Mark Lukach

His Lovely Wife in the Psych Ward: An Interview on Love, Writing, and Mental Illness (with Mark Lukach)

Carol Tamminga

The Last Undiscovered Organ in the Body (with Carol Tamminga, M.D.)

Janae Sharp

In the final part of our discussion with Janae Sharp, Janae further discusses the loss of her husband and how best to support others through grief. She details some unique differences in responses by others when her husband died by suicide (eg, no GoFundMe pages, but requests for donations!) and emphasizes the importance of other survivors and their stories to her and her new community. She responds to the question of whether she is "sensationalizing" her husband’s death, but focuses on her ability to do good as a result. She is particularly interested in digital solutions and discusses a few that she has been working on here. Finally, she explains what she feels the role of psychiatry is in this important topic.TRANSCRIPTWelcome to Psyched!, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in. David Carreon: You've been through such a difficult experience just in what happened, but what are things that people did or didn't do that were helpful after the suicide? How did people support you or fail to support you? And maybe more generally, how do people support or fail to support families who've had someone die by suicide? Janae Sharp: Oh, that's a great question. It was hard because the first few days, people ask you what they can do. The first few days, you're really in the closet, not recovering at all. That was hard and it was hard for me to feel like my children were getting less. That was heart-breaking how some people supported it. People who had lost someone though, they were really good at following up and being thoughtful. I had a friend who would send me articles about grief, and she did that for several years after John's death, just randomly saying, "Hey, I saw this and I was thinking of you." That's something I always tell people is important to schedule something further out, like six months from then and say ... Think of what you would do right after someone dies. Maybe you would go to their house and help them. Maybe you would make them a meal. Don't do it the day after, schedule it for a year later. Schedule it for the next birthday of that person, for any holiday is hard for people. Purposefully do something instead of asking what you can do because we're socialized to not accept help and when you have grief, you don't always know what you want, it's too overwhelming. The people that were the most supportive were the people who had been through some kind of death and understood the cyclical nature, that some dies will be hard and some days are easier. That it's harder the second year when everyone has forgotten, and you're still taking your kids to a grave, or talking to your kids about their dad who's dead. So just keep that in mind. I did have some friends who were really supportive and still understand that it's a permanent loss. It's not always permanently devastating. It's not always so immediate as right when they die, but they're still gone. So that's what I tell people. Jessi Gold: Yeah. And then you mentioned that you were surprised afterwards, like some of the bad reactions, or some of the lack of things that you maybe thought would be around or given to you that weren't. Janae Sharp: Oh yeah. Well, some of that is surprising because like with suicide prevention, some people they'll reach out to you. Some people asked us for money to donate to suicide prevention, and that was really overwhelming. If you look up things like GoFundMe, they raise less ... or like a memorial for kids ... they'll do it a lot of times if someone dies of cancer, but not necessarily with a suicide death. That stuff was hard and then it's so strange talking about finances ever. When you're like, "Oh, wow. That's interesting that my kids didn't have a memorial fund." But then, you survived so what do you say? It's this horribly tacky topic where like, "Oh, that's weird." And then people are asking you for money for like awareness and ... Actually, Loss Survivors are the number one funder of suicide prevention initiatives. You're also a number one funder then for a topic that is really hitting you personally, and it kind of makes you ... it's kind of off-putting, but it's also ... now I like want to help those things. It's like the people who are hurting you in some ways, also some of those people were the most supportive. I don't know if that answers the question. David Carreon: No, it does and I think that I've heard mental illness described as the no potluck disease. The no casserole disease. Janae Sharp: We did not have funeral potatoes. David Carreon: Yeah, it's like you get cancer and you get a casserole. You have a broken leg, you get a casserole. But you get mental illness and you get no casserole. Janae Sharp: Yeah, you just can't post on Facebook, "Guys I just really could use a casserole today because of my depression. I am sad about something from five years ago still." Oopsies. Jessi Gold: I can imagine, too, that like some people can say posting at all is sensationalizing a personal topic. What would you say to somebody who would say that? Janae Sharp: Maybe it is. Maybe I should post something like, "Oh, and this is an inspirational story," and also life-coaching. If you think about it too ... because I thought about that. We've started like MD Suicide where people are sharing stories, and I shared our story and talked to my friend who helped me create that website, you know, "Do we want to make sure we're protecting stories of the children?" And I did talk to my kids and get their input on it. But in the end, I'm paying for my children and creating their world, and that's a choice everyone has to make for themselves. If they feel like they're sensationalizing it, then hopefully they're sensationalizing it and trying to help people at the same time. If not, it's sad that we're so stingy with our attention and positive energy, that we think someone asking for help or asking for attention, is something negative. I also think, in terms of sensationalized stories, it's interesting when media wants more views, but they don't necessarily want to help. Like if someone wants to sell software, but they don't necessarily care about your story.When people are sharing their own story, you know that they have a personal interest, so take that for what it is. Like I do have a personal interest in this, and it has impacted my life directly. That also means that ... maybe it is just sensationalizing them. Jessi Gold: Right. Janae Sharp: That's how it is. Like you get to pick- Jessi Gold: Sensationalizing for good or something. Janae Sharp: Yeah, I mean, people should maybe worry a little less about that and share their own story. I don't think that hurts people as much as lying about something and carefully remaining silent. Some of the stories that people shared online, that I read after John died, made a huge difference for me. So you have to find a balance. Everyone has to find a balance. Hopefully, I have friends who will call me out if they feel I'm getting too wrapped up in those things and I do. I also have to make that decision for myself. Is that bad? You're like, "So people can say it's just for attention." I'm like, "Well, maybe it is. Maybe it is for attention." You share your story to be able to share it, and for people to know your story, and know you. I think that's a very basic need with humanity, to be known and to connect with people. I think that when you have suicide death, that need for connection and to be known is not met. David Carreon: Yeah, I think you're absolutely right about the need for connection. Sort of, a lot of the things you've talked about and mentioned today have been about how sometimes community has come around and supported, but sometimes it hasn't. But I guess, how has this changed the community that you had before or put you into communities that you hadn't been? Janae Sharp: I think it's actually had a huge impact on my community. I've been able to meet some people who are really supportive and Suicide Prevention, amazing people. Some of the friends that I'd had for a long time had a harder time dealing with the death, and they didn't have that same connection. That's really hard to see how it will change your support group but it's also ... It's good and bad, but I feel like I've been able to connect with people who really care too about burnout, and about improving a system, and care about doing that work, and want to do stuff together. That's been amazing. Jessi Gold: I know you're really interested in digital solutions to things. What do you think is different about that, and what do you think makes that a kind of an untapped resource for this community? Janae Sharp: Oh, I think digital solutions are interesting just because we have lower barriers. If you think about it, the things you'll say to someone on your Facebook posts, you might not say to them online. Or the things that you'll text people, you wouldn't always say that to their face. There's a place to be more honest, but also if you feel like you have these questions about depression or about suicide, and you don't know who to talk to them about, then digital tools can offer you that community support that might not be available somewhere else. I think one of the other important things to remember, for me, is how quickly some social media tools or those things can connect you. Because if you have a question about something, you can find answers a lot quicker. So I think it's a great opportunity, like we set up a virtual support group, which it's better with your time, but it also helps people in terms of that barrier to entry being lower.I do think in-person connection is best, but there are people who would never have those connections because they don't have time or they have some other barrier that would keep them from being involved. I think it's important to ... digital tools can enable them to be involved when they might not otherwise get any help. David Carreon: Yeah, I think that's a fascinating new dimension. I know that a lot of the talk has been around how there's some ... at least in our field ... magic in the room if you're physically face-to-face present. Some people say even if there's a video camera present for training purposes, that that takes away the magic. Certainly being in a different room when you're doing teletherapy, that completely ruins things. Your experience with the online support group has been that there is ... maybe not as good as face-to-face ... but there is still something there? Janae Sharp: Yeah, it might not be as good as face-to-face, but some people don't wanna be face-to-face because they aren't really ready for that level of directly combating their problem. Maybe they're not ready for that. Jessi Gold: And from your perspective, I know that maybe your support groups aren't run by psychiatrists, right? What do you think the role of psychiatry is in all of this? Janae Sharp: I think they can help. Jessi Gold: In what way? Janae Sharp: No, we work with a licensed clinical social worker currently and psychiatrists ... we're always looking for people to get involved. I think psychiatrists should be more involved, and I think they should be overseeing most of the clinical development, and we worked with a psychiatrist to develop some of it. Obviously, they have expertise in identifying medications or identifying things that other people might miss. I would need to talk to more psychiatrists about how they should improve it. Because I have talked with some about improving the measurement tools, and improving the design, and making sure the tools are efficient but not as much about how to really work together. David Carreon: Well, we really appreciate your coming on to talk with us and just wanted to give you one last opportunity to ... Is there anything you would say to a young doctor or young trainee who's just getting started? Any advice you'd have? Janae Sharp: I think my advice to them is to keep an open mind and to actively seek out the best workplace solutions that they can. If they find themselves getting hopeless, to be brutally honest, more than they would normally be and think of that. I also think new physicians are less tolerant of some the things that are creating these horrible environments. They are great activists for improving the mental health and improving the workforce for all physicians. Jessi Gold: Yeah. If there's one thing that you would say like what psychiatry gets wrong, what would you say that is? Janae Sharp: I think psychiatry also takes itself too seriously. Jessi Gold: Totally. Janae Sharp: They take it so very seriously, and they're already a group where they've been fighting for validation. If you can't diagnose many of your classmates with some form of crazy, then I don't know if you really went to school. But I would tell them to be more vocal about how psychiatry interacts with burnout, and be more critical of other specialties, and be really self-aware of their own limitations. Is that bad to tell them to be more critical? I probably shouldn't do that. Jessi Gold: I don't think so. What's your favorite book? This is a random question. Janae Sharp: My favorite book? Well, I really like Tad Williams. He's a fantasy writer. David Carreon: Nice. And another rapid fire question. Somebody who you admire, a hero of yours either from fiction or real life? Janae Sharp: Oh, that's a great question. I have a lot of people that I really admire. One of the people in suicide activism that I really like, her name's Dese'Rae Stage, and she shares stories of attempt survivors, Live Through This, and she was super supportive. So she's someone that I really respect in the space as someone who cares about individuals. That's one person I really admire. David Carreon: Our last question for the interview. What is the largest quilt you've ever made? Janae Sharp: Largest quilt? You know it's interesting. When we lived outside of Philadelphia, we made about 2,000 quilts for under-served people, and the largest quilt I've ever made is just little bit bigger than a king size quilt I made for myself. Jessi Gold: 2,000's a lot. David Carreon: That's a lot of quilts. I was not expecting 2,000 quilts. Janae Sharp: We made a bunch. It wasn't just me, but it was a really cool thing to be involved in. Jessi Gold: Totally. David Carreon: Excellent. Well, Janae, we really appreciate your time and thank you for joining us on Psyched! Jessi Gold: Thank you. Janae Sharp: Thank you. Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at Janae@sharpindex.org. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: MDsuicide.com and Sharpindex.org. Find her on Twitter @CoherenceMed. ep14-sharp_3_of_3.mp3File Size:  17050 kbFile Type:   mp3Download File

In the final part of our discussion with Janae Sharp, Janae further discusses the loss of her husband and how best to support others through grief. She details some unique differences in responses by others when her husband died by suicide (eg, no GoFundMe pages, but requests for donations!) and emphasizes the importance of other survivors and their stories to her and her new community. She responds to the question of whether she is "sensationalizing" her husband’s death, but focuses on her ability to do good as a result. She is particularly interested in digital solutions and discusses a few that she has been working on here. Finally, she explains what she feels the role of psychiatry is in this important topic. TRANSCRIPT Welcome to Psyched!, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in. David Carreon: You've been through such a difficult experience just in what happened, but what are things that people did or didn't do that were helpful after the suicide? How did people support you or fail to support you? And maybe more generally, how do people support or fail to support families who've had someone die by suicide? Janae Sharp: Oh, that's a great question. It was hard because the first few days, people ask you what they can do. The first few days, you're really in the closet, not recovering at all. That was hard and it was hard for me to feel like my children were getting less. That was heart-breaking how some people supported it. People who had lost someone though, they were really good at following up and being thoughtful. I had a friend who would send me articles about grief, and she did that for several years after John's death, just randomly saying, "Hey, I saw this and I was thinking of you." That's something I always tell people is important to schedule something further out, like six months from then and say ... Think of what you would do right after someone dies. Maybe you would go to their house and help them. Maybe you would make them a meal. Don't do it the day after, schedule it for a year later. Schedule it for the next birthday of that person, for any holiday is hard for people. Purposefully do something instead of asking what you can do because we're socialized to not accept help and when you have grief, you don't always know what you want, it's too overwhelming. The people that were the most supportive were the people who had been through some kind of death and understood the cyclical nature, that some dies will be hard and some days are easier. That it's harder the second year when everyone has forgotten, and you're still taking your kids to a grave, or talking to your kids about their dad who's dead. So just keep that in mind. I did have some friends who were really supportive and still understand that it's a permanent loss. It's not always permanently devastating. It's not always so immediate as right when they die, but they're still gone. So that's what I tell people. Jessi Gold: Yeah. And then you mentioned that you were surprised afterwards, like some of the bad reactions, or some of the lack of things that you maybe thought would be around or given to you that weren't. Janae Sharp: Oh yeah. Well, some of that is surprising because like with suicide prevention, some people they'll reach out to you. Some people asked us for money to donate to suicide prevention, and that was really overwhelming. If you look up things like GoFundMe, they raise less ... or like a memorial for kids ... they'll do it a lot of times if someone dies of cancer, but not necessarily with a suicide death. That stuff was hard and then it's so strange talking about finances ever. When you're like, "Oh, wow. That's interesting that my kids didn't have a memorial fund." But then, you survived so what do you say? It's this horribly tacky topic where like, "Oh, that's weird." And then people are asking you for money for like awareness and ... Actually, Loss Survivors are the number one funder of suicide prevention initiatives. You're also a number one funder then for a topic that is really hitting you personally, and it kind of makes you ... it's kind of off-putting, but it's also ... now I like want to help those things. It's like the people who are hurting you in some ways, also some of those people were the most supportive. I don't know if that answers the question. David Carreon: No, it does and I think that I've heard mental illness described as the no potluck disease. The no casserole disease. Janae Sharp: We did not have funeral potatoes. David Carreon: Yeah, it's like you get cancer and you get a casserole. You have a broken leg, you get a casserole. But you get mental illness and you get no casserole. Janae Sharp: Yeah, you just can't post on Facebook, "Guys I just really could use a casserole today because of my depression. I am sad about something from five years ago still." Oopsies. Jessi Gold: I can imagine, too, that like some people can say posting at all is sensationalizing a personal topic. What would you say to somebody who would say that? Janae Sharp: Maybe it is. Maybe I should post something like, "Oh, and this is an inspirational story," and also life-coaching. If you think about it too ... because I thought about that. We've started like MD Suicide where people are sharing stories, and I shared our story and talked to my friend who helped me create that website, you know, "Do we want to make sure we're protecting stories of the children?" And I did talk to my kids and get their input on it. But in the end, I'm paying for my children and creating their world, and that's a choice everyone has to make for themselves. If they feel like they're sensationalizing it, then hopefully they're sensationalizing it and trying to help people at the same time. If not, it's sad that we're so stingy with our attention and positive energy, that we think someone asking for help or asking for attention, is something negative. I also think, in terms of sensationalized stories, it's interesting when media wants more views, but they don't necessarily want to help. Like if someone wants to sell software, but they don't necessarily care about your story. When people are sharing their own story, you know that they have a personal interest, so take that for what it is. Like I do have a personal interest in this, and it has impacted my life directly. That also means that ... maybe it is just sensationalizing them. Jessi Gold: Right. Janae Sharp: That's how it is. Like you get to pick- Jessi Gold: Sensationalizing for good or something. Janae Sharp: Yeah, I mean, people should maybe worry a little less about that and share their own story. I don't think that hurts people as much as lying about something and carefully remaining silent. Some of the stories that people shared online, that I read after John died, made a huge difference for me. So you have to find a balance. Everyone has to find a balance. Hopefully, I have friends who will call me out if they feel I'm getting too wrapped up in those things and I do. I also have to make that decision for myself. Is that bad? You're like, "So people can say it's just for attention." I'm like, "Well, maybe it is. Maybe it is for attention." You share your story to be able to share it, and for people to know your story, and know you. I think that's a very basic need with humanity, to be known and to connect with people. I think that when you have suicide death, that need for connection and to be known is not met. David Carreon: Yeah, I think you're absolutely right about the need for connection. Sort of, a lot of the things you've talked about and mentioned today have been about how sometimes community has come around and supported, but sometimes it hasn't. But I guess, how has this changed the community that you had before or put you into communities that you hadn't been? Janae Sharp: I think it's actually had a huge impact on my community. I've been able to meet some people who are really supportive and Suicide Prevention, amazing people. Some of the friends that I'd had for a long time had a harder time dealing with the death, and they didn't have that same connection. That's really hard to see how it will change your support group but it's also ... It's good and bad, but I feel like I've been able to connect with people who really care too about burnout, and about improving a system, and care about doing that work, and want to do stuff together. That's been amazing. Jessi Gold: I know you're really interested in digital solutions to things. What do you think is different about that, and what do you think makes that a kind of an untapped resource for this community? Janae Sharp: Oh, I think digital solutions are interesting just because we have lower barriers. If you think about it, the things you'll say to someone on your Facebook posts, you might not say to them online. Or the things that you'll text people, you wouldn't always say that to their face. There's a place to be more honest, but also if you feel like you have these questions about depression or about suicide, and you don't know who to talk to them about, then digital tools can offer you that community support that might not be available somewhere else. I think one of the other important things to remember, for me, is how quickly some social media tools or those things can connect you. Because if you have a question about something, you can find answers a lot quicker. So I think it's a great opportunity, like we set up a virtual support group, which it's better with your time, but it also helps people in terms of that barrier to entry being lower. I do think in-person connection is best, but there are people who would never have those connections because they don't have time or they have some other barrier that would keep them from being involved. I think it's important to ... digital tools can enable them to be involved when they might not otherwise get any help. David Carreon: Yeah, I think that's a fascinating new dimension. I know that a lot of the talk has been around how there's some ... at least in our field ... magic in the room if you're physically face-to-face present. Some people say even if there's a video camera present for training purposes, that that takes away the magic. Certainly being in a different room when you're doing teletherapy, that completely ruins things. Your experience with the online support group has been that there is ... maybe not as good as face-to-face ... but there is still something there? Janae Sharp: Yeah, it might not be as good as face-to-face, but some people don't wanna be face-to-face because they aren't really ready for that level of directly combating their problem. Maybe they're not ready for that. Jessi Gold: And from your perspective, I know that maybe your support groups aren't run by psychiatrists, right? What do you think the role of psychiatry is in all of this? Janae Sharp: I think they can help. Jessi Gold: In what way? Janae Sharp: No, we work with a licensed clinical social worker currently and psychiatrists ... we're always looking for people to get involved. I think psychiatrists should be more involved, and I think they should be overseeing most of the clinical development, and we worked with a psychiatrist to develop some of it. Obviously, they have expertise in identifying medications or identifying things that other people might miss. I would need to talk to more psychiatrists about how they should improve it. Because I have talked with some about improving the measurement tools, and improving the design, and making sure the tools are efficient but not as much about how to really work together. David Carreon: Well, we really appreciate your coming on to talk with us and just wanted to give you one last opportunity to ... Is there anything you would say to a young doctor or young trainee who's just getting started? Any advice you'd have? Janae Sharp: I think my advice to them is to keep an open mind and to actively seek out the best workplace solutions that they can. If they find themselves getting hopeless, to be brutally honest, more than they would normally be and think of that. I also think new physicians are less tolerant of some the things that are creating these horrible environments. They are great activists for improving the mental health and improving the workforce for all physicians. Jessi Gold: Yeah. If there's one thing that you would say like what psychiatry gets wrong, what would you say that is? Janae Sharp: I think psychiatry also takes itself too seriously. Jessi Gold: Totally. Janae Sharp: They take it so very seriously, and they're already a group where they've been fighting for validation. If you can't diagnose many of your classmates with some form of crazy, then I don't know if you really went to school. But I would tell them to be more vocal about how psychiatry interacts with burnout, and be more critical of other specialties, and be really self-aware of their own limitations. Is that bad to tell them to be more critical? I probably shouldn't do that. Jessi Gold: I don't think so. What's your favorite book? This is a random question. Janae Sharp: My favorite book? Well, I really like Tad Williams. He's a fantasy writer. David Carreon: Nice. And another rapid fire question. Somebody who you admire, a hero of yours either from fiction or real life? Janae Sharp: Oh, that's a great question. I have a lot of people that I really admire. One of the people in suicide activism that I really like, her name's Dese'Rae Stage, and she shares stories of attempt survivors, Live Through This, and she was super supportive. So she's someone that I really respect in the space as someone who cares about individuals. That's one person I really admire. David Carreon: Our last question for the interview. What is the largest quilt you've ever made? Janae Sharp: Largest quilt? You know it's interesting. When we lived outside of Philadelphia, we made about 2,000 quilts for under-served people, and the largest quilt I've ever made is just little bit bigger than a king size quilt I made for myself. Jessi Gold: 2,000's a lot. David Carreon: That's a lot of quilts. I was not expecting 2,000 quilts. Janae Sharp: We made a bunch. It wasn't just me, but it was a really cool thing to be involved in. Jessi Gold: Totally. David Carreon: Excellent. Well, Janae, we really appreciate your time and thank you for joining us on Psyched! Jessi Gold: Thank you. Janae Sharp: Thank you. Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at <a href="mailto:janae@sharpindex.org?subject=Psychiatric%20Times%20podcast%20question">Janae@sharpindex.org</a>. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: <a href="http://mdsuicide.com/" rel="nofollow" target="_blank">MDsuicide.com</a> and <a href="http://sharpindex.org/" rel="nofollow" target="_blank">Sharpindex.org</a>. Find her on Twitter <a href="https://twitter.com/CoherenceMed" rel="nofollow" target="_blank">@CoherenceMed</a>. <a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep14-sharp_3_of_3.mp3" rel="nofollow" target="_blank"></a> ep14-sharp_3_of_3.mp3File Size: 17050 kbFile Type: mp3<a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep14-sharp_3_of_3.mp3" rel="nofollow" target="_blank">Download File</a>

Digital and Community Solutions After a Physician Suicide (part 3 of 3 with Janae Sharp)

In the second part of our interview with Janae Sharp, she discusses why she feels she has been a different kind and less restricted voice for physician suicide awareness. She notes that it is important for physicians to speak on this issue and that there is true power in community. However, she feels physicians are more silent on this issue as they tend to avoid "unsafe" and "uncertain" topics and are ultimately afraid of the potential repercussions to their licensure. Using her background in social determinants for health, she also answers a challenging question of whether physicians "deserve" our attention and help. TRANSCRIPTWelcome to Psyched. A podcast about psychiatry that covers every thing from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in. David Carreon: I think there is a lot of bravery in approaching this topic no matter where you come from or what your background is and I think that especially so, when some people might say that this is kind of a intramural problem, that this is a physician problem and physicians need to deal with it. Or maybe alternatively that this is a health care problem and so physicians need to deal with it. What would you say to that perspective? Are you, you said you've been silenced, but should this be something that is only for physicians to talk about? Janae Sharp: The difficult thing about having physicians be the only people who talk about it is that a physician has a direct financial impact in their lives by this topic. If you have a serious mental illness as a physician, that can mean you lose your job. If you have a financial incentive as a health care system to not employ a physician with a mental illness, what does that mean in terms of disability rights and what does that mean in terms of our ability? So I think physicians know a lot. I think they're super accomplished and I think they really value academics and I really like that they want things that are validated, I like the healing belief. I also think they don't have the freedom that the system, the system isn't designed for them to criticize itself. It's designed for them to perform. Or not perform. So someone like me, it had the biggest direct financial impact as like the loss of the, you know the loss of all that medical school and all that training directly impacted my kids financially, obviously, and I had a bigger loss than a specific physician would have. I mean not a physician that's losing their job, or passing away, but those voices are sometimes lost and the people in the conversation can't, they aren't as unfettered as we want to, we need them to be to make honest decisions and discuss that honestly. Jessi Gold: But you feel less limited by external forces, because it's your life and your story not some story controlled by their job? Janae Sharp: Yes. Like this is something where I don't have to put it on my licensure, my complete mental health history, which I think in 29 states they ask you to do that, even in your renewal. I don't have to report to my employer. When you've already had a suicide loss, there's nothing to do lose anymore. And physicians want that stability and they want that safety that they've confined in academic medicine and within knowing what's right and wrong, but this isn't a safe topic. So I think it's important for people like me, to be there and say, "Yeah, but, you guys are saying all this stuff." Even when you talk about it sometimes, it's like an alternate universe. They talk about it as if physicians are all saints or all so sad, instead of they're really just human, you know. Some of them are jerks. Some of them that you work with, you don't like and you can talk to nurses and doctors about that. So maybe it needs more sarcasm. David Carreon: Oh, I don't know if I've ever met a nurse or doctor that I don't like. Janae Sharp: Never. Never. I've never, I've literally never met an unreasonable either and neither have you. Jessi Gold: It's just like, you know, it's the same. Like there's sad ones, there are happy ones, there are people who get better, there are people who don't. It's the same. Janae Sharp: Right. Yeah. Like everyone knows that one guy who they just didn't like, and like how when we're talking about mental health and when we're talking about a healthy system, we need to separate those two. So it's not just like that one selfish guy who thought he was the best person ever, now he's talking about how he's the best person ever with mental health, and he's going to make things better for everybody if you were just more like him. You know? Because that's a little off putting. Jessi Gold: Yeah. Janae Sharp: Yeah. So I think it's, I actually think it gives me more freedom, because I can say things like, "Yeah, but it was shocking to me how much some of the people that I've met in medicine do coke, or other performance enhancing drugs and they don't think it's a big deal because they're just enhancing their performance." So I can talk about the culture but not be controlled by the culture, because I don't have the same requirements for having the best school, having the best resume, having those things to check off my list, because I was just married to one. And I wasn't trying to compete with everyone. So I think that it's been positive for me in a lot of ways to be outside that, because I, because they're not threatened by it and I'm not competing with them. Like the one-up-manship, I'm like, "Well, that's too bad, you went to medical school, that sounds brutally awful. That sounds like something I would not do." Jessi Gold: And you didn't. Janae Sharp: And maybe I would. You know? I thought about that. We never know where life will take us. And so yeah, that's a great question too, because I think part of the stigma is that no one wants to hear the rich doctor whining either. Like, because they do in a lot of ways have a lot of privilege and they have a lot of respect and authority in the community. So hearing them say how hard it is sometimes, please are like, "Really?" You know, it's hard. It's hard for people to really grasp that. David Carreon: Yes, say more about that. I think that especially nowadays there's this idea of sort of that we get a lot of attention and probably justly to those who are victims, or those who are underprivileged, or in fact even some of your own work on social determinants of health and outside of work hours, physicians have pretty good social determinants of health, usually. So how do we balance giving our I guess presumably limited stores of compassion, why should physicians get any because we make a lot of money? Janae Sharp: That's a great question. I think no one has to be compassionate to other people, first of all. That's bad to say. I mean they don't have to be compassionate to physicians. The reality is a lot of them have tons of debt. Some of them have great social support. Some of them have crippling anxiety and desire to perform. If you're living in poverty where you can't feed your children, sometimes you forget that other people are struggling, but you're not able to remove yourself from the immediacy of your pain. And that's a triage that our society isn't very good at. We aren't very good at allowing people to have pain if we have pain. And I think some of that is a little bit competitiveness. When John died people would say, "Oh, I'm having a bad day but I don't want to tell you about it." And there are two things that I learned there. One, if I was in a very bad place and didn't have a lot of energy to give, I wasn't as good at being present with them. I just wasn't. And two, that didn't lessen the fact that they were hurting. So we can say, "Oh look, they have a lot more money than I do, they have a great car", and they're still having enough mental pain that they die by suicide. That's something that we need to be able to talk about. How can we come together and have enough community support that we can allow everyone to have a healthy life and not say it's a limited commodity. And that's something I think about with social determinants of health. They say your community support has a huge impact on whether or not you're going to survive an illness, whether or not you're going to make it through a burnout, or your risk of suicide. And that lack of support can exist at any level and any socio-economic status. And just because I have less doesn't mean someone with more doesn't also have more mental pain than they can manage. Jessi Gold: So like you're saying community support's important. Janae Sharp: Yeah. Jessi Gold: But you're also sort of criticizing the physician community a little bit on how we deal with things. What do you think we're doing wrong, what do you think we need to do better as a community to be supportive of this as a thing? Janae Sharp: Oh, that's a great question. I think as a community they need better support but also more honest dialogue. So I mean criticizing the community is difficult, because a lot of people really want to do what's right and I think of it in terms of the suicide prevention community too. A lot of people involved there have lost someone by suicide and if you haven't lost someone by suicide you don't assume that it touches you and the physician community is kind of the same way, where you don't want those things to touch you. And if you treat it like leprosy, like something that is contagious, that's really difficult. And I think a lot of the times, people want to be safe. Like in the physician community too, they want to be safe, they want to have their job. They've done a lot of work, to accomplish what they do, and they want to achieve something. And everyone is that way. They want to be safe and they don't want to have the things that they love threatened.And in terms of society fixing that, we can, we need to re-evaluate our standard of measure for success. That's not saying that people won't be very successful or we need to lower our standards. It's saying, what can we do to make a place where people can talk about thoughts of suicide and some people that are physicians will think of that every day of their career, and is that something that you should talk about. And we need better integration with ... And I think some of this is understanding. We don't really understand or since I like data, we don't have very good data or very good math models to predict your suicide risk or to predict your mental health. And you see that with pharmacology, people don't really know 100% what's going to happen with your prescriptions and medicine doesn't like if they don't have good data that they can back up all their decisions and say this is for sure going to be the outcome that we want. So maybe it just needs more attention and better research so that we can have better data, but maybe we also need people who admit that they don't know everything and that this is an unpredictable thing. David Carreon: So you're saying that maybe the metrics of how many hours have I continuously been awake or how many hours above a 100 did I work this week might be bad metrics? Janae Sharp: Well, we don't really use those metrics though to predict like, you don't ... There are some ways that you could use metrics like that to avoid scheduling and those would have a direct impact on physician burnout, if we treated it more like how are we going to optimize someone's health and get some neurologist in there, what happens to your brain and your performance after you've worked 100 hours? How can we manage and develop the work flow and our workforce to look like that? That would be success. I'm saying we don't know exactly what's happening to people after those 100 hours and them taking a stimulant and continuously working. What's going to be the impact on your ability to interact with people and to relate and to maintain a level of empathy seven years from now, if you're doing that to yourself now. David Carreon: Yeah. No, it's sort of the slow burn, or the burn out, I suppose is the metaphor that we're using. Janae Sharp: Yeah. Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at  Janae@sharpindex.org. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: MDsuicide.com and Sharpindex.org. Find her on Twitter @CoherenceMed. ep13-sharp_2_of_3.mp3File Size:  13175 kbFile Type:   mp3Download File

In the second part of our interview with Janae Sharp, she discusses why she feels she has been a different kind and less restricted voice for physician suicide awareness. She notes that it is important for physicians to speak on this issue and that there is true power in community. However, she feels physicians are more silent on this issue as they tend to avoid "unsafe" and "uncertain" topics and are ultimately afraid of the potential repercussions to their licensure. Using her background in social determinants for health, she also answers a challenging question of whether physicians "deserve" our attention and help. TRANSCRIPT Welcome to Psyched. A podcast about psychiatry that covers every thing from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in. David Carreon: I think there is a lot of bravery in approaching this topic no matter where you come from or what your background is and I think that especially so, when some people might say that this is kind of a intramural problem, that this is a physician problem and physicians need to deal with it. Or maybe alternatively that this is a health care problem and so physicians need to deal with it. What would you say to that perspective? Are you, you said you've been silenced, but should this be something that is only for physicians to talk about? Janae Sharp: The difficult thing about having physicians be the only people who talk about it is that a physician has a direct financial impact in their lives by this topic. If you have a serious mental illness as a physician, that can mean you lose your job. If you have a financial incentive as a health care system to not employ a physician with a mental illness, what does that mean in terms of disability rights and what does that mean in terms of our ability? So I think physicians know a lot. I think they're super accomplished and I think they really value academics and I really like that they want things that are validated, I like the healing belief. I also think they don't have the freedom that the system, the system isn't designed for them to criticize itself. It's designed for them to perform. Or not perform. So someone like me, it had the biggest direct financial impact as like the loss of the, you know the loss of all that medical school and all that training directly impacted my kids financially, obviously, and I had a bigger loss than a specific physician would have. I mean not a physician that's losing their job, or passing away, but those voices are sometimes lost and the people in the conversation can't, they aren't as unfettered as we want to, we need them to be to make honest decisions and discuss that honestly. Jessi Gold: But you feel less limited by external forces, because it's your life and your story not some story controlled by their job? Janae Sharp: Yes. Like this is something where I don't have to put it on my licensure, my complete mental health history, which I think in 29 states they ask you to do that, even in your renewal. I don't have to report to my employer. When you've already had a suicide loss, there's nothing to do lose anymore. And physicians want that stability and they want that safety that they've confined in academic medicine and within knowing what's right and wrong, but this isn't a safe topic. So I think it's important for people like me, to be there and say, "Yeah, but, you guys are saying all this stuff." Even when you talk about it sometimes, it's like an alternate universe. They talk about it as if physicians are all saints or all so sad, instead of they're really just human, you know. Some of them are jerks. Some of them that you work with, you don't like and you can talk to nurses and doctors about that. So maybe it needs more sarcasm. David Carreon: Oh, I don't know if I've ever met a nurse or doctor that I don't like. Janae Sharp: Never. Never. I've never, I've literally never met an unreasonable either and neither have you. Jessi Gold: It's just like, you know, it's the same. Like there's sad ones, there are happy ones, there are people who get better, there are people who don't. It's the same. Janae Sharp: Right. Yeah. Like everyone knows that one guy who they just didn't like, and like how when we're talking about mental health and when we're talking about a healthy system, we need to separate those two. So it's not just like that one selfish guy who thought he was the best person ever, now he's talking about how he's the best person ever with mental health, and he's going to make things better for everybody if you were just more like him. You know? Because that's a little off putting. Jessi Gold: Yeah. Janae Sharp: Yeah. So I think it's, I actually think it gives me more freedom, because I can say things like, "Yeah, but it was shocking to me how much some of the people that I've met in medicine do coke, or other performance enhancing drugs and they don't think it's a big deal because they're just enhancing their performance." So I can talk about the culture but not be controlled by the culture, because I don't have the same requirements for having the best school, having the best resume, having those things to check off my list, because I was just married to one. And I wasn't trying to compete with everyone. So I think that it's been positive for me in a lot of ways to be outside that, because I, because they're not threatened by it and I'm not competing with them. Like the one-up-manship, I'm like, "Well, that's too bad, you went to medical school, that sounds brutally awful. That sounds like something I would not do." Jessi Gold: And you didn't. Janae Sharp: And maybe I would. You know? I thought about that. We never know where life will take us. And so yeah, that's a great question too, because I think part of the stigma is that no one wants to hear the rich doctor whining either. Like, because they do in a lot of ways have a lot of privilege and they have a lot of respect and authority in the community. So hearing them say how hard it is sometimes, please are like, "Really?" You know, it's hard. It's hard for people to really grasp that. David Carreon: Yes, say more about that. I think that especially nowadays there's this idea of sort of that we get a lot of attention and probably justly to those who are victims, or those who are underprivileged, or in fact even some of your own work on social determinants of health and outside of work hours, physicians have pretty good social determinants of health, usually. So how do we balance giving our I guess presumably limited stores of compassion, why should physicians get any because we make a lot of money? Janae Sharp: That's a great question. I think no one has to be compassionate to other people, first of all. That's bad to say. I mean they don't have to be compassionate to physicians. The reality is a lot of them have tons of debt. Some of them have great social support. Some of them have crippling anxiety and desire to perform. If you're living in poverty where you can't feed your children, sometimes you forget that other people are struggling, but you're not able to remove yourself from the immediacy of your pain. And that's a triage that our society isn't very good at. We aren't very good at allowing people to have pain if we have pain. And I think some of that is a little bit competitiveness. When John died people would say, "Oh, I'm having a bad day but I don't want to tell you about it." And there are two things that I learned there. One, if I was in a very bad place and didn't have a lot of energy to give, I wasn't as good at being present with them. I just wasn't. And two, that didn't lessen the fact that they were hurting. So we can say, "Oh look, they have a lot more money than I do, they have a great car", and they're still having enough mental pain that they die by suicide. That's something that we need to be able to talk about. How can we come together and have enough community support that we can allow everyone to have a healthy life and not say it's a limited commodity. And that's something I think about with social determinants of health. They say your community support has a huge impact on whether or not you're going to survive an illness, whether or not you're going to make it through a burnout, or your risk of suicide. And that lack of support can exist at any level and any socio-economic status. And just because I have less doesn't mean someone with more doesn't also have more mental pain than they can manage. Jessi Gold: So like you're saying community support's important. Janae Sharp: Yeah. Jessi Gold: But you're also sort of criticizing the physician community a little bit on how we deal with things. What do you think we're doing wrong, what do you think we need to do better as a community to be supportive of this as a thing? Janae Sharp: Oh, that's a great question. I think as a community they need better support but also more honest dialogue. So I mean criticizing the community is difficult, because a lot of people really want to do what's right and I think of it in terms of the suicide prevention community too. A lot of people involved there have lost someone by suicide and if you haven't lost someone by suicide you don't assume that it touches you and the physician community is kind of the same way, where you don't want those things to touch you. And if you treat it like leprosy, like something that is contagious, that's really difficult. And I think a lot of the times, people want to be safe. Like in the physician community too, they want to be safe, they want to have their job. They've done a lot of work, to accomplish what they do, and they want to achieve something. And everyone is that way. They want to be safe and they don't want to have the things that they love threatened. And in terms of society fixing that, we can, we need to re-evaluate our standard of measure for success. That's not saying that people won't be very successful or we need to lower our standards. It's saying, what can we do to make a place where people can talk about thoughts of suicide and some people that are physicians will think of that every day of their career, and is that something that you should talk about. And we need better integration with ... And I think some of this is understanding. We don't really understand or since I like data, we don't have very good data or very good math models to predict your suicide risk or to predict your mental health. And you see that with pharmacology, people don't really know 100% what's going to happen with your prescriptions and medicine doesn't like if they don't have good data that they can back up all their decisions and say this is for sure going to be the outcome that we want. So maybe it just needs more attention and better research so that we can have better data, but maybe we also need people who admit that they don't know everything and that this is an unpredictable thing. David Carreon: So you're saying that maybe the metrics of how many hours have I continuously been awake or how many hours above a 100 did I work this week might be bad metrics? Janae Sharp: Well, we don't really use those metrics though to predict like, you don't ... There are some ways that you could use metrics like that to avoid scheduling and those would have a direct impact on physician burnout, if we treated it more like how are we going to optimize someone's health and get some neurologist in there, what happens to your brain and your performance after you've worked 100 hours? How can we manage and develop the work flow and our workforce to look like that? That would be success. I'm saying we don't know exactly what's happening to people after those 100 hours and them taking a stimulant and continuously working. What's going to be the impact on your ability to interact with people and to relate and to maintain a level of empathy seven years from now, if you're doing that to yourself now. David Carreon: Yeah. No, it's sort of the slow burn, or the burn out, I suppose is the metaphor that we're using. Janae Sharp: Yeah. Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at  <a href="mailto:Janae@sharpindex.org?subject=Psychiatric%20Times%20podcast%20question">Janae@sharpindex.org</a>. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: <a href="http://mdsuicide.com/" rel="nofollow" target="_blank">MDsuicide.com</a> and <a href="http://sharpindex.org/" rel="nofollow" target="_blank">Sharpindex.org</a>. Find her on Twitter <a href="https://twitter.com/CoherenceMed" rel="nofollow" target="_blank">@CoherenceMed</a>. <a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep13-sharp_2_of_3.mp3" rel="nofollow" target="_blank"></a> ep13-sharp_2_of_3.mp3File Size: 13175 kbFile Type: mp3<a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep13-sharp_2_of_3.mp3" rel="nofollow" target="_blank">Download File</a>

Physician Suicide and the Need to Talk About It (part 2 of 3 with Janae Sharp)

In Part 1 of our 3-part interview with Janae Sharp—a physician suicide loss survivor and the Founder and CEO of the Sharp Index, a nonprofit dedicated to better physician mental health—Janae shares her story of loss, grief, and her call to action to start her non-profit.She discusses how suicide loss is different from other losses, in part because it is a "messy topic," but also how grief itself is imperfect. She details the experience of telling her 3 children and why she feels compelled to create "better memories" for them. She constantly reinforces the power and complexity of humanity.​Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at  Janae@sharpindex.org. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: Mdsuicide.com and Sharpindex.org. Find her on Twitter @CoherenceMed.TRANSCRIPT:David Carreon: This is David Carreon.Jessi Gold: This is Jessi Gold.David Carreon: And this is Psyched!, a psychiatry podcast. Today we have Janae Sharp. Janae is a physician suicide loss survivor and the founder and CEO of the Sharp Index, a non-profit dedicated to better physician mental health.Her main work involves health care data and analytics marketing to improve health care outcomes for the underserved. Python is her preferred code language, but her true passion is match making companies to create elegant health IT systems and to improve health.She's worked with interoperability and social determinants of health and is an expert on patient and physician engagement. Janae has 3 children, enjoys hiking, triathlon and quilting. Janae, thank you for joining us.Janae Sharp: Thank you. I hate writing bios as well. I feel like that's important.Jessi Gold: Yeah, it is really important.David Carreon: We should have added that to your bio.Janae Sharp: Yeah.Jessi Gold: And writing a bio was not your favorite thing to have done.Janae Sharp: Hearing my own bio I'm always like, "That's a terrible bio. Someone should rewrite that. That poor lady."Jessi Gold: Well, okay, so how about we start with you just telling us more about you and your story and then as much as you feel like telling us, yeah.Janae Sharp: Oh, well, that could be pretty long, but so the story of starting the Sharp Index, I can talk about. Like it says, I have a background in health care IT, and I've worked with people creating data products and worked in social media a lot, and I am also a physician suicide loss survivor.My former spouse, John Madsen, was a physician. He died by suicide, and we created the index actually in his memory and through my experiences with his death. We have 3 children, and I've been able to share a lot of our story and trying to create good memories and, really, how that type of loss was pretty different in terms of the support that my kids got.It was really frustrating. I felt like people didn't really know what to say or had a lot of advice that wasn't helpful or advice that really was hurtful in some ways. And we wanted to create something that brought awareness to physician suicide but also addressed that, created a better place, and that's really our hope, to have better memories for people.But also, the index is focused on reducing burnout. So you can look at scores and information about your burnout risk or reasons for that or mental health. And we want to create a network of peer support that's outside of your employer because when … physicians are really driven to succeed and to accomplish a lot, and that doesn't always ... You don't always want to tell your employer you're really struggling.And in addition, people aren't always aware. If you've always been really in a work environment where you have a lot of stress and you've been a higher achiever, you aren't always aware and in touch with things that might put you at risk.So that's been kind of my personal story is just that we had just kind of this impossible situation, and I wanted ... And when people would ask me, “What should you do? What are solutions?” I didn't feel like there was a lot out there that was focused on a realistic approach and not just doing lip service to the topic, especially since I was a family member and didn't have any of those stigmas where I can't talk about it.I won't lose my job talking about it, so the stories that people will tell me are different than the stories that they tell their licensing committee. So, that's some of my background. Yeah, is that helpful?David Carreon: Thank you for telling us about this. It's got to be a difficult place to be in, where on the one hand you're advocating for other people to prevent suicide or to improve health care systems, while at the same time having this have been a personal struggle for you, something that you're ... It's personally affected and been a challenge in your own life.Janae Sharp: Yeah, it's interesting too because sometimes I do find myself getting more worked up. Like it's more personal, like people don't want to do much. I kind of feel ... I take it more personally than with other things, and that's been a challenge to find that balance of making sure you find the right people who want to help move things forward and to make sure that I'm respectful of their needs and vice versa.So sometimes throughout the process of telling the story, I've had to take breaks, and it does take an emotional toll, but it also, I think, is really powerful, and it makes me feel like I'm giving my kids a better memory for their dad. So they know that it's important and that other kids who go through that, or people might not have to go through that because of stuff that we've done and to honor that and to work on that huge problem.Jessi Gold: Yeah. I'd imagine that speaking to your kids about their father's death was complicated to say the least?Janae Sharp: Oh, it was terrible. I did a terrible job. I'm like in the example. I feel like part of me doing this is I'm the example of what not to do in a lot of ways. I quit my job. I kind of fell apart. I didn't always keep it together. If I was angry, sometimes I would tell people, and that's part of grief, but I think we only want to hear grief stories when they're very cleaned up and very done.Yeah, telling my kids, I, yeah. I tell that story where ... I told that story actually on a podcast only once, where on the ZDogg show, I said how I just screwed it up. I felt like I screwed it up because he died in a pretty graphic way, and I was in shock still.So I just told them, I was like, "Your dad died in a fire." And I'm like, "That's probably going to be the most traumatic possible way to tell your children." And then, I kind of dropped it for almost a year, and they were going to start a counseling group that one of the requirements was you had to say that they had actually died by suicide.And they explained that it can retraumatize a child if they feel like you've lied about how they've died, and once you have that mental health support, it's good for them to be able to work through their feelings. So I told them, but then, normally, you would just ... I had practiced saying, "His brain was sick, and then he found a away to make his body end" because my children were quite young at that time.And they still are. Right now, they're 10, eight and six, and it's been almost 3 years, so it was a real experience kind of coming because you are also traumatized. You don't always handle things the way that is quote/unquote "best," and it's really ... You don't know what to do.So telling my kids was ... really difficult and watching them grieve and not always being able to be as supportive as they needed. That was a really hard thing to watch and to realize about yourself that when you're in such a bad place, you're not really there for people.David Carreon: No, and it just hard to imagine how difficult a experience that was for you, that is for anybody who has to do that, and-Janae Sharp: I know, and you guys talk to people like that for ... They come to you. You guys are the experts, so I couldn't imagine that. I would not be good at that job. I think it's really humbling because you realize how important humanity is. Grief is something that teaches you that there are human needs that are bigger than what you should or shouldn't do or your list of to-do lists or your goals in life.There are just some points in your life when you're kind of knocked on your feet, and you realize the power of humanity that there are things that will happen to you that will change you, but also, you can't ignore them, and you can't just put them on a checklist and go away. They'll heal on their own time.David Carreon:  I want to hear more about what you said about something like having a better memory or having your kids be able to remember things in a better light or having a better memory. How do you tell a story of tragedy well? Or how do you advise people to?Janae Sharp: Oh, that's an interesting question. I don't know. I don't know the best way to tell a story of tragedy. For me, I didn't want to talk about such a graphic way to die without always offering support that there are people who will help you talk about suicide and thoughts of suicide, and I always tell people to be patient with themselves and to be honest as much as they can.With John, it was frustrating not feeling like some of the people he knew were offered a lot of support, like all his classmates. They were in their residency, and it felt like they weren't really reached out to to have offer of counseling or a way to deal with those feelings.So you might not have the prefect thing to say, and you can try to talk anyway. That's what I like to tell people a lot. Suicide and burnout, those are messy topics that we don't like to talk about because you can't always package them up in one neat little bundle and say, "This is how it's going to get better."And talking about those messy topics is important, so I advise people and think in John's memory, we need to remember that we aren't perfect and that we are going to have to find a place to have those messy problems, where there isn't one solution, and there isn't one cause.The more we can talk about those and connect with solutions that already exist, the better things will be for people like my kids. And it's hard for them to tell the story, too. They don't want to ... My daughter even said that the other day. She's like, "I don't want to make people feel sad or make people uncomfortable," and that's a real problem that we aren't able to deal with difficult things, and we have such a strong desire to make people feel not uncomfortable.And I'm sure I've made some people feel uncomfortable and hope that they are patient with me or that they do what they can and make sure to protect your own ability to handle things but also we don't need to always talk about sad things, but we need to be able to accept more complexity of problems and emotions within to our narrative. We need to not just put someone into the good or bad bucket and realize how complex humanity is.Jessi Gold: Do you think that around the time that John died, your initial reaction was to not tell people how, or did you right off the bat know that you needed to do that, and you had this somewhat of a calling, I guess you could say to not fall into the stigma and to actually say it was suicide?Janae Sharp: It was on the news that he died, but not everyone wanted to talk about it at all, like some friends were very uncomfortable with even talking about how he died, and I wanted to be aware of the loss everyone had because that's a serious loss, and people want to go through the memories that they have and honor those.But I also felt like the memories my children had and their experiences were more important, honestly. So I didn't know that I would speak about it at a health care conference or anywhere else, but I did know that it was an impossible experience and that I didn't find that acceptable.I knew that I wanted to find a way to make things better. Especially in health care, where we say that mental illness is real, and we actually are trying to heal people, It doesn't make any sense to have a workforce and training experience that controverts everything we know about health.​So some of my desire to talk about it was the desire to have a voice where I felt like I was silenced when it first happened. But I didn't know for sure I wanted to talk to people about it because I'm not perfect, just like anyone else. But I did feel like it was a huge opportunity to create a space to talk about those hard things and be brave. ep12-sharp_1_of_3.mp3File Size:  14882 kbFile Type:   mp3Download File

In Part 1 of our 3-part interview with Janae Sharp—a physician suicide loss survivor and the Founder and CEO of the <a href="http://sharpindex.org/" rel="nofollow" target="_blank">Sharp Index</a>, a nonprofit dedicated to better physician mental health—Janae shares her story of loss, grief, and her call to action to start her non-profit. She discusses how suicide loss is different from other losses, in part because it is a "messy topic," but also how grief itself is imperfect. She details the experience of telling her 3 children and why she feels compelled to create "better memories" for them. She constantly reinforces the power and complexity of humanity. ​Janae is always looking for collaborators (she wants more psychiatrists!) and donors, so if you are interested in getting involved contact her at  <a href="mailto:Janae@sharpindex.org?subject=Psychiatric%20Times%20podcast%20question">Janae@sharpindex.org</a>. For additional information or to learn more about Janae’s work for physicians, survivors, and families please visit the following websites: <a href="http://mdsuicide.com/" rel="nofollow" target="_blank">Mdsuicide.com</a> and <a href="http://sharpindex.org/" rel="nofollow" target="_blank">Sharpindex.org</a>. Find her on Twitter <a href="https://twitter.com/CoherenceMed" rel="nofollow" target="_blank">@CoherenceMed</a>. TRANSCRIPT: David Carreon: This is David Carreon. Jessi Gold: This is Jessi Gold. David Carreon: And this is Psyched!, a psychiatry podcast. Today we have Janae Sharp. Janae is a physician suicide loss survivor and the founder and CEO of the Sharp Index, a non-profit dedicated to better physician mental health. Her main work involves health care data and analytics marketing to improve health care outcomes for the underserved. Python is her preferred code language, but her true passion is match making companies to create elegant health IT systems and to improve health. She's worked with interoperability and social determinants of health and is an expert on patient and physician engagement. Janae has 3 children, enjoys hiking, triathlon and quilting. Janae, thank you for joining us. Janae Sharp: Thank you. I hate writing bios as well. I feel like that's important. Jessi Gold: Yeah, it is really important. David Carreon: We should have added that to your bio. Janae Sharp: Yeah. Jessi Gold: And writing a bio was not your favorite thing to have done. Janae Sharp: Hearing my own bio I'm always like, "That's a terrible bio. Someone should rewrite that. That poor lady." Jessi Gold: Well, okay, so how about we start with you just telling us more about you and your story and then as much as you feel like telling us, yeah. Janae Sharp: Oh, well, that could be pretty long, but so the story of starting the Sharp Index, I can talk about. Like it says, I have a background in health care IT, and I've worked with people creating data products and worked in social media a lot, and I am also a physician suicide loss survivor. My former spouse, John Madsen, was a physician. He died by suicide, and we created the index actually in his memory and through my experiences with his death. We have 3 children, and I've been able to share a lot of our story and trying to create good memories and, really, how that type of loss was pretty different in terms of the support that my kids got. It was really frustrating. I felt like people didn't really know what to say or had a lot of advice that wasn't helpful or advice that really was hurtful in some ways. And we wanted to create something that brought awareness to physician suicide but also addressed that, created a better place, and that's really our hope, to have better memories for people. But also, the index is focused on reducing burnout. So you can look at scores and information about your burnout risk or reasons for that or mental health. And we want to create a network of peer support that's outside of your employer because when … physicians are really driven to succeed and to accomplish a lot, and that doesn't always ... You don't always want to tell your employer you're really struggling. And in addition, people aren't always aware. If you've always been really in a work environment where you have a lot of stress and you've been a higher achiever, you aren't always aware and in touch with things that might put you at risk. So that's been kind of my personal story is just that we had just kind of this impossible situation, and I wanted ... And when people would ask me, “What should you do? What are solutions?” I didn't feel like there was a lot out there that was focused on a realistic approach and not just doing lip service to the topic, especially since I was a family member and didn't have any of those stigmas where I can't talk about it. I won't lose my job talking about it, so the stories that people will tell me are different than the stories that they tell their licensing committee. So, that's some of my background. Yeah, is that helpful? David Carreon: Thank you for telling us about this. It's got to be a difficult place to be in, where on the one hand you're advocating for other people to prevent suicide or to improve health care systems, while at the same time having this have been a personal struggle for you, something that you're ... It's personally affected and been a challenge in your own life. Janae Sharp: Yeah, it's interesting too because sometimes I do find myself getting more worked up. Like it's more personal, like people don't want to do much. I kind of feel ... I take it more personally than with other things, and that's been a challenge to find that balance of making sure you find the right people who want to help move things forward and to make sure that I'm respectful of their needs and vice versa. So sometimes throughout the process of telling the story, I've had to take breaks, and it does take an emotional toll, but it also, I think, is really powerful, and it makes me feel like I'm giving my kids a better memory for their dad. So they know that it's important and that other kids who go through that, or people might not have to go through that because of stuff that we've done and to honor that and to work on that huge problem. Jessi Gold: Yeah. I'd imagine that speaking to your kids about their father's death was complicated to say the least? Janae Sharp: Oh, it was terrible. I did a terrible job. I'm like in the example. I feel like part of me doing this is I'm the example of what not to do in a lot of ways. I quit my job. I kind of fell apart. I didn't always keep it together. If I was angry, sometimes I would tell people, and that's part of grief, but I think we only want to hear grief stories when they're very cleaned up and very done. Yeah, telling my kids, I, yeah. I tell that story where ... I told that story actually on a podcast only once, where on the ZDogg show, I said how I just screwed it up. I felt like I screwed it up because he died in a pretty graphic way, and I was in shock still. So I just told them, I was like, "Your dad died in a fire." And I'm like, "That's probably going to be the most traumatic possible way to tell your children." And then, I kind of dropped it for almost a year, and they were going to start a counseling group that one of the requirements was you had to say that they had actually died by suicide. And they explained that it can retraumatize a child if they feel like you've lied about how they've died, and once you have that mental health support, it's good for them to be able to work through their feelings. So I told them, but then, normally, you would just ... I had practiced saying, "His brain was sick, and then he found a away to make his body end" because my children were quite young at that time. And they still are. Right now, they're 10, eight and six, and it's been almost 3 years, so it was a real experience kind of coming because you are also traumatized. You don't always handle things the way that is quote/unquote "best," and it's really ... You don't know what to do. So telling my kids was ... really difficult and watching them grieve and not always being able to be as supportive as they needed. That was a really hard thing to watch and to realize about yourself that when you're in such a bad place, you're not really there for people. David Carreon: No, and it just hard to imagine how difficult a experience that was for you, that is for anybody who has to do that, and- Janae Sharp: I know, and you guys talk to people like that for ... They come to you. You guys are the experts, so I couldn't imagine that. I would not be good at that job. I think it's really humbling because you realize how important humanity is. Grief is something that teaches you that there are human needs that are bigger than what you should or shouldn't do or your list of to-do lists or your goals in life. There are just some points in your life when you're kind of knocked on your feet, and you realize the power of humanity that there are things that will happen to you that will change you, but also, you can't ignore them, and you can't just put them on a checklist and go away. They'll heal on their own time. David Carreon:  I want to hear more about what you said about something like having a better memory or having your kids be able to remember things in a better light or having a better memory. How do you tell a story of tragedy well? Or how do you advise people to? Janae Sharp: Oh, that's an interesting question. I don't know. I don't know the best way to tell a story of tragedy. For me, I didn't want to talk about such a graphic way to die without always offering support that there are people who will help you talk about suicide and thoughts of suicide, and I always tell people to be patient with themselves and to be honest as much as they can. With John, it was frustrating not feeling like some of the people he knew were offered a lot of support, like all his classmates. They were in their residency, and it felt like they weren't really reached out to to have offer of counseling or a way to deal with those feelings. So you might not have the prefect thing to say, and you can try to talk anyway. That's what I like to tell people a lot. Suicide and burnout, those are messy topics that we don't like to talk about because you can't always package them up in one neat little bundle and say, "This is how it's going to get better." And talking about those messy topics is important, so I advise people and think in John's memory, we need to remember that we aren't perfect and that we are going to have to find a place to have those messy problems, where there isn't one solution, and there isn't one cause. The more we can talk about those and connect with solutions that already exist, the better things will be for people like my kids. And it's hard for them to tell the story, too. They don't want to ... My daughter even said that the other day. She's like, "I don't want to make people feel sad or make people uncomfortable," and that's a real problem that we aren't able to deal with difficult things, and we have such a strong desire to make people feel not uncomfortable. And I'm sure I've made some people feel uncomfortable and hope that they are patient with me or that they do what they can and make sure to protect your own ability to handle things but also we don't need to always talk about sad things, but we need to be able to accept more complexity of problems and emotions within to our narrative. We need to not just put someone into the good or bad bucket and realize how complex humanity is. Jessi Gold: Do you think that around the time that John died, your initial reaction was to not tell people how, or did you right off the bat know that you needed to do that, and you had this somewhat of a calling, I guess you could say to not fall into the stigma and to actually say it was suicide? Janae Sharp: It was on the news that he died, but not everyone wanted to talk about it at all, like some friends were very uncomfortable with even talking about how he died, and I wanted to be aware of the loss everyone had because that's a serious loss, and people want to go through the memories that they have and honor those. But I also felt like the memories my children had and their experiences were more important, honestly. So I didn't know that I would speak about it at a health care conference or anywhere else, but I did know that it was an impossible experience and that I didn't find that acceptable. I knew that I wanted to find a way to make things better. Especially in health care, where we say that mental illness is real, and we actually are trying to heal people, It doesn't make any sense to have a workforce and training experience that controverts everything we know about health. ​So some of my desire to talk about it was the desire to have a voice where I felt like I was silenced when it first happened. But I didn't know for sure I wanted to talk to people about it because I'm not perfect, just like anyone else. But I did feel like it was a huge opportunity to create a space to talk about those hard things and be brave. <a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep12-sharp_1_of_3.mp3" rel="nofollow" target="_blank"></a> ep12-sharp_1_of_3.mp3File Size: 14882 kbFile Type: mp3<a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep12-sharp_1_of_3.mp3" rel="nofollow" target="_blank">Download File</a>

Surviving a Physician Suicide: Imperfect Grief and Shaping the Narrative for the Children Left Behind (part 1 of 3 with Janae Sharp)

Resilience

Charles Nemeroff, MD, PhD, discusses the role of social influences on biology, using the example of early life trauma. He explains brain changes, inflammation, and genetic risk factors that modulate the development of PTSD or depression in patients with a history of trauma.Keeping in line with epigenetic theory, Dr. Nemeroff discusses what happens to genes during psychotherapy, exploring the interaction between attachment to the therapist and how this contributes to the efficacy.Finally, he answers our rapid-fire questions and describes the challenges without parity in mental health care. He leaves us with excitement and hope for what he feels is the “golden age of psychiatry.”TRANSCRIPTDavid Carreon: I think that on the positive end, I think there's more research to do, but I think thinking about this relationship between the mind and the body, and the person's experience ... It makes me think of things like a difficult childhood, child abuse, or something like that could very well increase a person's stress level and inflammatory markers.Dr. Nemeroff: Well, you're prescient, because that's exactly what the data show. There's a wonderful meta-analysis by Andrea Danese at the Institute of Psychiatry in London. We've confirmed the findings in our own studies. Early life trauma is associated with a very persistent increase in inflammatory markers, and it's probably one of the reasons why those patients have a poorer response to psychotherapy and pharmacotherapy.Jessi Gold: And what counts as early life, and is it one trauma, multiple traumas, or is it different?Dr. Nemeroff: So another great question. The data is still being generated, but overall pre-pubertal abuse and neglect. The more severe, the worse the outcome, both in terms of inflammation, but also a host of other factors. Neuroanatomical changes ... The human brain doesn't mature until age 24, and we know that developing protoplasm is susceptible to insult. Susceptible to lead toxicity, susceptible to fetal alcohol, and in my way of thinking, it's susceptible to behavioral teratology, namely child abuse and neglect. So it's not surprising that we've seen these robust effects that we have.David Carreon: Yeah, and I think there's been an interesting body of literature developing around the social influences on biology. Rats that are isolated versus rats that are in paired housing versus rats that are in enriched environments have entirely different profiles of how they do and how they behave, and what that means for them. And I guess thinking about that both in childhood, but throughout the life, that environment plays a huge role ... And social environment plays a huge role in-Dr. Nemeroff: Well, remember that for major depression ... Not talking about bipolar disorder, but for major depression, about 35 to 40% of the risk for the disease is genetic. That means 60 to 65% is environmental, and I think a lot of this has to do with attachment. I think early life trauma disrupts attachment, and I think subsequent life stressors disrupt attachment, and if you follow these kids who've had terrible early lives, it's a very rocky adolescence and adulthood indeed.David Carreon: Is it possible that somebody who has had a difficult childhood would be able to overcome that and fully remit or fully…Dr. Nemeroff: Yeah, so most of our studies in this area have focused on trying to uncover genetic risk factors, that interact in a gene environment way to increase or modulate the risk for depression or PTSD in adulthood. What we've discovered is that there are some critical genes, of which certain of the SNPs, the variants, unfortunately markedly increase your risk for depression if you've been exposed to early trauma, and then their counterparts which are resilience genes that prevent it.So I believe many of our patients are probably patients who've just had pretty bad luck. They've pulled a bad hand. They have three, four, five or six of the vulnerability genes coupled with early life trauma that result in an increased risk for depression. What's really interesting is in our studies, in the absence of early life trauma, these genetic variants have no impact on whether you get depressed or not. It's only in the face of early life trauma. It's sort of like ... Imagine the guy who has the risk gene for lung cancer but never smokes, right? No effect, right? But smokes three packs a day and 80% likelihood. That's what Caspi saw with the serotonin transporter gene. It's we've seen with the CRH and the FKBP5 gene. I don't want to bore you with the nomenclature, but there are gonna be a category of genes.Now there is some data that both epigenetics is important, so the notion that life events change gene expression, not by changing the structure of the gene but by changing the expression of genes. That could be good or bad. It may be, if I was a betting person and I was Jessi's age, what I would do is I would like to look at the epigenetic consequences of psychotherapy. 'Cause I suspect, in my view, psychotherapy is a biological treatment, and I think it probably changes gene expression.David Carreon: That would be a fascinating thing to circle back on in a few years. I imagine people are already doing work like that. That sounds ... Maybe the inverse of what you're saying about the epigenetics of child abuse, that at least we tell ourselves in psychotherapy that we're filling this role or that this relationship is analogous to the nurturing relationships of childhood.Dr. Nemeroff: Well, it's absolutely essential, you know? I think we must be clear that genetics is not necessarily destiny. That genetics can be overcome, and gene expression can be modulated. There was a very nice study done in Seattle some years ago that I wrote a commentary for in the American Journal, which looked at two different foster care systems. One was funded by a foundation and was very high-end and hired the very best case workers, and every student in that program was guaranteed a full four-year college education if they completed it. That outcome was compared with a sort of standard foster care system in the public sector.Obviously, and I'm not casting any aspersions on the public sector, but the fact is when resources were put into place to guarantee a selection of case workers, foster care parents who were rigorously screened for the best of intentions, the outcomes were better. So I think attachment really does matter, and you can't overcome adversity and genetics.Jessi Gold: It begs the question whether social support or psychotherapy is somehow activating the resilience pathway or resilience genes in some other epigenetic way.Dr. Nemeroff: You know, it's interesting having been brought up academically in the psychoanalytic era, and then seeing the pendulum swing. Every study of efficacy of psychotherapy has always had the same conclusion, which is it's the quality of the relationship between the psychotherapist and the patient that is the best predictor of outcome, regardless of whether you're using cognitive behavior therapy, interpersonal psychotherapy or psychodynamic psychotherapy. In my mind, that's exactly what it's about. It's about the attachment. It's learning how to trust people, it's having somebody help guide you in a certain way and a safe environment when you haven't experienced that. There's no chance on Earth it doesn't have an effect on your stress system, on your endocrine response to stress, and on inflammation.David Carreon: I think that's a very optimistic note to shift into our last phase of questions here. We do rapid fire questions for our guests. So if the next two questions you could answer in one or two sentences. What's an area that psychiatry's going wrong, or an area that psychiatry can improve in?Dr. Nemeroff: So our treatments just simply aren't as good as we would like them to be, and we have to be upfront and honest about it. If only 28% of patients are in remission after monotherapy with an SSRI, we have a problem, and we must teach practitioners and the community to be aggressive about treating depression with whatever it takes. RTMS, psychotherapy, ECT, any of the FDA-approved treatments. We haven't been good at that. That's one.The second really quick answer has to do with the fact that we don't have parity. It's just simply a societal disgrace that our patients cannot get adequate treatment, and the notion that parity laws have passed and President Obama signed them ... The bottom line is my faculty get paid through third-party payers, minuscule amounts for their time compared to say oncologists or ophthalmologists or neurosurgeons. I have nothing against my colleagues in other branches of medicine, but if our patients can't get their treatment, and we can't pay our faculty, and practitioners can't get paid in the community, and companies are constantly denying medications we prescribe because everybody wants us to use generic medications, how can our patients get well?Jessi Gold: Yeah. Just for people listening, before I ask you the next question, what would be the price difference for, let's say, going to a psychiatrist and getting reimbursed versus even just going to primary care or something?Dr. Nemeroff: Well primary care's not a good example 'cause they don't get paid very well. Psychiatrists, pediatricians, general internists, family docs are paid very poorly. But depending on the plan and the state, Medicaid pays very poorly. As much of a help Obamacare was for many states, there was no provision for illegal immigrants to be paid. So many of us, particularly us in Miami but also in California, ended up seeing a lot of patients who were coming to the emergency room extremely sick, and there was no opportunity for them to be reimbursed at all. It's our job to take care of everybody, and so it's a pretty serious problem.Jessi Gold: Yeah. The next question is, what's your favorite book? ...Dr. Nemeroff: ... So I highly recommend ... One of my best friends is a novelist named John Katzenbach, whose father was Nicholas Katzenbach, the Attorney General of the United States. He writes really great psychiatric, psychological thrillers, and really delves into the minds of the characters. So I would highly recommend him. I would be remiss if I didn't mention that the fifth edition of our textbook of psychopharmacology was just released here at the APA.But yeah, I tend to enjoy fiction very much. I just read a fabulous novel by a guy named Peter Heller called Celine. It's about a 62-year-old woman who's a private detective. Very cool.Jessi Gold: Cool.David Carreon: What advice would you give to a young doctor?Dr. Nemeroff: So this is the golden age of psychiatry. All of the advances in neuroscience, molecular biology and genetics are now being applied, and in the next 10 years there's gonna be a sea change in terms of treatment. We're gonna develop personalized medicine in psychiatry. You're gonna see a patient, you're gonna get their genetics, you're gonna probably get imaging on them, you're gonna get inflammatory markers and based on those results, you'll be able to optimally match them to the best treatment and not have to play trial and error. That's gonna be a whole new world for us.Jessi Gold: A lot less dart-playing.Dr. Nemeroff: Alright.Jessi Gold: Yeah. And the nice question is, who is a person, fiction or history, that you consider a hero?Dr. Nemeroff: So ... Boy, that's a great question. I'd have to say Hank Aaron. I was in Atlanta for many years and Hank Aaron had the most incredible grace under pressure, at the toughest time. Here was somebody who broke Babe Ruth's record in baseball. The salary was never what the salaries are today, but he held his head high in the face of racial slurs in the most difficult time, particularly living in the South wasn't easy. I just respect the heck out of him.David Carreon: I guess this is also related to another person, who's somebody who is, in history or the story of someone who had a depression and was able to push through?Dr. Nemeroff: So there have been many folks in Hollywood that have suffered with depression. Some have been upfront about it, others have not. Certainly historically, we know Vincent van Gogh suffered with terrible depressions. ... Clearly Lincoln suffered with depression.Probably the best example was Churchill. The black dog of depression, he's the one who named it, and went through just periods of melancholia that were just so severe. His biographer actually said that to liken his depressions to sadness was actually the same as likening a canker sore to a carcinoma. That's how severe he viewed his depressions.David Carreon: Wow. Thank you for joining us on the show today. We really appreciate your time.Jessi Gold: Yeah, thank you.Dr. Nemeroff: It's my pleasure. Thank you. ep11-nemeroff_2_of_2.mp3File Size:  15137 kbFile Type:   mp3Download File

Charles Nemeroff, MD, PhD, discusses the role of social influences on biology, using the example of early life trauma. He explains brain changes, inflammation, and genetic risk factors that modulate the development of PTSD or depression in patients with a history of trauma. Keeping in line with epigenetic theory, Dr. Nemeroff discusses what happens to genes during psychotherapy, exploring the interaction between attachment to the therapist and how this contributes to the efficacy. Finally, he answers our rapid-fire questions and describes the challenges without parity in mental health care. He leaves us with excitement and hope for what he feels is the “golden age of psychiatry.” TRANSCRIPT David Carreon: I think that on the positive end, I think there's more research to do, but I think thinking about this relationship between the mind and the body, and the person's experience ... It makes me think of things like a difficult childhood, child abuse, or something like that could very well increase a person's stress level and inflammatory markers. Dr. Nemeroff: Well, you're prescient, because that's exactly what the data show. There's a wonderful meta-analysis by Andrea Danese at the Institute of Psychiatry in London. We've confirmed the findings in our own studies. Early life trauma is associated with a very persistent increase in inflammatory markers, and it's probably one of the reasons why those patients have a poorer response to psychotherapy and pharmacotherapy. Jessi Gold: And what counts as early life, and is it one trauma, multiple traumas, or is it different? Dr. Nemeroff: So another great question. The data is still being generated, but overall pre-pubertal abuse and neglect. The more severe, the worse the outcome, both in terms of inflammation, but also a host of other factors. Neuroanatomical changes ... The human brain doesn't mature until age 24, and we know that developing protoplasm is susceptible to insult. Susceptible to lead toxicity, susceptible to fetal alcohol, and in my way of thinking, it's susceptible to behavioral teratology, namely child abuse and neglect. So it's not surprising that we've seen these robust effects that we have. David Carreon: Yeah, and I think there's been an interesting body of literature developing around the social influences on biology. Rats that are isolated versus rats that are in paired housing versus rats that are in enriched environments have entirely different profiles of how they do and how they behave, and what that means for them. And I guess thinking about that both in childhood, but throughout the life, that environment plays a huge role ... And social environment plays a huge role in- Dr. Nemeroff: Well, remember that for major depression ... Not talking about bipolar disorder, but for major depression, about 35 to 40% of the risk for the disease is genetic. That means 60 to 65% is environmental, and I think a lot of this has to do with attachment. I think early life trauma disrupts attachment, and I think subsequent life stressors disrupt attachment, and if you follow these kids who've had terrible early lives, it's a very rocky adolescence and adulthood indeed. David Carreon: Is it possible that somebody who has had a difficult childhood would be able to overcome that and fully remit or fully… Dr. Nemeroff: Yeah, so most of our studies in this area have focused on trying to uncover genetic risk factors, that interact in a gene environment way to increase or modulate the risk for depression or PTSD in adulthood. What we've discovered is that there are some critical genes, of which certain of the SNPs, the variants, unfortunately markedly increase your risk for depression if you've been exposed to early trauma, and then their counterparts which are resilience genes that prevent it. So I believe many of our patients are probably patients who've just had pretty bad luck. They've pulled a bad hand. They have three, four, five or six of the vulnerability genes coupled with early life trauma that result in an increased risk for depression. What's really interesting is in our studies, in the absence of early life trauma, these genetic variants have no impact on whether you get depressed or not. It's only in the face of early life trauma. It's sort of like ... Imagine the guy who has the risk gene for lung cancer but never smokes, right? No effect, right? But smokes three packs a day and 80% likelihood. That's what Caspi saw with the serotonin transporter gene. It's we've seen with the CRH and the FKBP5 gene. I don't want to bore you with the nomenclature, but there are gonna be a category of genes. Now there is some data that both epigenetics is important, so the notion that life events change gene expression, not by changing the structure of the gene but by changing the expression of genes. That could be good or bad. It may be, if I was a betting person and I was Jessi's age, what I would do is I would like to look at the epigenetic consequences of psychotherapy. 'Cause I suspect, in my view, psychotherapy is a biological treatment, and I think it probably changes gene expression. David Carreon: That would be a fascinating thing to circle back on in a few years. I imagine people are already doing work like that. That sounds ... Maybe the inverse of what you're saying about the epigenetics of child abuse, that at least we tell ourselves in psychotherapy that we're filling this role or that this relationship is analogous to the nurturing relationships of childhood. Dr. Nemeroff: Well, it's absolutely essential, you know? I think we must be clear that genetics is not necessarily destiny. That genetics can be overcome, and gene expression can be modulated. There was a very nice study done in Seattle some years ago that I wrote a commentary for in the American Journal, which looked at two different foster care systems. One was funded by a foundation and was very high-end and hired the very best case workers, and every student in that program was guaranteed a full four-year college education if they completed it. That outcome was compared with a sort of standard foster care system in the public sector. Obviously, and I'm not casting any aspersions on the public sector, but the fact is when resources were put into place to guarantee a selection of case workers, foster care parents who were rigorously screened for the best of intentions, the outcomes were better. So I think attachment really does matter, and you can't overcome adversity and genetics. Jessi Gold: It begs the question whether social support or psychotherapy is somehow activating the resilience pathway or resilience genes in some other epigenetic way. Dr. Nemeroff: You know, it's interesting having been brought up academically in the psychoanalytic era, and then seeing the pendulum swing. Every study of efficacy of psychotherapy has always had the same conclusion, which is it's the quality of the relationship between the psychotherapist and the patient that is the best predictor of outcome, regardless of whether you're using cognitive behavior therapy, interpersonal psychotherapy or psychodynamic psychotherapy. In my mind, that's exactly what it's about. It's about the attachment. It's learning how to trust people, it's having somebody help guide you in a certain way and a safe environment when you haven't experienced that. There's no chance on Earth it doesn't have an effect on your stress system, on your endocrine response to stress, and on inflammation. David Carreon: I think that's a very optimistic note to shift into our last phase of questions here. We do rapid fire questions for our guests. So if the next two questions you could answer in one or two sentences. What's an area that psychiatry's going wrong, or an area that psychiatry can improve in? Dr. Nemeroff: So our treatments just simply aren't as good as we would like them to be, and we have to be upfront and honest about it. If only 28% of patients are in remission after monotherapy with an SSRI, we have a problem, and we must teach practitioners and the community to be aggressive about treating depression with whatever it takes. RTMS, psychotherapy, ECT, any of the FDA-approved treatments. We haven't been good at that. That's one. The second really quick answer has to do with the fact that we don't have parity. It's just simply a societal disgrace that our patients cannot get adequate treatment, and the notion that parity laws have passed and President Obama signed them ... The bottom line is my faculty get paid through third-party payers, minuscule amounts for their time compared to say oncologists or ophthalmologists or neurosurgeons. I have nothing against my colleagues in other branches of medicine, but if our patients can't get their treatment, and we can't pay our faculty, and practitioners can't get paid in the community, and companies are constantly denying medications we prescribe because everybody wants us to use generic medications, how can our patients get well? Jessi Gold: Yeah. Just for people listening, before I ask you the next question, what would be the price difference for, let's say, going to a psychiatrist and getting reimbursed versus even just going to primary care or something? Dr. Nemeroff: Well primary care's not a good example 'cause they don't get paid very well. Psychiatrists, pediatricians, general internists, family docs are paid very poorly. But depending on the plan and the state, Medicaid pays very poorly. As much of a help Obamacare was for many states, there was no provision for illegal immigrants to be paid. So many of us, particularly us in Miami but also in California, ended up seeing a lot of patients who were coming to the emergency room extremely sick, and there was no opportunity for them to be reimbursed at all. It's our job to take care of everybody, and so it's a pretty serious problem. Jessi Gold: Yeah. The next question is, what's your favorite book? ... Dr. Nemeroff: ... So I highly recommend ... One of my best friends is a novelist named John Katzenbach, whose father was Nicholas Katzenbach, the Attorney General of the United States. He writes really great psychiatric, psychological thrillers, and really delves into the minds of the characters. So I would highly recommend him. I would be remiss if I didn't mention that the fifth edition of our textbook of psychopharmacology was just released here at the APA. But yeah, I tend to enjoy fiction very much. I just read a fabulous novel by a guy named Peter Heller called Celine. It's about a 62-year-old woman who's a private detective. Very cool. Jessi Gold: Cool. David Carreon: What advice would you give to a young doctor? Dr. Nemeroff: So this is the golden age of psychiatry. All of the advances in neuroscience, molecular biology and genetics are now being applied, and in the next 10 years there's gonna be a sea change in terms of treatment. We're gonna develop personalized medicine in psychiatry. You're gonna see a patient, you're gonna get their genetics, you're gonna probably get imaging on them, you're gonna get inflammatory markers and based on those results, you'll be able to optimally match them to the best treatment and not have to play trial and error. That's gonna be a whole new world for us. Jessi Gold: A lot less dart-playing. Dr. Nemeroff: Alright. Jessi Gold: Yeah. And the nice question is, who is a person, fiction or history, that you consider a hero? Dr. Nemeroff: So ... Boy, that's a great question. I'd have to say Hank Aaron. I was in Atlanta for many years and Hank Aaron had the most incredible grace under pressure, at the toughest time. Here was somebody who broke Babe Ruth's record in baseball. The salary was never what the salaries are today, but he held his head high in the face of racial slurs in the most difficult time, particularly living in the South wasn't easy. I just respect the heck out of him. David Carreon: I guess this is also related to another person, who's somebody who is, in history or the story of someone who had a depression and was able to push through? Dr. Nemeroff: So there have been many folks in Hollywood that have suffered with depression. Some have been upfront about it, others have not. Certainly historically, we know Vincent van Gogh suffered with terrible depressions. ... Clearly Lincoln suffered with depression. Probably the best example was Churchill. The black dog of depression, he's the one who named it, and went through just periods of melancholia that were just so severe. His biographer actually said that to liken his depressions to sadness was actually the same as likening a canker sore to a carcinoma. That's how severe he viewed his depressions. David Carreon: Wow. Thank you for joining us on the show today. We really appreciate your time. Jessi Gold: Yeah, thank you. Dr. Nemeroff: It's my pleasure. Thank you. <a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep11-nemeroff_2_of_2.mp3" rel="nofollow" target="_blank"></a> ep11-nemeroff_2_of_2.mp3File Size: 15137 kbFile Type: mp3<a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep11-nemeroff_2_of_2.mp3" rel="nofollow" target="_blank">Download File</a>

Abuse, Attachment, and Resilience: Genes and the Environment (with Dr. Nemeroff, part 2 of 2)

Depression: A Killing Disease (with Dr. Nemeroff, part 1 of 2)

​In the second part of our interview with Melissa Arbuckle, MD, she continues to discuss active learning methods. What makes interaction in a learning environment difficult for people? She then summarizes the use of quantitative measurement in psychiatric care, including in therapy. She details its effectiveness as a tool for self-monitoring in patients and whether it can predict relapse and to quantify a "baseline." She further mentions the use of the Working Alliance Inventory as not only an outcome measure but also a teaching tool. Can doctors learn to tolerate that not every patient likes them? Dr. Arbuckle is Vice Chair for Education and Director of Resident Education in the department of psychiatry at Columbia University and the New York Psychiatric Institute, TRANSCRIPT Intro: Welcome to Psyched!, a podcast about psychiatry, that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in. Arbuckle: I remember the first grand rounds I did, where I decided I wasn't going to do a lecture, and I think it kind of shocked people in the audience, that no, we're actually going to do something different, and yet they walked away saying, "This was fun. Wow." David Carreon: Tell that story. Where were you, who invited you, and did they know what was coming? Arbuckle: The first time I did it, it was for a quality improvement curriculum that I teach, and the idea ... I asked everybody to come up with something they want to change in their own life and use that as a prompt for walking through the steps of quality improvement and how you set aims, how you measure outcomes. For example, if you're going to set a goal for yourself ... My favorite goal that residents always say when I say, "Oh, let's set some goals," it's always read more. That translates into, probably nothing's going to happen. So if you think about it in the context of a quality improvement paradigm, then you're going to think about, what exactly am I going to read, how much am I going to read, what's my goal, what's my timeline for doing that, and it's far more likely to happen. So we use that framework, I use that framework for teaching about quality improvement. So I did that exercise in a grand rounds and people played. I said, "You're going to pair up with a neighbor, and I want you to talk to your neighbor and report back," and it was fun. David Carreon: Where was it? What was the room like? Tell us more about that picture. Arbuckle: It was a traditional auditorium, so people were sitting in seats in an auditorium and kind of scattered about the room. I think the one thing that I sometimes have to do is get people to sit next to each other. So sometimes I say, "Okay, you're going to have to move, to sit next to somebody, because we're going to do something interactive." I think it takes people off guard. I think people are still a little uncomfortable about it. I did some interactive stuff, here at the APA, and a couple of people snuck out of the room rapidly. Jessi Gold: I noticed that, too. Not in yours, but I was noticing that it was like as soon as the workshop part started, everyone was like ... some people just snuck out. Arbuckle: Yeah. Jessi Gold: Yeah. Arbuckle: Yeah. Jessi Gold: I wonder what ... I mean, I guess it's scary to have to actively do something. I don't know. Arbuckle: Well, I think there's a piece of this thing that we're all afraid of being found out as a fraud, that we don't really know something, and perhaps, if you have to do something with someone else as part of an exercise, you're going to feel stupid or people are going to realize you're not the expert you're supposed to be. I think there's some performance anxiety that comes with that. Jessi Gold: Probably scary for all levels of whatever for different reasons. Arbuckle: Absolutely, yeah. Jessi Gold: Yeah. Arbuckle: Yeah. David Carreon: I mean, if somebody find out that we're not all omniscient, how are we going to be able to keep our jobs? Arbuckle: Exactly. David Carreon: Another thing we wanted to talk to you about was the ... In psychiatry, I mean, medicine in general, but particularly psychiatry, we like to not measure things. We prefer to just sort of go along without measuring things and particularly in psychotherapy training. There's a lot of thought, particularly in psychodynamic or those sorts of approaches, that it really isn't science, and so you really can't measure things. I know that some of your work has involved trying to measure that and trying to improve that. Arbuckle: Yeah. David Carreon: How would you even approach ... ? I mean, with all of the squishiness of the psychodynamic approach, how do you nail that down into something that is quantitative? Arbuckle: Well, I think it depends on, with any treatment, what your goals are. Many patients that come to us for treatment have depression, anxiety, and there are standard rating scales available that you can use to measure those things, and to track them over time. One of the classes I've taught is measurement based-care, and we literally talk about, how do you integrate this into a weekly treatment? Like, how often would you want to do measurement based care and how would you integrate it into a psychodynamic treatment, and it's not really any different than any other treatment. They fill out the scale at the beginning of the session, you look at the scale, you can a conversation about the scale, and then you can talk about their mother or whatever. Jessi Gold: That's usually where I go, from scale to mother. Arbuckle: Yeah. Jessi Gold: Yeah. Arbuckle: But I think it's actually incredibly valuable to measure outcomes with patients and actually not just your own subjective impression about how a patient's doing. It provides you with more objective data about how a patient is progressing over time through treatment, but it's also incredibly tool for self monitoring for patients. They can see when they start to relapse, what are the first things on the scale that they struggle with? One of my patients who has bipolar, we know it's sleep, so we're tracking that item really, really closely. One of my patients who has OCD ... I mean, I think the challenge was, for her, was, even though we both would have a subjective impression of how she was doing, the numbers were far more useful for the both of us. She would say, "Oh, ... " We would talk about, should we make a medication change, in terms of her treatment, and she'd say "No, I actually think this is probably my baseline. This is probably as good as I get." We pushed the medication, she got better. So for both of us, it was useful to say, "Oh, no, that wasn't your baseline. This is your baseline. This is as good as you get, so let's keep this as our marker and our goal in your treatment." I think no matter what kind of treatment you're doing, you want your patients to improve, and having real data for you and your patient to track that over time is helpful. Jessi Gold: I know that also, there's ways to measure whether the patient likes the doctor, or feels like they're doing a good job, and you've been trying to integrate that some, as well. David Carreon: Yeah, and that's challenging to our idea that we're always good doctors to all of our patients. Arbuckle: Right. Right. Jessi Gold: Right, or as a trainee, that we're never good doctors to any of our patients. Arbuckle: Yeah, right. Yeah, so the Working Alliance Inventory is one particular tool where you can track how that's going, and I think that's particularly useful for trainees, in terms of ... And that's probably one of the most useful indicators of outcomes, is how good of an alliance, working alliance you have. I think that probably translates into treatment adherence and lots of positive contributions in terms of outcome. So having that kind of feedback early on could be really helpful. Yeah. Jessi Gold: Also, could kind of kick your ego down a little bit. Arbuckle: It could. Jessi Gold: Yeah. Arbuckle: So a couple of years ago, our residents did a quality improvement project, where they did patient feedback surveys. Patients filled out the surveys anonymously, and then residents got a graphic report back about how their feedback was, relative to their peers. But what was interesting is that some people got feedback from only one patient and some people got feedback from 20 patients, and actually the more positive feedback was usually from people who got feedback from lots of patients. So I think the challenge with that kind of data is, if you have one data point, not to overestimate the value of that data, whether it's positive or negative. For me, the take home point was really that the more data you have, the more accurate of a representation it's going to be.  And as a psychiatrist, I think we also ... you have to learn how to tolerate that every patient is not going to love you and make a connection with you, for all hosts of reasons. Maybe it's complicated, so we're talking about counter-transference, or maybe it's that they haven't come to terms with the illness they have and they're ambivalent about treatment altogether, so I think learning how to work with patients who are ambivalent about treatment is also a very useful skill to develop. David Carreon: Well, we're coming toward the end of our time, and we like to ask a few rapid fire questions at the end. Arbuckle: Okay. David Carreon: And so we will ask you to keep your answers to one to two sentences, and this is very hard for psychiatrists and affiliated people- Arbuckle: Okay. David Carreon: ... so if we can try to keep it to two sentences, that'd be spectacular, so ... Arbuckle: Okay. David Carreon: First question is, what is something that psychiatry as a field can improve in, or an area that we, as a field, kind of get wrong? Arbuckle: Wow. One or two sentences, huh? Jessi Gold: If you want to talk longer, it's okay. Arbuckle: No, it's okay. Jessi Gold: Does that mean you have too much to say? Arbuckle: No, I think that ... I wouldn't say that we get it wrong, I just think there's all these things on the horizon, that's coming down the pike, that we need to be paying attention to, so whether it's neuroscience training and the impact of neuroscience on our field, whether it's thinking about new healthcare delivery models and integrated care, or thinking about resource manager, these are all things we could do better and we need to do better. Jessi Gold: What's your favorite book? Arbuckle: Wow. I'm probably not ... I'm not a good person to ask that. You know what it is? It's Better. Jessi Gold: By Atul Gawande? Arbuckle: Yes. I love that book. Jessi Gold: It sort of goes with quality improvement. Arbuckle: It does. I quote his stuff in my presentations all the time. Jessi Gold: Yeah. David Carreon: What's advice you would give to a trainee? Arbuckle: I think it would be about setting a framework for lifelong learning. I think they think ... you think, "Oh, I've got four years and I've got all this stuff to learn," and it's true, I think your learning during medical school and during residency is really exponential, in terms of all the things you learn, but there are going to be extraordinary advances in the field in your lifetime, and you need to be prepared to adapt to those changes. So I would recommend approaching learning in a way that really embraces a lifelong effort. Jessi Gold: And who is a person, either living or dead, or fiction, non-fiction, whatever, who you consider a hero? Or someone you look up to? Arbuckle: Wow. Well, there's a couple of different people that came to mind when you said that. I mean, I look up to my mother as a hero. She was a single mom for much of my childhood, raising four kids, and really struggled financially. I think that she was ... still maintained her compassion, and so I look up to her. I would say I also really have been so fortunate to have Maria Oquendo as a mentor. She, just so selflessly, has been invested in my career and supporting me in a way that, I think ... She's just an amazing, busy person with all these other things she's doing, and the fact that she always set aside time to mentor me, I think that was incredibly special, so people like that. David Carreon: You'd mentioned having fun is important. What's something fun that you've done, either as a child, or as an adult? Jessi Gold: Just one thing. Arbuckle: Just one fun thing ... Well, I have a seven-year old and an eight-year old, and ... I don't know, just spending time with them is super fun. My seven-year old just learned how to ride a bike a couple of weeks ago and seeing his excitement at figuring it out finally, that was really fun. David Carreon: Great. Thank you for joining us. Jessi Gold: Yeah, thank you. Arbuckle: All right. Thanks. Bye. ep09-arbuckle_2_of_2.mp3File Size:  13243 kbFile Type:   mp3Download File

​In the second part of our interview with Melissa Arbuckle, MD, she continues to discuss active learning methods. What makes interaction in a learning environment difficult for people? She then summarizes the use of quantitative measurement in psychiatric care, including in therapy. She details its effectiveness as a tool for self-monitoring in patients and whether it can predict relapse and to quantify a "baseline." She further mentions the use of the Working Alliance Inventory as not only an outcome measure but also a teaching tool. Can doctors learn to tolerate that not every patient likes them? Dr. Arbuckle is Vice Chair for Education and Director of Resident Education in the department of psychiatry at Columbia University and the New York Psychiatric Institute, TRANSCRIPT Intro: Welcome to Psyched!, a podcast about psychiatry, that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in. Arbuckle: I remember the first grand rounds I did, where I decided I wasn't going to do a lecture, and I think it kind of shocked people in the audience, that no, we're actually going to do something different, and yet they walked away saying, "This was fun. Wow." David Carreon: Tell that story. Where were you, who invited you, and did they know what was coming? Arbuckle: The first time I did it, it was for a quality improvement curriculum that I teach, and the idea ... I asked everybody to come up with something they want to change in their own life and use that as a prompt for walking through the steps of quality improvement and how you set aims, how you measure outcomes. For example, if you're going to set a goal for yourself ... My favorite goal that residents always say when I say, "Oh, let's set some goals," it's always read more. That translates into, probably nothing's going to happen. So if you think about it in the context of a quality improvement paradigm, then you're going to think about, what exactly am I going to read, how much am I going to read, what's my goal, what's my timeline for doing that, and it's far more likely to happen. So we use that framework, I use that framework for teaching about quality improvement. So I did that exercise in a grand rounds and people played. I said, "You're going to pair up with a neighbor, and I want you to talk to your neighbor and report back," and it was fun. David Carreon: Where was it? What was the room like? Tell us more about that picture. Arbuckle: It was a traditional auditorium, so people were sitting in seats in an auditorium and kind of scattered about the room. I think the one thing that I sometimes have to do is get people to sit next to each other. So sometimes I say, "Okay, you're going to have to move, to sit next to somebody, because we're going to do something interactive." I think it takes people off guard. I think people are still a little uncomfortable about it. I did some interactive stuff, here at the APA, and a couple of people snuck out of the room rapidly. Jessi Gold: I noticed that, too. Not in yours, but I was noticing that it was like as soon as the workshop part started, everyone was like ... some people just snuck out. Arbuckle: Yeah. Jessi Gold: Yeah. Arbuckle: Yeah. Jessi Gold: I wonder what ... I mean, I guess it's scary to have to actively do something. I don't know. Arbuckle: Well, I think there's a piece of this thing that we're all afraid of being found out as a fraud, that we don't really know something, and perhaps, if you have to do something with someone else as part of an exercise, you're going to feel stupid or people are going to realize you're not the expert you're supposed to be. I think there's some performance anxiety that comes with that. Jessi Gold: Probably scary for all levels of whatever for different reasons. Arbuckle: Absolutely, yeah. Jessi Gold: Yeah. Arbuckle: Yeah. David Carreon: I mean, if somebody find out that we're not all omniscient, how are we going to be able to keep our jobs? Arbuckle: Exactly. David Carreon: Another thing we wanted to talk to you about was the ... In psychiatry, I mean, medicine in general, but particularly psychiatry, we like to not measure things. We prefer to just sort of go along without measuring things and particularly in psychotherapy training. There's a lot of thought, particularly in psychodynamic or those sorts of approaches, that it really isn't science, and so you really can't measure things. I know that some of your work has involved trying to measure that and trying to improve that. Arbuckle: Yeah. David Carreon: How would you even approach ... ? I mean, with all of the squishiness of the psychodynamic approach, how do you nail that down into something that is quantitative? Arbuckle: Well, I think it depends on, with any treatment, what your goals are. Many patients that come to us for treatment have depression, anxiety, and there are standard rating scales available that you can use to measure those things, and to track them over time. One of the classes I've taught is measurement based-care, and we literally talk about, how do you integrate this into a weekly treatment? Like, how often would you want to do measurement based care and how would you integrate it into a psychodynamic treatment, and it's not really any different than any other treatment. They fill out the scale at the beginning of the session, you look at the scale, you can a conversation about the scale, and then you can talk about their mother or whatever. Jessi Gold: That's usually where I go, from scale to mother. Arbuckle: Yeah. Jessi Gold: Yeah. Arbuckle: But I think it's actually incredibly valuable to measure outcomes with patients and actually not just your own subjective impression about how a patient's doing. It provides you with more objective data about how a patient is progressing over time through treatment, but it's also incredibly tool for self monitoring for patients. They can see when they start to relapse, what are the first things on the scale that they struggle with? One of my patients who has bipolar, we know it's sleep, so we're tracking that item really, really closely. One of my patients who has OCD ... I mean, I think the challenge was, for her, was, even though we both would have a subjective impression of how she was doing, the numbers were far more useful for the both of us. She would say, "Oh, ... " We would talk about, should we make a medication change, in terms of her treatment, and she'd say "No, I actually think this is probably my baseline. This is probably as good as I get." We pushed the medication, she got better. So for both of us, it was useful to say, "Oh, no, that wasn't your baseline. This is your baseline. This is as good as you get, so let's keep this as our marker and our goal in your treatment." I think no matter what kind of treatment you're doing, you want your patients to improve, and having real data for you and your patient to track that over time is helpful. Jessi Gold: I know that also, there's ways to measure whether the patient likes the doctor, or feels like they're doing a good job, and you've been trying to integrate that some, as well. David Carreon: Yeah, and that's challenging to our idea that we're always good doctors to all of our patients. Arbuckle: Right. Right. Jessi Gold: Right, or as a trainee, that we're never good doctors to any of our patients. Arbuckle: Yeah, right. Yeah, so the Working Alliance Inventory is one particular tool where you can track how that's going, and I think that's particularly useful for trainees, in terms of ... And that's probably one of the most useful indicators of outcomes, is how good of an alliance, working alliance you have. I think that probably translates into treatment adherence and lots of positive contributions in terms of outcome. So having that kind of feedback early on could be really helpful. Yeah. Jessi Gold: Also, could kind of kick your ego down a little bit. Arbuckle: It could. Jessi Gold: Yeah. Arbuckle: So a couple of years ago, our residents did a quality improvement project, where they did patient feedback surveys. Patients filled out the surveys anonymously, and then residents got a graphic report back about how their feedback was, relative to their peers. But what was interesting is that some people got feedback from only one patient and some people got feedback from 20 patients, and actually the more positive feedback was usually from people who got feedback from lots of patients. So I think the challenge with that kind of data is, if you have one data point, not to overestimate the value of that data, whether it's positive or negative. For me, the take home point was really that the more data you have, the more accurate of a representation it's going to be.  And as a psychiatrist, I think we also ... you have to learn how to tolerate that every patient is not going to love you and make a connection with you, for all hosts of reasons. Maybe it's complicated, so we're talking about counter-transference, or maybe it's that they haven't come to terms with the illness they have and they're ambivalent about treatment altogether, so I think learning how to work with patients who are ambivalent about treatment is also a very useful skill to develop. David Carreon: Well, we're coming toward the end of our time, and we like to ask a few rapid fire questions at the end. Arbuckle: Okay. David Carreon: And so we will ask you to keep your answers to one to two sentences, and this is very hard for psychiatrists and affiliated people- Arbuckle: Okay. David Carreon: ... so if we can try to keep it to two sentences, that'd be spectacular, so ... Arbuckle: Okay. David Carreon: First question is, what is something that psychiatry as a field can improve in, or an area that we, as a field, kind of get wrong? Arbuckle: Wow. One or two sentences, huh? Jessi Gold: If you want to talk longer, it's okay. Arbuckle: No, it's okay. Jessi Gold: Does that mean you have too much to say? Arbuckle: No, I think that ... I wouldn't say that we get it wrong, I just think there's all these things on the horizon, that's coming down the pike, that we need to be paying attention to, so whether it's neuroscience training and the impact of neuroscience on our field, whether it's thinking about new healthcare delivery models and integrated care, or thinking about resource manager, these are all things we could do better and we need to do better. Jessi Gold: What's your favorite book? Arbuckle: Wow. I'm probably not ... I'm not a good person to ask that. You know what it is? It's <a href="https://www.amazon.com/Better-Surgeons-Performance-Atul-Gawande/dp/0312427654" rel="nofollow" target="_blank">Better</a>. Jessi Gold: By Atul Gawande? Arbuckle: Yes. I love that book. Jessi Gold: It sort of goes with quality improvement. Arbuckle: It does. I quote his stuff in my presentations all the time. Jessi Gold: Yeah. David Carreon: What's advice you would give to a trainee? Arbuckle: I think it would be about setting a framework for lifelong learning. I think they think ... you think, "Oh, I've got four years and I've got all this stuff to learn," and it's true, I think your learning during medical school and during residency is really exponential, in terms of all the things you learn, but there are going to be extraordinary advances in the field in your lifetime, and you need to be prepared to adapt to those changes. So I would recommend approaching learning in a way that really embraces a lifelong effort. Jessi Gold: And who is a person, either living or dead, or fiction, non-fiction, whatever, who you consider a hero? Or someone you look up to? Arbuckle: Wow. Well, there's a couple of different people that came to mind when you said that. I mean, I look up to my mother as a hero. She was a single mom for much of my childhood, raising four kids, and really struggled financially. I think that she was ... still maintained her compassion, and so I look up to her. I would say I also really have been so fortunate to have Maria Oquendo as a mentor. She, just so selflessly, has been invested in my career and supporting me in a way that, I think ... She's just an amazing, busy person with all these other things she's doing, and the fact that she always set aside time to mentor me, I think that was incredibly special, so people like that. David Carreon: You'd mentioned having fun is important. What's something fun that you've done, either as a child, or as an adult? Jessi Gold: Just one thing. Arbuckle: Just one fun thing ... Well, I have a seven-year old and an eight-year old, and ... I don't know, just spending time with them is super fun. My seven-year old just learned how to ride a bike a couple of weeks ago and seeing his excitement at figuring it out finally, that was really fun. David Carreon: Great. Thank you for joining us. Jessi Gold: Yeah, thank you. Arbuckle: All right. Thanks. Bye. <a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep09-arbuckle_2_of_2.mp3" rel="nofollow" target="_blank"></a> ep09-arbuckle_2_of_2.mp3File Size: 13243 kbFile Type: mp3<a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep09-arbuckle_2_of_2.mp3" rel="nofollow" target="_blank">Download File</a>

Innovation in Psychiatric Education: Interaction and Measurement (with Dr. Arbuckle, part 2 of 2)

In the first part of this interview, Dr. Melissa Arbuckle, Vice Chair for Education and Director of Resident Education in the department of psychiatry at Columbia University and the New York Psychiatric Institute, discusses neuroscience education for psychiatrists and the general public. She focuses on an innovative teaching curriculum that she co-developed called the National Neuroscience Curriculum Initiative and the ways in which this curriculum makes neuroscience accessible, clinically relevant, and interesting.She describes how understanding and teaching neuroscience can actually reduce stigma towards psychiatric illness (eg, addiction) for patients and decrease countertransference in psychiatrists. Additionally, she broadens the scope to discuss active teaching methods and adult learning principles in general. In rejecting lecture as a good teaching method, she also discusses what is so "scary" about teaching and "making" participants interact with each other.TRANSCRIPTDavid Carreon: Hey, everybody. This is David Carreon.Jessi Gold: This is Jessi Gold.David Carreon: And this is Psyched! Today we have Melissa Arbuckle with us, the Co-director of Resident Education in the Department of Psychiatry at Columbia and the New York State Psychiatric Institute. She went to medical school at the University of Oklahoma and did a residency at Columbia. She served as a New York State Office of Mental Health policy scholar, 2009 to 2012, exploring the implementation of standardized patient assessments and measurement based care in the clinical practice of residents in training. She directs the quality improvement curriculum for the residency training program. Thank you for joining us.Arbuckle: My pleasure.Jessi Gold: You have a correction?Arbuckle: Yeah.Jessi Gold: What is it? It's okay.Arbuckle: I'm now the Director of Residency Training and I'm the Vice Chair for Education, so, yeah, that hasn't been updated.Jessi Gold: So a promotion?Arbuckle: Yes, a promotion.Jessi Gold: That's always good.David Carreon: Congratulations.Arbuckle: Thank you.Jessi Gold: Congratulations.David Carreon: So, well, thank you for joining us, and we've got a lot of ... I'm excited to talk to you about a number of things, but particularly the role of neuroscience in the psychiatry curriculum.Arbuckle: Yeah.David Carreon: What are your thoughts on why that's a good idea or not?Arbuckle: Well, I think our knowledge, in terms of neuroscience and its relevance to the clinical practice of psychiatry, is increasing daily. The research in neuroscience and psychiatry is really exploding, and if that research is going to reach patients, it's going to require a clinician workforce that understands that work and can speak that kind of language.David Carreon: So, say more about what are some of the ways that neuroscience can be integrated into a curriculum. I mean, what would that look like?Arbuckle: In terms of medical training?David Carreon: Yeah.Arbuckle: I think that, as part of the National Neuroscience Curriculum Initiative, we've been developing teaching resources, and that started in terms of thinking about how we teach neuroscience in the classroom, and particularly how we make sure that neuroscience for a medical audience feels clinically relevant, that it's taught in a way that capitalizes on adult learning, and that it's experience near to trainees and their role with patients.When we first started, we were really thinking about how to do that in the classroom, but most of your training is in clinical settings, so more recently we've moved towards developing short videos, in terms of teaching core neuroscience topics, that can be used in clinical settings with both the teacher and the trainee together.I think we have this model for education where the teacher is supposed to be the expert, teaching something to a student, and for neuroscience, the field is exploding and most clinicians are not neuroscience experts and feel uncomfortable teaching. So we've developed really short educational videos that teachers or faculty and trainees can watch together and learn together. So it's really a different way of teaching.David Carreon: Yeah, no, I think that's definitely ... The old model, or at least the traditional model of expert trainee is ... that kind of turns it on its head. I mean, are these videos that are available online or what's-Arbuckle: Yes.David Carreon: What is the project?Arbuckle: Yes. In 2014, I joined with Mike Travis and David Ross to develop the National Neuroscience Curriculum Initiative, and in that project we put all of these open resource videos, papers online. Anyone can log in, create a login to access the materials, and the idea was to really disseminate neuroscience education in a way that was accessible and clinically relevant and all of those things.Jessi Gold: Do you feel like neuroscience has the potential for people that are in psychiatry to feel like it's boring?Arbuckle: In terms of the way it's currently taught?Jessi Gold: Yeah.Arbuckle: Yeah, so I think that's one of the major challenges in teaching neuroscience, is that the way it has been historically taught is, in our traditional models, that the expert will come in and do a lecture, because scientists are used to teaching to a scientific community, and that's usually ... that dissemination is usually a PowerPoint slide set. So they come in with their talk from their latest meeting, ready to engage medical students or residents, and I think they miss the mark a lot of times.They don't really realize the lack of foundational knowledge that medical trainees have, so they make a lot of assumptions about what clinical trainees know and don't know, and within a few minutes, trainees are often lost and it doesn't feel clinically relevant. It's about their latest rat study and they don't make that effort to say, "This is how this matters to the patient that's going to be in front of you tomorrow." I think that's been a huge challenge and partly why neuroscience in education has not been so great, up until now.David Carreon: Is this something that ... ? You said these modules are online, is this ... ? Some of our listeners are psychiatrists, but some of them are not. Some of them might be patients or family members. Is this something that you're hoping everybody can use?Arbuckle: Absolutely. When we first started, we had this idea that we would create different modules for different learners. So we would have some basic stuff that was more for the lay public, we'd have some intermediate stuff that might be for medical students and residents, and then perhaps expert level content. What we found is, really, everyone's kind of at the lay public level, that we don't know anything about neuroscience, and so all of these resources are incredibly accessible to anybody.One of our modules that I think is particularly great is called Talking Pathways to Patients, and in these sessions a ... in one, it's a trainee, in another it's a faculty member, role play what they would say to a patient. One is about the neuroscience underlying addiction, and the idea is that they're demonstrating what you could say to a patient, but there's no reason why those videos couldn't be directly useful to the patient population that they're targeting.David Carreon: Now, have you gotten any feedback from non-doctors or non-trainees about the modules? Do you know of anybody who's used these or who's gone through these modules, that's not a medical affiliate?Arbuckle: So, I don't know ... Our main outcome measure we've been looking so far is just uptake and we don't really know who's using the modules so far, but certainly the people who have been using them have been incredibly enthusiastic. We also have several resources that we've shared over Facebook and when we're getting the highest hits, in terms of the things we disseminate, my suspicion is that it's the lay public that's really doing the uptake, as opposed to faculty and trainees.I think it's a huge potential target for the work we're doing, and a lot of interest ... I think patients really want to understand what's going on, and to have a medical model that explains addiction in the context of the reward circuit, I think, can really decrease stigma, self stigma, and can be a really powerful treatment tool.Jessi Gold: It probably does patients a bit of a disservice to really, really dumb it down because we don't understand it ourselves.Arbuckle: That's right.Jessi Gold: Yeah.Arbuckle: Absolutely.Jessi Gold: Wow.David Carreon: With that, the stigma piece, from one perspective they could say, well, the dopamine sort of ... there's too much dopamine, simplistic 30-year old story. How would the neuroscience version of that, or the circuit based model of the past, you know, updating things, how could that reduce stigma even further than what's already been done, say with the more simplistic dopamine model?Arbuckle: Well, the current session that we have posted online really talks about the neurocircuit and different areas of the brain, and with happens with a heroin addiction. So what is the normal reward circuit, and then what happens and how heroin can hijack that circuit, and how different areas of the brain are upregulated and different control mechanisms are downregulated. I think that it explains why patients can find themselves with a lack of control over something that they feel they should be able to control. I think having that perspective can take away some of the self blame, the guilt that patients experience. It also provides a really robust model for thinking about how we can target each area of that circuit with different treatments, whether it's medication or psychotherapy. I think it's a model that brings together a lot of different treatment modalities in a unifying model.David Carreon: This is sort of a story that's more compelling, say, then a more simplistic biological version from the past, or a moralizing version from maybe the present.Arbuckle: Yeah. I think it's also helpful for physicians, in terms of counter-transference, that when you're working with patient populations where there is a lot of relapse, it can be incredibly frustrating, and particularly when it's associated with ineffective behaviors. So for clinicians to reframe what's happening with your patients, that your patient who is, quote, unquote, "drug seeking" isn't in your office to torture you, but there's something going on at a biological basis in their brain, I think it just reframes your own empathy for that person and could be really helpful in that way, as well.David Carreon: So there's a few ways to approach the counter-transference relationship and I think that, certainly, there's been some evidence to suggest that a neuroscience understanding, or a biological understanding, can sometimes increase stigma, that if you say, "I am this way because of stuff that happened to me in childhood," rather than, "I am this way because I have a brain disorder," there are some studies suggesting that there's even more stigma ...Arbuckle: Right. I think it's important to keep it balanced so that, you know, neuroscience isn't just about underlying genetics, but epigenetic changes, so it really is ... When we say that neuroscience and biology is a part of that, experience shapes biology, so these are not one or other.The other thing is that there's been some really interesting research looking at stigma and what shapes stigma, and some of the data suggests that if you pair psychiatric illness with a message of hope that there is treatment available, that that can be incredibly powerful in decreasing stigma. I think that when we start talking about these biological models, one of the things we've done in the sessions we've developed is really talk about how that biological perspective can inform treatment, and so pairing it with this message of hope and there's something we can do about it, and this how this transforms into treatment options for you and how we can frame treatment options within the context of the neuroscience, I think that could be very powerful.David Carreon: So sort of trying to take the fatalism out of biology.Arbuckle: Exactly. Exactly. Yeah.Jessi Gold: I noticed, also, that you've done some work with teaching trainees how to explain drugs and the side effects of medications to patients as well, and I'd assume that this falls into the same realm for you.Arbuckle: I think the things that they have in common is really thinking about active teaching approaches. I think medical education, in general ... I probably unfairly targeted the neuroscientists, coming in with their slide deck. This is actually what all of our professors do, right. They come in ... for psychopharmacology, let's say, they come in with their slide deck and they're going to run through, "These are the drugs, these are the starting doses, these are the side effects," and I can't imagine a more boring way to spend an hour, than having someone lecture on something I could look up in a book.So for teaching, in terms of talking to patients about psychopharm, it's really about using active teaching modules. So residents role play talking to each other, one playing the role of the physician, one playing the role of the patient, and saying, literally, what would you say to a patient when you're going to start a certain medication, in terms of informed consent? What do they need to know about the starting doses, the side effects? How do you talk about really scary side effects in a way that's not going to contribute to medication non-compliance? And that just transforms what was previously a passive learning experience into something incredibly active and incredibly applicable to clinical work. I think that's what's in common, is really thinking about different ways of teaching.David Carreon: Yeah, and I guess that gets into something that goes far beyond psychiatry, but you've mentioned a few times adult learning and ways that we, just as people, as human beings, remember things better. What are some principles that you've come to appreciate from your work in adult education?Arbuckle: Well, I think that learners have to be actively manipulating information. So being a passive recipient and not doing anything to actively manipulate information ... The data suggests that if you're sitting in an hour-long lecture, you might remember 5 to 10 minutes' worth of content. When we're pressed to teach so many thing in training, we can't afford to have wasted time, so it's really about getting trainees thinking and coming up with solutions themselves. If you can come up with a solution yourself rather than someone telling you the answer, that's more likely to stick. If you can learn something in an experiential way, that's more likely to stick.For example, in the neuroscience education, one of the modules is on the fear circuit, and prior to a conversation about the fear circuit, and how we understand the fear circuit, everyone watches a short horror film. Once you've had your own fear circuit activated then talking about what just happened in your brain, that's a very different experience than passively having someone lecture to you.Jessi Gold: And probably more fun.Arbuckle: Well, that's the thing. I don't know what happened in education, that somewhere between kindergarten and medical education we decided that learning shouldn't be fun. I'm a big fan of learning being fun, so as part of the NNCI we have trainees make brains out of play dough and it's fun. It's really fun.David Carreon: So let me get this straight, you have people with advanced degrees making play dough brains?Arbuckle: Absolutely.Jessi Gold: I think we did that.Arbuckle: You did it. I'm sure you did.David Carreon: Yeah, it was spectacular.Arbuckle: But, you know, it's funny, because I originally thought ... My anxiety about doing play dough brain and having people make a brain out of play dough was not that they would think it was too hokey and be unwilling to do it, but they just wouldn't know how to do it. When Dave Ross suggested we were going to do this, and we were going to create brains out of play dough, I said, "Well, I wouldn't even know how to start." He said, "No, no. We're going to make a video. We're going to show people how to make a brain out of play dough," and it was not only fun, it was incredibly useful.Usually, when you're sitting in a grand rounds, you're looking at some two dimensional image and you're trying to orient yourself, "Okay, they're pointing at something. What is that?" And actually, in this exercise, I discovered I'm a kinetic learner. I really learned in this way of manipulating objects in space was really a useful learning tool for me, so ...Jessi Gold: I think it's interesting, too, you mentioned kindergarten to college, like if you never tried any of these methods of learning, you wouldn't know that you were a kinetic learner, right?Arbuckle: Right.Jessi Gold: But you just kind of go with whatever the people do.Arbuckle: Yeah, right. Right.Jessi Gold: Yeah.David Carreon: So you're saying that most people are not dry, boring-slides-from-a-PowerPoint-deck-that-are-presented-monotone learners?Arbuckle: That's right. That's right, most people are not. That's probably the least effective way to teach, and yet we do it everywhere.     ep08-arbuckle_1_of_2.mp3File Size:  17624 kbFile Type:   mp3Download File

In the first part of this interview, Dr. Melissa Arbuckle, Vice Chair for Education and Director of Resident Education in the department of psychiatry at Columbia University and the New York Psychiatric Institute, discusses neuroscience education for psychiatrists and the general public. She focuses on an innovative teaching curriculum that she co-developed called the <a href="http://www.nncionline.org/" rel="nofollow" target="_blank">National Neuroscience Curriculum Initiative</a> and the ways in which this curriculum makes neuroscience accessible, clinically relevant, and interesting. She describes how understanding and teaching neuroscience can actually reduce stigma towards psychiatric illness (eg, addiction) for patients and decrease countertransference in psychiatrists. Additionally, she broadens the scope to discuss active teaching methods and adult learning principles in general. In rejecting lecture as a good teaching method, she also discusses what is so "scary" about teaching and "making" participants interact with each other. TRANSCRIPT David Carreon: Hey, everybody. This is David Carreon. Jessi Gold: This is Jessi Gold. David Carreon: And this is Psyched! Today we have Melissa Arbuckle with us, the Co-director of Resident Education in the Department of Psychiatry at Columbia and the New York State Psychiatric Institute. She went to medical school at the University of Oklahoma and did a residency at Columbia. She served as a New York State Office of Mental Health policy scholar, 2009 to 2012, exploring the implementation of standardized patient assessments and measurement based care in the clinical practice of residents in training. She directs the quality improvement curriculum for the residency training program. Thank you for joining us. Arbuckle: My pleasure. Jessi Gold: You have a correction? Arbuckle: Yeah. Jessi Gold: What is it? It's okay. Arbuckle: I'm now the Director of Residency Training and I'm the Vice Chair for Education, so, yeah, that hasn't been updated. Jessi Gold: So a promotion? Arbuckle: Yes, a promotion. Jessi Gold: That's always good. David Carreon: Congratulations. Arbuckle: Thank you. Jessi Gold: Congratulations. David Carreon: So, well, thank you for joining us, and we've got a lot of ... I'm excited to talk to you about a number of things, but particularly the role of neuroscience in the psychiatry curriculum. Arbuckle: Yeah. David Carreon: What are your thoughts on why that's a good idea or not? Arbuckle: Well, I think our knowledge, in terms of neuroscience and its relevance to the clinical practice of psychiatry, is increasing daily. The research in neuroscience and psychiatry is really exploding, and if that research is going to reach patients, it's going to require a clinician workforce that understands that work and can speak that kind of language. David Carreon: So, say more about what are some of the ways that neuroscience can be integrated into a curriculum. I mean, what would that look like? Arbuckle: In terms of medical training? David Carreon: Yeah. Arbuckle: I think that, as part of the National Neuroscience Curriculum Initiative, we've been developing teaching resources, and that started in terms of thinking about how we teach neuroscience in the classroom, and particularly how we make sure that neuroscience for a medical audience feels clinically relevant, that it's taught in a way that capitalizes on adult learning, and that it's experience near to trainees and their role with patients. When we first started, we were really thinking about how to do that in the classroom, but most of your training is in clinical settings, so more recently we've moved towards developing short videos, in terms of teaching core neuroscience topics, that can be used in clinical settings with both the teacher and the trainee together. I think we have this model for education where the teacher is supposed to be the expert, teaching something to a student, and for neuroscience, the field is exploding and most clinicians are not neuroscience experts and feel uncomfortable teaching. So we've developed really short educational videos that teachers or faculty and trainees can watch together and learn together. So it's really a different way of teaching. David Carreon: Yeah, no, I think that's definitely ... The old model, or at least the traditional model of expert trainee is ... that kind of turns it on its head. I mean, are these videos that are available online or what's- Arbuckle: Yes. David Carreon: What is the project? Arbuckle: Yes. In 2014, I joined with Mike Travis and David Ross to develop the National Neuroscience Curriculum Initiative, and in that project we put all of these open resource videos, papers online. Anyone can log in, create a login to access the materials, and the idea was to really disseminate neuroscience education in a way that was accessible and clinically relevant and all of those things. Jessi Gold: Do you feel like neuroscience has the potential for people that are in psychiatry to feel like it's boring? Arbuckle: In terms of the way it's currently taught? Jessi Gold: Yeah. Arbuckle: Yeah, so I think that's one of the major challenges in teaching neuroscience, is that the way it has been historically taught is, in our traditional models, that the expert will come in and do a lecture, because scientists are used to teaching to a scientific community, and that's usually ... that dissemination is usually a PowerPoint slide set. So they come in with their talk from their latest meeting, ready to engage medical students or residents, and I think they miss the mark a lot of times. They don't really realize the lack of foundational knowledge that medical trainees have, so they make a lot of assumptions about what clinical trainees know and don't know, and within a few minutes, trainees are often lost and it doesn't feel clinically relevant. It's about their latest rat study and they don't make that effort to say, "This is how this matters to the patient that's going to be in front of you tomorrow." I think that's been a huge challenge and partly why neuroscience in education has not been so great, up until now. David Carreon: Is this something that ... ? You said these modules are online, is this ... ? Some of our listeners are psychiatrists, but some of them are not. Some of them might be patients or family members. Is this something that you're hoping everybody can use? Arbuckle: Absolutely. When we first started, we had this idea that we would create different modules for different learners. So we would have some basic stuff that was more for the lay public, we'd have some intermediate stuff that might be for medical students and residents, and then perhaps expert level content. What we found is, really, everyone's kind of at the lay public level, that we don't know anything about neuroscience, and so all of these resources are incredibly accessible to anybody. One of our modules that I think is particularly great is called Talking Pathways to Patients, and in these sessions a ... in one, it's a trainee, in another it's a faculty member, role play what they would say to a patient. One is about the neuroscience underlying addiction, and the idea is that they're demonstrating what you could say to a patient, but there's no reason why those videos couldn't be directly useful to the patient population that they're targeting. David Carreon: Now, have you gotten any feedback from non-doctors or non-trainees about the modules? Do you know of anybody who's used these or who's gone through these modules, that's not a medical affiliate? Arbuckle: So, I don't know ... Our main outcome measure we've been looking so far is just uptake and we don't really know who's using the modules so far, but certainly the people who have been using them have been incredibly enthusiastic. We also have several resources that we've shared over Facebook and when we're getting the highest hits, in terms of the things we disseminate, my suspicion is that it's the lay public that's really doing the uptake, as opposed to faculty and trainees. I think it's a huge potential target for the work we're doing, and a lot of interest ... I think patients really want to understand what's going on, and to have a medical model that explains addiction in the context of the reward circuit, I think, can really decrease stigma, self stigma, and can be a really powerful treatment tool. Jessi Gold: It probably does patients a bit of a disservice to really, really dumb it down because we don't understand it ourselves. Arbuckle: That's right. Jessi Gold: Yeah. Arbuckle: Absolutely. Jessi Gold: Wow. David Carreon: With that, the stigma piece, from one perspective they could say, well, the dopamine sort of ... there's too much dopamine, simplistic 30-year old story. How would the neuroscience version of that, or the circuit based model of the past, you know, updating things, how could that reduce stigma even further than what's already been done, say with the more simplistic dopamine model? Arbuckle: Well, the current session that we have posted online really talks about the neurocircuit and different areas of the brain, and with happens with a heroin addiction. So what is the normal reward circuit, and then what happens and how heroin can hijack that circuit, and how different areas of the brain are upregulated and different control mechanisms are downregulated. I think that it explains why patients can find themselves with a lack of control over something that they feel they should be able to control. I think having that perspective can take away some of the self blame, the guilt that patients experience. It also provides a really robust model for thinking about how we can target each area of that circuit with different treatments, whether it's medication or psychotherapy. I think it's a model that brings together a lot of different treatment modalities in a unifying model. David Carreon: This is sort of a story that's more compelling, say, then a more simplistic biological version from the past, or a moralizing version from maybe the present. Arbuckle: Yeah. I think it's also helpful for physicians, in terms of counter-transference, that when you're working with patient populations where there is a lot of relapse, it can be incredibly frustrating, and particularly when it's associated with ineffective behaviors. So for clinicians to reframe what's happening with your patients, that your patient who is, quote, unquote, "drug seeking" isn't in your office to torture you, but there's something going on at a biological basis in their brain, I think it just reframes your own empathy for that person and could be really helpful in that way, as well. David Carreon: So there's a few ways to approach the counter-transference relationship and I think that, certainly, there's been some evidence to suggest that a neuroscience understanding, or a biological understanding, can sometimes increase stigma, that if you say, "I am this way because of stuff that happened to me in childhood," rather than, "I am this way because I have a brain disorder," there are some studies suggesting that there's even more stigma ... Arbuckle: Right. I think it's important to keep it balanced so that, you know, neuroscience isn't just about underlying genetics, but epigenetic changes, so it really is ... When we say that neuroscience and biology is a part of that, experience shapes biology, so these are not one or other. The other thing is that there's been some really interesting research looking at stigma and what shapes stigma, and some of the data suggests that if you pair psychiatric illness with a message of hope that there is treatment available, that that can be incredibly powerful in decreasing stigma. I think that when we start talking about these biological models, one of the things we've done in the sessions we've developed is really talk about how that biological perspective can inform treatment, and so pairing it with this message of hope and there's something we can do about it, and this how this transforms into treatment options for you and how we can frame treatment options within the context of the neuroscience, I think that could be very powerful. David Carreon: So sort of trying to take the fatalism out of biology. Arbuckle: Exactly. Exactly. Yeah. Jessi Gold: I noticed, also, that you've done some work with teaching trainees how to explain drugs and the side effects of medications to patients as well, and I'd assume that this falls into the same realm for you. Arbuckle: I think the things that they have in common is really thinking about active teaching approaches. I think medical education, in general ... I probably unfairly targeted the neuroscientists, coming in with their slide deck. This is actually what all of our professors do, right. They come in ... for psychopharmacology, let's say, they come in with their slide deck and they're going to run through, "These are the drugs, these are the starting doses, these are the side effects," and I can't imagine a more boring way to spend an hour, than having someone lecture on something I could look up in a book. So for teaching, in terms of talking to patients about psychopharm, it's really about using active teaching modules. So residents role play talking to each other, one playing the role of the physician, one playing the role of the patient, and saying, literally, what would you say to a patient when you're going to start a certain medication, in terms of informed consent? What do they need to know about the starting doses, the side effects? How do you talk about really scary side effects in a way that's not going to contribute to medication non-compliance? And that just transforms what was previously a passive learning experience into something incredibly active and incredibly applicable to clinical work. I think that's what's in common, is really thinking about different ways of teaching. David Carreon: Yeah, and I guess that gets into something that goes far beyond psychiatry, but you've mentioned a few times adult learning and ways that we, just as people, as human beings, remember things better. What are some principles that you've come to appreciate from your work in adult education? Arbuckle: Well, I think that learners have to be actively manipulating information. So being a passive recipient and not doing anything to actively manipulate information ... The data suggests that if you're sitting in an hour-long lecture, you might remember 5 to 10 minutes' worth of content. When we're pressed to teach so many thing in training, we can't afford to have wasted time, so it's really about getting trainees thinking and coming up with solutions themselves. If you can come up with a solution yourself rather than someone telling you the answer, that's more likely to stick. If you can learn something in an experiential way, that's more likely to stick. For example, in the neuroscience education, one of the modules is on the fear circuit, and prior to a conversation about the fear circuit, and how we understand the fear circuit, everyone watches a short horror film. Once you've had your own fear circuit activated then talking about what just happened in your brain, that's a very different experience than passively having someone lecture to you. Jessi Gold: And probably more fun. Arbuckle: Well, that's the thing. I don't know what happened in education, that somewhere between kindergarten and medical education we decided that learning shouldn't be fun. I'm a big fan of learning being fun, so as part of the NNCI we have trainees make brains out of play dough and it's fun. It's really fun. David Carreon: So let me get this straight, you have people with advanced degrees making play dough brains? Arbuckle: Absolutely. Jessi Gold: I think we did that. Arbuckle: You did it. I'm sure you did. David Carreon: Yeah, it was spectacular. Arbuckle: But, you know, it's funny, because I originally thought ... My anxiety about doing play dough brain and having people make a brain out of play dough was not that they would think it was too hokey and be unwilling to do it, but they just wouldn't know how to do it. When Dave Ross suggested we were going to do this, and we were going to create brains out of play dough, I said, "Well, I wouldn't even know how to start." He said, "No, no. We're going to make a video. We're going to show people how to make a brain out of play dough," and it was not only fun, it was incredibly useful. Usually, when you're sitting in a grand rounds, you're looking at some two dimensional image and you're trying to orient yourself, "Okay, they're pointing at something. What is that?" And actually, in this exercise, I discovered I'm a kinetic learner. I really learned in this way of manipulating objects in space was really a useful learning tool for me, so ... Jessi Gold: I think it's interesting, too, you mentioned kindergarten to college, like if you never tried any of these methods of learning, you wouldn't know that you were a kinetic learner, right? Arbuckle: Right. Jessi Gold: But you just kind of go with whatever the people do. Arbuckle: Yeah, right. Right. Jessi Gold: Yeah. David Carreon: So you're saying that most people are not dry, boring-slides-from-a-PowerPoint-deck-that-are-presented-monotone learners? Arbuckle: That's right. That's right, most people are not. That's probably the least effective way to teach, and yet we do it everywhere. <a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep08-arbuckle_1_of_2.mp3" rel="nofollow" target="_blank"></a> ep08-arbuckle_1_of_2.mp3File Size: 17624 kbFile Type: mp3<a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep08-arbuckle_1_of_2.mp3" rel="nofollow" target="_blank">Download File</a>

Neuroscience Education: Relevant, Stigma Reducing, and Fun to Learn (with Dr. Arbuckle, part 1 of 2)

Here: Part 3 of 3 with Emeran Mayer, MD, PhD on the mind-gut connection. Dr Mayer talks about the role of the gut in psychiatric illnesses and mood-from a history of forced colectomy in psychiatric patients to an inflammatory diet influencing mood. He answers the question: are we happier when we don’t eat sugar or gluten and should we all be gluten-free? Dr. Mayer is a pioneer of medical research into brain-gut interactions and author of The Mind-Gut Connection: How the Hidden Conversation Within Our Bodies Impacts Our Mood, Our Choices, and Our Overall Health.TranscriptDavid Carreon: Let's also talk about nutrition and diet and microbiology of psychiatric conditions. I know there's been some discussion and some work that you've ended up with around depression and probiotics or depression in the microbiome. How good is this evidence, or what is the relationship between something that we would consider a psychiatric illness and the gut?Emeran Mayer: As you know, some 100, 150 years ago, there were psychiatrists who are actually obsessed with the role of the colon and fermentation and it led to this unfortunate situation that many psychiatric inpatients in hospitals had to forcefully undergo colectomy and many died because ... There was a phase where psychiatry was actually very much interested in the microbes playing a major role in the psychiatric disease. That obviously has completely disappeared. Today, there's something new that's sort of come up, and that's the role of diet in influencing the nervous system. Felice Jacka in Australia has recently published the SMILE Study. She and her colleagues found that in a randomized study, if they compared the outcomes of patients, I think it was with major depressive disorder, who underwent conventional therapy and their regular diet vs with conventional therapy with a Mediterranean-type diet, there was a significant difference. She has written about this topic.One explanation of that is related to this concept of an inflammatory diet. We know that high fat, high sugar diets change the microbiota in a way that there's a whole series of events. Increased permeability of the gut is the result of that, increased access of micropolysaccharides or other pro-inflammatory molecules, the gut-associated immune system, which then creates a ... It's not full-blown inflammation, like in inflammatory bowel disease, but a low-grade inflammatory state which then often becomes systemic, so you have circulating LPS levels. My opinion, that's most plausible explanation. As you know, neuroinflammation has been so implicated for depression and other psychiatric diseases as well, so it could well be that diet plays a role in exacerbating it. Certainly not diet is the cause of psychiatric disease, but it's a significant modifier.Jessi Gold: I've heard people say that when they went on sugar-free diets, or when they went on gluten-free diets that their mood improved. Do you think that's true with what you're seeing in research? Is it totally subjective and they just believe in the diet?Emeran Mayer: There's certainly, with anything diet, a huge psychological dimension. I think there's few things that have such a placebo effect as diet has. The high-sugar phenomenon, I do believe, because we know a lot about this. High sugar, high fat, it's sort of like opiates. It makes you feel better right away. That's why people almost self-medicate when they're stressed out you crave for something like that. In the long-term, it has these detrimental effects and leads to this low-grade inflammatory state. I think when people say that when they switch their diet to a healthy diet that they feel better, I certainly believe that. In terms of the gluten, that's a whole other story.As a gastroenterologist, I'm obviously fully aware of the seriousness of celiac disease. It does appear now probably also related to the microbes and the early interaction with the immune system that people develop more and more hypersensitivities and even allergies to food items that 20 years ago nobody ... Like the peanuts and wheat ... If you have that condition, if you eliminate any agent, most likely you will feel better as well, but then you have, it's like 40% of the US population now, who thinks gluten is toxic for them. That's really unsubstantiated. There's nothing that's been found, sort of like IBS, you can take biopsies, you don't find any possible pathological or pathophysiological mechanism.There was an interesting phenomenon. This really started with a book that came out by a person, an author, won't mention the name, that before was really on the candida connections. This was an early phase that people say all your symptoms, including IBS and fibromyalgia and everything was related to candida and it was due to the high sugar. The same group of people that promoted that like some 20 years ago, are now promoting this gluten-free diet. All the things before there was sugar across all these orders, now it's gluten. That single book, called The Grain Brain, I personally think is responsible for most of that worldwide, I like to call it hysteria, really, which is centered in the US, which is interesting. You go to any other part of the world, people love bread, couldn't live without bread. Whenever I go to France, I ask people, "Have you heard of a gluten sensitivity?" They just laugh at you.Like many things in science, there may be a certain truth to it. Give you this example about the candida connection, so now that we not just measure the microbiomes, as people have started to look at the virome and the fungi, there is now scientific evidence that people have increased levels of certain fungi, including candida. It would be sort of an amazing thing that 25 years after this non-scientific theories came out that we would support this. That could happen with gluten as well. I have a personal opinion, but as a scientist, I like to say nothing is impossible.Jessi Gold: Yeah, it's crazy to think one person could write a book and then everyone stops eating bread.Emeran Mayer: Yeah, it's amazing. An amazing phenomenon.David Carreon: Yeah. We are running low on time, so we'll have a few more rapid-fire questions and if you can answer in one or two sentences max, we'll go through these questions. Before we do, I also wanted to ask you to say a little bit about the book that you just published. What's it about and who should read it?Emeran Mayer: It's called The Mind-Gut Connection. It's written for the lay public and I would say it's not just for the lay public, it's also the lay public, but also for a lot of professionals who are not microbiome experts and have not been aware of the science that has involved brain-gut connections and brain-gut microbiome connections. It has a lot of different things in it, different topics in it, from neurobiology of gut feelings, emotional regulation, early life events and influence to diet and optimal health, which is the final conclusion. I think everybody should read it. Even for experts in the area, there's parts in it, including patient anecdotes. Interesting thing to me, now a lot of patients come to me that have heard about the book or read the book and they say, "I am so-and-so in your book. I don't have to tell you much about my symptoms. I'm so-and-so in your book." I think it must have resonated a lot with patients.Jessi Gold: As a psychiatrist, which sort of patient in my clinic should I recommend would read your book? Is it any illness, anything?Emeran Mayer: I would certainly say patients with depression, anxiety, particularly if they also have experienced GI symptoms. Autism spectrum disorders, those would be the three main that ... There's also a lot of evidence, Parkinson's disease playing a role. I would say you could probably recommend it to every patient.David Carreon: Good. I think that sounds like a fascinating book and I'm looking forward to reading it myself.Jessi Gold: Me too.David Carreon: First rapid-fire question is, in a sentence or two, what does the field of psychiatry and mental health, where is it that we go most wrong? What is the biggest oversight or mistake that we make?Emeran Mayer: I don't see patients in a psychiatric clinic. I would say to kind of stop at the neck or not go into the body is, in my opinion, a big flaw. I'm sure there's some psychiatrists who do that. I see the same patients from the opposite end. Most of them have anxiety and depression and compulsive disorders, but I start at the body. I always see the symptoms at the body. They're clearly both there, and I think with psychiatrists, that would be an important lesson.Jessi Gold: What is your favorite book?Emeran Mayer: My favorite book, I would say The Black Swan by Taleb. Realizing the complexity of the world and the more complexity, the more interconnectedness and the more unpredictable it becomes. I think our brain functions, also discusses in the book, is a prediction machine that tries constantly to make predictions and if that's done in a linear way, they will almost certainly go wrong. In a complex world as today, it's no longer possible to do that.David Carreon: What advice would you give to a young doctor, a trainee?Emeran Mayer: I would say listen to your patient. Most things that the patient will tell you can be explained in a holistic model of brain and body. I would say listen to the patient and don't reject things that don't fit your textbook description. Most textbooks will become obsolete in 10, 15 years. What the patients say, I've experienced this in ideas, research, has stayed the same, and now we're finding so many answers.Jessi Gold: What is your favorite food and what is your favorite food to recommend to patients to feel better?Emeran Mayer: While writing my book, I've become a big fan of the Mediterranean diet for various reasons. Since then, since I pay a lot more attention now to dietary factors, it seems there's almost universal agreement that a Mediterranean-style diet, it doesn't have to come from Italy or Spain, many traditional Asian diets have the same composition of 75% plant-based foods and small amount of meat, protein. I would recommend, even in psychiatry now I think it's the same that's in the study showing the slowing of Alzheimer's progression, depression seems to be universal truth to that. It's tasty, you don't have to eat strange things or elimination diets. It's a tasty diet and it's probably one of the best documented health benefits of anything.David Carreon: What is your favorite species of bacteria?Emeran Mayer: That's a tough one. There's one, one out of several, that's called Akkermansia muciniphila, funny name. The second name, you can hear the recent connections. They are a bacteria that stimulate especially the cells in intestines that put mucin, mucous, and that's a very healthy thing because the thicker the mucous layer is, the more we're protected from a leaky gut and Akkermansia goes up with a high plant-based diet. It's the food that nourishes these organisms.David Carreon: Excellent.Jessi Gold: The last question is, is there a person that you would consider a hero, either living or dead or fiction, somebody that you would consider a hero?Emeran Mayer: In the microbiome field?Jessi Gold: Or in anything, really.Emeran Mayer: That's a tough one. I would say, let's limit it to the microbiome field, Martin Blaser from NYU, who has sort of been the main driving force behind revealing the detrimental effect of antibiotic use, inappropriate antibiotic use on microbial diversity. He's written a phenomenal book, Missing Microbes, which I would recommend to anybody because you will change your antibiotic prescribing behavior dramatically once you've read this book.David Carreon: Excellent. Thank you for joining us on the show.Jessi Gold: Yeah, thank you.Emeran Mayer: It was a pleasure.  ep07-mayer_3_of_3.mp3File Size:  15316 kbFile Type:   mp3Download File

Here: Part 3 of 3 with Emeran Mayer, MD, PhD on the mind-gut connection. Dr Mayer talks about the role of the gut in psychiatric illnesses and mood-from a history of forced colectomy in psychiatric patients to an inflammatory diet influencing mood. He answers the question: are we happier when we don’t eat sugar or gluten and should we all be gluten-free? Dr. Mayer is a pioneer of medical research into brain-gut interactions and author of <a href="https://www.amazon.com/Mind-Gut-Connection-Conversation-Impacts-Choices/dp/0062376551" rel="nofollow" target="_blank">The Mind-Gut Connection: How the Hidden Conversation Within Our Bodies Impacts Our Mood, Our Choices, and Our Overall Health.</a> Transcript David Carreon: Let's also talk about nutrition and diet and microbiology of psychiatric conditions. I know there's been some discussion and some work that you've ended up with around depression and probiotics or depression in the microbiome. How good is this evidence, or what is the relationship between something that we would consider a psychiatric illness and the gut? Emeran Mayer: As you know, some 100, 150 years ago, there were psychiatrists who are actually obsessed with the role of the colon and fermentation and it led to this unfortunate situation that many psychiatric inpatients in hospitals had to forcefully undergo colectomy and many died because ... There was a phase where psychiatry was actually very much interested in the microbes playing a major role in the psychiatric disease. That obviously has completely disappeared. Today, there's something new that's sort of come up, and that's the role of diet in influencing the nervous system. Felice Jacka in Australia has recently published the SMILE Study. She and her colleagues found that in a randomized study, if they compared the outcomes of patients, I think it was with major depressive disorder, who underwent conventional therapy and their regular diet vs with conventional therapy with a Mediterranean-type diet, there was a significant difference. She has written about this topic. One explanation of that is related to this concept of an inflammatory diet. We know that high fat, high sugar diets change the microbiota in a way that there's a whole series of events. Increased permeability of the gut is the result of that, increased access of micropolysaccharides or other pro-inflammatory molecules, the gut-associated immune system, which then creates a ... It's not full-blown inflammation, like in inflammatory bowel disease, but a low-grade inflammatory state which then often becomes systemic, so you have circulating LPS levels. My opinion, that's most plausible explanation. As you know, neuroinflammation has been so implicated for depression and other psychiatric diseases as well, so it could well be that diet plays a role in exacerbating it. Certainly not diet is the cause of psychiatric disease, but it's a significant modifier. Jessi Gold: I've heard people say that when they went on sugar-free diets, or when they went on gluten-free diets that their mood improved. Do you think that's true with what you're seeing in research? Is it totally subjective and they just believe in the diet? Emeran Mayer: There's certainly, with anything diet, a huge psychological dimension. I think there's few things that have such a placebo effect as diet has. The high-sugar phenomenon, I do believe, because we know a lot about this. High sugar, high fat, it's sort of like opiates. It makes you feel better right away. That's why people almost self-medicate when they're stressed out you crave for something like that. In the long-term, it has these detrimental effects and leads to this low-grade inflammatory state. I think when people say that when they switch their diet to a healthy diet that they feel better, I certainly believe that. In terms of the gluten, that's a whole other story. As a gastroenterologist, I'm obviously fully aware of the seriousness of celiac disease. It does appear now probably also related to the microbes and the early interaction with the immune system that people develop more and more hypersensitivities and even allergies to food items that 20 years ago nobody ... Like the peanuts and wheat ... If you have that condition, if you eliminate any agent, most likely you will feel better as well, but then you have, it's like 40% of the US population now, who thinks gluten is toxic for them. That's really unsubstantiated. There's nothing that's been found, sort of like IBS, you can take biopsies, you don't find any possible pathological or pathophysiological mechanism. There was an interesting phenomenon. This really started with a book that came out by a person, an author, won't mention the name, that before was really on the candida connections. This was an early phase that people say all your symptoms, including IBS and fibromyalgia and everything was related to candida and it was due to the high sugar. The same group of people that promoted that like some 20 years ago, are now promoting this gluten-free diet. All the things before there was sugar across all these orders, now it's gluten. That single book, called The Grain Brain, I personally think is responsible for most of that worldwide, I like to call it hysteria, really, which is centered in the US, which is interesting. You go to any other part of the world, people love bread, couldn't live without bread. Whenever I go to France, I ask people, "Have you heard of a gluten sensitivity?" They just laugh at you. Like many things in science, there may be a certain truth to it. Give you this example about the candida connection, so now that we not just measure the microbiomes, as people have started to look at the virome and the fungi, there is now scientific evidence that people have increased levels of certain fungi, including candida. It would be sort of an amazing thing that 25 years after this non-scientific theories came out that we would support this. That could happen with gluten as well. I have a personal opinion, but as a scientist, I like to say nothing is impossible. Jessi Gold: Yeah, it's crazy to think one person could write a book and then everyone stops eating bread. Emeran Mayer: Yeah, it's amazing. An amazing phenomenon. David Carreon: Yeah. We are running low on time, so we'll have a few more rapid-fire questions and if you can answer in one or two sentences max, we'll go through these questions. Before we do, I also wanted to ask you to say a little bit about the book that you just published. What's it about and who should read it? Emeran Mayer: It's called The Mind-Gut Connection. It's written for the lay public and I would say it's not just for the lay public, it's also the lay public, but also for a lot of professionals who are not microbiome experts and have not been aware of the science that has involved brain-gut connections and brain-gut microbiome connections. It has a lot of different things in it, different topics in it, from neurobiology of gut feelings, emotional regulation, early life events and influence to diet and optimal health, which is the final conclusion. I think everybody should read it. Even for experts in the area, there's parts in it, including patient anecdotes. Interesting thing to me, now a lot of patients come to me that have heard about the book or read the book and they say, "I am so-and-so in your book. I don't have to tell you much about my symptoms. I'm so-and-so in your book." I think it must have resonated a lot with patients. Jessi Gold: As a psychiatrist, which sort of patient in my clinic should I recommend would read your book? Is it any illness, anything? Emeran Mayer: I would certainly say patients with depression, anxiety, particularly if they also have experienced GI symptoms. Autism spectrum disorders, those would be the three main that ... There's also a lot of evidence, Parkinson's disease playing a role. I would say you could probably recommend it to every patient. David Carreon: Good. I think that sounds like a fascinating book and I'm looking forward to reading it myself. Jessi Gold: Me too. David Carreon: First rapid-fire question is, in a sentence or two, what does the field of psychiatry and mental health, where is it that we go most wrong? What is the biggest oversight or mistake that we make? Emeran Mayer: I don't see patients in a psychiatric clinic. I would say to kind of stop at the neck or not go into the body is, in my opinion, a big flaw. I'm sure there's some psychiatrists who do that. I see the same patients from the opposite end. Most of them have anxiety and depression and compulsive disorders, but I start at the body. I always see the symptoms at the body. They're clearly both there, and I think with psychiatrists, that would be an important lesson. Jessi Gold: What is your favorite book? Emeran Mayer: My favorite book, I would say The Black Swan by Taleb. Realizing the complexity of the world and the more complexity, the more interconnectedness and the more unpredictable it becomes. I think our brain functions, also discusses in the book, is a prediction machine that tries constantly to make predictions and if that's done in a linear way, they will almost certainly go wrong. In a complex world as today, it's no longer possible to do that. David Carreon: What advice would you give to a young doctor, a trainee? Emeran Mayer: I would say listen to your patient. Most things that the patient will tell you can be explained in a holistic model of brain and body. I would say listen to the patient and don't reject things that don't fit your textbook description. Most textbooks will become obsolete in 10, 15 years. What the patients say, I've experienced this in ideas, research, has stayed the same, and now we're finding so many answers. Jessi Gold: What is your favorite food and what is your favorite food to recommend to patients to feel better? Emeran Mayer: While writing my book, I've become a big fan of the Mediterranean diet for various reasons. Since then, since I pay a lot more attention now to dietary factors, it seems there's almost universal agreement that a Mediterranean-style diet, it doesn't have to come from Italy or Spain, many traditional Asian diets have the same composition of 75% plant-based foods and small amount of meat, protein. I would recommend, even in psychiatry now I think it's the same that's in the study showing the slowing of Alzheimer's progression, depression seems to be universal truth to that. It's tasty, you don't have to eat strange things or elimination diets. It's a tasty diet and it's probably one of the best documented health benefits of anything. David Carreon: What is your favorite species of bacteria? Emeran Mayer: That's a tough one. There's one, one out of several, that's called Akkermansia muciniphila, funny name. The second name, you can hear the recent connections. They are a bacteria that stimulate especially the cells in intestines that put mucin, mucous, and that's a very healthy thing because the thicker the mucous layer is, the more we're protected from a leaky gut and Akkermansia goes up with a high plant-based diet. It's the food that nourishes these organisms. David Carreon: Excellent. Jessi Gold: The last question is, is there a person that you would consider a hero, either living or dead or fiction, somebody that you would consider a hero? Emeran Mayer: In the microbiome field? Jessi Gold: Or in anything, really. Emeran Mayer: That's a tough one. I would say, let's limit it to the microbiome field, Martin Blaser from NYU, who has sort of been the main driving force behind revealing the detrimental effect of antibiotic use, inappropriate antibiotic use on microbial diversity. He's written a phenomenal book, Missing Microbes, which I would recommend to anybody because you will change your antibiotic prescribing behavior dramatically once you've read this book. David Carreon: Excellent. Thank you for joining us on the show. Jessi Gold: Yeah, thank you. Emeran Mayer: It was a pleasure. <a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep07-mayer_3_of_3.mp3" rel="nofollow" target="_blank"></a> ep07-mayer_3_of_3.mp3File Size: 15316 kbFile Type: mp3<a href="http://www.psyched.space/uploads/2/6/7/6/26769542/ep07-mayer_3_of_3.mp3" rel="nofollow" target="_blank">Download File</a>

Is There a Relationship Between Mood and Diet? (with Dr. Mayer, part 3 of 3)

Thought-provoking and covering a broad range of topics that interest a large spectrum of listeners, the Psyched! podcast is one of my favorites. It introduced me to the National Neuroscience Curriculum Initiative and encouraged me to think in new ways about depression and other mental health disorders. As a fourth-year medical student pursuing Psychiatry, I believe I will be a better psychiatrist in the future because of this podcast. I hope more episodes can be released soon. Thank you for your hard work!

Fascinating!

Thought-provoking, accessible intellectual goodness. Thanks for making this! There aren’t enough psychiatry podcasts out there, let alone ones that are comprehensible and organized. Looking forward to more!

Absolutely brilliant!

Psyched! a psychiatry blog - Episodes

The best philosophy podcast episodes. Asking questions about how to live a better life, what it means to be and do good, to the idea of God. This topic includes episodes that bring about important questions that everyone should be asking themselves. Add episodes you're interested into your queue below!

Best Episodes on Practical Philosophy & How To Live

The best podcasts about ourselves as well as the world through the lense of Science. Specific topics include things about our brain, emotions to biology, physics and more!