Tagged Mental Health and Disorders

Need to Dust Off Your Social Skills?

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

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

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

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

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

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

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

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

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

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

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

So how do we relearn how to be together?

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

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

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

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

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

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

8 Exercises to Strengthen Your Social Muscles

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

Share food with someone.

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

Tell someone a joke in person.

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

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

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

Reach out to someone you’ve lost touch with.

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

Strike up a conversation with a stranger.

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

Move with someone.

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

Sit quietly with someone …

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

Make a date for the future.

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


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

Depression in Young Children

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

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

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

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

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

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

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

What does depression look like in younger children?

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

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

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

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

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

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

Should I ask about suicidal thoughts?

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

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

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

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

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

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

How can treatment help?

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

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

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

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

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

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

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

How can I find help for my child?

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

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

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

Eating Disorder Symptoms Have Spiked During Covid

Anxiety, disrupted routines and loneliness are fueling people’s food issues as they hunker down during the Covid-19 crisis.

Malinda Ann Hill decided to resume treatment for her eating disorder almost as soon as she shifted to working remotely in March 2020. She knew even before the pandemic that isolation at home would be detrimental to her ongoing recovery from anorexia nervosa. “I had made a really distinct decision not to work from home, so that sent me into a tailspin,” said Ms. Hill, 49, who lives with her daughter in Wynnewood, Pa., and works as an art therapist and bereavement coordinator for a local hospital.

The community and structure of her workplace were helpful for someone who had struggled with disordered eating since her early teens. Sudden loneliness, mounting fears about the unfolding pandemic and a new lack of boundaries between work and home all helped tip off a relapse that Ms. Hill said had already been brewing.

“I thought maybe I should get back into treatment now,” she said. “Because this is going to be bad. And this is going to set off a lot of other people, too.”

Indeed, some doctors, therapists and dietitians who treat eating disorders, such as anorexia, bulimia and binge eating disorder, are reporting an overwhelming spike in the need for their services, with waiting lists growing at many practices and treatment centers across the country.

The National Eating Disorders Association reported a 41 percent increase in messages to its telephone and online help lines in January 2021 compared with January 2020. And in a study of about 1,000 American and Dutch people with eating disorders published last July, more than one-third of subjects reported that they were restricting their diet and increasing “compensatory behaviors,” like purging and exercise. Among the Americans, 23 percent also said they would regularly binge-eat stockpiled food.

“I’m seeing more clients, and I’m getting clients who are sicker when they come to me, because we cannot get them access to a higher level of treatment,” said Whitney Trotter, a registered dietitian and nurse in Memphis who provides one-on-one nutritional counseling for adolescents and adults of color with eating disorders. She noted that many in-patient treatment centers are fully booked due to the heightened demand.

The uptick in her practice stems from a mix of relapse cases, like Ms. Hill’s, and disorders that have newly taken hold in the past year. “I’m treating more teenagers, and also more teachers, doctors, nurses and other first responders and essential personnel,” Ms. Trotter said. “An eating disorder can manifest as a trauma response. Our nervous systems were not meant to deal with a long-term pandemic.”

How food scarcity can stoke eating disorders

Early on in the pandemic, fears around grocery store shortages and food access re-triggered some people’s disordered eating. “I found myself lying awake at 3 a.m., thinking, ‘What if there is no more baby food at the store?’” said Aneidys Reyes, 33, a stay-at-home father in Madison, Wis., who had been in eating disorder recovery for more than six years before the pandemic.

Mx. Reyes, who was raised as a girl, said that their eating disorder originally began as a coping strategy for the gender dysphoria they experienced as a teenager. Now that they identify as transgender, the urge to restrict food is less connected to body image anxieties. “It’s weird for me, because it’s not the same old eating disorder,” they said. “But once I’m at a certain level of anxiety, then my brain is like, ‘Do you remember these neuropathways? What if it’s what you’re eating? What if your clothes don’t fit tomorrow?’ All these old, familiar thoughts come back.”

Even after grocery store shortages eased, patients who were being treated for eating disorders struggled with how pandemic rules required them to navigate eating with less professional support. “For a patient who would previously have spent the day at a treatment center having all their meals provided for them, a virtual program requires so much more autonomy than they would have previously had,” said Lauren Muhlheim, a psychologist in private practice in Los Angeles.

Ms. Hill deliberately chose an in-person treatment program, even during the early days of social distancing, because she knew she needed hands-on help making decisions around what and how much to eat. When her program switched to virtual support, she had to think about meal planning again. “Suddenly I had to be in charge of the food,” she said. “They wanted me to have more variety, but I didn’t want to go back to the grocery store. I started having panic attacks.”

Our societal tendency, on social media especially, to demonize quarantine comfort eating and pandemic-related weight gain hasn’t helped. “The pressure to have used the pandemic time to have gotten or kept in shape is a big theme,” said Dr. Muhlheim. Ms. Hill said that “diet culture noise” had felt louder to her in the past year.

Why treating eating disorders over Zoom is harder

The majority of residential eating disorder treatment programs have stayed in-person, but they are typically reserved for patients who need the highest level of care due to the severity of their eating disorder behaviors or related medical complications. The next step down is known as a “partial hospitalization program,” where patients live at home and manage some meals themselves, but attend a mix of individual and group therapy meetings, plus meal support sessions (where eating is monitored so patients cannot restrict food or purge afterward), for anywhere from six to 11 hours a day.

Many such programs, as well as individual outpatient services (where patients have daily or weekly check-ins with a therapist or dietitian), have shifted to a virtual treatment model. In addition to leaving patients to navigate food shopping and meal preparation alone, the virtual model makes meal support sessions trickier. “You can’t tell as well from a camera how much someone is eating,” Dr. Muhlheim said.

Dr. Muhlheim said that she is also concerned about the loss of casual interactions that normally take place between participants in group treatment. “You can only have one conversation at a time on Zoom,” she said. “You can’t just pull someone over to chat, so you lose a lot of that connection.” In fact, in a recent survey of 63 eating disorder patients, 68 percent said they would not choose to continue with online therapy once in-person services resumed.

But some therapists said they are thrilled that virtual services have increased access for patients who would otherwise not be able to travel for treatment. “For my teacher clients, especially, virtual therapy is much more accessible because they can do a session on a planning period or right at the end of the school day,” noted Ms. Trotter, the dietitian. Virtual care can also be more affordable than residential treatment programs.

Sometimes it’s even free. In March of 2020, Diane Summers, a nutrition therapist in Seattle, asked her colleagues if anyone had time to offer no-cost meal support via Instagram Live. “I was kind of hoping for maybe two or three people a day to go live,” she said. “But we were just flooded with willingness to be a part of the project.” Therapists and dietitians signed up in every time zone, enabling the account (@covid19eatingsupport) to offer live meal support 24 hours a day for several months of the pandemic.

When teens fixate on restrictive eating

Teenagers have been particularly vulnerable to developing eating disorders during the pandemic, both because adolescence is already the most common time for such struggles to emerge and because of the added pressures they face now. “It’s a combination of the loss of structure, the loss of peer connections and the loss of their usual activities,” Dr. Muhlheim said. “They have all this time and they decide to focus on an exercise program, or maybe it feels like running is the only thing they can really still do. But we know exercise is a huge trigger.”

That’s how it started for Lily, a 16-year-old high school sophomore in Los Angeles who said that body image anxieties weren’t a big part of her life until the pandemic. “I don’t think weight loss was ever on my mind at all,” she said. “It was more of, ‘I love running, I have all this time, so why not push myself and see how far I can run?’” She began working out every day to fill the time previously occupied by school and team sports. “Lily is super book smart and school comes easily to her, so she’s had a lot of extra time,” with the switch to remote learning, her mom, Nikki, explained. (The family asked to use only their first names to protect Lily’s privacy.)

After a few weeks of intensive exercise, Nikki noticed that Lily was eating less at family meals, too. “I wasn’t necessarily skipping meals, but I was trying to eat less meat and dessert and more vegetables,” Lily said. “I thought I was being healthy.” But she also became more fixated on her weight and further curbed her eating.

In those who are vulnerable to eating disorders, even unintentionally dipping into a negative energy balance, which happens when you expend more energy than you consume in calories, can trigger the rigid, restrictive mindset that is the hallmark of most eating disorders, said Dr. Kenisha Campbell, director of adolescent medicine outpatient clinical services at the Children’s Hospital of Philadelphia.

“Eating disorders are brain disorders because the brain cannot function without appropriate nutrition. So once the ‘eating disorder brain’ is in control, they can’t make any decisions around eating,” explained Dr. Campbell, who specializes in eating disorder treatment. “We have to feed the brain, so the brain can fight the eating disorder.”

By December, Lily often felt dizzy and had developed a resting heart rate of 40 beats per minute, which was dangerously low for her. She was put on bed rest by her family doctor, and a psychologist prescribed an intensive family-based treatment in which her parents planned meals and monitored everything she ate. On tough days, it felt like the whole family was trapped in the house with her eating disorder, Nikki said.

Lily knows that once going out for dinner or getting ice cream with friends is again an option, she’ll be presented with more challenges than she currently has when eating in the safety of her own home. “It doesn’t feel like I have to miss out on things because of my eating disorder,” she said. “I’m missing out on everything because of the pandemic.”


Virginia Sole-Smith is the author of “The Eating Instinct: Food Culture, Body Image and Guilt in America,” and writes the newsletter Burnt Toast.

How to Lower Your Child’s Risk for Addiction

A strong sense of self-efficacy is one of the most powerful protective factors parents can give their children.

In the decade that I was an active alcoholic, my focus was on protecting my right to drink the way I wanted to drink, and keeping my drinking a secret from my family. From the day I got sober in 2013, however, my focus shifted to protecting my two sons from the genetic and environmental risks of addiction I’d strewn in their path.

For five years, I felt great about my efforts. I was setting a good example by being sober, my husband modeled healthy moderation and we were raising our kids with the support of a proverbial village of families we’d known and trusted for years.

Then, in 2018, my husband had a job opportunity that required us to leave that community and move to another state: Vermont. Our older son was already in college, so the change didn’t affect him too much, but our younger son, Finn, who was about to transition from middle to high school, was devastated.

“You are ruining my life,” he said, when we told him about the move. There was no yelling, no wild gesticulations, just a calm statement of fact, which was much, much worse.

According to all the research on risk for substance use disorder, the move had the potential to be a disaster for Finn. We had voluntarily exposed our 14-year-old boy to a host of risk factors for substance abuse during a vulnerable period of cognitive development on top of the genetic risk he already faced. A stressful physical and emotional transition that was out of his control? Check. Living in a state with permissive marijuana laws? Check. Sever ties with a peer group we trust? Check. Replace those peers and their supportive, loving parents with families we have never met? Check.

Before we moved, Finn had plenty of protections heaped on the prevention side of his metaphorical substance abuse scale: physical, financial and emotional stability; lack of stress; and his friends’ parents looking out for him and providing healthy models for sobriety, support and coping. My job was to figure out what I could do to balance the weight of his risk by loading the other side of the scale with as much protection as possible.

I could not help him make new friends, let alone pick their parents, but I could help restore Finn’s sense of control, agency and hope by building his sense of self-efficacy.

Self-efficacy, as defined by the psychologist Albert Bandura, is one’s belief in one’s ability to succeed; to regulate one’s thoughts, emotions and life; and to cope with challenges in a positive way. Self-efficacy is also the foundation for so many other positive traits, including resilience, grit, fortitude and perseverance. Self-efficacy is what gives kids a sense of control, agency and hope, even when the world around them feels out of control.

People with a weak sense of self-efficacy, on the other hand, tend to be pessimistic, inflexible, quick to give up, have low self-esteem, exhibit learned helplessness, get depressed, and feel fatalistic and hopeless. Not coincidentally, people who exhibit these traits are more likely to turn to drugs and alcohol to alleviate these negative feelings.

I wanted Finn to be able to talk to me about all his fears and anxiety around the move, and I knew that self-efficacy could help with that, too. It promotes open parent-child communication while helping kids resist peer pressure both directly and indirectly. Research shows that when a child believes he has the ability to resist peer pressure, he will be a lot more likely to do so, and further, he will be more likely to talk to his parents about those episodes of peer pressure when they arise. On the other hand, kids who don’t feel as if they can resist peer pressure don’t tend to talk to their parents about the things they do outside the home.

Lack of self-efficacy is a risk factor for substance abuse and other negative health outcomes, but when converted into its opposite and equal force, a strong sense of self-efficacy, it can be one of the most powerful protective factors we can give our children. Here are some practical ways parents can boost kids’ perceptions of their own self-efficacy and help kids with low self-efficacy get back on the right path:

Start with yourself.

Model, model, model self-efficacy for your kids. Start questioning your own assertions of “I can’t” with “I can’t yet,” then turn that perspective outward, toward your children. That helps kids believe competence is not congenital, it is learned, and often hard-won.

Give kids skills.

Praise alone won’t give your child a sense of self-efficacy or competence; these things come from the actual experience of trying, doing, failing, trying again, and succeeding. Give kids age-appropriate tasks that help them stay engaged and challenged while granting opportunities to taste success. Teach them how to make dinner from start to finish and see what they create on their own. Encourage your teen to take the family car to the garage and have that rattle behind the dash fixed.

Project optimism.

Optimism is about more than seeing a glass as half full; it’s a mind-set that has a very real impact on physical and mental health. Optimistic children are better able to resist learned helplessness and depression, whereas pessimists are much more likely to give in to feelings of helplessness and are consequently at much higher risk of suffering from a wide range of negative mental and physical health outcomes. According to the psychologist Martin Seligman, author of “The Optimistic Child,” pessimistic kids see obstacles as permanent, pervasive, and their fault. Optimistic children, on the other hand, view setbacks as temporary, specific and attributable to behaviors that can be changed. As Dr. Seligman explains: “Children learn their pessimism, in part, from their parents and teachers, so it is very important that you model optimism for your children as a first step.”

Make failures specific, but generalize success.

Guide children toward optimism by framing their success as generally as possible. If your daughter has a good day in math class, help her globalize that success. Instead of “I did well in math class because I paid attention,” move toward “School

is going well because I am doing all my assignments on time.” Help her expand her success beyond the boundaries of one class or one day.

Be specific in your praise.

General praise, such as “Good job!” is useless when it comes to bolstering self-efficacy in kids because it has no real meaning. Aim for behavior-specific praise that reinforces practices you want to encourage, such as, “I’m so proud of you for sticking with that project even when you got frustrated.” Behavior-specific praise describes the desired behavior, is specific to the child, and offers a positive, clear, statement.

Don’t go overboard with your praise.

Experts on the use of behavior-specific praise in the classroom recommend a 3:1 or 4:1 ratio of praise to correction, a ratio I have tried to maintain with my own students and children. I teach and parent older teens, but this guideline is effective for kids of any age. Research shows it not only boosts good behavior, but also creates a sense of community and positivity that helps kids hear our constructive criticism when it inevitably comes.

A belief in self-efficacy, Dr. Bandura writes in his book “Self-Efficacy: The Exercise of Control,” is “the foundation of human motivation, well-being, and accomplishments.” That might have been what my son needed most to get started in a new school, and not just as a protection against substance abuse. It could help him set and achieve goals, view obstacles as surmountable, have a lower fear of failure and approach new challenges with the assumption that he could succeed.

While I can’t know which, if any, of the preventions I’ve heaped on Finn during his adolescence will inoculate him against developing a substance use disorder, I do know that boosting his self-efficacy has been essential to building up his sense of competence, well-being and happiness.

One year after the move, Finn and I hiked up to the top of the mountain behind our house to pick wild huckleberries. We’d spent an hour or so crawling around on our hands and knees talking about whatever drifted through our minds, when Finn sat back on his heels, dumped a handful of berries into his mouth and admitted to being happy. What’s more, he was looking forward to his second year of high school. As we sat together, eating huckleberries and looking out over the Vermont landscape, I felt the weight of his risk ease from my shoulders, at least for a while.


Jessica Lahey is a former teacher and the author, most recently, of “The Addiction Inoculation,” from which this article is adapted.

Learning to Connect With My Male Friends

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I agree.


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

Weekly Health Quiz: Weight Gain, Covid and Exercise

1 of 7

During pandemic lockdowns, Americans gained, on average, about how many pounds a month?

Half a pound

1 pound

2 pounds

4 pounds

2 of 7

Spread of coronavirus at the gym would likely be highest among people attending this type of group exercise class:

Pilates

Yoga

Strength training

Spin class

3 of 7

Too much high-intensity exercise resulted in signs of damage to these cell structures, the energy generators found in every cell:

Ribosomes

Mitochondria

Lysozymes

Centrioles

4 of 7

Doctors are exploring a possible link between Covid-19 and ringing in the ears, a medical condition known as:

Anosmia

Dysgeusia

Tinnitus

Otitis

5 of 7

True or false? Once you’ve been fully vaccinated against coronavirus, you are fully protected against symptoms of Covid.

True

False

6 of 7

A study of patients in California who suffered from long-haul Covid found that this proportion had no cough, fever or other symptoms in the first 10 days after testing positive for coronavirus:

A tenth

A quarter

A third

Half

7 of 7

This psychiatric condition, formerly known as multiple personality disorder and depicted in films like “Sybil” and “The Three Faces of Eve,” now goes by this name:

Schizoaffective disorder

Borderline personality disorder

Dissociative identity disorder

Post-traumatic stress disorder

In ‘Hooked,’ Michael Moss Explores the Addictive Power of Junk Food

In “Hooked,” Michael Moss explores how no addictive drug can fire up the reward circuitry in our brains as rapidly as our favorite foods.

In a legal proceeding two decades ago, Michael Szymanczyk, the chief executive of the tobacco giant Philip Morris, was asked to define addiction. “My definition of addiction is a repetitive behavior that some people find difficult to quit,” he responded.

Mr. Szymanczyk was speaking in the context of smoking. But a fascinating new book by Michael Moss, an investigative journalist and best-selling author, argues that the tobacco executive’s definition of addiction could apply to our relationship with another group of products that Philip Morris sold and manufactured for decades: highly processed foods.

In his new book, “Hooked,” Mr. Moss explores the science behind addiction and builds a case that food companies have painstakingly engineered processed foods to hijack the reward circuitry in our brains, causing us to overeat and helping to fuel a global epidemic of obesity and chronic disease. Mr. Moss suggests that processed foods like cheeseburgers, potato chips and ice cream are not only addictive, but that they can be even more addictive than alcohol, tobacco and drugs. The book draws on internal industry documents and interviews with industry insiders to argue that some food companies in the past couple of decades became aware of the addictive nature of their products and took drastic steps to avoid accountability, such as shutting down important research into sugary foods and spearheading laws preventing people from suing food companies for damages.

PenguinRandomHouse

In another cynical move, Mr. Moss writes, food companies beginning in the late 1970s started buying a slew of popular diet companies, allowing them to profit off our attempts to lose the weight we gained from eating their products. Heinz, the processed food giant, bought Weight Watchers in 1978 for $72 million. Unilever, which sells Klondike bars and Ben & Jerry’s ice cream, paid $2.3 billion for SlimFast in 2000. Nestle, which makes chocolate bars and Hot Pockets, purchased Jenny Craig in 2006 for $600 million. And in 2010 the private equity firm that owns Cinnabon and Carvel ice cream purchased Atkins Nutritionals, the company that sells low-carb bars, shakes and snacks. Most of these diet brands were later sold to other parent companies.

“The food industry blocked us in the courts from filing lawsuits claiming addiction; they started controlling the science in problematic ways, and they took control of the diet industry,” Mr. Moss said in an interview. “I’ve been crawling through the underbelly of the processed food industry for 10 years and I continue to be stunned by the depths of the deviousness of their strategy to not just tap into our basic instincts, but to exploit our attempts to gain control of our habits.”

A former reporter for The New York Times and recipient of the Pulitzer Prize, Mr. Moss first delved into the world of the processed food industry in 2013 with the publication of “Salt Sugar Fat.” The book explained how companies formulate junk foods to achieve a “bliss point” that makes them irresistible and market those products using tactics borrowed from the tobacco industry. Yet after writing the book, Mr. Moss was not convinced that processed foods could be addictive.

“I had tried to avoid the word addiction when I was writing ‘Salt Sugar Fat,’” he said. “I thought it was totally ludicrous. How anyone could compare Twinkies to crack cocaine was beyond me.”

But as he dug into the science that shows how processed foods affect the brain, he was swayed. One crucial element that influences the addictive nature of a substance and whether or not we consume it compulsively is how quickly it excites the brain. The faster it hits our reward circuitry, the stronger its impact. That is why smoking crack cocaine is more powerful than ingesting cocaine through the nose, and smoking cigarettes produces greater feelings of reward than wearing a nicotine patch: Smoking reduces the time it takes for drugs to hit the brain.

But no addictive drug can fire up the reward circuitry in our brains as rapidly as our favorite foods, Mr. Moss writes. “The smoke from cigarettes takes 10 seconds to stir the brain, but a touch of sugar on the tongue will do so in a little more than a half second, or six hundred milliseconds, to be precise,” he writes. “That’s nearly 20 times faster than cigarettes.”

This puts the term “fast food” in a new light. “Measured in milliseconds, and the power to addict, nothing is faster than processed food in rousing the brain,” he added.

Mr. Moss explains that even people in the tobacco industry took note of the powerful lure of processed foods. In the 1980s, Philip Morris acquired Kraft and General Foods, making it the largest manufacturer of processed foods in the country, with products like Kool-Aid, Cocoa Pebbles, Capri Sun and Oreo cookies. But the company’s former general counsel and vice president, Steven C. Parrish, confided that he found it troubling that it was easier for him to quit the company’s cigarettes than its chocolate cookies. “I’m dangerous around a bag of chips or Doritos or Oreos,” he told Mr. Moss. “I’d avoid even opening a bag of Oreos because instead of eating one or two, I would eat half the bag.”

As litigation against tobacco companies gained ground in the 1990s, one of the industry’s defenses was that cigarettes were no more addictive than Twinkies. It may have been on to something. Philip Morris routinely surveyed the public to gather legal and marketing intelligence, Mr. Moss writes, and one particular survey in 1988 asked people to name things that they thought were addictive and then rate them on a scale of 1 to 10, with 10 being the most addictive.

“Smoking was given an 8.5, nearly on par with heroin,” Mr. Moss writes. “But overeating, at 7.3, was not far behind, scoring higher than beer, tranquilizers and sleeping pills. This statistic was used to buttress the company’s argument that cigarettes might not be exactly innocent, but they were a vice on the order of potato chips and, as such, were manageable.”

But processed foods are not tobacco, and many people, including some experts, dismiss the notion that they are addictive. Mr. Moss suggests that this reluctance is in part a result of misconceptions about what addiction entails. For one, a substance does not have to hook everyone for it to be addictive. Studies show that most people who drink or use cocaine do not become dependent. Nor does everyone who smokes or uses painkillers become addicted. It is also the case that the symptoms of addiction can vary from one person to the next and from one drug to another. Painful withdrawals were once considered hallmarks of addiction. But some drugs that we know to be addictive, such as cocaine, would fail to meet that definition because they do not provoke “the body-wrenching havoc” that withdrawal from barbiturates and other addictive drugs can cause.

The American Psychiatric Association now lists 11 criteria that are used to diagnose what it calls a substance use disorder, which can range from mild to severe, depending on how many symptoms a person exhibits. Among those symptoms are cravings, an inability to cut back despite wanting to, and continuing to use the substance despite it causing harm. Mr. Moss said that people who struggle with processed food can try simple strategies to conquer routine cravings, like going for a walk, calling a friend or snacking on healthy alternatives like a handful of nuts. But for some people, more extreme measures may be necessary.

“It depends where you are on the spectrum,” he said. “I know people who can’t touch a grain of sugar without losing control. They would drive to the supermarket and by the time they got home their car would be littered with empty wrappers. For them, complete abstention is the solution.”

Teenagers, Anxiety Can Be Your Friend

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

For many teenagers, anxiety is riding high these days.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


First Covid, Then Psychosis: ‘The Most Terrifying Thing I’ve Ever Experienced’

Ivan Agerton pulled his wife, Emily, into their bedroom closet, telling her not to bring her cellphone.

“I believe people are following me,” he said, his eyes flaring with fear.

He described the paranoid delusions haunting him: that people in cars driving into their suburban Seattle cul-de-sac were spying on him, that a SWAT officer was crouching in a bush in their yard.

It was a drastic change for the 49-year-old Mr. Agerton, a usually unflappable former marine and risk-taking documentary photographer whose most recent adventure involved exploring the Red Sea for two months in a submarine. He was accustomed to stress and said that neither he nor his family had previously experienced mental health issues.

But in mid-December, after a mild case of Covid-19, he was seized by a kind of psychosis that turned life into a nightmare. He couldn’t sleep, worried he had somehow done something wrong, suspected ordinary people of sinister motives and eventually was hospitalized in a psychiatric ward twice.

“Like a light switch — it happened this fast — this intense paranoia hit me,” Mr. Agerton said in interviews over two months. “It was really single-handedly the most terrifying thing I’ve ever experienced in my life.”

Mr. Agerton’s experience reflects a phenomenon doctors are increasingly reporting: psychotic symptoms emerging weeks after coronavirus infection in some people with no previous mental illness.

Doctors say such symptoms may be one manifestation of brain-related aftereffects of Covid-19. Along with more common issues like brain fog, memory loss and neurological problems, “new onset” psychosis may result from an immune response, vascular issues or inflammation from the disease process, experts hypothesize. Sporadic cases have occurred with other viruses, and while such extreme symptoms are likely to affect only a small proportion of Covid survivors, cases have emerged worldwide.

Much about the condition remains mysterious. Some patients feel urges to harm others or themselves. Others, like Mr. Agerton, have no violent impulses but become almost obsessively paranoid. Some need weeks of hospitalization with doctors trying different medications, while others improve faster. Some patients relapse.

Mr. Agerton spent about a week in a psychiatric ward in December, missing Christmas with his wife and three children. By mid-January, he seemed to have recovered and his doctor planned to taper his antipsychotic medication. In February, however, “the paranoia came screaming back,” Mr. Agerton said in an interview a day before being hospitalized a second time.

“I have all these questions,” said Dr. Veronika Zantop, a psychiatrist who has treated Mr. Agerton since his first hospitalization and who confirmed that he had no previous mental health issues. Among them: “Is this temporary? You know, how long does the risk continue?”

Paranoid delusions more commonly accompany schizophrenia in late adolescence or dementia in older adults, but so far, post-Covid psychosis has mostly afflicted patients in their 30s, 40s and 50s.

One of Mr. Agerton’s tattoos, the state of Nevada, where he grew up. A former Marine who works as a documentary photographer, Mr. Agerton said neither he nor his family had any history of mental illness.
One of Mr. Agerton’s tattoos, the state of Nevada, where he grew up. A former Marine who works as a documentary photographer, Mr. Agerton said neither he nor his family had any history of mental illness.Jovelle Tamayo for The New York Times

Another notable difference: Some post-Covid patients have realized something was wrong, while typical psychosis patients often “don’t have insight into their symptoms,” Dr. Zantop said.

With Mr. Agerton, she said, “It’s almost like he had a split self where he was able to say, ‘My brain is telling me that the police are after me.’ And then he was also able to say, ‘I know that’s not true on some level, but it feels like reality to me.’”

After a December New York Times article about post-Covid psychosis, several people reached out to say they, or someone they knew, had experienced it. Mr. Agerton said he wanted to share his experience to help others by raising awareness of the condition.

Mr. Agerton tested positive for the coronavirus in late November after returning from the Red Sea. Because the expedition team followed strict precautions, he assumes he became infected while flying home. With a low fever, mild respiratory symptoms and a loss of smell, he isolated in a bedroom at home on Bainbridge Island near Seattle for 10 days, protecting Ms. Agerton, 46, and their children, ages 5, 11 and 16.

Then, on Dec. 17, an ordinary spam call on his cellphone triggered a cascade of paranoia linked to technology, surveillance and government agents.

“I started having these auditory hallucinations,” he said. He would jump to the window at night, imagining voices outside. Fearing that families looking at their neighborhood’s Christmas lights were conducting espionage, he would grab the family’s Australian shepherd, Duke, and walk outside “to get eyeballs on the people in the car,” he said. Then, he would become convinced that police scanners were broadcasting his dog walking and every other move he made.

“I couldn’t control myself,” he said, adding “I was just thinking ‘I’m losing my mind.’”

After two mostly sleepless days of keeping it to himself, he confided in his wife, who was stunned. “To have your person that is great in a crisis experiencing a crisis was for me just total helplessness and fear,” she said.

He asked her to place the family’s phones in airplane mode and worried their house was bugged. He became “out-of-his-skin anxious” about an ambulance siren, said Ms. Agerton, who drove him around looking for it. “Probably every 30 minutes, he needed to make the rounds outside and see what was out there.”

She took him shopping, thinking “something as mindless as Costco would kind of help it be just a normal day,” but said he feared shoppers were plainclothes agents. “It was really torture for him.”

That evening, she called a friend, a nurse with mental health experience.

“You need to get to the emergency department right now,” the friend urged, adding, “lock up any guns,’” Ms. Agerton said.

Although Mr. Agerton had no suicidal or homicidal thoughts, his wife added an extra locking mechanism to a safe containing a pistol. “That he could harm himself or me or the kids hadn’t even occurred to me, but that’s an entirely different element of fear and protection that starts to surge through you,” she said.

Emergency room doctors ruled out a brain tumor and sent him home with sleeping pills. But after he slept, “the delusions picked right back up where he said good night to them the night before,” his wife said. “It was progressively worse. It was something new every 10 minutes.”

Ms. Agerton, a health care administrator and part-time graduate student studying organizational leadership, desperately sought psychiatric help for him. Finally, her nurse friend found space at the Swedish Medical Center in Seattle.

On the ferry to Seattle, Mr. Agerton imagined a FedEx truck driver was hacking their cellphones. At the hospital, a wrong-number call to the phone in his room rattled him. “It was this snowball effect,” he recalled.

“When he came to us, he was very psychotic,” said Dr. Zantop, who focuses on intersections between medical, neurological and psychiatric issues at the Swedish center. “He was having a really hard time functioning with these constant thoughts that he’s about to get picked up by the police or thrown into jail.”

He asked his wife to inform two photographer friends, explaining his absence from their text group.

“Ivan is a very self-aware, in-control-with-chaos guy,” said one, Vincent Laforet, who contacted anyone who might help, including the firm leading the Red Sea expedition, OceanX. “When that type of person reaches out to you through his wife, it’s almost like sending out an S.O.S. broadcast of ‘I’m losing control.’”

Vincent Pieribone, OceanX’s vice chairman and a Yale neuroscience professor, spoke with Mr. Agerton’s doctors. He said it was crucial that Mr. Agerton recognized he was in trouble and was not ashamed to seek help.

An M.R.I. and other tests found no identifiable problems, said Dr. Zantop, who dove into researching Covid-linked cases.

At first, Mr. Agerton wept and stared outside at a parking structure “where I thought guys were watching me,” he said. His photographer’s eye was discomfited by hospital lighting he said was “out of a bad movie.”

On Christmas, he spoke to his family by phone. “It was really sad,” his wife said.

He worried how their children would process his situation. He hoped doctors wouldn’t blame stress or danger from his job, which he loves.

“Part of me was thinking, ‘This is who I am and my career is over, my life is over,’” he said, his voice breaking.

Dr. Zantop said an antipsychotic medication, as well as information and assurances, including that security guards weren’t after him, helped him “kind of calm down.”

He also immersed himself in books about Napoleon and the Lost Boys of Sudan, although, he said, “I’d have to reread paragraphs two, three, four times.”

Recently, Mr. Agerton said he felt better, with most of the paranoia gone and his sense of smell is beginning to return. He hopes that signals lasting improvement. Jovelle Tamayo for The New York Times

Shortly before New Year’s Day, he returned home. Five days later, he estimated he was 85 percent recovered, except for “little twinges” like thinking a neighbor’s air vent was a submarine periscope.

Dr. Zantop found that Mr. Agerton was doing well. In mid-January, after his 50th birthday, he said he felt “100 percent.” But a month later, a headline about a police raid reignited the symptoms. He felt less anxiety than before, he said, but “my paranoia was overwhelming my rational mind,” making it “harder this time.”

He worried, “they were coming after me and I would lose my family,” he said. “It’s not real, but it feels so real, and it’s frightening and it’s lonely.”

Dr. Zantop said Mr. Agerton interrupted a telemedicine session that week to run outside and check an unfamiliar car’s license plate, and he expressed suspicion of helicopters flying over the house and a man with a backpack walking by.

“I was surprised that it came back, honestly,” she said.

She increased his antipsychotic, and added an anti-anxiety medication and two antioxidant supplements, but outpatient treatment wasn’t helping enough, she said.

Ms. Agerton said her husband’s paranoia seemed exacerbated by his being in their house, which they’d begun renting shortly before his first psychotic episode, so he associated it with that trauma. During his second hospitalization, he told her he felt safe. They plan to move when their lease ends.

In the hospital, Dr. Zantop prescribed different antipsychotic and anti-anxiety medications. Six days later he had improved enough to return home.

Recently, Mr. Agerton said he felt considerably better, with 90 percent of the paranoia gone. His sense of smell is beginning to return. He hopes that signals lasting improvement.

It’s unclear how long he will need medication and when he will be able to resume his adventurous work.

“There’s this fear of how long is this going to happen,” he said. “How long am I going to live with this?”

‘Busy Inside,’ a New Documentary, Explores Dissociative Identity Disorder

The condition, formerly called multiple personality disorder, affects a surprising 1 percent of the population.

Twenty-eight-year-old Marshay refers to herself as “the Little One” and says she feels as if she was born six years ago. Her mother knows something really bad must have happened to her when she was very young, although she doesn’t know what happened. When she asks her daughter why she thinks she’s still a small child, Marshay answers, “I don’t remember anything. I don’t want to grow up. I want to stay little.”

Marshay’s brain periodically seeks a safe haven, a persona where she feels immune to some horrific abuse she apparently suffered early in life. She has other identities as well who “come out” when provoked by certain triggering events and she needs these alternate identities to feel safe.

Marshay is one of several people with dissociative identity disorder who are featured in a new documentary called “Busy Inside,” available on public television’s World Channel: America ReFramed. It can be watched free online through April 15. She is among a surprising 1 percent of the population with this psychiatric condition, formerly called multiple personality disorder, which was famously portrayed decades ago in films like “The Three Faces of Eve” and “Sybil.” It mostly affects women.

The new film shows the challenges involved in learning to live with the disorder. Still, most of those affected never seek professional help until and unless their lives become unmanageable.

Karen Marshall, Marshay’s therapist, a licensed social worker, also has the disorder, and told me that 17 different personalities inhabit her psyche and can emerge from time to time. She suffered severe sexual and physical abuse as a young child at the hands of her mother, and said she experienced tremendous relief when she died “and couldn’t hurt me anymore.” She says her own trauma, and the ways she learned to manage it, has helped her be an effective therapist.

Dr. David Spiegel, a Stanford University psychiatrist who gave the disorder its modern name, explained, “We develop our identity in childhood, and if you’re abused by someone who is supposed to love and protect you, you try to detach yourself from” that abusive situation. “In extreme forms, you assume other identities. It becomes a disorder.” The hippocampus, a part of the brain that deals with stress, may shrink and cause an extreme sensitivity to stress hormones, he said.

Early in life when the brain can’t handle something, “it puts it in a little box in the brain,” Ms. Marshall said. Then something else it can’t handle goes into another compartment in the brain, and so forth, resulting in some people developing different personalities, any of which can take over for a time.

A woman in the film named Sarah who has seven or eight identities describes her childhood trauma as being in a freezing cold basement with few clothes on and two men grabbing at her while others stood around laughing. “I can see this happening but I can’t stop it,” she recalls. “The monster keeps coming out, obliterating everything.”

In the documentary, Ms. Marshall encourages Marshay to accept herself as an adult woman with many facets, saying reassuringly, “We all have different roles, and we all wear different masks in a way.”

For those with the disorder, when an alternate identity takes over, the person may lose track of time and have no memory of what the other personality did while it was “out.” Ms. Marshall said one woman she treated had an alternate personality who was a shoplifter and when she reverted to her main identity, had no idea how she had acquired all the things in her apartment.

Dissociative identity disorder is both underdiagnosed and often misdiagnosed as depression or anxiety disorder and consequently mistreated, Dr. Spiegel said. Once affected individuals acknowledge that they have a problem, it takes an average of six years for them to learn what is causing their symptoms if they should seek help, Dr. Spiegel said.

Some people with the disorder never do, and somehow manage to live normal lives until and unless something very stressful causes their alternate identities to take over and disrupt their ability to function. For example, Ms. Marshall told me, one person in the film performed well as a company executive for many years until a family trauma so unnerved her that her identities split, very hostile and disabling personalities emerged and she could no longer do her job.

Dr. Spiegel said some people with the disorder “are afraid of treatment or ambivalent about it; they don’t believe I’m here to help them because, based on their history, they see helpers as potentially harming them.”

Alternate identities can also emerge at the same time, as if the person is two people who oppose one another. The identities develop specialized roles, coming out under certain circumstances, Dr. Spiegel said. For example, one identity may “protect” against another that might be aggressive or harmful. The protective identity may think, “I’m going to stay out while so-and-so is around,” he said. As Ms. Marshall explained, people can have one or two identities that act as gatekeepers, keeping the others inside.

In treatment, by identifying and emphasizing the person’s core values and beliefs, the person’s adult identity that enables them to function normally can learn to take over for identities that are distressing or troublemakers, Ms. Marshall said.

Her approach to treatment does not necessarily try to rid people of their alternate identities unless, of course, that’s what they want to accomplish. Rather, she said, they may learn to use their alternates constructively so they can live a normal life as an adult in society.

Also helpful is learning to recognize circumstances that can prompt a distressing identity to emerge and temporarily replace the adult persona. Ms. Marshall said she has learned, “If I’m tired or sick or stressed, I can end up splitting,” and a childlike personality emerges.

As in post-traumatic stress disorder, people with multiple identities can have flashbacks and experience their abuse all over again. Ms. Marshall said, “I don’t watch shows about child abuse.” In treating dissociative identity disorder, she said, “I try to get the ‘Little Ones,’ who were traumatized, to know they’re safe, that they’re not going to be hurt again.”

Dr. Richard P. Kluft, a psychiatrist in Bala Cynwyd, Pa., focuses therapy for the disorder on providing “good, caring, nurturing, comforting support” that helps patients feel safe. “The mind starts to heal in the face of loving care,” he said. Both he and Dr. Spiegel often use hypnosis to facilitate therapy and teach patients how to calm themselves down with self-hypnosis between sessions.

For patients reluctant to leave behind their “rich inner world,” Dr. Kluft says he welcomes all parts of their personality, helping their various identities learn to empathize with and respect one another.

Ms. Marshall said that as people with multiple identities start to get healthier, “they can look at what they’re feeling and experiencing and then make a different choice. They can learn to use their alternates constructively so they can function in society as an adult person,” which Marshay is gradually learning to do.

Yearning for Life on Tour, Roadies Open Up Online

Backstage music crews were set adrift by the pandemic. For some, a weekly Zoom group has been the answer.

LONDON — William Frostman, a lighting supervisor who has toured with the Rolling Stones and Queen, has just spent a whole year at home, the longest time in his decades-long career.

“I just want to wake up on a bus,” Frostman, 60, told dozens of his fellow roadies on a recent Zoom call.

Nostalgic as he was for life on the road, there were a few fears at the back of his mind, he said: Would anyone employ him? How would a vaccine passport work?

There was another big issue, too, Frostman added. He loved seeing his family every day during the pandemic. “Am I going to be mentally ready to wake up on a bus each morning and go, ‘They’re not here’?” he said.

In the Zoom grid onscreen, several roadies nodded in agreement.

In the popular imagination, those skilled crew members who make music tours work are taciturn figures, dressed in all black, who talk about music, but not much else. We don’t think of roadies opening up about their feelings. But the tour managers, sound engineers, lighting technicians and others who call into the Back Lounge support group every Wednesday couldn’t be further from that outdated image.

The crew of a European tour by Katie Melua and the Gori Women’s Choir that Green organized, at Liverpool Philharmonic Hall in Liverpool, England, in 2018.
The crew of a European tour by Katie Melua and the Gori Women’s Choir that Green organized, at Liverpool Philharmonic Hall in Liverpool, England, in 2018.Simon Schofield

The group’s members weren’t there to chat about bands, but to check in on each other’s mental health.

A year into the coronavirus pandemic, many are hoping that cultural life will soon restart. Concerts are set to resume in New York next month, albeit with tiny audiences. In England, the government has said entertainment events will be allowed again from May 17, if infection levels are under control.

But for many roadies — who often rely on monthslong world tours to make a living — a return to full-time work feels a long way off.

“My fear is being disappointed again,” said Suzi Green, a veteran tour manager who set up the group, adding that she was concerned restrictions would be reimposed.

Other members had their own worries. Some were scared that they wouldn’t get work when concerts returned. One said she feared if she did find work, she’d go back to unhealthy on-the-road habits, like surviving solely on pizza.

The mental health impact of the pandemic on touring crew members has been widespread. Last November, the Production Services Association and other British organizations representing live events workers surveyed its membership on the issue. Half the 1,700 respondents said they had suffered depression, and nearly 15 percent said they had experienced suicidal thoughts.

Green, who has run tours for musicians including PJ Harvey and James Blake, started the Back Lounge last June after finding herself, “really depressed, in a real state” she said in a telephone interview.

When events were canceled last March, she felt as if she’d lost her whole identity, she said. “As a lifestyle, you’re away nine, 10 months a year,” she said. “It’s your whole life.”

One of Green’s friends, a teacher, told her that they had benefited from attending a professional support group during the pandemic, and she wondered if there was anything out there for people in her own line of work. She did a search online and found Backline Care, a Brooklyn-based nonprofit group that promotes mental health in the music industry.

An online meeting that she attended organized by Backline Care was “a lifesaver,” she said. So Green decided to create something similar for British and European music crews who would find it difficult to join the U.S. meetings because of the time difference.

The first Back Lounge — named after the area at the rear of a tour bus where staff members chill out after shows — took place one Wednesday last June, at 6 p.m. It has been running at the same time every week since, attracting attendees ranging from industry veterans who run stadium shows, to up-and-coming tour managers who drive small bands around Europe.

Green has brought in guests including therapists and personal trainers, but the focus is always on the roadies talking about what’s on their mind, Green said.

Clockwise from top left: Nathalie Candel, a tour manager who attends the Back Lounge, backstage in Oslo in 2019; Debbie Taylor, another regular attendee, at the Forum in Los Angeles; William Frostman, right, at a show in London with the show’s lighting designer.Rob Gwin; via Debbie Taylor; via William Frostman

“I didn’t know I needed it, but I needed it,” Frostman, the lighting supervisor, said later in a telephone interview, adding that he has been working as a mail carrier to make ends meet. “It’s nice being on a call where people understand you,” he added.

Simon Schofield, 52, who is usually in charge of film and graphics displays on major tours, said the Back Lounge had helped him to deal with a host of emotions during the pandemic. There was a point last year, he said, when he couldn’t listen to the radio, because he’d hear “every single band I’d toured with, and it’d be a bombardment of reminding of what my life used to be like.”

As well as attending the Back Lounge, he said, he has been having therapy and taking antidepressants, but the group has been helpful, too. “It’s such a weight off your mind, off your soul, to know other people are feeling and suffering the way you are,” he said.

Said Schofield: “Our industry is terrible when it comes to mental illness. You don’t talk about it until it’s too late, and we need to be more compassionate.”

Nathalie Candel, 29, a tour manager who regularly attends the Back Lounge, said she hoped the group would continue to meet once the industry got back on the road. “We need to look at what we put people though on tour,” she said. Some crew members, including herself, had boasted about working 19-hour days, she added, and that clearly was not healthy.

One recent Wednesday, the Back Lounge was back in session, to discuss the theme of “being left behind.”

Some of the roadies said they feared that the music industry had moved on without them or that their contacts had moved into new lines of work. “The fear of being left behind is very real,” said Debbie Taylor, who manages the crew for Guns N’ Roses world tours. “It’s something I have nightmares about,” she added.

The tone was serious, but then Keith Wood, a stadium tour manager, brightened the mood.

“I’ll tell you a story about being left behind,” Wood said, before launching into a tale about the time one of Suzanne Vega’s tour buses drove off without him at a truck stop in Nebraska. That was before cellphones, he said, and he only made it to the tour’s next stop with the help of a friendly local pilot.

Everyone laughed, and, for a moment, their worries were relieved. But then came the longing for the road.

“I miss being on a bus so much,” Taylor said.

“You and me both,” added Frostman.

Health Care Workers on the Frontline Face a Year of Risk, Fear and Loss

Gabrielle Dawn Luna followed her father into emergency nursing. She was the last person to hold his hand when he died of Covid in April at her hospital in Teaneck, N.J.
Gabrielle Dawn Luna followed her father into emergency nursing. She was the last person to hold his hand when he died of Covid in April at her hospital in Teaneck, N.J.Credit…Calla Kessler for The New York Times

A Year of Risk, Fear and Loss for Families in Medicine

For many nurses and doctors, medicine was an inherited calling and one that bound couples. Then the virus threatened the ones they love.

Gabrielle Dawn Luna followed her father into emergency nursing. She was the last person to hold his hand when he died of Covid in April at her hospital in Teaneck, N.J.Credit…Calla Kessler for The New York Times

  • March 12, 2021, 9:42 a.m. ET

Gabrielle Dawn Luna sees her father in every patient she treats.

As an emergency room nurse in the same hospital where her father lay dying of Covid last March, Ms. Luna knows firsthand what it’s like for a family to hang on to every new piece of information. She’s become acutely aware of the need to take extra time in explaining developments to a patient’s relatives who are often desperate for updates.

And Ms. Luna has been willing to share her personal loss if it helps, as she did recently with a patient whose husband died. But she has also learned to withhold it to respect each person’s distinct grief, as she did when a colleague’s father also succumbed to the disease.

It’s challenging, she said, to allow herself to grieve enough to help patients without feeling overwhelmed herself.

“Sometimes I think that’s too big a responsibility,” she said. “But that’s the job that I signed up for, right?”

The Lunas are a nursing family. Her father, Tom Omaña Luna, was also an emergency nurse and was proud when Ms. Luna joined him in the field. When he died on April 9, Ms. Luna, who also had mild symptoms of Covid-19, took about a week off work. Her mother, a nurse at a long-term-care facility, spent about six weeks at home afterward.

“She didn’t want me to go back to work for fear that something would happen to me, too,” Ms. Luna said. “But I had to go back. They needed me.”

When her hospital in Teaneck, N.J. swelled with virus patients, she struggled with stress, burnout and a nagging fear that left her grief an open wound: “Did I give it to him? I don’t want to think about that, but it’s a possibility.”

Like the Lunas, many who have been treating the millions of coronavirus patients in the United States over the past year come from families defined by medicine. It is a calling passed through generations, one that binds spouses and connects siblings who are states apart.

It’s a bond that brings the succor of shared experience, but for many, the pandemic has also introduced a host of fears and stresses. Many have worried about the risks they’re taking and those their loved ones face every day, too. They worry about the unseen scars left behind.

And for those like Ms. Luna, the care they give to coronavirus patients has come to be shaped by the beloved healer they lost to the virus.

Working through grief

Dr. Shawki Zuabi, right, who was from Nazareth, Israel, loved painting, fishing and rich conversation.Credit…Gabriella Angotti-Jones for The New York Times
“He believed in me so much,” Dr. Nadia Zuabi said. They had talked about working together one day.Credit…Gabriella Angotti-Jones for The New York Times

For Dr. Nadia Zuabi, the loss is so new that she still refers to her father, a fellow emergency department physician, in the present tense.

Her father, Dr. Shawki Zuabi, spent his last days in her hospital, UCI Health in Orange County, Calif., before dying of Covid on Jan. 8. The younger Dr. Zuabi almost immediately returned to work, hoping to keep going through purpose and her colleagues’ camaraderie.

She had expected that working alongside the people who had cared for her father would deepen her commitment to her own patients, and to some extent it has. But mainly, she came to realize how important it is to balance that taxing emotional availability with her own well-being.

“I try to always be as empathetic and compassionate as I can,” Dr. Zuabi said. “There’s a part of you that maybe as a survival mechanism has to build a wall because to feel that all the time, I don’t think it’s sustainable.”

Work is filled with reminders. When she saw a patient’s fingertips, she recalled how her colleagues had also pricked her father’s to check insulin levels.

“He had all these bruises on his fingertips,” she said. “It just broke my heart.”

The two had always been close, but they found a special connection when she went to medical school. Physicians often descend from physicians. About 20 percent in Sweden have parents with medical degrees, and researchers believe the rate is similar in the United States.

The older Dr. Zuabi had a gift for conversation and loved talking about medicine with his daughter as he sat in his living room chair with his feet propped up. She is still in her residency training, and throughout last year she would go to him for advice on the challenging Covid cases she was working on and he’d bat away her doubts. “You need to trust yourself,” he’d tell her.

When he caught the virus, she took time off to be at his bedside every day, and continued their conversations. Even when he was intubated, she pretended they were still talking.

She still does. After difficult shifts, she turns to her memories, the part of him that stays with her. “He really thought that I was going to be a great doctor,” she said. “If my dad thought that of me, then it has to be true. I can do it, even if sometimes it doesn’t feel like it.”

Love tempered by risk and horror

“We definitely have cathartic moments together where we just let it all out,” said Dr. Fred E. Kency Jr., who met his wife in medical school.Credit…Rory Doyle for The New York Times

In the same way that medicine is often a passion grown from a set of values passed from one generation to the next, it’s also one shared by siblings and one that draws healers together in marriage.

About 14 percent of physicians in the United States have siblings who also earned medical degrees, according to an estimate provided by Maria Polyakova, a health policy professor at Stanford University. And a fourth of them are married to another physician, according to a study published in the Annals of Internal Medicine.

In interviews with a dozen doctors and nurses, they described how it has long been helpful to have a loved one who knows the rigors of the job. But the pandemic has also revealed how frightening it can be to have a loved one in harm’s way.

A nurse’s brother tended to her when she had the virus before volunteering in another virus hot spot. A doctor had a bracing talk with her children about what would happen if she and her husband both died from the virus. And others described quietly weeping during a conversation about wills after putting their children to bed.

Dr. Fred E. Kency Jr., a physician at two emergency departments in Jackson, Miss., understood that he was surrounded by danger when he served in the Navy. He never expected that he would face such a threat in civilian life, or that his wife, an internist and pediatrician, would also face the same hazards.

“It is scary to know that my wife, each and every day, has to walk into rooms of patients that have Covid,” Dr. Kency said, before he and his wife were vaccinated. “But it’s rewarding in knowing that not just one of us, both of us, are doing everything we possibly can to save lives in this pandemic.”

The vaccine has eased fears about getting infected at work for those medical workers who have been inoculated, but some express deep concerns about the toll that working through a year of horrors has taken on their closest relatives.

“I worry about the amount of suffering and death she’s seeing,” Dr. Adesuwa I. Akhetuamhen, an emergency medicine physician at Northwestern Medicine in Chicago, said of her sister, who is a doctor at the Mayo Clinic in Rochester, Minn. “I feel like it’s something I’ve learned to cope with, working in the emergency department before Covid started, but it’s not something that’s supposed to happen in her specialty as a neurologist.”

“Of all my family members, I worry about her the most,” Dr. Adesuwa I. Akhetuamhen said.Credit…Sebastian Hidalgo for The New York Times
“We keep each other safe,” Dr. Eseosa T. Ighodaro said.Credit…Caroline Yang for The New York Times

She and her sister, Dr. Eseosa T. Ighodaro, have regularly talked on the phone to compare notes about precautions they’re taking, provide updates on their family and offer each other support. “She completely understands what I am going through and gives me encouragement,” Dr. Ighodaro said.

The seemingly endless intensity of work, the mounting deaths and the cavalier attitudes some Americans display toward safety precautions have caused anxiety, fatigue and burnout for a growing number of health care workers. Nearly 25 percent of them most likely have PTSD, according to a survey that the Yale School of Medicine published in February. And many have left the field or are considering doing so.

Donna Quinn, a midwife at N.Y.U. Health in Manhattan, has worried that her son’s experience as an emergency room physician in Chicago will lead him to leave the field he only recently joined. He was in his last year of residency when the pandemic began, and he volunteered to serve on the intubation team.

“I worry about the toll it’s taking on him emotionally,” she said. “There have been nights where we are in tears talking about what we’ve encountered.”

She still has nightmares that are sometimes so terrifying that she falls out of bed. Some are about her son or patients she can’t help. In one, a patient’s bed linens transform into a towering monster that chases her out of the room.

A nurse’s purpose

When Ms. Luna first returned to her emergency room at Holy Name Medical Center in Teaneck, N.J., after her father died, she felt as though something was missing. She had gotten used to having him there. It had been nerve-racking as every urgent intercom call for a resuscitation made her wonder, “Is that my dad?” But she could at least stop by every now and again to see how he was doing.

More than that though, she had never known what it was like to be a nurse without him. She remembered him studying to enter the field when she was in elementary school, coloring over nearly every line in his big textbooks with yellow highlighter.

Over breakfast last March, Ms. Luna told her father how shaken she was after holding an iPad for a dying patient to say goodbye to a family who couldn’t get into the hospital.

“This is our profession,” she recalled Mr. Luna saying. “We are here to act as family when family can’t be there. It’s a hard role. It’s going to be hard, and there will be more times where you’ll have to do it.”

Tom Omaña Luna, who was from the Philippines, had warm humor, deep faith and a funny way of shuffling his feet as he walked through the family home in Woodbridge, N.J. “I just miss it,” his daughter said.Credit…Calla Kessler for The New York Times

Kitty Bennett contributed research.

How Meghan Markle Has Already Changed the Way We Talk About Suicide

How Meghan Markle Has Already Changed the Way We Talk About Suicide

Meghan’s decision to speak openly about her suicidal thoughts challenges a culture of secrecy that has stopped many people from seeking or offering help.

Credit…Neil Hall/EPA, via Shutterstock

  • March 9, 2021, 10:21 a.m. ET

To many people, suicide is unspeakable. Even mental health professionals sometimes do verbal gymnastics to avoid saying the word.

That’s why Meghan Markle’s decision to talk openly about her suicidal thoughts in her interview with Oprah Winfrey has the potential to change the way we all talk about suicide. By speaking about her experiences, Meghan helped chip away at the stigma that constrains people from disclosing their suicidal thoughts. Her disclosure also educates others about the universality of suicide risk. Nobody is immune, whether they live in a palace or in poverty.

But many people keep suicidal thoughts to themselves, while friends, family and even mental health professionals often don’t ask those in distress if they’re considering suicide. In my work as a psychotherapist and suicidologist, I train mental health professionals and students how to interview people to assess suicide risk. Professionals with decades of experience have told me they don’t dare ask a client with depression or other major risk factors if they’re thinking of suicide.

More than one therapist has told me something like, “I don’t want to give them the idea” or, “If they’re thinking of suicide, they’ll tell me.”

It’s a myth that talking about suicide gives somebody the idea. Research consistently shows that asking somebody about suicide, even several times a day, doesn’t cause or increase suicidal thoughts. Even among children, by the third grade most kids already have a clear sense of what suicide is on their own.

It’s also a myth that most people will admit they’re considering suicide if asked directly. Many people don’t answer honestly because of embarrassment, fears of being hospitalized against their will, fears of being judged, fears that they can’t be helped or a desire not to worry others.

At first, Meghan didn’t speak directly about suicide, either. In her interview with Ms. Winfrey, she described how trapped, maligned and miserable she felt in her royal role, one that she said engendered racist attacks in the media based on her heritage. (Her mother is African-American, and her father is white.)

“I just didn’t see a solution,” she told Ms. Winfrey. “But I knew that if I didn’t say it that I would do it — and I just didn’t want to be alive anymore. And that was a very clear and real and frightening constant thought.”

“I would do it.” That’s what she said — not, “I would kill myself” or “I would end my life.” Simply, “it.” Ms. Winfrey had to say outright, “So, were you thinking of harming yourself? Were you having suicidal thoughts?”

“Yes,” Meghan said, “this was very, very clear.”

Later, we learned just how clear it was. She recalled what she told her husband: “It was like, these are the thoughts that I’m having in the middle of the night that are very clear, and I’m scared, because this is very real. This isn’t some abstract idea. This is methodical, and this is not who I am.”

Meghan said she asked a senior member of the royal family about the possibility of being hospitalized for her mental health problems but said that this person refused in order to protect the family’s image. She said she was too scared to be left alone, worried that she might end her life. So she confided in Prince Harry, who supported her emotionally but didn’t share the extent of her troubles with his family.

“I guess I was ashamed of admitting it to them, and I don’t know whether they’ve had the same feelings or thoughts,” he told Ms. Winfrey. “I have no idea. It’s a very trapping environment that a lot of them are stuck in.”

This is why Meghan’s disclosure is a gift to so many strangers. You don’t have to be royalty to be trapped into silence. According to one 2015 study, almost 10 million American adults had seriously considered suicide during the previous year; a 2019 survey found that almost one in five high school students had such thoughts. Despite the relatively high prevalence of suicidal thoughts, fewer than half of people experiencing them tell a friend or family member. Among those who died by suicide between 2000 and 2017, only about one in three had seen a therapist or psychiatrist in the past year.

Some people may be concerned that Meghan’s disclosures could trigger other vulnerable individuals to view suicide as, to use her word, a “solution.” Indeed, research indicates that knowing someone who died by suicide or who attempted suicide is linked to increased risk of suicide. When a celebrity dies by suicide, suicide rates increase slightly in the month following their death.

Yes, contagion can occur after a suicide, but hope is also contagious.

Hearing stories of people resisting suicidal thoughts without acting on them has been linked to decreases in suicide rates. Perhaps tales of recovery can inspire hope and healing.

The tragedy of the silence around suicide isn’t only that people suffer alone. It’s also that they rarely hear the stories of those who have been suicidal and survived. Research indicates that almost half of people say they know someone who died by suicide. Though this hasn’t been studied, far more people likely know someone who has recovered from suicidal thoughts, since roughly 240 times more people consider suicide in a given year than die by it.

Meghan’s story is one of recovery. Near the end of the interview, she credited her husband with saving her life, because of his willingness to step away from the royal family. By sharing her story, she demonstrates that confiding in a loved one, problem-solving with him and making changes in her life took her off the path to suicide.

By encouraging more openness about suicidal thoughts, like Meghan’s, we can send the message to others that they are not alone, that change is possible and that people do make it out alive. I’m one of those people. I attempted suicide twice in my 20s. For two decades, I kept my story secret from all but a few people. Now I share my story openly as an act of defiance against stigma.

Here are some ways to weaken the walls of silence around suicide:

  • Name it. Ask the question, “Are you having thoughts of suicide?” or “Do you have thoughts of ending your life?” If you are nervous, couch the question: “A lot of people who feel the way you’re describing think of suicide. Do you think of killing yourself?”

  • Frame suicidal thoughts as the mind’s understandable attempt to stop hurting. This can help alleviate shame or embarrassment. For example, you might say, “It makes sense that that’s where your mind goes. We’re biologically wired to avoid pain. But there are other ways to stop the pain, and let’s brainstorm those.” You can empathize with the suicidal wish without validating suicide as an option.

  • Don’t panic. Don’t call 911 unless the person is clearly in danger of acting on suicidal thoughts this instant. Don’t respond with clichés, false encouragement or guilt.

  • Respond with curiosity, not judgment. Ask questions that invite the person to tell their story. “Tell me more.” “What’s happening that’s made you feel so bad?”

  • Connect. Offer emotional support, and help the person find professional help.

There is hope. Most people with suicidal thoughts don’t make an attempt. Of those who make an attempt and survive, most don’t go on to die by suicide. Almost always, life can get better.

As Meghan said: “I’m still standing. My hope for people in the takeaway from this is to know that there’s another side, to know that life is worth living.”

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


Stacey Freedenthal is a psychotherapist and an associate professor at the University of Denver Graduate School of Social Work.

Signs Someone May Be Suicidal

Signs Someone May Be Suicidal

Olivier Douliery/Agence France-Presse — Getty Images

Meghan Markle revealed in her interview with Oprah Winfrey on Sunday that life as a royal had made her suicidal.

If you think someone you know might want to end their life, here’s what to look for →

When I Lost My Sense of Taste to Covid, Anorexia Stepped In

Voices

When I Lost My Sense of Taste to Covid, Anorexia Stepped In

With flavor gone, my old eating disorder came roaring back.

Credit…Nathalie Lees

  • March 3, 2021, 11:22 a.m. ET

The day after my family and I were diagnosed with Covid-19 last September, I made myself a cup of coffee. I had been awake most of the night with chills and hoped I’d find comfort in its familiar aroma and warmth.

I lowered my face to the surface of my mug and inhaled. Nothing. I started searching for smell wherever I could. In the bathroom, I untwisted the cap on one of my perfume bottles and couldn’t detect its jasmine fragrance. I brought a candle up to my nose, but it was scentless.

When I sipped my coffee, all I could sense was its warmth. I started to make breakfast for my 4-year-old daughter and my 3-year-old son ­— maybe there I could find something with taste. I put a strawberry in my mouth and could feel its seeds but couldn’t detect its sweetness. I bit down on an almond-butter granola bar, sinking my teeth into the sadness of a reality I didn’t want to face.

I was diagnosed with anorexia at age 12, the year after my mom died. She’d been sick with metastatic breast cancer for three years, and even when it spread to her bone marrow, her liver and her brain, I was still convinced she’d get better. It’s what my family had told me, and so I believed it to be true. Until it wasn’t.

When she died, I felt as though life had become out of control. Pretty quickly, I realized that I could not impose order on the larger world, but I could control something that had always been in my life and always would be: food. And so began a three-year stretch of multiple hospitalizations and a 17-month-long stay at a residential treatment facility.

Now, at 35, after 20 years in recovery, I’m far better than I’d ever thought I’d be. But some days, my mind still flirts with anorexia. The disorder secretly seduces me, satisfying my affinity for control and order. It always lurks in the background and I have to make a concerted effort to keep it cornered.

Without taste, I was triggered. Anorexia beckoned me, reminding me that I could shed even more weight off my already slender frame if I skimped here and slacked there. When I would make my breakfast in the mornings after losing my taste, I’d forgo frothed milk in my coffee, opting to drink it black instead. I’d put one and a half slices of cheese on my grilled cheese sandwich instead of two and a half. I’d start to place granola on top of my yogurt, but uncomfortably familiar questions would stop me.

Do you really need to eat that? Why waste the calories?

Without taste, food became a formality. It was merely sustenance, and so I settled for the bland, bare minimum. Chewing felt like a chore, and every bite took effort I didn’t want to expend.

I was craving comfort. After days of not eating enough, I decided to seek it in a food that I used to love eating with my mom: ice cream. I ordered a pint of Ben and Jerry’s Glampfire Trail Mix and as soon as it arrived I dug my spoon into satisfying chunks of pretzel, chewy marshmallows and crunchy fudge-covered almonds. I couldn’t taste a thing, but I detected texture. I liked the act of digging my teeth into something that took work to chew. I liked hearing the crunch of the almonds, and swirling the softness of marshmallow in my mouth.

I found myself relating to one of Ben & Jerry’s founders, Ben Cohen, who has very little sense of taste and no sense of smell. When he and his partner, Jerry Greenfield, were developing their signature ice cream in the 1970s, anosmia-stricken Ben advocated for chunks. He became the texture taster, the one who would determine if teeth could be satisfied even when the tongue could not. After three small spoonfuls, I put the ice cream back in the freezer, not allowing myself to have any more.

There are often competing forces at play in my recovery; the healthy side of me that recognizes I need to eat more and wants to indulge in foods I enjoy, and the old eating disorder that tells me I shouldn’t.

The next day, family friends dropped off a homemade broccoli and cheese casserole, coloring books for my kids and a dozen bags of groceries filled with food we like to eat: cinnamon raisin bagels, red grapes, smoothie mixes and more. I wanted nothing more than to enjoy the home-cooked meal, which looked like something my mom would have made. I ate some of it, but not enough.

As our symptoms subsided and our two-week quarantine ended, I started to see the effects of eating too little. I could see it in my slightly sunken-in cheeks, could feel it in the contours of my hip bone, could hear it in my stomach, which groaned in the dark of night. I took a photo of myself and recognized I was too thin. My husband noticed, too. He reassured me that my taste would come back, and he reminded me of how much traction I’d lose if I let myself get stuck in the setback.

Over the years, I’ve had to change my perspective on what it means to be in recovery. I used to strive for “full recovery” — a life without slip-ups or setbacks — and would always feel like I had failed whenever I faltered. Now I frame my thinking around what I call “the middle place,” that sticky space between sickness and full recovery. I make it my goal to continuously progress through that space — for myself, for my family. Recovery is about recognizing that I’m in control of my choices, even when anorexia comes knocking, pleading for another chance. During Covid, I opened the door a crack, but eventually closed it.

My sense of taste was gone for about five weeks, and once it came back I started to regain my footing and, eventually, the pounds I had lost. Taste first showed up one morning when I was eating a banana; soon more flavors re-emerged.

And then one Sunday afternoon, I ate creamy tomato bisque and felt and smelled and tasted every single spoonful. There was the warmth, the savory tomatoes, the bliss of basil.

I finished the soup and was still hungry. So I got myself a generous side of crackers and Gouda cheese, which I ate with unfettered enjoyment. For the first time in five weeks, I finished that meal feeling full.

If you need help with an eating disorder, the National Eating Disorders Association helpline can be reached at 800-931-2237. For crisis situations, text “NEDA” to 741741 to be connected with a trained volunteer at Crisis Textline.


Mallary Tenore Tarpley teaches journalism at the University of Texas at Austin, where she is the associate director of the Knight Center for Journalism in the Americas. She is writing a memoir about her childhood experiences with anorexia.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

During the pandemic, suicidal thinking is up. And families find that hospitals can’t handle adolescents in crisis.

Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”
Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”Credit…Jacob Biba for The New York Times
Benedict Carey

  • Published Feb. 23, 2021Updated Feb. 24, 2021, 5:00 a.m. ET

When the pandemic first hit the Bay Area last spring, Ann thought that her son, a 17-year-old senior, was finally on track to finish high school. He had kicked a heavy marijuana habit and was studying in virtual classes while school was closed.

The first wave of stay-at-home orders shut down his usual routines — sports, playing music with friends. But the stability didn’t last.

“The social isolation since then, over all this time, it just got to him,” said Ann, a consultant living in suburban San Francisco. She, like the other parents in this article, asked that her last name be omitted for privacy and to protect her child. “This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

“We called 911, and he was taken to the emergency room,” his mother said. “But there they just stitched him up and released him.” The doctors sent him home, she said, “with no support, no therapy, nothing.”

Ann and her son are like many families over the last year. Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink. Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn. They need help, but it’s hard to come up with a psychiatric diagnosis. They are trying to manage a surprise interruption in their lives, a vague loss. And without a diagnosis, reimbursement for therapy is hard to come by. And that is assuming parents know what kind of help is appropriate, and where to find it.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

Many E.R. departments across the country are now seeing a surge in such cases. Through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year, according to a recent report by the Centers for Disease Control and Prevention.

And the local emergency department is frequently unprepared for the added burden. Workers often are not specially trained to manage behavioral problems, and families don’t have many options for where to go next, leaving many of these pandemic-insecure adolescents in limbo at the E.R.

“This is a national crisis we’re facing,” Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C. “Kids are having to board in the E.R. for days on end, because there are no psychiatric beds available in their entire state, never mind the hospital. And of course, the child or adolescent is lying there and doesn’t understand what’s happening in the E.R., why they’re having to wait there or where they’re going.”

What Adolescents Are Feeling

Most teenagers and young adults have done fine through this pandemic year, provided that their families have stayed healthy and economically stable. They may be irritable or missing their friends, but their support networks have been enough to get them through the pandemic.

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say. Most are temperamentally sensitive and after months of being socially cut off from friends and activities, they have much less control over their moods.

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,” said Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine. It is this prolonged stress, Dr. Spinks-Franklin said, that in time blunts the brain’s ability to manage emotions.

Jean, an artist and mother of two living in Hendersonville, N.C., said that her 17-year-old son was doing fine through last spring. But the months of virtual classes and loss of simple social pleasures — hanging out with friends, playing chess — changed him through the fall months.

“Now, he’s become very reclusive, he has mood swings, he cries a lot,” Jean said. “This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.
Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.Credit…Brett Deering for The New York Times

Lisa, a mother of three in Asheville, said that the months of virtual classes and relative social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”

His grades slipped badly, and he began to withdraw. “Next, he was telling us he couldn’t make himself do the work, that he didn’t want to disappoint us all the time, that he was worthless. Worthless.”

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one.) Rather, they are trying to manage an interruption in their normal development, child psychologists say: a sudden and indefinite suspension of almost every routine and social connection, leaving a deep yet vague sense of loss with no single, distinct source.

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.” The concept is usually reserved to describe the experience of immigrants, displaced from everything familiar, who shut down emotionally in a new and strange country. Or to describe disaster survivors, who return to neighborhoods that are hollowed out, transformed.

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

System Overload

The resulting changes in behavior can seem sudden: A bright sixth-grader is found cutting herself; a sweet-natured sophomore takes a swing at a parent or sibling. Parents, frightened, often don’t know where to go for appropriate help. Many don’t have the resources or knowledge to hire a therapist.

Families that land in the emergency departments of their local hospitals often find that the clinics are poorly equipped to handle these incoming cases. The staff is better trained to manage physical trauma than the mental variety, and patients are often sent right back home, without proper evaluation or support. In severe cases, they may linger in the emergency department for days before a bed can be found elsewhere.

In a recent report, a research team led by the C.D.C. found that less than half of the emergency departments in U.S. hospitals had clear policies in place to handle children with behavior problems. Getting to the bottom of any complex behavior issue can takes days of patient observation, at minimum, psychiatrists say. And many emergency departments do not have the on-hand specialists, dedicated space or off-site resources to help do the job well.

For Jean, diagnosing her son has been complicated. He has since developed irritable bowel syndrome. “He has been losing weight, and started smoking pot due to the boredom,” Jean said. “This is all due to the anxiety.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents. But well before the arrival of the coronavirus, the department was straining to handle increasing numbers of patients with behavior problems.

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

Last March, to address the crowding, Nationwide Children’s opened a new pavilion, a nine-story facility with 54 dedicated beds for observation and for longer-term stays for those with mental challenges. It has taken the pressure off the hospital’s regular emergency department and greatly improved care, Dr. Axelson said.

Over this pandemic year, with the number of admissions for mental health problems up by some 15 percent over previous years, it is hard to imagine what it would have been like without the additional, devoted behavioral clinic, Dr. Axelson said.

Other hospitals from out of state often call, hoping to place a patient in crisis, but there is simply not enough space. “We have to say no,” Dr. Axelson said.

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it,” said  Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C.Credit…Jacob Biba for The New York Times

Dr. Rachel Stanley, the chief of emergency medicine at Nationwide, said that most hospitals have far fewer resources. “I worked at a hospital in Michigan for years, and when these kinds of kids come in, everyone dreaded seeing them, because we didn’t feel like we had the tools to help,” she said. “They have to go into a safe room; they can’t be in a shared area. You have to provide a sitter for the child, a staff person to stay with them all the time to make sure they’re not suicidal or homicidal. It could take hours and hours to get social workers involved, and all this time they’re getting worse.”

Anne, the consultant in the Bay Area, said that her son’s visit to the emergency room this month was his third in the past 18 months, each time for issues related to drug withdrawal. On one visit, he was misdiagnosed with psychosis and sent to a locked county psychiatric ward. “That experience itself — locked for days in a ward, with no one telling him why, or how long he’d be there — was the most traumatic thing he’s experienced,” she said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

Lisa has hired a therapist for her son, a Zoom session every other week. That seems to have helped, she said, but it is too early to tell. And Jean, for the moment, is hoping the infection risk will diminish soon, so her son can get a safe job.

All three parents have become keen observers of their children, more aware of shifting moods. Listening by itself usually helps relieve distress, therapists say. “Trying to educate parents is a routine part of the job,” said Dr. Robert Duffey, a pediatrician in Hendersonville. “And of course we need these kids back in school, so badly.”

But medical professional say that until the health care system finds a way to equip and support emergency departments for what they have become — the first and sometimes last resort — parents will be left to navigate mostly on their own, leaning on others who have managed similar problems.

“Covid has put our system under a microscope in terms of the things that don’t work,” said Dr. Baum, the pediatrician in Asheville. “We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

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.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

For Some Teens, It’s Been a Year of Anxiety and Trips to the E.R.

During the pandemic, suicidal thinking is up. And families find that hospitals can’t handle adolescents in crisis.

Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”
Lisa, a mother of three in Asheville, N.C., said that months of virtual classes and social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”Credit…Jacob Biba for The New York Times
Benedict Carey

  • Feb. 23, 2021, 3:48 p.m. ET

When the pandemic first hit the Bay Area last spring, Ann thought that her son, a 17-year-old senior, was finally on track to finish high school. He had kicked a heavy marijuana habit and was studying in virtual classes while school was closed.

The first wave of stay-at-home orders shut down his usual routines — sports, playing music with friends. But the stability didn’t last.

“The social isolation since then, over all this time, it just got to him,” said Ann, a consultant living in suburban San Francisco. She, like the other parents in this article, asked that her last name be omitted for privacy and to protect her child. “This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

“We called 911, and he was taken to the emergency room,” his mother said. “But there they just stitched him up and released him.” The doctors sent him home, she said, “with no support, no therapy, nothing.”

Ann and her son are like many families over the last year. Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink. Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn. They need help, but it’s hard to come up with a psychiatric diagnosis. They are trying to manage a surprise interruption in their lives, a vague loss. And without a diagnosis, reimbursement for therapy is hard to come by. And that is assuming parents know what kind of help is appropriate, and where to find it.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

Many E.R. departments across the country are now seeing a surge in such cases. Through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year, according to a recent report by the Centers for Disease Control and Prevention.

And the local emergency department is frequently unprepared for the added burden. Workers often are not specially trained to manage behavioral problems, and families don’t have many options for where to go next, leaving many of these pandemic-insecure adolescents in limbo at the E.R.

“This is a national crisis we’re facing,” Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C. “Kids are having to board in the E.R. for days on end, because there are no psychiatric beds available in their entire state, never mind the hospital. And of course, the child or adolescent is lying there and doesn’t understand what’s happening in the E.R., why they’re having to wait there or where they’re going.”

What Adolescents Are Feeling

Most teenagers and young adults have done fine through this pandemic year, provided that their families have stayed healthy and economically stable. They may be irritable or missing their friends, but their support networks have been enough to get them through the pandemic.

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say. Most are temperamentally sensitive and after months of being socially cut off from friends and activities, they have much less control over their moods.

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,” said Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine. It is this prolonged stress, Dr. Spinks-Franklin said, that in time blunts the brain’s ability to manage emotions.

Jean, an artist and mother of two living in Hendersonville, N.C., said that her 17-year-old son was doing fine through last spring. But the months of virtual classes and loss of simple social pleasures — hanging out with friends, playing chess — changed him through the fall months.

“Now, he’s become very reclusive, he has mood swings, he cries a lot,” Jean said. “This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.
Dr. Adiaha I. A. Spinks-Franklin, an associate professor of pediatrics at the Baylor College of Medicine, says it’s the prolonged stress that blunts the brain’s ability to manage emotions.Credit…Brett Deering for The New York Times

Lisa, a mother of three in Asheville, said that the months of virtual classes and relative social isolation had changed her extroverted 13-year-old son “in profound ways I would never have anticipated.”

His grades slipped badly, and he began to withdraw. “Next, he was telling us he couldn’t make himself do the work, that he didn’t want to disappoint us all the time, that he was worthless. Worthless.”

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one.) Rather, they are trying to manage an interruption in their normal development, child psychologists say: a sudden and indefinite suspension of almost every routine and social connection, leaving a deep yet vague sense of loss with no single, distinct source.

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.” The concept is usually reserved to describe the experience of immigrants, displaced from everything familiar, who shut down emotionally in a new and strange country. Or to describe disaster survivors, who return to neighborhoods that are hollowed out, transformed.

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

System Overload

The resulting changes in behavior can seem sudden: A bright sixth-grader is found cutting herself; a sweet-natured sophomore takes a swing at a parent or sibling. Parents, frightened, often don’t know where to go for appropriate help. Many don’t have the resources or knowledge to hire a therapist.

Families that land in the emergency departments of their local hospitals often find that the clinics are poorly equipped to handle these incoming cases. The staff is better trained to manage physical trauma than the mental variety, and patients are often sent right back home, without proper evaluation or support. In severe cases, they may linger in the emergency department for days before a bed can be found elsewhere.

In a recent report, a research team led by the C.D.C. found that less than half of the emergency departments in U.S. hospitals had clear policies in place to handle children with behavior problems. Getting to the bottom of any complex behavior issue can takes days of patient observation, at minimum, psychiatrists say. And many emergency departments do not have the on-hand specialists, dedicated space or off-site resources to help do the job well.

For Jean, diagnosing her son has been complicated. He has since developed irritable bowel syndrome. “He has been losing weight, and started smoking pot due to the boredom,” Jean said. “This is all due to the anxiety.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents. But well before the arrival of the coronavirus, the department was straining to handle increasing numbers of patients with behavior problems.

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

Last March, to address the crowding, Nationwide Children’s opened a new pavilion, a nine-story facility with 54 dedicated beds for observation and for longer-term stays for those with mental challenges. It has taken the pressure off the hospital’s regular emergency department and greatly improved care, Dr. Axelson said.

Over this pandemic year, with the number of admissions for mental health problems up by some 15 percent over previous years, it is hard to imagine what it would have been like without the additional, devoted behavioral clinic, Dr. Axelson said.

Other hospitals from out of state often call, hoping to place a patient in crisis, but there is simply not enough space. “We have to say no,” Dr. Axelson said.

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it,” said  Dr. Rebecca Baum, a developmental pediatrician in Asheville, N.C.Credit…Jacob Biba for The New York Times

Dr. Rachel Stanley, the chief of emergency medicine at Nationwide, said that most hospitals have far fewer resources. “I worked at a hospital in Michigan for years, and when these kinds of kids come in, everyone dreaded seeing them, because we didn’t feel like we had the tools to help,” she said. “They have to go into a safe room; they can’t be in a shared area. You have to provide a sitter for the child, a staff person to stay with them all the time to make sure they’re not suicidal or homicidal. It could take hours and hours to get social workers involved, and all this time they’re getting worse.”

Anne, the consultant in the Bay Area, said that her son’s visit to the emergency room this month was his third in the past 18 months, each time for issues related to drug withdrawal. On one visit, he was misdiagnosed with psychosis and sent to a locked county psychiatric ward. “That experience itself — locked for days in a ward, with no one telling him why, or how long he’d be there — was the most traumatic thing he’s experienced,” she said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

Lisa has hired a therapist for her son, a Zoom session every other week. That seems to have helped, she said, but it is too early to tell. And Jean, for the moment, is hoping the infection risk will diminish soon, so her son can get a safe job.

All three parents have become keen observers of their children, more aware of shifting moods. Listening by itself usually helps relieve distress, therapists say. “Trying to educate parents is a routine part of the job,” said Dr. Robert Duffey, a pediatrician in Hendersonville. “And of course we need these kids back in school, so badly.”

But medical professional say that until the health care system finds a way to equip and support emergency departments for what they have become — the first and sometimes last resort — parents will be left to navigate mostly on their own, leaning on others who have managed similar problems.

“Covid has put our system under a microscope in terms of the things that don’t work,” said Dr. Baum, the pediatrician in Asheville. “We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

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.

Mental Health Providers Struggle to Meet Pandemic Demand

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

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

Credit…Jo Zixuan Zhou
Christina Caron

  • Feb. 17, 2021, 5:26 p.m. ET

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

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

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

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

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

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

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

A rise in demand

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

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

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

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

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

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

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

‘Every single person I see needs therapy right now’

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

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

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

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

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

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

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

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

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

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

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

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

How to find help if you’re struggling

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Credit…Jo Zixuan Zhou
Christina Caron

  • Feb. 17, 2021, 5:26 p.m. ET

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

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

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

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

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

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

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

A rise in demand

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

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

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

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

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

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

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

‘Every single person I see needs therapy right now’

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

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

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

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

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

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

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

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

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

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

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

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

How to find help if you’re struggling

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

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

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

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

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

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

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

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

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

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

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

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

Emptying the Dishwasher Can Enrich Kids’ Mental Health

Emptying the Dishwasher Can Enrich Kids’ Mental Health

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

Credit…Jack Taylor

  • Feb. 11, 2021, 5:00 a.m. ET

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Pandemic Brought Depression and Anxiety. Reaching Out Helped.

Voices

The Pandemic Brought Depression and Anxiety. Reaching Out Helped.

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

Credit…Evan Cohen

  • Feb. 9, 2021, 5:00 a.m. ET

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

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

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

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

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

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

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

Fear had become my constant companion.

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

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

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

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

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

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

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

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

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

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.

Alzheimer’s Prediction May Be Found in Writing Tests

Alzheimer’s Prediction May Be Found in Writing Tests

IBM researchers trained artificial intelligence to pick up hints of changes in language ahead of the onset of neurological diseases.

An M.R.I. scan of a patient over the age of 60 with Alzheimer’s disease.
An M.R.I. scan of a patient over the age of 60 with Alzheimer’s disease.Credit…Zephyr/Science Source
Gina Kolata

  • Feb. 1, 2021, 10:41 a.m. ET

Is it possible to predict who will develop Alzheimer’s disease simply by looking at writing patterns years before there are symptoms?

According to a new study by IBM researchers, the answer is yes.

And, they and others say that Alzheimer’s is just the beginning. People with a wide variety of neurological illnesses have distinctive language patterns that, investigators suspect, may serve as early warning signs of their diseases.

For the Alzheimer’s study, the researchers looked at a group of 80 men and women in their 80s — half had Alzheimer’s and the others did not. But, seven and a half years earlier, all had been cognitively normal.

The men and women were participants in the Framingham Heart Study, a long-running federal research effort that requires regular physical and cognitive tests. As part of it, they took a writing test before any of them had developed Alzheimer’s that asks subjects to describe a drawing of a boy standing on an unsteady stool and reaching for a cookie jar on a high shelf while a woman, her back to him, is oblivious to an overflowing sink.

The researchers examined the subjects’ word usage with an artificial intelligence program that looked for subtle differences in language. It identified one group of subjects who were more repetitive in their word usage at that earlier time when all of them were cognitively normal. These subjects also made errors, such as spelling words wrong or inappropriately capitalizing them, and they used telegraphic language, meaning language that has a simple grammatical structure and is missing subjects and words like “the,” “is” and “are.”

The members of that group turned out to be the people who developed Alzheimer’s disease.

The A.I. program predicted, with 75 percent accuracy, who would get Alzheimer’s disease, according to results published recently in The Lancet journal EClinicalMedicine.

“We had no prior assumption that word usage would show anything,” said Ajay Royyuru, vice president of health care and life sciences research at IBM Thomas J. Watson Research Center in Yorktown Heights, N.Y., where the A.I. analysis was done.

Alzheimer’s researchers were intrigued, saying that when there are ways to slow or stop the illness — a goal that so far remains elusive — it will be important to have simple tests that can warn, early on, that without intervention a person will develop the progressive brain disease.

“What is going on here is very clever ” said Dr. Jason Karlawish, an Alzheimer’s researcher at the University of Pennsylvania. “Given a large volume of spoken or written speech, can you tease out a signal?”

For years, researchers have analyzed speech and voice changes in people who have symptoms of neurological diseases — Alzheimer’s, ALS, Parkinson’s, frontotemporal dementia, bipolar disease and schizophrenia, among others.

But, said Dr. Michael Weiner, who researches Alzheimer’s disease at the University of California, San Francisco, the IBM report breaks new ground.

“This is the first report I have seen that took people who are completely normal and predicted with some accuracy who would have problems years later,” he said.

The hope is to extend the Alzheimer’s work to find subtle changes in language use by people with no obvious symptoms but who will go on to develop other neurological diseases.

Examples from the Framingham Heart Study, including (a) an unimpaired sample, (b) an impaired sample showing telegraphic speech and lack of punctuation and (c) an even more impaired sample showing in addition significant misspellings and minimal grammatic complexity.
Examples from the Framingham Heart Study, including (a) an unimpaired sample, (b) an impaired sample showing telegraphic speech and lack of punctuation and (c) an even more impaired sample showing in addition significant misspellings and minimal grammatic complexity.Credit…Elif Eyigoz et al., The Lancet 2020

Each neurological disease produces unique changes in speech, which probably occur long before the time of diagnosis, said Dr. Murray Grossman, a professor of neurology at the University of Pennsylvania and the director of the university’s frontotemporal dementia center.

He has been studying speech in patients with a behavioral form of frontotemporal dementia, a disorder caused by progressive loss of nerves in the brain’s frontal lobes. These patients exhibit apathy and declines in judgment, self control and empathy that have proved difficult to objectively quantify.

Speech is different, Dr. Grossman said, because changes can be measured.

Early in the course of that disease, there are changes in the pace of the patients’ speech, with pauses distributed seemingly at random. Word usage changes, too — patients use fewer abstract words.

These alterations are directly linked to changes in the frontotemporal parts of the brain, Dr. Grossman said. And they appear to be universal, not unique to English.

Dr. Adam Boxer, director of the neurosciences clinical research unit at the University of California, San Francisco, is also studying frontotemporal dementia. His tool is a smartphone app. His subjects are healthy people who have inherited a genetic predisposition to develop the disease. His method is to show subjects a picture and ask them to record a description of what they see.

“We want to measure very early changes, five to 10 years before they have symptoms,” he said.

“The nice thing about smartphones,” Dr. Boxer added, “is that you can do all kinds of things.” Researchers can ask people to talk for a minute about something that happened that day, he said, or to repeat sounds like tatatatata.

Dr. Boxer said he and others were focusing on speech because they wanted tests that were noninvasive and inexpensive.

Dr. Cheryl Corcoran, a psychiatrist at Icahn School of Medicine at Mount Sinai in New York, hopes to use speech changes to predict which adolescents and young adults at high risk for schizophrenia may go on to develop the disease.

Guillermo Cecchi, a principal researcher for computational psychiatry and neuroimaging at IBM.Credit…IBM Research

Drugs to treat schizophrenia may help those who are going to develop the disease, but the challenge is to identify who the patients will be. A quarter of people with occasional symptoms saw them go away, and about a third never progressed to schizophrenia although their occasional symptoms persisted.

Guillermo Cecchi, an IBM researcher who was also involved in the recent Alzheimer’s research, studied speech in 34 of Dr. Corcoran’s patients, looking for “flight of ideas,” meaning the instances when patients were off track when talking and spinning off ideas in different directions. He also looked for “poverty of speech,” meaning the use of simple syntactic structures and short sentences.

In addition, Dr. Cecchi and his colleagues studied another small group consisting of 96 patients in Los Angeles — 59 of whom had occasional delusions. The rest were healthy people and those with schizophrenia. He asked these subjects to retell a story that they had just heard, and he looked for the same telltale speech patterns.

In both groups, the artificial intelligence program could predict, with 85 percent accuracy, which subjects developed schizophrenia three years later.

“It’s been a lot of small studies finding the same signals,” Dr. Corcoran said. At this point, she said, “we are not at the point yet where we can tell people if they are at risk or not.”

Dr. Cecchi is encouraged, although he realizes the studies are still in their infancy.

“For us, it is a priority to do the science correctly and at scale,” he said. “We should have many more samples. There are more than 60 million psychiatric interviews in the U.S. each year but none of those interviews are using the tools we have.”

Doctors, Facing Burnout, Turn to Self-Care

Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.
Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.Credit…Dustin Franz for The New York Times

Doctors, Facing Burnout, Turn to Self-Care

A growing number of programs aim to help doctors, nurses and medical students who are struggling with mental health issues during the pandemic.

Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.Credit…Dustin Franz for The New York Times

  • Jan. 26, 2021, 5:00 a.m. ET

Dr. Michelle Thompson knows a lot about self-care. A family medicine physician in Vienna, Ohio, she specializes in lifestyle and integrative care, using both conventional and alternative therapies to help her patients heal. She also teaches medical personnel how to prevent and treat burnout.

But despite what she recommends to others, taking care of her own emotional well-being hasn’t been easy during the pandemic.

When the pandemic hit in March, Dr. Thompson, 46, who is also chair of medicine for the University of Pittsburgh Medical Center Horizon regional health service, was seeing about 25 patients a day in her office, whom she had to convert to seeing via telemedicine “overnight,” she said.

In April, she joined an eight-week online mind-body skills program run by Dr. James S. Gordon, founder and executive director of The Center for Mind-Body Medicine, which since its founding in 1991 has trained nearly a thousand health care professionals in various self-care measures that they can use in their practices. Dr. Gordon, a psychiatrist, started the skills group earlier this year to help doctors and other health care workers cope with the extra demands and psychological suffering the pandemic has brought. The program included weekly Zoom calls with others on the front lines, along with meditative exercises like drawing pictures, visualizations and guided imagery.

“It allowed me two hours a week to check in with myself and share my experience with other health care professionals who could relate to the overwhelm and intensity of the pandemic,” Dr. Thompson said. “I never realized the power of group support.”

Physician burnout has long been a serious concern in the medical community, with roughly 400 doctors dying by suicide each year in the United States. The issue of pandemic burnout among physicians came to the forefront in the early months of the pandemic following the death of Dr. Lorna M. Breen, who supervised the emergency department at New York-Presbyterian Allen Hospital in Manhattan. Dr. Breen, who had been sick with Covid but working remotely, was later admitted to a psychiatric ward for 10 days. Fearing the professional repercussions of her mental health treatment, she took her own life in April.

“She was overwhelmed with the volume of death and dying, and she could not keep up,” said her brother-in-law, Corey Feist, a lawyer in Charlottesville, Va. “The industry needs a big cultural change.”

Mr. Feist and his wife, Jennifer Feist, Dr. Breen’s sister, have since co-founded the Dr. Lorna Breen Heroes’ Foundation, a nonprofit dedicated to protecting the emotional well-being of health care workers. The Feists also worked with politicians and a cross section of health care industry experts to develop the Dr. Lorna Breen Health Care Provider Protection Act, which aims to reduce and prevent burnout, mental and behavioral health conditions and suicide among health care professionals.

Dr. Thompson teaches medical personnel how to prevent burnout, but learning how to take care of herself during the pandemic has been a challenge.
Dr. Thompson teaches medical personnel how to prevent burnout, but learning how to take care of herself during the pandemic has been a challenge.Credit…Dustin Franz for The New York Times

An October poll of 862 emergency physicians nationwide from the American College of Emergency Physicians and Morning Consult found that 87 percent felt more stressed since the onset of Covid-19, with 72 percent experiencing a greater degree of professional burnout. Concerns about family, friends and their own health were among their chief concerns, along with financial and job security and a lack of personal protective equipment. Yet consistent with a longstanding stigma surrounding physician mental health, 45 percent weren’t comfortable seeking mental health treatment, citing concerns about workplace stigma and fear of professional reprisal.

The American Psychiatric Association, the American Medical Association and other professional groups, have formal statements against punishing doctors who seek mental health treatment. The Americans With Disabilities Act, which prohibits discrimination based on disability, including psychiatric disability, applies to professional licensing bodies. Still, the stigma persists.

A growing number of organizations and programs have taken up the charge to help doctors, nurses, residents, interns and medical students who are struggling with mental health issues.

Columbia University, for example, created CopeColumbia for employees of Columbia University Irving Medical Center. Another program called #FirstRespondersFirst, from the Harvard T.H. Chan School of Public Health, Thrive Global, and the CAA Foundation, recently unveiled its new mental health initiative, designed to provide support to health care workers in the United States and abroad. The Frontline Workers Counseling Project includes some 500 volunteer therapists in the San Francisco Bay Area, while the Physician Support Line, started in late March, is a free, national support line of some 700 volunteer psychiatrists who provide peer support.

A Body Mind Skills group helped Dr. Thompson to take time out for her own needs.Credit…Dustin Franz for The New York Times

“Part of the healing for me is helping other people,” said Dr. Lois Kroplick, a psychiatrist in private practice in Pomona, N.Y., who co-ran a weekly support group for psychiatrists and psychologists at Garnet Health Medical Center, in Middletown, N.Y., and volunteered with the Physician Support Line. During this same period, Dr. Kroplick lost her first grandchild and mother-in-law. “The best way to cope with my own grief was to help others,” she said.

Doctors recognize the growing need for mental health help for others, and for themselves. And as the infection rate continues to climb, many health care workers feel torn between their duty to help patients while also caring for themselves.

Elizabeth M. Goldberg is an associate professor of emergency medicine at Brown University, in Providence, and an emergency room physician. “In March and April there was this sense that you choose either your patients or yourself and it was your expectation to be there,” said Dr. Goldberg, 38, who has three young children. “Many of us wanted to be there, but I did experience fear and anxiety about going to work.”

She attended a free support group for health care workers, which she had never done before. “It was great hearing other people share similar experiences I had of not sleeping well and worrying about our family’s health and talking openly about our anxiety and fear of contracting the illness,” she said.

Kathleen S. Isaac, 32, clinical assistant professor at NYU Langone Health who is also in private practice in New York, created a weekly support group in June for her residents. But not many doctors showed up. Part of that she attributes to time constraints and demanding schedules, but also that many were simply trying to be stoic and power through.

“Asking for help is less stigmatized in the psychological community, but sometimes I think there’s a sense of ‘I’m fine, I know what I’m doing,’” she said. “There’s such a culture of perfectionism, and it’s so competitive that people want to present their best self. It’s harder to admit they’re struggling.”

This applies in her own life, too. She talks to friends and colleagues, exercises, goes to therapy and admits to binge-watching the sitcom “That’s So Raven” to help her unwind.

As for Dr. Thompson, she credits the Body Mind Skills group with helping her change her own self-care routine, checking in with herself hourly. “I ask myself, ‘What do I need? How am I caring for myself in this moment? Do I need a cup of tea? Should I implement some mind-body medicine?’” she said.

This might include soft belly breathing, dancing, mindful eating or just heading outside to get a breath of fresh air. “Maybe I just need to use the restroom and need to make time for simple basic self-care needs,” she said.

“This has been the hardest time of my life, and I am super grounded and really well balanced,” she added. “I am doing OK, but it is constant work and making sure I’m staying aware of my own self.”