Mental Health Promotion: A Practical Approach

1. Mental Health Promotion: A Practical Approach Nimi Singh, MD, MPH Division of Adolescent Health and Medicine Department of Pediatrics University of Minnesota, Minneapolis

2. Overview • Current standard of care • Role of stress physiology • Effects of stress on cognition and mood • Alternative definition of mood disorders • Homeostasis (psychological resilience) • Shutting of the stress response • Sleep, nutrition, physical activity, recreation • Stress reduction strategies

3. Epidemiology of mental health needsin children and adolescents • Mild to moderate depression • Prevalence: one in five • age of onset is decreasing • Estimated that about 80% of adolescents with “depression” really have what can better be termed an “adjustment disorder” • Current Treatment: medication plus/ minus psychotherapy • Untreated major depressive disorder in adolescents • Lasts 7-9 months • Recurrence: 40% within 2 yrs, 70% within 5 yrs (Beasley et al., Adol. Med., 1998:18)

4. Treatment: Pharmacotherapy vs. Psychotherapy? • JAMA Aug. 18, 2004- Vol. 292, No. 7 (807-820): • Treatment for Adolescents with Depression Study (TADS): • Randomized placebo-controlled 12-week trial • N= 436 (Major Depressive Disorder) • CBT + Fluoxetine vs. Fluoxetine vs. CBT vs. placebo • Response: 71% vs. 60.6% vs. 43.2% vs. 34.8% • 1.6% attempted suicide (no completed suicides) • CBT was the most protective against this (not statistically significant, possibly due to small number of subjects)

5. Treatment: Pharmacotherapy • NEJM Jan. 17, 2008- Vol. 358, No. 3 (252-260): • Selection bias in RTC’s of SSRI’s: • Meta-analysis, 74 RTC’s, 12 antidepressants • 12,500 patients (1987- 2004) • Of 38 positive studies, all but one was published • Of 36 the FDA considered negative or equivocal • 22 were not published • 11 were published with positive conclusions THEREFORE: • 48/ 51 appeared to be positive, but…. only 38/ 74 actually produced positive results • Need effective non-pharmacological approaches to optimizing mental health and supporting recovery

6. Psychological Stress 101: • Evolutionarily advantageous: • Example of caveperson and saber-tooth tiger • Blood get shunted to organs critical for survival (heart, lungs, muscles, brainstem) • Blood gets shunted away from organs NOT critical for survival (GI track, reproductive track, immune system, prefrontal cortex) • Allows for “fight, flight or freeze” response • Gets triggered equally by EXTERNAL as well as INTERNAL events (i.e. negative thoughts) • Not all events are true threats to survival (but our body doesn’t know this!)

7. Psychological Stress Response:(continued) • Increased arousal, alertness, vigilance • Over-interpretation of stimuli as potential threat to survival • Maximizes ability to stay alive in life-threatening circumstances • Chronic: cycle of negative emotions and distorted perception • Inhibition of higher (cortical) mental activity • Mind goes “blank” (thinking is reflexive, not reflective) • Unable to take in and process new information as easily (car keys) • Chronic repetitive negative thoughts can become: • Anxiety disorders (worries about the future) • Depressive disorders (anger, sadness, regrets about the past) • PTSD • Harmful/ addictive behaviors: an attempt to “quiet the mind” • Drug and alcohol use • Cutting behavior

8. Definitions of psychological functioning: • Mental/ psychological distress: • Temporary loss of the ability to self-right psychologically • the “stress” response keeps getting triggered • Produces distorted thinking (moods, behavior): everything is perceived as a potential threat to survival • Distorted thinking, in turn, re-triggers the stress response • Mental health: • The ability of the mind to self-right (innate) • A state of psychological well-being and security • Ability to access common sense, wisdom, creative problem-solving, etc.. • related to being in a state of “non-stress” or “alert but relaxed” • Ability to let go of negative thought and return to “present moment” thinking

9. HOMEOSTASIS The ability of the body (and mind) to balance and heal itself

10. Psychological Homeostasis • The mind’s ability to SELF-RIGHT (innate) • Allows access to higher cognitive functioning (pre-frontal cortex) • During a stress response, blood is shunted from this region to the brainstem in order to facilitate the “fight, flight or freeze” response • Most of the time, we’re able to return to non-stress-based thinking, but sometimes we get stuck • In order to facilitate the mind’s ability to self-right, therefore… …we needs to support our body’s ability to shut off the STRESS response

11. Optimizing Homeostasis • Stress Management techniques • CRITICAL first steps: • Good sleep hygiene • Optimal nutrition • Physical activity • Recreational activities • Self-regulatory techniques ( biofeedback, self-hypnosis) • Body movement therapies (Yoga, Tai chi, Qi gong) • Cognitive/ Behavioral: • Traditional cognitive behavioral therapies • Mindfulness-based Stress Reduction (Jon Kabat-Zinn, Ph.D) • Health Realization (focus on innate capacity to self-right)

12. Health Realization • Healthy psychological functioning • What it looks like • What gets in the way • What you can do about it • Notice poor psychological functioning in others and in self • Shift to a higher state of functioning

13. Health Realization • WE are the creators of our own thought • The quality of our thinking (positive vs. negative) creates our perception of reality in the moment • Negative thoughts distorts our perceptions, and yield unreliable/ inaccurate information • We can notice and disengage from negative thought • Result: Shuts of stress response, clears the mind • What bubbles up in its place is ALWAYS of a higher quality ( “wisdom”, “common sense”, “higher cognitive functioning”)

14. HEALTH REALIZATION • How does this work in day-to-day life?!!! • CONCEPTS: • Thoughts • Moods • Separate realities • Levels of Understanding

15. THOUGHTS • Come and go • Can’t control which thoughts come in • Can choose which thoughts one chooses to give life to, and which to let go of • Quieting/ slowing down one’s thoughts allows us to access our INNATE WISDOM • Everyone has it ( …psychological homeostasis!) • It is never damaged by life experiences • Gets clouded over by negative thinking • Recognize yourself as the “thinker” of your thoughts and that thoughts aren’t facts (movie analogy)

16. Conditioned (left brain) Type:“Computer mode”: Accesses stored info. Comparison Computation Good for finite variables State of mind: Busy Mechanical Original/Open (right brain) Type: “Receiver” mode: Accesses one’s own wisdom/common sense Creativity/Insight Good for relationships State of mind: Calm Peaceful Two modes of thought(adapted from Glenwood-Lyndale Health Realization Training Center 1999, Cindi Claypatch, (612) 823-823-5973 )

17. Two modes of thought (cont.) • We get into trouble when we use “conditioned” thought when we should be using “open” thought: • Human-human interactions: • Trying to break an old “habit” of interaction with someone • Trying to understand a new/ different point of view (we keep reverting back to “what we already know” which becomes a block to understanding) • Trying to solve a problem under new circumstances

18. Come and go Are neutral (high/low vs. good/bad) Can affect quality of thinking Are internal May be created by the quality of one’s thoughts (internal) May also be affected external factors: Tiredness Illness Weather Stressful life-event Food Chemicals MOODS

19. THOUGHTS : → HIGH perspective Secure Light-hearted In the moment Effortless Exploratory LOW perspective Insecure Serious/personal Forever Hard Fear-based EMOTIONS: HIGH mood Flexible Involved Responsive Positive outlook Creates sense of security in others LOW mood Controlling/rigid Distorted Reactive False sense of urgency Thoughts and Moods(adapted from Glenwood-Lyndale Health Realization Training Center 1999, Cindi Claypatch, (612) 823-823-5973 )

20. GUIDELINES around MOODS • When in a low mood: • Develop a way to recognize this in yourself • Suspend major decisions • Don’t always trust your own thinking • Be careful about taking yourself/others seriously • Be cautious of verbal/ behavioral interactions • Don’t commiserate (moods can be infectious!) • Let others know what you need • Slow down your thinking (drop, distract, dismiss, ignore) • Pamper yourself • Give yourself a “time-out”

21. GUIDELINES around MOODS(cont.) • Assess mood level of self and others • Recognize role of thought • Remember: YOU create/ sustain moods (inside-out process) • Be easy on yourself and others • “SEE THE INNOCENCE”

22. SEPARATE REALITIES Every individual has a separate view of life given : • their moment-to-moment ability to create thought • the quality of their state of mind in the given moment

23. Separate Realities (cont): • Thoughts, along with our past experience, shape our sense of “reality” • Moment to moment, our view of reality changes, depending on our emotional state • The “lower” our mood, the more attached we are to our view of reality • The “higher” our mood, the more comfort and tolerance we experience with respect to different realities

24. Separate Realities (cont): • People are INNOCENTLY creating their reality all the time (unaware how mood is affecting thinking) • Whatever thoughts are in our minds IS what creates our experience/ view of reality • If we’re not in present-moment thinking, our perception is distorted

25. Health Realization in Action(when interacting with others) “Parenting from the Heart” Jack Pransky, Ph.D • See your [children] as having health, wisdom and common sense within them • “Problem behavior”: a result of insecure thinking

26. Communication Skills (cont.): • Notice your own mood (insecure vs. secure) • Quiet your own thinking and observe • Listen for understanding

27. Communication Skills (cont.): • Feeling of warmth/safety→ Helps the other feel more secure→ Raises the quality of their thinking • Postpone acting/decision-making when not coming from a place of calm/security

28. Resources • Internet search terms: • Health Realization • Psychology of Mind • Books: • “Parenting from the Heart” Jack Pransky, Ph.D • “ You can be happy no matter what” Richard Carlson, Ph.D • “Slowing down to the speed of life” Joe Bailey, Ph.D • “Mental health naturally” Kathi Kemper, MD • Henry Emmons, MD • “Chemistry of Joy/ Chemistry of Joy workbook” • “Chemistry of Calm”