Fertility and Mental Health: The Potential for Provider Intervention
Posted: April 2021
1 in 8 couples suffer from a form of infertility, whether that may be difficulty getting pregnant or sustaining a pregnancy. As medical providers, we understand the physiologic and medical component to this diagnosis, but we also have an opportunity and a duty to address the often, co-occurring psychological component as well.
There are many emotional, relational and financial facets to this diagnosis that can be profoundly stressful and disappointing. It is not unusual to feel a sense of sadness and longing for however long this process takes. Separate from the journey itself, there are often medications prescribed to treat infertility, that may result in changes in mood. If feelings of depression persist, the patient or their partner may start to develop symptoms of a major depressive episode. Perhaps a loss of motivation, difficulty completing normal everyday activities, worthlessness, hopelessness, apathy or worsening anxiety which can be detrimental to their quality of life.
A study done in 2015 showed that MDD in patients undergoing fertility treatment was common. 39.1% of the women and 15.3% of the men met the criteria for MDD during the 18-month course of the study. It is recommended that routine screening for MDD be completed throughout treatment so that we are better able to offer counseling, support services, or medication as well as education about depression and potential warning signs.
References & Resources:
Looking Ahead: Starting with a Self-Care Plan
Posted: December 2020
Self-care has become a hot topic for wellbeing; and since the start of the COVID-19 pandemic, many of our self-care routines have been up-ended by a drastically changing world. As we look ahead, it is important for both providers and patients to care for their physical, mental, and emotional wellbeing through acts of self-care that may help prevent future health conditions.
Plus, taking care of yourself is essential for caring for others, whether those are your patients, your family, or friends.
In creating a self-care plan for yourself or a patient, use evidence-based practices that are known to support and foster physical, emotional, social, and spiritual wellbeing. These can be straightforward activities such as drinking enough water or engaging in social interactions.
It is also important to encourage SMART goals with each activity, making them specific, measurable, attainable, realistic, and time bound to ensure we are tracking them and holding ourselves accountable. This also means setting a manageable number of goals, as too many changes at once can be overwhelming and work against your efforts.
At times, we may not know where to begin formulating a self-care plan. Fortunately, there are quick, easy assessment tools to evaluate multiple areas and help bring focus to one’s efforts. The University at Buffalo School of Social Work offers a self-care assessment and multiple worksheets to help build a self-care plan.
With resources like these, we can take steps toward forming our individual plans for improving wellness; and keep in mind, self-care isn’t one-size-fits-all, find the activity or activities that are most helpful and restorative for you.
Reflecting on how you’re doing and identifying a well-rounded and consistent plan for our patients or ourselves are the first steps to bring about a happier, healthier future!
More tips on building a self-care plan:
Managing Mental Health During a COVID-19 Holiday Season
Posted: November 2020
It is hard to believe the holiday season is upon us: 2020 has blown by and has been a blur for many. Nonetheless, here we are; and November and December bring celebrations such as Diwali, Thanksgiving, Día de la Virgen de Guadalupe, Hanukkah, Kwanzaa, Christmas, and New Year’s – and they will most certainly look different this year.
How do we and our patients make decisions about whether to gather in our traditional ways – or not – and how do we all emotionally manage change?
While the holidays can be a difficult time for some due to loss or other trauma, many look forward to the gatherings and energy that comes with the time of year and the traditions they have participated in since childhood. However, considering the pandemic due to the novel coronavirus (COVID-19), many are facing tough decisions and struggling to manage the stress, depression, and anxiety that comes along with such change.
There are great resources online for managing the holidays in the COVID-19 environment, and some are included below. As providers, take note of these resources and talk openly with your patients about how they are feeling; share ways that they can make the best of a challenging situation. Perhaps you will have an opportunity to share something that you will be doing differently. Sometimes it’s helpful to our patients to remember that we are in it with them. Just remember – the priority is to stay safe, minimize risk of exposure and spread of coronavirus, and to recognize symptoms of depression and anxiety that may warrant treatment. Encourage counseling and prescribe or refer for medication as appropriate.
Let us try to find the silver lining; and if we can’t find one – let’s create one with new traditions and a safe holiday season.
References & Resources:
Substance Use Disorder and COVID-19: A Resource for the Primary Care Setting
Posted: October 2020
With the onset of the Covid-19 pandemic, we have seen an increase in use and worsening of outcomes in our patients struggling with substance abuse. A national study recently published in JAMA found that the overall frequency of alcohol consumption increased by 14% among adults over age 30, compared to the same time in 2019. Symptoms of depression and anxiety have become more prevalent with increase in isolation and lack of access to treatment like AA and other social supports; key components in managing substance use disorder. This lack of access to care increases our patients risk of relapse and death.
Patients with substance abuse problems are most often seen for the first time in a primary care setting. Being able to address this population is especially important with the growing need secondary to the pandemic. Aside from an increase in substance abuse and mental health symptoms, you may notice worsening of their comorbid diseases like hypertension or diabetes due to lack of self-care or medication noncompliance. This may be the first sign your patient is struggling.
Recognizing substance abuse is easy when your patient asks for the help. It can be difficult to treat when your patient is in denial of their problem. The use of screening tools is a simple way to gauge the severity of their use and willingness for change. It allows you to start the conversation and offer resources. Sometimes less is more when it comes to treating this population. Eliminating, minimizing or monitoring use of habit-forming medication you may be prescribing is crucial. Long term treatment is standard of care and primary care providers must be aware of the resources available for their patients especially during these tumultuous times.
COVID-19 & Burnout: Going the Distance for Patients Means Caring for Self
Posted: September 2020
COVID-19 has changed the dynamic of medicine over the past several months. During these unprecedented and uncertain times, you may have found yourself faced with difficult cases and adverse outcomes that have been hard to forget. Maybe you have been required to work long hours, wear PPE, and change the way that you interact with patients, especially those who have struggled because of COVID-19. At the end of the day, do you go home wondering how you are going to manage through another day? Do you wonder if it will ever get better for you and your patients? Well, you are not alone.
Through it all, we, as providers, often put our own lives and well-being on hold while caring for those with coronavirus. The one thing we can’t forget to do is to take care of ourselves.
There should be no shame or guilt about becoming overwhelmed. We are a profession that takes pride in the way we provide care for our patients; and it is natural to feel pain over those that we have lost. We need to make it a point to take time for ourselves. There are resources available to help providers experiencing burnout. In addition, most people have access to an Employee Assistance Program (EAP) that can get you in touch with the help that you need.
There was an article about an ER doctor in New York that became so overwhelmed with COVID-19 cases and the number of patients that she lost, she was unable to cope, and she ended up taking her own life. Remember, you are not alone. Being a provider doesn’t mean we are superhuman or that we are without emotion. Provider burnout and PTSD are real and impacting our profession right now. Recognize it in ourselves and in our co-workers and do what you can to help those that are in need, even if that person is you.
More than Everyday Worries: Addressing Anxiety
Posted: March 2020
Anxiety disorders are the most common and pervasive mental health disorders in the US and worldwide; many people deal with an anxiety disorder daily. While there are several types of anxiety, one thing remains constant: Occasional anxiety is an expected part of life. You might feel anxious when faced with a problem at work, before taking a test, or before making an important decision. When anxiety involves more than just temporary worry or fear, PAs and providers need to recognize the signs.
Here are just a few statistics to consider:
- Nearly 40 million people in the US (18%) experience an anxiety disorder in any given year.
- Approximately 8% of children and teenagers experience an anxiety disorder with most people developing symptoms before age 21.
- Only about one-third of those suffering from an anxiety disorder receive treatment, even though the disorders are highly treatable.
- The World Health Organization (WHO) reports 1 in 13 globally suffers from anxiety, with specific phobia, major depressive disorder, and social phobia being the most common.
While there is no one thing that will cause anxiety for everyone, some things can increase risk for having an anxiety disorder, including genetics, brain chemistry, a person’s personality, and life events. It is estimated that about 30% of the people that have anxiety will go through their life being untreated. So, as providers, how can we recognize and treat anxiety?
Screening tools can be helpful. SMIAdviser offers an app for your phone that includes the Generalized Anxiety Disorder-7 (GAD-7) screening tool, so you can access it easily while talking to your patients about symptoms of anxiety. Another helpful tool may be the Hamilton Anxiety Rating Scale (HARS), which helps to assess the severity of anxiety symptoms.
While treatment plans should consider several factors, providers may consider medication and psychotherapy. SSRI’s and SNRI’s are often the first line of treatment. It is also possible to use benzodiazepines, but those are not recommended for routine treatment of anxiety. Further, it is possible to use beta blockers, tricyclic antidepressants, buspirone, or other medications like clonidine or hydroxyzine, although those are not as recommended as some of the other options. In addition, psychotherapy, specifically Cognitive Behavioral Therapy and Dialectical Behavioral Therapy, has been shown to be an effective treatment for anxiety, both independently of and in conjunction with medication.
Untreated anxiety has been implicated in several chronic physical illnesses, including heart disease, chronic respiratory disorders, and gastrointestinal conditions, which underscores the need for all PAs and providers to be equipped to recognize and treat anxiety. Anxiety can also result in someone not being able to go to school, or to work, or to even be able to go to the store; and sometimes anxiety doesn’t present as obviously as other mental health disorders. As providers, we should be frequently asking questions about anxiety, recognize signs and symptoms, and initiate treatment.
SMIAdviser: https://smiadviser.org/ Anxiety Screening Tools:
Healing the Healer: Resources for Stress Management and Burnout Prevention
Posted: December 2019
As we wind down the year, and the holidays are upon us, it is important to discuss opportunities to embrace and manage the inevitable stress that we will experience. As a medical provider, you may notice an uptick in sick visits, an increase in depressive and anxiety symptoms in your patients, and an overall increase in demand to get work done faster. Of course, stress occurs year-round and the holiday season is not the only time where you may experience exhaustion, detachment, or lack of motivation, also referred to as provider burnout.
The American Psychological Association defines burnout as the physical, emotional, or mental exhaustion, especially in one's job or career, accompanied by decreased motivation, lowered performance, and negative attitude towards oneself and others. It may result from performing at a high level until stress, especially from extreme and prolonged physical and mental exhaustion or an overburdening workload, takes its toll.
It is important to recognize burnout’s signs and symptoms and to evaluate your work environment for stressors that may be eliminated or lessened. Burnout can manifest physically, emotionally and behaviorally. For example, feeling drained, frequent headaches and muscle tension, having a negative outlook towards patients, feeling detached, powerless or even clinically depressed. You may find yourself withdrawing from responsibilities or using food, drugs, or alcohol to cope.
What is the best way to treat or prevent burnout? That really depends on the provider. It does not have to be time consuming or expensive, and it should not feel like a chore. Multiple studies have found exercise and eating well for your mental health may help manage stress and burnout. In addition, there are many evidence-based strategies beyond these cornerstones of health including mindfulness, unplugging during time off, advocating for yourself to your administration or seeking social and professional support. Healing thyself can be a challenge, but self-care is best for patient care.
Post-Traumatic Stress Disorder: Screening is the First Step
Posted: November 2019
We all probably know someone that has seen combat in war, has been victimized, or has been subjected to or witnessed some other traumatic experience. After such an experience, the mind and body are in shock. As people make sense of what happened and process their emotions, they start to move through the shock. For some though, they continue to relive the events over and over. These people have Post-traumatic Stress Disorder (PTSD) and remain in psychological shock.
Typically, PTSD symptoms will start within a month of the traumatic event; but for some, the symptoms can manifest years later. People with PTSD tend to experience nightmares or flashbacks and may avoid places or things that remind them of the traumatic experience. They also tend to be hyper-vigilant.
Statistics estimate that 7-8 (up to as many as 13) people out of 100 will experience PTSD at some point in their life. It is estimated that 50% of people with PTSD will never reach out for professional help.
While several different types of medications are used to treat PTSD, antidepressants are the most studied. They can help with worry, anger, sadness, and feelings of numbness. Other medications may be used to help with sleep disturbances. Psychotherapy, including Exposure Therapy and Cognitive Restructuring, is another type of PTSD treatment. Getting patients into psychotherapy so they can talk about what happened is important for their overall recovery. In addition, each person should be encouraged to do things on their own to achieve the best possible treatment outcome.
As providers, we need to recognize the changes in our established patients, especially if we know of a recent traumatic experience in their life. Don’t be afraid to ask questions about and screen for PTSD symptoms. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) is a 5-item screen that was designed for use in primary care settings and can identify individuals with probable PTSD. The sooner that the signs of PTSD are recognized, the better the outcome for the patient.
Beyond the PHQ9: Being Resource Ready
Posted: October 2019
According to the Anxiety and Depression Association of America, Major Depressive Disorder affects more than 16.1 million American adults. That’s approximately 6.7% of the U.S. population age 18 and older in a given year.
In primary care and many other practice settings, certified PAs periodically utilize the Patient Health Questionnaire-9, (PHQ9) or other depression screening tools as part of periodic assessment for depression. When these questionnaires are positive, certified PAs have an opportunity to manage the disease along multiple fronts. It starts with being prepared.
Medical management options for depression are plentiful; however, treatment modalities span far beyond prescription medications. These include lifestyle changes, support groups, cognitive behavioral therapy, psychiatry/psychology consultations, and inpatient/residential treatment.
Have you considered recommending lifestyle changes or therapy for your patients? Are you familiar with the mental health community resources, practitioners, and facilities in your area? To get started, become resource ready using the suggestions below. Take your preparations a step further! Develop your own informational handout to share with patients.
SMI Adviser: A Clinical Support System for Serious Mental Illness includes additional resources for clinicians and providers as well as individuals and families.
Suicide Prevention: Conversation to Save a Life
Posted: September 2019
1.4 million - that’s the estimated number of suicide attempts in 2017. As the 10th leading cause of death in the United States, there is drastic room for improvement in suicide prevention and in the mental healthcare system, and we must become proactive about having difficult conversations.
What can you do as a medical provider, colleague, friend, or family member? Knowledge and compassion are crucial when it comes to preventing suicide. Know the warning signs for risk of suicide and ACT – talk to those that you believe may be at risk. This can be an awkward conversation, but here are six easy steps from the American Foundation for Suicide Prevention:
1. Talk to them in private. 2. Listen to their story. 3. Tell them you care about them. 4. Ask directly if they are thinking about suicide. 5. Encourage them to seek treatment or to contact their healthcare provider or therapist. 6. Avoid debating the value of life, minimizing their problems, or giving advice.
Then, be prepared if they are contemplating suicide:
1. Take them seriously. 2. Stay with them. 3. Help them remove lethal means. 4. Call the National Suicide Prevention Lifeline 1-800-273-8255. 5. Escort them to mental health services or an emergency room.
Suicide prevention doesn’t have to be hard. As family members, friends, colleagues, and healthcare providers, we need to start conquering these difficult conversations, being honest, and looking out for others. Having this conversation just once can change someone’s life forever.
National Suicide Prevention Lifeline: 1-800-273-8255.
Or, text TALK to 741741 to text with a trained crisis counselor form the Crisis Text Line for free, 24/7”
SAMHSA’s suicide prevention resources, including screening and assessment tools as well as population-specific toolkits, help identify persons at risk for suicide and offer resources to help.
The American Foundation for Suicide Prevention raises awareness, funds science-based research, and assists those affected by suicide.
Let’s Talk About It: Help End Stigma Around Mental Illness
Posted: August 2019
Despite scientific advancements in the understanding and treatment of mental illness, there continues to be a stigma associated with mental illness. In fact, the Surgeon General identified stigma as a public health concern.
Stigma stems at least in part from the fact that for hundreds of years, mental illness was perceived as something bad, like the mark of the devil or a type of moral punishment. Unfortunately, individuals with mental illness were ostracized and isolated; and most treatments were inhumane.
While we know more about mental illness today and can more effectively manage it with treatments and medications, people still tend to shy away from mental illness like it is taboo. Stigma also contributes to patients not seeking treatment that would improve their quality of life.
As providers, we can help change society’s perceptions about mental illness as well as an individual’s perceptions about their illness. We can help them understand they have an illness that can be treated and remind them that they are not alone. Encourage your patients to connect with organizations like the National Alliance on Mental Illness (NAMI).
Plus, as providers, we should be doing all that we can to debunk the stigma of mental illness by educating those around us. We can use respectful language to talk about mental illness, recognize the connection between mental and physical health, challenge misperceptions when we see them, and encourage all to see individuals rather than their condition.
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
Social media: Follow the #EndStigma hashtag and connect with others seeking to change perceptions about mental health.
Low Testosterone and its Effect on Mood and Behavior
Posted: June 2019
June is upon us and with that we often associate the warmer and sunnier days, outdoor activities, and “summer fun” with an improved mood. Unfortunately, these changes do not bring a better mood for all.
As we celebrate Men’s Health Month, it seems appropriate to take note of an often-missed contributor to mental health issues in the male population – specifically how low testosterone can impact mood and anxiety.
Low testosterone is a clinical condition that can be caused by chronic illnesses, medications, or can simply be part of the natural aging process. Regardless, symptoms can impact more than just libido – men may experience mood swings, depression, fatigue, and anxiety. Sometimes when men present with mood symptoms or problems with anxiety, clinicians are quick to treat with antidepressants or other psychiatric medications. This may not adequately address the problem, and men may be left with unresolved symptoms that are affecting their everyday lives.
While low testosterone is not the only possible differential diagnosis for mental health symptoms, it is one that should not be missed. This month let’s all make a special effort to consider the whole person with symptoms of depression or anxiety and rule out the physiologic possibilities before prescribing.
Bain, J. The Many Faces of Testosterone, Clinical Interventions in Aging. 2007 Dec; 2(4): 567-576. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686330/
Taking Care of Baby … and Mom: Maternal Mental Health in the "Fourth Trimester"
Posted: May 2019
As we settle into the spring season and enjoy a time of new beginnings, growth and restoration, may it also be a reminder to bringing awareness to our mental health and self-care.
May is Mental Health Awareness month; and the internet and social media have covered thousands of stories from different women who have experienced post-partum depression. This brings awareness and hope to new moms everywhere because you too are not alone!
According to the CDC, post-partum depression and anxiety are common disorders that affect 1 in 7 women, but only a small number of women will seek treatment. You do not have to have a history of depression to experience post-partum depression or anxiety. Symptoms can appear any time during pregnancy and the first 12 months after childbirth. Symptoms may include feeling sadness, guilt, irritability, inadequacy, or difficulty connecting with your baby; and these symptoms can range in severity.
Regardless of clinical presentation, every woman should be assessed for depression in the post-partum period. Women are encouraged to speak to your certified PA or another healthcare provider about exactly how you are feeling. There are effective research-based treatment options available to help women recover.
If at any point you have thoughts of harming yourself or baby, please call 911 or 1-800-SUICIDE to receive immediate care. Here are a few resources for women in the perinatal and post-partum period to help guide you with more support through this journey.
1. My Wish for Women: A social cause initiative to reduce the stigma of postpartum depression and anxiety
2. Social Media: Knowing you are not alone is very important to healing through this process. Use #mywishformoms on Instagram to find women from all over the world who are telling their stories.
3. Postpartum Support International: Includes great patient and provider resources