ones that showed women to be twice as likely as men to experience depression. For example, a 2013 University of Michigan study concluded, “when alternative and traditional symptoms are combined, sex disparities in the prevalence of depression are eliminated.” In other words, men and women may be equally at risk.

The first step in recognizing depression in men is diagnosing it properly, which means establishing accurate criteria — and making sure mental health practitioners know what to look for. The second step, which may be even more difficult, is getting men to speak up about it.

Which leads back to my own silence. One reason I’ve been unable to talk about my condition until now is that, as the Cymbalta ad says, “depression hurts.” When I first heard that tagline I rolled my eyes, but I’ve since come to appreciate the copywriter’s genius. Imagine suffering from a bad flu, the kind that seems to have poisoned your blood, physically incapacitating you. For me, depression can feel like the worst flu ever, with no end in sight. It is tough to talk about when you’re in that much pain.

And then there’s the stigma. As much as I understand that illness is illness, whether mental or physical, and that there is a greater openness about depression now than a generation ago, I feel shame.

My own encounters with stigma have been profound. I once dated a fellow who dumped me unceremoniously when he found out I took Lexapro, an antidepressant. Before the Affordable Care Act became law, I was rejected for health insurance — not because of my cancer history, but because of my medication history. Having sought help, I was penalized. “It doesn’t make any sense,” my primary care doctor said to me.

So I have decided to be more truthful. Last fall, when I needed to beg off from a commitment, I didn’t fabricate some physical ailment, as I had in the past. Instead, I emailed: “The depression I’m suffering from right now makes it difficult for me to be there as promised. I’m sorry.”

Depression need not be the loneliest fight, as Mr. Solomon has so well characterized it. But if I don’t tell you, you can never really know me — or help. Now I can appreciate it when friends ask me how I’m feeling (but not in that dreadful way: “How. Are. You?”). And I appreciate those who offer: “Is there anything I can do?”

Steven Petrow, a regular contributor to Well, lives in Hillsborough, N.C.

Should Doctors-in-Training Work Fewer Hours?

How many hours should medical residents work?

Hospital care is a 24-hour-a-day enterprise, but the question of which doctor should be there — and how long he or she should already have been there — is among the most controversial and unsettled in medicine. It’s a question that comes up almost daily among my peers, and my own feelings about the issue often depend on whether I’m trying to grasp details about a new patient or struggling to stay awake at the end of a very long shift.

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Dr. Dhruv Khullar

Dr. Dhruv KhullarCredit Tom Fitzsimmons

In 2003, at the genesis of the modern patient safety movement, the Accreditation Council for Graduate Medical Education mandated that residents work no more than 80 hours per week. In 2011, it limited individual shifts for first-year residents to 16 hours. Since then, research has been mixed on whether reducing the length of shifts or total number of hours worked has improved resident health, medical education or patient outcomes.

This year, two large national trials, known as iCompare and First, aim to shed new light on the issue. Researchers randomized first-year residents at internal medicine or general surgery programs across the country to work either 16-hour shifts, the current maximum, or longer shifts of 28 hours or more. Shortly after the iCompare trial began, two advocacy groups sent an open letter to the Office for Human Research Protections, calling the trial “unethical” and arguing that it exposes patients to dangerously sleep-deprived residents while exposing residents to a greater risk of car accidents, needlestick injuries and depression.

These trials come at a critical time, amid mounting evidence of serious mental health concerns for medical trainees. A recent study found that almost one-third of residents exhibit symptoms of depression; other studies show that almost 10 percent of fourth-year medical students and 5 percent of first-year residents admitted to having suicidal thoughts in the previous two weeks — with higher rates among minorities.

And yet, it’s not clear whether more restrictive work hours will make things better for residents or patients. When residents work fewer hours, there are more patient “handoffs” — when a patient is transferred from one doctor to another. The process makes it more likely that important details are overlooked, and intimate familiarity with a patient’s recent clinical course is often left behind. And residents may not even be reporting their hours accurately. Whistle-blower protections are lacking, and the penalty for work hour violations is loss of program accreditation, which could hurt the resident reporting the problem.

In the face of uncertainty, we need more data — and we’re starting to get it. Results from the First trial, published yesterday, found no significant differences in patient outcomes, resident satisfaction or educational quality when surgical trainees worked longer shifts. (Results from iCompare, which is looking at internal medicine residents, are expected in June.)

But I worry about how to interpret the results of trials like these, and what positive or negative findings may mean for residency training discussions going forward. In a profession driven by evidence, data is useful. But it’s important to recognize data’s limitations.

Many patient-care metrics we use to evaluate the impact of duty hour restrictions — mortality, procedural complications, adverse events, readmission rates — are crude. They might make sense for hospitals and health systems designed to increase efficiency and insulate patients from human fallibility. But they fail to capture the nuances of care delivered at the doctor-patient level. Good patient care is about more than surgical infection rates and medication errors. At the end of a long shift, am I the kind of doctor — and person — I want to be? Do I make time to sit with a suffering patient? Do I snap at a well-meaning colleague?

Well-being is similarly difficult to study. Research suggests that one’s judgment of happiness and life satisfaction is surprisingly fickle. For example, people interviewed on sunny days report being more satisfied with their entire lives than those interviewed on rainy days. So if you ask me about my training program after a particularly bad 16-hour shift, I’m likely to rate it worse than during a particularly good 30-hour shift.

Medical educators also worry that work hour restrictions force residents to see fewer patients and miss important educational experiences. At the same time, we allow residents to spend hours scheduling appointments, faxing medical records, gathering vital signs, obtaining prior authorization, and completing many other nonclinical tasks. We don’t learn to do these tasks in medical school; we shouldn’t be spending our time on them as residents. If we’re concerned about resident education, let’s focus on increasing quality time spent on direct patient care and educational activities.

The right answer on how many hours residents should work may be more nuanced than we’ve been willing to accept. It isn’t the same today as it was 20 years ago, as the complexity of caring for patients and medical technology continue to evolve. It varies by subspecialty — discontinuity may have graver consequences for neurosurgery, say, than for radiology. And it hinges more on the character of work than the length of it — I’d spend twice as long at a patient’s bedside if I could spend half as long at a computer.

Ultimately, the answer may be as philosophical as it is empirical. What kind of doctors do we want to be? What kind of doctors do patients want us to be? And does what we can’t measure still matter in a profession that’s now judged and motivated by what we can?

Dhruv Khullar, M.D., MPP is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.