​May was Mental Health Awareness Month.  As with any campaign to raise awareness of a thing, there was an internet flurry of blogs, articles and infographics.  I added all kinds of great things to the flurry.  (Twitter, @KitKo_Psych NP).  Campaigns to raise awareness are effective, and reducing the stigma around mental health is a fantastic goal.  Although estimates vary significantly, as many as 50-60% of individuals with symptoms of severe mental illness do not get adequate treatment.  Symptoms such as severe depression, anxiety, or paranoia may make it hard to seek treatment, and access to affordable psychiatric care may be another issue.  

Some resist the idea of treatment because of their beliefs about mental illness and treatment.  Our sense of self, who we are, is tightly intertwined with how we think and act.  It is difficult to separate these things, but in order to understand mental illness, we must do it.  A person's psychiatric symptoms are not a reflection of their values, abilities, or personality.  The individual who has ADHD was not late to the dinner party because because she doesn't value her friendship with the host.  Her brain perceives the passage of time differently than most of her friends, in fragmented chunks, rather than a continuous process.  The person with depression who can hardly get off the couch, is not "wallowing" in it.  The fatigue of depression is much like the malaise that people experience when they are sick with the flu.  Not the sore throat or fever, but the exhaustion, poor appetite, and apathy of it.  It's not personal.  It's biological.  And yet, this idea that we should be able to cure ourselves by sheer force of will is pervasive.  People delay treatment, because they "should be able to handle this".  They delay treatment because they worry that others will think they are somehow less, because they cannot handle it alone.

People also delay treatment because they are afraid of treatment.  Will the therapist think I am bad or crazy?  (Certainly not!)  Will I need medications?  What if there are side effects?  What if the medications work?  Will I have to take them forever?  What if they don't work?  Medications aren't always the right answer, that's why it's important to be evaluated by a doctor or nurse practitioner who specializes in psychiatry, but the right medication can be life altering.  Of course, there are risks associated with taking medications.  They're not that good at making drugs that do only the one thing we want them to, and nothing else.  But there are risks associated with NOT taking medication too!  Relationship difficulties, job loss, increased risk of substance abuse, reduced immune functioning, increased risk of cardiovascular disease are just a few of the risks.

I recently had dinner with author and medical educator, Eric Arauz.  He wondered aloud, why is it so hard to convince people to take psychiatric medications...even when they stand to gain so much by taking them?  People will agree to chemotherapy when they have cancer.  These drugs are incredibly toxic, and have some of the worst side effects imaginable.  Yet people still show up every week for their IV infusion.  Because they believe that the medication can improve or prolong their lives.  Psychiatric medication can do that too, with far less severe side effects!  That's the awareness I want to raise.  Treatment can improve and prolong the lives of people with psychiatric illnesses, and treatment is not as scary as you think!

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We all know how amazing it feels to get a good night's sleep...waking up naturally, feeling rested and ready for the day?  We tend to think of that as a luxury and it's often the first thing to be cut when life gets hectic.  But is it really a luxury that people can do without?  Science says no.

Virtually every aspect of health is hurt by inadequate sleep.  Immune function is reduced, increasing your risk of catching that nasty cold that is going around.  There is also evidence that disrupted sleep may increase your risk of developing cancer, as well as worsen your chances of recovery. Sleep deprivation also increases your risk for obesity and diabetes.  Pay attention to your eating habits after an inadequate night's sleep.  Normally, your body uses the hormones ghrelin and leptin to regulate energy balance, by stimulating or suppressing appetite. Sleep deprivation causes these hormones to become dysregulated. Abnormally high ghrelin triggers increases appetite, low leptin levels throw the system further out of balance, and hunger runs unchecked.  Compounding this, inadequate sleep impairs your body's ability to use insulin by as much as 30%, a level typical for the most common form of diabetes.  The relationship between sleep and mental health is complex, but no less dramatic.  Difficulty falling or staying asleep can be a nonspecific symptom of virtually every mental illness, from ADHD to schizophrenia.  It can also cause or trigger psychiatric symptoms, and people with ongoing sleep problems have poorer treatment responses.  

I was assessing sleep habits as part of a recent initial psychiatric evaluation, when my new patient let out a frustrated sigh, and reminded me that he was there to talk about his concentration and possible ADHD.  Why was I spending so much time talking about sleep?  Sleep deprivation can cause cognitive symptoms that closely mimic true ADHD.  After only 1-2 nights of 6 or less hours of sleep, cognitive impairment is already measurable.  Mental fatigue impairs performance on monotonous tasks, as well as those that require quick reaction times.  It also reduces working memory, making it more difficult to mentally manipulate complex information.  When sleep deprived, people demonstrate reductions in the divergent thinking that is vital for creativity and problem solving.  Imagine what it is like for someone who is sleep deprived and truly has ADHD!  A stimulant may keep that person awake, but it will not treat the ADHD as effectively.  It will not produce as much improvement in symptoms, and the limited benefit it does produce, will not last as many hour as in a well rested individual.  And it will not prevent negative impact of inadequate sleep on your physical health!

Sleep is also critically important in bipolar (manic-depressive) disorder.  It's fairly commonly known that bipolar disorder is associated with erratic sleep patterns.  Sleep is a key component of how we define and diagnose the disorder.  During a manic/hypomanic episode, the person experiences reduced need/ability to sleep, but without the expected degree of tiredness or fatigue.  Keeping a regular sleep schedule is critically important for anyone who may have bipolar disorder.  It, of course, makes it easier for us to monitor for signs of an oncoming mood shift, but sleep deprivation can actually cause a mood episode in people with bipolar disorder.  A single night of inadequate sleep, is enough to impair the brain's ability to regulate mood state.  This dysregulation can be severe enough trigger a manic episode and throw the person right back into the emotional roller coaster that they so desperately want to get off of!  Sleep is so important in the management of bipolar disorder, that they developed a whole type of therapy around it!  Interpersonal and Social Rhythm Therapy has been shown to help people get well more quickly, stay well longer, and function better in their lives.

By now, I'm sure it's clear that sleep is a big deal!  So what can you do to improve your sleep?  I'm including the basics here, but check out my twitter feed for more!

1. Keep a regular schedule.  Go to bed and wake up at about the same time every day!
2. Reserve the bed for sleep and sex only!  No TV, homework, paying bills, or anything else. 
3. Dim the lights and turn off electronics at least 1 hour before bedtime.  Give your brain the message that it will soon be time to sleep.
4. Avoid caffeine (8 hours), alcohol (2 hours) and nicotine (1 hour) before bed.
5. Get exercise.  Every day.  If you find that doing strenuous exercise in the evening makes it harder to fall asleep, consider yoga or Tai Chi
6. Limit use of over the counter sleep aids.  Most contain antihistamines, which can have long term negative health effects.

If your sleep problems are severe, or don't improve with the above suggestions, make an appointment with your doctor, ARNP, or me!

Be well, and get some sleep!

Kit Ko, ARNP

​​Panacea: noun. A solution or remedy for all diseases.
Most people know that exercise is "good for you." But do you know HOW good it is?  Exercise can extend your life by as much as 4.5 years, by reducing your risk of heart attack, stroke, diabetes, and breast cancer, colon cancer, and possibly lung and endometrial cancers as well.  Not only can you live longer, but you can live better.  Regular exercise boosts immune functioning, reduces your risk for osteoporosis and bone fractures and reduces your risk of developing dementia!  

Obviously, there are lots of physical benefits, but are you ready for this? Regular exercise can be extremely effective in preventing and treating mental health problems too!  When making treatment recommendations, I always look at the science.  The research evidence is clear:  Exercise has an important role in the treatment of depression, insomnia, ADHD, and anxiety disorders.

Regular exercise is explicitly recommended in the treatment guidelines for depression.  I believe it should be considered first line treatment for mild to moderate depression.  For milder depression that does not improve enough with exercise and therapy, and for more severe depression, medication is absolutely appropriate, but exercise is still very important!  There is strong research data showing that it reduces risk of developing future depressive episodes!  Once you get well, exercise can help keep you well.  

Multiple studies on treating anxiety disorders have shown that medication plus exercise is significantly more effective than either treatment alone.  This has been found for generalized anxiety disorder, panic disorder, phobias including social phobia, and PTSD.

Parents of children with ADHD have long known that exercise helps with ADHD related hyperactivity.  In the past year, researchers have found evidence that exercise also helps with inattentive symptoms.  At present, studies have only involved children with ADHD, but as I often say, children are not aliens.  At any age, exercise releases norepinephrine in the brain.  Medications to treat ADHD have a stronger effect on norepinephrine, but work in much the same way.  Additional studies are being done, but exercise plus medication can be a really powerful combination in the treatment of ADHD.

What kind of exercise should you do?  Anything that you enjoy and is accessible enough for you to stick with.  For me, it's Zumba fitness classes.* Music and dancing make me happy and the friends I've made motivate me to make getting to class an even bigger priority.  But maybe dance isn't your thing, or you prefer to work out at home.  Good news!  It doesn't seem to matter what you do, as long as you're moving your body. Cardio, strength training, TaiChi, and yoga have all found to be beneficial for mental health.  There are no specific recommendations of type of weight training or yoga, but for cardio, the recommendation is 30-60 minutes more days than not, intense enough to raise your heart rate.** 

So maybe calling exercise a "panacea" is not completely accurate, because it does not always completely solve or cure all problems.  But incorporating this one thing, exercise, into your life can dramatically improve almost all aspects of your physical and mental health.  I believe that's as close to a panacea as we've found, and for that reason, it is a part of every single treatment plan I make.  You can't pick it up at the pharmacy, but consider it a prescription.

For more on exercise and mental health and other great self care tips, follow me on Facebook or Twitter! 

Be well,
Kit Ko, ARNP